The British Orthopaedic Association has endorsed a website, . www.orthoconsent.com. , allowing surgeons free access to a bank of pre-written consent forms. These are designed to improve the level of information received by the patient and lessen the risk of successful litigation against surgeons and Health Trusts

Aims. Supracondylar fractures are the most frequently occurring paediatric fractures about the elbow and may be associated with a neurovascular injury. The British Orthopaedic Association Standards for Trauma 11 (BOAST 11) guidelines describe best practice for supracondylar fracture management. This study aimed to assess whether emergency departments in the United Kingdom adhere to BOAST 11 standard 1: a documented assessment, performed on presentation, must include the status of the radial pulse, digital capillary refill time, and the individual function of the radial, median (including the anterior interosseous), and ulnar nerves. . Materials and Methods. Stage 1: We conducted a multicentre, retrospective audit of adherence to BOAST 11 standard 1. Data were collected from eight hospitals in the United Kingdom. A total of 433 children with Gartland type 2 or 3 supracondylar fractures were eligible for inclusion. A centrally created data collection sheet was used to guide objective analysis of whether BOAST 11 standard 1 was adhered to. Stage 2: We created a quality improvement proforma for use in emergency departments. This was piloted in one of the hospitals used in the primary audit and was re-audited using equivalent methodology. In all, 102 patients presenting between January 2016 and July 2017 were eligible for inclusion in the re-audit. Results. Stage 1: Of 433 patient notes audited, adherence to BOAST 11 standard 1 was between 201 (46%) and 232 (54%) for the motor and sensory function of the individual nerves specified, 318 (73%) for radial pulse, and 247 (57%) for digital capillary refill time. Stage 2: Of 102 patient notes audited, adherence to BOAST 11 standard 1 improved to between 72 (71%) and 80 (78%) for motor and sensory function of the nerves, to 84 (82%) for radial pulse, and to 82 (80%) for digital capillary refill time. Of the 102 case notes reviewed in stage 2, only 44 (43%) used the quality improvement proforma; when the proforma was used, adherence improved to between 40 (91%) and 43 (98%) throughout. Conclusion. Adherence to BOAST 11 standard 1 is poor in hospitals across the country. This is concerning as neurovascular deficit may be an indication for emergent surgery, and missed neurovascular injury can cause long-term, or even permanent, functional impairment. We present a simple proforma that improves adherence to this standard, can easily be implemented into emergency departments, and may improve patient safety. Cite this article: Bone Joint J 2018;100-B:346–51

Competition ratios for Core Surgical Training (CST) and Higher Specialist Training in Trauma & Orthopaedic (T&O) surgery have decreased over the last 5 years. Whilst multifactorial, one reason thought to contribute to career decision- making, is junior doctors' experience whilst working in that specialty. This study aimed to identify ‘who’ is currently working on the “1st on call” tier in T&O in the UK, and what clinical activities are undertaken.

Collaborators were recruited between 12/09/2015 – 17/01/2016 via the BOTA networks. Data was prospectively collected between 18/01/2015 and 22/01/2015. Each collaborator completed a coded clinical activity diary for all doctors on the “1st on call” rota for T&O in their hospital. Activity parameters included doctor grade, rota gaps, operative and clinic exposure, on call activity, and ward cover.

221 collaborators submitted clinical activity data regarding 933 junior doctors from 100 T&O departments in the UK. 30 rota gaps were identified. The mean number of junior tier doctors was 9 (range 1–23). The “Lost Tribe” comprised Foundation Year 2 (26%), Core Surgical Trainee (19%), Trust Grade (20%), and locum doctors (13%), amongst other grades. During the study period, 2.5% of the ‘Lost Tribe’s' time was allocated to clinic, 2.7% to theatre, 27% to ward cover and 34.6% to zero sessions.

Doctors-in-training make up a minority of the workforce and as such, the T&O profession need to do more to ensure that junior doctors are exposed to clinics and operative lists to specifically address the balance between training and service delivery.

Aims. Most patients with advanced malignancy suffer bone metastases, which pose a significant challenge to orthopaedic services and burden to the health economy. This study aimed to assess adherence to the British Orthopaedic Oncology Society (BOOS)/British Orthopaedic Association (BOA) guidelines on patients with metastatic bone disease (MBD) in the UK. Methods. A prospective, multicentre, national collaborative audit was designed and delivered by a trainee-led collaborative group. Data were collected over three months (1 April 2021 to 30 June 2021) for all patients presenting with MBD. A data collection tool allowed investigators at each hospital to compare practice against guidelines. Data were collated and analyzed centrally to quantify compliance from 84 hospitals in the UK for a total of 1,137 patients who were eligible for inclusion. Results. A total of 846 patients with pelvic and appendicular MBD were analyzed, after excluding those with only spinal metastatic disease. A designated MBD lead was not present in 39% of centres (33/84). Adequate radiographs were not performed in 19% of patients (160/846), and 29% (247/846) did not have an up-to-date CT of thorax, abdomen, and pelvis to stage their disease. Compliance was low obtaining an oncological opinion (69%; 584/846) and prognosis estimations (38%; 223/846). Surgery was performed in 38% of patients (319/846), with the rates of up-to-date radiological investigations and oncology input with prognosis below the expected standard. Of the 25% (215/846) presenting with a solitary metastasis, a tertiary opinion from a MBD centre and biopsy was sought in 60% (130/215). Conclusion. Current practice in the UK does not comply with national guidelines, especially regarding investigations prior to surgery and for patients with solitary metastases. This study highlights the need for investment and improvement in care. The recent publication of British Orthopaedic Association Standards for Trauma (BOAST) defines auditable standards to drive these improvements for this vulnerable patient group. Cite this article: Bone Joint J 2023;105-B(10):1115–1122

Aims. This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England. Methods. Longitudinal data collected by the Trauma Audit and Research Network were used to identify 38,347 patients with open fractures, and a subgroup of 12,170 with severe open fractures of the tibia, between 2008 and 2019 in England. Incidence rates per 100,000 person-years and 95% confidence intervals were calculated. Clinical care was compared with the British Orthopaedic Association Standards for Trauma and National Major Trauma Centre audit standards. Results. In total, 60% of all open fractures occurred in males; the median age was 48 years (interquartile range (IQR) 29 to 68). Between 2012 and 2019, the overall incidence in England was 6.94 per 100,000 person-years. In males, the highest incidence observed was in those aged 20 to 29 years (11.50 per 100,000 person-years); in females, incidence increased with age, peaking at 32.11/100,000 person-years at 90 years of age and over. Among those with severe open fractures of the tibia, there was a bimodal distribution in males, peaking at 20 to 29 years (3.71/100,000 person-years) and greater than 90 years of age (2.84/100,000 person-years) respectively; among females, incidence increased with age to a peak of 9.91/100,000 person years at 90 years of age and over. There has been variable improvement with time in the clinical care standards for patients with severe open fractures of the tibia. The median time to debridement was 13.0 hours (IQR 6.4 to 20.9); almost two-thirds of patients underwent definitive soft-tissue coverage within 72 hours from 2016 to 2019. Conclusion. This is the first time the incidence of all open fractures has been studied using data from a national audit in England. While most open fractures occurred in young males, the incidence increased with age in females to a much greater level than observed in older males. The degree of missing data in the national audit is startling, and limits the certainty of inferences drawn concerning open fracture care. Cite this article: Bone Joint J 2022;104-B(6):736–746

Aims. The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland. Methods. The Fragility Fracture Postoperative Mobilisation (FFPOM) multicentre audit included all patients aged 60 years and older undergoing surgery for a fragility fracture of the lower limb between 1 January 2019 and 30 June 2019, and 1 February 2021 and 14 March 2021. Fractures arising from high-energy transfer trauma, patients with multiple injuries, and those associated with metastatic deposits or infection were excluded. We analyzed this patient cohort to determine adherence to the British Orthopaedic Association Standard, “all surgery in the frail patient should be performed to allow full weight-bearing for activities required for daily living”. Results. A total of 19,557 patients (mean age 82 years (SD 9), 16,241 having a hip fracture) were included. Overall, 16,614 patients (85.0%) were instructed to perform weightbearing where required for daily living immediately postoperatively (15,543 (95.7%) hip fracture and 1,071 (32.3%) non-hip fracture patients). The median length of stay was 12.2 days (interquartile range (IQR) 7.9 to 20.0) (12.6 days (IQR 8.2 to 20.4) for hip fracture and 10.3 days (IQR 5.5 to 18.7) for non-hip fracture patients). Conclusion. Non-hip fracture patients experienced more postoperative weightbearing restrictions, although they had a shorter hospital stay. Patients sustaining fractures of the shaft and distal femur had a longer median length of stay than demographically similar patients who received hip fracture surgery. We have shown a significant disparity in weightbearing restrictions placed on patients with fragility fractures, despite the publication of a national guideline. Surgeons intentionally restrict postoperative weightbearing in the majority of non-hip fractures, yet are content with unrestricted weightbearing following operations for hip fractures. Cite this article: Bone Joint J 2022;104-B(8):972–979

Aims. Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. Methods. A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). Results. In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. Conclusion. A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing. Cite this article: Bone Jt Open 2024;5(3):236–242

Aims. The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK. Method. Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded. Results. Across 51 centres, 1,175 patients were analyzed. Antibiotics were given to 754 (69.0%) in the emergency department, 240 (22.0%) pre-hospital, and 99 (9.1%) as inpatients. Wounds were photographed in 848 (72.7%) cases. Median time to first surgery was 16 hrs 14 mins (interquartile range (IQR) 8 hrs 29 mins to 23 hrs 19 mins). Complex injuries were operated on sooner (median 12 hrs 51 mins (IQR 4 hrs 36 mins to 21 hrs 14 mins)). Of initial procedures, 1,053 (90.3%) occurred between 8am and 8pm. A consultant orthopaedic surgeon was present at 1,039 (89.2%) first procedures. In orthoplastic centres, a consultant plastic surgeon was present at 465 (45.1%) first procedures. Overall, 706 (60.8%) patients required a single operation. At primary debridement, 798 (65.0%) fractures were definitively fixed, while 734 (59.8%) fractures had fixation and coverage in one operation through direct closure or soft-tissue coverage. Negative pressure wound therapy was used in 235 (67.7%) staged procedures. Following wound closure or soft-tissue cover, 509 (47.0%) patients received antibiotics for a median of three days (IQR 1 to 7). Conclusion. OPEN provides an insight into care across the UK and different levels of hospital for open fractures. Patients are predominantly operated on promptly, in working hours, and at specialist centres. Areas for improvement include combined patient review and follow-up, scheduled operating, earlier definitive soft-tissue cover, and more robust antibiotic husbandry. Cite this article: Bone Joint J 2022;104-B(9):1073–1080

Aims

This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

Aims. Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines. Methods. This is a national cross-sectional cohort study comprising centres with VFC services across the UK. All consecutive adult patients assessed in VFC in a two-week period pre-lockdown (6 May 2019 to 19 May 2019) and in the same two-week period at the peak of the first lockdown (4 May 2020 to 17 May 2020), and a randomly selected sample during the ‘second wave’ (October 2020) will be eligible for the study. Data comprising local VFC practice, patient and injury characteristics, unplanned re-attendances, and complications will be collected by local investigators for all time periods. A telephone questionnaire will be used to determine patient satisfaction and patient-reported outcomes for patients who were discharged following VFC assessment without face-to-face consultation. Ethics and dissemination. The study results will identify changes in case-mix and numbers of patients managed through VFCs and whether this is safe and associated with patient satisfaction. These data will provide key information for future expert-led consensus on management of trauma injuries through the VFC. The protocol will be disseminated through conferences and peer-reviewed publication. This protocol has been reviewed by the South East Scotland Research Ethics Service and is classified as a multicentre audit. Cite this article: Bone Jt Open 2021;2(3):211–215

Introduction. The aim of this study is to report the 30 day COVID-19 related morbidity and mortality of patients assessed as SARS-CoV-2 negative who underwent emergency or urgent orthopaedic surgery in the NHS during the peak of the COVID-19 pandemic. Method. A retrospective, single centre, observational cohort study of all patients undergoing surgery between 17 March 2020 and 3May 2020 was performed. Outcomes were stratified by British Orthopaedic Association COVID-19 Patient Risk Assessment Tool. Patients who were SARS-CoV-2 positive at the time of surgery were excluded. Results. Overall, 96 patients assessed as negative for SARS-CoV-2 at the time of surgery underwent 100 emergency or urgent orthopaedic procedures during the study period. Within 30 days of surgery 9.4% of patients (n = 9) were found to be SARS-CoV-2 positive by nasopharyngeal swab. The overall 30 day mortality rate across the whole cohort of patients during this period was 3% (n = 3). Of those testing positive for SARS-CoV-2 66% (n = 6) developed significant COVID-19 related complications and there was a 33% 30-day mortality rate (n = 3). Overall, the 30-day mortality in patients classified as BOA low or medium risk (n = 69) was 0%, whereas in those classified as high or very high risk (n = 27) it was 11.1%. Conclusion. Orthopaedic surgery in SARS-CoV-2 negative patients who transition to positive within 30 days of surgery carries a significant risk of morbidity and mortality. In lower risk groups, the overall risk of becoming SARS-CoV-2 positive, and subsequently developing a significant postoperative related complication, was low even during the peak of the pandemic. In addition to ensuring patients are SARS-CoV-2 negative at the time of surgery it is important that the risk of acquiring SARS-CoV-2 is minimized through their recovery. Cite this article: Bone Joint Open 2020;1-8:474–480

Cite this article: Bone Joint Res 2023;12(4):256–258.

Aims. Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type. Methods. Overall, 90 patients were assessed in a cross-sectional cohort study using a mixed, retrospective-prospective approach. Consecutive sampling of 30 patients pre-lockdown (P1), 30 during lockdown (P2), and 30 during post-lockdown (P3) was applied. Type of block, operative status, follow-up, and complications were extracted. Primary endpoints were early complications (≤ one week). Secondary endpoints were later complications including malunion, delayed union or osteotomy. Results. In P1, 86.6% of patients were seen between days one to three, 26.7% in P2, and 56.7% in P3. There were no documented complications from days one to three. Operative rate was 35.5%, which did not vary significantly (p= 0.712). Primary endpoints occurred between day four to seven, and included one patient each period treated for plaster cast pain. Secondary endpoints in P1 included delayed union (one patient). During P2, this included malunion (one patient), a pressure sore (one patient) and ulnar cutaneous nerve symptoms (two patients). In P3, malunion was identified in one patient. Mean follow-up was six months (4 to 9) with union rate 96%. Change in block practice varied significantly (p =＜0.05). The risk ratio of complications using regional block (Bier’s) over haematoma block was 0.65. Conclusion. Follow-up adaptations during lockdown did not adversely affect patient outcomes. Regional anaesthesia is gold standard for manipulation of displaced distal radial fractures. Cite this article: Bone Jt Open 2021;2(5):338–343

Aims

The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement.

One of the ethical and legal requirements of valid consent for treatment is that patients must be fully informed about the complications involved. The General Medical Council (UK) insists that all adverse outcomes of a treatment, which are serious or frequently occurring, must be discussed with the patient. Previous studies have found a large variance in the risks documented on consent forms for orthopaedic hip operations. The aim of this study was to compare the risks documented for three orthopaedic hip operations against pre-constructed operation-specific consent forms endorsed by the British Orthopaedic Association. We retrospectively analysed 300 consent forms for total hip replacements, hip hemiarthoplasties and dynamic hip screw operations (n=100 for each) and noted the risks documented, whether the form was completely legible, the grade of the Doctor obtaining consent and whether a copy of the consent form was given to the patient. We found that of the 300 operations, only 43.1% of the complications were documented as recommended by the British Orthopaedic Association. Furthermore, 26.3 % of consent forms were illegible, 72.7% of patients were consented by the Senior House Officer and only 13.7% of patients were offered a copy of the consent form. Our results indicate that the Methods: of obtaining consent and filling in the consent forms for orthopaedic hip operations could be vastly improved. One method which could be utilized to achieve this would be the incorporation of procedure specific templates in the consenting process. These templates are already in the public domain and free to use at . www.orthoconsent.com. This would allow the patient to weigh up the risks and make a valid informed decision about their treatment and also protect the Doctors from any possible litigation

Purpose of the study: Our aim was to look at, how we are following the British Orthopaedic Association (BOA) guidelines regarding the clinic times. The decrease in doctor working hours and increase in sub-specialisation has added to the problem. Methods: 55 Orthopaedic clinics were observed and time mapped to the nearest second by an independent observer. 5 clinics observed for each of 11 clinicians (5 Consultants and 6 Registrars). The patient factors viz age, sex, mobility, BMI, site of disease were recorded. The clinician factors viz. seniority, sub-specialisation were also recorded. Results: Of total Clinic time, 45% spent for consulting follow-up cases, 26% for new cases and 29% lost in in-between patient transit time. Of the total clinic time, patient time was 75%, procedures 4%, investigations 3%, consent 4%, dictation 13%, teaching 1%. Mean time for consultation was 13 minutes 6 seconds for new and 8 minutes 43 seconds for follow up patients which was significantly less than that recommended by BOA guidelines (15 – 20 minutes for new and 10 –15 minutes for follow up patients). Conclusion: Since the British Orthopaedic Association (BOA) guidelines in 1990, there has been a change in patient’s expectation, responsibility of the clinician towards well informed patients, detailed investigation, consenting in clinics etc. Despite the clinics over running in time the BOA guidelines are not being adhered to potentially compromising quality consultation and training at the cost of pressures to see the recommended 22 unit patients per clinic. There is a need to revise BOA guidelines regarding clinics to provide more time in clinics per patient to maintain quality of care and training

Aims

The aims of this study were to describe the demographic, socioeconomic, and educational factors associated with core surgical trainees (CSTs) who apply to and receive offers for higher surgical training (ST3) posts in Trauma & Orthopaedics (T&O).

Aims

Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme.

Introduction. Despite the established guidelines on lower extremity free flap reconstruction by the British Orthopaedic Association Standard for Trauma (BOAST-4) the post-operative care has yet to be standardised. There is currently no coherent evidence in the literature regarding clinical monitoring, warming, dangling and compression; the optimal regimes and their respective physiological benefits. The aim of this study is to survey all UK Major Trauma Centres (MTCs) with regards to the post-operative care of lower extremity free flaps and elucidate the current protocols for clinical monitoring, warming, dangling and compression. Materials & Methods. All UK-based adult MTCs were surveyed. We formulated a detailed questionnaire to enquire about the post-operative care of lower extremity free flap reconstructions; the number of free flap reconstructions per month and take backs per month and for which post-operative methods a protocol is used in each MTC. We asked specific questions concerning: clinical monitoring, warming, dangling and compression. This questionnaire was distributed to consultant leads in the form of multiple choice questions, with an option of free-text box for further comments, using JISC online surveys. Results were analysed in Excel and presented in percentages. Results. The 28 adult MTCs were contacted. The results showed a lack of formal regional protocols with great variability, suggesting there is no general consensus on post-operative care of lower extremity free flap reconstructions with regards to clinical monitoring, warming, dangling and compression. Conclusions. This survey of UK MTCs on the post-operative protocols for lower extremity free flap reconstruction demonstrated lack of evidence, consensus and large variability in common practice which requires standardisation

Aims. To assess the proportion of patients with distal radius fractures (DRFs) who were managed nonoperatively during the COVID-19 pandemic in accordance with the British Orthopaedic Association BOAST COVID-19 guidelines, who would have otherwise been considered for an operative intervention. Methods. We retrospectively reviewed the radiographs and clinical notes of all patients with DRFs managed nonoperatively, following the publication of the BOAST COVID-19 guidelines on the management of urgent trauma between 26 March and 18 May 2020. Radiological parameters including radial height, radial inclination, intra-articular step-off, and volar tilt from post-reduction or post-application of cast radiographs were measured. The assumption was that if one radiological parameter exceeds the acceptable criteria, the patient would have been considered for an operative intervention in pre-COVID times. Results. Overall, 92 patients formed the cohort of this study with a mean age of 66 years (21 to 96); 84% (n = 77) were female and 16% (n = 15) were male. In total, 54% (n = 50) of patients met at least one radiological indication for operative intervention with a mean age of 68 years (21 to 96). Of these, 42% (n = 21) were aged < 65 years and 58% (29) were aged ≥ 65 years. Conclusion. More than half of all DRFs managed nonoperatively during the COVID-19 pandemic had at least one radiological indication to be considered for operative management pre-COVID. We anticipate a proportion of these cases will require corrective surgery in the future, which increases the load on corrective upper limb elective services. This should be accounted for when planning an exit strategy and the restart of elective surgery services. Cite this article: Bone Joint Open 2020;1-10:612–616

Abstract. Objective. Open fracture management in the United Kingdom and several other countries is guided by the British Orthopaedic Association's Standards for Trauma Number 4 (BOAST-4). This is updated periodically and is based on the best available evidence at the time. The aim of this study is to evaluate the evidence base forming this guidance and to highlight new developments since the last version in 2017. Methods. Searches have been performed using the PubMed, Embase and Medline databases for time periods a) before December 31, 2017 and from 01/01/2018–01/02/2021. Results have been summarised and discussed. Results. Several contentious issues remain within the 2017 guideline. Antibiotic guidance, the use of antibiotic impregnated PMMA beads and intramedullary devices, irrigation in the emergency department, time to theatre and the use of negative pressure dressings and guidance regarding the management of paediatric injuries have all demonstrated no clear consensus. Conclusion. The advent of the BOAST-4 guideline has been of huge benefit, however the refinement and improvement of this work remains ongoing. There remains a need for further study into these contentious issues previously listed

The burden of metastatic disease presenting with axial skeleton lesions is exponentially rising predominantly due to advances in oncological therapies. A large proportion is these lesions are located in the proximal femora, which given its unique biomechanical architecture is problematic. These patients are frequently comorbid and require prompt and concise decision making regarding their orthopaedic care in line with recent British Orthopaedic Association guidelines. We present data detailing the outcomes for patients with proximal femoral metastatic disease referred and treated over a three year period in an Regional Cancer Centre. We retrospectively reviewed a prospectively maintained database of all patients referred for discussion at MDT with axial skeletal metastatic disease. From this we isolated patients with femoral disease. Demographic data along with primary tumour and metastatic disease site were assessed. Treatment regimens were analysed and compared. Finally predicted and actual mortality data was collated. 331 patients were referred over the analysed time period, of which 99 had femoral disease. 66% of patients were managed conservatively with serial monitoring while 34% underwent operative treatment. 65% of those received an intramedullary fixation while 35% had arthroplasty performed. There was a 51:49 split male to female with Prostate, Lung and Breast being the predominant primary tumours. Concurrent spinal metastatic disease was noted in 62% of patients while visceral mets were seen in 37%. Mortality rate was 65% with an average prognosis of 388 days (1.06years) while average mortality was noted within 291 days (0.8 years). Proximal femoral metastatic disease accounts for a large volume of the overall mets burden. There is an overall tendency towards conservative management and of those requiring surgery IM nailing was the treatment of choice. The data would indicate that outcomes for these patients are guarded and on average worse than those predicted

Aims. Is it feasible to conduct a definitive multicentre trial in community settings of corticosteroid injections (CSI) and hydrodilation (HD) compared to CSI for patients with frozen shoulder? An adequately powered definitive randomized controlled trial (RCT) delivered in primary care will inform clinicians and the public whether hydrodilation is a clinically and cost-effective intervention. In this study, prior to a full RCT, we propose a feasibility trial to evaluate recruitment and retention by patient and clinician willingness of randomization; rates of withdrawal, crossover and attrition; and feasibility of outcome data collection from routine primary and secondary care data. Methods. In the UK, the National Institute for Health and Care Excellence (NICE) advises that prompt early management of frozen shoulder is initiated in primary care settings with analgesia, physiotherapy, and joint injections; most people can be managed without an operation. Currently, there is variation in the type of joint injection: 1) CSI, thought to reduce the inflammation of the capsule reducing pain; and 2) HD, where a small volume of fluid is injected into the shoulder joint along with the steroid, aiming to stretch the capsule of the shoulder to improve pain, but also allowing greater movement. The creation of musculoskeletal hubs nationwide provides infrastructure for the early and effective management of frozen shoulder. This potentially reduces costs to individuals and the wider NHS perhaps negating the need for a secondary care referral. Results. We will conduct a multicentre RCT comparing CSI and HD in combination with CSI alone. Patients aged 18 years and over with a clinical diagnosis of frozen shoulder will be randomized and blinded to receive either CSI and HD in combination, or CSI alone. Feasibility outcomes include the rate of randomization as a proportion of eligible patients and the ability to use routinely collected data for outcome evaluation. This study has involved patients and the public in the trial design, dissemination methods, and how to include groups who are underserved by research. Conclusion. We will disseminate findings among musculoskeletal clinicians via the British Orthopaedic Association, the Chartered Society of Physiotherapy, the Royal College of Radiologists, and the Royal College of General Practitioners. To ensure wide reach we will communicate findings through our established network of charities and organizations, in addition to preparing dissemination findings in Bangla and Urdu (commonly spoken languages in northeast London). If a full trial is shown to be feasible, we will seek additional National Institute for Health and Care Research funding for a definitive RCT. This definitive study will inform NICE guidelines for the management of frozen shoulder. Cite this article: Bone Jt Open 2024;5(3):162–173

Orthopaedics has been left behind in the worldwide drive towards diversity and inclusion. In the UK, only 7% of orthopaedic consultants are female. There is growing evidence that diversity increases innovation as well as patient outcomes. This paper has reviewed the literature to identify some of the common issues affecting female surgeons in orthopaedics, and ways in which we can address them: there is a wealth of evidence documenting the differences in the journey of men and women towards a consultant role. We also look at lessons learned from research in the business sector and the military. The ‘Hidden Curriculum’ is out of date and needs to enter the 21st century: microaggressions in the workplace must be challenged; we need to consider more flexible training options and support trainees who wish to become pregnant; mentors, both male and female, are imperative to provide support for trainees. The world has changed, and we need to consider how we can improve diversity to stay relevant and effective.

Cite this article: Bone Jt Open 2021;2-10:893–899.

The significance of ring-fencing orthopaedic beds and protected elective sites have recently been highlighted by the British Orthopaedic Association & Royal College of Surgeons. During the pandemic many such elective setups were established with various degrees of success. This study aimed to compare the functioning and efficiency of a Orthopaedic Protected Elective Surgical Unit (PESU) instituted during the pandemic with the pre-pandemic elective service at our hospital (Pre-Pandemic ward or PPW). We retrospectively collected data of all patients who underwent elective Orthopaedic procedures in a protected elective unit during the pandemic (March 2020 – July 2020) and a similar cohort of patients operated via the routine elective service immediately prior to the pandemic (October 2019 – February 2020). Various parameters were compared and analysed. To minimise the effect of confounding factors a secondary analysis was undertaken comparing total hip replacements (THR) by a single surgeon via PESU (PESU-THR) and PPW (PPW-THR) over 5 months each from March-July 2021 and March-July 2019 respectively. A total of 192 cases were listed on PESU during the studied period whereas this number was 339 for PPW. However more than half (52%) of those listed for a surgery on PPW were cancelled and only 162 cases (48%) were actually performed. PESU had a significantly better conversion rate with only 12.5% being cancelled and 168 (87.5%) cases performed. 49% (87 out of 177) of the cases cancelled on PPW were due to a ‘bed unavailability’. A further 17% (30/177) and 16% (28/177) were cancelled due to ‘emergency case prioritisation’ and ‘patient deemed unfit’ respectively. In contrast only 3 out of the 24 patients cancelled on PESU were due to bed unavailability and the main reason for cancellation here was ‘patient deemed unfit’ (9/24). Single surgeon THR, showed similar demographic features for the 25 patients on PESU and 37 patients on PPW. The average age for these patients was 63 on PESU and 69 on PPW whereas the BMI was 33 and 30 respectively. The patients on PESU also demonstrated a decrease in length of hospital stay with an average of 3 days in comparison to 4.8 days for those admitted to PPW. PROMS scores were comparable at 6 weeks with an average improvement of 16.4/48 in the PESU-THR cohort and of 18.8/48 in the PPW-THR cohort. There were no readmissions or revisions recorded in the PESU-THR cohort while the PPW-THR cohort had 1 readmission and revision. Our study shows how a small ring fenced Orthopaedic elective unit in a district general hospital, even during a global pandemic, can function more efficiently than a routine elective facility with many shared services

The British Orthopedic Association recommends that patients referred to fracture clinic are reviewed within 72 hours. With the increase in referrals and limited clinic capacity it is becoming increasingly difficult to see every referral with in a 72 hour time frame. Some patients are waiting 2 weeks or more before they can be seen in a fracture clinic. With the aim of improving care by seeking to meet BOAST 7 target, waiting times for fracture clinic appointments at the Homerton University Hospital were audited prospectively against this national guideline, before virtual fracture clinic was implemented and 6 weeks after the implementation of virtual fracture clinic at our hospital. Virtual fracture clinic is where an Orthopedic consultant reviews a patients x-rays and A&E documentation and decides if that patients needs to be seen in a face to face fracture clinic to discuss operative vs. non-operative management of their injury or if a treatment plan can be delivered without the patient having to come back to hospital. The study was conducted as a prospective closed-loop audit in which the second cycle took place after the implementation of the new virtual fracture clinic service. The first cycle showed a non-compliant waiting time with only 18% of patients being seen within 72 hours. Following the implementation of virtual fracture clinic, 84% of all patients were reviewed within 72 hours. Virtual fracture clinic delivered a significant reduction in waiting times. Virtual fracture clinic has only just been implemented at the Homerton University Hospital and hopefully at the next audit we will be 100% compliant with the BOA BOAST 7 Guideline. We would recommend that virtual fracture clinics being rolled out in Orthopedic departments in all hospitals which have Orthopedic services

The number of total knee arthroplasties continues to increase annually with over 90,000 total knee replacements performed in the United Kingdom in 2018. Multiple national bodies including the British Association for Surgery of the Knee (BASK) and the British Orthopaedic Association collaborated in July 2019 to produce best practice guidance for knee arthroplasty surgery. This study aims to review practice in a regional healthcare trust against these guidelines. Fifty total knee replacement operation notes were reviewed between January and February 2020 from 11 different consultant orthopaedic surgeons. Documents were assessed against 17 criteria recommended by the BASK guidance. Personnel names and grades were generally well documented. Tourniquet time and pressure were documented in over 98% of operation notes however, protection from spirit burns was not documented at all. Trialling and soft tissue balancing was well recorded in 100% and 96% of operation notes respectively. Areas lacking in documentation included methods utilised to optimise cementation technique and removal of cement debris. Protection of key knee structures was documented in only 56% of operation notes clearly. Prior to closure, final assessment of mechanism integrity, collateral ligament was not documented at all and final ROM after implantation of components was recorded 34% of the time. Subsequently authors have created a universal operation note template, uploaded onto the patient electronic notes, which prompts surgeons to complete documentation of the relevant criteria advocated by BASK. In conclusion, detailed and systematic documentation is vital to prevent adverse events and reduce the risk of litigation. By producing detailed operative templates this risk can be mitigated

Objectives. To assess the clinical and cost-effectiveness of a virtual fracture clinic (VFC) model, and supplement the literature regarding this service as recommended by The National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association (BOA). Methods. This was a retrospective study including all patients (17 116) referred to fracture clinics in a London District General Hospital from May 2013 to April 2016, using hospital-level data. We used interrupted time series analysis with segmented regression, and direct before-and-after comparison, to study the impact of VFCs introduced in December 2014 on six clinical parameters and on local Clinical Commissioning Group (CCG) spend. Student’s t-tests were used for direct comparison, whilst segmented regression was employed for projection analysis. Results. There were statistically significant reductions in numbers of new patients seen face-to-face (140.4, . sd. 39.6 versus 461.6, . sd. 61.63, p < 0.0001), days to first orthopaedic review (5.2, . sd. 0.66 versus 10.9, . sd. 1.5, p < 0.0001), discharges (33.5, . sd. 3.66 versus 129.2, . sd. 7.36, p < 0.0001) and non-attendees (14.82, . sd. 1.48 versus 60.47, . sd. 2.68, p < 0.0001), in addition to a statistically significant increase in number of patients seen within 72-hours (46.4% 3873 of 8345 versus 5.1% 447 of 8771, p < 0.0001). There was a non-significant increase in consultation time of 1 minute 9 seconds (14 minutes 53 seconds . sd. 106 seconds versus 13 minutes 44 seconds . sd. 128 seconds, p = 0.0878). VFC saved the local CCG £67 385.67 in the first year and is set to save £129 885.67 annually thereafter. Conclusions. We have shown VFCs are clinically and cost-effective, with improvement across several clinical performance parameters and substantial financial savings for CCGs. To our knowledge this is the largest study addressing clinical practice implications of VFCs in England, using robust methodology to adjust for pre-existing trends. Further studies are required to appreciate whether our results are reproducible with local variations in the VFC model and payment tariffs. Cite this article: A. McKirdy, A. M. Imbuldeniya. The clinical and cost effectiveness of a virtual fracture clinic service: An interrupted time series analysis and before-and-after comparison. Bone Joint Res 2017;6:–269. DOI: 10.1302/2046-3758.65.BJR-2017-0330.R1

Thromboprophylaxis after elective orthopaedic surgery remains controversial. Recent guidelines from the National Institute for Clinical Excellence (NICE) have suggested that low molecular weight heparin should be given to all patients undergoing total hip replacement. The British Orthopaedic Association is currently debating this guideline with NICE, as it is not clear whether published evidence supports this view. We present the early mortality in our unit after total hip replacement using aspirin as chemical thromboprophylaxis. The 30-day and 90-day mortality after primary total hip arthroplasty was zero. We compare this with that reported previously from our unit without using chemical thromboprophylaxis. With the introduction of routine aspirin thromboprophylaxis, deaths from cardiovascular causes have dropped from 0.75% to zero. These results demonstrate that there is a strong argument for the routine administration of aspirin after elective total hip replacement

Despite increasing scientific investigation, the best method for preventing post-operative deep-vein thrombosis remains unclear. In the wake of the publication of the Pulmonary Embolism Prevention trial and the Scottish Intercollegiate Guidelines Network (SIGN) on the prevention of thromboembolism, we felt that it was timely to survey current thromboprophylactic practices. Questionnaires were sent to all consultants on the register of the British Orthopaedic Association. The rate of response was 62%. The survey showed a dramatic change in practice towards the use of chemoprophylaxis since the review by Morris and Mitchell in 1976. We found that there was a greater uniformity of opinion and prescribing practices in Scotland, consistent with the SIGN guidelines, than in the rest of the UK. We argue in favour of the use of such documents which are based on a qualitative review of current scientific literature

Following the publication in 2007 of the guidelines from the National Institute for Health and Clinical Excellence (NICE) for prophylaxis against venous thromboembolism (VTE) for patients undergoing surgery, concerns were raised by British orthopaedic surgeons as to the appropriateness of the recommendations for their clinical practice. In order to address these concerns NICE and the British Orthopaedic Association agreed to engage a representative panel of orthopaedic surgeons in the process of developing expanded VTE guidelines applicable to all patients admitted to hospital. The functions of this panel were to review the evidence and to consider the applicability and implications in orthopaedic practice in order to advise the main Guideline Development Group in framing recommendations. The panel considered both direct and indirect evidence of the safety and efficacy, the cost-effectiveness of prophylaxis and its implication in clinical practice for orthopaedic patients. We describe the process of selection of the orthopaedic panel, the evidence considered and the contribution of the panel to the latest guidelines from NICE on the prophylaxis against VTE, published in January 2010

Objectives. To explore whether orthopaedic surgeons have adopted the Proximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial results routinely into clinical practice. Methods. A questionnaire was piloted with six orthopaedic surgeons using a ‘think aloud’ process. The final questionnaire contained 29 items and was distributed online to surgeon members of the British Orthopaedic Association and British Elbow and Shoulder Society. Descriptive statistics summarised the sample characteristics and fracture treatment of respondents overall, and grouped them by whether they changed practice based on PROFHER trial findings. Free-text responses were analysed qualitatively for emerging themes using Framework Analysis principles. Results. There were complete responses from 265 orthopaedic and trauma surgeons who treat patients with proximal humeral fractures. Around half (137) had changed practice to various extents because of PROFHER, by operating on fewer PROFHER-eligible fractures. A third (43) of the 128 respondents who had not changed practice were already managing patients non-operatively. Those who changed practice were more likely to be younger, work in a trauma unit rather than a major trauma centre, be specialist shoulder surgeons and treat fewer PROFHER-eligible fractures surgically. This group gave higher scores when assessing validity and applicability of PROFHER. In contrast, a quarter of the non-changers were critical, sometimes emphatically, of PROFHER. The strongest theme that emerged overall was the endorsement of evidence-based practice. Conclusion. PROFHER has had an impact on surgeons’ clinical practice, both through changing it, and through underpinning existing non-operative practice. Although some respondents expressed reservations about the trial, evidence from such trials was found to be the most important influence on surgeons’ decisions to change practice. Cite this article: L. Jefferson, S. Brealey, H. Handoll, A. Keding, L. Kottam, I. Sbizzera, A. Rangan. Impact of the PROFHER trial findings on surgeons’ clinical practice: An online questionnaire survey. Bone Joint Res 2017;6:590–599. DOI: 10.1302/2046-3758.610.BJR-2017-0170

Aims. The primary aim of the survey was to map the current provision of simulation training within UK and Republic of Ireland (RoI) trauma and orthopaedic (T&O) specialist training programmes to inform future design of a simulation based-curriculum. The secondary aims were to characterize; the types of simulation offered to trainees by stage of training, the sources of funding for simulation, the barriers to providing simulation in training, and to measure current research activity assessing the educational impact of simulation. Methods. The development of the survey was a collaborative effort between the authors and the British Orthopaedic Association Simulation Group. The survey items were embedded in the Performance and Opportunity Dashboard, which annually audits quality in training across several domains on behalf of the Speciality Advisory Committee (SAC). The survey was sent via email to the 30 training programme directors in March 2019. Data were retrieved and analyzed at the Warwick Clinical Trials Unit, UK. Results. Overall, 28 of 30 programme directors completed the survey (93%). 82% of programmes had access to high-fidelity simulation facilities such as cadaveric laboratories. More than half (54%) had access to a non-technical skills simulation training. Less than half (43%) received centralized funding for simulation, a third relied on local funding such as the departmental budget, and there was a heavy reliance on industry sponsorship to partly or wholly fund simulation training (64%). Provision was higher in the mid-stages (ST3-5) compared to late-stages (ST6-8) of training, and was formally timetabled in 68% of prostgrammes. There was no assessment of the impact of simulation training using objective behavioural measures or real-world clinical outcomes. Conclusion. There is currently widespread, but variable, provision of simulation in T&O training in the UK and RoI, which is likely to expand further with the new curriculum. It is important that research activity into the impact of simulation training continues, to develop an evidence base to support investment in facilities and provision

Rib fracture fixation by orthopaedic and cardiothoracic surgeons has become increasingly popular for the treatment of chest injuries in trauma. The literature, though mainly limited to Level II and III evidence, shows favourable results for operative fixation. In this paper we review the literature and discuss the indications for rib fracture fixation, surgical approaches, choice of implants and the future direction for management. With the advent of NICE guidance and new British Orthopaedic Association Standards for Trauma (BOAST) guidelines in production, the management of rib fractures is going to become more and more commonplace

Accurate documentation of operative findings is a fundamentally important part of any procedure and forms part of the Royal College of Surgeons of England's guidelines to good care, especially to “ensure that there are legible operative notes (typed if possible) for every operative procedure.” However, many hospitals fall short of this guideline when it comes to arthroscopic procedures because of the difficulty in reproducing visually representative and easy-to-understand images. There is an inability to properly record and archive findings of arthroscopic procedures. We, along with the British Orthopaedic Association, have developed an interactive, free Web-based operative note template that allows the surgeon to draw findings on diagrams of the joints commonly undergoing arthroscopy, type the findings, and then print as many copies as required. The use of the forms has allowed for quicker, easier, and more accurate documentation of arthroscopic procedures. The forms can then be saved to a database and used as a research tool

Studies of operation notes have shown they can vary in quality and affect patient safety. This audit compares the quality of operation notes against standards set by the Royal College of Surgeons of England and the British Orthopaedic Association. Information from operation notes was collected prospectively over a two-week period. All operations performed were included and trainees from the region coordinated data collection in 9 hospitals. Data from 1091 operation notes was reviewed. A number of standards were nearly met including legibility (98.4%), the name of operating surgeon (99.3%) and operation title (99.1%). However a number of standards were not met and those with potential patient safety implications include availability on the ward (88.8%), documentation of type of anaesthetic used (78.6%), diagnosis (73.4%) and findings (80.1%). In addition, the postoperative instructions recorded the need for and type of postoperative antibiotics or venous thromboembolism prophylaxis in only 49.7% and 48.8% of cases respectively. The quality of operation notes studied across the region in this period was variable. Software programmes meant some hospitals had better results for date, time and patient identification details. Following this study, awareness of the standards combined with additional local measures may improve the quality of operation notes

The organisation of accident services must be undertaken by the state as a quasi-military operation. To provide the whole country with integrated accident services on the lines suggested in this memorandum will clearly mean the expenditure of considerable sums of money over many years. Nevertheless, a beginning must be made; and the British Orthopaedic Association recommends that Her Majesty's Government should authorise each Regional Hospital Board, in conjunction with Boards of Governors of Teaching Hospitals. to set up forthwith at least one comprehensive accident service within its area. In the fullness of time such units would be multiplied and integrated to form a nation-wide accident service. If the Government so desired, the Association would be willing to nominate an Advisory Panel to assist in the organisation of such an accident service

To audit adherence to the British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons 2009 review of the acute management of severe open lower limb fractures (BOAST4). Audit: Retrospective study of adherence to BOAST4 standards of 37 cases treated at Derriford Hospital between March 2010 and 2011. Intervention: a multidisciplinary approach towards the management of such injuries. Assigning department-specific roles across all specialities involved and establishing an early patient transfer pathway from non-specialist centres in the region. Re-audit: Prospective data collection of adherence to BOAST4 of 18 cases between October 2011 and April 2012. Eleven of 15 standards were comparable. Statistical analysis was performed using Fisher's exact test (p≤0.05). Six standards showed statistically significant improvement: antibiotic therapy; regular assessment of neurovascular status; urgent surgery for contaminated wounds; initial wound care; appropriate splinting and early patient transfers. One standard was adhered to in all cases. 3 standards showed improvement, although not statistically significant and 1 standard remained consistently low in adherence. Although doctors are familiar with BOAST4, many are not aware of the specific details. A coordinated and informed multidisciplinary team has enabled the successful application of an evidenced-based approach to the management these injuries

The British Orthopaedic Association assessment questionnaire for knee replacements was adapted to allow comparison of the severity of underlying polyarthritis with the benefits of geometric knee replacement in a retrospective study of 150 knees between six months and six years after operation. Total or partial relief of pain was achieved in 81 per cent of the operation, and changes in mobility occurred in fewer patients. Late sepsis remained a serious complication of nine per cent of the operations and one patient died from septicaemia. Late sepsis was associated with previous synovectomy or osteotomy. Retropatellar pain rarely interfered with the mobility of the patient. There was no association of operations that failed with a high erythrocyte sedimentation rate, a high platelet count, a low haemoglobin level or with a strongly positive rheumatoid factor but pain in the contralateral knee was associated with a diminished functional capacity

The accurate and detailed documentation of surgical procedures is essential, forming part of good clinical practice set out by the General Medical Council (GMC). In the case of knee arthroscopy, it is vital for planning further management when referring to a soft tissue knee specialist. This study assesses the quality of documentation of knee arthroscopy and evaluates the implementation of a novel operative template. A retrospective study of 50 operative-notes of patients undergoing knee arthroscopy was completed. A 41-point assessment was made based on guidelines from the GMC, Royal College of Surgeons of England (RCSE), British Orthopaedic Association (BOA) and British Association for Surgery of the Knee (BASK). An operative-note template was devised to address the criteria important for further interventions and then assessed for its efficacy in providing appropriately detailed findings. Detailed documentation deemed essential by current guidelines were lacking the minimum standards expected. Criteria that were considered necessary for an arthroscopic procedure were as low as 4%. After instigating the new operative template, there was a statistically significant increase (p < 0.001) in documentation accuracy throughout the necessary criteria set out by the GMC, RCSE, BOA and BASK. We have devised an operative template for knee arthroscopy that improves the quality of documentation and allows for optimal further surgical planning. Clear documentation is important for patient safety, adequate referral to a specialist, research and coding purposes. This will ideally reduce the number of repeat knee arthroscopies performed and optimise patient care from the outset

Background. The British Orthopaedic Association Standards for Trauma (BOAST) for peripheral nerve injuries. 1. states:. “A careful examination of the peripheral nervous and vascular systems must be performed and clearly recorded for all injuries. This examination must be repeated and recorded after any manipulation or surgery.”. This study investigated whether this standard was met for patients with upper limb trauma at a busy London Accident and Emergency (A&E) Department. Method. Data was gathered prospectively from A&E admission notes for 30 consecutive patients with upper limb injuries from the week beginning 11. th. March 2013. Eligibilty: All patients with upper limb injuries. Results. 30 patients: 18 Males mean age of 39.2 and 12 Females mean age of 40.1. 17 patients (56.6%) had documentation of examination of neurovascular status. 14 patients required manipulation and/or splinting of their injury. Of these, no patients had their neurovascular examination documented after the procedure. Poor adherence to the standard is evident across all grades of doctors: FY2, SHO and SpR. Conclusion. There is clear scope to improve documentation of neurovascular status in upper limb injuries. It is especially important to clearly document neurovascular status following manipulation or splinting from a medico-legal perspective. This applies to all grades of staff in A&E. Recommendations. 1. Education of A&E staff of all grades at the departmental induction. 2. Posters in A&E with simple treatment algorithm for managing fractures and dislocated joints. 3. Re-audit in 6 months

Everywhere I visited, both in England and in other parts of Europe, I met with wonderful hospitality and friendliness. Generally our common language was English, and I felt thoroughly ashamed of my poor efforts at speaking other languages. During my tour in England, France, Germany, Austria, Italy, Denmark, Norway and Sweden I heard many new ideas propounded, and have seen many new and different methods of treatment. In particular I have been able to compare thoughts on such subjects as tuberculosis of the spine, congenital dislocation of the hip, osteoarthritis of the hip, scoliosis, many aspects of trauma, Perthes' disease, hand surgery, poliomyelitis, paraplegia, the treatment of cerebral palsy, rehabilitation of patients suffering from all kinds of orthopaedic disabilities, and surgical appliances. I am very grateful indeed to the British Orthopaedic Association for making this six-months' tour possible

Total hip and total knee arthroplasty both provide a considerable improvement in quality of life, but there is no evidence to suggest that one is more successful than the other. We studied 72 patients in a prospective trial before and after total hip or total knee replacement. We recorded scores for disability and distress derived from the Harris hip score and the British Orthopaedic Association knee assessment score, and used them to generate quality of life (QoL) scores using the Rosser Index Matrix immediately before and at one year after surgery. The patients awaiting knee replacement had significantly lower QoL scores than those awaiting hip replacement (p = 0.011). The QoL scores at one year were high and almost identical for both groups (p = 0.46). Further analysis showed that gender and weight were not significant predictors of improvement of QoL scores, but age (p = 0.03) and whether the hip or knee was replaced (p = 0.006) were significant factors

We have reviewed 105 Liverpool Mark II knee replacements in 71 patients to assess survival and long-term results. Assessment was both clinical and radiological, using a modification of the British Orthopaedic Association knee function assessment chart, and analysis was by the survivorship method as advocated by Tew and Waugh. The follow-up period was between 13 and 113 months with 42 prostheses being in situ for over six years. Eight knees (7.6%) have been revised or arthrodesed because of infection or loosening, giving a cumulative success rate of 89% after seven years based on prosthesis survival alone. Of the remaining knees, 71.1% were either free of pain or caused only minimal pain. The cumulative success rate as judged by the stricter criteria of the prosthesis being in situ and causing little or no pain suggested a 50% survival between 73 and 96 months. Most patients (77.3%) were enthusiastic or satisfied with their results. Complications included deep wound infection (8.6%), and loosening which needed further surgery (11.4%)

The number of primary Total Knee Arthroplasty (TKA) and primary Total Hip Arthroplasty (THA) procedures carried out in England and Wales is increasing annually. The British Orthopaedic Association guidelines for follow up currently differ for patients with TKA and THA. In THA the BOA recommends that Orthopaedic Data Evaluation Panel (ODEP) 10A rated implants should be followed up in the first year, once at seven years and three yearly thereafter. The BOA guidelines for TKA minimum requirement is radiographs at 5 years and each five years thereafter. Few studies have investigated if early follow up affects patient management following total hip and knee arthroplasty. We carried out a retrospective review of all revision procedures carried out in our institution between April 2010 to April 2013. The medical notes and radiographs for each patient were examined to determine the operative indications and patients symptoms. 92 knee revisions and 143 hip revisions were identified. Additionally we retrospectively reviewed the outcome of 300 one year routine arthroplasty follow up appointments. The mean time of hip revision was 8.5years (range 0 to 27years) and 5.6years (range 0 to 20years) for knee revisions. The commonest cause for revision was aseptic loosening associated with pain in 49 (53%) of knee revision patients and 89 (63%) of hip revisions. Infection accounted for 26 (28%) knee revisions and 16 (12%) hip revisions. Only 1% of hip and knee revisions was carried out in asymptomatic patients with aseptic loosening. We did not identify any cases were a patients management was altered at the routine arthroplasty review clinic and none were referred on for further surgical treatment. The findings of our study suggest there is no evidence for a routine one year arthroplasty review and revisions were carried out in asymptomatic patients in 1% of patients

Aims. Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. Patients and Methods. A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. Results. There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. . Conclusion. Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544–53

A prospective, comparative study of two Total Knee Replacement systems was undertaken to compare the traditional end point of revision of the prosthesis with three other end points based on the British Orthopaedic Association Knee Assessment Protocol. These were an unacceptable pain score plus revision, Knee Score of 60% or less plus revision, and a fall to below the preoperative Knee Score plus revision. 182 Knees entered the trial (74 St Leger and 108 Miller-Galante 11 prostheses), and all were assessed for Knee Score pre-operatively. Patients were subsequently assessed for Knee Score at 6 months, 1 year and annually thereafter. 63 implants had reached the five year stage at the time of this study. The results indicate that different patients are designated as ‘failures’ depending on the end point selected, and that different survivorship figures can therefore be calculated with up to 6% variation depending on the end point used. In addition, the most successful prosthesis varies with the end point selected. Although the 95% confidence intervals in this study did not permit us to draw any firm conclusions, we suggest that further investigation into the definition of failure in survivorship analysis is necessary in order to reflect the performance as well as the longevity of Total Knee Replacements

Background: There remains no clear guidance from the British Orthopaedic Association regarding the use of closed suction drains after primary total knee replacement (TKR). Previous studies suggest no benefit in their use and no significant difference between the type of drain used. Aims: To assess whether allogenic transfusion requirements are altered by the use of closed suction drainage and to establish if drains reduce post-operative complications and length of stay in hospital. Materials and Methods: 60 patients undergoing TKR in Eastbourne between December 2008 and June 2009 were evaluated pre- and post-operatively. The population was divided into those with no drain, a Redivac drain (fluid discarded) and a re-transfusion drain (fluid filtered and transfused into the patient). Results: 23 patients had Redivac drains and 5 (22%) required an allogenic blood transfusion. 37 patients had no drain and 2 (5%) required allogenic blood. For the 14 re-transfusion drain patients none received allogenic blood. There was no significant difference in the length of stay across all 3 groups (p=> 0.25). There was a significantly higher incidence of wound ooze and cellulitis in patients with no drain (50%; p=< 0.01). This is in comparison to the other two groups where only 30% of patients with a Redivac drain and 7% of patients with a re-transfusion drain experienced these complications. There was no significant difference in the average haemoglobin drop between the 3 groups (p=> 0.1). Conclusions: The results suggest a benefit in using drains to reduce the risk of post-operative wound ooze and cellulitis after TKR. Re-transfusion drains also appear to reduce the requirement for allogenic blood transfusion in the post-operative period

Anterior Cruciate Ligament (ACL) reconstruction is performed widely across the United Kingdom by orthopaedic surgeons many of whom are members of the British Association for Surgery to the Knee (BASK), The choice of graft and fixation devices varies, based on surgeon’s preference, experience and patient needs. No data has been published with regards to choice of graft material or fixation devices in primary ACL reconstruction within the United Kingdom (UK). To find out what current practice is, we undertook a postal questionnaire of BASK members. 62% responded. Of these, 55% of surgeons have been undertaking ACL reconstruction for more than 10 years. Only 39% are performing over 50 ACL reconstructions per year. 71% of surgeons have read the Good Practice for ACL reconstruction booklet published by the British Orthopaedic Association (BOA). For the femur, the most popular devices used were metal screws (49%), rigidfix (17%), endobutton (14%), transfix (8%) and bioscrews (6%). For the tibia it was metal screws (57%), bioscrews (25%) and intrafix (14%). 16% use bone patellar tendon bone graft (BPTB), 18% use hamstrings, while 66% use either. Overall the most popular method seems to be the use of hamstrings or BPTB secured at both ends with metal interference screws without the use of a tensioner. Whether the variation alters clinical result is difficult to prove. With no national registry, comparison of outcomes becomes impossible. Our survey should serve as a baseline for any future research in this area

Introduction. The rising incidence of metastatic bone disease (MBD) in the UK poses a significant management problem. Poorly defined levels of service provision have meant that improvements in patient prognosis have been mediocre at best. For that reason the British Orthopaedic Association (BOA) in conjunction with the British Orthopaedic Oncology Society (BOOS) issued guidelines in 2002 on good practice in the management of MBD. Despite the availability of these standards, there is very little robust data available for audit. The aim of this study was to conduct a regional survey of how these guidelines are being used in the management of MBD. Methods. A questionnaire was designed with 9 multiple choice questions representing the most common MBD scenarios. This was posted to 106 Consultant Orthopaedic Surgeons in 12 NHS Trusts in the South East of England. Results. The overall response rate to the questionnaire was 44%. There was considerable variation in the management of solitary femoral diaphyseal lesions, pathological subtrochanteric and intertrochanteric femoral neck fractures and vertebral metastases. Furthermore only 2 out of the 12 Trusts surveyed had a designated MBD lead as per the BOA/BOOS guidelines. Discussion. Our study reflects the variation in the management of MBD throughout the region, which may in turn be linked to poorer clinical outcomes. The results demonstrate the possibility of (i) inappropriate initial treatment, (ii) subsequent late tertiary referral and (iii) poor understanding of the biomechanical basis of orthopaedic implants, with the potential for inappropriate choice of prostheses and high failure rates. Streamlining cancer care will involve establishing regional MBD units within large centres where multidisciplinary services are available. Consequently all surrounding hospitals will need a designated MBD lead that can function as a conduit to this integrated care for selected patients

British Orthopaedic Association (BOA) Guidelines recommend clinical and radiological follow-up after Total Hip Arthroplasty (THA) at 1 year, 5 years and every 5 years thereafter to detect asymptomatic failure. To evaluate the importance of routine follow-up appointments (OPAs) in detecting failing implants the presentation of patients undergoing revision THA was reviewed. 176 patients who received 183 first-time revision THAs over a seven-year period (2003-2010) were identified from an arthroplasty database. A preliminary study sampled 46 THAs in 45 patients. Retrospective chart review recorded symptoms and mode of presentation. Follow-up OPA costs were calculated to estimate savings. All patients had symptoms at the time of revision (pain 96%, decreased mobility 76%, limp 35%, stiffness 26%, night pain 24%). Route of presentation was 80% new referrals (GP 63%, in-patient 9%, A&E 4%, Rheumatology 4%) vs 20% routine orthopaedic follow-up. The minimum cost for a routine follow-up OPA was £35. Assuming discharge after the earliest review when the patient has returned to full normal activities the estimated saving for the 2009 cohort of 377 primary THAs performed in our hospital is £13195 at 1 year and £52780 over the lifespan of the implants (assuming average 15 year survival). Following uncomplicated primary cemented THA in our hospital asymptomatic implant failure is unlikely. Symptomatic patients tend to present mainly to their GP and other specialities, rather than orthopaedic follow-up OPAs. Early discharge after return to full normal activities would be safe and lead to significant financial savings

Purpose: The aim of this survey was to assess the practice of obtaining informed consent for Total Knee Replacement Surgery in the United Kingdom. Method: A postal questionnaire was distributed to consultant members of the British Orthopaedic Association. They were questioned regarding their practice for obtaining informed consent for Total Knee Replacement Surgery. Results: Of the 1571 consultant members contacted 34% (526) replied. From these 76% (400) performed total knee replacements. Informed consent was obtained in a pre-operative assessment clinic in 64%, on admission in 32.5% and during the first clinic visit in 3.5% of cases. Consent was routinely obtained by Consultants in 76%, Senior House Officers in 38%, Pre-Registration House Officers in 4% and Specialist Nurses in 5% of cases. Consultants warned of the following complications: Infection 99.2%, Stiffness 70.5%, Aseptic loosening 81.6%, neurovascular damage 56.9%, DVT 96.5%, PE 88.5%, Wear 61.2% and Mortality 67.4%. Patient information leaflets were provided by 71.5% of consultants for Total Knee Replacement. Conclusions: This survey has identified inconsistencies in the complications described to patients. Junior practitioners are continuing to obtain informed consent. Informed consent should be obtained by a suitably experienced practitioner. Patient information leaflets should be provided to patients at the time of listing. We recommend national guidelines relating to obtaining consent for Total Knee Replacement should be published by the BASK. These could be incorporated into their best practice document regarding Total Knee Replacement Surgery

Venous thrombo-embolism is a common complication following hip replacement. The recently-published pulmonary embolism prevention study reported that aspirin decreased the fatal pulmonary embolism rate in patients with femoral neck fractures. In addition, new products (synthetic factor X-inhibitor Fondaparinux and direct thrombin-inhibiter Desirudin) have been reported to be more effective than low-molecular-weight heparin in preventing asymptomatic DVT. We thought it important to update the 1997 survey on thrombo-embolism prophylaxis by British Orthopaedic Surgeons. A single page questionnaire was sent to 1308 members of the British Orthopaedic Association who are consultant orthopaedic surgeons. Those who did not respond received a reminder. We had a 72% response rate. All surgeons use some form of prophylaxis, with 85% using pharmacological agents. Low-molecular-weight heparin is used by 55% of surgeons, while 20% use only aspirin. Fewer than 1% (five consultants) use early mobilisation and nearly 2% (13 consultants) use graded stockings and early mobilisation as their only prophylactic measures. Unit policies govern 74% of surgeons. In the last 3 years, 30% have changed their regime. Most British orthopaedic surgeons still use pharmacological thromboprophylaxis. The use of aspirin has increased from 5% to 30%. Aspirin is often combined with a mechanical prophylactic. The use of intermittent calf compression has increased from 3% to 22% and of foot pumps from 12% to 19%. The use of low-molecular-weight heparin has fallen by 10%

Following introduction of the second offer scheme in April 2004, Cardiff and Vale NHS Trust sent 227 patients (254 knees) to the independent sector treatment centre in Weston-Super-Mare for total knee arthroplasty. The Kinemax total knee system was used in all cases. There was a perception that there were a large number of dissatisfied patients, and a previous British Orthopaedic Association report (of a 14 case sample) questioned the quality of the surgery performed. All of the patients concerned were offered a review in order to assess the outcome. Of the 227 patients (254 knees), 77% have been reviewed (167 patients, 190 knees). 23% (59 patients, 64 Knees) have not been seen. Of these, 30 patients (34 knees) declined review on the basis that they were happy with the result of surgery. 14 Patients (15 knees) were unobtainable by post of by phone. A further 12 patients (12 knees) did not attend appointments. 3 Patients (3 Knees) had died. The total number of re-operations was 27/254, giving a re-operation rate of 10.6%. There were 21 revisions, 17 for aseptic causes (oversized components, malalignment, aseptic loosening) and 4 for infection. There were 6 secondary patella resurfacings. A life table survivorship analysis was calculated for the 254 knees. The cumulative survival rate at 3 years was 85.8%. These results are considerably worse than those reported in the current published literature. This has resulted in a significant economic impact on our service

Introduction: Polyethylene wear of the prosthetic knee tibial component is currently the main cause of medium and long term failure of total knee arthroplasty. The use of a mobile bearing knee prosthesis is intended to decrease the rate polyethylene wear and therefore delay medium and long term failure. We present our five year clinical results of a mobile bearing knee prosthesis. Material and methods: 150 mobile bearing knee arthroplasties implanted between 1993 and 1996 in our institution were followed. 15 knees were lost to follow up. All knees followed up were operated on for osteoarthritis. The British Orthopaedic Association knee function score was used to access the clinical results and the Knee Society Radiographic evaluation was used for radiological evaluation. Results: 33% of patients achieved an excellent result, 52% a good result, and only 3% were not satisfied with the end result. Flexion was greater than 90 degrees in 97% of the patients. Three knees required re-surgery, 1 for deep sepsis, 1 for patello femoral problems and 1 for a fractured polyethylene component. No knee required revision for polyethylene were or loosening. Conclusions: Our mid term results are comparable to those of other prosthesis both mobile and fixed bearing knees as far as revision and radiological and functional scores are concerned. We noted that patient satisfaction in the face of good radiological and functional scores is less than would be expected

Introduction: The rising incidence of metastatic bone disease (MBD) in the UK poses a significant management problem. Poorly defined levels of service provision have meant that improvements in patient prognosis have been mediocre at best. For that reason the British Orthopaedic Association (BOA) in conjunction with the British Orthopaedic Oncology Society (BOOS) issued guidelines in 2002 on good practice in the management of MBD. Despite the availability of these standards, there is very little robust data available for audit. The aim of this study was to conduct a regional survey of how these guidelines are being used in the management of MBD. Methods: A questionnaire was designed with 9 multiple choice questions representing the most common MBD scenarios. This was posted to 106 Consultant Orthopaedic Surgeons in 12 NHS Trusts in the South East of England. Results: The overall response rate to the questionnaire was 44%. There was considerable variation in the management of solitary femoral diaphyseal lesions, pathological subtrochanteric and intertrochanteric femoral neck fractures and vertebral metastases. Furthermore only 2 out of the 12 Trusts surveyed had a designated MBD lead as per the BOA/BOOS guidelines. Discussion: Our study reflects the variation in the management of MBD throughout the region, which may in turn be linked to poorer clinical outcomes. The results demonstrate the possibility of. inappropriate initial treatment,. subsequent late tertiary referral and. poor understanding of the biomechanical basis of orthopaedic implants, with the potential for inappropriate choice of prostheses and high failure rates. Streamlining cancer care will involve establishing regional MBD units within large centres where multidisciplinary services are available. Consequently all surrounding hospitals will need a designated MBD lead that can function as a conduit to this integrated care for selected patients

We set out to ascertain if there is a consensus in elective orthopaedic practice for the screening and management of MRSA. A questionnaire was distributed to all British Orthopaedic Association Linkmen, with prepaid return envelopes. A response rate of 60% (159 of 250) was recorded. 62% do have a screening policy in practice: all admissions (44%), high risk patients only (22%), only patients for joint replacement (12%), both patients for joint replacement and patients at high risk of carriage (21%). Eradication therapy is used in a MRSA - positive patient prior to joint replacement surgery by 91%, following which the MRSA status would be checked by 88%. The efficacy of eradication would be confirmed by obtaining: one set (29%), two sets (13%), and three sets (49%) of negative swabs, prior to proceeding with surgery. A 2nd generation Cephalosporin (77%), followed by Teicoplanin/Vancomycin (16%) are in routine use for antibiotic prophylaxis. The majority of responders have adopted a practice of screening patients; however, significant differences exist in the population that is selected for screening. Eradication in MRSA positive patients is a common practice, but there is variation in the number of subsequent screens performed. Cephalosporins remain the antibiotic of choice for prophylaxis but first line therapeutic agents are also being used which may have implications for resistance. These variations can be partly attributed to the lack of evidence from which practical guidelines can be drafted, as highlighted by national guidelines published in 1998. Until further research is done into the cost effectiveness of screening and the further management of MRSa we have to rely on strict adherence to infection control practices, and appropriate use of antibiotics

Neurological examination in children presenting with upper limb fractures is often poorly performed. In the peripatetic emergency department environment this may be confounded by patient distress or reduced comprehension. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our hospital and performed a further 3 month review to detect resulting changes in practice. In the initial study period, 121 children presented with upper limb fractures. 10 (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients. However, information on nerves examined was only recorded in 5 (5%) with the majority (85%) documented as ‘neurovascuarly intact’. None of the nerve injuries were detected on initial assessment. Following guideline introduction, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (Fisher's Exact Test, p=0.02) with details of nerves examined increasing to 69%. Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. The recent British Orthopaedic Association Standards for Trauma (BOAST) guideline on peripheral nerve injuries emphasises the importance of clearly recorded neurological assessment in trauma patients. Our study shows that introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

Introduction. The management of degenerative arthritis of the knee in the younger, active patient presents a challenge to the orthopaedic surgeon. Surgical treatment options include: high tibial osteotomy (HTO), unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The aim of this study was to examine the long-term survival of closing wedge HTO in a large series of patients up to 19 years after surgery. Methods. Four hundred and fifty-five consecutive patients underwent lateral closing wedge HTO for medial compartment osteoarthritis (MCOA) between 1990 and 2001. Between 2008-2009, patients were contacted via telephone. Assessment included: incidence of further surgery, current body mass index (BMI), Oxford Knee Score, and British Orthopaedic Association (BOA) Patient Satisfaction Scale. Failure was defined as the need for revision HTO or conversion to UKA or TKA. Survival analysis was completed using the Kaplan-Meier method. Results. High tibial osteotomy survival was determined on 413 patients (91%) and, of the 397 patients who were alive at the time of final review, 394 (99%) were contacted for follow-up via telephone interview. The probability of survival for HTO at 5, 10 and 15 years was: 95%, 79% and 56% respectively. Multivariate regression analysis showed that age < 50 years (p=0.001), BMI < 25 kg/m. 2. (p=0.006) and ACL deficiency (p=0.03) were associated with better odds of survival. Mean Oxford Knee Score was 40/48 (range 17-48). Overall, 85% of patients were enthusiastic or satisfied and 84% would undergo HTO again at mean 12 years follow-up. Conclusion. High tibial osteotomy can be effective for periods longer than 15 years. However, results do deteriorate over time. Age < 50 years, normal BMI and ACL deficiency were independent factors associated with improved long-term survival of HTO

Introduction: The role of prophylactic antibiotics in reducing the incidence of infection following hip and knee arthroplasty is well established. The British Orthopaedic Association (BOA) published best practice guidance on the use of prophylactic antibiotics in hip and knee arthroplasty. The guidance stated that all patients should receive prophylactic antibiotics at induction of anaesthesia and that each unit should have a locally agreed policy with advice from microbiologist. The aim of this audit was to compare the practice in our unit with the BOA guidance and implement necessary changes. Patients and Methods: A prospective audit was conducted over a one month period in 2007 and included all patients undergoing elective primary hip and knee replacements. A similar re-audit was conducted over one month period in 2008 after the initial audit recommendations were implemented. Results: Forty patients (40) were included in the initial audit. All patients received prophylactic antibiotics at induction but the choice, dose and duration of administration of antibiotics varied widely among surgeons in the unit. After discussion with the local microbiologist, we recommended a departmental policy for prophylactic antibiotics. The policy recommended a single dose of Cefuroxime and Gentamycin for standard cases and a single dose of Teicoplanin and Gentamycin for high-MRSA risk cases. A re-audit was conducted after the new policy was agreed. The re-audit included 33 patients. All patients received prophylactic antibiotics at induction. The choice of antibiotics was concordant with the policy in 79% of cases and duration of administration was appropriate in 85% of cases. Overall, the policy was adhered to in 22 cases (67 %). Discussion & Conclusions: The closed audit cycle resulted in improvement of our practice but the compliance rate with the new policy was lower than expected. Although it is the primary responsibility of the operating surgeon to ensure the appropriate prophylactic antibiotics are administered, more awareness of other team members is necessary to improve the compliance rate with the new policy

This work aims to quantitatively assess the current opinions of foot and ankle surgery provision by podiatric surgeons within the UK. Three groups were targeted by postal questionnaire; Orthopaedic surgeons with membership to BOFAS, Orthopaedic surgeons not affiliated to the specialist foot and ankle society and surgical Podiatrists. In addition we aim to identify areas of conflict and suggestions for future integration. A postal questionnaire was sent to all Fellows of the Faculty of Podiatric Surgery, College of Podiatrists (136), members of the British Orthopaedic Foot and Ankle Society, (156), and a randomly selected number of Fellows of the British Orthopaedic Association, who are not members of BOFAS (250). We have received replies from 99 (73%) of the Podiatric Surgical group, 77 (49%) of the Orthopaedic Foot and Ankle surgeons and 66 (26%) from non-Foot and Ankle Orthopaedic Surgeons. Respondents were asked to detail their present practice and issues that they considered to restrict closer working between Orthopaedic Surgeons and Podiatric surgeons. Additionally, each surgeon was given a range of surgical procedures and asked to identify the most appropriate surgical profession to undertake the procedure. The good response rate amongst Foot and Ankle Practitioners (both Podiatric and Orthopaedic) reflects the interest in these issues compared to Orthopaedic Surgeons from other sub-specialties. Poor understanding of Podiatric surgical training, impact on private practice and medical protectionism were areas identified by podiatric respondents. Conflicts over job-title, concerns over training, role boundaries and responsibilities were identified by Orthopaedic respondents as being significant restrictors to further integration. The paper will present the full results of the survey and discuss the suitability and feasibility of closer working practices between Orthopaedic and Podiatric surgeons

Introduction. Deep vein thrombosis(DVT) and pulmonary embolism(PE) are well-recognised complications following lower limb arthroplasty (Cohen et al, 2001). The National Institute for Clinical Excellence and British Orthopaedic Association recommend the use of both mechanical and chemical prophylaxis. At our institute regimens have changed reflecting new developments in the use of thombo-prophylaxis. Our aim was to assess the efficacy of these methods in preventing complications. Methods. Since moving from Aspirin and compression stockings (TEDS) only, three different treatment methods were prospectively audited. Regimen 1 consisted of Aspirin (150 mg OD) and TEDS for 6 weeks (n=660). Regimen 2 used Clexane 40mg OD (n=448). Regimen 3 used Rivaroxaban (n=100) as licensed and Regimen 4 Dabigatran (n=185) as licensed. We looked at rates of venous thromboembolism (VTE), rates of post op bleeding/haematoma and wound complications. Patients were reviewed prior to discharge, and at a six-week follow-up. Any casualty attendances were also recorded up to 12 weeks post-operatively. Results. Symptomatic VTE rates were as follows 3.78% for Regimen 1, 1.9% for Regimen 2, 0% for Regimen 3 and 1.6% for regimen 4. Haematoma/bleeding rates were as follows 1.06% Regimen 2, 5% Regimen 3, and 2.7% Regimen 4. Rates of serosanguineous exudate were as follows 0.2% Regimen 2, 8% Regimen 3 and 5.4% Regimen 4. Conclusion. Our move from Aspirin was based on local audit, which highlighted a higher than national average PE rate. A change towards oral based prophylaxis was based on ease of administration and potential reduction in costs. Although DVT/PE rates were lower with the oral thrombo-prophylaxis, bleeding and wound complications appear higher. This study highlights the need to monitor both VTE and bleeding rates when adopting any changes in protocol, with a view on individualised treatment on balance of risks

Every country has its own criteria for consent. In most, a written consent form is used to reflect patient understanding and permision for the procedure to happen. While oral consent has as much legal sway as the written consent form, the presence of a signature acts as proof of discussion. All European hospitals should have a 100% compliance with patient’s signing consent forms, but their completion is often incomplete and inaccurate, have errors of omission and have lead to litigation, poor patient understanding and recall. We (along witht the BOA) introduce an computer programme of procedure specific orthopaedic consent forms. They have been created for most common elective and trauma operations. The forms follow the UK Department of Health guidelines on consent and contain a brief explanation of the procedure, offer alternative therapies/consequences of not having the procedure (where appropriate), the serious risks and commonly occurring complications. They are written in layman’s English (aimed at a reading age of 14 years). Preliminary trials have also shown the time taken to print and complete a pre-designed form is much less than that of the current handwritten form, reducing errors of omission whilst still allowing discussion with the patient. The forms are currently available as word documents from an easily navigable website. With a view towards European usage, the forms can be easily translated to other languages at minimal cost. With support from the British Orthopaedic Association (BOA), the BOA medico-legal committee, the specialist societies and consultant users (via the website) we hope that the project will continue to evolve with a greater selection of procedural consent forms becoming available. It is believed, from the evidence available, that this approach should decrease the incidence of patient misunderstanding, and the potential risk of successful litigation, while encouraging better communication between patients and surgeons

Background: The British Orthopaedic Association (BOA) guidelines regarding consultation time were published in 1990. There has been a change in the expectation of the patient and the responsibilty of the clinician to provide more information to the patients and more detailed investigation and consent forms to fill with a greater emphasis on clinical governance and increasing awareness of the patients over the years. The decrease in doctor working hours and increase in sub specialisation can not be ignored. Methods: 55 Orthopaedic clinics were observed and time mapped to the nearest second. 5 clinics observed for each of 11 clinicians (5 Consultants and 6 Registrars). From the time the clinician entered the consultation room to start the clinic till the time he left after finishing the clinic the entire span of time was mapped with a stop watch by an independent observer. The patient factors viz age, sex, mobility, BMI, site of disease were recorded. The clinician factors viz. seniority, sub-specialisation were also recorded. Results: Of total Clinic time, 45% spent for consulting follow up cases, 26% for new cases and 29% lost in in-between patient transit time. Of the total clinic time, patient time (time spent by clinician with the patient) was 75%, 4% spent on procedures, 3% on investigations, 4% on consent, 13% on dictation, only 1% on teaching. The mean time for consultation was 13 minutes 6 seconds for New patients and 8 minutes 43 seconds for Follow up patients which was significantly less than that recommended by BOA guidelines (15 – 20 minutes for new and 10 –15 minutes for follow up pateints in Orthopaedic clinics). Conclusion: Despite the clinics over running in time the BOA guidelines are not being adhered to potentially compromising quality consultation and training at the cost of pressures to see the recommended 22 unit patients per clinic. There is a need to revise guidelines to provide for more time in clinics per patient to maintain quality of care and training

To date, there are no clear guidelines from the National Institute of Clinical Excellence or the British Orthopaedic Association regarding the use of Autologous Blood Transfusion (ABT) drains after elective primary Total Knee Replacement (TKR). There is little evidence to comparing specifically the use of ABT drains versus no drain. The majority of local practice is based on current evidence and personal surgical experience. We aim to assess whether the use of ABT drains effects the haemoglobin level at day 1 post-operation and thus alter the requirement for allogenic blood transfusion. In addition we aim to establish whether ABT drains reduce post-operative infection risk and length of hospital stay. Forty-two patients undergoing elective primary TKR in West London between September 2011 and December 2011 were evaluated pre- and post-operatively. Patient records were scrutinised. The patient population was divided into those who received no drain post-operatively and those with an ABT drain where fluid was suctioned out of the knee in a closed system, filtered in a separate compartment and re-transfused into the patient. Twenty-six patients had ABT drains and 4 (15.4%) required an allogenic blood transfusion post-operatively. Sixteen patients received no drain and 5 (31.3%) required allogenic blood. There was no statistical difference between these two groups (p=0.22). There was no statistical difference (p=0.75) in the average day 1 haemoglobin drop between the ABT drain and no drain groups with haemoglobin drops of 2.80 and 2.91 respectively. There was no statistical difference in the length of hospital stay between the 2 groups (p=0.35). There was no statistical difference (p=0.26) in infection rates between the 2 groups (2 in ABT drains Vs. 0 in no drains). Of the 2 patients who experienced complications one had cellulitis and the other had an infected haematoma, which was subsequently washed out. The results identify little benefit in using ABT drains to reduce the requirement for allogenic blood transfusion in the post-operative period following TKR. However, due to small patient numbers transfusion rates of 31.3% in the ABT drain group Vs. 15.4% in the no drain group cannot be ignored. Therefore further studies including larger patient numbers with power calculations are required before a true observation can be identified

In January 2012, the Department of Health reportedly claimed that data demonstrated ‘half of knee surgery does not substantially change the outcome for patients: their mobility is not improved that much, nor their pain’. Furthermore, in recent years knee replacement surgery has been described as a procedure of limited clinical value (PLCV) by commissioning bodies nationwide. This study aimed to establish whether patients in Reading were satisfied with their surgery at five years and whether there was an objective improvement in their pain and function following surgery. Five-year data was retrospectively reviewed from 130 knee replacements performed between January 2004 and July 2005. Patient details, intra-operative data and patient reported outcome measures (PROMs) were downloaded from our OrthoWave database. The Oxford Knee Score was completed pre-operatively, at six months and then yearly to five years, measuring pain and function specific to the knee operated on. In addition, patients were asked directly whether they felt satisfied with their joint replacement surgery. The sample population consisted of 52 males and 78 females, with a mean age of 70 and mean body mass index of 30.2. Twenty-three of the patients had undergone uni-compartmental surgery (either Oxford or St George), with the remainder having either PFC or Scorpio total knee replacements. The mean pre-operative Oxford Knee Score was 20.4. The mean improvement in scores at six months was 14.77 (95% confidence interval 13.25–16.28, p<0.0001) and 17.23 at five years (95% confidence interval 15.66–18.79, p<0.0001). On direct questioning, 85.6% of patients were satisfied with their knee replacement, 3.4% were dissatisfied and 10.9% remained unsure. Reasons identified for dissatisfaction included chronic pain syndromes and the need for early revision surgery. Patient reported outcome measures are increasingly being used to justify outcomes of surgery and the Oxford Knee Score is particularly helpful as it relates function and pain to the knee operated on, whilst attempting to minimise the effect of confounding co-pathology. This five-year data suggests that the majority of patients are satisfied with their knee surgery. A significant improvement in pain and function is evident at six months post-operatively and continues to be demonstrable at five years, supporting the British Orthopaedic Association's strong rebuttal of the recent negative press regarding knee surgery

Introduction and Aims: Venous Thromboembolism is a common complication following a hip replacement. Recently the pulmonary embolism prevention study was published. It reported that aspirin decreased the fatal pulmonary embolism rate in patients admitted with a fracture neck of femur. In addition, new products (synthetic factor X inhibitor-Fondaparinux, and a direct thrombin inhibiter-Desirudin) have been reported to be more effective than low molecular weight heparin in preventing asymptomatic deep vein thrombosis. We felt it was important to repeat a survey, done in 1997, on the use of thromboembolism prophylaxis among British Orthopaedic Surgeons. Method: A single page questionnaire was sent out to all 1308 consultants – orthopaedic surgeons who were members of the British Orthopaedic Association. Those who did not respond were sent a reminder letter. Results: We achieved a 72% response rate. All surgeons use some form of prophylaxis. Eighty-five percent of surgeons use pharmacological prophylaxis. Low molecular weight heparin is used by 55% of surgeons. Twenty percent of surgeons use aspirin as their only form of pharmacological prophylaxis. Less than 1% (five consultants) use early mobilisation alone and nearly 2% (13 consultants) use graded stockings and early mobilisation as their only form of prophylaxis. Seventy-four percent of surgeons have a unit policy. Thirty percent have changed their regime in the last three years. Conclusion: The majority of British orthopaedic surgeons still use pharmacological thromboprophylaxis. There has been a significant increase in the use of Aspirin, from 5% to 30%. Aspirin is often combined with a mechanical prophylaxis. This has led to an increase in the use of intermittent calf compression (3% to 22%), and foot pumps (12% to 19%). Low molecular weight heparin use has fallen by 10%

Introduction: The nature of orthopaedic surgery often demands a high level of physical activity that may be associated with a variety of musculoskeletal symptoms. We designed this study to identify the prevalence and variety of musculoskeletal symptoms affecting orthopaedic surgeons working in Britain. Methods: A questionnaire was designed to explore relevant musculoskeletal symptoms. The case group included all fellows of the British Orthopaedic Association working in Britain (n=1300) and the control group was the primary anaesthetist working with that surgeon (n=1300). All questionnaires were anonymous and completed by post. Results: The response rate was 47% (n=605) for orthopaedic surgeons and 20% for the control group (n=255). The prevalence of back pain was higher in the orthopaedic surgeons (50%) compared to controls (40%; p< 0.05) as was neck pain (28% vs 19%; p< 0.01), carpal tunnel syndrome (20% vs. 5%; p< 0.001), hand pain (20% vs 8%; p< 0.001) and shoulder pain (29% vs 19%; p< 0.005). Although orthopaedic surgeons reported more symptoms than controls, it was notable that significantly more controls used analgesics compared to surgeons (59% vs 35%; p< 0.001). The use of glucosamine was equal in both groups (3% vs 6%). There were two reports of injuries in surgeons that occurred whilst operating (meniscal tear and lumbar disc prolapse). Significantly more surgeons felt their symptoms would lead to early retirement compared to controls (15% vs 8%; p< 0.01). Discussion: This study has shown that occupational musculoskeletal morbidity is higher in orthopaedic surgeons compared to a control group. The reasons for this are multifactoral. The cumulative nature of the symptoms may lead to early retirement in more orthopaedic surgeons compared to other specialities. This study highlights an important occupational health issue and raises the question of increased health and safety awareness from our managers when considering the demands placed on surgeons

Purpose : The purpose of our study is to present, our long term experience of a total knee joint arthroplasty using a mobile bearing polyethylene platform. Material and Method : From 1990 to 1998 we operated 324 knees in 259 patients. During the last follow-up 301 knees were assessed in 241 patients. 7 patients died (9 knees) and 11 patients did not attend. The postoperative follow-up time ranged from 4–12 years (average 8,5 yrs). 207 patients were women (265 knees) and 34 were men (36 knees) aged from 20 to 82 years (average 67,2yrs) at the time of operation. 275 patients suffered from osteoarthritis, 23 from rheumatoid arthritis and 3 from avascular necrosis. Results : The preoperative and postoperative evaluation was done according to the British Orthopaedic Association Knee Assessment Chart. The knee pain was improved in all of our patients. The knee flexion was improved from an average of 87° pre-op to an average of 113° post-op. The pre-op valgus deformity was corrected in 24 from 26 knees and the varus was corrected in 157 from 172 knees. Postoperative alignment was achieved in 286 knees (94,65%). Radioluscent line was observed in 14 knees (in 6 knees < 1mm and in 8 knees 1–2mm of thickness). There were 7 complications of the prosthesis needing re-operation. In 6 cases wear and breakage of the polyethylene and in 1 dislocation of the meniscus was confirmed. Conclusion : The Rotaglide T.K.R is a reliable solution with satisfactory long-term results. The prosthesis design allows correction of a small rotational malalignment of the femoro–tibial axis. In our patients we did not observe any component loosening and there was no need for re-operation and metal component replacement. We recommend the use of Rotaglide total knee replacement in more active and biologically young patients when needed

Healthcare organisations are accountable for improving the quality of their services, safeguarding high standards of care and meeting shorter waiting time targets. This presents a challenge of how to achieve such targets with limited resources. This paper looks at the hypothesis that adequate and appropriate clinical governance can be undertaken while increasing orthopaedic spinal clinic throughput in order to decrease outpatient waiting times. A spinal outpatient clinic was used as the test bed for the hypothesis of the project. The theoretical number of patients an individual consultant can see per session was calculated from recommended British Orthopaedic Association consultation times for new and follow-up cases. Patients were asked to complete the MODEMS (Musculoskeletal Outcomes Data Evaluation and Management System) questionnaire. A prospective randomised trial utilising a touch-screen computerised version of the questionnaire was also used. Time taken for outcome data management is included in the analysis. The time taken to see new and follow up patients was 31–42 and 24–35 minutes respectively. These times have implications in terms of waiting times and Director of Performance Management targets. The shortfall is calculated in terms of additional support necessary to reach these targets. Salary costs and infrastructural support costs are projected. The figure is likely to represent that required by any specialist clinic to realise the ideals of clinical governance and conservatively estimated to be £35, 000 per year. Total clinical governance and patient outcomes are inextricably linked. This is true of orthopaedic spinal surgery in that important information about clinical practice can be obtained. The organizational infrastructure and methods to implement data collection is technically feasible however is not without cost. In terms of economic evaluation the correct price for a resource is its opportunity cost. ‘Don’t just buy more healthcare, invent new healthcare’ is as incongruous as total clinical governance and increased capacity without support