Purpose of study: To assess the effect of 18-month waiting list, on the subsequent requirement of knee arthros-copy.

Materials and methods: Medical records of 310 patients with knee pain, who had been placed on the non-urgent arthroscopy waiting list in 2003, were assessed. Diagnoses and the grade of doctor placing the patients on the list were also noted. The percentages of patients undergoing surgery as planned, as well as of those being cancelled were looked at.

Results: 61% of patients underwent knee arthroscopy as planned. 12% considered their symptoms insignificant as to require operation. 11% wanted a later operation date because of personal reasons, 7% had their surgery privately or had been expedited through the waiting list scheme because of deterioration in their condition but remained on NHS waiting list, and 9% patients had their surgeries postponed because of other medical reasons.

Conclusion: For a group of patients having been placed on an 18-month waiting list for knee arthroscopy, 40% did not subsequently have surgery within the NHS setting, as planned initially.

Introduction. Idiopathic scoliosis is a lateral curvature of the spine >10° as measured on a frontal plane radiograph by the Cobb angle. Important variables in assessing the risk of curve progression include a young age at presentation, female sex, a large amount of growth remaining, the rate of growth, the curve magnitude, and the curve location. Curves >20° have an inherently low risk of progression. Surgery is indicated for curves >50° or rapidly progressing curves. The timing of surgery is paramount in order to intervene in cases where rapid progression is evident to prevent further deterioration. There is a greater likelihood for more complex surgery to be required in major curves. At present, there are severe restrictions on resources to cater for patients with scoliosis. As a result, patients spend excessive periods on waiting lists prior to having their procedure. The aim of this study is to analyse the progression of curves of patients while on the waiting list and assess the cost implications of curve deterioration. Methods. A retrospective analysis of 40 cases of adolescent idiopathic scoliosis performed from between 2007-2010 was carried out. All radiographs at the time of being placed on the waiting list and the time of admission were reviewed to assess the Cobb angle. The radiographs were analysed independently by three spinal surgeons to determine what level of surgical intervention they would recommend at each time point. The final procedure performed was also recorded. A cost analysis was carried out of all of the expenses that are incurred as part of scoliosis surgery, including length of hospital stay, intensive care admission, spinal monitoring, implant cost, and the requirement for multiple procedures. Results. The average time on the waiting list was 12 months (range 6 – 16 months). Comparison of radiographs at the time of listing and time of admission revealed a deterioration of the Cobb angle by an average of 12°. The average Cobb angle at time of surgery was 78° (range 55° - 96°). Analysis of cost implications revealed an increase in cost based on implant requirements, length of stay and intensive care admission estimated at 25%. Conclusion. The results of this study demonstrate that there is a significant deterioration of scoliosis curvature in patients while on the waiting list. The consequence of this progression results in longer operative time, increased requirement for intensive care beds, an increase in requirements for additional levels of pedicle instrument, and a prolonged length of stay. The implications of the deterioration in curvature result in an increase in overall cost estimated at 25%. Waiting list initiatives established over the past 6 months have reduced the waiting list to 6-9 months. Further efforts to continue this initiative are likely to give rise to further cost reductions and result in more manageable curvatures being dealt with in a timely fashion

Waitemata DHB serves a population of approximately 500,000. There are 396 general practitioners who refer to the services. Approximately 400 patients are referred per month. Budget constraints mean not all patients referred can be seen and various Ministry of Health guidelines and Health and Disability Commission rulings help to determine which patients will be seen.

All referrals to the service are assessed by one surgeon. There are specific requirements for referral of patients with certain complaints.

Assistance is given to the general practitioner in organising the more specialist investigations. Help is given to GPs by telephone for patient management particularly of the simpler conditions.

Approximately a quarter of patients referred are referred back to the GP. MRI and CT scans are arranged of which half are returned.

Time must be allocated within the department to allow this specialist liaison with GPs to occur.

Aim: To analyse the Dunedin residual orthopaedic waiting list based on a simple patient questionnaire and a quality of life assessment using EuroQol and SF12.

Method: All patients on the residual waiting list were sent a postal questionnaire enquiring about their need for surgery and their quality of life. Based on their answers, patients were entered into three action groups: 1. back to GP care 2. clinical review 3. booked for surgery. Those patients requiring a clinical review were seen in a special clinic and reassessed in relation to their need for surgery.

Results: Two hundred and sixty-one patients were surveyed. One hundred and fifty-eight had complete data available for analysis and of the remaining 103 patients, 88 were taken off the waiting list for various reasons. Fifteen did not reply. The average time on the waiting list was 19 months (range: < six months to eight years). Sixty percent of the patients felt that their condition had changed and 99% felt that they still required the surgery. The results of the EuroQol and DF12 questionnaire revealed three groups of patients. 1. normal (9 patients). 2. slight impairment (115 patients) 3. moderate impairment (34 patients). Most of these patients had stable conditions except the sub group with deteriorating osteoarthritis of the hip/knee. Group 1 patients were all referred back to their GP. Thirty percent of group 2 patients were referred back to their GP, 60% were booked for a review and 10% were booked for surgery. None of Group 3 patients were referred back to their GP. Seventy percent required a clinical review and 30% were booked for surgery. Our clinical review is continuing but it is anticipated that those who still require surgery and score above the financial threshold will probably be less than one third of the cases.

Conclusion: This paper describes a decision making rationale in relation to assessment of continuing need for surgery in patients on the residual orthopaedic waiting list. Eighty percent of patients had stable conditions, which were not interfering significantly with their activities of daily living and could be managed safely by the GP. Further work is required to identify those patients who are at risk of deteriorating and to work out a practical and cost effective monitoring programme.

Purpose/Background

More than 20 million UK citizens have MSK conditions, and post-pandemic the backlog awaiting access to MSK services has increased. The most prevalent MSK condition is low back pain (LBP), and getUBetter has been recommended by NICE as one of five digital health technologies for helping manage LBP. Purpose: Evaluate impact of getUBetter on a community MSK waiting list.

Funding for the health service is limited and this inevitably leads to rationing. However, the allocation of funding to different specialities and clinical areas often has no rational basis. The aim of this study was to evaluate the health status of patients on the orthopaedic waiting list.

The SF-36 was used as a postal questionnaire and sent to all adult patients on the elective orthopaedic waiting list at our hospital. Demographic data was collected and patients were grouped by intended operation. The health domains of the SF-36 were adjusted for demographic variables and compared to population norms using non-parametric statistical methods.

The SF-36 was sent to 1586 patients and 1155 responded (73%). Analysis was undertaken for hip replacement (n=194), knee replacement (n=291), knee arthroscopy (n=232), foot and ankle (n=147) and cruciate ligament reconstruction (n=46). All diagnostic groups had significantly worse (p< 0.05) scores for all domains of health when compared to population norms. Patients awaiting joint replacement had worse disability (p< 0.001) than other groups, particularly for pain and physical function. Patients over 40 years awaiting arthroscopy had disability approaching these levels and those awaiting ACL reconstruction had poor physical function. In general, patients awaiting foot or ankle surgery had better health than other diagnostic groups but still had significant reductions when compared to normal. Health scores were not related to the Townsend index for social deprivation, indicating equity of access within the health service.

Patients awaiting hip and knee replacement have worse health than others on the waiting list. The SF-36 could be a useful tool if priority on waiting lists were to be determined by pain and disability rather than waiting time.

Objective: To do assess changes in patients’ symptoms and the operative plan.

Materials and methods: 147 patients on a spinal surgery waiting list were assessed at a mean wait of 15.8 ± 1.3 months. 89 (61%) were male and 58 (39%) were female at a mean age of 49.7 yrs (16–78). 123 patients had a degenerative condition (20 cervical; 03 lumbar); 20 patients were seen for scoliosis; 2 with a post-traumatic kyphosis and 1 each with ankylosing spondylitis and a psudarthrosis.

Outcomes assessed: Changes in patients symptoms; changes from the initial operative plan when listed; requirement for re-imaging due to the wait.

Results: 31 patients reported improved symptoms at the re-assessment, while 96 were worse off and 20 were unchanged. 137 had axial pain when listed which changed to 116 at review (p=0.0018). 130 had radicular pain when listed which improved to 80 on re-assessment (p< 0.0001). However 19 reported an increase in the axial and 17 in the radicular symptoms. 71 patients (48.3%) required to be re-imaged at the re-assessment due to changes in the clinical picture. 42 patients received the procedure as originally listed. 30 patients were taken off the list, 24 received a different operation, and 38 had an interim or a definitive needling procedure while 13 await a re-assessment.

Conclusions: On the basis of the observations on our cohort, 1 in 5 operations were cancelled; 65% had an increased severity of the symptoms and just 1 in 3 patients were operated as planned while 48% required re-imaging. A long wait inevitably leads to changed symptoms and a review of these patients is mandatory. The review and the re-imaging adds to the burden on the already over-loaded system.

The aim of this study was to

Report the clinical scores of patients placed on the waiting list for joint arthroplasty in Tauranga (CPAC, Oxford hip and knees scores, WOMAC and SF-12)

In this prospective study all patients complete Oxford hip or knee scores, SF-12, and WOMAC scores. An initial subset of patients (457) who had been entered onto the waiting list prior to May 2005 also completed CPAC scores. A literature search for published studies using Oxford, WOMAC, SF-12 and SF-36 scoring tools was performed using Medline and PubMed databases.

Four hundred and fifty seven waiting list patients completed all 4 scores. Results, including correlation between scoring systems and comparisons with international data are reported.

We found significant variation between internationally accepted scores and the CPAC scoring system. Current waiting list Oxford scores for Tauranga patients are significantly worse than those published in the literature although when including the entire group the difference is small. 2.04 (1.34–2.74 95% CI). After rescoring, patients reaching the certainty threshold, (cTT), and active review threshold, (aTT), have scores that are much worse than those in the published literature.

Introduction: Elective Orthopaedics has been targeted by the department of health in the U.K. as a maximum six-month waiting time for operations could not be met. National Orthopaedic project was initiated as a consequence and Independent Sector Treatment Centres (ISTC) and well established private hospitals were utilised to treat NHS long wait patients.

Materials and Methods: We audited the primary total hip replacements performed in our hospital in 1998 and 2003 to compare the differences in the patient characteristics in particular age, length of stay and ASA grade.

Results: The number of hip replacements increased to 308 in year 2003 from 194 in year 1998. Whilst, the number of ASA I patients were the same, the ASA II. III, IV increased by 40%, 260%, 266% respectively. The average length of stay decreased from 14.3 to 11.9 days which was statistically significant, in spite of increased numbers of ASA II – IV patients.

Discussion: The NHS hospitals are treating increasing number of patients who have a higher anaesthetic risk and are likely to stay longer in the hospital in the post-operative period. The case mix for primary total hip replacements in large tertiary referral hospitals have changed due to altered patient flow due to cherry picking of NHS waiting lists by the ISTC. NHS hospitals should be appropriately remunerated for dealing with complex cases and for managing complications referred by ISTC hospitals. In fact, the National joint registry’s 2^nd annual report confirms that 40% of primary total hip replacements operated in ISTC’s were ASA I while only 25% of primary total hip replacements operated in NHS hospitals were ASA I. None of the ISTC’s performed complex primary THRs.

Aims: In order to reduce the waiting list, the Spanish National Institute of Health sent a large number of patients from Badajoz to other private hospitals, from October 1996 to December 2000, to undergo knee replacement. No medium or long-term follow-up was arranged. Our aims were to compare revision operations in those patients with the ones performed locally.

Material and methods: In that period of time 791 knee arthroplasties were sent to distant centres and 620 were performed in our institution. All revision surgery was performed in our hospital after two months of the index operation in the distant hospitals. We stopped entry of patients in this study in December 2003.

Results: 82 (10.3%) knees have so far required revision surgery in the distant centres group. Of these, 45 have been for deep infection, 26 for aseptic loosening, 5 failed unicompartmental, 3 stiffness, 2 painful non-replaced patellas, 1 non-union of the tibial tuberosity

In the local group 17 (2.6%) knees have so far been revised in the same period of time. Of these 10 have been for deep infection, 3 for aseptic loosening, 3 for instability, and 1 for soft tissue impingement.

Conclusion: The causes for such a difference in revision rates were analysed and include implant selection, surgical technique and absence of follow-up. A constant and angry complaint of all patients sent to other hospitals and subsequently revised was the lack of follow-up.

We report on two patient groups questioned about travelling for surgery outside of their base hospital to cut waiting times.

Firstly 30 patients travelled approximately 50–60 miles to have hip replacements. After surgery we asked them their thoughts regarding an unknown surgeon, self and relatives expenses and any inconvenience. Five (17%) were anxious about taking part and 3 (10%) incurred extra expense (transport was provided). Eight (27%) stated that relatives incurred extra expense and 5 (17%) stated relatives had difficulty visiting. All were not concerned about having their operation carried outside of the local area by a new surgeon. Asking the question as: how keen were you on having the surgical team you first met at your local hospital to do your joint replacement? responses were: 1 not keen (4%), 25 not bothered (83%) and 4 very keen (13%). Three (10%) stated that relatives had to take time off work to visit them. All patients thought that the idea of reducing waiting lists by doing the operation in a private hospital was good. We felt their response was perhaps too positive and decided to look at a local preoperative group.

Our preoperative group involved thirty patients. Four (13%) were anxious about taking part in a waiting list initiative and 10 (33%) were worried about extra expense. Seven (23%) were worried about their relatives extra expense and 6 (20%) would be discouraged if their relatives had difficulty visiting. Fourteen (47%) raised concern about having their operation carried outside of the local area by a new surgeon. Fourteen were keen to have treatment from their original surgeon. None felt that relatives having to take time off work to visit them was a problem. All patients thought that reducing waiting lists by doing the operation early in another hospital was a good idea.

We conclude that patients are accepting of waiting list initiatives if their preoperative wait can be decreased.

Despite a variety of reports to the contrary it was felt by the Christchurch Orthopaedic group that the “wait” on the orthopaedic waiting list has been escalating rapidly to the point that a routine operation is now in the order of approximately 3 years from the time of GP referral.

A review of the time taken for GP referrals to be assessed by an Orthopaedic Surgeon was undertaken. The waiting lists from October 98 to May 02 were analysed, in addition to the operation outputs from the Burwood Hospital elective theatre records over the same period. Time taken from referral to be seen, time taken from been placed on the waiting list to receive an operation and volume of elective procedures were evaluated. A breakdown was made of those removed from the list vs those operated on. A major reduction in the waiting list over the last three years was secondary to 1/3 of the people on the list (1177) been “culled”. This was initiated in January 1999 and completed by January 2001. Since January 1999, 2538 patients had received their operations. The waiting list had dropped from 3303 to a low of 1164. It has since climbed to 2036. That waiting longer than 12 months for surgery, initially 64%, had dropped to 29% and has climbed back up to 40%. The figures have climbed dramatically since the waiting list initiative for arthroplasty was discontinued. The culling of the list has been responsible for removal of 1/3 of people off the original list without having an operation and has given a false sense of success in reducing the waiting list to various political interests. The criteria set for culling people assessed as requiring an operation has been set arbitrarily There is twice the number of patients waiting to see an orthopaedic surgeon than 2 years ago of which a proportion are requiring reassessment to be deemed eligible for an operation that they have already been assessed as requiring.

The waiting list initiative was effective as an addition to the regular DHB lists in maintaining the lists at a manageable level. Even if all those culled represented a group that no longer required their operation the current list cannot be considered to have such a group as they have all been recently reviewed and are in genuine need. There is an apparent lack of concern and denial over the current escalation in the numbers on the waiting list, and no plan instituted to address it.

The New Zealand health score was developed by the New Zealand government to ensure that patients with the greatest needs were given priority. It allows explicit rationing of health care by clinical priority rather than waiting time (the current UK system). The scoring system has not been validated against an accepted measure of health status and the aim of this study was to compare the New Zealand score with the SF-36.

Patients on the orthopaedic waiting list for hip or knee replacement were sent postal questionnaires to collect demographic data and complete an SF-36 and New Zealand score.

581 patients were sent questionnaires. The response rate was 72% and data was available on 243 knee replacement and 168 hip replacement patients. For patients awaiting hip replacement there was good correlation between the NZ and all health domains of the SF-36 (correlation coefficient: 0.19 – 0.62). In contrast, there was poor correlation between the NZ score and the SF-36 for patients awaiting knee replacement with only physical function having a significant correlation (coefficient 0.25). Breakdown of the NZ score into pain and function components did not improve the correlation with SF-36 scores for these patients.

The New Zealand clinical priority scoring system correlates well with health status, as measured by the SF-36, for patients with hip arthritis awaiting hip replacement. However, the NZ score does not correlate with the SF-36 for patients awaiting knee replacement. This system is now being used by some centres in the UK for waiting list management but has been introduced without comparison to any well-established measures of health status. Its use for the prioritisation of patients who require knee replacement should be questioned.

Long waiting times and a growing demand on services for joint replacement surgery (JRS) prompted the Victorian Department of Human Services to fund a University of Melbourne/Melbourne Health partnership to develop and implement an osteoarthritis (OA) hip and knee service delivery and prioritisation system for those who may require JRS.

The service delivery model consists of a multidisciplinary team providing, comprehensive early assessment, evidence-based interventions, including support for patient self-management, continuity of care processes, and prioritisation for both surgical assessment and JRS. Prioritisation occurs via clinical assessment and the Hip and Knee Multi-Attribute Prioritisation Tool (MAPT), a patient, clinician, or proxy-administered 11-item questionnaire, resulting in a 100-point scale ranking of need for surgery. The Hip and Knee MAPT was developed using intensive consultation with surgeons, state-of-the-art clinimetrics and with input from patients, hospital management groups. Ninety-six surgeons contributed to the developing the final scoring system.

Over 4000 patients per year are entering the system across 14 hospitals in Victoria. Under the supervision of the orthopaedics unit, musculoskeletal coordinator (MSC), typically an experienced physiotherapist or nurse, as part of the multidisciplinary team, undertakes early comprehensive assessment, referral and prioritisation of patients with hip or knee OA referred to orthopaedic outpatient clinics. In addition, the MSC coordinates the monitoring and management of patients on the orthopaedic surgery waiting list. The processes enable patients who are most needy (via higher MAPT score and clinical assessment) to be fast-tracked to orthopaedic surgery; conversely those patients with lower scores receive prompt conservative management.

Time to first assessment and waiting times to see a surgeon for many patients have reduced from 12+ months to weeks. Patients seen by surgeons are more likely to be ready for surgery and have had more comprehensive non-operative optimisation. Patients placed on the surgical waiting list receive quarterly reassessments and evidence of deterioration is used as a basis for fast-tracking to surgery.

The OWL system is a whole of system(tm) approach informed by patients needs and surgeons needs. Clinicians have developed confidence in the clinical relevance of the MAPT scores. Uptake of the OWL model of care has been very high because it facilitates better care and better patient outcomes.

The aim was to determine the knowledge patients have about Total Hip Joint Replacement, their expectations from it and to evaluate the degree of disability from their hip and co-morbidities.

A total of eighty questionnaires were posted to two groups of patients. The survey consisted of open ended questions. They were also requested to complete Hospital for Special Surgery Hip Replacement Expectation Survey. Patients awaiting a Total Hip Joint replacement were assessed using Harris Hip Score and Index for Coexistent Disease.

Response rate was 81%. Average Harris hip score of 44.96 for the group on the waiting list for THJR.16 of 29 patients fell between mild to severe ICED. Questions to ascertain patient’s knowledge of THJR its risks and complications were open ended. 32–67% either expressed being unaware or answered incorrectly to these questions. Analysis of the Expectation survey revealed that over 75%of patients in both groups rated 15 of the 18 items as being an important expectation. The three items rated low/not applicable in expectation were related to employment, sexual activity and use of support for mobilizing.

This survey reveals a population waiting for a THJR possessing inadequate and unacceptable levels of knowledge about it while having high expectations of improvement in their quality of life. Unmet expectations can form grounds for complaints and even recourse to medico legal action. The expectations of the patients waiting for a THJR should be discussed and realistic goals set.

The practice of selecting patients with a low ASA(American Society of Anesthesiologists) grade to have joint replacement performed at remote centres such as DTCs (Diagnosis and Treatment Centres) and by teams of visiting surgeons is becoming more commonplace. This leaves NHS Hospitals with a patient population skewed towards the higher ASA grades. This study was undertaken to identify the extra burden that this may place on a District General Hospital.

All patients undergoing total hip or knee arthroplasty at Blackpool Victoria Hospital in the year 2002 were identified. Of 191 patients, 132 were classified as ASA grade I or II. 59 patients (31%) were classified as ASA grade III or IV. The immediate postoperative complication rate for the patients with ASA grade III and IV was found to be 25%. All complications were treated appropriately and all patients had a satisfactory outcome at 6 weeks. The reported immediate postoperative complication rate for hip and knee replacement ranges from 3–6%. It is clear from these figures that removal of fitter patients from waiting lists will effectively increase the complication rate following arthroplasty in NHS Hospitals. We feel that the Government has not identified the extra care involved in treating these higher risk patients.

Introduction

Elective Orthopaedics has been targeted by the UK Department of Health as a maximum six-month waiting time for operations could not be met. The National Orthopaedic Project was initiated as a consequence and Independent Sector Treatment Centres (ISTCs) and well established private hospitals were utilised to treat NHS long wait patients.

In 2002, one hundred and thirty nine patients had their names removed from the orthopaedic surgical waiting list at Taranaki Base Hospital for financial reasons. They fell below the “financially sustainable threshold” for access to publicly funded services. We wished to determine the status of these patients and the effects of this management decision.

All patients were invited to attend clinic for assessment. They completed the SF-36 Health Survey and were interviewed regarding effects of not having surgery. In addition, hips were assessed using Harris Hip Scores and knees were assessed using Knee Society Scores.

These standardised methods of assessment allowed comparisons to be made with overseas data. Our group of patients are experiencing significant impairment as a result of not being able to have surgery. A number of resulting medical and social problems were identified in the course of assessment. Patients also expressed a high level of discontent with the process.

Removing patients who have been assessed and placed on an orthopaedic surgical waiting list is an inefficient means of utilising health resources. It has also been met with a high level of patient dissatisfaction.

Aims. This study aimed to investigate the estimated change in primary and revision arthroplasty rate in the Netherlands and Denmark for hips, knees, and shoulders during the COVID-19 pandemic in 2020 (COVID-period). Additional points of focus included the comparison of patient characteristics and hospital type (2019 vs COVID-period), and the estimated loss of quality-adjusted life years (QALYs) and impact on waiting lists. Methods. All hip, knee, and shoulder arthroplasties (2014 to 2020) from the Dutch Arthroplasty Register, and hip and knee arthroplasties from the Danish Hip and Knee Arthroplasty Registries, were included. The expected number of arthroplasties per month in 2020 was estimated using Poisson regression, taking into account changes in age and sex distribution of the general Dutch/Danish population over time, calculating observed/expected (O/E) ratios. Country-specific proportions of patient characteristics and hospital type were calculated per indication category (osteoarthritis/other elective/acute). Waiting list outcomes including QALYs were estimated by modelling virtual waiting lists including 0%, 5% and 10% extra capacity. Results. During COVID-period, fewer arthroplasties were performed than expected (Netherlands: 20%; Denmark: 5%), with the lowest O/E in April. In the Netherlands, more acute indications were prioritized, resulting in more American Society of Anesthesiologists grade III to IV patients receiving surgery. In both countries, no other patient prioritization was present. Relatively more arthroplasties were performed in private hospitals. There were no clinically relevant differences in revision arthroplasties between pre-COVID and COVID-period. Estimated total health loss depending on extra capacity ranged from: 19,800 to 29,400 QALYs (Netherlands): 1,700 to 2,400 QALYs (Denmark). With no extra capacity it will take > 30 years to deplete the waiting lists. Conclusion. The COVID-19 pandemic had an enormous negative effect on arthroplasty rates, but more in the Netherlands than Denmark. In the Netherlands, hip and shoulder patients with acute indications were prioritized. Private hospitals filled in part of the capacity gap. QALY loss due to postponed arthroplasty surgeries is considerable. Cite this article: Bone Jt Open 2022;3(12):977–990

Aims

The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state ‘worse than death’ (WTD).