Aims. National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD. Methods. We compared 17 hip fracture registries covering 20 countries (Argentina; Australia and New Zealand; China; Denmark; England, Wales, and Northern Ireland; Germany; Holland; Ireland; Japan; Mexico; Norway; Pakistan; the Philippines; Scotland; South Korea; Spain; and Sweden), setting each of these against the 20 core and 12 optional fields of the MCD. Results. The highest MCD adherence was demonstrated by the most recently established registries. The first-generation registries in Scandinavia collect data for 60% of MCD fields, second-generation registries (UK, other European, and Australia and New Zealand) collect for 75%, and third-generation registries collect data for 85% of MCD fields. Five of the 20 core fields were collected by all 17 registries (age; sex; surgery date/time of operation; surgery type; and death during acute admission). Two fields were collected by most (16/17; 94%) registries (date/time of presentation and American Society of Anesthesiologists grade), and five more by the majority (15/17; 88%) registries (type, side, and pathological nature of fracture; anaesthetic modality; and discharge destination). Three core fields were each collected by only 11/17 (65%) registries: prefracture mobility/activities of daily living; cognition on admission; and bone protection medication prescription. Conclusion. There is moderate but improving compatibility between existing registries and the FFN MCD, and its introduction in 2022 was associated with an improved level of adherence among the most recently established programmes. Greater interoperability could be facilitated by improving consistency of data collection relating to prefracture function, cognition, bone protection, and follow-up duration, and this could improve international collaborative benchmarking, research, and quality improvement. Cite this article: Bone Joint J 2023;105-B(9):1013–1019

Aims. The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care. Methods. We compared all ten established national hip fracture registries: England, Wales, and Northern Ireland; Scotland; Australia and New Zealand; Republic of Ireland; Germany; the Netherlands; Sweden; Norway; Denmark; and Spain. We tabulated all questions included in each registry, and cross-referenced them against the 32 questions of the MCD dataset. Having identified those questions consistently used in the majority of national audits, and which additional fields were used less commonly, we then used consensus methods to establish a revised MCD. Results. A total of 215 unique questions were used across the ten registries. Only 72 (34%) were used in more than one national audit, and only 32 (15%) by more than half of audits. Only one registry used all 32 questions from the 2014 MCD, and five questions were only collected by a single registry. Only 21 of the 32 questions in the MCD were used in the majority of national audits. Only three fields (anaesthetic grade, operation, and date/time of surgery) were used by all ten established audits. We presented these findings at the Asia-Pacific FFN meeting, and used an online questionnaire to capture feedback from expert clinicians from different countries. A draft revision of the MCD was then presented to all 95 nations represented at the Global FFN conference in September 2021, with online feedback again used to finalize the revised MCD. Conclusion. The revised MCD will help aspirant nations establish new registry programmes, facilitate the integration of novel analytic techniques and greater multinational collaboration, and serve as an internationally-accepted standard for monitoring and improving hip fracture services. Cite this article: Bone Joint J 2022;104-B(6):721–728

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. Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma. Methods. This will be an international, multicentre audit comparing antimicrobial practices in hand trauma to the standards outlined by WHO. Through the Reconstructive Surgery Trials Network (RSTN), hand surgeons across the globe will be invited to participate in the study. Consultant surgeons/associate specialists managing hand trauma and members of the multidisciplinary team will be identified at participating sites. Teams will be asked to collect data prospectively on a minimum of 20 consecutive patients. The audit will run for eight months. Data collected will include injury details, initial management, hand trauma team management, operation details, postoperative care, and antimicrobial techniques used throughout. Adherence to WHO global guidelines for SSI will be summarized using descriptive statistics across each criteria. Discussion. The Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) will provide an understanding of the current antimicrobial practice in hand trauma surgery. This will then provide a basis to guide further research in the field. The findings of this study will be disseminated via conference presentations and a peer-reviewed publication. Cite this article: Bone Jt Open 2024;5(4):361–366

Aims. Current levels of hip fracture morbidity contribute greatly to the overall burden on health and social care services. Given the anticipated ageing of the population over the coming decade, there is potential for this burden to increase further, although the exact scale of impact has not been identified in contemporary literature. We therefore set out to predict the future incidence of hip fracture and help inform appropriate service provision to maintain an adequate standard of care. Methods. Historical data from the Scottish Hip Fracture Audit (2017 to 2021) were used to identify monthly incidence rates. Established time series forecasting techniques (Exponential Smoothing and Autoregressive Integrated Moving Average) were then used to predict the annual number of hip fractures from 2022 to 2029, including adjustment for predicted changes in national population demographics. Predicted differences in service-level outcomes (length of stay and discharge destination) were analyzed, including the associated financial cost of any changes. Results. Between 2017 and 2021, the number of annual hip fractures increased from 6,675 to 7,797 (15%), with a rise in incidence from 313 to 350 per 100,000 (11%) for the at-risk population. By 2029, a combined average projection forecast the annual number of hip fractures at 10,311, with an incidence rate of 463 per 100,000, representing a 32% increase from 2021. Based upon these projections, assuming discharge rates remain constant, the total overall length of hospital stay following hip fracture in Scotland will increase by 60,699 days per annum, incurring an additional cost of at least £25 million per year. Approximately five more acute hip fracture beds may be required per hospital to accommodate this increased activity. Conclusion. Projection modelling demonstrates that hip fracture burden and incidence will increase substantially by 2029, driven by an ageing population, with substantial implications for health and social care services. Cite this article: Bone Joint J 2024;106-B(1):62–68

Aims. The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. Methods. This UK-based multicentre retrospective national audit studied foot and ankle patients who underwent surgery between 13 January and 31 July 2020, examining time periods pre-UK national lockdown, during lockdown (23 March to 11 May 2020), and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included. A total of 43 centres in England, Scotland, Wales, and Northern Ireland participated. Variables recorded included demographic data, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. Results. A total of 6,644 patients were included. Of the operated patients, 0.52% (n = 35) contracted COVID-19. The overall all-cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n = 9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n = 3 deaths). Matching for age, American Society of Anesthesiologists (ASA) grade, and comorbidities, the odds ratio of mortality with COVID-19 infection was 11.71 (95% confidence interval 1.55 to 88.74; p = 0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and among patients with and without COVID-19 infection. After lockdown the COVID-19 infection rate was 0.15% and no patient died of COVID-19. Conclusion. COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and postoperative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions. Cite this article: Bone Joint Open 2021;2(4):216–226

Background. BANDAIDE aka Back and Neck Discomfort relief with Altered behaviour, Intelligent Postures, Dynamic movement and Exercises (ISBN - 0995676933) is a concise self-help booklet containing strengthening exercises and illustrated information to enable patients self-manage their back and neck pain. The aim of this preliminary audit was to determine patient opinion on BANDAIDE. Institutional audit approval was obtained – No. 8429. Methods and Results. BANDAIDE was distributed to 40 patients, who were asked to evaluate the booklet using the Usefulness Scale for Patient Information Material (USE). USE consists of nine positive statements which are subdivided into three sub-domains; cognition, emotional and behavioural. The cognition sub-domain assesses the knowledge obtained from the material, the emotional sub-domain evaluates the effects of the material on an individual's ability to cope with the illness and the behavioural sub-domain assesses ability to self-manage. Responders were required to rate the extent to which they agreed with each of the nine statements on a scale of 0 to 10, where 0 denotes ‘completely disagree’ and 10 denotes ‘completely agree’. Each subsection is on a scale of 0–30, with a higher score suggesting better usefulness. 23 participants provided their opinions of BANDAIDE through the USE. For the three sub-domains, the mean ratings for cognition, emotional and behavioural were 27.2, 24.7, and 26.4 respectively. Conclusions. This preliminary audit suggests that BANDAIDE provides coherent advice that enables a patient to self-manage their back and neck pain. Nevertheless, the opinions of a larger cohort should be pursued to obtain more robust conclusions. Conflict of Interest: George Ampat sells the BANDAIDE booklet online through Amazon and other platforms. S Rhodes and J Sims are employed by Talita Cumi Ltd, of which Bandaide is a trading name. Shantanu Kundu is a medical student and has no conflict of interest. Sources of funding: No funding was obtained

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

The National Hip Fracture Database (NHFD) is a clinically led web based audit used to inform national policy guidelines. The aim of this audit was to establish the accuracy of completion of NHFD v13.0 theatre collection sheets, identify common pitfalls and areas of good practice, whilst raising awareness of the importance of accuracy of this data and the manner in which it reflects performance of CAH Trauma & Orthopaedic unit in relation to national guidelines. Our aim was to improve completion up to >80% by the operating surgeon and improve overall accuracy. The methodology within both cycles of the audit were identical. It involved reviewing the NHFD V13.0 completed by the operating surgeon and cross-checking their accuracy against clinical notes, operation notes, imaging, anaesthetic charts and A&E admission assessment. Following completion of cycle 1 these results were presented, and education surrounding V13.0 was provided, at the monthly trust audit meeting. At this point we introduced a sticker onto the pre-operative checklist for Hip fractures. This included time of admission and reason for delay. We then completed a re-audit. Cycle-1 included 25 operations, 56% (n=14) had a completed V13.0 form. Of these 21% (n=3) were deemed to be 100% accurate. Cycle-2 included 31 operations (between April – June 21) 81% (n=25) had a completed intra-operative from and showed an increase in accuracy to 56% (n=14). Through raising awareness, education and our interventions we have seen a significant improvement in the completion and accuracy of v13.0. Although 100% accuracy was not achieved its clear that education and intervention will improve compliance over time. Through the interventions that we have implemented we have shown that it is possible to improve completion and accuracy of the NHFD V13.0 theatre collection sheet locally and feel this could be implemented nationally

Introduction. VTE is a possible complication of foot and ankle surgery, however there is an absence of agreement on contributing risk factors in the development of VTE. The primary outcome of this study was to analyse the 90-day incidence of symptomatic VTE following foot and ankle surgery and to determine which factors may increase the risk of VTE. Methods. This was a national, multi-centre prospective audit spanning a collection duration of 9 months (2022/2023). Primary outcomes included incidence of symptomatic VTE and VTE related mortality up to 90 days following foot and ankle surgery and Achilles tendon rupture, and analysis of risk factors. Results. In total 11,363 patients were available for analysis. 5,090 patients (44.79%) were elective procedures, 4,791 patients (42.16%) were trauma procedures (excluding Achilles ruptures), 398 patients (3.50%) were acute diabetic procedures, 277 patients (2.44%) were Achilles ruptures undergoing surgery and 807 patients (7.10%) were Achilles ruptures treated non-operatively. There were 99 cases of VTE within 90 days of admission across the whole group (Total incidence = 0.87%), with 3 cases of VTE related mortality (0.03%). On univariate analysis, increased age and ASA grade showedhigher odds of 90-day VTE, as did previous cancer, stroke, history of VTE, and type of foot and ankle procedure / injury (p<0.05). However, on multivariate analysis, the only independent predictors for 90-day VTE were found to be the type of foot and ankle procedure (Achilles tendon rupture = Odd's Ratio 11.62, operative to 14.41, non-operative) and ASA grade (grade III/IV = Odd's Ratio 3.64). Conclusion. The incidence of 90-day post procedure VTE in foot and ankle surgery in this national audit was low. Significant, independent risk factors associated with the development of 90-day symptomatic VTE were Achilles tendon rupture management and high ASA grade

Objectives. The primary aim was to determine the differences in COVID-19 infection rate and 30 day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second national lockdowns. Design. Multicentre retrospective national audit. Setting. This was a combined retrospective (Phase 1) and prospective (Phase 2) national audit of foot and ankle procedures in the UK in 2020. Participants. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway. Results. 10,846 patients were included, 6,644 from phase 1 and 4,202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6,470) and 0.21% on a green pathway (9/4,280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p = .109), lockdown (p = .923) or post-lockdown (p = .577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p < .001) and lockdown periods (p < .001). There was no significant difference in COVID-19 related mortality between pathways. Conclusions. There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways; however the success of the pathways only became significant in phase 2 of the study. The study shows a developing success in using green pathways in reducing the risk to patients undergoing foot and ankle surgery

In 2007, the National Hip Fracture Database (NHFD) was conceived in the United Kingdom (UK) as a national audit aiming to improve hip fracture care across the country. It now represents the world's largest hip fracture registry. The purpose of the NHFD is to evaluate aspects of best practice for hip fracture care, at an institutional level, that reflect the evidence-based clinical guidelines and quality standards developed by the National Institute for Health and Care Excellence. No national program currently exists, equivalent to the NHFD, in Canada despite evidence suggesting that national audit programs can significantly improve patient outcomes. The purpose of this study was to evaluate aspects of best practice for hip fractures at our Canadian academic tertiary referral center using the Key Performance Indicators (KPI) and benchmarks used by the NHFD. In doing so, we aimed to compare our performance to other hospitals contributing to the NHFD database. A retrospective cohort study was conducted on consecutive patients who presented to our Canadian center for surgical management of a hip fracture between August 2019 to September 2020. Fracture types included intertrochanteric, subtrochanteric, and femoral neck fractures treated with either surgical fixation or arthroplasty. Cases were identified from the affiliate institute's Operatively Repaired Fractures Database (ORFD). The ORFD prospectively collects patient-level data extracted from electronic medical records, operating room information systems, and from patients’ discharge summaries. All applicable data from our database were compared to the established KPI and benchmarks published by the NHFD that apply to the Canadian healthcare system. Six hundred and seven patients’ data (64.5% female) were extracted from the ORFD, mean age 80.4 ± 13.3 years. The NHFD contains data from 63,284 patients across the entire UK. The affiliate institute performed inferiorly compared to the NHFD for two KPIs: prompt surgery (surgery by the day following presentation with hip fracture, 52.8% vs. 69%) and prompt mobilization after surgery (mobilized out of bed by the day after operation, 43.0% vs. 81.0%). However, more patients at the affiliate institute were not delirious when tested postoperatively (89.6% vs. 68.4%). There was no significant difference in the average length of stay (12.23 days versus 13.5 days) or in 30-day mortality rate (8.4% versus 8.3%). More than half of all KPI's and benchmarks for patients receiving a hip fracture surgery at our tertiary referral center in Canada ranked significantly lower than patients receiving a hip fracture surgery in the UK. These findings indicate that perhaps a national audit program should be implemented in Canada to improve aspects of hip fracture care, at an institutional level. Following evidence-based clinical guidelines and using standardized benchmarks would encourage change and foster improvement across Canadian centres when necessary

To evaluate the performance of this institution in its delivery of care to elderly patients with a hip fracture over an 11-year period and to establish recommendations to improve practice. Regular prospective audits of a cohort of 50 patients have been undertaken between 1990 and 2000. A larger and more comprehensive retrospective audit of 100 patients was performed in 2001. Goals were set regarding time to admission, time to surgery and to discharge in close accordance with the best practice guidelines devised by the Royal College of Physicians in 1989. There has been an alarming decline in standards in key areas. Time from A& E to admission: at best 78% of patients within 3 hours, 4% in 2001. Time from admission to surgery: at best 89% within 24 hours, 31% in 2001. Persistence of significant morbidity for patients delayed to surgery for non-medical reasons: 65% of these patients developed a post operative complication and 20% died within 30 days of admission. Delay to discharge: at best 13 acute bed days, now 18 (2001). Current practice is less than ideal. Clinical governance involves a dual responsibility – of the clinician to maintain high standards and of the management to provide adequate resources. Both need addressing to reverse the current trend

Objective. Guidelines published by the British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and intervention in individuals suspected of having CES. The need for an evidence based protocol is driven by a lack of 24/7 MRI services and centralisation of neurosurgery to tertiary centres, compounded by CES's significant medico-legal implications. We conducted an audit to evaluate the pathway for suspected CES in BCUHB West between 2018 and 2021. Methods. A retrospective audit of patients managed for suspected CES between 01/11/2018 and 01/05/2021 was performed, using the SBNS/BASS guidelines as the standard. Results. A total of 252 patients received an emergency MRI for suspected CES between 2018 and 2021. 99% of patients were scanned in compliance with SBNS/BASS standards. Radiological evidence of CES was found in 18% of patients. 33% of emergency scans were performed by out-of-hours services. 4% of patients had repeated scans within the same 6-month period. The majority of referrals originated from Orthopaedics surgeons (78%), or staff in the Emergency Department (8%). 92% of ambulatory patients were not admitted to hospital. During the peak of the COVID-19 pandemic, referrals increased from 2.5 to 3.5 per week. Conclusion. SBNS/BASS standards were largely met, avoiding life changing disability and medico-legal consequences. The department should continue to follow SBNS/BASS guidance on the management of individuals with suspected CES. Challenges regarding the use of repeated scans should be addressed to avoid unnecessary costs. Introduction of new early recognition guidelines and Same Day Emergency Care (SDEC) has likely driven an increase in suspected CES referrals, and subsequent MRI demand. This audit should be utilised as an ongoing tool to ensure best practice continues, and to implement simple measures which may improve compliance with the pathway

Objectives. The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. Design. Multicentre retrospective national audit. Setting. UK-based study on foot and ankle patients who underwent surgery between the 13. th. January to 31. st. July 2020 – examining time periods pre- UK national lockdown, during lockdown (23. rd. March to 11. th. May 2020) and post-lockdown. Participants. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Main Outcome Measures. Variables recorded included demographics, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. Results. 6644 patients were included. In total 0.52% of operated patients contracted COVID-19 (n=35). The overall all cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n=9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n=3 deaths). Matching for age, ASA and comorbidities, the OR of mortality with COVID-19 infection was 11.71 (95% CI 1.55 to 88.74, p=0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and amongst patients with and without COVID-19 infection. After lockdown COVID-19 infection rate was 0.15% and no patient died of COVID-19 infection. Conclusions. COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and post-operative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions

Distal radius fractures (DRF) are very common injuries. National recommendations (British Orthopaedic Association, National Institute for Health and Care Excellence (NICE)) exist in the UK to guide the management of these injuries. These guidelines provide recommendations about several aspects of care including which type of injuries to treat non-operatively and surgically, timing of surgery and routine follow-up. In particular, current recommendations include considering immobilizing patients for 4 weeks in plaster for those managed conservatively, and operating on fractures within 72 hours for intra-articular injuries and 7 days for extra-articular fractures. With increased demands for services and an ageing population, prompt surgery for those presenting with distal radius fractures is not always possible. A key factor is the need for prompt surgery for hip fracture patients. This study is an audit of the current standard of care at a busy level 2 trauma unit against national guidelines for the management of DRFs. This retrospective audit includes all patients presenting to our emergency department from June to September 2018. Patients over 18 years of age with a diagnosis of a closed distal radius fracture and follow-up in our department were included in the study. Those with open fractures were excluded. Data was retrieved from clinical coding, electronic patient records, and IMPAX Client (Picture archiving and communication system). The following data was collected on patients treated conservatively and those managed surgically:- (1)Time to surgery for surgical management; (2)Period of immobilization for both conservative and operative groups. 45 patients (13 male, 32 female) with 49 distal radius fractures (2 patients had bilateral injuries) were included. Patients had mean age 63 years (range 19 to 92 years) 30 wrists were treated non-operatively and 19 wrists treated surgically (8 K-wires, 10 ORIF, 1 MUA). Mean time to surgery in the operative group was 8 days (range 1 – 21 days, median 7 days). Mean time to surgery for intra-articular fractures was 7 days (range 1 – 21) and 12 days for extra-articular fractures (range 4 – 20). Mean immobilization period in those treated in plaster is 6 weeks (range 4 – 13 weeks, median 5.6 weeks). At busy level 2 trauma units with limited theatre capacity and a high volume of hip fracture admissions, time to surgery for less urgent injuries such as wrist fractures is often delayed. National guidelines are useful in helping to guide management however their standards are often difficult to achieve in the context of increasing populations in urban areas and an ageing population

There is high morbidity and mortality associated with infection following orthopaedic procedures. In accordance to local guidelines, most hospitals follow a set protocol for surgical prophylaxis, which expects a compliance rate of 100%. A new protocol was introduced to the orthopaedic department of a teaching hospital in August 2013, changing from a cephalosporin, with potential C. difficile risk, to teicoplanin and gentamicin, within 30 minutes of incision. Our aim was to audit how well the protocol was followed across 3 different time periods. Data was collected for 3 different time periods following the introduction of the new protocol (August-November 2013, April-May 2014 & November 2014) on the choice of antibiotic. Both elective and trauma cases were included. After each cycle, the data was presented to the orthopaedic surgical and anaesthetic departments to raise awareness and draw attention to the antibiotic prophylaxis posters in theatre. The 1st audit cycle (n=30) indicated that there was 0% compliance with the current protocol and 100% compliance with the previous protocol. The 2nd audit cycle (n=27) indicated that 0% complied with the current protocol, 54% complied with the previous protocol and that there was a combination of both protocols being used in 46% of the patients. Finally the 3rd audit cycle (n=33) indicated a 100% compliance rate in terms of antibiotic choice. However, only 9% were given the appropriate dose according to body weight and within the appropriate time based on the documented evidence. This audit demonstrates the value of auditing and then disseminating the findings to relevant departments to influence practice. Each audit cycle demonstrated a progressive uptake in compliance with the hospital trust's antibiotic prophylaxis policy. The last audit cycle highlighted discrepancy in dosage based on weights; a further intervention will be to provide ideal body weight (IBW) vs dose tables in all orthopaedic theatres to ensure the correct antibiotic dosage is given

Audit is an important part of surgical practice. Commissioners may use it as evidence of quality assurance. No comprehensive audit exists in spinal surgery. Usage of existing databases is disappointing. We developed an audit database which was comprehensive and gathered patient outcomes. The underlying principles were:. All patients having surgery should enter,. Duplicate data entry should be avoided. No effort should be required of the participating surgeons. Demographic data, OPCS codes, length of stay and other data were downloaded directly from the hospital information systems. A monthly printout of patients enrolled was provided to the audit coordinator. She was responsible for the collection of clinical outcomes at 6 months, 12 months, and 2 years after surgery. The initial audit involved the Northwest and Mersey Regions. Data from the hospital information systems (HIS) for two years were available for comparison. Unfortunately only two centres gathered clinical outcomes. We have continued to gather data. 380 patients have been enrolled. HIS data are available for all. With varying lengths of follow up, there are 1045 potential clinical outcomes available. Only 8 patients (2%; 8 outcomes, 0.76%) have been lost to follow up. Using this data we are able to compare outcomes between surgeons, between surgical procedures, and see changes over time. As far as we know we are the only centre in the UK able to do this. It is a valuable Clinical Governance tool. We believe that the principles underlying this audit are the only means to obtain comprehensive outcome audit in surgery

Abstract. Background. University Hospital of Wales (UHW) went live as a Major Trauma Centre (MTC) on the 14th September 2020. New guidelines have been set up by the Wales Trauma Network. Aim. Prospective audit to see how many admissions, correct pathways were followed?. Materials & Methods. Prospective data collection prospective over a period of 3 months: starting from 8.11.2020 to 31.01.2021. Results. Spinal admissions represent around 22% of MTC admissions. The closing loop showed higher amount of admission (45 in comparison with the first audit 28). 42 patients had fractures where three had cord syndromes. 13 patients out of the 45 (29%) were managed operatively. After changing to MTC, more indirect referral from other hospitals representing 64% of total admission with one wrong referral (2.2%) that came to the MTC and could have been managed locally. On the other hand, repatriation rate has improved from 61% to 84%, however, repatriation time was longer than expected with >1 week represents 78%. Conclusions. Changing to MTC had a great impact with increased work load in the trust. Repatriation would be aimed for within 72 hours from treatment either conservative or postoperative. More attention should be paid towards the appropriate referral pathways to avoid wrong referral

Background. Cauda equina syndrome (CES) is a spinal condition requiring emergency spinal surgery once diagnosed. The patient-reported symptoms are often subtle and none have been shown to be sensitive or specific in confirming CES. Magnetic resonance image (MRI) is the diagnostic gold standard, and guidelines recommend MRI access within 24-hours of symptom presentation. Limited sequence MRI scans (sagittal T2 sequences of the whole spine) have been shown to successfully identify patients with scan-positive CES despite reducing the duration of an MRI. The aim of this audit was to examine utilisation of same-day MRI requests by spinal practitioners from a newly operational same-day emergency care spinal unit over the two-year period. Methods and results. Data was routinely collected over the two-year period and retrospectively reviewed. Data extraction occurred for cases of suspected CES with a same-day scan. Data extraction included type of MRI scan (lumbar/ whole spine/ CES protocol); outcome (admission/ discharge); final diagnosis. After clinical examination, only 258 (24% of 1085) suspected CES cases were identified and scanned within 24 hours, 58% (n=149) of which were with CES limited sequence scans. Only 12% (n=30) demonstrated scan- positive CES resulting in surgery within 24-hours. MRI same-day requests increased between 2020 (n=81, 21%) and 2021 (n=177, 26%), although utilisation of limited sequence scans improved (n=39, 48% in 2020; n=109, 62% in 2021). Conclusion. Limited sequence MRI scans are a time- and cost-saving means of providing screening for those with suspected CES. Improved utility was demonstrated over the 2-year period by the spinal practitioners. Conflicts of interest: No conflicts of interest. Sources of funding: No sources of funding

Introduction: Ankle diastasis injury occurs in up to 20% of ankle fractures. Various techniques have been used to treat syndesmosis injuries, but controversy remains and outcome is variable. In light of some recent cases of substandard syndesmosis fixations requiring revision, an audit of our results was undertaken. Method: Study type: Retrospective audit of radiographs and patient records. Data collection: patients were selected using an orthopaedic database search for operations coded as distal tib/fib ORIF or ankle ORIF. Study period: 12 months, July 2008 to July 2009 (currently data has been analyzed on the first 6 months only, the remaining 6 months will follow). Audit questions to be answered: How is ankle diastasis injury being managed? Are we reducing syndesmosis correctly? Should there be a revision to local policy?. Audit standard: Syndesmoses should be adequately reduced and fixation techniques employed should be in accordance with recommendations in standard Orthopaedic reference texts (Rockwood & Green, AO fixation manual 3). Results: 76 ankle ORIFs in July to December 2008 inclusive. Out of these, 16 had diastasis fixation (21%). 2 of the patients had a syndesmosis width over 6 mm indicating an inadequate reduction of the syndesmosis 1. Both of these required revision surgery. In total 70% of the post operative x-rays showed inadequate syndesmosis fixation or reduction. Discussion: The single most predictive indicator of a favourable function is accurate reduction of the syndesmosis 2. Substandard fixations are associated with poor long term outcomes. This raises the potential for litigation and the requirement for education and policy change. We have produced policy guidelines for theatre and circulated the information to all surgeons. A further audit will be carried out to assess the effectiveness of this in 6 months time. (The data will be available from this re-audit for presentation at the conference.)

The ankle radiograph is a commonly requested investigation as the ankle joint is commonly injured. Each radiograph exposes 0.01 mSv of radiation to the patient that is equivalent to 1.5 days of natural background radiation [1]. The aim of the clinical audit was to use the Ottawa Ankle Rule to attempt to reduce the number of ankle radiographs taken in patients with acute ankle injuries and hence reduce the dose of ionising radiation the patient receives. A retrospective audit was undertaken. 123 ankle radiograph requests and radiographs taken between May and July 2018 were evaluated. Each ankle radiograph request including patient history and clinical examination was graded against the Ottawa Ankle Rule. The rule states that 1 point(s) indicates radiograph series; (1) malleolar and/or midfoot pain; (1) tenderness over the posterior 6cm or tip of the lateral or medial malleolus (ankle); (1) tenderness over the navicular or the base of the fifth metatarsal (foot); (1) unable to take four steps both immediately and in the emergency department [2]. Patients who score 0 do not need radiograph series. Each radiograph was reviewed if a fracture was present or not. The clinical audit identified 14 true positives where the Ottawa Ankle Rule scored 1 and the patient had an ankle fracture, and 2 false negatives (sensitivity 88%). There were 81 false positives, and 23 true negatives (specificity 22%). Therefore, a total of 23/123 ankle radiographs were unnecessary which is equivalent to 34.5 days of background radiation. The negative predictive value of the Ottawa Ankle Rule in this audit was 92%. The low rate of Ottawa rule utilisation may unnecessarily cause patient harm that should be addressed. An educational intervention with physicians combined with integration of the Ottawa rule scoring in ankle radiograph requests is planned with re-audit in 6 months

The Scottish Hip Fracture Audit started in four hospitals in 1993. To date, all except two, hospitals doing hip fractures have been involved in the audit. Participation has been intermittent due to a lack of funds to pay for the audit staff. Nonetheless there are now 19,000 patients recorded on the database. This allows individual hospitals to compare their workload over time and to compare local data with national comparators. Unfortunately many of the outcome parameters involve soft end points such as the delay in operation or the proportion of patients who are sent for formal rehabilitation. Much of the data has simply confirmed what surgeons have always suspected. The injury is becoming more common, the patients are getting older and the patients are becoming less fit. Co-morbidities are frequent and the strongest predictor of mortality is the age of the patient at presentation. What the audit has done from a surgeon’s viewpoint is to define the general lack of resources devoted to this injury and to provide evidence which has been used in many hospitals particularly to increase the availability of operating time. Equally as no surprise comes the realisation that surgery is often the least part of the care of these patients. Evidence from the audit has allowed many hospitals to encourage greater participation by geriatricians in the overall care of these patients. The use of the specialist nurse in hip fractures who has responsibility for all aspects of care including follow up has been particularly useful and is recommended in all units. There are however, two huge problems arising from this data. The first, is that the existence of the data means there is something which can be measured and in consequence this has been used as a management tool to measure performance yet where hospitals have been found lacking, resources have not always been made available to improve performance. The second and newer problem relates to the existing anonymity of data. At present the system is very much like critical incident reporting in the airline industry and no surgeon, anaesthetist or hospital is individually identified in any of the published data. The Freedom of Information Act, which has recently come into force in the UK, may now make is possible for anyone to obtain individual named data on both doctors and hospitals. While threatening, this development now seems inevitable but may discourage full participation in future audit. In spite of these concerns individual clinicians remain enthusiastic about the audit and England, Wales and Northern Ireland have shown considerable interest in developing the audit into a UK wide system

Virtual Fracture Clinic (VFC) is a consultant-led orthopaedic trauma outpatient triage and management service. The use of VFC has recently become commonplace in the United Kingdom. It allows multiple referral sources to the orthopaedic team, with clinical information and imaging reviewed by a consultant in VFC who formulates an appropriate management plan with the patient contacted; either to attend clinic for consultation or discharged with advice over the phone. The VFC is more efficient than a traditionally delivered outpatient fracture clinic service. We have utilized VFC for 1 year at our hospital, East Kent University Hospital Foundation Trust (EKHUFT), and undertook a closed loop audit to evaluate the service and highlight potential areas of improvement. The Objective of the study was to identify whether the implementation of new re-designed VFC referral guidelines together with teaching set across one of the hospitals in EKHUFT improved the effectiveness and standards of VFC referrals. An initial audit was performed of all referrals made to VFC over a 2 weeks period in December 2018. Changes to the VFC referral pathway were implemented, and teaching sessions performed by the orthopaedic team to all referring units, including minor injury units (MIU) and the emergency department (ED). After implementation, re-audit of VFC referrals was performed in February 2019 over a similar 2 weeks period. Patient demographics, diagnosis and outcomes were collected from the online patient record with images reviewed using PACS software. Following intervention, referral rates dropped by 27.7% (136 vs 188 patients) over the 2 weeks periods. Patient demographics, injury type and severity remained the same between the 2 groups. 51.5% (70/136) did not meet VFC pathway criteria after the intervention and were considered inappropriate, compared to 70% in the original group. 15.4% (21/136) referrals could have been managed in the emergency department using the new guidelines and leaflet discharge. 5.1% (7/136) of the referrals should have been referred to orthopaedic on-call acutely and 22% (30/136) of the referrals had a soft tissue injury or no injury identified. This did not change between the 2 groups despite intervention. Referring MIU and ED units require continued support and teaching over a prolonged time period to hopefully see further improvements. Immediate hot reporting of radiographs may further benefit the service, but staffing and funding issues particularly out of hours, means this remains an aspiration

There has been extensive research into neck of femur fractures in the elderly. Fragility non-hip femoral fractures share many of the same challenges [1]. Surgical management is complex, patients are frail and mortality rates have been reported as high as 38% [2]. Despite this, relatively little data is available evaluating the level of MDT care provided to non-hip femoral fractures. This audit aimed to evaluate the standard of MDT care provided for patients with non-hip femoral fractures according to the NHFD key performance indicators. The following fractures were included in the dataset: distal femoral, femoral shaft and peri-prosthetic femoral. Patients under 65 were excluded. Data was retrospectively collected using post-operative and medical documentation. Performance was assessed according to five key performance indicators:. Did orthogeriatrics review the patient within 72-hours?. Was surgery performed within 36-hours?. Was the patient weight bearing post-operatively?. Was a confusion assessment completed?. Was the patient discharged home?. 38 patients met the inclusion criteria. 84% of patients were seen by orthogeriatrics within 72 hours of admission. 32% of patients were operated on within 36-hours of admission, with time to theatre exceeding 36-hours in 92% of peri-prosthetic fractures. 37% of patients were not advised to full weight bear post operatively. 84% of patients received a confusion assessment whilst 61% of patients were discharged to their prior place of living. Our results suggest that non-hip femoral fractures do not receive the same standard of MDT care as neck of femur fractures. Greater prioritisation of resources should be given to this patient subset so that care is equivalent to hip-fracture patients. Time to surgery is a particular area for improvement, particularly in peri-prosthetic fractures, a trend that is mirrored nationally. Greater emphasis should be placed on encouraging full-weight bearing post-operatively to prevent post-surgical complications

Clinical governance encompasses audit. Audit is a requirement of our professional bodies and our hospital trusts. It is not usually resourced adequately and the ability to audit spinal surgical outcomes is haphazard nationally. This presentation describes the results that can be achieved in the absence of formal audit support. A surgical database was started in 1993; its evolution involved the use of standard outcome measures in 1995. Between 1995 and 1999, four hundred and one major spine procedures were undertaken by a single surgeon. The outcome measures were the Oswestry disability index, the low back outcome, MSP MZD and a visual analogue pain scale. Pre-operative data was collected on all 233 elective cases. Follow up was 59% at 6 months, 51% at one year and 57% at 2 years. At two years a Macnab score was available in 106 cases and the results were excellent/ good 81%, fair/poor 19%. There were 56 recorded perioperative complications. 21 occurred in the 77 instrumented procedures and 35 in the 156 non instrumented procedures. The results of this type of audit can only be cautiously compared to published data because of poor follow up. Quality outcome measures and audit probably require a funded resource to be of value

All multidisciplinary audit projects from January 1998 to March 2002 involving an Orthopaedic department were assessed to measure their impact on improving clinical practice. Data were derived from reports formulated by the Trust’s Audit department, which listed findings, conclusions and proposals for each project. Among 41 studies performed, 37 listed a formal proposal of actions. 4 projects had a completed outcome of which 2 closed the loop with re-audit. 9 other projects recommended re-audit but none had been initiated. Although Trusts actively partake in regular audit, it seems more as a service or training commitment, rather than contributing towards improving the quality of healthcare

Prophylactic pinning of the contralateral hip in unilateral Slipped Upper Femoral Epiphysis (SUFE) persists as a source of debate with the majority of surgeons selecting this option in a proportion of patients whom they regard as at increased risk of a subsequent slip. Universal prophylactic pinning was introduced in our region in 2005 after an audit of ten years local practice identified 25% of unilateral cases presented with a subsequent slip. This study reports our experience between 2005 and 2020. In this prospective study, 44 patients presented with 55 affected hips compared with 60 patients with 67 affected hips in the original study. Two patients were excluded as their initial slip had not been treated in our unit. Of the 42 hips seven were bilateral, 34 of the 35 unilateral hips underwent prophylactic pinning. The one exception subsequently underwent prophylactic pinning due to developing pain. Consistent with our original series, at a minimum follow up of 13 months there have been no complications of infection, fracture, chondrolysis or avascular necrosis subsequent to prophylactic pinning. Over 25 years 70 patients have undergone prophylactic pinning without complication. On the premise that 25% of our unpinned hips presented with subsequent slips before instituting our policy we estimate that we have prevented 17 subsequent slips over 25 years including the consequences which can be significant. We continue to advocate universal prophylactic pinning as an effective and safe practice in the management of SUFE

Introduction We performed an audit of tunnel position in primary anterior cruciate ligament reconstructions performed by two surgeons at a single centre. The audit cycle was opened with a retrospective review of a cohort of patients in order to establish existing surgical practice. Following this review our practice changed with the use of intra-operative image intensifier to confirm tunnel positions. The audit loop was closed with a prospective study of a second cohort of patients undergoing surgery using the new technique. Results Twenty five patients were reviewed in each group. The case-mix for the two groups were similar with regard to age, sex, side, graft selection and surgical technique. The first cohort of patients had optimal tibial tunnel placement in 56% (sagittal) and 88% (coronal) of cases. The femoral tunnel was correctly positioned in the sagittal plane in 52% of patients. The second cohort, in which an intra-operative image-intensifier was used, had optimal tunnel position for the femur in 100% of cases and for the tibia (sagittal) in 48% of patients. Conclusion In this study we have shown that the use of an image intensifier, intra-operatively, greatly improved femoral tunnel position but had no significant effect on tibial tunnel placement. We have also demonstrated that audit is effective in improving clinical practice

Background. National hip fracture programmes are becoming widespread, but this practice is nascent and varied. The Scottish Hip Fracture Audit (SHFA) was an early adopter of this strategy and is credited with substantial systemic improvements in quality and outcomes. Objectives. To provide evidence and incentive to clinicians and administrators to adopt successful improvement strategies, and to facilitate data-driven change hip fracture care. Study Design and Methods. We reviewed the practice of seven national hip fracture improvement programmes in: Sweden, Denmark, Norway, Australia, New Zealand, UK, Scotland, and Ireland. We report our experience from the SHFA and describe: the results of our programme; challenges and learning points encountered, and successful strategies for implementing change. Results. There is variance in approach to data collection and reporting, for example: standalone programmes versus combined trauma and arthroplasty registries; annual trend reporting versus ‘snapshot’ or real-time information; population-level versus patient-level data, and the emphasis placed on service-level characteristics. The governance model also varies – some act as a passive data registry whereas others act as active agents of change and regulation. There is consensus on the key performance makers: prompt admission; early surgery and mobilisation, and a multidisciplinary approach. There have been significant challenges encountered by the SHFA with respect to funding, logistical, and political issues. Analysis of the effects of our programme have demonstrated its clinical efficacy, and has identified successful strategies for improvement. We describe this experience. Conclusions. The establishment of national audit programmes has resulted in significant improvements in quality, efficiency, and outcomes. This study of major national programmes provides evidence, incentive, and instruction to clinicians and administrators who seek to improve healthcare systems

Few doctors answer their bleep by stating who they are. Answering the phone in a formal manner is of utmost importance in the hospital setting especially by on-call teams who are normally referred patients by other specialties, general practitioners and in some cases by other hospitals. An audit to evaluate the internal hospital communication was completed. In the first part of this audit, junior doctors within the orthopaedic department at the RAH were bleeped. Doctors were expected to answer by initiating the conversation by stating (1) name, (2) department, (3) grade and (4) a greeting. A list of omissions was recorded. If the call went through switchboard, it was expected that the hospital name was stated. The second part of the audit extended to other specialties in the RAH as well as orthopaedic departments in hospitals within the Greater Glasgow and Clyde health board (NHS GGC). Forty-three bleeps were made to doctors of various grades over a period of two months. Nine bleeps (two from other hospitals) were not answered. Five doctors answered their bleep in full. Only twenty-one doctors stated their name whilst eleven stated their grade. In both instances the department was not necessarily stated. The results were similar between the different departments as well as between the seven hospitals offering an orthopaedic service within NHS GGC. Of the thirteen on-call doctors that were bleeped as an external call through switchboard, only one doctor stated the hospital name. This has implications since most hospitals within NHS GGC share a common switchboard. These results emphasise the need for a protocol within NHS GGC for a standard etiquette for intra and inter hospital communication to ensure that patient safety and confidentiality is safeguarded

Aims

The primary aim was to determine the influence of COVID-19 on 30-day mortality following hip fracture. Secondary aims were to determine predictors of COVID-19 status on presentation and later in the admission; the rate of hospital acquired COVID-19; and the predictive value of negative swabs on admission.

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

Background. Both surgeon and hospital volume influence patient outcomes following revision knee arthroplasty. Purpose. To audit all centres performing revision knee procedures in England and Wales over a 2-year period. All centres were audited against two pre-defined standards linked to hospital volume. Operative volume should be greater than 10 revisions per year;. More than 2.5 revisions should be performed for every 100 primary arthroplasties implanted. Methods. Data for 9659 knee revisions performed in 359 different centres between 01/07/08 and 30/06/10 was accessed from the National Joint Registry for England and Wales. For each centre information on the volume of primary and revision knee procedures undertaken during this period was available and was used as the basis for audit. Results. During the 2-year study period 396 different centres performed 153133 primary knee arthroplasties. Of these 359 (91%) performed 9659 knee revisions, equivalent to 6.2 revisions for every 100 primary arthroplasties performed. Revision centres included 208 (58%) NHS hospitals performing 8148 revisions, 141 (39%) independent hospitals performing 1258 revisions and 10 (3%) Independent Sector Treatment Centres (ISTC) performing 253 revisions. The median number of revisions performed per hospital was 7 per year (Range 1 to 144). Volume differed dependent upon hospital type (NHS=14/year vs. Independent=3/year, p< 0.001). Two hundred and twelve (59%) centres performed < 10 revisions per year and thus fell below the audit standard. Eighty of these centres also performed < 2.5 revisions per 100 primaries. Of the 141 independent hospitals 128 (91%) fell below the suggested standards for revision volume. Conclusions. A significant number of institutions are performing only a small volume of knee revision procedures. To ensure safe and sustainable practice with better outcomes, consideration should be given to rationalising the revision service in fewer centres

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

Literature suggests that joint orthopaedic and geriatric care, and geriatric orthopaedic rehabilitation units, would provide best care for fractured neck of femur (NOF) patients. These are often elderly frail patients with concurrent illnesses and co-morbidities who also have a fracture. There is to date no quantitative data. This completed audit quantifies the care provided on the orthopaedic wards in the first phase solely by orthopaedic team, and in the repeat phase with additional regular geriatric input from an orthogeriatric senior house officer (SHO) and consultant geriatrician ward rounds. A retrospective audit of fractured NOF patients admitted to acute orthopaedic wards under orthopaedics and treated operatively. The first phase analysed 72 patients with sole orthopaedic care. The repeat phase analysed 25 patients after the introduction of an orthogeriatric SHO and geriatric ward rounds. The first audit phase of orthopaedic care alone found that 50% of patients were reviewed each day of the first post op seven-day week. The mean number of reviews in the post-op week was three. A total of 58% patients were operated on the next day. A minority never had post-op bloods or x-rays prior to discharge from the acute bed. Ad hoc medical input by referral occurred in 50% of patients. The repeat audit of combined orthogeriatric care found that 75% of patients were reviewed each day in the post-op week. The mean number of reviews in the post-op week rose to five. Similar to the first phase, 59% proceeded to next day surgery with combined care. All patients had timely bloods and x-rays before discharge from the acute bed. Medical input rose to 80% due to regular ward rounds, and ad hoc referrals decreased in quantity whilst increased in quality. Length of stay and mortality were reduced. The clinical risk of fractured NOF patients was reduced on the appointment of an orthogeriatric SHO in combination with formal reviews by consultant geriatrician. Further models of care are being evaluated. This audit adds evidence that joint care is better for these usually elderly and co-morbid patients

Introduction: The use of allogeneic blood is associated with many complications. A baseline audit performed in our institution in 2000 showed that 11% of patients undergoing primary total knee arthroplasty required post-operative transfusion. Following this audit, patients undergoing primary knee arthroplasty were no longer routinely cross matched, a Haemovigilance Nurse was employed in compliance with the National Blood Users Group guidelines, and post-operative cell salvage was introduced for patients with a pre-operative haemoglobin level of less than 12 g/dL. Aim: To assess the impact of these changes on our transfusion practice. Methods and materials A prospective audit was performed over a nine month period, from 1. st. January to 30. th. September 2003. Data was collected on 233 patients who had primary total knee arthroplasty performed during this period. Patients were transfused if their blood loss exceeded a pre-calculated maximal allowable loss, or based on a 48 hour post-operative haemoglobin level. Results: Seventeen of the 233 patients (7%) received allogeneic blood. The average amount received was two units. Pre-operative anaemia and advanced patient age were predictive for increased risk of transfusion. Thirty six per cent of patients who were given a cell saver did not collect sufficient blood for re-transfusion. Ten per cent of this group required further transfusion with allogeneic blood. Conclusion: There was no statistically significant difference in either the percentage of patients transfused or the volume of blood given to each patient between the two periods of audit. We did not find post-operative cell salvage to be an effective method of reducing allogeneic blood use

More than half of patients with neck of femur (NOF) fractures report their pain as severe to very severe in the first 24hrs. Opioids remain the most commonly used analgesia and are effective for static pain but not dynamic pain. Opioids provide suboptimal analgesia when patients are in a dynamic transition state and their side-effects are a source of morbidity in these patients. The Fascia Iliaca Compartment Block (FICB) involves infiltration of the fascia iliaca compartment with a large volume of low concentrated local anaesthetic to reduce pain by affecting the femoral and lateral cutaneous nerve of the thigh. The London Quality Standards for Fractured neck of femur services (2013) stated that the FICB should be routinely offered to patients. We performed an audit of patient outcomes following the introduction of the FICB across three centres. We performed a two-cycle audit across two hospitals in 2014/15. The first cycle audited compliance with the NICE guidance in the management and documentation of pain and AMTS (Abbreviated Mental Test Scores) in patients. The second cycle was conducted following the integration of the FICB into the multidisciplinary NOF fracture protocol across three hospital sites. Data was collected on numeric pain scores, pre and post-op AMTS and opioid requirements. There were 40 patients audited with 20 in the first cycle prior to the introduction of the FICB and 20 following this. In the second cycle, there was a statistically significant improvement (p<0.001) in the difference between the pre and post-op AMTS. The preliminary findings in this audit support the use of the FICB adjunct to analgesia in the pre-operative management of NOF fracture patients. The FICB is a safe procedure and the organisational learning of this procedure through a multidisciplinary approach can significantly improve the outcomes of NOF fracture patients

Parker et al examined the effect that delay to surgery has on patients with proximal femoral fractures. They found that a delay of more than 48 hours to surgery significantly increased the patient’s length of stay. They examined delays due to lack of theatre resource only. Therefore an audit was proposed at the RUH Bath to set a standard of care that fracture neck of femur patients should be operated on within 48 hours. One month of data was collected (August 2005) and analysed. Of 52 fracture neck of femur patients 23% were waiting longer than 48 hours. The recommendation was made to have extra lists made available for fracture neck of femur patients. In January 2006 the elective orthopaedic ward was closed (for 12 days) due to diarrhoea and vomiting. Therefore elective lists were utilised for trauma. The audit was repeated comparing these 12 days with 12 in December. In the December cohort seven neck of femur fracture patients waited more than 48 hours, in the January cohort no neck of femur patient waited more than 48 hours. A further recommendation was made for increased theatre capacity for neck of femur patients. Subsequent to these recommendations 2 half day fracture neck of femur lists have been added to the rota at the RUH Bath. (Tuesday and Thursday pm). The patients can be assessed and worked up as planned trauma and can be seen in advance by the anaesthetist. Audit of January 2007 fractured neck of femur patients showed that there were 46 patients treated with only 1 waiting more than 48 hours due to theatre capacity. In conclusion the audit process can work and achieve beneficial results as shown here. An accepted standard of care was taken from the literature, department performance analysed, changes implemented and closure of the audit loop has shown that it has worked

Background. The approach to Intramedullary (IM) fixation of long bone fractures remains a controversial issue. Early reports demonstrated less favourable results of retrograde nailing as compared with antegrade options due to higher non-union rates. The aim of this audit was to evaluate the outcomes of practice within the Trauma and Orthopaedic department with relation to IM nail fixation of diaphyseal femur fractures. Methodology. The Trauma database between February 2010 and September 2013 was used to identify all femur IM nailing procedures. Picture Archiving and Communication System (PACS) software was used to classify the fractures according to the Muller AO classification. All 3–2 (Diaphyseal femur fractures) were included in the audit. PACS imaging together with outpatient documentation was evaluated for radiological and clinical outcome. Results. A total sample size of 23 patients was identified (13 antegrade vs. 10 retrograde approach fixations). Mean patient age was 67 years and male to female ratios were similar (11M vs. 12F). Antegrade nailing was performed in a younger population as compared to retrograde nailing (mean age 60 vs. 73 respectively). Mean time to union was somewhat more protracted in the retrograde group (7 vs. 5 months), although all fractures united. The most common complication with relation to antegrade nailing was due to distal locking screws backing out. I case of infection was reported in the retrograde nail group, which was treated successfully with antibiotic therapy. There were 2 cases of nonunion observed in the antegrade group. Conclusions. The results of our practice were comparable to those published in recent literature. Overall, union rates for the two groups of fixation were similar. Each fixation technique is associated with its own specific set of complications. As a general rule antegrade nailing was reserved for a younger population so as to prevent trauma to the native knee joint

Aim. The knee radiograph is a commonly requested investigation as the knee joint is commonly injured. Each radiograph exposes 0.01mSv of radiation to the patient that is equivalent to 1.5 days of natural background radiation. Also, each knee radiograph costs approximately £37.16 to produce. The aim of the clinical audit was to use the Pittsburgh knee rules to attempt to reduce the number of knee radiographs taken in patients with acute knee injuries and hence reduce the dose of ionising radiation the patient receives. Method. A retrospective audit was undertaken. 149 knee requests and radiographs taken during October 2016 were evaluated. Each knee radiograph request including patient history and clinical examination was graded against the Pittsburgh knee rules to give a qualifying score. The Pittsburgh knee rules assigns 1 point for each of the following; blunt trauma or a fall, age less than 12 years or over 50 years, and unable to take 4 limping weight bearing steps in the emergency department. A Pittsburgh knee rule qualifying score warranting a knee radiograph is 2 or more points, where the patient must have had blunt trauma or a fall. A Pittsburgh knee rule score less than 2 points predicts a non-fractured knee and hence no radiograph warranted. Each radiograph was reviewed if a fracture was present or not. Results. The clinical audit identified 85 true negative patients where their Pittsburgh knee rule score was less than 2 points and they did not have a fracture of the knee joint. The Pittsburgh knee rule score of less than 2 points did not warrant obtaining knee radiographs. Therefore, a total of 85 knee radiographs were unnecessary which is equivalent to 127.5 days of background radiation. The financial burden of these unnecessary radiographs is £2648.60. The negative predictive value of the Pittsburgh knee rules in this audit was 93.4%. Discussion. The clinical audit shows that the use of the Pittsburgh knee rules scoring system can reduce the number of knee radiographs obtained by 57.4% and hence the doses of ionising radiation patients are exposed to. The audit also showed this clinical scoring system has a high negative predictive value that when utilised can discern patients with a normal knee joint who do not require a knee radiograph. In conclusion employing the Pittsburgh knee rule scoring system can improve patient safety by reducing ionising radiation exposure and can reduce financial costs of patient encounters

The results are reported of an audit of allografts collected in the first 18 months of the Leicester Bone Bank. We retrieved 161 femoral heads at primary arthroplasty of which 103 were implanted into 59 patients. There were deep infections in two recipients and wound infections in five. In two of these cases, culture of the femoral head at implantation was positive but the organisms grown were not those which caused the clinical infection. We retrieved 22 large allografts from six cadavers. Four of these were contaminated at retrieval and required irradiation for sterilisation. There has been one clinical infection in the nine large allografts implanted so far. We recommend that all bone banks undertake prospective audit to ensure that high standards are maintained and wastage minimised

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently IMN use has increased compared to SHS constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies. A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders, were performed utilising Multivariable logistic regression for dichotomous outcomes and Mann-Whitney-U tests for non-parametric data. A sub-group analysis was also performed focusing on AO-A1/A2 configurations which utilised additional regional data. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book. In all analyses p<0.05 denoted significance. 13638 records were included (72% female). 9867 received a SHS (72%). No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95%CI 0.90–1.23; p=0.532), (OR 1.10, 95%CI 0.97–1.24; p=0.138) between SHS and IMN's. There was however a significantly lower early mobilisation rate with IMN vs SHS (OR 0.64, 95%CI 0.59–0.70; p<0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95%CI 0.71–0.84; p<0.001). Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p<0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations. Differences in LOS potentially increases costs by £1230 per-patient, irrespective of the higher costs of IMN's v SHS. Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted

Background. Best practice tariff (BPT) for hip fracture was introduced in April 2010, offering financial incentive to encourage trusts to implement best practice and improve quality of care. This equates to £1335. An early indicator of a patient's outcome is the time to operation from admission, with best practice targets of <36hours as a key marker of quality. As well as being detrimental to patient experience, delays in the time to operation have clear links to increased mortality rates. Method. We performed a retrospective audit of neck of femur fracture patients from 01.01.14 for 12 months, investigating time to theatre, other BPT targets, and attainment of BPT. A cost analysis was also performed from financial data. Results. Of 471 patients, 461 operations were performed. Our median time to surgery was 24.9 hours. 140 (30%) of patients were not operated on within 36 hours. 134 of these (96%) would have met the BPT had they been operated on within the 36 hour target i.e. all other BPT targets were met. This equates to a loss of £178,890. Conclusions. We achieved time to theatre target for 70% of patients (compared to 71.7% reported nationally), which is suboptimal. A solution is to dedicate more theatre time to hip fractures on theatre lists or lengthened daily trauma lists. However, at £1200 per hour running theatre, this on its own would not be cost effective. Improved theatre utilisation by 10% can potentially save the trust £3,960,000 in a year. We have put forward plans to audit our current theatre usage, potentially improving utilisation and efficiency (e.g. planned hip fracture first on list from previous day to avoid start delay). Additionally we have introduced a “Time of breach” onto our trauma board to concentrate attention on this part of best practice. Level of Evidence. Level 3

Purpose of the study and background. This audit report outlines a physiotherapy lead spinal triage program for inpatients in a private hospital. The reason to trial this model was proposed as a way to expedite the assessment of inpatients presenting with back pain and implement an appropriate and prompt management plan. Summary of the methods used and the results. An audit tool was developed to record the patient details and outcomes of referrals to the spinal triage program. Length of time between referral and triage was recorded as was the number of patients that went on to require a spinal surgeon consult and spinal intervention. A total of 75 patients were referred into Spinal Triage over a 7 month period. The majority of in patients referred for spinal consult within this private hospital setting were triaged solely by physiotherapy (56%) and a management plan decided on in conjunction with the spinal surgeon on call who could access any imaging remotely. Six patients (8%) involved in the triage program went on to have spinal surgical intervention. Conclusion. Results indicate that the majority of spinal consults at inpatient level do not proceed to require surgical intervention. These results support the model of using Physiotherapists to triage this patient group. I can confirm that this abstract has not previously been published in whole or substantial part nor has it been presented previously at a national meeting. Conflicts of interest: No conflicts of interest. Source of funding: No funding obtained

Introduction: Sliding screws has been described to use in hip fractures since 1950s. Failure of fixation varies from 16 – 23%. We aim to assess the effect of audit and re auditing the failure rate after introduction of the Tip apex distance concept since January 2000 to December 2004. Methodology: We measured the tip apex distance in 161 (93 in the audit group and the rest re audit patients, 140 available for analysis. Their mean age at diagnosis 82.2 years [range 56.2–100.6 years] and male and female ratio was 1:6. Average time to Operation 1.7 days form the day of admission. The average Hospital Stay was 15.8 days. Result & discussion: We found that Patients had recorded Lag screw length 92.6mm [75–115], Side plate: 4 hole:6 hole = 4:1, Measured TAD 27.6 mm [6.3–66.4] in 140 patients,. The mean radiation time was 38.27 sec (7–71) and the dosage 0.68 Cgycm2 (0.93–2.06),. The mean Tip Apex Distance in the failed fixation group of 16 patients with cut out screw (13 in the audit group and 3 in the re audit group) is 43.05 [27.2–65.8]. Conclusion: We found the auditing and re auditing could potentially improve the surgical outcome. Although the Risk of cut out depends on many variable such as increasing age, Unstable fracture, poor reduction, high angle side plate 150deg, TAD is the stronger predictor than any other variable. This variable can be controlled by regular audit of the surgical practice

Aim: To assess satisfaction of patients seen in the fracture clinic in our DGH. The results from the audit were compared with the National Average to assess the efficiency and patient satisfaction. Methods: We did a questionnaire survey of patient satisfaction attending the fracture clinic in our DGH. The above audit was done for a period of 4 weeks on patients attending one orthopaedic surgeon fracture clinic during the month of March 2006. 130 patients completed the questionnaire, 20 of which were incomplete. This left us with 110 questionnaires for assessment. Results: The M:F was 11:7. 88% of them felt access to the clinic was easy. 12% of the patients were disabled of which only 15% felt the access was easy. 28% were seen on time and 65% were seen within 15 minutes of the stated appointment time. 82% of them felt that were not informed of the waiting time. 87% of them felt that were able to discuss their problem with the doctor. 95% of them felt the doctor explained the diagnosis and the reasons for their action in an understandable way. 94% felt the staffs were courteous. 91% were satisfied with the fracture clinic service, 60% felt the clinic was organised well, 88% felt their dignity was respected and 88% rated the care they received to be excellent to good. Conclusion: The above audit showed that majority of the patients seen in the fracture clinic were satisfied and level of service was comparable to the national average

The European Working Time Directive is a directive from the Council of Europe to protect the health and safety of workers in the European Union. The working time directive currently ensures a 56 working hour week and by August 2009 a 48 hour maximum working week. To accommodate such a reduction in working hours, the on call rotas for institutions have had to change. Has this had an affect on trauma exposure for current specialist registrars?. Materials and Methods: Data collection was from electronic logbooks of orthopaedic specialist registrars and locum appointment trainees on the Southwest Thames rotation. From the elogbooks indexed trauma procedures were audited, this included: dynamic hip screw, hemiarthroplasty, open reduction and internal fixation ankle, intramedullary nail femur, intramedullary nail tibia, and intramedullary nail humerus. The data was divided into year groups and then the data was subdivided into on call rotas. Obtained from the data collection was the number of indexed linked operations carried out per 6 months per year group. Results: The data collection was over an 18 month period October 2006 – April 2008. The total number of trainee logbooks who had the complete data from the logbook available was 90. The number of trainees for each year = n, the total number of operations =x and mean number of operations for each year of training =μ. The results for year groups are as follows:Year 1 n=18, x=4897, μ= 272:Year 2 n=12, x=2853, μ= 238: Year 3 n=22, x=4106, μ= 187:Year 4 n=19, x=3176, μ= 167:Year 5 n=4, x=658, μ=165:Year 6 n=15, x=3249, μ=217.Data for on call rotas were subdivided into the following groups: 1in13, 1in9, 1in8 and 1in7. The number of trainees for each on type of on call rota =n, the total number of operations = x, the mean number of operations for each on call rota group = μ.The results were as follows:1in13 on call: n=12, x=2215, μ=185; 1in9 on call: n=11, x=3195, μ=290. 1in8 on call: n=20, x=3754, μ=188; 1in7 on call: n=47, x=9775, μ=208. The results for the number of indexed linked operations carried out per 6 months per year group are as follows:YEAR 1 257.73:YEAR 2 228.24:YEAR 3 173.49: YEAR 4 173.23:YEAR 5 164.50: YEAR 6 208.49. Conclusion: The results show that year groups 1, 2 and 6 have carried out the highest number of procedures. The data also shows that trainees on the lowest frequency of on call rota call have the lowest number of indexed operations. The results for the number of indexed linked operations carried out per 6 months per year group shows that as the year groups progress the number of procedures carried out continues to decrease from year 1 to 5 and then increases again at year 6. The structure of orthopaedic training is being overhauled. The need for effective training has intensified. This audit aims to demonstrate some of the effects of the changes made in higher speciality training in orthopaedics

Hallux rigidus was first described by Davies-Colley and Cotterill in 1887 and varied management techniques have been described by authors since. This paper carries out an audit looking at the management of hallux rigidus in 108 patients. A retrospective study was carried out on 108 patients coded as hallux rigidus/hallux valgus over a ten year period from 1992 to 2002 (33 male and 75 female) with a follow-up range from 3 to 144 months. Thirty three toes (27 patients) were fused, 20 toes had Tel Aviv procedures (17 patients) and 61 patients were managed conservatively. Of the 33 toes fused, 18 required a second procedure in the form of wire removal, two developed transient transfer metatarsalgia, one developed IP joint pain and one had asymptomatic fibrous non-union. Of the 20 Tel Aviv procedures, one toe developed hallux valgus requiring re-operation and two toes had unrelated complications, one requiring re-operation. A single method of MTP fusion when the audit was performed revealed an interesting outcome. Hallux rigidus must be managed as an ongoing continuum, not a static state

Introduction. Flexor tendon injuries are quite common injuries. They can result in persisting functional deficit if not repaired and appropriately rehabilitated. We look at flexor tendon injuries over a period of 1 year and re-audited three years later. Method. We audited all flexor tendon injuries that were treated at our institution and repeated the same audit three years after. We looked at various aspects of the injuries including the site injured, the zone of injury, other structures injured, the type of repair and material used as well as the rehabilitation regime. Results. The initial audit had 43 patients, 83% male, 55% unemployed with 85 tendon injuries. There were 35% zone 5 injuries with 34% repaired in <24hrs with modified Kessler core 3.0 prolene sutures and 6.0 prolene peripheral sutures. The rupture rate was 3% and the infection rate was 1%. A re-audited was done 3 years later, over the same time period, there were 69 patients, 83% male, 1% unemployed with 102 tendon injuries. There were 40% zone 2 injuries with 43% repaired with modified Kessler core 3.0 prolene sutures and 6.0 prolene peripheral sutures. Rupture rate was 9% and infection rate was 1% and 10% median nerve injury. All injuries were rehabilitated using the Belfast regime. Discussion and Conclusion. Flexor tendon injuries are frequently occurring injuries and require a careful and meticulous attention to detail, relative to repair, to achieve the most effective recovery. We found that over a three year period that the zone of injury in the cohort of patients in our region had changed, as well as the unemployment rate. Other parameters were generally similar. We conclude that treatment of flexor tendon injuries should undergo the audit cycle to ensure that best practice is achieved and maintained