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

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

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

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. 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

Diagnosis of complex regional pain syndrome (CRPS) can be challenging. We explore the role of fracture clinic in diagnosis and management with a closed-loop audit of new guidelines. We retrospectively reviewed patients with CRPS over 3.5 years. We determined the delay from injury to commencement of treatment and monitored symptoms. New guidelines were introduced to fracture clinic in January 2013. The Budapest Criteria aids diagnosis. GAD-7 and PHQ-9 patient questionnaires grade symptoms. Orthopaedic surgeons prescribe nortriptylline or pregabalin, refer to physiotherapy and review patients after six weeks. We re-audited prospectively after implementing these guidelines. The first audit cycle found 11 patients in 3.5 years. The mean delay to anti-neuropathic medication from injury was 4.7 months. Two patients required psychotherapy, one intravenous pamidronate, three inpatient physiotherapy under nerve blocks and two spinal cord stimulators. After implementing guidelines, there were 14 patients with CRPS in 9 months. All but two patients received anti-neuropathic medication on the day of diagnosis. All patients treated appropriately improved markedly within 4–12 weeks. No patients required escalation of treatment. Our guidelines increased pick-up rates of CRPS, diagnoses were made earlier and treatment started sooner. Physiotherapy modalities remained varied, however, early anti-neuropathic treatment led to a rapid improvement in all cases

We present a complete audit cycle of Emergency Department management of paediatric clavicle fractures at Derriford Hospital. Local guidelines divide the clavicle into three zones. Fractures with minimal displacement in the middle 3/5th heal in the majority of cases without complication and can be discharged without need for follow up, provided parents are adequately educated. An initial audit cycle of 63 cases identified short comings in adherence to the guidelines. These included: Unnecessary fracture clinic follow up of ‘Zone 2’ fractures in 85% and omission of written advice in 86%. The results were circulated, ‘aide memoir’ icons were added to the department's computer coding system, staff teaching sessions were organised and a patient advice sheet was produced. Following the implementation of changes, a 23 case re-audit showed fewer unnecessary referrals to fracture clinic (17% vs. 85%) and improvements in the number of parents being given written advice (43% vs. 14%). Staff training, provision of information leaflets and changes to the ED coding system dramatically improved the adherence to hospital guidance. This resulted in standardisation of care, fewer unnecessary appointments and cost savings to the trust. Following this audit, a telephone survey was completed to assess parent's satisfaction with their treatment

Introduction

Virtual fracture clinics (VFC's) aim to reduce the number of outpatient appointments while improving the clinical effectiveness and patients experience through standardisation of treatment pathways. With 4.6% of ED admissions due to trauma the VFC prevents unnecessary face to face appointments providing a cost savings benefit to the NHS.

The administration of prophylactic antibiotics is essential in the prevention of surgical site infection, particularly when metalwork is implanted. Intravenous Cefuroxime has been the antibiotic of choice for prophylaxis in our unit over the last few years. Unfortunately this has been linked to an increased rate of Clostridium Difficile infection. Our departmental antibiotic prophylaxis guidelines, based on the Scottish Intercollegiate Guidelines Network (SIGN), were therefore revised, such that intravenous Flucloxacillin and Gentamicin became the first line agents. We primarily aimed to assess whether prophylactic antibiotics were being administered according to our revised local guidelines. Steps were then taken to improve adherence to the guidelines, and the audit repeated. Data was collected prospectively between 1. st. November 2010 and 28. th. November 2010 (cycle 1). Demographic data, type of surgery, details of choice, dose and timing of antibiotic administration were compiled. The quality of documentation was also reviewed. Interventions to improve adherence to the guidelines were commenced between 1. st. January 2011 and 28. th. February 2011. This included a departmental presentation, supplementary distribution of the guidelines and email communication to all orthopaedic surgeons and anaesthetists to increase awareness. A repeat audit cycle was performed between 1. st. March 2011 and 28. th. March 2011 (cycle 2). All data was stored and statistically analysed using SPSS for Windows 17.0. A total of 130 patients were included, with 65 patients in each cycle. Demographic data and type of surgery were reasonably similar in both cycles. Intravenous antibiotics, when required, were administered within 30 minutes of the surgical incision in most cases in both cycles of the audit. In the first cycle of the audit only 9 out of 65 patients (14%) received the correct antibiotics as suggested by our updated guidelines. This improved significantly to 46 out of 57 patients (81%) in the second cycle. Documentation of antibiotic prescribing in the anaesthetic record, operation note and drug charts also improved in the second cycle. We observed poor initial adherence to our updated guidelines as most patients received incorrect antibiotic prophylaxis. However, following our audit interventions to increase awareness of the new guidelines, we witnessed a significant improvement in compliance. Our next step will be to ensure that the new policy of using intravenous Flucloxacillin and Gentamicin does indeed reduce the rate of Clostridium Difficile infection while maintaining a low rate of deep and superficial wound infection

Patients with hip fracture are at high risk of venous thromboembolism (VTE). Chemical thromboprophylaxis with low molecular weight heparin (LMWH) is associated with a risk of major bleeding in certain patient groups, such as those with renal failure. In these patients, unfractionated heparin should be used. Our aim was to determine the practice of VTE risk assessment in patients admitted with hip fracture against the national guidance, which states that all should have VTE risk assessment on admission. We also assessed the impact of introducing the VTE risk assessment form on prescribing practice of chemical thromboprophylaxis in patients with renal failure. Prospective audit of patients of 50 patients admitted with hip fracture from 4/8/10 with re-audit of 50 patients admitted from 17/2/2011 after introducing the VTE risk assessment form into the hip fracture admissions proforma. Retrospective analysis was undertaken to determine chemical thromboprophylaxis prescribing in patients with eGFR <30ml/min/1.73m. 2. . Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). There were similar numbers of patients with eGFR <30ml/min/1.73m. 2. in both audit loops with 8% (n=4) in the initial audit, and 10% (n=5) in the re-audit. Frequency of VTE risk assessment significantly increased from 16% to 86% after including the VTE risk assessment form in the hip fracture proforma (p<0.0001). Despite this, there was no significant reduction in prescribing of LMWH in patients with renal failure with eGFR <30ml/min/1.73m. 2. , (P=0.52). Documentation of VTE risk assessment in patients admitted with hip fracture can be improved by simple measures such as inclusion of the VTE risk assessment form in the admissions proforma. However, this did not result in a reduction of LMWH prescribed in patients with significant renal failure and risk of major bleeding

Paediatric wrist fractures are routinely managed with closed reduction and a molded cast. Gap(GI) and Cast indices(CI) are useful in predicting re-displacement following application of cast. Over 6 months we audited the efficacy of molded cast application following closed reduction of distal radial fractures in paediatric patients. The standard was that proposed by Malviya et al where GI >0.15 and CI >0.8 indicate an increased risk of re-displacement. Age, date and time of operation and surgeon's grade were collected. Pre-op displacement, post-reduction GI and CI and subsequent re-displacement were measured using imaging. Post audit intended changes to practice were presented to all surgeons, a “one-pager” was placed above scrub sinks. Re-audit was conducted at 1 year. The audit and re-audit included 28 and 24 patients respectively. Cast molding (CI) improved minimally following intervention (32% to 29%). Cast padding (GI) improved significantly (82% to 63%). Loss of reduction decreased slightly (14% to 12%), this was not accurately predicted by GI and CI in the re-audit. Audit demonstrated that casts were loose, over-padded and did not hold reduction adequately. Re-audit demonstrated that tighter, less padded but still inadequately molded casts were being applied with minimal change in loss of reduction

Introduction. We conducted an audit on hip fractures to analyse the accuracy of coding and payment by results in our institution. Materials/Methods. The initial audits analysed hip fracture over a period of four months at two different trusts. Case notes were reviewed to extract data regarding diagnosis, comorbidities and operative procedures. The findings were compared with the data from clinical coding department and difference in the tariff was analysed. A re-audit was performed at Trust B after implementation of changes to assess improvement. Results. In the initial audit 111 patients were reviewed. Twenty-three percent patients had all data correctly coded. In the remaining 77%, some of the co-morbidities had been missed, e.g. UTI, anaemia and osteoporosis etc. 11.7% of operative procedures and 16.5% of fracture patterns were incorrectly coded resulting in loss of £53 000 over the 4 month period. Poor documentation and the use of ‘uncodable’ language by clinicians were responsible for missing co-morbidities, while inadequate medical knowledge of clinical coders resulted in the incorrect recording of operative procedures. We implemented changes in the form of clinical coders training, awareness of “codable words” by medical staff and writing the procedure codes by the surgeons themselves. A re-audit at Trust B showed an estimated savings of £18540.00 over 3 months period, demonstrating a significant improvement. Conclusion. Inaccuracies in clinical coding result in loss of tariff. Awareness of codable words, writing the operative codes by surgeons and training of clinical coders can improve clinical coding and payment by results in NHS hospitals

Background and Aims:. In 2009 a combined clinic was formed by the orthopaedic Surgeons and Developmental Paediatricians in our hospital. The aim was to help improve the assessment and management of patients with Cerebral Palsy. Included in the assessment team, are the paediatric orthopaedic surgeons, the developmental paediatricians, physiotherapists and occupational therapists. Our aim was to audit the patients presenting to this clinic over a 15 month period to look at the demographic data, clinical severity and decisions taken for these patients. Methods:. We looked at patients seen in the clinic from January 2013 to March 2014. We recorded the age, gender and primary caregiver. We also recorded the reason for referral. Clinically we wanted to know the type and distribution of the CP, GMFCS score, attainment of milestones and type of schooling. We recorded underlying aetiologies and HIV status of the patients. Finally the access the patients had to physiotherapy and Occupational therapy. Results:. We saw 41 patients in total with 18 males and 23 females. The ages ranged from 5 months to 9 years (mean 4.9 years). 36 of 41 (88%) had spastic CP, 2 (5%) dystonic, 1 (2%) mixed and 2 (5%) were not recorded. Diplegic and hemiplegic predominated with 15 (37%) and 14 (34%) respectively, there were 6 (15%) quadriplegics, 1 double hemiplegic and 5 were not recorded. 13 (31%) of patients had birth asphyxia as an aetiology, 13 (31%) had brain anomalies, 9 (22%) were premature babies, the remaining 16% comprised HIV, post natal sepsis and injury. 38 (93%) were cared for by at least one parent and the remaining 3 (7%) were cared for by a grandparent. 39 (95%) had access to physiotherapy and 30 (73%) had access to occupational therapy. 21 (51%) had no access to appropriate schooling. 9 (22%) were known to be HIV positive. The recommended orthopaedic interventions were continued physiotherapy for 17 (41%) and botox in 22(54%). Discussion:. The combined clinic has highlighted the diverse nature of cerebral palsy and the challenges facing our patients. It is an invaluable tool in the goal directed management of complex cases

An audit was carried out to assess the management of patients with fragility fractures in fracture clinic and primary care. NICE guidelines advise these patients require treatment for osteoporosis if 75 years or older, and a DEXA scan if below this age. Distal radius and proximal humeral fractures were identified in a retrospective review of letters from 10 fracture clinics. Current medication of all patients ≥ 75 years was accessed and DEXA scan requests identified for patients < 75 years. There were 69 fragility fractures: 53 distal radius and 16 proximal humerus. 4 letters (6%) mentioned fragility fracture and advised treatment and 3 (3%) correctly advised a DEXA scan. Only 3 of 25 (10%) patients ≥ 75yrs not previously on osteoporosis medication had treatment started by their GPs. 3 of a possible 29 (10%) patients < 75 years were referred for a DEXA scan. A text box highlighting fragility fractures and NICE guidelines was added to all clinic letters for patient ≥ 50 years old. Re-audits showed an improvement in management of these fractures, with 45% of patients ≥ 75 years being started on treatment and 39% of patients < 75 years being referred for a DEXA scan

We present a complete audit cycle of Emergency Department (ED) management of paediatric buckle fractures of the distal radius at Derriford Hospital. Local hospital management guidelines state that the limb should be supported in a wrist splint for 3 weeks following injury and, provided parents are adequately educated, no formal follow-up is required. Auditable standards were obtained from the local guidance. An initial audit cycle of 54 cases identified shortcomings in compliance with guidelines. These included: Inappropriate immobilisation in 34 (63%) cases, omission of written advice in 35 (65%) cases and arrangement of unnecessary follow-up in 31 (57%) cases. Following circulation of the results, ‘aide-memoir’ icons were added to the emergency department computer coding system, teaching sessions for emergency department staff were organised and new paediatric specific wrist splints were introduced. A re-audit of 33 patients evaluated the effect of the changes. This demonstrated a 27% improvement in correct wrist support usage (27/33, 82%) and 25% fewer unnecessary referrals to fracture clinic (27/33, 82%). Staff training and provision of appropriate wrist splints were crucial to improving the adherence to guidance. This resulted in standardisation of care, fewer unnecessary appointments for patients and cost savings to the hospital trust

Introduction

The use of intramedullary lengthening devices is becoming increasingly popular. There are no published data regarding the incidence of venous thromboembolism following intramedullary lengthening and no reports or guidance for current practices on use of thromboprophylaxis. Following a case of post-operative deep vein thrombosis in our institution, we felt that it is important to assess best practice. We conducted this survey to collect data that would describe current practice and help guide consensus for treatment.

Introduction. ‘VTE disease is the new MRSA’, with much attention received in the media and the political world. Following the 2010 NICE guidelines all patients admitted to hospital should have VTE prophylaxis considered and a formal VTE risk assessment done with documentation and review in a 24 hour period. We carried out a completed audit cycle to identify our adherence to these guidelines and introduced a novel method to ensure compliance. Materials/Methods. An audit of 400 patients admitted to the orthopaedic department was carried out with review of case notes. Three key parameters were investigated: Firstly the compliance of carrying out a risk assessment for VTE disease with correct documentation, secondly investigating how many patients got re-assessed in 24 hours and finally if patients received appropriate VTE prophylaxis. The data was re-audited following the introduction of a new drug chart with a box section for VTE risk assessment and prophylaxis on the chart itself. Results. In the first cycle VTE risk assessments were carried out in 2.5% with 0% having a re-assessment in 24 hours and 93.5% of patients having correctly prescribed VTE prophylaxis. Following the new drug charts, the risk assessments were carried out in 79%, re-assessment in 50% and correct prescribed prophylaxis in 99% of the patients. Conclusions. We recommend all hospitals should have a section in the drug chart itself for VTE risk assessment and prophylaxis as this greatly improves compliance to the NICE guidelines. This ensures optimal patient care and protects the trust from litigations

Cognitive impairment is common in patients with hip fracture both on admission and may develop later on. Reduced cognitive function is a risk factor for development of delirium, correlates with poor rehabilitation, and is an independent predictor of increased mortality. Despite its commonplace and potential for serious morbidity, cognitive dysfunction is often poorly assessed & diagnosed. Our aims were to 1) assess the practice of cognitive assessment on admission for hip fracture patients according to local guidelines and 2) ascertain whether it can be improved by the formal introduction of Abbreviated Mental Test Score (AMTS) & Clock Drawing Test (CDT) in the hip fracture admission proforma. A prospective audit was undertaken of cognitive assessment by either AMTS or CDT for 50 consecutive patients admitted with hip fracture from 4/8/2010. Subsequently, the hip fracture admission proforma was amended to include both the AMTS & CDT. A re-audit was performed on 50 consecutive patients admitted from 17/2/2011 to determine the change in practice. Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). Cognitive assessment by either AMTS or CDT significant increased from 28% (n=14) to 86% (n=43) in the re-audit (p<0.0001). All AMTS were completed in accordance with instructions, whereas almost half of CDTs were incompletely or incorrectly filled out (45%). The assessment of cognitive function can be greatly improved by inclusion of both the AMTS & CDT to the hip fracture admission proforma, allowing the most appropriate multi-disciplinary care to be planned for the patient. Whilst both CDT and AMTS are good screening tools for cognitive impairment, many are unfamiliar with CDT & more training is needed

Transferring patient data to the care of the oncoming team is the point at which the patient is most vulnerable on their journey through the healthcare system. Effective handover is vital to protect patient safety and has become increasingly more important after introduction of shift patterns for junior doctors following the implementation of the European Working Time Directive. The aim was to assess whether the introduction of a standardised proforma and traffic light system, would improve weekend handover of patients in our orthopaedic unit. Data was collected in the form of hand written data, for 3 months, in our department. This was analysed and a standardised handover sheet and traffic light system to highlight patient priority was introduced. Following a 1 week trial, the proformas were reviewed following feedback from colleagues. A re-audit was commenced and data collected for a further 2 months. There were 108 patients handed over on weekends during the re-audit compared to the 126 in the initial audit. The handover of patient data improved across all areas, with the most improved areas in recording the patients' diagnosis (58.4% to 94.4%) and noting the results of significant or pending investigations (61.2% to 91.7%). The traffic light system improved recording the patient's condition (8.5% to 81.5%) as well as logging the urgency or frequency of patient review (25.9% to 96.8%). Standardised proformas improve patient data transferred at handover and the traffic light system allows improved prioritisation of patients, thus improving patient safety at weekends

Presenters Position:. Purpose of Study:. To perform a retrospective audit of the spectrum of management of tibial pseudarthrosis by a single surgeon over a seven year time period. Description of Methods:. All discharge summaries and operation logs from 2004 to 2011 were reviewed to identify patients, and their case notes and x-rays were examined. Patients were contacted telephonically for follow-up examination. Summary of Results:. Eleven patients presented with pseudarthrosis or bowing of the tibia (six females, five males, age range 4 months–7 years). Three were being treated conservatively and two patients had undergone primary below-knee amputation for severe deformity and functional deficit. Six patients had undergone resection of the pseudarthrosis with intramedullary fixation with a Williams' rod. Three of these patients had Neurofibromatosis type 1. In all instances autogenous iliac crest bone graft was used. Fibular osteotomy was performed in five of these patients and the fibula was stabilised with a K-wire in four patients. All patients were discharged in an above knee cast. Mean follow-up from 1st surgery was 23.75 (1.5–72) months. In one patient, histology confirmed suspected fibrous dysplasia. One patient had had a revision procedure 12 months prior to last follow-up for re-fracture and rod displacement. Mean residual deformity was recorded as 4.2° (1° to 10°) valgus and 6.6° (−2° to 20°) anterior bowing. We had no instances of non-union or sepsis at latest follow-up in this small series. Conclusion:. Patients with tibial pseudarthrosis have a wide spectrum of presentation. Not every patient requires immediate surgery. Our treatment aim in the young patient is to maintain optimum ambulation, clinical union and alignment with radiographic appearance assuming secondary consideration. In our hands, internal fixation using a Williams' rod with autograft is safe and effective as the initial surgical procedure. Continued follow-up of these patients is mandatory as the risk of complications is high even after apparent union