There is little evidence on the cost effectiveness of different brands of hip prostheses. We compared lifetime cost effectiveness of frequently used brands within types of prosthesis including cemented (Exeter V40 Contemporary, Exeter V40 Duration and Exeter V40 Elite Plus Ogee), cementless (Corail Pinnacle, Accolade Trident, and Taperloc Exceed) and hybrid (Exeter V40 Trilogy, Exeter V40 Trident, and CPT Trilogy). We used data from three linked English national databases to estimate the lifetime risk of revision, quality-adjusted life years (QALYs) and cost. . For women with osteoarthritis aged 70 years, the Exeter V40 Elite Plus Ogee had the lowest risk of revision (5.9% revision risk, 9.0 QALYs) and the CPT Trilogy had the highest QALYs (10.9% revision risk, 9.3 QALYs). Compared with the Corail Pinnacle (9.3% revision risk, 9.22 QALYs), the most commonly used brand, and assuming a willingness-to-pay of £20 000 per QALY gain, the CPT Trilogy is most cost effective, with an incremental net monetary benefit of £876. Differences in cost effectiveness between the hybrid CPT Trilogy and Exeter V40 Trident and the cementless Corail Pinnacle and Taperloc Exceed were small, and a cautious interpretation is required, given the limitations of the available information. However, it is unlikely that cemented brands are among the most cost effective. Similar patterns of results were observed for men and other ages. The gain in quality of life after total hip arthroplasty, rather than the risk of revision, was the main driver of cost effectiveness. Cite this article: Bone Joint J 2015;97-B:762–70

Purpose: The purpose of our study is to compare hips to knees in regards to the cost per increase in function, to determine the relationship of economic investment to improved quality of life. Method: During the year 2005, a total of 23 TKA and 41 THA revisions were performed for aseptic mechanical failure. Patients were enrolled prospectively and quality of life questionnaires including the SF-36, WOMAC, Harris Hip Score (HHS), and Knee Society Score (KSS) were collected prior to and following their procedure at two year follow-up. The total cost of the procedure including the hospital, implant, and surgeon fee were implemented in a cost effectiveness model to calculate the mean cost per SF-36, WOMAC, and HHS or KSS point gained. Demographical variables and co-morbidities were collected to determine risk factors for low cost-effectiveness. Results: The majority of patients had significant improvement in SF-36, WOMAC, HHS and KSS scales. Patients with THA revisions experience a cost per point increase for HHS of $3,000, and $500 per point SF-36 compared to knee patients who experienced a cost per point increase for KSS of $2,000, and $2,800 per point SF-36. The WOMAC exhibited similar cost effectiveness in the subscales of pain, stiffness and functioning. Conclusion: There are few studies that have compared the cost effectiveness of total joint arthroplasty revision procedures. Given the increasing cost of health care expenditures, prioritization of funding for the different health practices will become necessary. This study demonstrates that revision THA and TKA are relatively cost effective procedures compared to other non-orthopaedic interventions

Aims. A pragmatic multicentre randomised controlled trial (PROFHER) was conducted in United Kingdom National Health Service (NHS) hospitals to evaluate the clinical effectiveness and cost effectiveness of surgery compared with non-surgical treatment for displaced fractures of the proximal humerus involving the surgical neck in adults. . Methods. A cost utility analysis from the NHS perspective was performed. Differences between surgical and non-surgical treatment groups in costs and quality adjusted life years (QALYs) at two years were used to derive an estimate of the cost effectiveness of surgery using regression methods. . Results. Patients randomised to receive surgical intervention accumulated mean greater costs and marginally lower QALYs than patients randomised to non-surgery. The surgical intervention cost a mean of £1758 more per patient (95% confidence intervals (CI) £1126 to £2389). Total QALYs for the surgical group were smaller than those for non-surgery -0.0101 (95% CI -0.13 to 0.11). The probability of surgery being cost effective was less than 10% given the current NICE willingness to pay at a threshold of £20 000 for an additional QALY. The results were robust to sensitivity analyses. Discussion. The results suggest that current surgical treatment is not cost effective for the majority of displaced fractures of the proximal humerus involving the surgical neck in the United Kingdom’s NHS. Take home message: The results of this trial do not support the trend of increased surgical treatment for patients with displaced fractures of the proximal humerus involving the surgical neck within the United Kingdom NHS. Cite this article: Bone Joint J 2016;98-B:152–9

Many different designs of total hip arthroplasty (THA) with varying performance and cost are available. The identification of those which are the most cost-effective could allow significant cost-savings. We used an established Markov model to examine the cost effectiveness of five frequently used categories of THA which differed according to bearing surface and mode of fixation, using data from the National Joint Registry for England and Wales. Kaplan–Meier analyses of rates of revision for men and women were modelled with parametric distributions. Costs of devices were provided by the NHS Supply Chain and associated costs were taken from existing studies. Lifetime costs, lifetime quality-adjusted-life-years (QALYs) and the probability of a device being cost effective at a willingness to pay £20 000/QALY were included in the models. The differences in QALYs between different categories of implant were extremely small (<  0.0039 QALYs for men or women over the patient’s lifetime) and differences in cost were also marginal (£2500 to £3000 in the same time period). As a result, the probability of any particular device being the most cost effective was very sensitive to small, plausible changes in quality of life estimates and cost. . Our results suggest that available evidence does not support recommending a particular device on cost effectiveness grounds alone. We would recommend that the choice of prosthesis should be determined by the rate of revision, local costs and the preferences of the surgeon and patient. Cite this article: Bone Joint J 2015;97-B:449–57

Background. Collagenase represents a novel non-surgical treatment for Dupuytrens disease. Xiapex (Injectable collagenase, Pfizer pharmaceuticals) was recently approved by the MHRA for clinical use. The main objective of this study was to assess the proportion of patients with Dupuytrens disease that are suitable for treatment with collagenase and the financial implications of its introduction. Methods. All new patients diagnosed with Dupuytrens disease over a three month period (Sept-Nov) were enrolled into study. Patients were assessed in clinic by a senior surgeon. All patients with a palpable Dupuytrens cord without significant skin tethering were offered collagenase. Comparisons were made with the corresponding quarter in the previous 2 years. Management trends were compared over the three years (2009–11) to identify the impact of collagenase. Cost effectiveness analysis was based on a comparison with costs incurred by a fasiectomy, the most common intervention in the management of Dupuytrens disease. Results. Total number of patient referrals was relatively static over the three years with a range of 269 to 285. 23 (36.9%) of 58 patients received collagenase in the time period it was available. Needle fasiotomies which accounted for 11/76 (14%) procedures in 2009 and 5.2% of procedures in 2010 was not performed once collagenase was available. There was a significant reduction in the number of fasiectomies performed over the three year period. 42% (28/58) of procedures performed were fasiectomies in 2010 this had significantly fallen to 32% (21/58) in 2011. Dermofasiectomies were stable over the three year 17% in 2009 to 13% in 2011 with the introduction of collagenase. Cost effectiveness analysis revealed a significant reduction in cost with collagenase. Conclusions. Upto 40% of patients with established Dupuytrens disease maybe suitable for management with collagenase. This represents a cost-effective, clinically effective non-surgical option in the management of Dupuytrens disease

Economic evaluation of surgical procedures is necessary in view of emerging, often more expensive newer techniques and the budget constraints in an increasingly cost conscious NHS. The purpose of the study was to compare the cost effectiveness of open cuff repair with arthroscopic repair for moderate size tears. This was a prospective study involving 20 patients. Ten had an arthroscopic repair and 10 had an open procedure. Effectiveness was measured by pre and post-operative Oxford scores. The patients also had Constant scores done. Costs were estimated from the departmental and hospital financial data. Rotator cuff repair was an effective operation in both the groups. At the last follow up there was no statistically significant difference in the patients Oxford and Constant scores between the two methods of repair. There was no significant difference in the time in theatre, inpatient time, post-operative analgesia, number of pre and post-operative outpatient visits, physiotherapy costs and time off work between the two groups. The arthroscopic cuff repair was significantly more expensive than open repair. The incremental cost of each arthroscopic repair was £610 higher than open procedure. This was mainly in the area of direct health-care costs (instrumentation in particular). Health care policy makers are increasingly demanding evidence of cost effectiveness of a procedure. Such data is infrequently available in orthopaedics. To our knowledge there no published cost-utility analysis for the above said two types of interventions for cuff repair. Both methods of repair are effective but in our study open cuff repair is more cost effective and is likely to have better (lower) cost-utility ratio

To audit and assess the cost effectiveness and patient satisfaction of an orthopaedic pre-admission clinic. A pre-admission clinic for patients undergoing elective orthopaedic surgery has been in use in our hospital for the past 3 years. We audited the activities of this clinic over a period of 1 year and also assessed the cost effectiveness and patient satisfaction over the study period. Over 1 year, 2391 patients were invited and 2167 (90. 63 %) attended the clinic. Patients’ satisfaction was assessed using a multidimensional questionnaire which included information on time spent with patients by doctors and nurses and communication, facilities, patient involvement and overall quality of the clinic. Patient cancellation and deferring of surgery was also calculated. Cost of bed blocking due to cancellation following admission and cost of theatre time was also calculated. During the 1 year period, the non-attendance rate was 9. 37 % (224 patients). The cancellation rate following admission was 3. 4% (75 patients). 270 patients (11. 3%) had their surgery postponed due to medical and social reasons. Of the 2167 patients, 1822 (84%) had their surgery performed as scheduled. Thirty percent of the patients were unaware that they would be seen by both doctors and nurses. All the patients were satisfied with time spent with them and the information given regarding the surgery. 90% of the attending patients rated the service as excellent to good. Based on average cost of one night stay and overnight bed blocking and theatre time, this clinic has saved over £200, 000 for the Trust. The pre-admission clinic for elective orthopaedic surgery is not only cost effective but also reduces the ward-based workload for the junior doctors

We present an economic evaluation using data from the Distal Radius Acute Fracture Fixation Trial (DRAFFT) to compare the relative cost effectiveness of percutaneous Kirschner wire (K-wire) fixation and volar locking-plate fixation for patients with dorsally-displaced fractures of the distal radius. . The cost effectiveness analysis (cost per quality-adjusted life year; QALY) was derived from a multi-centre, two-arm, parallel group, assessor-blind, randomised controlled trial which took place in 18 trauma centres in the United Kingdom. Data from 460 patients were available for analysis, which includes both a National Health Service cost perspective including costs of surgery, implants and healthcare resource use over a 12-month period after surgery, and a societal perspective, which includes the cost of time off work and the need for additional private care. . There was only a small difference in QALYs gained for patients treated with locking-plate fixation over those treated with K-wires. At a mean additional cost of £714 (95% confidence interval 588 to 865) per patient, locking-plate fixation presented an incremental cost effectiveness ratio (ICER) of £89 322 per QALY within the first 12 months of treatment. Sensitivity analyses were undertaken to assess the ICER of locking-plate fixation compared with K-wires. These were greater than £30 000. . Compared with locking-plate fixation, K-wire fixation is a ‘cost saving’ intervention, with similar health benefits. Cite this article: Bone Joint J 2015;97-B:1082–9

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

Aims: To investigate whether blood transfusion practice in primary total knee replacement (TKR) was being managed appropriately, and to assess the cost effectiveness of pre-operative autologous donation (PAD). Methods: A retrospective survey of blood transfusion practice was conducted for all TKR. The unit has an established PAD service with over 60% uptake for suitable candidates. An analysis of all pre-operative and post-operative haemoglobin concentrations (Hb) was performed. Using Hb concentration of 8 g/dl or 9 g/dl as the transfusion criteria, the total units of blood used, saved or discarded was calculated. Results: 174 TKR were performed, 84 (48%) patients were transfused. 52 patients (117 units) received allogenic blood, 35 patients (61 units) received PAD blood, 8 patients received both. 60 units (50%) of PAD were discarded. Using a level of Hb of 8 g/dl, 46 patients (96 units) would have received allogenic blood, 30 patients (51 units) would have received PAD blood and 7 patients both. 70 units (58%) of PAD would have been discarded. Using a level of Hb of 9 g/dl, 35 patients (69 units) would have received allogenic blood, 22 patients (36 units) would have received PAD blood and 6 patients both. 85 units (70%) of PAD would have been discarded. If the transfusion threshold used were < 8 g/dl and < 9 g/dl, the potential saving was estimated at approximately £9578 and £6884 respectively. Conclusions: PAD service is considerably more expensive than allogenic blood. With high percentages of PAD being discarded, the service is not cost effective. Substantial saving can be achieved with a þrmer transfusion policy for post-operative patients

Introduction: Common pathologies seen in hand clinics include Dupuytren’s contracture, ganglia and trigger digits. Some patients can be treated in the out patient department by percutaneous fasciotomy, aspiration, or percutaneous A1 pulley release. The effectiveness and safety of these procedures has been documented in the literature. There are no studies investigating the cost effectiveness these of treatments. Aim: Our aim was to compare the cost of treatment of Dupuytren’s contracture, ganglia and trigger digits in the out-patient department with the operating theatre. Methods: All patients seen in a new patient hand clinic with a diagnosis of Dupuytren’s contracture, trigger digit or ganglion of the wrist or hand were prospectively identified over a 6 month period.. The number undergoing a procedure in the out-patient clinic or theatre was recorded. Costings of theatre time and out-patient time were obtained from the hospital management. Results: 80, 26, and 52 patients were treated with regard to Dupuytrens contracture, ganglia, and trigger digits respectively over the 6-month period. Of these, 37, 23, and 44 were treated by an out patient procedure, and 43, 3 and 8 underwent a formal operation. Based on a cost of £216 per out-patient clinic session, the cost of the out-patient procedures was calculated at £1872 over 6 months, or £3744 per annum. Based on a theatre cost of £1785 per session, to perform all the clinic procedures as formal operations would have cost £60,690 over 6 months, or £121380 per annum. The cost savings were therefore £117636 per annum. Discussion: We conclude that outpatient interventions for dupuytrens disease, ganglions and trigger digits results in significant cost savings over formal surgical treatment

Aims

Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate a novel screening programme that included both the primary risk factors of breech presentation and family history, and the secondary risk factors of oligohydramnios and foot deformities.

We present a retrospective study of comparision between two types of aritifical boen graft substitues. There is an overwhelming marketting drive on part of companies to sell alternative bone grafts/BMP. We in this study compae two such producsts and their cost effectiveness. This is an interventional, retrospective, non consecutive, non randamised case series study of 27 patients. Type I bone graft is Mini MIIG which is surgical grade calciun sulphate which is osteoconductive. Type II bone graft is Allomatrix which conatins bone marrow aspirate, bone morphogenic protein, concellous bone chips and surgical grade calciun sulphate which is osteogenic, osteoinductive and osteoconductive. In this study 14 cases were treated with Mini MIIG and 18 with Allomatrix. There were 24 primary fractures with bone defect, 2 non union and 1 delayed union. Complete bony union were seen in all 27 patients. Average time to heal since bone grafting is 3 months. Complications are extrubent callus formation, bone formatiom in soft tissue, but no patient required secondary procedure to trim the bone. Cost for Allomatrix is £ 356.00 and Mini MIIG is £348.00. Use of such artificial bone grafting avoids the complication of autografting which includes bone graft side morbidity like pain, bleeding and neurvascular damage. For fresh fractures useage of such artificial bone grafts doesnt shorten the healing time, doesnt prevent collapse at fracture site and it is not cost effective. For non union and delyaed unions it avoids the cost for artifical bone grafting. But autograft also incurs the cost of removing, theatre timing. human resources cost and hospital inpatient costs. There is no difference between one type of bone graft over the other and for fresh fracture both of them has no advantage over using no bone grafts. Our study concludes artifical bone graft is of no advantage for fresh fractures and for non union and delayed unions it is too small a number to come to any conclusion

Aims

Patellofemoral arthroplasty (PFA) has experienced significant improvements in implant survivorship with second generation designs. This has renewed interest in PFA as an alternative to total knee arthroplasty (TKA) for younger active patients with isolated patellofemoral osteoarthritis (PF OA). We analysed the cost-effectiveness of PFA versus TKA for the management of isolated PF OA in the United States-based population.

Purpose: To study the judicious use of re-infusion drains in knee replacement on a target population with strict inclusion criteria and its impact on the transfusion rate and cost savings.

Method: We devised an inclusion criterion after a preliminary study on 200 knee replacements and identified the target population likely to need transfusion after the index procedure. All bilateral total knee replacements, revision total knee replacements and primary total knee replacements were the pre-operative haemoglobin was less then 5 gm/l above the patient’s transfusion trigger were included. These criteria were further validated by retrospective application.

56 patients fulfilled the criteria and 50 patients were included in the study between September 2006 – May 2007. Male/female ratio was 18: 32. Mean age was 66.2 years. Procedure included 33 total knees, 13 bilateral and 4 revision knee replacements.

Results: The overall transfusion rates dropped to 3% (bilateral, revisions 12%) during the period of this study. Mean volume re-infused was 600 ml (0–2600). Average drop in haemoglobin was 2.9 g/dl. No adverse incidents were reported.

Prior to our study the expenditure on allogenic blood transfusion was £13,230. The estimated cost of using the re-infusion system was £6230

A saving of £ 7500 was achieved as a result of using the drain in the “at risk” patient.

Conclusion: Post-operative autologous transfusion is a safe and efficient way to reduce patient’s exposure to donor blood. Use of re-infusion drains directed at a target population reduces need for allogenic blood and is cost effective.

Introduction: While computer navigation has been shown to improve radiographic alignment and eliminate outliers in limb and component position in total joint arthoplasty, adoption has been relatively slow. One argument against the use of navigation has been the concern about the cost of the capital equipment and surgical disposables. The purpose of this paper was to evaluate whether the direct cost of patient care was greater for the senior author, who navigates all joint replacements, than other surgeons, who perform total joint arthroplasty without navigation.

Methods: The author’s institution is a 200 bed community hospital that performs over 1000 joint replacements per year. This study consisted of reviewing the fiscal year 2007 data at the author’s institution and comparing the direct costs of medical care, length of stay and discharge disposition for the senior author to his peers at his institution.

Results: In fiscal year 2007, the hospital performed 624 primary total knee and 213 primary total hip replacements of which the senior author performed 284(45%) knees and 156(73%) hips respectively. The average charge for the entire hospital was $38, 877 and LOS was 2.7 days for knees, and charges of $40, 076 and LOS was 2.7 days for hips. The senior authors charges were $33, 801 and LOS was 2.4 days for knees and $36, 403 and LOS 2.4 for hips. 78% of the knees and 81 % of the hips were discharged to home overall for the institution and 86% of both knees and hips by the senior author. The capital equipment purchase for navigation was $204,000 or $463 per primary arthroplasty(senior author).

Conclusions: Computer navigation did not increase the direct cost of primary total joint replacement for the senior author relative to his peers even if the entire capital equipment purchase was added to the case cost.

Computer navigation in total joint arthroplasty has been shown to be effective in improving the radiographic outcome in patients undergoing both hip and knee arthroplasty. However, critics have argued that the required capital equipment and added time to perform the procedure is cost prohibitive. To test this hypothesis, we compared our hospital discharge experience with computer navigation to national standards published by the Agency for Healthcare Research and Quality for the years 2004 and 2005

In the AHRQ database the average length of stay for DRG 209 in 2004 and 2005 respectively, in the Midwest region was 4.6 days and 4.3 days, with a mean charge of $27,403 and $27,948, with only 40% and 45%, of patients discharged to home with or without home health care. In 2004 and 2005, the senior author performed 125 and 117 Medicare primary hip and knee replacements, respectively, with computer navigation with a mean length of stay of 2.9 days and 2.8 days, with charges of $22,134 and $24,612, and 63% and 71% discharged to home.

On a pure charge basis, the senior author experience a decreased overall charge compared to published data. Even if the entire cost of the navigation system in our system $204,000 was spread equally over only the Medicare patients over the two year period, the additional $842/case still results in a case charge below published data.

Based on the senior author’s experience with hospitalization cost, length of stay and discharge disposition, computer navigation in total joint replacement is not associated with an increased cost/case and may result in dramatically lower indirect costs due to shorter length of stay and increased number of discharges to home compared to published regional Medicare discharge data.

INTRODUCTION

Physical therapy(PT) is an integral component in the management of musculoskeletal conditions. On the other hand, there have been few reports exclusively dedicated to studying PT interventions on the same day of total hip arthroplasty(THA). In this study, we investigate the role of rehabilitation in the early postoperative period on length of stay (LOS), total medical cost, and physical recovery following total hip arthroplasty.

The South Wales Air ambulance is a charity-funded helicopter service that started functioning on 1 April 2001. There are 10 staff involved in the running of the service, including pilot and paramedics. The territory covered is the South and Mid-Wales regions. The service costs on average £500 per flight and the net cost per year is approximately £750,000.

A retrospective study was performed to evaluate the extent and appropriateness of the air-ambulance call-outs over a 12-month period. The guidelines for call-out are based on medical and non-medical criteria. During this period the helicopter made 315 sorties. On 159 occasions the helicopter was stood down once airborne or following landing at the scene. £80,000 has been spent on non-patient -carrying call-outs. Of the 156 patient-carrying sorties 70% were transferred to Mor-riston Hospital, Swansea. 67% of these patients were categorised as trauma patients. Transfer distance averaged just 15 miles (range 2.6-41.2 miles). The majority of trauma cases were categorised as spinal soft tissue injuries or soft tissue injuries. 52% of patients were discharged by A& E staff without requiring orthopaedic assessment. 59% of trauma transfers were deemed to be inappropriate for helicopter transfer by the senior author.

Our study concludes that the air-ambulance is used inappropriately in at least 50% of the call-outs. The call-out criteria require amending and should place more emphasis on pick-up location rather than the nature of the casualty. It is not used cost effectively and is not always clinically effective.

We completed a retrospective case study of 66 consecutive isolated closed 5^th metacarpal neck fractures that presented to our Hospital between September 2009 and March 2010. Their management was established by referring to outpatient letters and A&E notes. The aim of the study was to establish if it would be more efficient and cost effective for these patients to be managed in A&E review clinic without compromising patient care.

Of these 66 patients, 56 were males and the mean age was 26 years (12–88 years). Four fractures were not followed up at our Trust, six did not attend their outpatient appointment, one did not require follow up.

Of the remaining 55, reviewed at a fracture clinic, all but two were managed conservatively, with 47% requiring one outpatient appointment only. The cost of a new patient Orthopaedic outpatient appointment is £180 with subsequent follow up appointments costing £80 per visit, in contrast to an A&E review clinic appointment at a cost of £60.

In view of the small percentage in need of surgical intervention: we highlight the possibility for these patients to be managed solely in the A&E department with a management plan made at the A&E review clinic with an option to refer patients if necessary, and the provision of management guidelines and care quality assurance measures.

This, we believe, would maintain care quality for these patients, improve efficiency of fracture clinics and decrease cost. We calculate that even if only all the patients that required one follow up appointment could have been managed by A&E alone then the saving to the local health commissioning body over a six month period from within our trust alone, would have been £3000, which across all trusts providing acute trauma services within the NHS would amount to a substantial saving nationwide.