Aims. We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function. Methods. All patients managed via this protocol between March and October 2020 were contacted by a medical secretary at a minimum of six months post-injury. The patients were asked to complete the Patient-Rated Wrist Evaluation (PRWE), a satisfaction questionnaire, advise if they had required surgery and/or contacted any health professional, and were also asked for any recommendations on how to improve the service. A review with a hand surgeon was organized if required, and a cost analysis was also conducted. Results. Overall 71/101 patients completed the telephone consultation; no patients required surgery, and the mean and median PRWE scores were 23.9/100 (SD 24.9) and 17.0/100 (interquartile range (IQR) 0 to 40), respectively. Mean patient satisfaction with treatment was 34.3/40 (SD 9.2), and 65 patients (92%) were satisfied or highly satisfied. In total there were 16 contact calls, 12 requests for a consultant review, no formal complaints, and 15 minor adjustment suggestions to improve patient experience. A relationship was found between intra-articular injuries and lower patient satisfaction scores (p = 0.025), however no relationship was found between PRWE scores and the nature of the fracture. Also, no relationship was found between the type of immobilization and the functional outcome or patient satisfaction. Cost analysis of the self-care pathway V traditional pathway showed a cost savings of over £13,500 per year with the new self-care model compared to the traditional model. Conclusion. Our study supports a VFC self-care pathway for patients with minimally displaced distal radius fractures. The pathway provides a good level of patient satisfaction and function. To improve the service, we will make minor amendments to our patient information sheet. Cite this article: Bone Jt Open 2022;3(9):726–732

Background:. Developing a successful outpatient service for Ilizarov frame removal provides both patient and cost benefits. Misinformation and patient trepidation can be detrimental to recovery and influence choices. Education may play an important role in tailoring an efficacious service. Objective:. Review Belfast Regional Limb Reconstruction frame removal practice, introduce changes aimed at improving care and evaluate effects. Methods:. 1 year retrospective review of Ilizarov frame removal. Evaluation of service prior to and following provision of a new patient information leaflet, alongside a test wire removal technique. Subsequent service evaluation supplemented via patient reported feedback questionnaire. Results:. Retrospectively 85% Ilizarov frames removed in clinic, 54% required Entonox. Annual cost £19000. 46% patients unaware of process, gathering information from unprofessional sources. General anaesthetic and analgesic requirements related to psychosocial influences; no correlation between fracture configuration, elective reconstructive cases and operative techniques. Prospectively 96% patients found information leaflet educational and beneficial. 87% Ilizarov frames removed in clinic. 100% patients who had outpatient removal recommend this method. Entonox use reduced to 15% with average pain score 4.6/10 without analgesia. Patients felt happier. Projected annual cost savings £3000. 100% rated service excellent. Discussion:. Professional education and a standardised outpatient removal process for Ilizarov frames, delivered by a dedicated specialist team, reduces morbidity and positively impacts service provision

This paper describes an audit loop. We studied patients undergoing hip and knee surgery (arthroplasty and revision arthroplasty). All the patients were ‘complex elective’. I.e. they were either ASA grade 3 or 4, or had a body mass index in excess of 40. We collected data concerning postoperative admissions to HDU, ICU and PACU (planned and unplanned rates of admission, length of stay). We also noted mortality. In the first part of the study (April 2005 to March 2006) we studied 298 patients. All patients were assessed independently by an anaesthetist on the day of surgery. A multidisciplinary preoperative assessment clinic commenced in April 2006. After this date all patients were assessed preoperatively by a multidisciplinary anaesthetic lead team (anaesthetist, orthopaedic senior house officer, nurse practitioner). The need for an HDU or ICU bed was assessed and the bed was booked at part of the pre-operative plan. In the second part of the study (May 2006 to April 2009) a further 1147 arthroplasty patients were studied. Data was again collected regarding HDU, ICU, PACU and mortality as noted above. We found statistically significant (p=0.001) reductions in the admissions to PACU (22% down to 10%) and in mortality (6.1% down to 1.2%) after the introduction of the pre assessment clinic. There was also statistically significant (p=0.01) reduction in the HDU length of stay(2.1 days to 1.6 days), ITU unplanned admissions (1.3% to 0.4%) and the ITU length of stay in days (2.3 to 1.9 days). We also estimated cost savings of nearly £50 000 in the second limb of the study. This is based on the average decrease in HDU and ICU length of stay. We recommend the use of a multidisciplinary pre assessment clinic for complex orthopaedic surgery

Over the last few decades, the All-Poly Monoblock Tibia has been relegated to a minimum use in the major healthcare systems of the western world. The main reason for this has been the perception that this tibial component is inferior in its ability to withstand stresses. This perception originated and subsequently gained ground, due to certain historical reasons, leading to the widespread use of the modular metal-backed tibial component despite a higher cost. The recent economic downturn has enforced even the rich western healthcare systems to look for cost-effective solutions. The author works in India, where the society is still highly price-sensitive and takes value for money very seriously. Further, the routine ADL of the Indian population requires them to adopt high flexion postures such as cross-legged sitting and squatting. The author has used the All-Poly Tibia extensively, which is the most economical of tibial components. Further, he has developed a surgical technique which has resulted in his patients achieving high flexion (greater than 135 degrees) in more than 75% cases. This paper presents the 10 year results of a series of 500 cases of Primary TKR in which the All-Poly Monoblock Tibia had been used. All the patients had cross-legged sitting activity as part of their ADL, thus presumably generating significant pressures on the joint surfaces. Of the original 500 cases, we could follow up 434 cases. We report a 96% survival rate of the implant in this series. There was not a single aseptic plastic failure. The revisions required were due to infection, peri-prosthetic fracture, and instability. The message being conveyed in this paper is that the All-Poly Tibia is a very cost-effective solution in routine Primary TKRs, and is able to deliver excellent long-term results even in high stress situations like cross-legged sitting activity. It would offer a huge cost savings to the healthcare system if the Orthopaedic Surgeons start using this implant more frequently

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Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation.

Introduction. The peri-operative analgesic management of patients having either Total Knee Replacement (TKR) or Unicompartmental Knee Replacement (UKR) is an area that continues to have prominence, driven in part by the desire to reduce hospital stay, while maintaining high patient satisfaction. This is particularly relevant in the current climate of healthcare cost savings. We evaluated the role of “top up” intra-articular local anaesthetic injection after identifying that an appreciable number of patients in the unit suffered “breakthrough pain” on the first post-op day, when the effects of local analgesia are wearing off. Method. 43 patients, who were scheduled to have a cemented Oxford UKR, were prospectively recruited and randomised. All patients had the same initial anaesthetic regime of general anaesthesia, femoral nerve block and intra-operative intra-articular infiltration of the cocktail. All patients had a 16G multi-holed epidural catheter placed intra-articularly prior to wound closure. Patients had the same operative technique, post operative rehabilitation and rescue analgesia. An independent observer recorded post-operative pain scores using a visual analogue score (1–10) every 6 hours and any rescue analgesia that was required. On the morning after surgery, 22 patients, (Group I), received 20 mls of 0.5% bupivicaine through the catheter whilst 21 patients, (Group II), had 20 mls of normal saline by the same observer, (who was blinded to the contents of the solution being injected), after which the catheter was removed. Results. When comparing these two groups there was no statistical difference found in their pain scores on the day of operation. However, patients in Group I had a significantly better pain score initially post top up and then at 6 hours (2.4 (0–8) vs 5.7 (2–9), Mann-Whitney p<0.001). This cohort of patients required less rescue analgesia (22% vs 75%, Mann-Whitney p<0.001). In addition, Group I had statistically significant higher patient satisfaction outcome scores after the infiltration, (p<0.001), with 16 reporting very good satisfaction in comparison to 1 in Group II. There were no complications in either group. Discussion. Our study has shown that injection of local anaesthesia via an intra-articular catheter does reduce pain scores when compared to placebo. This implies that this technique may have a role in providing optimal pain relief after UKR

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Prior cost-effectiveness analyses on osseointegrated prosthesis for transfemoral unilateral amputees have analyzed outcomes in non-USA countries using generic quality of life instruments, which may not be appropriate when evaluating disease-specific quality of life. These prior analyses have also focused only on patients who had failed a socket-based prosthesis. The aim of the current study is to use a disease-specific quality of life instrument, which can more accurately reflect a patient’s quality of life with this condition in order to evaluate cost-effectiveness, examining both treatment-naïve and socket refractory patients.

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The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion.

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Fracture clinics are often characterised by the referral of large numbers of unselected patients with minor injuries not requiring investigation or intervention, long waiting times and recurrent unnecessary reviews. Our experience had been of an unsustainable system and we implemented a ‘Trauma Triage Clinic’ (TTC) in order to rationalise and regulate access to our fracture service. The British Orthopaedic Association’s guidelines have required a prospective evaluation of this change of practice, and we report our experience and results.