Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be challenging. There is particular difficulty distinguishing septic arthritis (SA) from transient synovitis (TS) and consequently clinical prediction algorithms have been devised to differentiate the conditions using the presence of fever, raised erythrocyte sedimentation rate (ESR), raised white cell count (WCC) and inability to weight bear. Within Europe measurement of the ESR has largely been replaced with assessment of C-reactive protein (CRP) as an acute phase protein. We have evaluated the utility of including CRP in a clinical prediction algorithm to distinguish TS from SA.

Joint arthroplasty is a common surgical procedure, with over 185,000 primary hip and knee arthroplasties performed in England, Wales and Northern Ireland in 2014. After total hip or knee arthroplasty, about 1% of patients develop deep prosthetic joint infection (PJI), which usually requires further major operations to clear the infection. Although PJI affects only a small percentage of patients it is one of the most devastating complications associated with this procedure. Research evidence has focussed on clinical effectiveness of revision surgery while there has been less focus on the impact on patients and support needs. Using a systematic review approach, the aim of this study was to assess support needs and evaluate what interventions are routinely offered to support patients undergoing treatment for PJI following hip or knee arthroplasty.

We systematically searched MEDLINE, Embase, Web of Science, PsycINFO, Cinahl, Social Science Citation Index, and The Cochrane Library from 1980 to February 15, 2015 for observational (prospective cohort, nested case-control, case-control, and retrospective cohort) studies, qualitative studies, and clinical trials that report on the support needs and interventions for patients being treated for PJI or other major adverse occurrences following joint arthroplasty. Data were extracted by two independent investigators and consensus reached with involvement of a third.

Of 4,161 potentially relevant citations, we identified one case-control, one prospective cohort and two qualitative studies for inclusion in the synthesis. Patients report that PJI and treatment had a profoundly negative impact affecting physical, emotional, social and economic aspects of their lives. No study evaluated support interventions for PJI or other major adverse occurrences following hip and knee arthroplasty.

The interpretation of study results is limited by variation in study design, outcome measures and the small number of relevant eligible studies. Findings show that patients undergoing treatment for PJI have extensive physical, psychological, social and economic support needs. Our review highlights a lack of evidence about support strategies for patients undergoing treatment for PJI and other adverse occurrences. There is a need to design, implement and evaluate interventions to support these patients.

The objectives of this study are to evaluate the impact of the CoVID-19 pandemic on the development of relevant emerging digital healthcare trends and to explore which digital healthcare trend does the health industry need most to support HCPs. A web survey using 39 questions facilitating Five-Point Likert scales was performed from 1.8.2020 – 31.10.2020. Of 260 participants invited, 90 participants answered the questionnaire. The participants were located in the Hospital/HCP sector in 11.9%, in other healthcare sectors in 22.2%, in the pharmaceutical sector in 11.1%, in the medical device and equipment industry in 43.3%. The Five-Point Likert scales were in all cases fashioned as from 1 (strongly disagree) to 5 (strongly agree). As the top 3 most impacted digital health care trends strongly impacted by CoVID-19, respondents named:. - remote management of patients by telemedicine, mean answer 4.44. - shared data governance under patient control, mean answer 3.80. - new virtual interaction between HCP´s and medical industry, mean answer 3.76. Respondents were asked which level of readiness of the healthcare system currently possess to cope with the current trend impacted by CoVID-19. - Digital and efficient healthcare logistics, mean answer 1.54. - Integrated health care, mean answer 1.73. - Use of big data and artificial intelligence, mean answer 2.03. Asked if collaborative research in the form of digital data platforms for research data sharing and increasing collaboration with multi-centric consortia would have a positive impact on the healthcare sector, the agreement was high with a value of mean 4.10 on the scale. We can conclude that the impact of COVID-19 appears to be a high agreement of necessary advances in digitalization in the health care sector and in the collaboration of HCPs with the health care industry. Health care professional are unsure, in how far the national health care sector is capable of transformation in healthcare logistics and integrated health care

Access to health care, including physiotherapy, is increasingly occurring through virtual formats. At-home adherence to physical therapy programs is often poor and few tools exist to objectively measure low back physiotherapy exercise participation without the direct supervision of a medical professional. The aim of this study was to develop and evaluate the potential for performing automatic, unsupervised video-based monitoring of at-home low back physiotherapy exercises using a single mobile phone camera. 24 healthy adult subjects performed seven exercises based on the McKenzie low back physiotherapy program while being filmed with two smartphone cameras. Joint locations were automatically extracted using an open-source pose estimation framework. Engineered features were extracted from the joint location time series and used to train a support vector machine classifier (SVC). A convolutional neural network (CNN) was trained directly on the joint location time series data to classify exercises based on a recording from a single camera. The models were evaluated using a 5-fold cross validation approach, stratified by subject, with the class-balanced accuracy used as the performance metric. Optimal performance was achieved when using a total of 12 pose estimation landmarks from the upper and lower body, with the SVC model achieving a classification accuracy of 96±4% and the CNN model an accuracy of 97±2%. This study demonstrates the feasibility of using a smartphone camera and a supervised machine learning model to effectively assess at-home low back physiotherapy adherence. This approach could provide a low-cost, scalable method for tracking adherence to physical therapy exercise programs in a variety of settings

Artificial Intelligence (AI) is becoming more powerful but is barely used to counter the growth in health care burden. AI applications to increase efficiency in orthopedics are rare. We questioned if (1) we could train machine learning (ML) algorithms, based on answers from digitalized history taking questionnaires, to predict treatment of hip osteoartritis (either conservative or surgical); (2) such an algorithm could streamline clinical consultation. Multiple ML models were trained on 600 annotated (80% training, 20% test) digital history taking questionnaires, acquired before consultation. Best performing models, based on balanced accuracy and optimized automated hyperparameter tuning, were build into our daily clinical orthopedic practice. Fifty patients with hip complaints (>45 years) were prospectively predicted and planned (partly blinded, partly unblinded) for consultation with the physician assistant (conservative) or orthopedic surgeon (operative). Tailored patient information based on the prediction was automatically sent to a smartphone app. Level of evidence: IV. Random Forest and BernoulliNB were the most accurate ML models (0.75 balanced accuracy). Treatment prediction was correct in 45 out of 50 consultations (90%), p<0.0001 (sign and binomial test). Specialized consultations where conservatively predicted patients were seen by the physician assistant and surgical patients by the orthopedic surgeon were highly appreciated and effective. Treatment strategy of hip osteoartritis based on answers from digital history taking questionnaires was accurately predicted before patients entered the hospital. This can make outpatient consultation scheduling more efficient and tailor pre-consultation patient education

Ankle fractures are among the most common types of fractures. If surgery is not performed within 12 to 24 hours, ankle swelling is likely to develop and delay the operative fixation. This leads to patients staying longer in the ward waiting and increased hospital occupancy. This prolonged stay has significant financial implication as well as it is frustrating for both patients and health care professionals. The aim was to formulate a pathway for the ankle fracture patients coming to the emergency department, outpatients and planned for operative intervention. To identify whether pre-operative hospital admissions of stable ankle fracture patients are reduced with the implementation of the pathway. We formulated an ankle fracture fixation pathway, which was approved for use in December 2020. A retrospective analysis of 6 months hospital admissions of ankle fracture patients in the period between January to June 2020. The duration from admission to the actual surgery was collected to review if some admissions could have been avoided and patients brought directly on the surgery day. A total of 23 patients were included. Mean age was 60.5 years and SD was 17years. 94% of patients were females. 10 patients were appropriately discharged.7 Patients were appropriately admitted. 6 Patients were unnecessarily admitted. These 6 patients were admitted on presentation to ED. Retrospective analysis of this audit showed that this cohort of patients met the safe discharge criteria and could have been discharged. Duration of unnecessary stay ranged from 1 to 11 days (21 days in total). Total saving could have been £6300. Standards were met in 74% of cases. Preoperative hospital admission could be reduced with the proposed pathway. It is a valuable tool to be used and should be implemented to reduce unnecessary hospital admissions

The purpose of the this survey study was twofold: 1) to examine different aspects of satisfaction with post-operative care in injured workers who have undergone rotator cuff surgery and 2) to examine the relationship between receiving a newly implemented summary report and the overall satisfaction with surgery and recovery. The clinical communication summary report was given to injured workers following their review assessment to share with the family doctor or other health care providers. The form indicated a need for further assessments or investigations and return to work recommendations. The study involved using a satisfaction survey that examined different aspects of follow-up visit and workers’ opinion about their understanding of the nature of surgery, their progress, clinical management, and usefulness of the newly implemented summery report. Eighty patients completed the questionnaire (mean age: 54 (8), 62(78%) males, of whom 26 (34%) had a rotator cuff decompression and 31 (40%) had a rotator cuff repair with 20 (26%) having both procedures and three missing data. There were no statistically significant relationships between the patient demographics (age, sex or type of surgery) and satisfaction. However, there was a significant correlation between how patients perceived the summary report in terms of helpfulness and the overall satisfaction with surgery (FTE<0.0004, p=0.001) and the satisfaction with recovery (FTE<0.0001, p=0.001). This may indicate that improvement in worker's understanding of their treatment recommendations and restrictions is associated with higher levels of overall satisfaction in this population. Our results indicate a positive linear relationship between expressing a high satisfaction and the helpfulness of the summary report. As part of improving care, adding a summary report may facilitate sharing information with the injured workers, their care providers and their workplace

In absence of available quantitative measures, the assessment of fracture healing based on clinical examination and X-rays remains a subjective matter. Lacking reliable information on the state of healing, rehabilitation is hardly individualized and mostly follows non evidence-based protocols building on common guidelines and personal experience. Measurement of fracture stiffness has been demonstrated as a valid outcome measure for the maturity of the repair tissue but so far has not found its way to clinical application outside the research space. However, with the recent technological advancements and trends towards digital health care, this seems about to change with new generations of instrumented implants – often unfortunately termed “smart implants” – being developed as medical devices. The AO Fracture Monitor is a novel, active, implantable sensor system designed to provide an objective measure for the assessment of fracture healing progression (1). It consists of an implantable sensor that is attached to conventional locking plates and continuously measures implant load during physiological weight bearing. Data is recorded and processed in real-time on the implant, from where it is wirelessly transmitted to a cloud application via the patient's smartphone. Thus, the system allows for timely, remote and X-ray free provision of feedback upon the mechanical competence of the repair tissue to support therapeutic decision making and individualized aftercare. The device has been developed according to medical device standards and underwent extensive verification and validation, including an in-vivo study in an ovine tibial osteotomy model, that confirmed the device's capability to depict the course of fracture healing as well as its long-term technical performance. Currently a multi-center clinical investigation is underway to demonstrate clinical safety of the novel implant system. Rendering the progression of bone fracture healing assessable, the AO Fracture Monitor carries potential to enhance today's postoperative care of fracture patients

Tourniquet is a commonly used tool in orthopaedic practice. Incidence of complications is low but if any develops, it is devastating. Transient nerve damage, ischemia or skin burns are the possible tourniquet related complications. There is big variation in practice regarding the limb occlusion pressure. 51 procedures in 50 patients were reviewed retrospectively in our district general hospital. We looked at quality of documentation guided by the BOAST standard (The Safe Use of Intraoperative Tourniquets, published in October 2021). Limb occlusion pressure and ischemic time were analysed. Intra-operative and post-operative notes were reviewed to assess quality of documentation and post-operative complications. Although limb occlusion pressure was above the recommended range in more than 75% of cases, there were no significant complications observed. Two cases only developed transient neuropraxia in common peroneal nerve and median nerve following tibial plateau ORIF and trapeziectomy simultaneously. Tibial ORIF fixation case had prolonged ischemic time (more than 120 minutes) and the limb occlusion pressure for the hand case was above the recommended range. Both have recovered within few days with no long-term consequences. Minimum documentation threshold was not met with regarding tourniquet site condition, method of skin isolation and padding, and exsanguination method. This relatively new standard with no previous similar guidance needs time until it is followed by the health care professionals especially when there is no high incidence of complications related to the use of the tourniquet. However, it is crucial to increase the theatre staff awareness of such standards. This will prevent devastating complications specifically in vulnerable patients. Adjustments to theatre checklist have been suggested to improved documentation. Additionally, local teaching sessions will be delivered to theatre personnel aiming at improving our compliance to this standard

The primary purpose of this longitudinal study was to examine the impact of physical and mental well-being on a successful return to work after cartilage or ligament knee injury. A secondary purpose was to examine the effectiveness of our program regarding ordering imaging (plain X-rays, US, MRI, CT scan), and the impact that costly investigations made in clinical management. Workers who had sustained a work-related knee injury and were assessed at the lower extremity specialty clinic of our hospital program were followed up until they were discharged. All patients completed the numeric pain rating scale (NPRS), the Lower Extremity Functional Scale (LEFS), and the Hospital Anxiety and Depression Scale (HADS) on the initial assessment and at final follow-up. We included 30 patients, mean age, 50(9), 11(37%) females, 19(63%) males. The most common mechanisms of injury were twisting (13, 45%) and falls (12, 41%). The knee injuries included 10 anterior collateral ligament (ACL), 3 posterior collateral ligament (PCL), 19 medical and lateral ligament injuries, and 22 meniscus injuries with some injuries overlapping. Ten patients (30%) underwent surgery (8 meniscectomy, two ligamentous repairs). Patients showed improvement in pain scores (p<0.0001) and the LEFS scores (p=0.004). Seventeen patients (57%) returned to full-time work and 11 (37%) were not working at the time of discharge with one patient performing part-time work, and one on re-training. Higher levels of pre (p=0.02) and post-treatment (p=0.03) depression and post-treatment anxiety (p=0.02) had a negative impact on a successful return to work. Most clients had proper investigations ordered by their family physicians in the community (24 plain x-rays, 11 US, and 21 MRI). Our team ordered only 6 plain x-rays and 6 new MRI. We found significant improvement in pain and disability in injured workers who received an expedited multidisciplinary care. Anxiety and depression were the most important predictors of poorer recovery and a less successful work status. The judicious use of costly imaging is expected to reduce the overall health care cost of an injury, while providing new important information such as adding a new diagnosis or changing the management

Chronic low back pain (cLBP) is a complex, multifaceted disorder where biological, psychological, and social factors affect its onset and trajectory. Consequently, cLBP encompasses many different disease variants, with multiple patient-specific mechanisms. The goal of NIH Back Pain Consortium (BACPAC) Research Program is to develop understanding of cLBP mechanisms and to develop algorithms that optimally match specific treatments to individual patients. To accomplish this, one research activity of BACPAC is to develop theoretical models for chronic low back pain based on the current state of knowledge in the scientific community, and to interrogate the relationships implied by the theoretical models using data generated by or available to BACPAC. The models consider biopsychosocial perspectives, and encompass both peripheral (i.e. low back) and central (i.e. spinal and supra-spinal) factors as well as proposed mechanisms of action of cLBP treatments. However, absent explanations, models/algorithms may fall short of regulatory requirements and clinician expectations, and ultimately may not be embraced by physicians and patients. To address this, BACPAC is developing a clinical utility roadmap (CUR) to clarify how models will be used in practice for selecting optimal treatments, monitoring response to treatment, and reducing health care utilization. This presentation will review the goals of BACPAC and how theoretical models and CUR are being used to support computational knowledge networks to integrate data from deeply phenotyped cLBP patients

Introduction and Objective. Over the past few years, a reorganization of the educational pathways has been promoted with the purpose of optimizing the acquisition of competences and their assessment, so as to reduce the risks to both health care professionals and end users. Virtual reality (VR) has been repeatedly tested, initially as a positive reinforcement for more traditional educational pathways and, more recently, as their potential substitute. The aim of this study was to demonstrate the potentiality of VR simulation training in spine surgery. Materials and Methods. The VR simulator reproduced the lateral lumbar access to the spine. The simulation included a tutorial, the preoperative settings, and the surgical session with different levels of procedural complexity. A total of 10 users were recruited for this study: 3 senior surgeons (group A) and 7 orthopedic residents or junior orthopedic surgeons (group B). Each user completed the simulation twice. Results. The user's age or previous experience with VR technology did not show any relevance. On average, the entire simulation was completed in 24 minutes and 36 seconds. Group B showed an improvement between the 2 attempts in both sessions, the preoperative settings and the surgical simulation. The number of major errors dropped from an average of 5.2 to 1.8 and from an average of 4 (1–6) to 1.4, respectively. The simulation was never interrupted because of technical bugs or adverse effects related to the technology. Conclusions. VR-based training pathways might promote a high standard of care. Our preliminary experience suggests an effective implementation of the traditional coaching process

Minimally invasive surgery for the restoration of bone tissues lost due to diseases and trauma is preferred by the health care system as the related costs are continuously increasing. Recently, efforts have been paid to optimize injectable calcium phosphate (CaP) cements which have been recognized as excellent alloplastic material for osseous augmentation because of their unique combination of osteoconductivity, biocompatibility and mouldability. The sol-gel synthesis approach appears to be the most suitable route towards performing injectable calcium phosphates. Different strategies used to prepare bioactive and osteoinductive injectable CaP are reported. CaP gels complexed with phosphoserine-tethered poly(ε-lysine) dendrons (G3-K PS) designed to interact with the ceramic phase and able to induce osteogenic differentiation of human mesenchymal stem cells (hMSCs) is discussed. Recently, attention has been given to the modification of hydroxyapatite with Strontium (Sr) due to its dual mode of action, simultaneously increasing bone formation (stimulating osteoblast differentiation) while decreasing bone resorption (inhibiting osteoclast differentiation). The effect of systems based on strontium modified hydroxyapatite (Sr-HA) at different composition on proliferation and osteogenic differentiation of hMSC is described. One more approach is based on the use of antimicrobial injectable materials. It has been demonstrated that some imidazolium, pyridinium and quaternary ammonium ionic liquids (IL) have antimicrobial activity against some different clinically significant bacterial and fungal pathogens. Here, we report several systems based on IL at different alkyl-chain length incorporated in Hydroxyapatite (HA) through the sol-gel process to obtain an injectable material with simultaneous opposite responses toward osteoblasts and microbial proliferation

Osteoarthritis (OA) is a painful and disabling chronic condition that constitutes a major challenge to health care worldwide. There is currently no cure for OA and the analgesic pharmaceuticals available do not offer adequate and sustained pain relief, often being associated with significant undesirable side effects. Another disease associated with degenerating joints is Intervertebral disc degeneration (IVDD) which is a leading cause of chronic back pain and loss of function. It is characterized by the loss of extracellular matrix, specifically proteoglycan and collagen, tissue dehydration, fissure development and loss of disc height, inflammation, endplate sclerosis, cell death and hyperinnervation of nociceptive nerve fibers. The adult human IVD seems incapable of intrinsic repair and there are currently no proven treatments to prevent, stop or even retard disc degeneration. Fusion is currently the most common surgical treatment of symptomatic disc disease. However, radiographic follow-up studies have revealed that many patients develop adjacent segment disc degeneration due to altered spine biomechanics. The development of safe and efficacious disease modifying OA drugs (DMOADs) that treat pain and inflammation in joints will improve our ability to control the disease. I addition, a biologic treatment of IVDD is desirable. This presentation will provide an overview of recent advances and future prospects of a multimodal biologic treatment of OA, and IVDD. We will focus on Link N, a naturally occurring peptide representing the N terminal region of link protein and the first 1–8 residues of Link N (short Link N, sLN) responsible for the biologic therapy in question

Introduction and Objective. Total knee arthroplasty (TKA) is a frequently and increasingly performed surgery in the treatment of disabling knee osteoarthritis. The rising number of procedures and related revisions pose an increasing economic burden on health care systems. In an attempt to lower the revision rate due to component malalignment and soft tissue imbalance in TKA, robotic assistance (RA) has been introduced in the operating theatre. The primary objective of this study is to provide the results of a theoretical, preliminary cost-effectiveness analysis of RA TKA. Materials and Methods. A Markov state-transition model was designed to model the health status of sixty-seven-year-old patients in need of TKA due to primary osteoarthritis over a twenty-year period following their knee joint replacement. Transitional probabilities and independent variables were extracted from existing literature. Patients’ state in the transition model was able to change on an annual basis. The main differences between the conventional and RA TKA were the outlier rate in the coronal plane and the cost of the procedure. In RA TKA, it was hypothesized that there were lower revision rates due to a lower outlier rate compared to conventional TKA. Results. The value attributed to the utility both for primary and revision surgery has the biggest impact on the ICER, followed by the rate of successful primary surgery and the cost of RA-technology. Only 2.18–2.34% of the samples yielded from the probabilistic sensitivity analysis proved to be cost-effective (threshold set at $50000/QALY). A calculated surgical volume of at least 191–253 cases per robot per year is needed to prove cost-effective taking the predetermined parameter values into account. Conclusions. Robot-assisted TKA might be a cost-effective procedure compared to conventional TKA if a minimum of 191 cases are performed on a yearly basis, depending on the cost of the robot. The cost-benefit of the robotic TKA surgery is mainly based on a decreased revision rate. This study is based on the assumption that alignment is a predictor of success in total knee arthroplasty. Until there is data confirming the assertion that alignment predicts success robot-assisted surgery cannot be recommended

Congenital talipes equinovarus (CTEV), also known as club foot or talipes is a common congenital disorder. Parents are using the Internet more and more as a source of information about health care. Unfortunately, the quality of health care information on the Internet varies. This study looked at information available to parents using two instruments for judging the equality of information on the internet. The top five search engines were searched on Google. Three of these were also included in the top 50 sites in Ireland so these 3 sites were used. The phrases CTEV and club foot were searched from all 3 platforms. Websites were then scrutinized using the HON code and the DISCERN tool. 54 organic sites were found for the 3 search engines using the key word club foot. For the key word CTEV 55 matches were returned for the three search engines. 4 websites displayed the HON code. Using the discern tool CTEV websites had a mean score of 60 with a standard deviation of 17. While club foot had a mean score of 56.8 with a standard deviation of 13. Max score 80. Large volumes of information are available to parents on the Internet. Often parents find comfort in sharing experiences and feel empowered by learning about their children's illnesses. However, information provided on the interned can also be ambiguous and disingenuous. Practitioners should be aware of a number of key websites that parents can be directed towards

Introduction and Objective. Hip fractures represent one of the most challenging injuries in orthopaedic practice due to the associated morbidity, mortality and the financial burden they impose on the health care systems. By many still considered as the gold standard in the management of intertrochanteric fractures, the Dynamic Hip Screw utilizes controlled collapse during weight bearing to stabilize the fracture. Despite being a highly successful device, mechanical failure rate is not uncommon. The most accepted intraoperative indicator for lag screw failure is the tip apex distance (TAD), yet lateral femoral wall thickness (LWT) is another evolving parameter for detecting the potential for lateral wall fracture with subsequent medialization and implant failure. The aim of this study is to determine the mean and cut off levels for LWT that warrant lateral wall fracture and the implications of that on implant failure, revision rates and implant choice. Materials and Methods. This prospective cohort study included 42 patients with a mean age of 70.43y with intertrochanteric hip fractures treated with DHS fixation by the same consultant surgeon from April 2019 to December 2019. The study sample was calculated based on a confidence level of 90% and margin of error of 5%. Fracture types included in the study are 31A1 and 31A2 based on the AO/OTA classification system. LWT was assessed in all patients preoperatively using Surgimap (Nemaris, NY, USA) software. Patients were divided into two groups according to the post-operative integrity of the lateral femoral wall, where group (A) sustained a lateral femoral wall fracture intraoperatively or within 12 months after the index procedure, while in group (B) the lateral femoral wall remained intact. All patients were regularly followed up radiologically and clinically per the Harris Hip Score (HHS) for a period of 12 months. Results. At 12 months five patients (12%) suffered a postoperative lateral wall fracture, while in 37 patients (88%) the lateral femoral wall remained intact. The mean preoperative LWT of patients with a postoperative lateral wall fracture was 18.04 mm (SD ± 1.58) compared to 26.22mm (SD ± 5.93) in the group without a lateral wall fracture. All patients with post-operative lateral femoral wall fracture belong to 31A2 group, while 78.4% of the patients that did not develop post-operative lateral femoral wall fracture belong to 31A1 group. Eighty percent of patients in group (A) experienced shortening, collapse, shaft medialization and varus deformity. The mean Harris hip score of group (A) was 39.60 at 3 months and 65.67 at 6 months postoperatively, while that of group (B) was 80.75 and 90.65 at 3 and 6 months respectively, denoting a statistically significant difference (P<0.001). Treatment failure meriting a revision surgery was 40 % in group (A) and 8% in group (B) denoting a statistically significant difference (p<0.001). The cut-off point of LWT below which there is a high chance of post-operative lateral wall fracture when fixed with DHS is 19.6mm. This was shown on the receiver operating curve (ROC) by plotting the sensitivity against the 100 % specificity with a set 95% confidence interval 0.721 – 0.954. When lateral wall thickness was at 19.6 mm, the sensitivity was 100% and specificity was 81.8%. The area under the curve (AUC) was 0.838, which was statistically significant (P = 0.015). Conclusions. Preoperative measurement of LWT in elderly patients with intertrochanteric hip fractures is decisive. The cut off point for postoperative lateral wall fracture according to our study is 19.6 mm; hence, intramedullary fixation has to be considered in this situation

Abstract. Objective. In this systematic review we aim to analyse the economical impact of using Negative Pressure Wound Therapy (NPWT) in primary total knee arthroplasty (TKA). Methods. Four medical electronic databases were searched. Eligible studies included those investigating the costs of NPWT in primary TKA. Exclusion criteria included studies investigating cost of NPWT not related to primary TKA. We also excluded studies with poor scientific methodology. We retrieved and analysed data on dressing costs and hospital length of stay (LOS). Results. Three studies (359 patients) reported on dressing and associated health care costs, and two further studies (330 patients) reported on hospital LOS in primary TKA. The cost of NPWT ranged between £125 and £196; with an average cost of £155, compared to £23 for the regular surgical dressing. The hospital LOS in NWPT patients ranged from 1.9 – 3.8 days, while LOS in patients managed with regular surgical dressing ranged between 2.3 – 4.7 days. The hospital LOS accounted for delayed discharge due to wound complications. Any extended LOS secondary to medical comorbidities or for other reasons were not included here. Conclusion. Our pooled analysis found a decrease in hospital LOS from wound related problems when using NWPT instead of regular dressings after accounting for other variables responsible for LOS. If the mean cost of overnight inpatient hospital stay for elective TKA is estimated as £275, the range of overnight admission cost for one TKA patient would be £522 - £1045 when NPWT dressing is used, and £632.5 - £1292 when using regular dressings. The cost savings from reduced LOS amounts to £110 - £247 per patient when NPWT is used. We hypothesize that in primary TKA patients with high risk of wound related problems that may delay discharge from hospital, there may be an overall cost saving when using NWPT dressings. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Background. Recent articles in the medical press highlight the potential dangers of Cauda Equina Syndrome (CES). CES has the highest rates of litigation due to its long-term neurological impairment, which can lead to devastating outcome on patients. The aim of this study was to assess health care professionals knowledge with regards to the urinary symptoms of CES and the timeframe in which treatment should be offered. Objectives. To assess health care professionals knowledge with regards to urinary symptoms of CES and when treatment should be offered. Design. A 4-part questionnaire established profession and number of cases seen per week. The participant was asked to rank 15 urinary symptoms, 7 of these symptoms were not related to CES. The participants were asked the ideal time to surgical intervention for Complete CES and Incomplete CES. Setting. Primary and Secondary Care. Participants. 60 questionnaires were complete. Participants had to successfully complete the first three parts of the questionnaire (n = 44). Any who failed to complete section four were excluded from analysis from that part only (n = 41). Interventions. Nil. Outcome measures. As design. Results. A total of 44 questionnaires were analysed. Both doctors and physiotherapists ranked the CES symptoms on average significantly higher than then the non-CES symptoms. The physiotherapists rated the CES symptoms significantly higher than the doctors (P = 0.05) and on average rated the non-CES symptoms significantly lower than doctors (P < 0.05). 87.8% thought that complete CES should be treated < 24 hours and 9.76% thought that complete CES should be treated from 24-48 hours. 46.34% thought that CESI should be treated < 24 hours and 43.9% thought that CESI should be treated from 24-48 hours. Conclusion. These results demonstrate that physiotherapists are better than Doctors at identifying the urinary symptoms in CES. The majority of health care professional who took part in this study stated that they would offer surgical intervention for both Complete and Incomplete CES within 24 hours. The gap in knowledge highlights the need for education to all medical professionals in the symptoms of CES and also the timing of treatment

Background-. Health care is best delivered face to face, doctor to patient. However, in some places like Scotland, patients can be in remote areas, far from the nearest health care provider. Medical video conferencing (VC) enables patients and doctors to meet for consultations from wherever they may be without the need for travel, and is already used widely in countries like Australia and Canada. Aim-. To do a pilot study of using the existing VC facility at our hospital for surgical pre-assessment of patients for elective foot/ankle and lower limb arthroplasty surgery. Methods- A prospective pilot study was performed at our hospital after approval from our ethics committee. Patient-records were vetted to include/exclude from the study and cases considered as “straightforward” were included. Two separate rooms with VC facility were set up in the orthopaedic outpatients, one with the patient and a trained physiotherapist, while the surgeon used the second room to discuss patient's complaints, do a physical examination, and discuss surgery where appropriate. Results-. 120 patients were included in the study out of which 82 (68 %) patients were seen exclusively through VC. Out of the 82, there were 42 foot/ankle cases and 40 cases for lower limb arthroplasty (TKR/THR). There were 40 cases where the VC consultation had to be converted into a face-to-face consultation mainly because the surgeon (31/40) was not entirely satisfied with the VC consultation (inadequate information in notes, anxious patient, etc). Conclusion-. We found that the VC consultation worked for a large majority of “straightforward” elective foot/ankle and lower limb arthroplasty conditions. We believe that there is certainly a role for VC consultation, especially for patients in rural/remote areas of Scotland, thus bringing down the cost and inconvenience of patient transport considerably