Abstract. Hospitals during Covid 19 were faced with extreme pressures notably on Emergency Departments. This led to delays in treatment for patients in Trauma and Orthopeadics. In order to support Emergency Departments and improve the service provided, this District General Hospital introduced a Specialty Doctor and Consultant led walk in trauma clinic running on weekdays from 9am-5pm. This abstract focusses on three factors. Firstly the time spent in A&E, secondly the time taken for patients to receive basic radiographic imaging and finally availability of the next fracture clinic appointment. A random sample of 100 patients were selected over a 4 week period prior to introduction of this service and compared with 100 patients since this service began. The average time spent in A&E before this service was 197 minutes which was reduced by 86% by to 27 minutes. The average time taken to receive basic imaging reduced by 18.5% from 81 minutes to 66 minutes. Finally prior to the introduction of these clinics the waiting time of the next fracture clinic varied from 3 to 17 days where as now the patient can be seen by a Consultant in a fracture clinic the next working day. Our findings show the walk in Trauma clinic service has proven to be an invaluable service to this DGH and the NHS. As a result of this service patients are receiving a higher quality of care sooner and a case can be made for the introduction of these clinics throughout the country

Abstract. Introduction. Acute kidney injury (AKI) is a common post-operative complication which, in turn, significantly increases risk of other post-operative complications and mortality. This quality improvement project (QIP) aimed to evaluate and implement measures to decrease the incidence of AKI in post-operative Trauma and Orthopaedics (T&O) patients. Methods. Three data collection cycles were conducted using all T&O patients admitted to a single UK West Midlands NHS trust across three six-month periods between December 2018 and December 2020 (n=8215). Patients developing a post-operative AKI were identified using the Acute Kidney Injury Network criteria. Data was collected for these patients including demographic details and AKI risk factors such as ASA grade, hypovolaemia and use of nephrotoxic medications. Results. The percentage of post-operative AKI decreased from 2% (71 patients from 5899 operations) in the first cycles to 1.5% (19 from 1273 operations) by the final cycle. There was a high prevalence of modifiable risk factors for AKI, including post-operative hypovolaemia (50%) and use of nephrotoxic aminoglycosides (81%). Measures implemented between cycles included a pre-operative medication review identifying nephrotoxic medications, early post-operative assessment for consideration of intravenous fluids and junior doctor teaching on fluid therapy. There was a substantial decrease in use of multiple nephrotoxic medications (98% to 59%) and in use of aminoglycosides (88% to 42%) between the final cycles which may explain the reduction in observed AKI incidence. Conclusion. This QIP highlights the benefits of a multifaceted approach in the peri-operative period, through targeting of risk factors in preventing post-operative AKI

Abstract

Background. In the UK 70,000 knee arthroplasties are performed each year. Although outcomes from knee arthroplasties are usually excellent, they can nevertheless lead to negligence claims. The aim of this study was to establish the incidence, cost and cause of negligence claims arising from knee arthroplasties. Method. All claims made to the NHS Litigation Authority between 2003 and 2008, where the operation was knee arthroplasty, were included in this study. Data obtained from the NHS Litigation Authority were reviewed, coded and analysed. For negligence to have occurred, patients must have suffered harm as a result of substandard care. Hence the cause of negligence claims was analysed in terms of: (1) Substandard care and (2) Harm caused. Results. There were 326 claims over the five-year period, resulting in an incidence of 65 claims per year. Of the 326 claims, 246 have been closed with 80 remaining open. 40% of closed claims resulted in the payment of damages. The total cost of negligence claims over the period was £6.6 million. Substandard care commonly encountered in negligence claims was: surgical quality (56%), post-op care (23%), and infection control (8%). Harms commonly encountered in negligence claims were: additional/unnecessary operation (30%), pain (23%) and amputation (8%). Conclusion. There is a significant litigation burden associated with knee arthroplasties. The unexpected prominence of additional/unnecessary operation, pain and amputation in negligence claims emphasise the need for patients to be warned about these risks

We compared the early complication rates of total hip (THA) and total knee (TKA) arthroplasty carried out at a regional orthopaedic hospital (AOC) and two Independent Sector Treatment Units (ISTUs) (WGH and CNH). After THA, reoperation rates were higher at CNH (9%) than AOC (0.6%) or WGH (1.4%). After TKA, reoperation rates at CNH were (8%) higher than AOC (1%) and WGH (1.9%). 5% of patients undergoing TKR at CNH underwent 2 stage revision for deep infection. After THA, dislocation rates at CNH (6%) were higher than AOC and WGH (1.8%). Readmission from CNH (13%) was higher than AOC (1.2%) and WGH (0.6%). Major wound problems at CNH (20%) were higher than WGH (3.8%) and AOC (0.4%). After TKA, major wound problems were higher at CNH (19%) compared to WGH (1.9%) and AOC (1.1%). Readmission rates not requiring surgery from CNH (13%) were higher than AOC. (1.1%) and WGH (1%). AOC and WGH audited their outcomes. None were available from CNH. WGH initially missed many of their complications because they presented at base hospitals elsewhere. ISTUs performed approximately 2/3rds of procedures for which patients had been referred from base hospitals. At CNH, 23% were rejected on grounds of potential co-morbidity. Audit from ISTUs is inferior to NHS hospitals and the results in one of those audited significantly worse. Patients offered surgery at ISTUs should be told that the audited outcome of the surgeon who will be treating them is not known and that, in some, results are inferior to surgery in the NHS

Introduction. Elective Orthopaedics has been targeted by the UK Department of Health as a maximum six-month waiting time for operations could not be met. The National Orthopaedic Project was initiated as a consequence and Independent Sector Treatment Centres (ISTCs) and well established private hospitals were utilised to treat NHS long wait patients. Materials and methods. We audited the primary total hip replacements performed in our hospital in 1998 and 2003 to compare the differences in the patient characteristics in particular age, length of stay and ASA grade. Results. The number of hip replacements increased to 308 in year 2003 from 194 in year 1998. Whilst the number of ASA I patients was the same, the ASA II, III and IV increased by 40%, 260% and 266% respectively. The average length of stay decreased from 14.3 to 11.9 days which was statistically significant, in spite of increased numbers of ASA II - IV patients. Discussion. The NHS hospitals are treating an increasing number of patients who have a higher anaesthetic risk and stay longer in the hospital in the post-operative period. The case mix for primary total hip replacements in large tertiary referral hospitals has changed due to altered patient flow due to cherry picking of NHS waiting lists by the ISTCs. NHS hospitals should be appropriately remunerated for dealing with complex cases. On average based on our data, ASA III patients stay 3 days longer than ASA I (ASA IV - 5 days). The extra cost incurred is £221 (£433) / day x 3 extra days = £ 663 (£ 1329) / case. According to the 2nd annual NJR report, 4,617 ASA III patients were operated in NHS hospitals and the extra cost incurred towards their length of stay would be £3.06 million (£6.1 million)

Purpose. A comparison of patient satisfaction of service provided by independent sector treatment centres versus an index NHS hospital in total knee replacement surgery. Methods. Patients were all initially listed for total knee replacement (TKR) by a single consultant from the index NHS hospital, Derbyshire Royal Infirmary (DRI). Patients were sent a postal questionnaire and asked to rate the TKR service provided by a given hospital, based on recent inpatient experience. Questions covered quality of care delivered by hospital staff and quality of ward environment. Overall satisfaction was rated. Patients electing surgery under Patient Choice at an independent sector treatment centre (ISTC) were asked about factors that influenced their hospital choice. 100 consecutive patients undergoing TKR at DRI and 100 patients choosing ISTC hospitals were identified. All surgery occurred between April 2003 and September 2006. Results. Questionnaire response rates were 79% for DRI patients and 54% for ISTC. Overall patient satisfaction for TKR service was 95% for DRI and 87% for ISTC. An equal 61% rated the surgeons as excellent in both DRI and ISTC hospitals. Nurses and physiotherapists (& occupational therapists) both scored more highly in ISTC groups (Nurses 69% v 45%; physio/OT 57% v 35%). Ward environment rated excellent in 73% for ISTC and 24% for DRI. The most common reason for choosing ISTC was shorter waiting list (42%). Conclusion. ISTC hospitals scored more highly in terms of nurses, physiotherapy & occupational therapy, and ward environment. In part, this may arise from better staffing levels and newer facilities in the ISTC sector. Despite this, overall patient satisfaction for TKR service remained greater at the index NHS hospital. This suggests overall satisfaction depends on more complex factors than staff and ward environment. Further work is needed to compare objective clinical outcomes of TKR between hospital groups within the NHS

Revision surgery for total knee replacement is a complex procedure, carrying an increased risk for the patient and cost for hospitals. As well as increased cost of peri-operative investigations, blood transfusions, surgical instrumentation, implants and theatre time, there is a well documented increased length of stay (LOS), accounting for the majority of actual costs associated with surgery. We compared revision surgery for infection vs. other causes (aseptic loosening, dislocation, mal-alignment). Clinical, demographic and economic data were obtained for 180 consecutive revision total knee replacements performed at a tertiary referral centre between 2003 and 2012. Actual costs and National Health Service tariffs were compared per patient and mean difference calculated. Mean age was 66 years (range 17–87) with 62 male and 117 female patients. Mean LOS for aseptic cases was 10 days (range 1–62) and 20 days (range 4–103) for infection. Mean cost difference in aseptic cases (n = 125) was £−933 (SD = £12,204), and £−3907 (SD = £7,256) for infection (n = 54). Surgery for infection was associated with increased operating times, blood loss and complications compared to revision for aseptic causes. LOS for infection was on average double that for aseptic cases (p < 0.05). Current NHS tariffs do not fully reimburse the increased costs associated with providing a revision knee surgery service, with even greater cost incurred by the treating hospital for infected cases. These losses may negatively influence the provision of revision surgery in the NHS

Background. Medical complications and death are rare events following elective orthopaedic surgery. Diagnostic and operative codes are routinely collected on every patient admitted to English NHS hospitals. This is the first study investigating rates of these events following total joint replacement (TJR) on a national scale. Methods. All patients (585177 patients) who underwent TJR (hip arthroplasty [THR], knee arthroplasty [TKR], or hip resurfacing) between 2005 and 2010 were identified. Patients were subdivided based on Charlson co-morbidity score. Data was extracted on 30-day complication rates for myocardial infarction (MI), cerebrovascular event (CVA), chest infection (LRTI), renal failure (RF), pulmonary embolus (PE) and inpatient 90-day mortality (MR). Results. The overall 90-day MR after THR was 0.44% (1116 of 256013 patients), after hip resurfacing 0.06% (17 in 27314), and after TKR 0.34% (1023 of 301850). MI rate was 0.39% (2257 of 585177). Of these 15.8% (356) died. CVA rate was 0.01% (53). Of these 32.1% (17) died. LRTI rate was 0.60% (3389). Of these 12.1% (410) died. RF rate was 0.35% (2066). Of these 13.9% (287) died. PE rate was 0.71% (4144). Of these 3.9% (161) died. For patients with no co-morbidities, no personal history of PE or DVT, and no post-operative complications (70.8% of all patients in this study, 414061 of 585177), MR was 0.09% (394 patients). Discussion. This national data analysis allows a greater understanding of mortality risk following post-operative complications. Despite the concerns regarding VTE and the high investment in prevention, fatal PE is in fact far less common than mortality after MI, LRTI and RF. This data also shows that the risk of mortality for fit patients without post-operative complications was very low

Anterior Cruciate Ligament injuries are a common cause of downgrade in Service personnel. The Multidisciplinary Injury Assessment Clinic (MIAC) is a service which patients can be referred to for expert musculoskeletal injury management. MIAC has a Fast Track (FT) referral system in place for imaging, and can subsequently refer isolated ACL injuries to a private provider for reconstruction. We examined this pathway in the South West region which has an overall population at risk of 19775. Over 4 years 173 knee injuries were referred to MIAC, of which 32 were ACL injuries. Of the 29 patients referred for MRI, the median time to imaging was 8 days with FT (n=13, range 2–14) and. 15 days via the NHS (n=16, range 5–64). The majority of injuries were found to involve multiple pathologies (n=19), excluding them from FT surgery. Time to NHS clinic from point of referral took a median time of 54 days, and onward delay to surgery was 47 days. None of the referrals to the private provider for reconstruction were accepted (n=3). We have identified aspects of current referral and treatment pathways that are inefficient and discuss a current solution utilising Military surgeons

Background. A recent Cochrane review has shown that total shoulder arthroplasty (TSA) seems to offer an advantage in terms of shoulder function over hemiarthroplasty, with no other obvious clinical benefits. This is the first study to compare complication rates on a national scale. Methods. All patients (9804 patients) who underwent either TSA or shoulder hemiarthroplasty as a planned procedure between 2005 and 2008 in the English NHS were identified using the hospital episodes statistic database. Data was extracted on 30-day rates of readmission, wound complications, reoperation and medical complications (myocardial infarction (MI) and chest infection (LRTI)), and inpatient 90-day DVT, PE and mortality rates (MR). Revision rate at 18 months was analysed for the whole cohort and, for a subset of 939 patients, 5-year revision rate. Odds ratio (OR) was used to compare groups. Results. Mean age was 70.6 years for the TSA group and 69.3 for hemiarthroaplasty. There were no significant differences in 30-day readmission (0.82% vs. 0.83%, OR 0.99 (95% CI 0.63–1.55)), wound complication (0.57% vs. 0.51%, OR 1.11 (0.63–1.94)), and reoperation rates (0.20% vs. 0.22%, OR 0.89 (0.36–2.19)). 18-month revision was significantly higher in the TSA groups (3.03% vs. 1.76%, OR 1.75 (1.33–2.28), but at 5-years no difference was seen (3.85% vs. 3.67%, OR 0.95 (0.46–1.91). The overall 90-day MR was 0.43% (42 patients). 0.58% had a LRTI and 0.29% had an MI. There were 13 DVTs (0.13%) and 22 PEs (0.22%, 5 fatal). Discussion. Despite concerns regarding osteolysis around the glenoid peg after TSA, revision rates at 5 years were not significantly different to hemiarthroplasty. Except for 18-month revision rates, there were no differences in any of the outcome measures in this study. Methods of national data analysis described in this study can provide benchmark values for future subspecialty revalidation

Background. In 2011 20% of intracapsular fractured neck of femurs were treated with an uncemented hemiarthroplasty in the English NHS. National guidelines recommend cemented implants, based on evidence of less pain, better mobility and lower costs. We aimed to compare complications following cemented and uncemented hemiarthroplasty using the national hospital episode statistics (HES) database in England. Methods. Dislocation, revision, return to theatre and medical complications were extracted for all patients with NOF fracture who underwent either cemented or uncemented hemiarthroplasty between January 2005 and December 2008. To make a ‘like for like’ comparison all 30424 patients with an uncemented impant were matched to 30424 cemented implants (from a total of 42838) in terms of age, sex and Charlson co-morbidity score. Results. In patients with an uncemented implant, 18-month revision (1.62% versus 0.57% (OR 2.90 [2.44–3.45], p< 0.001)), 4-year revision (2.45% vs 1.11% (OR 2.28 [1.45–3.65], p< 0.001)) and 30-day chest infection (8.14% versus 7.23% (OR 1.14 [1.08–1.21], p=0.028)) were significantly higher. Interestingly, 4-year dislocation rate was higher in cemented implants (0.60% versus 0.26% (OR 0.45 [0.36–0.55], p< 0.001). No significant differences were seen in 30-day return to theatre, myocardial infarction, cerebrovascular event or 90-day pulmonary embolus. Discussion. In this national analysis of matched patients short and medium term revision rate, and perioperative chest infection was significantly higher in the uncemented group. This supports the published evidence and national guidelines recommending cement fixation of hemiarthroplasty

In the current austere financial climate within the NHS where local healthcare Trusts are reimbursed in a Payment by Results system it is important that we accurately identify the costs associated with surgical procedures. We retrospectively reviewed data of 589 consecutive patients undergoing lower limb arthroplasty surgery and recorded their age, BMI and co-morbidities. The effect of these parameters on operative duration and length of stay (LOS) was analysed. We demonstrate that for a 1 point increase in BMI we expect LOS to increase by a factor of 2.9% (p<0.0001) and mean theatre time to increase by 1.46 minutes (p<0.0001). We also show that for a l-year increase in age, we expect LOS to increase by a factor of 1.2% (p<0.0001). We have calculated the extra financial costs associated with this and believe that the current OPCS coding system for obesity underestimates the financial impact of increasing BMI and age on lower limb arthroplasty Trusts are being inadequately reimbursed. The results of this study have been used to produce a chart that allows prediction of LOS following lower limb arthroplasty based on BMI and age. We also believe that the data produced is of use in planning operating lists

The coronavirus 2019 (COVID-19) global pandemic has had a significant impact on trauma and orthopaedic (T&O) departments worldwide. To manage the peak of the epidemic, orthopaedic staff were redeployed to frontline medical care; these roles included managing minor injury units, forming a “proning” team, and assisting in the intensive care unit (ICU). In addition, outpatient clinics were restructured to facilitate virtual consultations, elective procedures were cancelled, and inpatient hospital admissions minimized to reduce nosocomial COVID-19 infections. Urgent operations for fractures, infection and tumours went ahead but required strict planning to ensure patient safety. Orthopaedic training has also been significantly impacted during this period. This article discusses the impact of COVID-19 on T&O in the UK and highlights key lessons learned that may help to proactively prepare for the next global pandemic.

Cite this article: Bone Joint Open 2020;1-7:420–423.

Introduction. We conducted a study of 312 patients undergoing primary hip and knee arthroplasty in 2005. The aim was to identify the correlation between length of stay, ASA (American society of Anaesthesiologist) grade and BMI (Body Mass Index). Method and materials. 312 patients underwent hip and knee arthroplasty in 2005. ASA grade for surgery was documented by the anaesthetist and BMI by the nurses. 67 patients had inadequate documentation. SPSS software was used for analysis. Results. Of the 245 patients; 35 had ASA grade 1, 144 had ASA grade 2, 64 had ASA grade 3 and 2 had ASA grade 4. Mean length of stay for ASA grade 1 was 6.8 days, ASA grade 2 was 9.75 days, ASA grade 3 was 12.5 days and ASA grade 4 was 13.5 days. There was significant positive correlation (p < 0.01) between the ASA grade and post-operative length of stay. BMI was graded as I (<18.5), II (18.5-24.9), III (25-29.9) and IV (>30). There was no correlation (Pearson's correlation coefficient = 0.184) between BMI and post-operative length of stay. Conclusion. As the ASA grade increases the length of stay in hospital increases. ‘Cherry picking’ of ASA grade I and II patients by the ISTC will increase the average length of stay in NHS hospitals resulting in increased cost. Length of stay on its own is not a good indicator of hospital performance

Background

Dislocation is a major complication following total hip arthroplasty (THA). Aetiology is multi-factorial, but increasing femoral head size may result in lower dislocation rates. The latest England and Wales National Joint Registry (NJR) annual report has highlighted a statistically significant increase in the use of femoral heads of size 36mm+ from 5% in 2005 to 26% in 2009, together with an increase in the use of the posterior approach. The aim of this study was to determine whether national dislocation rates have fallen over the same period.

Aims. The primary aim is to estimate the current and potential number of patients on NHS England orthopaedic elective waiting lists by November 2020. The secondary aims are to model recovery strategies; review the deficit of hip and knee arthroplasty from National Joint Registry (NJR) data; and assess the cost of returning to pre-COVID-19 waiting list numbers. Methods. A model of referral, waiting list, and eventual surgery was created and calibrated using historical data from NHS England (April 2017 to March 2020) and was used to investigate the possible consequences of unmet demand resulting from fewer patients entering the treatment pathway and recovery strategies. NJR data were used to estimate the deficit of hip and knee arthroplasty by August 2020 and NHS tariff costs were used to calculate the financial burden. Results. By November 2020, the elective waiting list in England is predicted to be between 885,286 and 1,028,733. If reduced hospital capacity is factored into the model, returning to full capacity by November, the waiting list could be as large as 1.4 million. With a 30% increase in productivity, it would take 20 months if there was no hidden burden of unreferred patients, and 48 months if there was a hidden burden, to return to pre-COVID-19 waiting list numbers. By August 2020, the estimated deficits of hip and knee arthroplasties from NJR data were 18,298 (44.8%) and 16,567 (38.6%), respectively, compared to the same time period in 2019. The cost to clear this black log would be £198,811,335. Conclusion. There will be up to 1.4 million patients on elective orthopaedic waiting lists in England by November 2020, approximate three-times the pre-COVID-19 average. There are various strategies for recovery to return to pre-COVID-19 waiting list numbers reliant on increasing capacity, but these have substantial cost implications. Cite this article: Bone Jt Open 2021;2(2):103–110

Abstract. Introduction. Specialist Spinal Services provide operative and non-operative management strategies for a variety of conditions ranging from simple pathologies to complex disabling conditions. The existing spinal hub and spoke model implemented in 2015 nationally across the NHS. We aim to assess the effectiveness and pitfalls of the Spinal hub and spoke model in this questionnaire-based study. Methods. We conducted a prospective questionnaire-based study in the Northwest England and attendees of the BOA conference in 2021. Questionnaires included from the hospitals with no local spinal services and those with on-site services were excluded. Questions specific to initial assessment, referrals process, MRI availability, and awareness of Spine Hub and Spoke model. Results. Data collected from 254 orthopaedic surgeons including residents from different regions. Ninety per cent of initial assessments done in the emergency department by doctors without spinal experience. The spinal referral process took between 4–12 hours to receive an opinion. The initial advice given by middle grades of hub following the spinal referrals. 86% of hospitals had no provision to obtain MRI scans out of hours. 90% of orthopaedic surgeons were not confident to convey spine referral outcomes and review them in local clinics. Only 46% surgeons satisfaction with the current model. 78% of middle grades were not aware of the Hub and spoke model. Conclusions. Our survey identified that orthopaedic surgeons expressed the need for local spinal services for non-urgent cases. Based on this survey we recommend a restructuring of the hub and spoke model across hospitals in the NHS

Aims. In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery. Methods. A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”. Results. A total of 13 studies were included in the final analysis. All papers studied the environmental impact of orthopaedic surgery in one of three areas: waste management, resource consumption, and carbon emissions. Waste segregation was a prevalent issue and described by nine studies, with up to 74.4% of hazardous waste being generated. Of this, six studies reported recycling waste and up to 43.9% of waste per procedure was recyclable. Large joint arthroplasties generated the highest amount of recyclable waste per procedure. Three studies investigated carbon emissions from intraoperative consumables, sterilization methods, and through the use of telemedicine. One study investigated water wastage and demonstrated that simple changes to practice can reduce water consumption by up to 63%. The two most common barriers to implementing environmentally sustainable changes identified across the studies was a lack of appropriate infrastructure and lack of education and training. Conclusion. Environmental sustainability in orthopaedic surgery is a growing area with a wide potential for meaningful change. Further research to cumulatively study the carbon footprint of orthopaedic surgery and the wider impact of environmentally sustainable changes is necessary. Cite this article: Bone Jt Open 2022;3(8):628–640

Introduction. We present the first 12 consecutive patients, undergoing elective paediatric limb reconstruction with an external fixator, for the 12-month period October 2020-October 2021. This is a single surgeon series for a newly appointed Consultant with limited previous experience. Arrangements were made for mentoring by a senior surgeon recently retired from the NHS but still active in private practice. Materials and Methods. The average age of patients was 10.5years at the time of frame application (5—15 years). Four frames in three patients were for Blount's; two for sequelae of NF1; two for posteromedial tibial bow with shortening, two for fibula hemimelia; one congenital short femur, one for sequelae of neonatal sepsis and one for bone loss following tumour resection. Results. We present early outcomes and complications for this challenging cohort. Two frames were revision frames, and a further two had had previous frame treatment. Where shortening was a primary component of the deformity (six cases) the mean lengthening required was 5cm (4–6cm). Conclusions. The benefits of this arrangement include enabling newly appointed Consultants to take on complex cases from the start of appointment, dealing with enormous waiting pressures and minimising complications. The BOA reported this year that 25% of the over 45 consultant workforce intend to retire within three years. In this context, a renewed focus is needed on succession planning, proleptic appointments, and novel schemes to retain experienced surgeons within complex NHS practice: we present a successful example of this strategy