16 to 34% of the population suffer from shoulder pain, the most common cause being rotator cuff tears. NICE guidance recommends using ultrasound scan (USS) or MRI to assess these patients, but does not specify which is preferable. This study assesses the accuracy of USS and MRI in rotator cuff tears in a DGH, to establish the most appropriate imaging modality. Patients who had at least two of shoulder ultrasound, MRI or arthroscopy within a seven month period (n=55) were included in this retrospective study. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated using arthroscopy as the true result, and kappa coefficients calculated for each pairing. 59 comparisons were made in total. Sensitivity for MRI in full supraspinatus tears was 0.83, and for USS 0.75. Specificity for MRI in these tears was 0.75, and for USS 0.83. Values were much lower in other tears, which occurred less frequently. USS and MRI completely agreed with each other 61.3% of the time. Both modalities were only completely accurate 50% of the time. Kappa coefficient between arthroscopy and MRI for supraspinatus tears was 0.658, and for USS was 0.615. There was no statistical difference between MRI and USS sensitivity or specificity (p=1), suggesting that one modality cannot be recommended over the other for full supraspinatus tears. They also do not tend to corroborate one another, suggesting that there is no benefit from doing both scans. Further research is needed to see how both modalities can be improved to increase their accuracy

Total hip replacement (THR) is NICE recommended for a group of patients with neck of femur fracture (NOF) and guidance published in 2011. In our institution a Hip Fracture Program was established at this time to improve patient care. An audit of the Hip Fracture Program, appropriateness of THR and management following THR was undertaken and compared to NICE standards, set at 100%, and National Hip Fracture Database (NHFD) results. The case-notes for 53 patients (38 female, 15 male) undergoing THR for NOF between 2011 and 2013 were reviewed: median age 70 yrs (34–87), follow-up 28 months (3–57). All patients were initiated on a Hip Fracture Program. 92% were eligible for THR according to NICE guidance. Pre-operative pain management (67%), hourly assessment of pain in ED (4%), surgery with 48 hours (32%), pre-operative orthogeriatric review (58%) and intra-operative nerve block (38%) are areas for development, but most results are comparable to NHFD. Post-operative care is satisfactory with daily mobilisation (87%) and post-operative pain management (100%). No post-operative dislocation or infection was recorded. There was one case of post-operative DVT. This study highlights areas for improvement in hip fracture management and emphasises the benefits in implementing a Hip Fracture Program in this vulnerable patient population

NICE technology appraisal guidance 157 suggests that the oral anticoagulation medication Dabigatran etexilate can be used for the primary prevention of venous thromboembolic events (VTE's) in adult patients who have undergone elective total hip or knee replacement surgery. The NICE guidance reports that 13.8% of patients receiving recommended doses of Dabigatran experienced adverse bleeding events. In the pivotal hip and knee VTE trial, wound secretion only accounted for 4.9% of patients treated with Dabigatran (cf 3.0% of patients treated with Enoxaparin). We report our wound secretion experience after Dabigatran use at Warwick Hospital from March 2009 to March 2010. Of the 788 lower-limb arthroplasties performed, 55 patients (6.9%) had oozing wounds after discharge (Mean=8 days, Range=1-39 days). This resulted in 226 extra home-visits by discharge nurses, 26 positive microbiology cultures and 5 confirmed wound infections needing antibiotic treatment and/or surgical intervention. Incidentally, there were also 2 known cases each of deep vein thrombosis and pulmonary embolus in this cohort. The number of complications was markedly increased from previous years when LMWH was the VTE prophylaxis used. This data suggests that the use of Dabigatran in Warwick Hospital may significantly increase surgical site morbidity and resource output after lower limb arthroplasty

The National Institute of Clinical Excellence (NICE) published guidance for reducing the risk of venous thromboembolism (VTE) in January 2010. This guidance has had a significant impact on the management of all inpatients. It is now mandatory to risk assess every inpatient and commence appropriate treatment if indicated. The guidelines specifically exclude outpatients although NICE recognises' that lower limb cast immobilisation is a risk factor for VTE. The purpose of our study was to establish the current practice for the management of outpatients treated with lower limb casts in England. The NHS Choices website lists 166 acute hospitals in England. A telephone audit was conducted in February 2011. A member of the on call orthopaedic team was asked: 1. Are you aware of the NICE guidelines for VTE prophylaxis? 2. In your department, outpatients treated with a lower limb cast, are they risk assessed for VTE? 3. If a patient undergoes Open Reduction Internal Fixation (ORIF) for an ankle fracture and is discharged wearing a cast, are they given VTE prophylaxis? 4. If yes - for how long are they treated?. Responses were obtained from 150 eligible hospitals (1 FY1, 28 FY2, 44 ST1-ST2, 76 ST3+, 1 Consultant). 62% of responders stated that they were aware of the NICE guidance. 40% of responders stated that outpatients were routinely risk assessed for VTE. 32% of responders stated that ankle fractures treated with an ORIF and discharged wearing a cast would receive VTE prophylaxis. The duration of treatment varied from 5 days, to 6 weeks, to removal of cast. The management of patients treated with a lower limb cast is variable and inconsistent throughout England. Although there are no national guidelines for this patient group, the routine risk assessment of outpatients was higher than anticipated by the authors. We recommend that if VTE prophylaxis is commenced as an inpatient, then it should be continued until the cast is removed

Aim. A new multidisciplinary hip fracture pathway, based on national BOA and NICE guidance, was introduced in our institution to facilitate rapid preoperative medical optimisation and early surgery for patients with hip fractures. The aim of this audit was to assess its impact on patient care and outcomes. Method. A prospective audit of 161 patients admitted with a fractured neck of femur was conducted in the six months before (92 patients) and after (69 patients) implementation of the new pathway. Data included: time to orthogeriatric assessment (TtG); time to surgery (TtS); length of hospital stay (LOS); return to original accommodation; and inpatient mortality rate. Significance was tested using Chi Squared, Fisher's exact and unpaired Student t-Tests. Results. The two groups of patients were equivalent in terms of age, male:female ratio, ASA grade and preoperative AMTS. In the six months after the introduction of the pathway, 85% of patients received a pre-operative medical assessment compared to 19% before (p=0.0001). Average TtG dropped from 91 to 19 hours (p=0.0001). LOS dropped from 24.8 days to 19.5 days (p=0.029). Furthermore, a significant reduction in mortality of 10% (14% before, 4% after, p=0.0336) was found, with an increase in the proportion of patients returning to their original place of accommodation (57% before, 80% after, p=0.0069). Whilst limited by theatre scheduling, there was an observed reduction in TtS of 6 hours (37 vs 31, p=0.0663). Conclusions. Rapid medical optimisation and prompt surgery can significantly reduce length of stay and inpatient mortality of patients with hip fractures. This is especially important in light of their often fragile physiological state and complex co-morbidities. Successful implementation of a multidisciplinary hip fracture pathway can increase the return of patients to their preoperative accommodation, thus maintaining their level of pre-morbid independence and potentially leading to significant future cost savings

NICE technology appraisal guidance 157 suggests that the oral anticoagulation medication Dabigatran etexilate (Pradaxa®, Boehringer Ingelheim) can be used for the primary prevention of venous thromboembolic events (VTE's) in adult patients who have undergone elective total hip (THR) or knee replacement (TKR) surgery. The NICE guidance and the Pradaxa® Summary of Product characteristics (SPC) report that 13.8% of patients receiving recommended doses of Dabigatran experience adverse bleeding events. In the manufacturer's pivotal clinical trials, wound secretion accounted for 4.9% of patients treated with Dabigatran as compared to 3.0% treated with Enoxaparin. The aim of this audit was to assess the impact of Dabigatran on wound complications at a UK district general hospital and to quantify the effect on the postoperative discharge home support services provided by the award-winning South Warwickshire Accelerated Transfer Team (SWATT). We report our experience of Dabigatran use at Warwick Hospital from March 2009 to March 2010. Of the 788 lower limb arthroplasties performed, 681 patients (81.0%) were accepted for SWATT follow-up. Fifty-five (8.6%) of patients accepted by SWATT showed increased wound secretion for greater than 5 days. This included 12.7% of THR and 5.5% of TKR patients. Increased wound secretion resulted in 226 extra home visits by SWATT, at an extra cost of £23,104 (7.5% increase in SWATT budget). Twenty-six of the 55 patients had positive microbial growth when wound secretions were swabbed. Five patients were admitted for management of wound infections. Incidentally, there were 2 reported cases of DVT and PE. These were not in the increased wound secretion patients. In summary, Dabigatran at Warwick Hospital was associated with a higher than predicted incidence of surgical site morbidity, increased resource output and increased postoperative discharge costs. As a consequence, Dabigatran use has been reduced and other oral anticoagulants are being trialled

Introduction. Venous Thromboembolism is a well documented complication of Total hip and total knee replacement, and NICE guidelines recommend use of pharmacological prophylaxis routinely after these procedures. Current practice in our department is use of mechanical prophylaxis routinely, and chemical prophylaxis in high risk cases only. Previous departmental audit has shown VTE rates to be lower than the national average, however medical and haematology audit has contradicted this, and suggested that practices should be revised to include chemical prophylaxis routinely. This study seeks to determine whether we are seeing the full extent of the problem and whether our practices should be revised accordingly. Methods. Retrospective study of all patients presenting to our hospital with suspected DVT/PE from February 2009 – August 2009. Patients were identified through radiology records; every patient undergoing venous Doppler studies or CT pulmonary angiography were included. The casenotes of patients with positive scans were reviewed; and relevant information extracted from the notes. Results. 475 patients presenting with suspected DVT/PE between February 2009 and August 2009. 39 confirmed DVT; 37 confirmed PE. 87% admitted under acute medical intake. 2 confirmed DVT's in post operative THR/TKR patients, accounting for 5.1% of DVT's in this timeframe. No PE's following THR/TKR in this timeframe. Overall postoperative THR/TKR accounts for 2.6% of confirmed VTE in this hospital. Rates of DVT 1.19% of total hip replacements; 0.93% of total knee replacements. Discussion. Actual rates of VTE low amongst our post operative patients, suggesting current methods of thromboprohylaxis are effective. Changes in thromboprophylaxis practices probably not cost-effective; however it is difficult to justify not changing practices due to recent publication of NICE guidance. Rates comparable to previous audit, suggesting that patients are not being ‘missed by orthopaedic audit’

Introduction. Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower limb arthroplasty. Trials supporting its use have not fully evaluated the risks of wound complications related to rivaroxaban. Method. A retrospective cohort analysis of 1558 consecutive patients who underwent total hip or knee replacements within the same hospital during a 19 month period (2009–2010) was performed. The first 489 patients (Group 1) were given tinzaparin postoperatively as per NICE guidance. The following 559 patients (Group 2) were given rivaroxaban. Concerns regarding wound complications prompted a change back to tinzaparin for the next 510 patients (Group 3.) Other than the thromboprophylactic agent used there were no other differences in the pre and postoperative treatments of all these patients. Results. Nine of the 489 patients in Group 1 (tinzaparin) (1.8%, 95% CI 0.9–3.5%) returned to theatre with wound complications within 30 days compared with 22 out of 559 patients in Group 2 (rivaroxaban) (3.94%, 95% CI 2.6–5.9%.) This increase in RTT rate was statistically significant (p=0.046.) After reverting back to tinzaparin 8 out of 510 patients in Group 3 (tinzaparin) (1.6% 95% CI 0.74–3.1%) returned to theatre. This reduction in RTT rate was statistically significant (p=0.02.) Combining the tinzaparin groups (1 and 3) and comparing with the rivaroxaban group (2) further increases the significance of our observations. Tinzaparin RTT was 1.7% (95% CI 1.0–2.7%) compared with rivaroxaban RTT of 3.94% (95% CI 2.6–5.9%) (p=0.01.). Discussion. We observed a significant rise in wound complication necessitating further surgery after a change in thromboprophylactic agent from tinzaparin to rivaroxaban, followed by a significant reduction after reverting back to tinzaparin. We call for further independent randomised controlled clinical trials examining wound related complications with respect to new pharmacological treatments

The rate of Metastatic Spinal Cord Compression (MSCC) has been increasing over recent years with increased patient survival from improved cancer treatment. MSCC presents an increasing demand for spinal surgical resources. NICE guidance was issued in 2008 to improve diagnosis and management and to prevent unnecessary delays which may result in disability. The recent advances in management of cancers coupled with improved spinal surgical approaches have improved the outcome in MSCC. Early surgery has been shown to improve restoration of function. A recent systematic review found that surgery produced superior results to radiotherapy alone for the management of MSCC. However, the quality of evidence so far is mostly from observational studies. We would like to use Bluespier to create a database of MSCC patients referred to our tertiary centre. Our database would include all adult patients referred to the spinal surgical service with MSCC. Information recorded would be the diagnosis, time of onset and imaging, comorbidities, previous interventions, clinical findings, ASIA score, mobility status, sphincteric status, Karnofsky, Tokuhashi, Tomita and Bauer scores. These scores have been shown by numerous studies to have the best predictive value for outcome following MSCC. The SINS and Boriani MSCC protocols will be collected and externally validated. Time to surgery, operative data and intra operative complications will be recorded. PROMs will include the Oswestry / Neck disability index, VAS and SF36 scores. Post operative complications, morbidity and mortality will be collected and the details of any other therapy received. We would score the patients on admission and at 3 months, 6 months and one year post operatively (if survival allows). This will be done in out patients and via postal and telephone questionnaires. The database will flag the time intervals. This database will enable us to improve the quality of care given to patients with MSCC, provide evidence to highlight the importance of prompt referral and surgical intervention, audit our care against the standards set out by NICE and establish the risks, complications and outcomes of surgical intervention in this high risk group. It will be the first study to externally validate and compare several different scoring systems and protocols (above) in the same cohort. Finally, the data can be used to perform a costing analysis for the treatment of MSCC in the NHS

Since NICE issued guidance on preventing venous thromboembolism (VTE), the use of chemoprophylaxis has increased dramatically in trauma and orthopaedics. However, enthusiasm is tempered by a lack of data regarding the true incidence of VTE in everyday practice. We investigated the epidemiology of VTE among ambulatory patients with lower limb injuries within our Trust. We identified all patients who suffered pulmonary embolism (PE) or deep vein thrombosis (DVT) over an 18 month period, and cross-referenced them with our trauma database. All lower limb injuries were included, whether operated or not. Hip fractures routinely receive dalteparin and were excluded. There were 11,594 new attendances or post-operative attendances in all fracture clinics over 18 months. Of these, 4530 had lower limb injuries and were immobilised. There were 21 DVTs and 7 PEs in these patients, an incidence of 0.43% and 0.14% respectively. Of note, three DVTs were in patients with Achilles tendon rupture. The incidence of symptomatic VTE is low in a population of ambulant patients with lower limb injuries in casts, without chemical thromboprophylaxis. Prophylaxis for VTE would thus have a large number needed to treat. The costs and complications of chemoprophylaxis should also be considered before it is introduced universally

Recent recommendations by the National Institute for Health and Care Excellence (NICE) suggest that all patients undergoing elective orthopaedic surgery should be assessed for the risk of venous thromboembolism (VTE).

Little is known about the incidence of symptomatic VTE after elective external fixation. We studied a consecutive series of adult patients who had undergone elective Ilizarov surgery without routine pharmacological prophylaxis to establish the incidence of symptomatic VTE.

A review of a prospectively maintained database of consecutive patients who were treated between October 1998 and February 2011 identified 457 frames in 442 adults whose mean age was 42.6 years (16.0 to 84.6). There were 425 lower limb and 32 upper limb frames. The mean duration of treatment was 25.7 weeks (1.6 to 85.3).

According to NICE guidelines all the patients had at least one risk factor for VTE, 246 had two, 172 had three and 31 had four or more.

One patient (0.23%) developed a pulmonary embolus after surgery and was later found to have an inherited thrombophilia. There were 27 deaths, all unrelated to VTE.

The cost of providing VTE prophylaxis according to NICE guidelines in this group of patients would be £89 493.40 (£195.80 per patient) even if the cheapest recommended medication was used.

The rate of symptomatic VTE after Ilizarov surgery was low despite using no pharmacological prophylaxis. This study leads us to question whether NICE guidelines are applicable to these patients.

Cite this article: Bone Joint J 2014;96-B:426–30.

Osteoporosis is common and the health and financial cost of fragility fractures is considerable. The burden of cardiovascular disease has been reduced dramatically by identifying and targeting those most at risk. A similar approach is potentially possible in the context of fragility fractures. The World Health Organization created and endorsed the use of FRAX, a fracture risk assessment tool, which uses selected risk factors to calculate a quantitative, patient-specific, ten-year risk of sustaining a fragility fracture. Treatment can thus be based on this as well as on measured bone mineral density. It may also be used to determine at-risk individuals, who should undergo bone densitometry. FRAX has been incorporated into the national osteoporosis guidelines of countries in the Americas, Europe, the Far East and Australasia. The United Kingdom National Institute for Health and Clinical Excellence also advocates its use in their guidance on the assessment of the risk of fragility fracture, and it may become an important tool to combat the health challenges posed by fragility fractures.