Aims

To develop a multidisciplinary health research agenda (HRA) utilizing expertise from various disciplines to identify and prioritize evidence uncertainties in orthopaedics, thereby reducing research waste.

The authors felt that it would be an interesting and worthwhile exercise to examine the process and management of open long-bone fractures referred to East Grinstead as we felt that we were not achieving the timeframe, as advised by the BOA/BAPS guidelines. Methods The notes of patients who were referred East Grinstead for soft tissue management of long-bone fractures were examined over a 1 year period and analysed. After the results were seen to be poor in terms of management, practices were changed and the following year’s patients’ management underwent the same analysis prospectively. Results The first years audit revealed average day of referral of 6.1, day of transfer was 13.2 days and time to soft tissue coverage was 18.3 days. 8% of patients achieved the BOA/BAPS guidelines of coverage by day 5. The second cohort of patients showed little improvement in their process of care

Background. We identified several opportunities to significantly reduce cost for hip and knee arthroplasty procedures:. Customized instruments: by identifying the essential instruments for arthroplasty cases, we managed to have one universal tray for each case, and 3 specific trays from the implant manufacturing company. Customized wrap-free, color-coded, stackable trays: by using a wrap-free trays, preparation time in central sterile, opening tray time in OR and turn-over time were reduced. Also, stackable trays were organized based on side and size, therefore only 2 trays needed to be used in each case. Discounted implants: negotiated through optional case coverage with revision system and reps available as backup. Optional rep coverage protocols: designed through process management of the operating room surgical staff and central sterile. Aim of the study was to measure the cost savings, efficacy, and outcomes associated with primary total hip and knee arthroplasty by implementing these protocol. Methods. This is a prospective study from January to October 2016 for selected primary total hip and knee arthroplasties were performed with the above protocols by 2 experienced arthroplasty trained surgeons, were followed for minimum 3 months. Initiating the cost saving protocols were achieved by re-engineering customized trays, discounted implants through optional case coverage (Sourced Based Selection of a Cooperating Manufacturer, MTD), and focused on process management of the staff training. Staff responsibilities were divided into 2 categories:. Familiarity of the instruments, implant, and techniques; trays set up and assurance of availability of the implants. These responsibilities were covered by a trained OR technician and the surgeon. Final verification of the accurate implants prior to opening the packaging. This was achieved by a trained OR nurse and the surgeon. Results. We did not have any intra-operative complications. We also did not encounter any issued with the trays or errors in opening of the implants. There were no re-admissions, fracture, dislocation, or infection. The mean length of stay was 2.2 ± 0.5 days (range 1–3 days) with 68% home discharges. The cost of the implant was reduced from $4,800 to $1,895 with $2,905 cost saving per case and total savings of $58,100. The projected savings only for uncomplicated primary total hip arthroplasty (minimum 120 cases/year between 2 surgeons) is $384,600. Further cost saving from the process management changes were seen in central sterile processing time. Prior to the one tray system, the hospital had 3 in-house trays and there were 4 device company trays. We also noticed an approximate 27% improvement in turnover time. Conclusion. Repless model has significant cost saving potential. Preparation for the transition, proper patient selection, standardization of the trays and implants, and distribution of the responsibilities between OR nurses, technicians and the surgeon are essential

Purposes of the study and background. Cognitive Functional Therapy (CFT) is a psychologically informed, physiotherapist-led intervention that targets the biopsychosocial complexity of persistent low back pain (LBP). CFT has demonstrated positive outcomes in two randomised controlled trials (RCT) but has not previously been evaluated in the United Kingdom National Health Service (NHS). This study aimed to determine the feasibility of completing a definitive RCT, that will evaluate the clinical and cost-effectiveness of CFT in comparison to usual physiotherapy care (UPC) for people with persistent LBP in the NHS. Methods and results. A two-arm parallel feasibility RCT compared CFT with UPC in participants with persistent LBP. Data concerning study processes, resources, management and patient reported outcome measures (disability, pain intensity, quality of life and psychosocial function) were collected at baseline, three and six-month follow-up, analysed and evaluated in order to establish feasibility. Sixty participants (n=30 CFT and n=30 UPC) were recruited with 71.6% (n=43) retained at six-month follow-up. CFT was delivered to fidelity, relevant and clinically important outcome data were rigorously collected and CFT was tolerated by participants with no safety concerns. The Roland-Morris disability questionnaire was the most suitable primary outcome measure and sample size calculations were completed for a definitive RCT. Intention to treat analysis indicated a signal of effect in favour of CFT with moderate and large between group effect sizes observed across outcome measures at six-month follow-up. Conclusion. It is feasible to conduct a randomised study of CFT in comparison to UPC for NHS patients. A future fully powered clinical and cost effectiveness RCT could be completed. Conflicts of interest: No conflicts of interest. Sources of funding: Chartered Society of Physiotherapy, Physiotherapy Research Foundation

Introduction. Hip and knee device sales representatives (reps) can provide intra-operative guidance through their knowledge of the products, especially in complicated cases such as revision hip and knee arthroplasty. However, for an experienced arthroplasty surgeon in the majority of straightforward primary cases, the rep's presence may not be required for clinical decision-makings. With recent challenges in cost savings and bundle payments, hospitals and surgeons have focused on reducing the implant costs, among others, with a “repless” model. The aim of this study was to describe the process of utilizing this model, assess its efficacy, and analyze the cost savings in primary hip arthroplasty. Methods. During the month of January 2016, 20 cases of primary, straightforward total hip arthroplasties were performed with the repless model by 2 experienced arthroplasty trained surgeons. All patients were followed prospectively for minimum 3 months. Prior to initiating the repless model, we focused on process management of the operating room with staff training and re-engineering of the trays to obtain a setup that included one hospital tray and one device company tray for each operation. The responsibilities of the rep were divided into 2 categories for better management:. Familiarity of the instruments, implant, and techniques; trays set up and assurance of availability of the implants. These responsibilities were covered by a trained OR technician and the surgeon. Final verification of the accurate implants prior to opening the packaging. This was done by a trained OR nurse and the surgeon. Results. We did not have any intra-operative complications. We also did not encounted any issued with the trays or errors in opening of the implants. There were no re-admissions, fracture, dislocation, or infection. The mean length of stay was 2.2 ± 0.5 days (range 1–3 days) with 68% home discharges. The cost of the implant was reduced from $4,800 to $1,895 with $2,905 cost saving per case and total savings of $58,100. The projected savings only for uncomplicated primary total hip arthroplasty (minimum 120 cases/year between 2 surgeons) is $384,600. Further cost saving from the process management changes were seen in central sterile processing time. Prior to the one tray system, the hospital had 3 in-house trays and there were 4 device company trays. We also noticed an approximate 27% improvement in turnover time. Conclusion. Repless model has significant cost saving potential. Preparation for the transition, proper patient selection, standardization of the trays and implants, and distribution of the responsibilities between OR nurses, technicians and the surgeon are essential

A variety of challenging shoulder pathology will be presented to a panel of expert shoulder surgeons for their diagnostic evaluation, decision making, surgical management and aftercare. They will discuss the decision making processes and management options to consider in striving to obtain optimal outcomes

The undergraduate curricula in the UK have no designated modules on sarcomas. Lumps and bumps are commonly presented to surgeons, hence awareness of sarcoma is important. The aim of this study was to identify the awareness and knowledge of orthopaedic and surgical trainees relating to the presentation, referral and management of sarcomas. Participants were invited to take part and complete an online questionnaire. Sarcoma knowledge was assessed using a variety of questions. Key resources were provided to improve knowledge at the end of the questionnaire. There were 250 respondents, which included medical students (n=49), foundation doctors (n=37), core surgical trainees (n=58), registrars (n=73), post-CCT surgeons (n=9) and academic fellows (n=4). Both UK and international trainees were included. 45% did not recall receiving sarcoma teaching at undergraduate level, with 61% stating they did not have adequate training to identify sarcoma “red flags”. 58% did not have sufficient background knowledge of sarcomas whilst 38% were unable to identify sarcoma red flags. 64% and 25% of trainees had insufficient knowledge of the correct referral process and management for sarcomas respectively. There appears to be a deficiency in training regarding sarcoma identification and management within trainees. “Red flags” for lumps are not widely known who may be asked to review these patients. Many trainees are not aware of the national guidelines for referral and management. The large sample of respondents is likely to be representative of the larger trend and may lead to inappropriate management, poor outcomes and litigation

There is a high rate of mortality in elderly patients who sustain a fracture of the hip. We aimed to determine the rate of preventable mortality and errors during the management of these patients. A 12 month prospective study was performed on patients aged > 65 years who had sustained a fracture of the hip. This was conducted at a Level 1 Trauma Centre with no orthogeriatric service. A multidisciplinary review of the medical records by four specialists was performed to analyse errors of management and elements of preventable mortality. During 2011, there were 437 patients aged > 65 years admitted with a fracture of the hip (85 years (66 to 99)) and 20 died while in hospital (86.3 years (67 to 96)). A total of 152 errors were identified in the 80 individual reviews of the 20 deaths. A total of 99 errors (65%) were thought to have at least a moderate effect on death; 45 reviews considering death (57%) were thought to have potentially been preventable. Agreement between the panel of reviewers on the preventability of death was fair. A larger-scale assessment of preventable mortality in elderly patients who sustain a fracture of the hip is required. Multidisciplinary review panels could be considered as part of the quality assurance process in the management of these patients. Cite this article: Bone Joint J 2014;96-B:1178–84

UK personnel have been deployed in Afghanistan since 2001 and over this time a wealth of experience in contemporary war surgery has been developed. Of particular note in the latter Herrick operations the injury pattern suffered by personnel is largely blast wounds, primarily from improvised explosive devices. With the development of improved body armour, previously unsurvivable blasts now result in a large number of traumatic amputations, predominantly affecting the lower limb. Faced with this, deployed medical personnel in the Role 3 facility, Camp Bastion, have developed, by a process of evolution, a standard process for timely management of these injuries. We present a documented schema and photographic record of the ‘Bastion’ process of management of traumatic amputation through the resuscitation department, radiology, theatres and post-operatively. In resuscitation the priority is control of catastrophic haemorrhage with exchange of CAT tourniquets to Pneumatic tourniquets. While undergoing a CT, time can be used to complete documentation. In theatre a process of social debridement & wash then sterile prep followed by formal debridement allows rapid management of the amputated limbs. This work provides a record of current best practice that generates maximum efficiency of personnel and time developed over a large number of procedures. This allows reflection both now in relation to continuing Herrick operations and when military medical services are faced with a future conflict and an inevitable change in injury patterns