This article presents an overview of mycetoma and offers guidelines for orthopaedic surgeons who may be involved in the care of patients with this condition.

Cite this article: Bone Joint J 2014;96-B:420–5.

Chondroblastomas arise in the epiphyseal area of bones. In the femoral head this can cause considerable difficulty in obtaining access as the epiphysis is entirely intra-articular. We have reviewed management and outcome of 10 patients with chondroblastoma of the femoral head to identify outcome and complications. The mean age was 14 years and all presented with pain (frequently in the knee) and a limp. All were diagnosed on plain Xray and MRI. Five younger children were treated by curettage by a lateral approach up the femoral neck (to try and minimise damage to the epiphysis) and five by a direct approach through the joint. Two of the five patients with a lateral approach developed local recurrence whilst none of the direct approaches did. Both local recurrences were cured with a direct curettage. One patient developed overlengthening of the leg by 1cm but there was no case of growth arrest or osteoarthritis. We recommend a direct approach to the lesion whenever possible to give the best chance of cure with a low risk of complications

Aim. This study aimed to evaluate the impact on length of hospital stay from dedicated infectious diseases input for orthopaedic infection patients compared to sporadic infection specialist input. Method. We conducted an observational cohort study of 157 adults with orthopaedic infections at a teaching hospital in the UK. The orthopaedic infections included were: osteomyelitis, septic arthritis, infected metalwork and prosthetic joint infections, and adults were aged 18 years or more. Prior to August 2016, advice on orthopaedic infection patients was adhoc with input principally from the on-call infectious diseases registrar and phone calls to microbiology whereas after August 2016 these patients received regular input from dedicated infectious diseases doctor(s). The dedicated input involved bedside reviews, medical management, correct antimicrobial prescribing, managing adverse drug reactions, increased use of outpatient parenteral antimicrobial therapy (OPAT) services especially self-administration of intravenous antibiotics and shared decision-making for treatment failure, whilst remaining under orthopaedic team care. Orthopaedic patients operated on for management of their infection between 29/8/16 and 15/3/17 were prospectively identified and orthopaedic operation records were used to retrospectively identified patients between 29/8/15 and 15/3/16. The length of stay was compared between the 2 groups. Results. There were 83 patients in the dedicated infectious diseases input group (dedicated group) and 74 patients in the sporadic infection specialist input group (sporadic group). The dedicated group were significantly younger: median 58 years versus 69years (p<0.001), and there was a trend to significant differences in the breakdown of diagnosis (p=0.06), but no significant sex difference. The median length of stay for the sporadic group was 20 days (interquartile range (IQR) 13–29 days) compared to 14 days (IQR 9–27 days) for the dedicated group, with a trend to significance (p=0.06) but no effect from age or diagnosis. Our hospital values one day in hospital at £864, therefore over the 6.5 months trial period of the dedicated infectious diseases input there was a cost saving of £430,272 (£864 × 6 days × 83 patients). Conclusions. Dedicated infectious diseases input would be expected to improve patient care but by additionally reducing median length of stay for orthopaedic infection patients, this encourages investment to achieve both. In this era of increased scrutiny of health budgets demonstrating value for money, not just improved quality of patient care, is essential

Introduction. The Center for Medicare Services (CMS) recently proposed its phase 3 “Quality metrics” which include a section on patient engagement. CMS uses a fitness monitor as an example of an acceptable way for patients to contribute to the health record. Wearable technology allows measurement of activity, blood glucose, heart rate, sleep, and other health metrics, all of which can be useful in the management of patients in the orthopaedic practice. The purpose of this study is to thoroughly review existing fitness devices; and evaluate their potential uses in orthopaedic practice. Methods. Several fitness devices exist; we focused on the top 27 based on popularity mentioned in reputable tech review articles. Features of each device were reviewed including type, specifications, interfaces, measurable outcomes (HR, steps, distance, sleep, weight, calorie intake), cost to the patient, barriers to compliance and strengths. Ultimately all these factors were taken into consideration to look into potential uses for orthopaedic surgery. The orthopedic applications of these devices were reviewed. Nonsurgical management applications were: compliance with physiotherapy, distance walked and stairs completed, and compliance with activity restrictions. Preoperative optimization included detection of sleep apnea, blood glucose monitoring, preoperative weight, and preoperative activity level. Postoperative outcomes included postoperative activity level, stairs, and distance walked. Results. Twenty-seven devices were reviewed of which 26% were targeted for the beginner, 33% for runners and 41% were multipurpose fitness trackers. Most were designed as either a wrist band (26%) or watch (30%). Several used a smartphone as an interface (33%) while the majority (52%) synced automatically via Bluetooth to either the online, mobile device, smartphone or pc application. The majority (37%) had excellent battery life, over 7 days; all were either waterproof (26%) or water resistant (74%), and some (41%) had GPS tracking. A pedometer was included in 85% of devices, 63% monitored HR of which 26% required a separate chest strap or forearm strap, 7% measured respiratory rate and 7% devices measured temperature. Sleep was recorded in 63% of devices, mostly as length of sleep and quality of sleep based on wrist movement. One device was able to differentiate between sleep phases allowing the application of sleep apnea assessment for preoperative testing. Twenty devices monitored weight, twenty two monitored calorie intake, three could monitor glucose readings, seventeen measured distance walked, whereas five measured both stairs and distance walked. A few devices (15%) are already linked to electronic medical records (EMR), the majority allowed for sharing (67%) and 19% are linked to insurance companies which provide incentivized reimbursement rates. Conclusion. The fitness device technology has yet to be explored or implemented widely in orthopaedic surgery. We demonstrated how fitness devices can assist the orthopaedic surgeon in measurement of basic outcomes and can also assist with preoperative, perioperative and postoperative care. Further research is warranted as the use of these devices increases. Patient privacy issues may come into play as more practices employ these devices for their patients

Frequently, radiological data is transferred verbally between ED/GP/LMO to the Orthopaedic registrar. Given the different medical backgrounds and presentation skills there is often a limit to the verbal description of the radiographs. The aim of this study is to determine the feasibility and benefits of concurrently using picture messaging of X-rays to enhance communication between ED and Orthopaedic Registrars to optimise patient care. The X-rays of 40 patients referred to orthopaedics OPD or admitted from the ED were photographed and retrospectively reviewed on a mobile phone screen (240 × 320) by an orthopaedic registrar along with a printout of the patient history and verbal description of the x-ray as interpreted by the ED staff. No further information was provided to the registrar. A questionnaire was completed to subjectively and objectively evaluate the therapeutic benefit of the image review. Patient(tm)s management was compared to management plans after image review and differences were attributed to the visual inspection of the x-rays on the mobile phone. Concurrent to the retrospective review, the ED is currently trialling this with a Sony-Erickson K750i. After hours orthopaedic cases are sent via MMS to the registrar prior to consultation. In the emergency department, 10% of patients who presented with a fracture were reviewed in person by an orthopaedics registrar and none were admitted straight from ED whilst two were admitted following review at the OPD. X-rays of 40 patients were reviewed in this study. Twenty-seven patients presented with a fracture and four with islocations. When the clinical data was reviewed alongside images of x-rays by an orthopaedic registrar, a difference in management plans were observed in 25% of cases and 7.5% where surgical intervention would yield a better result. Twenty-six of the twenty-seven fractures and four dislocations were successfully visualised on the MMS. In 18 cases, picture messaging provided additional information compared to verbal report alone. The limiting factor in picture messaging was the resolution and size of the radiograph. Ease of operation and portability was found to be satisfactory by both ED and Orthopaedic staff. Equipping the ED with the phone has enhanced communication with the orthopaedics department and increased the potential for optimising patient care. This will be formally assessed through questionnaires after 12 months trial of the phone. Picture messaging is an inexpensive way of utilising technical advancements to improve patient care. Consistent with current literature, the quality of images was not sufficient as a diagnostic tool but rather a screening tool. Picture messaging is valuable practically and educationally and enhances the consultation and teaching process whilst encompassing medical staff who have limited skills in radiological description