In current practice in the UK there are three main approaches to investigating suspected scaphoid fractures not seen on initial plain film x-rays. Early MRI of all cases. Review all cases in clinic at two weeks with repeat x-rays. Hybrid model. Virtual Fracture Clinic (VFC) triage to reduce those who are seen in clinic at two weeks by:. ∘. Organising early MRI for those with high-risk presentation. ∘. Discharging those with an alternative more likely diagnosis. Our unit uses the VFC model. We aimed to evaluate its efficiency, safety, clinical outcomes and economic viability. All patients attending the emergency department with either a confirmed or suspected scaphoid fracture between March and December 2020 were included (n=305). Of these 297 were referred to the VFC: 33 had a confirmed fracture on x-ray and 264 had a suspected fracture. Of the suspected fractures reviewed in VFC 14% had an MRI organised directly owing to a high-risk presentation, 79% were brought for fracture clinic review and 17% discharged with an alternative diagnosis such as osteoarthritis. Of those subsequently reviewed in fracture clinic at two weeks: 9% were treated as scaphoid fractures (based on clinical suspicion and repeat x-rays), 17% had MRI or CT imaging organised, 5% did not attend and 69% were discharged. Overall, 17% of cases initially triaged, had further imaging – 41 MRIs and 5 CTs. MRI detected: 5% scaphoid fracture, 17% other fracture, 24% bone contusion, complete ligament tear 10%, partial ligament tear 39% and normal study 10%. The results of MRI minimally affected management. 3 patients were taken out of plaster early, 1 patient was immobilized who was not previously and no patients underwent operative management. In the following 12-month period one patient re-presented with a hand or wrist issue. This approach avoided 218 MRIs, equating to £24000 and 109 hours of scanner time. VFC triage and selective use of MRI scanning is a safe, efficient and cost-effective method for the management suspected scaphoid fractures. This can be implemented in units without the resource to MRI all suspected scaphoid fractures from the emergency department

Knee pain is common, representing a significant socioeconomic burden. Caused by a variety of pathologies, its evaluation in primary-care is challenging. Subsequently, an over-reliance on magnetic resonance imaging (MRI) exists. Prior to orthopaedic surgeon referral, many patients receive no, or incorrect, imaging. Electronic-triage (e-triage) tools represent an innovative solution to address this problem. The primary aim of this study was to ascertain whether an e-triage tool is capable of outperforming existing clinical pathways to determine the correct pre-hospital imaging based on knee pain diagnosis.

Patients ≥18 years with a new presentation of knee pain were retrospectively identified. The timing and appropriateness of imaging was assessed. A symptom-based e-triage tool was developed, using the Amazon LEXbotplatform, and piloted to predict five common knee pathologies and suggest appropriate imaging.

1462 patients were identified. 17% of arthroplasty patients received an ‘unnecessary MRI’, whilst 28% of arthroscopy patients did not have a ‘necessary MRI’, thus requiring a follow-up appointment, with a mean delay of three months (SD 2.6, range 0.2-20.2). Using NHS tariffs, a wasted cost through unnecessary/necessary MRIs and subsequent follow-up appointments was estimated at £45,816. The e-triage pilot was trialled with 41 patients (mean age:58.4 years, 58.5% female). Preliminary diagnoses were available for 34 patients. Using the highest proportion of reported symptoms in the corresponding group, the e-triage tool correctly identified three of the four knee pathologies. The e-triage tool did not correctly identify anterior cruciate ligament injuries (n=3). 79.2% of participants would use the tool again.

A significant number of knee pathology patients received incorrect imaging prior to their initial hospital appointment, incurring delays and unnecessary costs. A symptom-based e-triage tool was developed, with promising pilot data and user feedback. With refinement, this tool has the potential to improve wait-times and referral quality, whilst reducing costs.

Abstract. Objective. Meta-analysis of clinical trials highlights that non-operative management of degenerative knee meniscal tears is as effective as surgical management. Surgical guidelines though support arthroscopic partial meniscectomy which remains common in NHS practice. Physiotherapists are playing an increasing role in triage of such patients though it is unclear how this influences clinical management and patient outcomes. Methods. A 1-year cohort (July 2019–June 2020) of patients presenting with MRI confirmed degenerative meniscal tears to a regional orthopaedic referral centre (3× ESP physiotherapists) was identified. Initial clinical management was obtained from medical records alongside subsequent secondary care management and routinely collected outcome scores in the following 2-years. Management options included referral for surgery, conservative (steroid injection and rehabilitation), and no active treatment. Outcome scores collected at 1- and 2-years included the Forgotten Joint Score-12 (FJS-12) questionnaire and 0–10 numerical rating scales for worst and average pain. Treatment allocation is presented as absolute and proportional figures. Change in outcomes across the cohort was evaluated with repeated measures ANOVA, with Bonferroni correction for multiple testing, and post-hoc Tukey pair-wise comparisons. As treatment decision is discrete, no direct contrast is made between outcomes of differing interventions but additional explorative outcome change over time evaluated by group. Significance was accepted at p=0.05 and effect size as per Cohen's values. Results. 81 patients, 50 (61.7%) male, mean age 46.5 years (SD13.13) presented in the study timeframe. 32 (40.3%) received conservative management and 49 (59.7%) were listed for surgery. Six (18.8%) of the 32 underwent subsequent surgery and nine of the 49 (18.4%) patients switched from planned surgery to receiving non-operative care. Two post-operative complications were noted, one cerebrovascular accident and one deep vein thrombosis. The cohort improved over the course of 2-years in all outcome measures with improved mean FJS-12 (34.36 points), mean worst pain (3.74 points) average pain (2.42 points) scores. Overall change (all patients) was statistically significant for all outcomes (p<0.001), with sequential year-on-year change also significant (p<0.001). Effect size of these changes were large with all Cohen-d values over 1. Controlling for age and BMI, males reported superior change in FJS-12 (p=0.04) but worse pain outcomes (p<0.03). Further explorative analysis highlighted positive outcomes across all surgical, conservative and no active treatment groups (p<0.05). The 15 (18%) patients that switched between surgical and non-surgical management also reported positive outcome scores (p<0.05). Conclusion(s). In a regional specialist physiotherapy-led soft tissue knee clinic around 60% of degenerative meniscal tears assessed were referred for surgery. Over 2-years, surgical, non-operative and no treatment management approaches in this cohort all resulted in clinical improvement suggesting that no single strategy is effective in directly treating the meniscal pathology, and that perhaps none do. Clinical intervention rather is directed at individual symptom management based on clinical preferences. 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

Virtual Fracture Clinic (VFC) is a consultant-led orthopaedic trauma outpatient triage and management service. The use of VFC has recently become commonplace in the United Kingdom. It allows multiple referral sources to the orthopaedic team, with clinical information and imaging reviewed by a consultant in VFC who formulates an appropriate management plan with the patient contacted; either to attend clinic for consultation or discharged with advice over the phone. The VFC is more efficient than a traditionally delivered outpatient fracture clinic service. We have utilized VFC for 1 year at our hospital, East Kent University Hospital Foundation Trust (EKHUFT), and undertook a closed loop audit to evaluate the service and highlight potential areas of improvement. The Objective of the study was to identify whether the implementation of new re-designed VFC referral guidelines together with teaching set across one of the hospitals in EKHUFT improved the effectiveness and standards of VFC referrals. An initial audit was performed of all referrals made to VFC over a 2 weeks period in December 2018. Changes to the VFC referral pathway were implemented, and teaching sessions performed by the orthopaedic team to all referring units, including minor injury units (MIU) and the emergency department (ED). After implementation, re-audit of VFC referrals was performed in February 2019 over a similar 2 weeks period. Patient demographics, diagnosis and outcomes were collected from the online patient record with images reviewed using PACS software. Following intervention, referral rates dropped by 27.7% (136 vs 188 patients) over the 2 weeks periods. Patient demographics, injury type and severity remained the same between the 2 groups. 51.5% (70/136) did not meet VFC pathway criteria after the intervention and were considered inappropriate, compared to 70% in the original group. 15.4% (21/136) referrals could have been managed in the emergency department using the new guidelines and leaflet discharge. 5.1% (7/136) of the referrals should have been referred to orthopaedic on-call acutely and 22% (30/136) of the referrals had a soft tissue injury or no injury identified. This did not change between the 2 groups despite intervention. Referring MIU and ED units require continued support and teaching over a prolonged time period to hopefully see further improvements. Immediate hot reporting of radiographs may further benefit the service, but staffing and funding issues particularly out of hours, means this remains an aspiration

Objectives. “Virtual fracture clinics” have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a “top-down” analysis of the cost effectiveness of this virtual fracture clinic pathway. Methods. National Health Service financial returns relating to our institution were examined for the time period 2009 to 2014 which spanned the service redesign. Results. The total staffing costs rose by 4% over the time period (from £1 744 933 to £1 811 301) compared with a national increase of 16%. The total outpatient department rate of attendance fell by 15% compared with a national fall of 5%. Had our local costs increased in line with the national average, an excess expenditure of £212 705 would have been required for staffing costs. Conclusions. The virtual fracture clinic system was associated with less overall use of staff resources in comparison to national cost data. Adoption of this system nationally may have the potential to achieve significant cost savings. Cite this article: P. J. Jenkins. Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care. Bone Joint Res 2016;5:33–36. doi: 10.1302/2046-3758.52.2000506

The medical model of history, examination and investigation forms the bedrock of diagnosis and management of all patients. The essence is the recognition of patterns of symptoms and signs. In the modern era there are an increasing number of non-medical resources ranging from web-based information, computer diagnostic aids and non-specialist healthcare professionals to provide a diagnosis and commence management of a wide range of conditions, including knee problems. We analysed the quality and patterns of clinical presentation in order to answer the question how closely clinical symptoms and examination findings correlate to diagnosis based on MRI scan and/or arthroscopic findings. The analysis was a dataset of a consecutive series of patients, aged 18 to 45, with no past history of knee problems or end stage arthritis, presenting to a single specialist triage physiotherapist, working within an integrated knee service, who fully completed a standardised knee assessment proforma of presenting symptoms and signs at a large district general hospital. The study comprises 86 patients and 98 knees. We analysed this data based on diagnostic findings of MRI scan or arthroscopy to provide definitive intra-articular diagnosis. Based on standard textbook descriptions of common presentations, we went on to define the patients' presentation history and examination as typical or atypical, with typical meaning the symptoms and signs correlated with the diagnosis. The null hypothesis is that patients have a high chance of typical presentations for common knee conditions. In the 75% of patients with a significant intra-articular pathology we found the majority had chondral rather than meniscal tears 1.7 to 1. Forty four percent of patients had atypical symptoms and 71% had atypical clinical signs, 30% and only 26% of the cohort had both typical symptoms and signs together, reflecting a surprisingly low positive predictive probability of symptoms and signs in this group of patients, particularly those with chondral lesions which was 44%. In this cohort, 57% of the cohort has 3 or more multiple diagnoses. In the diagnostically normal group, 43% had symptoms and signs typical for a meniscal tear. We conclude that clinical symptoms and signs surprisingly inaccurate in guiding intra-articular pathology within the knee, even in a sub-set considered the easy and accurate to assess. The number of multiple diagnoses and the incidence of false positive results also means that simplistic interpretations of non-definitive diagnoses and linear causation of pain pathways should be treated cautiously

The Cochrane Collaboration has produced three new reviews relevant to bone and joint surgery since the publication of the last Cochrane Corner. These are relevant to a wide range of musculoskeletal specialists, and include reviews in lateral elbow pain, osteoarthritis of the big toe joint, and cervical spine injury in paediatric trauma patients.

Objective. The STarT Back Screening Tool (STarT) is a 9-item patient self-report questionnaire that classifies low back pain patients into low, medium or high risk of poor prognosis. When assessed by GPs, these subgroups can be used to triage patients into different evidence-based treatment pathways. The objective of this study was to translate the English version of STarT into Danish (STarT-dk) and test its discriminative validity. Methods. Translation was performed using methods recommended by best practice translation guidelines. Psychometric validation of the discriminative ability was performed using the AUC statistic. The AUC was calculated for seven of the nine items where reference standards were available and compared with the original English version. Results. The linguistic translation required minor semantic and layout alterations. The response options were changed from “agree/disagree” to “yes/no” for four items. No patients reported item ambiguity using the final version. The AUC ranged from .735 to .855 (CI95% .678 to .897) in a Danish cohort (n=311) and .840 to .925 (CI95% .772 to .948) in the original English cohort (n=500). On four items, the AUC was statistically similar between the two cohorts but lower on three psychosocial sub-score items. Conclusions. The translation was linguistically accurate and the discriminative validity broadly similar, with some differences probably due to differences in severity between the cohorts and the Danish reference standard questionnaires not having been validated. Despite those differences, we believe the results show that the STarT-dk has sufficient patient acceptability and discriminative validity to be used in Denmark. Conflicts of interest. None. Sources of funding. This study was financed by a grant from the Region of Southern Denmark. This has not been presented at a national meeting