The progressive painful and disabling predicament of patients with severe osteoarthritis awaiting a total hip or knee arthroplasty (THA/TKA) results in a decline in muscle mass, strength and function also known as Sarcopenia.

We conducted a cross-sectional, prospective study of patients on the waiting-list for a THA/TKA in the South Australian public healthcare system and compared the findings to healthy participants and patients newly referred from their general practitioners. Participants with a history of joint replacements, pacemakers and cancers were excluded from this study. Outcomes of this study included (i) sarcopenia screening (SARC-F ≥4); (ii) sarcopenia, defined as low muscle strength (hand grip strength M<27kg; F<16kg), low muscle quality (skeletal muscle index M<27%, F<22.1%) and low physical performance (short physical performance battery ≤8). Additional outcomes include descriptions of the recruitment feasibility, randomisation and suitability of the assessment tools.

29 healthy controls were recruited; following screening, 83% (24/29) met the inclusion criteria and 75% (18/24) were assessed. 42 newly referred patients were recruited; following screening, 67% (30/45) met the inclusion criteria and 63% (19/30) were assessed. 68 waiting list patients were recruited; following recruitment, 24% (16/68) met the inclusion criteria and 75% (12/16) were assessed. Preliminary data shows increasing waiting time is associated with higher SARC-F scores, lower hand grip strength and lower muscle quality.

As a pilot study, preliminary data demonstrate that: (1) study subjects’ willingness to participate will enable a larger study to be conducted to establish the prevalence of sarcopenia and the diagnostic cut-off points for this patient group. (2) SARC-F is a suitable tool to screen for sarcopenia. (3) There is a positive correlation between waiting time for a THA/TKA and sarcopenia.

A pilot study of a physiotherapy led shoulder clinic was initiated in January 1999 as a direct response to increasing orthopaedic consultant out-patient clinic waiting times.

The orthopaedic consultant reviews letters from GP’s to the orthopaedic clinic. Patients with benign musculoskeletal shoulder problems are referred to Shoulder Assessment Clinic (SHAC). The physiotherapist completes a subjective and objective assessment and a shoulder score is recorded using Constant and Murley Shoulder (Constant and Murley 1985). The scoring system has a maximum of 100 points indicating perfect, pain-free movement and function. The Constant and Murley Shoulder score remains most widely used and validated scoring system in Europe for the shoulder.

A total of 130 patients were referred to SHAC between January 1999 and December 1999. Sixty-six patients were treated and discharged by physiotherapy alone with an average increase in shoulder score of 40 points. Twenty-seven had surgery, 19 had steroid injection. Overall waiting time to be seen in SHAC was 58 days. Since this initial pilot, 320 patients have been assessed and treated in the SHAC.

Our experience of physio-led shoulder clinic shows patients can be assessed and treated with a far shortened waiting time, and the improved shoulder scores suggest effective treatment. This allows more patients of an appropriate type to be seen in the outpatient orthopaedic clinic.

Objective: Prolonged waiting time after being referred for a specialist opinion has plagued the NHS despite pressures to deliver optimum healthcare. We have assessed changes in clinical situation in patients referred to a spinal service while awaiting the first assessment.

Materials & Results: 89 patients were referred to our unit between Jan 2001 and December 2004. The gender distribution in this cohort was equal and the mean age was 50.7 yrs. The mean delay for being seen in the clinic was 28.4 mo (16–58 mo). Significant changes in the symptom pattern were noted in 46 patients, of which 8 patients reported radicular symptoms on a different side. In addition, 7 patients experienced an increased severity in the existing symptoms. 43 patients had been referred to us with an MRI. However due to the delay, 20 of these patients required re-scanning. Following the clinical assessment 25 patients were referred for Physiotherapy, 4 patients required a further clinical review and 44 patients were referred for further imaging.

Conclusion: The problem of excessive out-patient waiting time results in changes in symptom patterns and an increase in the severity of existing symptoms. The changes frequently results in an increased requirement of re-imaging.

Aims

The aim of this study was to report health-related quality of life (HRQoL) and joint-specific function in patients waiting for total hip or knee arthroplasty surgery (THA or TKA) in Northern Ireland, compared to published literature and a matched normal population. Secondary aims were to report emergency department (ED) and out-of-hours general practitioner (OOH GP) visits, new prescriptions of strong opioids, and new prescriptions of antidepressants while waiting.

Aims

Elective orthopaedic surgery was cancelled early in the COVID-19 pandemic and is currently running at significantly reduced capacity in most institutions. This has resulted in a significant backlog to treatment, with some hospitals projecting that waiting times for arthroplasty is three times the pre-COVID-19 duration. There is concern that the patient group requiring arthroplasty are often older and have more medical comorbidities—the same group of patients advised they are at higher risk of mortality from catching COVID-19. The aim of this study is to investigate the morbidity and mortality in elective patients operated on during the COVID-19 pandemic and compare this to a pre-pandemic cohort. Primary outcome was 30-day mortality. Secondary outcomes were perioperative complications, including nosocomial COVID-19 infection. These operations were performed in a district general hospital, with COVID-19 acute admissions in the same building.

Aims. Waiting times for arthroplasty surgery in Northern Ireland are among the longest in the NHS, which have been further lengthened by the onset of the COVID-19 global pandemic in March 2020. The Department of Health in Northern Ireland has announced a new Elective Care Framework (ECF), with the framework proposing that by March 2026 no patient will wait more than 52 weeks for inpatient/day case treatment. We aimed to assess the feasibility of achieving this with reference to total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods. Mathematical modelling was undertaken to calculate when the ECF targets will be achieved for THA and TKA, as well as the time when waiting lists for THA and TKA will be cleared. The number of patients currently on the waiting list and percentage operating capacity relative to pre-COVID-19 capacity was used to determine future projections. Results. As of May 2021, there were 3,757 patients awaiting primary THA and 4,469 patients awaiting primary TKA in Northern Ireland. Prior to April 2020, there were a mean 2,346 (2,085 to 2,610) patients per annum boarded for primary THA, a mean 2,514 (2,494 to 2,514) patients per annum boarded for primary TKA, and there were a mean 1,554 primary THAs and 1,518 primary TKAs performed per annum. The ECF targets for THA will only be achieved in 2030 if operating capacity is 200% of pre COVID-19 pandemic capacity and in 2042 if capacity is 170%. For TKA, the targets will be met in 2034 if capacity is 200% of pre-COVID-19 pandemic capacity. Conclusion. This modelling demonstrates that, in the absence of major funding and reorganization of elective orthopaedic care, the targets set out in the ECF will not be achieved with regard to THA and TKA. Waiting times for THA and TKA surgery in Northern Ireland are likely to remain greater than 52 weeks for most of this decade. Cite this article: Bone Jt Open 2022;3(4):302–306

Waiting times for arthroplasty surgery in Northern Ireland are among the longest in the National Health Service, which have been further lengthened by the onset of the SARS-CoV-19 global pandemic in March 2020. The Department of Health (DoH) in Northern Ireland has announced a new Elective Care Framework (ECF), with the framework proposing that by March 2026 no patient will wait more than 52 weeks for inpatient/day case treatment. We aimed to assess the feasibility of achieving this with reference to Total Hip Arthroplasty (THA). Waiting list information was obtained via a Freedom of Information request to the DoH (May 2021) and National Joint Registry data was used to determine baseline operative numbers. Mathematical modelling was undertaken to calculate the time taken to meet the ECF target and also to determine the time to clear the waiting lists for THA using the number of patients currently on the waiting list and percentage operating capacity relative to pre-Covid-19 capacity to determine future projections. As of May 2021, there were 3,757 patients awaiting primary THA in Northern Ireland. Prior to April 2020, there were a mean 2,346 patients/annum added to the waiting list for primary THA and there were a mean 1,624 primary THAs performed per annum. The ECF targets for THA will only be achieved in 2026 if operating capacity is 200% of pre COVID-19 pandemic capacity and will be achieved in 2030 if capacity is 170%. Surgical capacity must exceed pre-Covid capacity by at least 30% to meet ongoing demand. THA capacity was significantly reduced following resumption of elective orthopaedics post-COVID-19 (22% of pre-COVID-19 capacity – 355 THAs/annum post-COVID-19 versus 1,624/annum pre-COVID-19). This modelling demonstrates that, in the absence of major funding and reorganisation of elective orthopaedic care, the targets set out in the ECF will not be achieved with regards to hip arthroplasty. Waiting times for THA surgery in the NHS in Northern Ireland are likely to remain greater than 52 weeks for most of this decade

Objective: This article describes the outcome of a nurseled service developed to manage patients referred with a presumptive diagnosis of carpal tunnel syndrome. We also describe the implementation of a nurse-led preoperative assessment and postoperative care clinic. Design: We assess the safety, efficacy and outcomes of 402 patients referred to the Department of Orthopaedic, University Hospital Lewisham for carpal tunnel decompression surgery prospectively. Patients and Methods: The service was developed around the role of a nurse practitioner providing a single practitioner pathway from first clinic appointment to discharge. General practitioners were advised of the service and the criteria for referral, which included patients with symptoms and physical signs, and some response to conservative treatment. Patients were assessed in the nurse-led preoperative assessment clinic and those deemed suitable for surgery were listed for operation. Results: 12.7 % patients (51 patients) were referred for electromyographic studies and 5.2% patients (21 patients) were referred to doctors for further consultations. Only 4 patients had trigger finger and a further 4 patients had De Quervians syndrome. Of the remaining 373 patients, 7 patients (1.8%) choose to wait before considering surgery, and 2 patients (0.5%) declined surgery. Waiting times improved considerably whilst the standard and quality of care was maintained. Conclusions: We developed a rapid-access service in response to unacceptable waiting times for patients with carpal tunnel syndrome. Implementing such a clinic improved access to care for patients with this particular problem. The safety and efficacy of the program and patient-centred outcomes commend its adaptation and implementation to other institutions. As the clinical diagnosis of Carpal tunnel syndrome is often easily made, a system of direct referral for carpal tunnel surgery was introduced. The service was an alternative to standard consultants’ outpatient referral. Direct access to a nurse-led carpal tunnel syndrome assessment clinic works well and it will reduce delays and the costs of treatment. Adequate patient information is vital to make the best of the service. There is a role for nurses to perform certain clinic within a well-defined environment

In the first half of 2000, the Auckland District Health Board was not effectively meeting the Government’s Elective Waiting Times. The Auckland Hospital Orthopaedic Department was initially targeted as it had one of the worst high profile examples given by the Ministry of Health of non-actively managed waiting list and FSA (First Specialist Assessment) process. In September of that year at Auckland Hospital 224 patients were waiting longer than six months to be seen and a number of spinal referrals were waiting up to two years. An Elective Service Project Team was established to place proactive resources to meet the governments’ objectives. A prospective study enlisting all referred patients seen at the spinal clinic was undertaken to determine those patients who subsequently became surgical candidates. The nature of the GP referral in terms of accuracy of urgency, status of the patient at clinic, diagnosis, need for surgery, need for investigation, and finally the patients decision about surgical options were recorded. Concurrently a working party composed of spinal surgeon, clinic staff, hospital GP liaison staff, GP’s, and management was co-ordinated, to develop guidelines for the local GP’s, with the intention of allowing GP’s to better identify those patients who would benefit from referral. Subsequently we liased with the pain clinic to develop a treatment program for those patients who would not be seen by an orthopaedic surgeon, so that their individual problems would be addressed to their satisfaction, and that of the referring GP. A Primary Care Management Guide was also produced for the GP’s. The FSA time has been significantly reduced. Patients have responded positively. We are now able to safely screen patients from referral letters to a back pain management programme and review those at the orthopaedic spinal clinics who are most likely to require surgery so as to maximise the utilisation of resources and to provide better care

Introduction: Waiting times for first specialist assessments (FSA’s) are excessively long and a significant number of patients have to wait for more than six months. Less than 30% of the patients referred to an orthopaedic clinic will require surgery. This means that some patients have to wait over six months to be told that there is no surgical solution to their problem. Aim: To evaluate the role of ‘paper only’ assessments for FSA’s in orthopaedics. Method: One hundred GP referrals were selected randomly and all available investigations (mostly x-rays) were retrieved. The referral letters were retyped and the x-rays processed in order to eliminate all identifying information. A pro forma was used to record data including quality of referral letter, clinical information, investigations and recommendation to the GP in the form of a mock letter. Subsequently the patients were booked into routine orthopaedic clinics without prior knowledge of the investigator and after the face-to-face assessment a letter to the GP was generated. Correlation between the mock and real GP letter was carried out in all cases. Results: The majority of referrals were for back pain and hip or knee problems. The quality of the referrals was satisfactory with only a small percentage of poor and excellent letters. Pain and physical disability information was more consistently available compared with data on social disability. The X-rays when appropriate were available in most cases. The correlation between the mock and real letter was outstanding and in over 90% of the cases the face to face assessment did not alter the outcome of the paper assessment. Conclusions: Paper assessments in orthopaedics are an effective and safe alternative to face-to-face assessments as long as the clinical information in the referral letter is appropriate. This allows for timely advice to the GP and a reduction in waiting times for specialist assessments. This new assessment method is particularly appropriate for conditions that do not benefit from surgery

Introduction. Implant-cement debonding at the knee has been reported previously [1]. The strength of the mechanical interlock of bone cement on to an implant surface can be associated with both bone cement and implant related factors. In addition to implant surface profile, sub-optimal mixing temperatures and waiting times prior to cement application may weaken the strength of the interlock. Aims. The study aimed to investigate the influence of bone cement related factors such as mixing temperature, viscosity, and the mixing and waiting times prior to application, in combination with implant surface roughness, on the tensile strength at the interface. Materials and Methods. Tensile tests were carried out on two types of hand-mixed cement, high (HV) and medium viscosity (MV), sandwiched between two cylindrical Cobalt-Chrome coupons with either smooth (60 grit) or rough (20 grit) surface finishes. 144 Specimens were prepared with a cement thickness layer of 2.5 mm in customised rigs (Figure 1). The samples were grouped and tested at two mixing temperatures (23 and 19 degrees), at different mixing times (HV-30s, MV-45s). Waiting times after mixing were varied between early (1.5 min), optimal (4.5 min) or late (8 min); for HV and 4 min, 7.5 min and 11 min for MV cements. All the samples were cured for 24 hours prior to testing. The peak force and stress was calculated for all specimens. Results and Conclusion. Surface Finish: Rough surfaced samples had significantly higher (p < 0.05) mean tensile forces and stress than smooth samples at both 19 and 23 degrees across HV and MV cement types. Cement Type: MV cements, when applied to rough samples with waiting times of 4 minutes at 23 degrees, and 11 minutes at 19 degrees, resulted in the highest peak tensile forces, followed by 7.5 minutes at 23 and 19 degrees respectively (Figure 2). Temperature at different application times for rough and smooth samples: for MV cement, rough samples prepared at 23 degrees, 4 minutes, and smooth samples at 19 degrees, 7.5 minutes were found to be significantly better (p < 0.05) than their counterparts. For HV cement, 23 degrees was found to be better (p < 0.05) for smooth samples at applications times of 4.5 and 8 minutes and 19 degrees for application times of 1.5 minutes. No significant difference was noted for rough samples for the same. Application times at different temperatures for rough and smooth samples: at both 19 and 23 degrees, there were no differences between application times within the rough sample groups for HV or MV. However, for smooth samples, HV cement, tensile forces were significantly higher (p < 0.05) at 23 degrees in the following order; 8 minutes > 4.5 minutes > 1.5. The results show that implant surface roughness and cement mixing time, temperature, viscosity and application times affect the strength of the interlock at the interface

Introduction: The purpose of this study was to utilise data from the Canadian Joint Replacement Registry (CJRR) to determine trends in the 43,000 total hip and knee replacement surgeries performed annually in Canada. This data will promote improved access to care and evidence-based surgical practice. Total knee replacement in Canada is associated with greater utilisation rates, less morbidity, less re-admissions and lower satisfaction compared to total hip arthroplasty. Method: The Canadian Joint Replacement Registry is conducted by orthopaedic surgeons under the umbrella of the Canadian Orthopaedic Association, funded by Health Canada and administered by the Canadian Institute of Health Information. Inaugurated in 2000, the Canadian Joint Replacement Registry has issued three annual reports, which highlight trends in total hip and knee replacement in Canada over the past decade. Data from this voluntary Registry provide the data for this study. Results: THR and TKR utilisation in Canada increased by 34% from 1994–5 to 2000–01. Total knee replacement utilisation exceeded total hip replacement rates in the mid-1990s and increased TKR use continues to grow. Considerable provincial area variations exist with regards THR and TKR utilisation in Canada. THR and TKR are more commonly performed in female patients with peak utilisation being between 65 and 74 years of age. One third of THRs and TKRs are now performed on patients < 65 years of age. Average length of stay has dropped precipitously over the last two decades. Average length of stay is now approximately five days for THRs and TKRs. In-hospital mortality is higher for THRs (1.51%) as compared to TKRs (0.54%). Complications leading to readmission are more common in THRs. Age-standardised rates of THR and TKR/100,000 population have increased from 1994–5 to present, but are still lower than other countries. Waiting times for surgery remain a problem with most patients waiting more than six months for surgery. One year post-operatively, 96% of patients would have their primary or revision total hip or knee replacement performed again. Patients are more satisfied with the outcome of primary procedures as compared to revisions. THR patients have a higher level of satisfaction than TKR patients. Conclusion: THR and TKR utilisation are dynamic in nature. A national registry such as the CJRR is important in pooling large data sets, allowing trends to be recognised, influencing health care providers and promoting evidence-based surgical practice

Telehealth has the potential to change the way we approach patient care. From virtual consenting to reducing carbon emissions, costs, and waiting times, it is a powerful tool in our clinical armamentarium. There is mounting evidence that remote diagnostic evaluation and decision-making have reached an acceptable level of accuracy and can safely be adopted in orthopaedic surgery. Furthermore, patients’ and surgeons’ satisfaction with virtual appointments are comparable to in-person consultations. Challenges to the widespread use of telehealth should, however, be acknowledged and include the cost of installation, training, maintenance, and accessibility. It is also vital that clinicians are conscious of the medicolegal and ethical considerations surrounding the medium and adhere strictly to the relevant data protection legislation and storage framework. It remains to be seen how organizations harness the full spectrum of the technology to facilitate effective patient care.

Cite this article: Bone Joint J 2023;105-B(8):843–849.

Aims

The primary aim was to assess change in health-related quality of life (HRQoL) of patients as they waited from six to 12 months for a total hip (THA) or total or partial knee arthroplasty (KA). Secondary aims were to assess change in joint-specific function, mental health, quality of sleep, number living in a state worse than death (WTD), wellbeing, and patient satisfaction with their healthcare.

Aims

The aim of this study was to explore whether time to surgery affects functional outcome in displaced proximal humeral fractures

Objectives

Intramedullary fixation is considered the most stable treatment for pertrochanteric fractures of the proximal femur and cut-out is one of the most frequent mechanical complications. In order to determine the role of clinical variables and radiological parameters in predicting the risk of this complication, we analysed the data pertaining to a group of patients recruited over the course of six years.