The poor reporting and use of statistical methods in orthopaedic papers has been widely discussed by both clinicians and statisticians. A detailed review of research published in general orthopaedic journals was undertaken to assess the quality of experimental design, statistical analysis and reporting. A representative sample of 100 papers was assessed for compliance to CONSORT and STROBE guidelines and the quality of the statistical reporting was assessed using a validated questionnaire. Overall compliance with CONSORT and STROBE guidelines in our study was 59% and 58% respectively, with very few papers fulfilling all criteria. In 37% of papers patient numbers were inadequately reported; 20% of papers introduced new statistical methods in the ‘results’ section not previously reported in the ‘methods’ section, and 23% of papers reported no measurement of error with the main outcome measure. Taken together, these issues indicate a general lack of statistical rigour and are consistent with similar reviews undertaken in a number of other scientific and clinical research disciplines. It is imperative that the orthopaedic research community strives to improve the quality of reporting; a failure to do so could seriously limit the development of future research

Purpose: Distal humeral fractures are often difficult injuries to treat. We hypothesise that more complex distal humeral fractures have unacceptable functional outcomes due to multi-factorial reasons.

Methods: 42 patients with AO/ASIF type B and C fractures of the distal humerus who were treated with open reduction and internal fixation over a six year period were included in the study. All patients were from a single district general hospital. 37 (88%) were clinically, radiologically, and functionally assessed for this study, with the remainder either lost to follow-up or expired.

Results: There were 21 type B and 16 type C fractures, all managed by open reduction and internal fixation. Various fixation techniques were utilised. These were performed by consultant surgeons in 14 cases and by surgeons in training in 23 cases. Average follow up was 38 months (range 22–54 months). The arc of elbow motion was 94 degrees (range 58–130), with an average extension deficit of 28 degrees (range 20–55) and an average flexion deficit of 32 degrees (range 15–45). The average arc of forearm rotation was 136 degrees (range 45–140), with an average supination of 68 (range 35–85) and an average pronation of 72 (range 45–90). The complications (n=20/37) included superficial skin infection (n=4), ulnar nerve neurapraxia (n=3), non-union of the humerus fracture (n=2), non-union of olecranon osteotomy site (n=1), intra-articular screw placement (n=1), loosened plate (n=1), loose/backed out screw (n=2), fixed flexion deformity (n=4) and mild elbow instability (n=2). Second surgery was performed in 24% (n=9/37), revision of metal work (n=2), bone grafting (n=2), anterior capsulectomy (n=4), and removal of screw (n=1).

Conclusions: Fractures of the distal humerus are often more complex than appreciated, and challenging to treat, with respect to fracture union and functional outcome. A generalist practice appears adequate for achieving bony union, but inadequate for obtaining low complication rates and functional outcomes. Our data suggest that such injuries may constitute a fracture group requiring the acute intervention by centres that have specific sub-specialisation and adequate rehabilitation facilities

Purpose: There are numerous papers from specialist arthroplasty centres outlining results of total knee arthroplasties but little information from outside these major centres. We carried out a review of a fixed bearing total condylar knee replacement used in Dunedin by a variety of surgeons for over 10 years.

Method: All patients who received a Duracon/PCA fixed bearing total knee replacement between 1992 and 1996 were assessed clinically, fluoroscopically and completed an SF12, WOMAC and IKSS questionnaire.

Results: At a mean 9.7 (8–12) years follow up, 126 (69.6%) patients were available for review and 46 (25%) were deceased. The average age was 72 years (52–88) and the primary diagnosis was osteoarthritis in 95% of the cases. There were 34% Charnley Grade A, 37% Grade B and 29% Grade C respectively.

The average IKS Knee score was 72 (23–97) and the functional score was 68 (0–100) with 74% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 55 (14–99). Ninety per cent of patients were satisfied with their knee and 89% would have the operation again if required.

There was one operative death (PE), one deep infection, 3 PE’s, 3 DVT’s and 5 superficial infections. An MUA was required in 9 cases.

Eight knees were revised. Using ‘all revisions’ as an end point. The survival rate was 95.3% at 10 years.

Conclusion: These results suggest that knee replacements carried out outside specialist arthroplasty centres perform very well with a survival rate of the implant of 95% at 10 years.

Aim. Assess the incidence of Vitamin D deficiency from a cohort of new referrals to a general Paediatric Orthopaedic outpatient clinic and evaluate the relationship between Vitamin D deficiency and the diagnosis of radiological or biochemical nutritional rickets. Methods. We performed a retrospective case note and biochemistry database review of all new patients seen in an elective Paediatric Orthopaedic clinic in the year 2010, who had Vitamin D levels measured. Radiographs were reviewed by the senior author to determine the presence or absence of radiological rickets. Biochemical rickets was diagnosed if there was deficient Vitamin D (< 20 mcg/ml) and raised PTH. Results. We identified 115 children with a mean age of 10.95 years (95% CI 10.24 to 11.68). There were 63 females, 52 males and 51 were of Asian ethnicity. The mean vitamin D level was 18.27mcg/ml (95% CI 16.13 to 20.41). One hundred and three patients (88%) were found to have sub-optimum vitamin D levels. Although, males and those of Asian origin were more likely to be deficient, this was not statistically significant. Winter/Springtime blood sampling was statistically more likely to show Vitamin D deficiency than in Summer/Autumn. Three Asian female children (2.61%) had radiological rickets. The association between low Vitamin D levels (< 20) and radiological or biochemical rickets had poor positive predictive values PPV. Conclusion. Suboptimal Vitamin D levels are common in children presenting with vague limb or back pain, suggesting ‘growing pains’ might reflect deficiency. Vitamin D levels cannot be used as a screening test for the diagnosis of radiological or biochemical ‘rickets’ due to its poor Positive Predictive Value. Further research into Vitamin D requirement is necessary, particularly in relation to growth and age, as growth is not linear and Vitamin D requirement is likely to vary accordingly

Aims

Prevalence of artificial intelligence (AI) algorithms within the Trauma & Orthopaedics (T&O) literature has greatly increased over the last ten years. One increasingly explored aspect of AI is the automated interpretation of free-text data often prevalent in electronic medical records (known as natural language processing (NLP)). We set out to review the current evidence for applications of NLP methodology in T&O, including assessment of study design and reporting.

The role of dual consultant operating (DCO) in general orthopaedics has not been researched; where it has shown benefit in other specialties, there is a lack of information on how DCO affects the surgeons themselves. We wanted to explore the potential effects of DCO on stress, as a foundation for further research to guide support for our surgeons. We conducted a survey among orthopaedic consultants around New Zealand, containing questions pertaining to the demographics of respondents, their experience with DCO, what the expected risks and benefits of DCO would be, and provided two high-stress exemplar clinical scenarios where respondents were asked to rate their expected stress level at baseline, with a more junior consultant present, and with a more senior consultant present. We found 99% of respondents had been involved in DCO at some point in their careers, yet only 38% were involved in DCO on at least a monthly basis. Perceived benefits greatly outweighed potential risks: 95% felt DCO would decrease their stress, 91% felt it improved intraoperative decision making, and 89% felt it provided more enjoyment at work and enhanced collegiality. A decrease in perceived stress was seen from baseline with a more junior consultant available and a greater decrease in stress seen with a more senior consultant, particularly in a complex elective setting. All respondents felt there is benefit in DCO and the vast majority feel it has positive effects on stress levels. In a time where burnout is more prevalent, using tools such as DCO could be an effective way to decrease stress, enhance enjoyment and collegiality — challenging some key contributors to burnout — and support mentorship with further skill acquisition. This research provides a good base to pursue further qualitative and quantitative research into the area, with a view to addressing barriers to provision of regular DCO

Introduction. This study aimed to assess the relationship between preparation times and operative procedures for elective orthopaedic surgery. A clearer understanding of these relationships may facilitate list organisation and thereby contribute to improved operating theatre efficiency. Methods. Two years of elective orthopaedic theatre data was retrospectively analysed. The hospital medical information unit provided de- identified data for 2015 and 2016 elective orthopaedic cases, from which were selected seven categories of procedures with sufficient numbers to allow further analysis - primary hip and knee replacement, spinal surgery, shoulder surgery (excluding shoulder replacement), knee surgery, foot and ankle surgery (excluding ankle replacement), Dupuytrens surgery and general orthopaedic surgery. The data analysed included patient age, ASA grade, operation, operation time, and preparation time (calculated as the time from the start of the anaesthetic proceedings to the patient's admission to Recovery, with the operating time [skin incision to skin closure] subtracted). Statistical analysis of the data was undertaken. Results. A total of 1596 procedures performed over the two year period were analysed. Preparation times for the different procedures were assessed, along with the relationship to the procedure complexity. Neither age nor ASA correlated strongly with preparation times. Spine procedures had greater preparation times than hip and knee arthroplasty. Greater uniformity in preparation times for hip and knee arthroplasty was seen across the anaesthetic group than operative times across the surgeon group. Discussion. Preparation times are just one aspect that may be evaluated with regard to theatre utilisation. This study did not address the theatre turn-over time between cases, which includes transfer of the patient from the admitting/pre-operative area into the theatre. Conclusion. Preparation times for elective procedures follow a pattern which may be used to inform list planning, with the potential for greater theatre efficiencies with regard to list utilisation and staff allocation

Introduction. A greater emphasis has been placed on fracture related infection (FRI) orthopaedic practice as a separate entity in recent years. Since the publication of the FRI consensus definition and guidelines, there has been an increase in the published literature on the topic and a move towards considering FRI as separate from general orthopaedic practice and as work that requires a more specialist approach. The aim of this study was to audit current FRI practice in the UK. Materials & Methods. Orthopaedic practice related to FRI in the UK was audited using a semi-structured questionnaire. Respondents were from a range of institutions, specialties and clinical roles to reflect the multi-disciplinary nature of treating FRI. The online tool SurveyMonkey was used to share the survey at the 2022 annual meeting of the British Limb Reconstruction Society. Twenty-one questions were asked in the following domains: scope of practice, theatre and clinic capacity, availability of the multidisciplinary team, renumeration for work and scope of FRI networks. Results. Of the 36 respondents, the majority (64%) worked in a major trauma centre. In the majority of cases, bone infection was managed by the limb reconstruction team (68%) although in most centres the wider team was often also involved including the general on call, the trauma team and the arthroplasty team. When referrals were made elsewhere, this was usually done to known individuals rather than established FRI networks. 80% of respondents said that there was a bone infection MDT in their unit and this usually met weekly. This usually included orthopaedics and microbiology but plastics in only 43% of cases and radiology in only 23% of cases. Most respondents said that the lack of funding and appropriate tariffs were the main barrier to FRI management locally (62%) and nationally (83%). Most respondents (83%) said that bone infection practice should be centralised. The overwhelming majority of this cohort (90%) said that patient outcomes would be improved by cases being managed in dedicated centres. Conclusions. There is variation in practice for the management of bone infection in the UK. This reflects the lack of clear national guidelines and the lack of established networks for management and onward referral. There is agreement that patient outcomes would be improved by more formal networks and specialised centres but also recognition that remuneration is a significant barrier to implementing change. This survey reflects practice in units with an interest in limb reconstruction and bone infection. Further work is needed to evaluate practice across district general hospitals in the UK and to build consensus around best practice and national strategies for improved care

Three developments in the last 10 to 15 years have made it necessary to review how we ensure rapid access to treatment of patients with disabling low back pain. Firstly, there would appear to be an increase in the numbers of patients seeking medical help for low back pain, whether due to increased patient expectation, or better reporting, or a true increase associated with the increasing sedentary nature of life, is uncertain. Secondly, there is the realisation that amongst the factors that encourage acute back pain to become chronic is being off work, and the sooner a diagnosis and treatment is started the more likely that chronicity will be prevented, so a long waiting time to be seen in a clinic is productive of disability. Thirdly, reorganisation of consultant services has created the spinal surgeon, who in return for being allowed to practice spinal surgery almost exclusively undertakes the load of patients referred with back pain, amongst whom lurk those with a surgically remediable problem. The effect has been that although waiting times for general orthopaedic patients have dropped, as general orthopaedic, or other specialist orthopaedic surgeons no longer see spinal cases, the specialist spinal surgeon is overwhelmed by a large group of patients with back pain for whom there is not a surgical solution. Unfortunately, there is a shortage of spinal surgeons, which is likely in the UK at any rate to get worse. Being overwhelmed with non-surgical back pain interferes with their ability to deal with surgical problems. It also does create a recruitment problem, as back pain is not seen as a rewarding or satisfying problem to treat. Triage is a method of screening patients into groups at an early stage, identifying those who might benefit from surgery, and fast tracking them, identifying those who will benefit from other management and tracking them accordingly. Pioneered in general orthopaedics by Robin Ling in Exeter, it has been developed in the hospital setting somewhat randomly, by dedicated enthusiasts, many of whom will be speaking today. The purpose of this meeting today is to hear about the various systems, their funding and organisation and location, the triage staff used, the investigations used in primary triage and the effect on hospital specialist waiting times, the safety and patient satisfaction. Is a multiplicity of systems best, is one better than another, why have some units achieved no waiting times for MRI, and others six months etc?. In 1994, the Clinical Standards Advisory Group produced two books, An epidemiological Review, largely the work of Gordon Waddell, and a second book on Back Pain, chaired by Professor Michael Rosen with, I suspect, considerable input from Professor Waddell and others. Many of us met them when they toured the country collecting facts about the treatment and management of back pain. It discusses back pain triage, and suggests that it can be done within the average GP Consultation time of 9 minutes. It deals with simple back ache, “red flags”, (we now have “yellow flags” denoting the psycho-social factors) nerve root pain, cauda equina and inflammatory disorders. It is to be noted that chronic back pain, is not alluded to in the diagnostic triage, but it is stated that 90% of simple back ache recovers in six weeks. Their management guidelines emphasise the value of physical therapy (manipulation and active exercises), but it will be noted that they are addressed to a group of patients, 90% of whom will recover in six weeks. Sadly, therefore, the effect of this very sensible document, in ignoring in the triage system the chronic patient, has in many cases directed therapy in general practice towards open access for patients who in any event will improve spontaneously. We must therefore address where triage should be, hospital, or GP level. Certainly a GP gatekeeper will remove the acute back pains that are going to get better soon anyway from attending hospital and in certain units, a separate fast track is provided for acute radicular problems (Acute Sciatic Clinics). Any successful triage system involving chronic back pain must be associated with treatment possibilities, and I shall briefly discuss these, although the main thrust of the afternoon will be the triage organisation itself. The session is designed to allow considerable audience participation, as it is hoped that information, comments and criticisms from the audience will allow us to subsequently produce a booklet, hopefully with support from our Professional Societies, describing what we feel is Best Practice in Back Pain Triage, which we hope, after appropriate circulation, will encourage Trusts and Community Health Groups to develop such units and ensure that back pain patients get a better deal

There are numerous papers from specialist arthroplasty centres outlining results of total knee replacement. This review was performed as there is little information on results in general orthopaedic centres. All patients received a Duracon/PCA replacement between 1992 and 1996. Patients were assessed clinically, fluoroscopically and completed SF12, WOMAC and IKSS questionnaires. At a mean of 6.7 (5–9) years follow up 93 (78%) were available for review. The average age was 70 years (52–88) with 58% being male. The primary diagnosis was osteoarthritis in 94.3%, with 41 %, 38% and 21 % being Charnley grades A, B and C respectively. The average IKS knee score was 71.4 (23–96) and functional score 70 (0–100), with 72.7% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 38 (14–63) and mental score of 53 (25–67). There were 88.6% of patients satisfied with their knee and 92% would have the operation again if required. There were no deep infections or PE’s but there were 7 superficial infections and 2 DVT’s. A MUA was required in 8 patients. One patient retains a radiologically loose prosthesis at 8 years but had mild pain with stairs only, a WOMAC functional score of 85 and was happy. There was a best-case survival of 94.4% at 5 years. There were 5 knees revised in 5 patients and no revisions of the deceased patients, all surviving greater than 5 years from surgery. These results suggest that those in general orthopaedic centres are a little less reliable than those in specialist centres. However they are acceptable and patient satisfaction remains high

Introduction: More than 140,000 joint replacements are carried out in England and Wales per annum costing from £4000 to £7000 each (. 1. , . 2. ). Implant costs are relatively fixed but there are considerable variations in length of stay [LOS] following surgery. The National Audit office estimated that a reduction of two days per patient could save the NHS £15.5 million per year (. 2. ). A specialist orthopaedic ward for elective arthroplasty was opened in Bangor in 2008 in an attempt to address these issues. The staff per bed ratio remained the same as in the general orthopaedic wards but beds were “ring fenced” and strict infection control measures protocols were implemented. This audit aimed to assess the effect of the specialist ward on LOS following arthroplasty. Method: Retrospective data on length of stay, demographics and surgical site infections [SSI] were collected for the six months before and six months after the specialist ward was opened. Only primary lower limb arthroplasty data was evaluated and LOS was calculated from day of operation to the day of discharge. Statistical analysis was performed on the length of stay with SPSS software using the two-sample t-test and Mann-Whitley U test. Results: Patients were managed by the same surgical teams in the same theatres but nursed in different ward settings. Group 1 included 222 patients managed in general orthopaedic wards and group 2 included 191 patients, managed in the ring fenced ward. The mean age for total hip replacements was 70.8 in group 1 and 71.2 years in group 2. The mean age for total knee replacements was 70.9 years in group 1 and 69.2 years in group 2. The overall mean LOS for both procedures was 7.61 days (95% CI: 7.14 – 8.07) in group 1 compared with 5.67 days (95% CI: 5.28 – 6.06) group 2. This was statistically significant (p< 0.001). The mode was 7 days in group 1 compared with 4 days in group 2. Three SSIs were noted in group 1 and zero in group 2. Conclusions: This audit demonstrates a two day reduction in LOS for patients managed in a ring fenced ward. The reasons for the reduction are multi factorial but include a trend for reduced SSI. Overall reduced stay frees up resources for other use and may reduce costs. Other units may benefit from similar dedicated wards in response to growing demand for arthroplasty within a system of fixed resources

Background: The Levels of Evidence Rating System is widely believed to categorize studies by quality, with Level I studies representing the highest quality evidence. We aimed to determine the reporting quality of Randomised Controlled Trials (RCTs) published in the most frequently cited general orthopaedic journals. Methods: Two assessors identified orthopaedic journals that reported a level of evidence rating in their abstracts from January 2003 to December 2004 by searching the instructions for authors of the four highest impact general orthopaedic journals. Based upon a priori eligibility criteria, two assessors hand searched all issues of the eligible journal from 2003–2004 for RCTs. The assessors extracted the demographic information and the evidence rating from each included RCT and scored the quality of reporting using the reporting quality assessment tool, which was developed by the Cochrane Bone, Joint and Muscle Trauma Group. Scores were conducted in duplicate, and we reached a consensus for any disagreements. We examined the correlation between the level of evidence rating and the Cochrane reporting quality score. Results: We found that only the Journal of Bone and Joint Surgery–American Volume (JBJS-A) used a level of evidence rating from 2003 to 2004. We identified 938 publications in the JBJS-A from January 2003 to December 2004. Of these publications, 32 (3.4%) were RCTs that fit the inclusion criteria. The 32 RCTs included a total of 3543 patients, with sample sizes ranging from 17 to 514 patients. Despite being labelled as the highest level of evidence (Level 1 and Level II evidence), these studies had low Cochrane reporting quality scores among individual methodological safeguards. The Cochrane reporting quality scores did not differ significantly between Level I and Level II studies. Correlations varied from 0.0 to 0.2 across the 12 items of the Cochrane reporting quality assessment tool (p> 0.05). Among items closely corresponding to the Levels of Evidence Rating System criteria assessors achieved substantial agreement (ICC=0.80, 95%CI:0.60 to 0.90). Conclusions: Our findings suggest that readers should not assume that. 1) studies labelled as Level I have high reporting quality and. 2) Level I studies have better reporting quality than Level II studies. One should address methodological safeguards individually

We have developed a list of 281 competencies deemed to be of importance in the training of orthopaedic surgeons. A stratified, randomised selection of non-university orthopaedic surgeons rated each individual item on a scale 1 to 4 of increasing importance. Summary statistics across all respondents were given. The mean scores and . sd. s were computed. Secondary analyses were computed in general orthopaedics, paediatrics, trauma and adult reconstruction. Of the 156 orthopaedic surgeons approached 131 (84%) responded to the questionnaire. They rated 240 of the 281 items greater than 3.0 suggesting that competence in these was necessary by completion of training. Complex procedures were rated to be less important. The structure, delivery and implementation of the curriculum needs further study. Learning activities are ‘driven’ by the evaluation of competencies and thus competency-based learning may soon be in the forefront of training programmes

Objective evaluations of resident performance can be difficult to simulate. A novel competency based surgical OSCE was developed to evaluate surgical skill. The goal of this study was to test the construct validity comparing previously validated Ottawa scores (O-scores) and Orthopaedic in-training evaluation scores (OITE). An OSCE designed to simulate typical general orthopaedic surgical cases was developed to evaluate resident surgical performance. Post-graduate year (PGY) 3–5 trainees have an encounter (interview and physical exam) with a standardized patient and perform a correlating surgery on a cadaver. Examiners evaluate all components of the treatment plan and provide an overall score on the OSCE and also provide an O-score on overall surgical performance. Convergent and divergent validity was assessed comparing OSCE scores to O-scores and OITE scores. SPSS was used for statistical analysis. ANOVA was used to compare PGY averages and Pearson correlation coefficients were calculated to compare OSCE versus O-score and OITE scores. A total of 96 simulated surgical cases were evaluated over a 3 year period for 24 trainees. There was a significant difference in OSCE scores based on year of training. (PGY3 − 6.06/15, PGY4 − 8.16/15 and PGY5 − 11.14/15, p < 0 .001). OSCE and O-scores demonstrated a strong positive correlation of +0.89 while OSCE and OITE scores demonstrated a moderate positive correlation of 0.68. OSCE scores demonstrated strong convergent and moderate divergent correlation. A positive trajectory based on level of training and stronger correlations with established, validated scores supports the construct validity of the novel surgical OSCE

The global economy has been facing a financial crisis. Healthcare costs are spiraling, and there is a projected £30 billion health funding gap by 2020 in the UK. 1. This has prompted a drive for efficiency in healthcare provision in the UK, and in 2012, the Health and Social Care Act was introduced, heralding a fundamental change to the structure of the National Health Service, especially in the way that healthcare is funded in England. 2. What is happening in the UK is a reflection of a global problem. Rationing of healthcare is a topic of much discussion; as unless spending is capped, providing healthcare will become unsustainable. Who decides how money is spent, and which services should be rationed? . In this article we aim to discuss the impact that rationing may have on orthopaedic surgery, and we will discuss our own experiences of attempts to ration local services. 3. We also seek to inform and educate the general orthopaedic community on this topic

Problem drinking was found to be likely in 21% of inpatients in a general orthopaedic and fracture service, and in 42% of outpatients attending the fracture clinics. The questionnaire showed that the problem was most common among young men, particularly among outpatients. Previous hospital admissions were more frequent in this group. Many of the health problems associated with the chronic abuse of alcohol are directly relevant to orthopaedic practice. Early intervention may be highly successful, and it is recommended that screening for problem drinking be considered in orthopaedic and fracture services

We present a study of 67 Oxford bicompartmental total knee replacements performed at a district general hospital. In this general orthopaedic unit, 57 of the knees (85%) had significant relief of pain with a mean flexion range of 95 degrees and a mean flexion deformity of only 9 degrees. There was a noticeable difference between osteoarthritic and rheumatoid knees. Poor results could be directly related to an avoidable postoperative complication. The results of this independent assessment may be compared favourably with the previously published series from the specialist centre at which the prosthesis was designed

Introduction: Outcome reporting following THR constitute a significant proportion of orthopaedic publications. Publication bias in the form of underreporting of studies showing non satisfactory or negative results is a well recognised problem in other specialities. We tried to find out the magnitude of this problem in orthopaedics publications dealing with THR. Method and materials: We reviewed all publications on THR in the year 2004 in three general orthopaedic journals namely JBJS (BR), JBJS (Am), CORR. Of the 1034 original articles published in these three journals more than 400 articles were concerned with total hip replacement. Results and Discussion: In this study we found only 6% of the published articles were showing non significant or negative results. This raises concerns about evidence based approach in THR and the need for preventive measures like registering all clinical trials and change in the attitude of editorial board

Since1986 we have monitored the actual diagnosis of all cases referred to our Unit with the diagnosis of ‘possible primary malignant bone tumour’. We have excluded all patients referred with a known diagnosis of either a benign condition or known to have bone metastases. In most cases the suspected diagnosis was based on X-rays alone, sometimes supported by further imaging. Method. Retrospective review of a prospective database that was started in 1986 identifying the actual diagnosis. Results. There were 5922 patients with a confirmed diagnosis over the 23 year time period of this study. 2205 (37%) were found to have a primary malignant bone sarcoma and 1309 (22%) had a benign bone tumour. 992 patients had a general orthopaedic condition (e.g. geode or a vascular necrosis) whilst 303 (5%) had a haematological malignancy and 289 (4.9%) infection. 533 patients (9%) had metastases. There was a similar pattern of frequency of all diagnoses except for metastatic disease and haematologic malignancy at different ages. The incidence of metastases increased from the age of 35 onwards. Discussion. Analysis of this data has led to an algorithm for investigating ‘worrying’ bones that should lead to earlier diagnosis whilst avoiding unnecessary investigations