This project began as an audit of performance against the 18-week referral to treatment time (RTT) target but became an interesting development in clinical training.

The electronic documents and PACS images for 50 consecutive routine GP referrals to an orthopaedic clinic were traced using the UCPN (Unique Care Pathway Number).

The average time from referral to 1^st clinic appointment was 57 days (range 29–117).

16 were discharged at 1^st visit. 26 were listed for surgery: 20 at the 1^st clinic, 3 at the 2^nd clinic, 2 at the 3^rd clinic, 1 after test results without clinic review. Average time from referral to listing was 68 days (range 28–177). For 25 patients who had surgery, average RTT was 164 days (61–394). 14 patients breached the target.

The UCPN allows an overview of the diagnostic work-up for the whole care pathway. Time constraints and less opportunity for continuity of care have hampered effective training in the outpatient clinic. Using the UCPN in this way allows detailed case-based discussions to develop the non-technical surgical skills (NOTSS) of situation awareness and decision-making.

In a system where 57 days are typically wasted waiting for a new clinic appointment, clinical reasoning skills must be scalpel sharp to meet the 18-week RTT target. This study hints that better characterising the third of patients discharged and the third directly listed for surgery at the first visit might help with demand management. Better characterising the third of patients needing further tests might allow those test results to be available by the first visit.

The next step is to test if, indeed, the UCPN is an effective tool to hone mental dissection.

We have encountered radiological reports of ‘normal Graf α-angles’ when the femoral head was subluxed. We therefore developed a simple method to determine femoral/acetabular congruency known as the 50/50 method. We compare our method to the established Graf method.

Two identical, randomly assorted sets of 100 ultra-sonograms were evaluated. All ultrasonograms were of patients under 3 months of age within our DDH screening program. The images were assessed to be either ‘normal’ or ‘abnormal’ by 6 FY1’s using each method after reading brief instructions. (Images were classified as normal or abnormal by consensus between an orthopaedic consultant and radiologist who also examined and preformed dynamic screening on each infant).

The mean proportion of abnormal scans with agreement and normal scans with agreement was 0.52 (95% CI 0.39–0.69) and 0.92 (CI 0.87–0.96) respectively, indicating moderate agreement (kappa 0.41, CI 0.12–0.71) for inter-observer variability using the Graf method. On average the inter-observer variability using the 50/50 method for abnormal and normal scans with agreement was 0.60 (CI 0.35–0.84) and 0.92 (95% CI 0.85–0.99) respectively with moderate agreement (kappa 0.50, CI 0.20–0.80). Intra-observer variability between the Graf and 50/50 methods revealed moderate agreement (mean kappa 0.41, CI 0.17–0.66) with the average proportion of abnormal and normal scans with agreement of 0.50 (CI 0.32–0.69) and 0.91 (CI 0.83–0.98) correspondingly. The accuracy of each test was equal, ranging from 84% to 93%.

The 50/50 method is straightforward to both use and teach. Moreover, it successfully serves as “red dot” system to flag up abnormal hips at clinic. The 50/50 method is at least as good as Graf with regard to accuracy, inter-observer and intra-observer variability. We recognise that dynamic screening remains the gold standard.

Anterior cruciate ligament (ACL) reconstruction is a common procedure; HIC figures for 1999 in Australia include 4652 primary reconstructions, and 279 revisions (6%). We all see many good results, with some being excellent; but I also see a lot of ‘ordinary’ knees, and large group of unhappy patients following this type of surgery. Second opinions are frequently sought, because the patients feel that they have not progressed as expected. I looked prospectively at 50 patients in this category. The most common symptoms were pain, crepitus, catching, and functional insecurity or instability - and subsequent failure-to-progress. They presented four months to 15 years following ACL surgery, many having unrealistic expectations, often brought about because of media reports. Many patients complained of ‘failure of communication’ with their surgeon, and were prompted to seek a second opinion by a vocal third party. Their problems were generally complex combinations of:

Ligamentous laxity.

Reviewing these patients who sought second opinions, emphasises the importance of a surgeon’s being an excellent technician, (as 60% of those reviewed had anterior placement of the drill holes); but equally being a team leader; understanding tissue responses, psycho-emotional factors and having good communication skills, time to listen to patients and offer adequate follow up.

We reviewed 63 patients with fractures of the distal tibial metaphysis, with or without minimally displaced extension into the ankle joint. The fractures had been caused by two distinct mechanisms, either a direct bending force or a twisting injury. This influenced the pattern of the fracture and its time to union. All fractures were managed by statically locked intramedullary nailing, with some modifications of the procedure used for diaphyseal fractures. There were few intra-operative complications. At a mean of 46 months, all but five patients had a satisfactory functional outcome. The poor outcomes were associated with either technical error or the presence of other injuries. We conclude that closed intramedullary nailing is a safe and effective method of managing these fractures.