In the current austere financial climate within the NHS where local healthcare Trusts are reimbursed in a Payment by Results system it is important that we accurately identify the costs associated with surgical procedures.

We retrospectively reviewed data of 589 consecutive patients undergoing lower limb arthroplasty surgery and recorded their age, BMI and co-morbidities. The effect of these parameters on operative duration and length of stay (LOS) was analysed.

We demonstrate that for a 1 point increase in BMI we expect LOS to increase by a factor of 2.9% (p<0.0001) and mean theatre time to increase by 1.46 minutes (p<0.0001). We also show that for a l-year increase in age, we expect LOS to increase by a factor of 1.2% (p<0.0001).

We have calculated the extra financial costs associated with this and believe that the current OPCS coding system for obesity underestimates the financial impact of increasing BMI and age on lower limb arthroplasty Trusts are being inadequately reimbursed.

The results of this study have been used to produce a chart that allows prediction of LOS following lower limb arthroplasty based on BMI and age. We also believe that the data produced is of use in planning operating lists.

There has been a growing concern amongst the Orthopaedic Department at Auckland Hospital regarding the time Orthopaedic acute patients are waiting for surgery. To address this concern this study was undertaken to examine the extent of the problem and to establish recommended practice guidelines for waiting times.

A literature search was undertaken to identify universally accepted delays for surgery for the six categories of fracture studied – compound fractures, femoral shaft fractures, tibial shaft fractures, ankle fractures, neck of femur fractures and distal radial fractures. Current practise guidelines were then compared with the literature to ensure they are an acceptable standard of care. Every patient operated on at Auckland Hospital in 2002 that had a fracture that fell within the six categories was included in the study. Data regarding the age and time to surgery for each patient was analysed.

The study demonstrated major discrepancies between recommended practise guidelines and the present acute service. The general trend is that the more acute the fracture, the less likely it is to be operated on within the guidelines.

Further investigation should be undertaken to look at reasons behind the delays and ways to improve access. This will assist in identifying responsibility for ensuring that an acceptable standard of care is maintained.

The period of time acute orthopaedic patients await surgery at Middlemore Hospital is of concern to a number of the Health Professionals involved in their care. This study has arisen out of that concern in an attempt to quantify the extent of these delays.

Every patient operated on at Middlemore Hospital between 01 June and 31 December 2002 who had a fracture that fell within the categories studied was analysed. The six categories analysed were: compound fractures, tibial shaft fractures, femoral shaft fractures, ankle fractures, neck of femur fractures and distal radial fractures. Data regarding the age and time to surgery for each patient was analysed and compared with established guidelines. For the patients with neck of femur fractures additional data regarding their medical fitness for theatre was also analysed.

The study showed there was significant delay in acute patients receiving operative treatment at Middlemore Hospital. Furthermore the study highlighted the large volume of acute patients presenting to Middlemore Hospital.

Further investigation should be undertaken to consider how a department such as Middlemore can provide operative treatment within an acceptable timeframe to nearly 6000 orthopaedic patients a year, while still providing timely surgery for elective patients.

Magnetic Resonance Imaging is increasingly utilised for the assessment of knee pathology. The aim of this study was to review our entire knee MRI scans and to assess the accuracy of diagnosis when compared with operative diagnosis. Using data from the radiology department and medical records (public and private) all patients having knee MRI scans in a 6-year period were identified.

There were 956 scans performed on 930 patients. Scan diagnosis, operative diagnosis and diagnostic accuracy were assessed. Of the scanned patients 181 (19.5%) had normal scans and of these 168 (92.8%) were accurately diagnosed as normal. The remaining 749 (80.5%) had an abnormality noted on scan and of these 298 (39.8%) proceeded on to surgery. Of those patients having surgery, diagnosis at surgery was found to exactly match the results of the scan in 163 (57.0%) patients. Furthermore 51.5% of patients with a diagnosis of meniscal degeneration by scan actually had a meniscal tear at operation. However the sensitivity for diagnosis of ACL tears was 89.0% and that of medial meniscal tears was 90.6%.

MRI diagnosis is far from infallible and clinicians should be conscious of its limitations. However it is particularly reliable in confirming the lack of pathology within a knee with an accuracy of 93%. It also has high sensitivity for diagnosis of ACL and meniscal tears.

Dynamic hyperextension of the big toe and supination of the forefoot may occur in the swing phase of walking in children with various neurological disorders. Symptoms arising from this have been successfully corrected in 13 feet of 11 children by transfer of extensor hallucis longus to the insertion of peroneus brevis.