The Enhanced Recovery Pathway aims to improve the patient experience as well as expediting discharge. We aim to discharge 85% of patients by day 3. This audit retrospectively looked at primary total hip replacements (THR) and total knee replacements (TKR) patients who had 7 days length of stay and evaluated the factors contributing to the delay.

There were 24 patients who stayed 7 days, 12 THR and 12 TKR. There were 15 females and 7 males, the mean age was 77 years (52 to 89). Causes for the delay included patient's reluctance to engage in their rehabilitation (21/24) and Occupational Therapists (OT) identifying difficulties in patient's home circumstances on admission (12/24). Medical problems also delayed early mobilisation, particularly urethral catheterisation (9/24), investigation for venous thromboembolism (6/24) and blood transfusion (3/24).

Delay in discharge is multifactorial and requires involvement of MDT. We have identified ways to enhance patient engagement, including a “patient journey” DVD shown preoperatively at “Joint School” and individual white boards for daily goal setting. Fostering greater self-efficacy in patients may improve participation in preoperative discharge planning with OTs. Specific preoperative education may help patients understand the importance of continuing their rehabilitation while medical problems are managed.

It has been reported that some of the local anaesthetic agents possess antimicrobial activity against clinically-significant bacteria. Although bupivacaine exhibits a bacteriostatic effect at concentrations above 0.25% there are concerns that it might interact with some of the other antibiotics administered to patients. Whilst these interactions may be potentially benign, the risk is that they are antagonistic and that local bupivacaine might predispose the patient to a higher risk of infection.

Bupivacaine is commonly administered as a local anaesthetic following knee arthroplasy; the purpose of this study was to assess its potential interactions with gentamicin eluting from the cement used to fix the device.

A strain of Saphylococcus aureus (29213) with established susceptible Minimal Inhibition Concentration (MIC) and Minimal Bactericidal Concentration (MBC) for gentamicin was used. This organism was inoculated into four types of broth; Mueller-Hinton broth (MH), MH with different concentrations of gentamicin, MH with 0.25% and 0.125% bupivacaine and MH with various combinations of gentamicin and bupivacaine. The broths were incubated at 37C and at 0.5, 1, 2, 3, 6 and 24 hours post inoculation the number of bacteria remaining were counted. From these data kill-curves were generated describing the absolute and individual rates of killing seen with bupivacaine and gentamicin alone and when in combination.

Bupivacaine showed a bacteriostatic effect only at concentrations of 0.25% and higher. All concentrations of gentamicin above or equal to the expected MBC showed bactericidal effect. However, in combination with both strengths of Bupivacaine (0.25 and 0.125%) the bacteriocidal effect of gentamicin was seen at a lower concentration and the rate of killing of bacteria was enhanced.

Bupivacaine has bacteriostatic effect at concentrations above 0.25% in line with published data. In these experiments we have shown that the use of bupivacaine together with gentamicin does not reduce the bactericidal property of the antibiotic and that the bactericidal effect of gentamicin appears to be enhanced by bupivacaine. This would suggest that the local use of bupivacaine is unlikely to increase the risk of infection in patients undergoing knee arthroplasty and may actually be beneficial.

Total knee arthoplasty (TKA) remains a standard treatment for advanced knee arthritis. The aim of the procedure is to restore function and relieve pain ideally for the rest of patient's life. Patient matched templating (PMT) or patient specific instrumentation (PSI) is a recent development for alignment of TKA components that uses disposable guides. The users of PSI claim it to be the optimum balance of new technology and conventional technique by reducing the complexity of conventional alignment and sizing tools.

To assess the clinical and radiological outcome of Primary TKA done with PSI.

More than 200 cases of TKA have been done in our unit using PSI and we analysed the radiographic outcome of these cases postoperatively. We also reviewed the clinical outcome of 103 patients with 1 year and 43 patients with 2 year follow-up. Data was collected prospectively: pre-operatively and at 1 year and 2 years post-operatively including Oxford knee score (OKS), WOMAC and American knee society score (AKS). Standard AP and lateral films were done pre-operatively and post-operatively.

Mean age was 66 years. There were 56 female and 47 male patients. Mean post-operative angles on standard films were: Alpha = 95.6, Beta = 88.4, Saggittal femur = 3.4 and Saggittal tibia = 90.8. Of the 103 cases with 1 year follow-up, there was significant improvement in all clinical outcome scores. Mean OKS improved from 18 to 39 at 1 year and remained the same at 2 years, WOMAC improved from 40 to 18 in both 1 and 2 years post-op. AKS Total improved from 79 to 173 at 1 year and 170 at 2 years.

Performing TKA using PSI is safe and provides good radiological alignment in the coronal and sagittal plane. Significant improvement in outcome scores were seen at one and two year follow up and reached levels that compared favourably with other reported series of TKA outcome from our unit.

A number of studies suggest revision of unicompartmental knee replacement (UKR) to total knee replacement (TKR) is straightforward. We hypothesise that this is not always the case in terms of complexity, cost and clinical outcome.

We identified 23 consecutive patients revised from UKR to TKR by 2 consultant surgeons (2005–2008). These were matched by age, sex and comorbidity to a cohort of primary TKRs (42 patients) performed during the same period. Data were collected regarding demographics, cost (surgical time & implants) and 1 & 5-year follow-up of clinical outcome (OKS) and outpatients attended.

There was no statistically significant difference in cost of implants for revision UKR to TKR vs. primary TKR (p=0.08), however operative time was significantly higher in the revision group. One year mean OKS was significantly higher in the primary TKR group (mean 30 vs. 23 p=0.03), but 5-year follow up showed no significant difference (mean OKS 27 vs. 32 p=0.20). The revision group had statistically significantly greater number of follow-up appointments (mean 6 Vs. 2 p<0.0001).

Revision of UKR to TKR is not a universally straightforward procedure, carrying significant overall cost implications. Clinical outcomes, although significantly different at 1 year are almost the same at 5 years.

This is a prospective review of consecutive patients who underwent knee revision surgery using the Legion knee system.

Clinical and functional assessments (American Knee Scores-AKS, WOMAC and Oxford knee score-OKS) were carried out preoperatively, one year and 2 years post op. Radiographic evaluation was done at 1 and 2 years included review of standing AP, lateral and skyline views. Figgie's method was used to measure the joint line reproduction.

210 patients underwent revision knee system 103 male: 107 females with a mean age of 66.4 (44–87) yrs. Mean BMI-26.03 (21–50). We had a 2-year follow up for 110 patients. Surgery was carried out at a single centre and performed by Bristol knee specialists.

Indications for surgery were aseptic loosening (84), infection (27) instability (47), pain and stiffness (31), progression of disease (6), peri-prosthetic fractures (15)

The AKS and WOMAC scores at, 1 year and 2 years follow up showed significant improvements in pain and function. The mean total AKS improved from 75.7/200 pre-operatively to 140.5/200 at 2 yrs. Radiographic assessment showed a mean AP coronal femoral angle of 95.3 degrees (89.6–99.9), coronal tibial angle of 90.1 degrees (88–92). The mean sagittal femoral and tibial angles were 88.4 and 90.4 degrees respectively.

The short-term results showed significant improvement in functional and pain scores irrespective of indications for revision surgery. The Legion system has showed good outcome scores that match or beat published series on revisions. It also showed a good ability to restore joint line.

Electronic PROMs have many potential uses in orthopaedic practice. The primary objective of this three-phase pilot study was to measure uptake using a web-based ePROM system following the introduction of two separate process improvements.

80 consecutive new elective orthopaedic patients in a single surgeon's practice were recruited. Group 1 (n=26) received a reminder letter, Group 2 (n=31) also received a SMS message via mobile or home telephone and Group 3 (n=23) also had access to Tablet Computer in clinic.

Overall 79% of patients had Internet access. 35% of Group 1, 55% of Group 2 and 74% of Group 3 recorded an ePROM score (p=0.02). There was no significant age difference between groups. In Group 3, 94% of patients listed for an operation completed an ePROM score (p=0.006).

Collecting PROM data effectively in everyday clinical practice is challenging. Electronic collection should improve healthcare delivery, but is in its infancy. This pilot study shows that the combination of SMS reminder and access to Tablet Computer within clinic setting enabled 94% of patients listed for an operation to complete a score on a clinical outcomes web-based system. Further process improvements, such as additional staff training and telephone call reminders, may further improve uptake.

There has been a trend towards operative management of pelvic injuries. Posterior pelvic integrity is more important for functional recovery. Percutaneous iliosacral screw fixation is being increasingly preferred for posterior pelvic stabilisation. Outcome reporting for this procedure remains inconsistent and un-standardised.

Retrospectively, all percutaneous iliosacral screw fixations done at this institute during a 5-year period (2008–2012) were reviewed. 28 patients, who had had at least 12 months follow-up, were contacted and clinical scoring was done by postal correspondence. Radiographs were measured for displacements and leg-length discrepancy. Possible factorial associations and correlations were investigated.

Mean Majeed score was 83 (median 87), mean EQ-Visual Analog Score (EQ-VAS) was 75.5 (median 80) and the two scores were correlated with statistical significance. Tile AO type C injuries produced worse outcomes and patients who'd anterior pelvic fixation did better.

Our results show high patient-reported outcomes, excellent radiologically measured reductions and unions. The incidence of complications is very low. There is a significant correlation between the EQ-VAS arm of the EQ5D instrument and the Majeed score in this patient population. Incidence of non-pelvic surgical procedures in these patients was significantly associated with worse outcomes. Leg length discrepancies appeared to increase after patients were fully weight bearing.

The PFNA is used routinely at the RUH for unstable peri-trochanteric and femoral fractures. Failure of operative treatment is associated with increased morbidity and financial burden. We analysed surgical and fracture factors, aiming to identify those associated with fixation failure.

Retrospective analysis of 76 consecutive patients treated with a PFNA between 2009–2012 was performed. Patient demographics were assessed, along with fracture classification, adequacy of reduction, tip apex distance (TAD) and grade of surgeon. Failure was defined as metal work failure, non-union or need for repeat procedure.

The mean age was 78.9 years (25.9–97.4). 21 were male and 49 female. There were 17 failures (24.3%) (7 required further surgery). 10 failures were per-trochanteric, 2 sub-trochanteric and 5 mid-shaft fractures. Complications included 4 broken and 6 backed-out distal locking screws, 2 blade cut-outs, 1 nail fracture and 4 non-unions. All per-trochanteric were adequately reduced with a TAD <25 mm. 11/17 had consultant supervision.

A high rate of backed-out distal locking screws was identified. We found no concerns with adequacy of reduction, TAD or consultant supervision.

In late 2011 there was a change in antimicrobial policy in orthopaedic surgery to reduce the Clostridium difficile (C. diff) rate, this was inducted top down from government, to PCT, to hospital trust. The previous antimicrobial policy was Cefuroxime, this was changed to Flucloxacillin and Gentimicin. Following this change it was noticed an increased number of patients appeared to suffer from acute kidney injury (AKI). This led us to evaluate the incidence of AKI pre and post antibiotic change and look at the causes behind this.

In this retrospective study all patients admitted with fracture neck of femurs were identified from the National Hip Fracture database and data pulled. The degree of AKI was classified according to the validated RIFILE criteria.

Evaluation showed 2–4 fold increase in AKI since antibiotic change. Although mortality was decreased in these patients, the incidence of AKI had increased significantly. However, C. difficile has been obliterated by this change.

The investigation highlights potential problems with increased rates of AKI amongst NOF patients, since antibiotic change. Flucloxacillin may have significant impact on this patient group. Dose dependent antibiotics will now be given based on weight and eGFR. Further analysis of this new change needs to be evaluated.

Routine postoperative radiographs following hip hemiarthroplasty are commonly undertaken despite it being suggested that they can cause delays to discharge, discomfort to patients and unnecessary radiation. Our study considered the necessity of these post-operative radiographs.

A retrospective search was conducted of all hemiarthroplasty procedures on the Royal Cornwall Hospital database. These were reviewed for cases where re-operation was conducted within 6 weeks. Notes and post-operative check radiographs of those who underwent re-operation were reviewed to determine how essential radiographs were in diagnosing complications requiring re-operations.

A total of 1557 hemiarthroplasty operations were identified. There were 37 incidences of re-operation within 6 weeks. 29 cases had normal check radiographs. 8 dislocations were picked up on post-operative radiographs. In all but one of these cases, clinical suspicion of complication had been raised prior to the radiograph. In the remaining case documentation was poor and no firm conclusion as to clinical suspicion could be drawn.

Our review of over 1500 hemiarthroplasty cases, demonstrated one incident where the check radiograph solely diagnosed an abnormality needing intervention that might not have been apparent clinically. We thus suggest that check radiographs following hip hemiarthroplasty should not be routinely ordered for all patients.

NICE guidelines support the use of total hip replacement (THR) in preference to cemented hemiarthroplasty for the treatment of fit and active elderly patients with a displaced intracapsular neck of femur fracture.

We hypothesized that not all patients eligible for a THR received one in our unit.

We performed a prospective cohort study including all consecutive hip fracture patients admitted to our unit over a 6 month period. Case notes and data from the National Hip Fracture Database were evaluated.

Patients were deemed suitable for a THR if they mobilised outdoors with a maximum of one stick, had an abbreviated mental test score of 8 or greater and had an ASA score of 1 or 2.

256 patients sustained a neck of femur fracture during the study period and 36 met the inclusion criteria. 26 (72%) had cemented hemiarthroplasties and 10 (22%) had a THR. THR rates varied with the day of surgery.

At our unit we have a low rate of THR for patients who fulfil the NICE criteria for suitability, however it is around the national average. This could be improved upon by increasing the availability of surgeons who are able to perform THR, especially on weekends.

Total hip replacement (THR) is NICE recommended for a group of patients with neck of femur fracture (NOF) and guidance published in 2011. In our institution a Hip Fracture Program was established at this time to improve patient care.

An audit of the Hip Fracture Program, appropriateness of THR and management following THR was undertaken and compared to NICE standards, set at 100%, and National Hip Fracture Database (NHFD) results

The case-notes for 53 patients (38 female, 15 male) undergoing THR for NOF between 2011 and 2013 were reviewed: median age 70 yrs (34–87), follow-up 28 months (3–57).

All patients were initiated on a Hip Fracture Program. 92% were eligible for THR according to NICE guidance. Pre-operative pain management (67%), hourly assessment of pain in ED (4%), surgery with 48 hours (32%), pre-operative orthogeriatric review (58%) and intra-operative nerve block (38%) are areas for development, but most results are comparable to NHFD. Post-operative care is satisfactory with daily mobilisation (87%) and post-operative pain management (100%). No post-operative dislocation or infection was recorded. There was one case of post-operative DVT.

This study highlights areas for improvement in hip fracture management and emphasises the benefits in implementing a Hip Fracture Program in this vulnerable patient population.

The Royal College of Surgeons of England (RCS) recently issued guidance regarding the use of re-operation rates in the re-validation of UK based orthopaedic surgeons. Currently, little has been published concerning acceptable rates of re-operation following primary surgical management of orthopaedic trauma, particularly with reference to re-validation.

We conducted a retrospective review of patients undergoing a clearly defined re-operation following primary surgical management of trauma between 1^st January 2010 and 31^st December 2011. 3688 patients underwent primary procedures while 83 (2.25%; 99%CI = 1.69 to 2.96%) required an unplanned re-operation. The mean age of patients was 46 years (range 2–98) with 46 (55%) males and a median time to re-operation of 34 days (IQR 12–134). Potentially avoidable re-operations occurred in 47 patients (56.6%; 99%CI = 42.6 to 69.8%) largely due to technical errors (46 patients; 55.4%; 99%CI = 41.4 to 68.7%), representing 1.27% (99%CI = 0.87 to 1.83%) of the total trauma workload. Within RCS guidelines 28 day re-operation rates for hip fractures, wrist fractures and ankle fractures were 1.4% (99%CI = 0.5 to 3.3%), 3.5% (99%CI = 0.8% to 12.1%) and 2.48% (99%CI = 0.7 to 7.6%) respectively.

We present novel work that has established baseline re-operation rates for index procedures required for revalidation of orthopaedic surgeons.

A group of UK paediatric surgeons (the UK SCFE Study Group) convened to design pertinent trials in slipped capital femoral epiphysis (SCFE), twelve centres across the UK reviewed the demographics and management of children with SCFE.

At all contributing centres with digital PACS records, a search for terms relating to SCFE were performed. From the results, radiographs and electronically stored clinic letters were assessed to confirm the diagnosis and ascertain age at presentation, incidence of bilaterality, chronicity, stability, management and complications.

A total of 601 SCFEs presented between 2007 and 2012 to the twelve units. The mean age at presentation was 12.5 years. The left hip was nearly twice as commonly involved compared to the right (R: L = 3.3: 5.1), with bilateral presentation in 22% of patients. The most common mode of presentation was acute-on-chronic. Stable slips were over twice as common as unstable. The most common intervention was percutaneous pinning in situ. Open reduction was required in 24% of cases. The commonest complication was osteonecrosis (10.5%).

This data concurs with earlier smaller audits and highlights current demographics and contemporary management of SCFE throughout the UK and informs the subject and content of potential future randomized control trials.

Meningococcal infection is the most common infective cause of death in children and causes significant morbidity in survivors.

Patients admitted to the Paediatric Intensive Care Unit (PICU) of the Bristol Royal Hospital for Children from 01/01/2001 to 31/12/2012 with a primary diagnosis of meningococcal septicaemia were reviewed.

A total of 10 (7.7%) of 130 patients developed orthopaedic complications. Those affected were significantly younger (p < 0.05), remained on PICU for longer (p < 0.001) and boys had a greater risk of developing orthopaedic complications (risk ratio: 3.1; 95% CI: 0.69–14.14). 9 patients required an amputation, 16/22 (72.7%) in the lower limb. Patient requiring amputation had multiple limb involvement. 48 growth plate abnormalities were identified in 8 patients, 39 (81.3%) in the lower limb, most commonly in the distal tibia.

This study has identified a high incidence of musculoskeletal morbidity. Close surveillance of these patients is recommended to identify growth arrest before the onset of clinically significant deformity. It identifies a defined population of patients with meningococcal septicaemia using admission to PICU as an entry criterion allowing accurate determination of the incidence and characteristics of the skeletal consequences of this condition.

Our study aims to demonstrate the efficacy of using endobutton and interference screw technique in the repair of acute distal biceps ruptures.

From April 2009 to May 2013, 25 consecutive patients had acute distal biceps tendon repairs using an endobutton and interference screw technique. 3 patients were lost to follow up leaving 22 patients for review. Mean follow up was 24 months (1–51). All were evaluated using a questionnaire, examination, radiographs, power measurements, and Oxford Elbow (OES) and MAYO scores.

Overall 95% patients (21/22) felt that their surgery was successful and rated their experience as excellent or good. Mean return to work was 100 days (0–280) and mean postoperative pain relief was 23 days (1–56). 55% returned to sport at their pre-injury level. There was one case (4.5%) of heterotopic calcification with 3 superficial infections (14%). There were no intra or postoperative radial fractures, metalwork failures or metalwork soft tissue irritations. Mean pre-operative OES were 18 (6–37) and post operative 43 (24–48) (p < 0.01). Mean pre-operative Mayo scores were 48 (5–95) and post-operative 95 (80–100) (p < 0.01).

Our study supports that distal biceps repairs' with endobutton and interference screw technique appears to lead to high patient satisfaction rates with a relatively early return to function.

We evaluated the long-term survival and patient reported outcome of the Copeland mark III humeral resurfacing hemi-arthroplasty (Biomet, Warsaw, Indiana).

At a UK District General Hospital 95 shoulder replacements in 85 patients were performed from 1994 to 2003 (mean age 68.9). At the time of follow-up (mean of 12 years, range 8.7–18.0) 49 patients had survived. This study group were posted Oxford Shoulder Score (OSS) and SF-12 questionnaires and their case notes were reviewed.

There was an 82% response rate. The responders comprised 46 shoulders in 40 patients. 40 shoulders had a pre-operative diagnosis of osteoarthritis and 6 had other pathologies. The median OSS was 36. The median functional score was 24 (IQR: 9.5), where 32 is the best. The median pain score was 13 (IQR: 7) with 16 being the best score. There was a median SF 12 score of 31 (IQR: 3), where the maximum score is 47. There were 3 revision operations and 95% survivorship at 18 years, according to Kaplan Meier survival analysis.

The Copeland mark III hemi-arthroplasty prosthesis has a good long term survival, few post-operative complications and a good functional outcome in an elderly population. We would advocate its use in this patient group.

Cementless surface replacement arthroplasty (CSRA) is an established treatment for glenohumeral osteoarthritis. Few studies however, evaluate its role in cuff tear arthopathy. The purpose of this study is to compare the outcomes of CSRA for both glenohumeral osteoarthritis and cuff tear arthopathy.

42 CSRA with the Mark IV Copeland prosthesis were performed for glenohumeral osteoarthritis (n=21) or cuff tear arthopathy (n=21). Patients were assessed with Oxford and Constant scores, patient satisfaction, range of motion and radiologically with plain radiographs.

Mean follow-up and age was 5.2 years and 74 years in both groups. Functional outcomes were significantly higher in OA compared with CTA with OSS improving from 18 to 37.5 and 15 to 26 in both groups respectively. Forward flexion improved from 60° to 126° and 42° to 74° in both groups. Three patients in the CTA group had a deficient subscapularis tendon, two of whom dislocated anteriorly.

Humeral head resurfacing arthroplasty is a viable treatment option for glenohumeral osteoarthritis. In patients with CTA, functional gains are limited. We suggest CSRA should be considered in low demand patients where pain is the primary problem. Caution should be taken in patients with a deficient subscapularis due to the high risk of dislocation.

Arthroplasty of the shoulder is a common procedure. Although there are many studies of the results of individual arthroplasty concepts, there is little published on the results of all shoulder replacements (with no exclusions) from a single centre.

We analysed 120 elective shoulder replacements in 106 patients performed over a 5 year period in our unit. 77 were female and average age was 70 years. 85 procedures were for osteoarthritis, 10 cuff arthropathy, 8 post-traumatic arthritis. 65 patients underwent a resurfacing hemiarthroplasty, 25 stemmed hemiarthroplasty and 30 had total shoulder replacements (5 reverse polarity). Mean follow up was 1.6 years.

There was a move away from resurfacing hemiarthroplasty towards stemmed total shoulder replacement over the study period.

The overall incidence of complications was 25.8%, 19.2% occurring within 12 months of surgery: 4 replacements dislocated, there were 5 periprosthetic fractures, 2 patients developed deep infection (treated by debridement), 2 patients aseptic loosening, 11 developed subacromial/biceps pain and 2 had glenoid erosions. The overall revision rate was 5.8%, the re-operation rate 10%.

The complication and re-operation rate in our unit is comparable with individual arthroplasty studies and may be useful as a reference for audits in centres across the UK.

This study aimed to determine if the adoption of collagenase treatment is economically viable.

Xiapex collagenase was trialled at Gloucestershire Hospitals NHS Trust in 50 patients suitable for fasciectomy, with a palpable cord and up to two affected joints. Retrospective data for contracture angle pre-injection, immediately post-manipulation and at an average 6 weeks (range 2–17) clinic follow up was collected from medical notes. At follow up the post-procedure number of days required for return to activities of daily living (ADLs) and/or work were recorded, along with overall patient satisfaction rating.

Complete data was obtained for 43 patients of average age 67 (range 45–82). At follow up 88% had ≤ 20° residual contracture. Average days return to full ADLs was 9 and work was 11. Overall satisfaction was 8.6 out of 10. Xiapex patients required an average 1 hand physiotherapy appointment post-manipulation compared to 6 for fasciectomy, saving £172.20. Total cost for one treatment course, excluding physiotherapy, was £1166 for Xiapex compared to £2801 for palmar fasciectomy and £5352 for digital fasciectomy.

The level of contracture after one Xiapex treatment course permitted return of hand function in the majority of patients whose overall treatment course required less financial and hospital resources.

For hallux valgus correction, distal first metatarsal osteotomy is generally used for minor to moderate deformities, diaphyseal osteotomy for moderate deformities and basal osteotomy or fusion for severe deformities. With the advent of locking plates, there has been renewed interest in opening wedge basal osteotomy. As little has been written about its geometry, we undertook this study in order to understand its power and limitations.

Proximal opening wedge osteotomies were performed on saw bone models in four orientations, with three different wedge sizes: 1. Perpendicular to the ground (PG); 2. Perpendicular to the shaft (PS); 3. Perpendicular to shaft with 30° declination (DEC); 4. 30° oblique (OB). Pre- and post-osteotomy measurements were made of axial and plantar translation and intermetatarsal angle.

Plantar translation and intermetatarsal angle correction increased with increasing wedge size. The DEC osteotomy produced the greatest increase in length of metatarsal shaft, while the PS osteotomy gave the least. The most plantar translation was achieved with the DEC osteotomy. Overall, the PS osteotomy gave the largest correction of the intermetatarsal angle.

Although there are several published clinical case series of the proximal opening wedge osteotomy, this is the first study to fully evaluate its geometry.

Foot and ankle surgery is a rapidly evolving specialty. As the number and complexity of cases increases, the number of complaints, litigation and pay-outs has also risen. We aim to assess any learning points discerned from NHS litigation data to allow us help improve patient care.

All claims made to the NHS Litigation Authority between 2007 and 2012 relating to foot and ankle problems were obtained under the Freedom of Information Act. These were reviewed, coded and split into subgroups to allow analysis.

There were 232 successful litigation cases between 2007 and 2012. The total amount paid out was almost £18.5 million (range £112 to £1.6 million). A significant number of successful cases were due to patients not having full, informed consent.

A large amount of money is spent in the NHS is spent on litigation. The amount of litigation and payout in foot and ankle surgery compares favourably with hip and knee surgery.

Lack of informed consent is an easily reversible problem that should be decreasing but is actually on the rise. In our trust, we advocate the use of consent clinics which provide a robust and patient-centred approach to informed consent in foot and ankle surgery.

All licensed doctors are required to revalidate from June 2012. The GMC states that patient feedback should form part of doctors provided evidence. A standardised GMC PSS has been shown to offer a reliable basis for the assessment of professionalism among UK doctors and has been suggested as a tool for revalidation. We aim to show its use in the secondary care setting to be simple and effective, offering further evidence for doctors undergoing revalidation.

Having sought permission from the Trust the GMC PSS was used in the manner directed for 3 doctors in a Trauma and Orthopaedic fracture clinic. The data was analysed using an automated system and the results made available to individual clinicians in a simple to present format.

3 clinicians used the survey across 13 clinic sessions. The mean number of clinics it took to generate sufficient responses was 3.25 (range 2–5). We found the survey easy to use, HCAs handed forms to patients before consultation. Survey results were collected as patients left clinic and analysed by the Patient Services Department.

The GMC PSS, although designed principally for use in Primary care appears to be a useful tool in secondary care.