Aim. NICE guidance on lumbar total disc replacement (TDR) recommends ongoing audit should be an integral part of disc replacement surgery. We present our ongoing audit data and the extent of problem of patients lost to follow up. Method. 35 patients underwent lumbar TDR surgery over 4.5 years. They were followed prospectively. A database is maintained and ODI and VAS were collected prospectively, including patient satisfaction and any failures. Results. At latest follow up full data was available for 30 out of 35 patients. The mean follow-up was 34 months (range 3-52 months). There were 13 males with a mean age 37.7 years (range 27-62) and 17 females with a mean age of 49.8 years (range 27-62). Surgery was single level in 24 cases and double level in 6 cases. 21 patients rated their outcome as good or very good and 7 as unsatisfactory. There were 2 failures, one secondary to late extrusion of the polyethylene liner (12 months post-surgery) and one early anterior migration of the prosthesis. ODI scores improved by a mean of 28 points (range -4 to 68) whilst VAB scores improved by a mean of 4.9 (range -1 to 9). Five patients had been lost to follow up. One patient migrated out of the area. Two came from out of the area and did not return for follow up after the initial period and two further patients DNAed multiple clinic appointments. Conclusion. We conclude that lumbar disc replacement surgery can provide substantial improvement in pain relief and function. Continued audit of this cohort of patients is essential to comply with NICE guidance. 14% loss to follow up/audit is encountered despite our best effort

Aims. Current National Institute for Health and Clinical Excellence (NICE) guidance advises that MRI direct from the emergency department (ED) should be considered for suspected scaphoid fractures. This study reports the current management of suspected scaphoid fractures in the UK and assesses adherence with NICE guidance. Methods. This national cross-sectional study was carried out at 87 NHS centres in the UK involving 122 EDs and 184 minor injuries units (MIUs). The primary outcome was availability of MRI imaging direct from the ED. We also report the specifics of patient management pathways for suspected scaphoid fractures in EDs, MIUs, and orthopaedic services. Overall, 62 of 87 centres (71%) had a guideline for the management of suspected scaphoid fractures. Results. A total of 11 of 87 centres (13%) had MRI directly available from the ED. Overall, 14 centres (17%) used cross-sectional imaging direct from the ED: MRI in 11 (13%), CT in three (3%), and a mixture of MRI/CT in one (1%). Four centres (6%) used cross-sectional imaging direct from the MIU: MRI in three (4%) and CT in two (2%). Of 87 centres’ orthopaedic specialist services, 74 (85%) obtained repeat radiographs, while the most common form of definitive imaging used was MRI in 55 (63%), CT in 16 (19%), mixture of MRI/CT in three (3%), and radiographs in 11 (13%). Conclusion. Only a small minority of centres currently offer MRI directly from the ED for patients with a suspected scaphoid fracture. Further research is needed to investigate the facilitators and barriers to the implementation of NICE guidance. Cite this article: Bone Jt Open 2021;2(11):997–1003

Considerable debate exists regarding which agent(s) should be preferred for venous thromboembolism (VTE) chemical prophylaxis following joint replacement. We assessed the practice of surgeons regarding VTE chemical prophylaxis for primary THR and TKR, pre and post issuing of updated NICE guidance in 2018. A survey, circulated through the British Hip Society and regional trainee networks/collaboratives, was completed by 306 UK surgeons at 187 units. VTE chemical prophylaxis prescribing patterns for surgeons carrying out primary THR (n=258) and TKR (n=253) in low-risk patients were assessed post publication of 2018 NICE recommendations. Prescribing patterns before and after the NICE publication were subsequently explored. Questions were also asked about surgeon equipoise for participation in future RCTs. Following the new guidance, 34% (n=87) used low-molecular weight heparin (LMWH) alone, 33% (n=85) aspirin (commonly preceded by LMWH), and 31% (n=81) direct oral anticoagulants (DOACs: with/without preceding LMWH) for THR. For TKR, 42% (n=105) used aspirin (usually monotherapy), 31% (n=78) LMWH alone, and 27% (n=68) DOAC (with/without preceding LMWH). NICE guidance changed the practice of 34% of hip and 41% of knee surgeons, with significantly increased use of aspirin preceded by LMWH for THR (before=25% vs. after=73%;p<0.001), and aspirin for TKR (before=18% vs. after=84%;p<0.001). Significantly more regimens were NICE guidance compliant after the 2018 update for THR (before=85.7% vs. after=92.6%;p=0.011) and TKR (before=87.0% vs. after=98.8%;p<0.001). Support from surgeons for future RCTs was dependent on the clinical question, ranging from 48% participation in trials (effectiveness of aspirin vs. a DOAC) to 79% (effectiveness of 14 days LMWH vs. 28 days LMWH). Over one-third of surveyed surgeons changed their VTE chemical prophylaxis in response to 2018 NICE recommendations, with more THR and TKR surgeons now compliant with latest NICE guidance. The major change in practice was an increased use of aspirin for VTE chemical prophylaxis. Furthermore, there is an appetite amongst UK surgeons for participating in future RCTs, with a trial comparing standard versus extended duration LMWH likely feasible in current practice

Objectives. As per NICE guidance, one of the cornerstones of management of AKI is risk assessment. Aim of the audit is to identify the potential risk factors for postoperative AKI in hip fracture patients. Design and Methods. Using local NOF registration data, Patient details were selected using inclusion and exclusion criteria. Electronic records of patients were assessed retrospectively including blood results, radiological investigations, clinical documentation and drug chart. Inclusion Criteria: All patients > 50 years old with NOF fractures underwent operative management from January 2022 to June 2022 Exclusion Criteria: 1- Pathological fractures. 2- Non-operative management. 3- Died directly postoperative. Results. 250 patients underwent hip fracture surgery at our hospital in 6 months (January 2022-June 2022) (Cemented Procedures were 133 (53 %) while Fixation procedures were 117 (47%)). Female patients were 174 (70%), and male were 76 patients. Average age was 83.4 years and number of operations done over Weekend (Friday-Sunday) = 123 (49%). The incidence of Postoperative AKI was 56 (22.4%). Forty-five from fifty-six cases were stage 1 (80.4%) while 7 cases (12.5%) were stage 2. The studied risk factors for Postoperative AKI were: cemented procedures (61% of postoperative AKI incidence), female Gender (66%), time from admission to operation (>24 hours =33 %), day of operation (operations done Friday/Saturday/Sunday = 55%) and Postoperative antibiotics (71%). Conclusion. We need strategies to reduce incidence of postoperative AKI like: AKI alert on laboratory results, IV fluid prescription preoperative since arrival of patients to ED, avoid/stop nephrotoxic medications on admission, regular review of postoperative U&Es and fluid balance especially in high-risk patients, increase nursing staff and junior doctors on wards over weekends and we need to review our policy of giving postoperative IV antibiotics

Over 200,000 osteoporotic fractures occur in the UK annually. Patients with fragility fractures are at highest risk of further fracture, though preventative treatment has been shown to reduce subsequent fracture incidence. In 2005, the National Institute for Health & Clinical Excellence (NICE) recommended bisphosphonates as a treatment option in women over 75 years without the need for prior DEXA scanning (Technology Appraisal Guidance 87). We prospectively reviewed the medication of such patients who were admitted to our Trauma Unit to identify if the NICE guidance was being followed. Over a three month period between May and July 2007, 54 women over 75 years old were discharged from our Trauma Unit having sustained an osteoporotic fracture. We prospectively reviewed their medication to identify if a bisphosphonate had been commenced by the General Practitioner and their discharge letters to their General Practitioners to see if it had been suggested to start one. 7 of the 54 women (13%) were already on a bisphosphonate and were therefore excluded. Only one (2%) of the discharge letters (written by the Orthopaedic doctor to the General Practitioner) recommended commencing a bisphosphonate. 6 of the 47 patients (13%) had been started on a bisphosphonate by the General Practitioner. Nice guidance from 2005 is clearly not being implemented in our area. A minority of patients will have contraindications or allergies to bisphosphonates (up to 1 in 4 patients as highlighted recently by the National Osteoporosis Society). Important deficiencies in local services have been identified, particularly with respect to communication between secondary and primary care. This study lead to an education initiative to ensure the Trauma department and our local General Practitioners were aware of the NICE guidance. A second prospective audit is currently being undertaken to assess the effect on our service

Introduction: Over 200,000 osteoporotic fractures occur in the UK annually. Patients with fragility fractures are at highest risk of further fracture, though preventative treatment has been shown to reduce subsequent fracture incidence. In 2005, the National Institute for Health & Clinical Excellence (NICE) recommended bisphosphonates as a treatment option in women over 75 years without the need for prior DEXA scanning (Technology Appraisal Guidance 87). We prospectively reviewed the medication of such patients who were discharged from our Trauma Unit to identify if the NICE guidance was being followed. Method: Over a three month period between May and July 2007, 54 women over 75 years old were discharged from our Trauma Unit having sustained an osteoporotic fracture. We prospectively reviewed their medication to identify if a bisphosphonate had been commenced by the General Practitioner and their discharge letters to their General Practitioners to see if it had been suggested to start one. Results: 7 of the 54 women (13%) were already on a bisphosphonate and were therefore excluded. Only one (2%) of the discharge letters (written by the Orthopaedic doctor to the General Practitioner) recommended commencing a bisphosphonate. 6 of the 47 patients (13%) had been started on a bisphosphonate by the General Practitioner. Conclusions: Nice guidance from 2005 is clearly not being implemented in our area. Some patients will have contraindications or allergies to bisphosphonates, however, they will be a minority (up to 1 in 4 patients as highlighted recently by the National Osteoporosis Society). We believe the results demonstrate a lack of health promotion opportunities to prevent future fracture. Although there is clear focus and impetus for developing falls prevention services nationwide, this enthusiasm has not been translated across to bone health, despite the potential savings in terms of morbidity, mortality and healthcare costs. Important deficiencies in local services have been identified, particularly with respect to communication between secondary and primary care. This study lead to an education initiative to ensure the Trauma department and our local General Practitioners were aware of the NICE guidance. A second prospective audit is currently being undertaken to assess the effect on our service

16 to 34% of the population suffer from shoulder pain, the most common cause being rotator cuff tears. NICE guidance recommends using ultrasound scan (USS) or MRI to assess these patients, but does not specify which is preferable. This study assesses the accuracy of USS and MRI in rotator cuff tears in a DGH, to establish the most appropriate imaging modality. Patients who had at least two of shoulder ultrasound, MRI or arthroscopy within a seven month period (n=55) were included in this retrospective study. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated using arthroscopy as the true result, and kappa coefficients calculated for each pairing. 59 comparisons were made in total. Sensitivity for MRI in full supraspinatus tears was 0.83, and for USS 0.75. Specificity for MRI in these tears was 0.75, and for USS 0.83. Values were much lower in other tears, which occurred less frequently. USS and MRI completely agreed with each other 61.3% of the time. Both modalities were only completely accurate 50% of the time. Kappa coefficient between arthroscopy and MRI for supraspinatus tears was 0.658, and for USS was 0.615. There was no statistical difference between MRI and USS sensitivity or specificity (p=1), suggesting that one modality cannot be recommended over the other for full supraspinatus tears. They also do not tend to corroborate one another, suggesting that there is no benefit from doing both scans. Further research is needed to see how both modalities can be improved to increase their accuracy

Aims. This study sought to estimate the clinical outcomes and describe the nationwide variation in practice, as part of the feasibility workup for a National Institute for Health and Care Excellence (NICE) recommended randomized clinical trial to determine the optimal treatment of torus fractures of the distal radius in children. Methods. Prospective data collection on torus fractures presenting to our emergency department. Patient consent and study information, including a copy of the Wong-Baker Faces pain score, was issued at the first patient contact. An automated text message service recorded pain scores at days 0, 3, 7, 21, and 42 postinjury. A cross-sectional survey of current accident and emergency practice in the UK was also undertaken to gauge current practice following the publication of NICE guidance. Results. In all, 30 patients with a mean age of 8.9 years were enrolled over a six-week period. Of the 150 potential data points, data was captured in 146, making the data 97.3% complete. Pain scores were recorded at day 0 (mean 6.5 (95% confidence interval (CI) 5.7 to 7.3)), day 3 (4.4 (95% CI 3.5 to 5.2)), day 7 (3.0 (95% CI 2.3 to 3.6)), day 21 (1.2 (95% CI 0.7 to 1.7)) and day 42 (0.4 (95% CI 0.1 to 0.7)). Of the 100 units who participated in the nationwide survey, 38% were unaware of any local or national protocols regarding torus fractures, 41% treated torus fractures with cast immobilization, and over 60% of patients had follow-up arranged, both contradictory to national guidelines. Conclusion. We have demonstrated the severity, recovery trajectory, and variation in pain scores among children with torus fractures. We demonstrate excellent follow-up of patient outcomes using text messages. Despite national guidelines, there is significant variation in practice. This data directly informed the development of an ongoing nationwide randomized clinical trial – the FORearm Fracture Recovery in Children Evaluation (FORCE) study

Background. The advent of EOS imaging has offered clinicians the opportunity to image the whole skeleton in the anatomical standing position with a smaller radiation dose than standard spine roentgenograms. It is known as the fifth modality of imaging. Current NICE guidelines do not recommend EOS scans over x-rays citing: “The evidence indicated insufficient patient benefit in terms of radiation dose reduction and increased throughput to justify its cost”. Methods. We retrospectively reviewed 103 adult and 103 paediatric EOS scans of standing whole spines including shoulders and pelvis for those undergoing investigation for spinal deformity in a tertiary spinal centre in the UK. We matched this against a retrospective control group of 103 adults and 103 children who underwent traditional roentgenograms whole spine imaging at the same centre during the same timeframe. We aimed to compare the average radiation dose of AP and lateral images between the two modalities. We utilised a validated lifetime risk of cancer calculator (. www.xrayrisk.com. ) to estimate the additional mean risk per study. Results. In the Adult EOS Group (AEG) the mean estimated effective dose of AP was 0.08 mSv (0.04–0.15) and Lateral 0.06 mSv (0.03–0.14). Conversely in the Adult Roentgenograms Group (ARG) the mean AP was 0.49 mSv (0.15–1.88) and Lateral was 0.29 mSv (0.07–1.20). In the Paediatric EOS Group (PEG): the mean dose of AP was 0.07 mSv (0.02–0.21) and Lateral 0.04 mSv (0.02–0.11). Conversely Paediatric Roentgenograms Group (PRG) had a mean dose in AP of 0.37 mSv (0.03–5.92) and in lateral of 0.17 mSv (0.03–0.44). The percentage differences were: ARG:AES AP 613%, ARG:AES Lat 483%, PPG:PEG AP 529%, PRG:PEG Lat 425%. Mean difference 513%. The additional lifetime cancer risk for AEG was 1 in 176056 for males and 1 in 138696 for females, compared to ARG 1 in 31596 for males and 1 in 24894 for females. In PEG that was 1 in 58207 for boys and 1 in 33367 for girls, compared to PRG 1 in 11860 for boys and 1 in 6797 in girls. Differences in additional lifetime risk of cancer per scan: ARG:AES Male 557%, Female 557%, PRG:PEG Male 491%, Females 491%. Conclusion. Standard plain film imaging of the whole spine requires approximately five-times higher doses of radiation compared to dual planar EOS scans. This carries a significant impact when considering the need for repeat imaging on additional lifetime malignancy risk in both children and adults. There is approximately 5-fold increase in risk of cancer for all groups with roentgenograms over EOS. We directly challenge the NICE guidance and recommend EOS dual planar imaging in favour of plane roentgenograms for investigation of spinal deformity

Objectives. The annual incidence of hip fracture is 620 000 in the European Union. The cost of this clinical problem has been estimated at 1.75 million disability-adjusted life years lost, equating to 1.4% of the total healthcare burden in established market economies. Recent guidance from The National Institute for Health and Clinical Excellence (NICE) states that research into the clinical and cost effectiveness of total hip arthroplasty (THA) as a treatment for hip fracture is a priority. We asked the question: can a trial investigating THA for hip fracture currently be delivered in the NHS?. Methods. We performed a contemporaneous process evaluation that provides a context for the interpretation of the findings of WHiTE Two – a randomised study of THA for hip fracture. We developed a mixed methods approach to situate the trial centre within the context of wider United Kingdom clinical practice. We focused on fidelity, implementation, acceptability and feasibility of both the trial processes and interventions to stakeholder groups, such as healthcare providers and patients. Results. We have shown that patients are willing to participate in this type of research and that surgeons value being part of a team that has a strong research ethos. However, surgical practice does not currently reflect NICE guidance. Current models of service delivery for hip fractures are unlikely to be able to provide timely total hip arthroplasty for suitable patients. Conclusions. Further observational research should be conducted to define the population of interest before future interventional studies are performed. Cite this article: C. Huxley, J. Achten, M. L. Costa, F. Griffiths, X. L. Griffin. A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur: Can a trial investigating total hip arthroplasty for hip fracture be delivered in the NHS? Bone Joint Res 2016;5:444–452. DOI: 10.1302/2046-3758.510.BJR-2015-0008.R1

Background. NICE guidance suggests that caudal epidural injections of steroid and local anaesthetic may be considered for acute and severe sciatica, however studies have demonstrated limited long-term benefit and impact on future surgery. This study aimed to investigate the use of caudal epidural injections in a district general hospital setting and the rate of subsequent operation. Methods. All patients undergoing caudal epidural injection between 1. st. January and 30. th. June 2015 were included. Records were reviewed to obtain diagnosis, pre- and post-epidural clinical findings, prior interventions, and subsequent operations. Results. A total of 141 patients underwent a caudal epidural, with a median age of 63 (18 – 90). 37 patients went on to surgical intervention within 3 years, resulting in a conversion rate of 26.1%. Amongst those not requiring surgery, 59 (56.19%) had disc herniation, 42 (40%) stenosis, 4 spondylolisthesis, and 1 a facet cyst. Pre-operatively 63.81% reported back pain and 93.33% sciatica. 39.05% of patients had sensorimotor changes. Post-operatively, 27.62% reported an improvement in their back pain, compared to 62.86% reporting improved leg pain. 36.59% of those with sensorimotor changes reported improvement. 32 later had a further caudal epidural or foraminal block, and 25 had facet and sacroiliac joint injections. Amongst those requiring surgery, 21 (56.76%) had disc herniation, 15 (40.54%) stenosis, and 1 spondylolisthesis (2.7%). Conclusion. In our series, approximately three quarters of patients undergoing caudal epidural injection did not subsequently require surgery. Lumbosacral radicular symptoms improved in two thirds, however the epidural was less effective at treating back pain. No conflicts of interest. No funding obtained

Background and purpose of the study. Axial Spondyloarthritis (axSpA) is commonly mistaken as chronic mechanical back pain. Delayed diagnosis averages 5- 8 years with impacts on effective and timely management, outcomes and quality of life. NICE Guidance (2017) highlights the importance of the recognition and referral of suspected axial spondyloarthritis. This study investigated the occurrence of physiotherapy care prior to diagnosis of axSpA within physiotherapy outpatient settings. Methods and results. A retrospective review was performed of all patients diagnosed with axSpA who had received physiotherapy care prior to their diagnosis from 1990–2016. Three or more episodes of care prior to diagnosis was taken as unrecognised axSpA. Information was obtained on diagnostic codes, number of episodes of care and contacts per episode from nine outpatient physiotherapy services. Analysis showed that 263 people (17–69 years) diagnosed with axSpAs had received physiotherapy care prior to diagnosis. Within this population, 103 (44%) had received ≥3 episodes of care. Number of contacts within each episode ranged from 3 (47 people) to 58 (1 person) [median=11 contacts-10 people]. Average time from initial physiotherapy episode to date of diagnosis was 6.4 years (range=0.3–12.8 years, median=8.8 years). The most common assigned diagnostic code was back pain (49.6%), followed by shoulder (11.1%), knee (8.5%), neck (7.7%), ankle/foot (4.3%), tendonitis (4.2%), joint pain (3.4%), osteoarthritis (3.4%) and sacroiliac joint (2%). Conclusion. Findings illustrate the extent of unrecognised axial spondyloarthritis referred to and missed in musculoskeletal physiotherapy practice. It is essential to improve screening and recognition of inflammatory back pain and possible axSpA in musculoskeletal assessments, supported by rheumatology referral guidance. No conflicts of interest. No funding obtained

Rib fracture fixation by orthopaedic and cardiothoracic surgeons has become increasingly popular for the treatment of chest injuries in trauma. The literature, though mainly limited to Level II and III evidence, shows favourable results for operative fixation. In this paper we review the literature and discuss the indications for rib fracture fixation, surgical approaches, choice of implants and the future direction for management. With the advent of NICE guidance and new British Orthopaedic Association Standards for Trauma (BOAST) guidelines in production, the management of rib fractures is going to become more and more commonplace

Background. Prosthetic implants used in primary total hip replacements have a range of bearing surface combinations (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, metal-on-metal); head sizes (small <36mm, large 36mm+); and fixation techniques (cemented, uncemented, hybrid, reverse hybrid), which influence prosthesis survival, patient quality of life, and healthcare costs. This study compared the lifetime cost-effectiveness of implants to determine the optimal choice for patients of different age and gender profiles. Methods. In an economic decision Markov model, the probability that patients required one or more revision surgeries was estimated from analyses of UK and Swedish hip joint registries, for males and females aged <55, 55–64, 65–74, 75–84, and 85+ years. Implant and healthcare costs were estimated from hospital procurement prices, national tariffs, and the literature. Quality-adjusted life years were calculated using utility estimates, taken from Patient-Reported Outcome Measures data for hip procedures in the UK. Results. Optimal choices varied between traditionally used cemented metal-on-polyethylene and cemented ceramic-on-polyethylene implants. Small head cemented ceramic-on-polyethylene implants were optimal for males and females aged under 65. The optimal choice for adults aged 65 and older was small head cemented metal-on-polyethylene implants. Conclusions. The older the patient, the higher the probability that small head cemented metal-on-polyethylene implants are optimal. Small head cemented ceramic-on-polyethelyne implants are optimal for adults aged under 65. Our findings can influence NICE guidance, clinical practice, and commissioning of services. Funding. NIHR Research for Patient Benefit programme PB-PG-0613-31032

Fractured neck of femur is a significant health concern within the UK. NICE guidance on the management of displaced intracapsular fractures states that total hip arthroplasty should be offered when patients can; walk independently out of doors with no more than a stick, not cognitively impaired, medically fit for anaesthesia and the procedure. We previously managed this subgroup using THA with standard sockets. Following an audit of this practice a dislocation rate of 9% was identified and practice was changed to using dual mobility (THA-DM) with the theoretical advantage of reducing dislocation. We reviewed all patients who underwent THA for fracture using Bluespier from 2013–2017. Operative notes and radiographs were reviewed to ensure the patients had undergone THA for displaced intracapsular fracture. Basic patient demographics were collected. Our primary outcome was dislocation rates at one year. Our secondary outcomes were length of time to surgery, length of stay, operative time, mortality, return to theatre rates and one year Oxford hip scores. We found a control group of 45 THA procedures and a dual mobility group of 143 procedures. The one year dislocation rate from the THA-SS group was 9% and the THA-DM group was 1.4%(CI±1.9%)(p=<0.05%). There were also non-significant reductions in time to surgery, length of stay, operative time, mortality, return to theatre rates. The one year Oxford hip score was comparable at 42.2 to 41.8. This study demonstrates a significant reduction in one year dislocation rates with comparable oxford hip scores. Use of THA-DM should be considered in those patients who meet NICE criteria. Further research is needed into long term dislocation rates

Contrary to NICE guidance there remains a role for Austin-Moore hemiarthroplasty (AM) for patients with significant pre-existing comorbidities who are at higher risk of death and complications following cemented hemiarthroplasty. We analysed prospectively-collected data comparing uncemented AM hemiarthroplasty in frail, poorly-mobile patients, and cemented hemiarthroplasty. We analysed age, pre-operative morbidity, duration of operation, death rate and complication rate. AM patients were significantly older with significantly higher ASA grades. It took significantly longer to optimise them before surgery. AM was significantly shorter to perform. There was no significant difference in complications requiring re-operation. Twice as many AM patients developed post-operative pneumonia despite absence of cement. Twice as many AM patients died after surgery and a significant proportion died within the first month despite no increased risk of repeat operation, shorter operating time and no risk of cement-disease. We infer that these patients would likely have fared badly had they undergone a longer, cemented procedure. A modern cemented prosthesis costs £691 more than AM. There exists a subset of patients within the neck of femur cohort who are significantly more unwell. Contrary to guidelines, we suggest that the cheaper, user-friendly Austin-Moore can be a reasonable prosthesis to use for this cohort

More than half of patients with neck of femur (NOF) fractures report their pain as severe to very severe in the first 24hrs. Opioids remain the most commonly used analgesia and are effective for static pain but not dynamic pain. Opioids provide suboptimal analgesia when patients are in a dynamic transition state and their side-effects are a source of morbidity in these patients. The Fascia Iliaca Compartment Block (FICB) involves infiltration of the fascia iliaca compartment with a large volume of low concentrated local anaesthetic to reduce pain by affecting the femoral and lateral cutaneous nerve of the thigh. The London Quality Standards for Fractured neck of femur services (2013) stated that the FICB should be routinely offered to patients. We performed an audit of patient outcomes following the introduction of the FICB across three centres. We performed a two-cycle audit across two hospitals in 2014/15. The first cycle audited compliance with the NICE guidance in the management and documentation of pain and AMTS (Abbreviated Mental Test Scores) in patients. The second cycle was conducted following the integration of the FICB into the multidisciplinary NOF fracture protocol across three hospital sites. Data was collected on numeric pain scores, pre and post-op AMTS and opioid requirements. There were 40 patients audited with 20 in the first cycle prior to the introduction of the FICB and 20 following this. In the second cycle, there was a statistically significant improvement (p<0.001) in the difference between the pre and post-op AMTS. The preliminary findings in this audit support the use of the FICB adjunct to analgesia in the pre-operative management of NOF fracture patients. The FICB is a safe procedure and the organisational learning of this procedure through a multidisciplinary approach can significantly improve the outcomes of NOF fracture patients

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

According to the National Institute of Clinical Excellence (NICE) Guidelines, some foot and ankle patients are, by definition, at high risk of DVT/PE. Despite NICE guidance, DVT recommendations are still controversial, and are being reviewed by the BOA to be more operation and context specific. One consultant at our institution therefore initiated a 6 week medical DVT prophylaxis regimen for all his post-operative hind–foot surgery patients who were placed in plaster. From January 2007 to February 2008 we audited 97 hind-foot patients to measure their compliance rate, complications and DVT/PE rate. Compliance was excellent (97%) particularly with regard to Low Molecular Weight Heparin (LMWH), but only 70% had medication prescribed for the 6 weeks, and 3% developed a DVT. Self administered LMWH is acceptable and compliance is excellent in post operative orthopaedic patients, but not necessarily effective

The 2007 National Institute for health and Clinical Excellence (NICE) thromboprophylaxis guidelines concerning hip arthroplasty remain contentious. A survey among British Hip Society members was performed to investigate the impact of these guidelines. Information on thromboprophylactic measures before and after guideline publication was gathered in the three categories of Total Hip Replacement (THR), hip fracture and high-risk patients as defined by NICE. The response rate was 185/250 (74%). All responders used thromboprophylaxis, but only 44%, 22% and 7% indicated they were currently acting in accordance with guidance for THR, high risk and hip fracture groups respectively. 19%, 14% and 14% had changed their practice since publication of the guidance in THR, high risk and hip fracture groups respectively. The effects of the NICE guidance in influencing the responders’ thromboprophylactic protocols have been very limited. These results do not appear to endorse the authority of NICE in decisions made in this area