We present a review of our Specialist Physiotherapy clinic for normal physiological variations of the lower limb (SPNV) clinics, demonstrating them to be clinically effective and cost effective.

Children with normal variation of rotational profile and limb angulation present much anxiety to parents and primary care. Providing consultation: to eliminate significant pathology and reassure families, is an important service that a Paediatric Orthopaedic department provides. In our tertiary referral department we have a Specialist Physiotherapy led clinics into which primary care practitioners refer children with whom there are concerns about lower limb development variation.

The (SPNV) Clinic was first set up by a Consultant and Senior Physiotherapist in 1999. The aim of the clinic was to reduce the waiting times for incoming referrals but ensuring they are seen in an appropriate environment by an experienced health care professional. Clinics are run by Senior Specialist Physiotherapists, alongside Consultant clinics who are available for advice and direction. This provides security for the physios, the Trust and the patient.

Over 15 years there have been more than 4000 patient visits to this clinic. Over 80% were new patient visits. 70% of these visits were discharged in one or two reviews. 97.4% of new referrals were discharged without subsequent review by an orthopaedic surgeon. The most common conditions reviewed were Genu valgum (25%), Genu Varum (16%), intoeing (17%) and flexible flat feet (11%).

The clinic has proven to be cost effective as well in drawing in up to £500,000 revenue into the trust in a single year. The department has been approached by other trusts to assist in the implementation of similar clinics.

We present this review of the patients, as a template for supporting the work of Paediatric Orthopaedic Departments. This service has facilitated the streamlining of our Consultant Paediatric Orthopaedic clinics.

Aims:

To assess the success rate of closed reduction after failing Pavlik harness for treatment of DDH.

Aim: To assess whether use of the Pavlik harness for the management of developmental dysplasia of the hip (DDH) can safely be discontinued without weaning.

Method: The study group comprised babies diagnosed with DDH at the Royal Liverpool Children’s hospital over a 10 year period, between January 1995 and August 2004. The decision to instigate treatment with a Pavlik harness was based upon the Graf grade. We used Graf IIB or worse as our treatment threshold for the use of the Pavlik harness. In our practice the harness was removed when the hips were ultrasonographically and clinically normal, without a period of weaning.

Results: There were 368 hips (273 babies) for analysis, 178 cases of unilateral DDH (128 left hips and 50 right hips) and 95 bilateral cases. Mean age at diagnosis was 59 days (range 1 – 187 days) with twenty-six patients presenting late after the usual 120 day time limit. Treatment with the Pavlik harness was successful in normalising 323 hips (87.8%). The Pavlik harness was unsuccessful in reducing 45 dislocations (12.2%). Patients were followed-up for a mean of 4.1 ± 2.7 years with no deterioration of acetabular indices on plane radiographs, according to the Tonnis classification. There were 4 hips with possible grade I avascular necrosis. To date there have been no cases of late dysplasia.

Conclusions: Although many units remove the harness after a period of gradual weaning, practice is varied. Since we did not encounter any negative outcome despite not weaning we conclude that that weaning is unnecessary.

Aim: To assess the effectiveness of a physiotherapist led normal variant clinic for children.

Method: The study comprised all children presenting to the physiotherapy clinic at the Royal Liverpool Children’s hospital between January 2000 and January 2006. The clinic is run by two specialist physiotherapists alongside a consultant led Orthopaedic clinic, providing support as required. Physiotherapy staff are able to request and interpret radiographs and order blood tests independently. The numbers of patients, the range of conditions seen in the clinic, and the outcome of the consultations recorded in the practitioner case-notes were examined for the purpose of this study.

Complete data was available for the full period under review except for the year 2003.

Results: During the five year study period 1594 children were seen, a mean of 318 patients annually (range 267–387). The age distribution of patients was 33.1% (527) under the age of 2, 38.9% (620) 2–5 years, 19.3% (307) 5–10 years and 8.8% (140) 10–16 years. The most common conditions seen were genu valgum 28.7% (458), genu varum 18.4% (293), in-toeing 14.7% (234) and toe walking 6.0% (96). Most patients (94.7% n=1509) were managed independent of consultant supervision by the physiotherapist. A minority of patients required consultant review in the clinic (4.2% n=67). Fewer still were referred to another medical clinic (1.1% n=18).

Conclusions: Children with a spectrum of orthopaedic conditions can be appropriately managed by a trained physiotherapist independent of consultant input.

Introduction: Increasing numbers of patients are being treated outside traditional NHS hospitals as part of GSup (General supplemental funding) projects and other initiatives to reduce waiting lists. Concerns regarding these arrangements include case mix at NHS hospitals, quality of clinical care and patient satisfaction.

Null Hypothesis: There is no difference between overall patient satisfaction following treatment within the NHS, as part of GSup or as an independent private patient.

Methods: Patients undergoing total hip arthroplasty by a single consultant were contacted 6 to 18 months postop. 3 groups were formed; those treated in the local NHS hospital, patients treated as part of GSup and private patients independently financed.

A previously validated patient satisfaction questionnaire was completed by each patient. This investigates satisfaction with admission, environment, healthcare professionals, treatment, leaving hospital and overall care. Fisher exact test used to compare groups for significant differences in responses, significance was assumed at p< 0.05 level.

Results: 144 of 202 patients responded. Though generally high overall levels of satisfaction were reported, areas of concern were identified, particularly regarding cleanliness of hospital, the availability of nursing staff, maintenance of patient confidentiality and communication with patients. In all cases the GSup patients reported significantly higher levels of satisfaction compared with the NHS patients. 12% of NHS patients felt their overall care fell below “very good” compared with 0% of the GSup patients (p< 0.05).

Discussion: Significant differences are identified between NHS and GSup patient satisfaction regarding hospital environment, healthcare professionals and overall standards of care. There were few differences between GSup and private patients treated in the same environment but where they did occur they were universally more positive for the GSup patients.

Conclusions: Concerns that GSup patients may be less satisfied with their care appear unfounded; in general they were better satisfied than NHS patients.