Background. Evidence suggests classification system (CS) guided treatments are more effective than generalized and practice guidelines based treatments for low back pain (LBP) patients. This study evaluated clinicians' and managers' attitudes towards LBP classification and its usefulness in guiding LBP management. Methods. Data from 3 semi-structured interviews with physiotherapy service managers and advanced spinal physiotherapy practitioner and a focus group (5 physiotherapists) in two NHS Health Boards, South Wales, UK, was thematically analysed. Results. Five themes emerged. CS knowledge: Clinicians and managers know different CSs and agree with its usefulness. Clinicians have specific CSs knowledge, managers viewed classification related to referral pathways and prognosis. Current CS use: Clinicians classify using their experience and clinical reasoning skills shifting between multiple CSs. Managers are confident that staff provide evidence-based service though believe classification is not always practiced across services. CS advantages/disadvantages: Effectively targeting the right patients for right treatments using evidence-based practice is advantageous. Prevalence of “guru led” CSs developed for research and of limited clinical use is disadvantageous. Barriers: Patients' treatment expectations, threat to clinical autonomy, lack of sufficiently complex CSs, lack of resources to up-skill clinicians and overall CSs fit into complex referral pathways. Enablers: CSs sufficiently complex & placed within clinical reasoning process, mentoring for inexperienced staff, positive engagement with all stakeholders and patients. Conclusion. Clinicians and managers are aware of CSs and agree with its usefulness to guide LBP management. Clinicians classify LBP though there is no formalized CS process in place. Whilst clinicians view classification as the relationship between patients and physiotherapy managers have a broader, whole service view. Conflicts of interest: None. Sources of funding: Wales School of Primary Care Research, Cardiff, UK. This abstract has not been previously published in whole or substantial part nor has been presented previously at a national meeting

Purpose and background of the study. Self-management and behaviour change is at the core of back pain management. Despite the high-rate of recurrence and healthcare utilisation, clinical guidelines do not include guidance for clinicians on return consultations. This project aimed to identify primary care clinicians’ reported practices and experiences of delivering self-management advice for people returning with persistent low back pain (LBP), to inform future delivery of self-management care. Methods and Results. In this qualitative study involving 27 primary care clinicians, four focus groups and two semi-structure interviews were conducted online. GPs (n=5) and physiotherapists working in primary care roles (First contact practitioners n=7, community and interface roles n=7, and mixed roles n=8) in England and Scotland shared their experience of delivering self-management advice to people returning with persistent LBP. Video recordings were transcribed verbatim and analysed with reflexive thematic analysis. Clinicians unanimously shared their frustrations identifying the challenges involved in supporting people who return with LBP. Helpful strategies to support self-management in return consultations were identified by clinicians in addition to service and system-level changes vital to optimise care. Patient-factors affecting delivery of care, lack of defined responsibility and challenges in meeting patients’ expectations illustrated the tensions that exist in return consultations. Conclusion. This novel study provides insight into the experiences and practices of the frontline primary care workforce seeing patients return with persistent or recurrent LBP. It identifies the tensions that exist between services, professional roles and between clinicians and patients regarding self-management. Important practice implications have been identified to improve information-sharing, agenda-setting, and exploring expectations. No conflicts of interest.  . Source of funding. Lisa Osborn-Jenkins is funded by University Hospital Southampton NHS Foundation Trust (UHS) Research & Development PhD Fellowship [GRT0723]

To test the knowledge of clinicians in Orthopaedic clinics and Emergency departments of the surface anatomical landmarks that should be examined during assessment of foot and ankle injuries. Specifically trained assessors observed 109 clinicians examining 6 anatomical landmarks on uninjured subjects. Each landmark was chosen for their relevance in assessment of foot and ankle injuries. The landmarks were the medial malleolus, lateral malleolus, fibula head, navicular, base of the 5th metatarsal and the anterior talo-fibular ligament (ATFL). Two participants failed to identify a single landmark. Of 109 assessed, 27% correctly identified all 6 landmarks. The average correctly identified by each clinician was 4.1 with a standard deviation of 1.5 and range of 0–6. One hundred and seven clinicians correctly identified the lateral malleolus, the most consistently identified. The most poorly identified landmark was the ATFL, by 45%. The knowledge of surface anatomy overall by junior Orthopaedic and Emergency clinicians was found to be poor and only seems to significantly improve once higher specialty training is reached. Despite the potential for subjectivity and bias the authors believe the methodology is sufficient to demonstrate a lacking in anatomical knowledge amongst clinicians. Poor anatomical knowledge leads to inaccurate examination. This can lead to incorrect diagnoses or even mal-treatment of patients. Clinicians are becoming more reliant on potentially unnecessary and expensive imaging investigations. They have neglected the basic art of physical examination based on sound knowledge of human anatomy. At present, the authors believe that the anatomical teaching in undergraduate medicine is inadequate

Clinicians ask patients “How are you now?” to ascertain treatment outcomes and to set a plan for subsequent care. However, sometimes patient views do not agree with those of the clinicians. This study compared patient and clinician views of outcome one to two years after an operatively managed extremity fracture and described any discordance. There were significant differences between groups, especially in areas such as pain and disruption of their personal and work lives. A discordance was observed between patient and physician views of recovery after fracture, likely associated with disruptions to personal life, unaccounted for in a clinician’s view of outcome. Clinicians ask patients “How are you now?” to ascertain treatment outcomes and to set a plan for subsequent care. However, sometimes patient views differ from those of clinicians’. The purpose of this study is to compare patient and clinician views of outcome one to two years after an extremity fracture and to describe any discordance. Cross-sectional survey of patients one to two years after an operatively managed upper or lower extremity fracture. Patients were recruited from two tertiary care centres and completed a mailback questionnaire that included measures of health (DASH, SMFA), self-rated recovery, burden of illness (Illness Intrusiveness, Loss of self), symptoms, and work status. These were linked with clinical records of radiologic and clinical recovery. Two hundred and fifty-five patients returned usable questionnaires. Mean age was forty-two years and 42% were female. Sixty-seven patients said that they were completely better (CB), one hundred and thirty-four almost better (AB) and fifty-four not completely better (NCB). Significant differences were found between groups. In four variables, NCB was distinct from AB/CB, while in all other variables, such as pain, disability and disruption of their personal and work lives, all three groups were unique (Duncan’s post hoc). However, of the patients who said they were not better, the radiologist and clinician reports stated that thirty (68%) and twenty-eight (64%) were healed, respectively. A discordance was observed between patient and physician views of recovery after fracture. It appeared associated with disruptions to personal life that may not be accounted for in a clinician’s view of outcome. Funding: Canadian Institutes of Health Research (CIHR)

A statement of the purposes of the study and background:. Merely publishing clinical guidelines is insufficient to ensure their implementation in clinical practice. We aimed to clarify the decision-making processes that result in the delivery of particular treatments to patients with low back pain (LBP) in primary care and to examine clinicians' perspectives on the National Institute for Health and Care Excellence (NICE) clinical guidelines for managing LBP in primary care. A summary of the methods used and the results:. We conducted semi-structured interviews with 53 purposively-sampled clinicians from south-west England. Participants were: 16 General Practitioners (GPs), 10 chiropractors, 8 acupuncturists, 8 physiotherapists, 7 osteopaths, and 4 nurses. Thematic analysis showed that official guidelines comprised just one of many inputs to clinical decision-making. Clinicians drew on personal experience and inter-professional networks and were constrained by organisational factors when deciding which treatment to prescribe, refer for, or deliver to an individual patient with LBP. Some found the guideline terminology - “non-specific LBP” - unfamiliar and of limited relevance to practice. They were frustrated by disparities between recommendations in the guidelines and the real-world situation of short consultation times, difficult-to-access specialist services and sparse commissioning of guideline-recommended treatments. A conclusion:. The NICE guidelines for managing LBP in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses. When revised, these guidelines could be made more clinically relevant by: ensuring guideline terminology reflects clinical practice terminology; dispelling the image of guidelines as rigid and prohibiting patient-centred care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended therapies; and commissioning guideline-recommended treatments for NHS patients

Aims. To identify factors influencing clinicians’ decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC). Methods. A SurveyMonkey questionnaire was electronically distributed to clinicians around the world through the Fragility Fracture Network (FFN)’s Perioperative Special Interest Group and clinicians’ personal networks between 24 May and 25 July 2021. Analyses were performed using Excel and STATA v16.0. Between-group differences were determined using independent-samples t-tests and chi-squared tests. Results. A total of 406 respondents from 51 countries answered the questionnaire, of whom 225 came from HIC and 180 from LMIC. Clinicians from HIC reported a greater median and mean estimated proportion of admitted patients with hip fracture undergoing surgery (median 96% (interquartile range (IQR) 95% to 99%); mean 94% (SD 8%)) than those from LMIC (median 85% (IQR 75% to 95%); mean 81% (SD 16%); p < 0.001). Global heterogeneity seems to exist regarding factors such as anticipated life expectancy, insufficient resources, ability to pay, treatment costs, and perception of risk in hip fracture management decision-making. Conclusion. This study represents the first international sampling of clinician perspectives regarding nonoperative hip fracture management. Several factors seemed to influence the clinician decision-making process. Further research is needed to inform the development of best practice guidelines to improve decision-making and the quality of hip fracture care among older people. Cite this article: Bone Jt Open 2023;4(10):766–775

Aims. Perthes’ disease is an idiopathic avascular necrosis of the developing femoral head, often causing deformity that impairs physical function. Current treatments aim to optimize the joint reaction force across the hip by enhancing congruency between the acetabulum and femoral head. Despite a century of research, there is no consensus regarding the optimal treatment. The aim of this study was to describe the experiences of children, their families, and clinicians when considering the treatment of Perthes’ disease. Methods. A qualitative study gathered information from children and their families affected by Perthes’ disease, along with treating clinicians. Interviews followed a coding framework, with the interview schedule informed by behavioural theory and patient and public involvement. Transcripts were analyzed using the framework method. Results. A total of 24 interviews took place, with 12 child/family dyads and 12 clinicians from UK NHS centres. Interviews identified widespread variation of routine care. Children/their families recounted positive experiences when included in the decision-making process for treatment. There is a strong desire from clinicians and children/families for consistent guidance from everyone involved in care, which should be based on clinical consensus. Conclusion. This is the first study to describe how children/families and clinicians experienced receiving or providing treatment in Perthes’ disease. The results indicate the need for robust evidence to support treatment decisions. Children and families valued feeling involved in the clinical decision-making process. Clinicians acknowledged the central importance of providing patient-centred care, particularly in the absence of robust evidence to guide the optimal treatment decisions. This study will inform a future Delphi project to develop clinical consensus guidelines for the treatment of Perthes’ disease. Cite this article: Bone Jt Open 2023;4(10):735–741

Aims. Hip fractures are some of the most common fractures encountered in orthopaedic practice. We aimed to identify whether perioperative hypotension is a predictor of 30-day mortality, and to stratify patient groups that would benefit from closer monitoring and early intervention. While there is literature on intraoperative blood pressure, there are limited studies examining pre- and postoperative blood pressure. Methods. We conducted a prospective observational cohort study over a one-year period from December 2021 to December 2022. Patient demographic details, biochemical results, and haemodynamic observations were taken from electronic medical records. Statistical analysis was conducted with the Cox proportional hazards model, and the effects of independent variables estimated with the Wald statistic. Kaplan-Meier survival curves were estimated with the log-rank test. Results. A total of 528 patients were identified as suitable for inclusion. On multivariate analysis, postoperative hypotension of a systolic blood pressure (SBP) < 90 mmHg two to 24 hours after surgery showed an increased hazard ratio (HR) for 30-day mortality (HR 4.6 (95% confidence interval (CI) 2.3 to 8.9); p < 0.001) and was an independent risk factor accounting for sex (HR 2.7 (95% CI 1.4 to 5.2); p = 0.003), age (HR 1.1 (95% CI 1.0 to 1.1); p = 0.016), American Society of Anesthesiologists grade (HR 2.7 (95% CI 1.5 to 4.6); p < 0.001), time to theatre > 24 hours (HR 2.1 (95% CI 1.1 to 4.2); p = 0.025), and preoperative anaemia (HR 2.3 (95% CI 1.0 to 5.2); p = 0.043). A preoperative SBP of < 120 mmHg was close to achieving significance (HR 1.9 (95% CI 0.99 to 3.6); p = 0.052). Conclusion. Our study is the first to demonstrate that postoperative hypotension within the first 24 hours is an independent risk factor for 30-day mortality after hip fracture surgery. Clinicians should recognize patients who have a SBP of < 90 mmHg in the early postoperative period, and be aware of the increased mortality risk in this specific cohort who may benefit from a closer level of monitoring and early intervention. Cite this article: Bone Joint J 2024;106-B(2):189–194

Background

Sciatica is common and associated with significant impacts for the individual, health care and society. The SCOPiC randomised controlled trial (RCT) is investigating whether stratified primary care for sciatica is more effective and cost-effective than usual, non-stratified primary care. Stratified care involves subgrouping patients to one of three groups based on a combination of prognostic and clinical indicators. Patients in one of these groups are ‘fast-tracked’ with an MRI scan to spinal specialist opinion. Our aim was to understand the perspectives of clinicians on the acceptability of this ‘fast-track’ pathway.

Dislocation following total hip arthroplasty (THA) is a well-known and potentially devastating complication. Clinicians have used many strategies in attempts to prevent dislocation since the introduction of THA. While the importance of postoperative care cannot be ignored, particular emphasis has been placed on preoperative planning in the prevention of dislocation. The strategies have progressed from more traditional approaches, including modular implants, the size of the femoral head, and augmentation of the offset, to newer concepts, including patient-specific component positioning combined with computer navigation, robotics, and the use of dual-mobility implants. As clinicians continue to pursue improved outcomes and reduced complications, these concepts will lay the foundation for future innovation in THA and ultimately improved outcomes. Cite this article: Bone Joint J 2022;104-B(1):8–11

Background and purpose of study: Communication between clinicians and patients forms an integral part of any treatment session. To promote positive treatment outcomes, this communication must be effective. To date, research into back pain management has tended to focus on the nature of interventions, neglecting the vital communication that co-exists.

This study aimed to measure verbal communication between clinicians and patients and identify trends in non-verbal communication. With a clearer understanding of how clinicians and patients interact, it is anticipated that this knowledge can be used to maximise health gain in subsequent treatments.

Methods: Following an assessment, the first follow-up treatment session was video recorded for 21 patients (aged 17–65 years), attending a hospital outpatient physiotherapy clinic. Patients with serious spinal pathology or those, whose first language was not English, were excluded.

Verbal communication during the interaction was measured using the validated Medical Communication Behaviour System (MCBS). Trends in non-verbal behaviour were analysed at 40-second intervals, using Heintzman’s classification (smiling, forward leaning, affirmative head nodding, touching and eye gaze). A brief semi-structured interview was undertaken with clinicians to determine the perceived effect of the presence of the video camera.

Results: In 21 treatment sessions, 2055 statements were observed, with clinicians spending approximately twice as long talking as patients. Using the MCBS categories, the majority of clinician and patient interaction related to ‘content’ behaviours (52% and 26% respectively). For the clinician, this includes history-taking, advice etc. The highest frequency of clinicians’ non-verbal behaviour was touch (n=352) and for patients, was eye gaze (n=36).

In a secondary analysis, age, gender and experience of the clinician were all shown to influence the communication that occurred.

Conclusion: Validated outcome measures can be used to analyse the complex communication that occurs between clinicians and patients with back pain. Video recording clinical sessions can provide valuable feedback for clinicians and students on their communication skills.

Background to the study:

The use of Patient Reported Outcome Measures (PROMs) to measure effectiveness of care, and supporting patient management is being advocated increasingly. PROMs data are often collected using hard copy questionnaires. New technology enables electronic PROM data collection.

Aims. Surgery is often delayed in patients who sustain a hip fracture and are treated with a total hip arthroplasty (THA), in order to await appropriate surgical expertise. There are established links between delay and poorer outcomes in all patients with a hip fracture, but there is little information about the impact of delay in the less frail patients who undergo THA. The aim of this study was to investigate the influence of delayed surgery on outcomes in these patients. Methods. A retrospective cohort study was undertaken using data from the Scottish Hip Fracture Audit between May 2016 and December 2020. Only patients undergoing THA were included, with categorization according to surgical treatment within 36 hours of admission (≤ 36 hours = ‘acute group’ vs > 36 hours = ‘delayed’ group). Those with delays due to being “medically unfit” were excluded. The primary outcome measure was 30-day survival. Costs were estimated in relation to the differences in the lengths of stay. Results. A total of 1,375 patients underwent THA, with 397 (28.9%) having surgery delayed by > 36 hours. There were no significant differences in the age, sex, residence prior to admission, and Scottish Index of Multiple Deprivation for those with, and those without, delayed surgery. Both groups had statistically similar 30-day (99.7% vs 99.3%; p = 0.526) and 60-day (99.2% vs 99.0%; p = 0.876) survival. There was, however, a significantly longer length of stay for the delayed group (acute: 7.0 vs delayed: 8.9 days; p < 0.001; overall: 8.7 vs 10.2 days; p = 0.002). Delayed surgery did not significantly affect the rates of 30-day readmission (p = 0.085) or discharge destination (p = 0.884). The results were similar following adjustment for potential confounding factors. The estimated additional cost due to delayed surgery was £1,178 per patient. Conclusion. Delayed surgery does not appear to be associated with increased mortality in patients with an intracapsular hip fracture who undergo THA, compared with those who are treated with a hemiarthroplasty or internal fixation. Those with delayed surgery, however, have a longer length of stay, with financial consequences. Clinicians must balance ethical considerations, the local provision of orthopaedic services, and optimization of outcomes when determining the need to delay surgery in a patient with a hip fracture awaiting THA. Cite this article: Bone Joint J 2023;105-B(11):1201–1205

Aims. We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture. Methods. Of 1,577 consecutive patients aged > 65 years with a fragility hip fracture admitted to one institution, for whom there were complete data, 1,255 (72%) were studied. Clinicians assigned CFS scores on admission. Audit personnel routinely prospectively completed the Standardised Audit of Hip Fracture in Europe form, including the following outcomes: 30-day survival; in-hospital complications; length of acute hospital stay; and new institutionalization. The relationship between the CFS scores and outcomes was examined graphically and the visual interpretations were tested statistically. The predictive values of the CFS and Nottingham Hip Fracture Score (NHFS) to predict 30-day mortality were compared using receiver operating characteristic area under the curve (AUC) analysis. Results. Significant non-linear associations between CFS and outcomes were observed. Risk of death within 30 days rose linearly for CFS 1 to 5, but plateaued for CFS > 5. The incidence of complications and length of stay rose linearly for CFS 1 to 4, but plateaued for CFS > 4. In contrast, the risk of new institutionalization rose linearly for CFS 1 to 8. The AUCs for 30-day mortality for the CFS and NHFS were very similar: CFS AUC 0.63 (95% CI 0.57 to 0.69) and NHFS AUC 0.63 (95% CI 0.57 to 0.69). Conclusion. Use of the CFS may provide useful information on outcomes for fitter patients presenting with hip fracture, but completion of the CFS by the admitting orthopaedic team does not appear successful in distinguishing between higher CFS categories, which define patients with frailty. This makes a strong case for the role of the orthogeriatrician in the early assessment of these patients. Further work is needed to understand why patients assessed as being of mild, moderate, and severe frailty do not result in different outcomes. Cite this article: Bone Joint J 2022;104-B(8):980–986

A large number of prognostic factors have been associated with recovery from an episode of back pain. The literature has placed much emphasis on psychosocial prognostic factors. The large number of prognostic factors and the lack of comparative analysis of different factors make their use difficult in clinical practice. The aim of this study was to evaluate the comparative usefulness of a range of factors to predict outcome using data from a randomized controlled trial. 312 patients with sub-acute to chronic back pain received a mechanical evaluation and were sub-grouped based on the presence or absence of directional preference (DP). Patients were then randomized to treatment that was matched or unmatched to that DP. Patients with a minimal reduction of 30% in RMDQ score were defined as the ‘good outcome’ group. 17 baseline variables were entered into a step-wise logistic regression analysis for their ability to predict a good outcome. 84 patients met the good outcome criteria and had a mean RMDQ decrease of 58.2% (9.8 points) in 4 visits. Leg pain, work status, depression, pain location, chronicity, and treatment assignment were significant predictors of outcome in univariate analysis. Only leg bothersomeness rating and treatment assignment survived multivariate analysis. Subjects with DP/centralization who received matched treatment had a 7.8 times greater likelihood of a good outcome. Matching patients to their DP is a stronger predictor of outcome than a range of other biopsychosocial factors.

Aims

The aim of this study was to produce clinical consensus recommendations about the non-surgical treatment of children with Perthes’ disease. The recommendations are intended to support clinical practice in a condition for which there is no robust evidence to guide optimal care.

Aims

The aim of this study was to explore clinicians’ experience of a paediatric randomized controlled trial (RCT) comparing surgical reduction with non-surgical casting for displaced distal radius fractures.

Telehealth has the potential to change the way we approach patient care. From virtual consenting to reducing carbon emissions, costs, and waiting times, it is a powerful tool in our clinical armamentarium. There is mounting evidence that remote diagnostic evaluation and decision-making have reached an acceptable level of accuracy and can safely be adopted in orthopaedic surgery. Furthermore, patients’ and surgeons’ satisfaction with virtual appointments are comparable to in-person consultations. Challenges to the widespread use of telehealth should, however, be acknowledged and include the cost of installation, training, maintenance, and accessibility. It is also vital that clinicians are conscious of the medicolegal and ethical considerations surrounding the medium and adhere strictly to the relevant data protection legislation and storage framework. It remains to be seen how organizations harness the full spectrum of the technology to facilitate effective patient care.

Cite this article: Bone Joint J 2023;105-B(8):843–849.

The use of artificial intelligence (AI) is rapidly growing across many domains, of which the medical field is no exception. AI is an umbrella term defining the practical application of algorithms to generate useful output, without the need of human cognition. Owing to the expanding volume of patient information collected, known as ‘big data’, AI is showing promise as a useful tool in healthcare research and across all aspects of patient care pathways. Practical applications in orthopaedic surgery include: diagnostics, such as fracture recognition and tumour detection; predictive models of clinical and patient-reported outcome measures, such as calculating mortality rates and length of hospital stay; and real-time rehabilitation monitoring and surgical training. However, clinicians should remain cognizant of AI’s limitations, as the development of robust reporting and validation frameworks is of paramount importance to prevent avoidable errors and biases. The aim of this review article is to provide a comprehensive understanding of AI and its subfields, as well as to delineate its existing clinical applications in trauma and orthopaedic surgery. Furthermore, this narrative review expands upon the limitations of AI and future direction.

Cite this article: Bone Joint Res 2023;12(7):447–454.