The Severity Scoring System (SSS) is a guide to interpreting findings across clinical, functional, and radiological findings, used by qualified, specially trained physiotherapists in the advanced practice role in order to provide consistency in determining the severity of the patient's condition and need for surgical consultation. The system has been utilized for over 14 years as a part of standardized assessment and management care and was incorporated into virtual care in 2020 following the pandemic restrictions. The present study examined the validity of the modified SSS in virtual care. Patients who were referred to the Rapid Access Clinic (RAC), were contacted via phone by two experienced advanced practice practitioners (APPs) from May to July 2020, when in-person care was halted due to the pandemic. The virtual interview included taking history, completing self-reported measures for pain and functional ability and reviewing the radiological reports. A total of 63 patients were interviewed (mean age 68, SD=9), 34 (54%) females. Of 63 patients, 33 (52%) were considered a candidate for total knee arthroplasty (TKA). Men and women were comparable in age, P4 and LEFS scores. The TKA candidates had a significantly higher SSS (p<0.0001) and pain scores (p=0.024). The variability of the total SSS score explained by the functional, clinical and radiological components of the tool were 55%, 48% and 4% respectively, highlighting the more important role of patient's clinical history and disability in the total SSS. The virtual SSS is a valid tool in directing patients for surgical management when used by highly trained advanced practice physiotherapists. A large component of the SSS is based on clinical data and patient disability and the APP's skillset rather than severity of pathology found on imaging

All patients undergoing knee arthroplasty at our institution complete Oxford Knee Scoring (OKS) at nurse-led pre-assessment and again at an admission physiotherapy visit on the ward which may be up to 2 months later. The aim of this study is to establish the extended reproducibility of the OKS by statistical analysis of scores taken at these intervals. 44 patients were required to achieve a 90 % probability to detect a difference at a two-sided 5 % significance level with a minimum clinical difference of 3 points, a cut off used in previous works regarding the use of OKS. Both the overall population means and the differences between individual questions were analysed by a paired samples t test and a Wilcoxon Signed Ranks Test respectively. Mean interval between attendance for pre-assessment and admission visit was 16 days (7–60). A statistically significant result at the 5% level was observed for the t test t= 2.197 (44df), p= 0.03. OKS at pre-assessment was lower than at admission to the ward by 1.1 point. (−2.1 – 0.9 95% CI). Analysis of difference between individual questions revealed only three of the pairs achieved statistical significance and in each case, the difference was less than 3 scoring units. This study demonstrates that although there is a difference in total scoring using the OKS between two patient episodes prior to arthroplasty, a clinically relevant difference is not detected, and neither is a statistically significant difference detected when all scoring steps are analysed. The original validation of the OKS was obtained using test-retest reproducibility over a 24 hour period. This work shows that the OKS is robust to violations in reproducibility at duration much greater than this and for practical purposes is valid if taken at any point during the pre-admission phase of care

Background:. Recently a new version of the Knee Society Knee Scoring System has been developed, adapted to the lifestyle and activities of contemporary patients with a Total Knee Arthroplasty (TKA). It is subdivided into 4 domains including an Objective Knee Score, a Satisfaction Score, an Expectations Score and a Functional Activity Score. Before this scale can be used in non-English speaking populations, it has to be translated and validated for specific populations. The aim of this study was to translate and validate the New Knee Society Knee Scoring System (new KSS) for Dutch speaking populations. Materials and Methods:. A Dutch translation of the New KSS was established using a forward-backward translation protocol. 137 patients undergoing TKA were asked to complete the Dutch translation of the New KSS as well as the Dutch WOMAC, Dutch KOOS and the Dutch SF12. To determine the test-retest reliability, 53 patients were asked to fill out a second questionnaire with one-week interval. We tested the test-retest reliability of the subjective domains of the New KSS by assessing the intra-class coefficient and the Pearson correlation coefficient between the first and second questionnaires. Systematic differences between the first and second questionnaires were investigated with T-tests and non-parametric statistics. Internal consistency of the Dutch new KSS was evaluated with Cronbach's alpha. The construct validity of the Dutch New KSS was determined by comparing it to the Dutch WOMAC, Dutch KOOS and Dutch SF12 using Pearson correlation coefficients. Content validity was assessed by examining the distribution and the floor and ceiling effects of the Dutch version of the new KSS. Results:. The reliability of the Dutch translation of the New KSS proved excellent with an ICC ranging from 0.75 to 0.92 for single measures and from 0.85 to 0.96 for average measures in the different domains. Cronbach's alpha ranged from 0.86 to 0.96 indicating good to excellent internal consistency. Paired t-tests and non-parametric statistics revealed no significant differences between the first and second questionnaires while paired samples correlations were highly significant (p < 0.001). The Dutch New KSS correlated well with the Dutch WOMAC score (r = 0.81; p < 0.001), the Dutch KOOS (r = 0.77; p < 0.001), and the Dutch SF12 (r = 0.62; p < 0.001). Content validity was good with a normal distribution of the calculated scores and absence of floor or ceiling effects. Conclusions:. The validation procedure demonstrated that the proposed Dutch version of the New Knee Society Knee Scoring System is a reliable and valid instrument for evaluating symptoms, function, expectations and satisfaction after TKA in Dutch speaking patients

Background and Objectives. There are various classifications to assess the degree of open fracture and each has it’s own advantages and disadvantages. We proposed a new system since we couldn’t find any which was simple, objective, reliable, reproducible and applicable in an emergency setting. We set five variables namely, skin break, bone damage, muscle injury, neurovascular impairment and the degree of contamination to make scoring. We needed to know if the proposed classification had a better reliability, was simple, objective and applicable. Design and Setting. A proposed diagnostic testing was set to better classifying the degree and severity open fractures. Every patient with open lower leg fracture was classified with the proposed Sardjito Scoring System. The residents on duty, medical students and nurse staffs were then asked to classify them with the proposed scoring Gustilo system . The debridement reports were used to be the standard as a comparison of the classification made by the residents, medical student and nurse staffs. Main Outcome Measurements. The classifications made by the residents, medical students and nurses were compared with the finding during the debridement to measure their reliability with kappa coefficient, sensitivity, specivity and accuracy. Results. We had 40 patients with open lower leg fracture. We found exelent reliability among the residents, medical students, and nurses (k: 0.86 p: 0.000). Conclusion. The proposed Sardjito Scoring system of the open lower leg fracture was so far reliable, making it reproducible and applicable

A novel scoring system for the grading of osteoarthritis has been developed. Scoring systems for the measurement of Osteoarthritis (OA) are essential for the understanding of the osteoarthritic process. OA is a mutifactorial degenerative joint disease affecting not only hyaline cartilage but also the surrounding tissues and particularly the subchondral bone. It as questionable as to why the articular cartilage remains the sole component used for histopathological assessment. The intimate relationship between the subchondral bone and overlying cartilage provide major difficulty in their independent measurement. A new scoring system has been developed to incorporate the subchondral bone into the assessment process and relating it to the structure of the overlying hyaline cartilage, which together permit a more accurate description of the degree of degenerate change. The new scoring system was developed from the analysis of 26 operative specimens from tibial plateau (TP) from patients who underwent total knee replacement (TKR). Multiple osteochondral plugs were taken from weight-bearing regions of the whole TP. The specimens were fixed and decalcified before being sectioned and stained with Masson's trichrome. Using a standard imaging system (Photoshop) the areas of bone and hyaline cartilage were identified and measured. Further parameters 1) cartilage thickness 2) tidemark integrity, 3) surface integrity 4) cartilage morphology were measured using a numeric measurement scale. The scoring system indicated a relationship between the area of subchondral bone and the hyaline cartilage degeneration. The overall sum of scores was also successful in distinguishing between the milder and more severe samples of OA. More comprehensive inter and intra observer variability needs to be tested in order validate the system. Quantifying changes to the subchondral bone may also serve beneficial to clinicians, as it is possible that monitoring these changes clinically could lead to early identification of OA

The aim of this study was to evaluate a new joint arthroplasty clinical priority scoring tool. A new arthroplasty scoring tool based on pain, function, social limitation, potential of benefit from surgery and consequence of more than 6 months delay was developed and evaluated using 16 patient scenarios (vignettes) related to hip and knee osteoarthritis. Sixteen orthopaedic surgeons were asked to score the vignettes using clinical ranking, ISS tool and the new tool. Significant variation in ranks allocated by surgeons was recorded for all three tools. Vignettes at either end of the scale ie. those who are severely or minimally disabled had less variability compared to a large group in the middle range. Comparing the three tools there did not appear to by any advantage of one over the other. Most of the variations occurred in the interpretation of benefit from the operation and consequence of delay. Scoring tools rely heavily on judgement based decisions. More work is required to understand judgement processes used by surgeons and audit/feedback mechanisms may help in reducing the variations in priority assignment

Introduction: The Oxford Knee Score (OKS) is commonly used in the assessment of outcome for knee arthroplasty. All patients having knee arthroplasty at our institution undergo OKS at both nurse led pre-assessment and admission physiotherapy visit, a period of 10 to 30 days pre-operatively. At both instances, the scoring form is left with the patient and collected at the end of the visit.

Anecdotal evidence from our centre suggested that patients attending for arthroplasty surgery were scoring differently at each visit.

The aim of this study is to establish if there is a significant difference OKS at pre-assessment visit and on admission to the ward.

Statistical Method: A pilot study was carried out. A power calculation revealed a requirement for 44 patients to enter the study. The resultant probability was 90 percent that the study would detect a difference at a two sided 5.0 percent significance level, if the minimum clinical difference is 3 points. This is based on the standard deviation of the difference in the response variables of 6. A clinical difference of 3 is drawn from previous studies investigating the use of the OKS.

44 patients undergoing arthroplasty surgery had their OKS for both visits retrospectively analysed.

The mean of the totals of both visits was analysed and found to conform to normality and hence was further investigated by a paired samples t test.

Comparison of individual scoring revealed a violation of normality and hence was further analysed using a Wilcoxon Signed Ranks Test.

Results: A statistically significant result at the 5% level was observed t= 2.197 (44df), p= 0.03. OKS at pre-assessment was lower than at admission to the ward by 1.1 point. (−2.1 – 0.9 95% CI).

Analysis of the individual scoring at both intervals revealed only three of the pairs achieved statistical significance and in each case, the difference was less than 3 scoring units. No significant difference was seen when time between assessments was analysed.

Conclusion: This study demonstrates that although there is a difference in total scoring using the OKS between two patient episodes prior to arthroplasty, a clinically relevant difference is not detected, and neither is a statistically significant difference detected when all scoring steps are analysed.

This work supports earlier studies that pre-operative assessment using the OKS is robust to variance in the pre-operative scoring window.

The Disability of Arm Shoulder and Hand (DASH) score questionnaire is a common self-administered tool to assess symptom severity and function in patients with injuries or pathology of the upper limb. However, having such a pertinent tool only in English is limiting in multi-cultural and multilingual populations where English is not always the first language, such as our South African context. IsiZulu is the most widely spoken language in South Africa (approximately 25% of the population). There are certain instances in research, particularly in international studies, where non-English speaking individuals need to be excluded based on translator reliability. This puts our institutions at a disadvantage by not being able to contribute to research.

As per the international Institute of Work and Health (IWH), we followed the 5 stage guidelines to achieve the most appropriate linguistic and cultural adapted translation for our setting. (1) Two independent translations from English to isiZulu. (2) A synthesis of the 2 initial translations. (3) Two independent back-translations from the synthesized isiZulu version into English. (4) Expert panel (consisting of university lecturers and official translators) to review all versions and re-create an optimized synthesized version. (5) Pre-testing of the final optimized synthesized version in a pilot study. This rigorous process allowed for a concise and more culturally relevant translation for use in our population. The fourth stage in the process was integral in synthesizing the tool while considering the colloquial and semantic differences and resolving them with appropriate equivalents.

The IWH guidelines aids in the cross-cultural adaptation of the DASH score while remaining valid and comparable to the original English version. This is beneficial in multi-national research projects and allows for the standardization of health outcome measures.

It has been proposed that scoring systems could be nationally used, initially on a secondary care level as a method of prioritising patients on waiting lists for hip and knee arthroplasty. If this were to be successful, scoring systems could be used as a way of tackling the ever increasing waiting list times for surgery which currently stand at around 15 months on the NHS. I studied and compared the New Zealand and Oxford Hip and Knee Scores, collecting data from 79 patients over a period of seven weeks. I found that generally, patients who scored highly were recommended for surgery; however I also found that in the group of patients recommended for surgery there was a wide range of scores obtained. There was also a great deal of overlap between the scores obtained by those who were recommended for surgery and those who were not. This means that it would be very difficult to predict a decision for an individual patient based purely on their scores. In addition, many confounding variables can affect the wide range of scores obtained. I concluded that there was too much variation between the scores obtained by patients undergoing surgery to be able to consistently and fairly prioritise them. In order to implement the use of scoring systems in this country, nationally approved criteria and priority banding categories need to be established. Scoring systems need to be modified to be clearer and to cover more variables. Larger studies need to be conducted with more patients and over a longer period of time; and further work could be done into the proposal that GP’s could use these systems as a tool for referral to consultant out-patient clinics

The purpose of the study was to compare three shoulder scoring systems with the aim of assessing their ability to identify disability over a spectrum of disease within a routine shoulder practice.

Considering our aims three systems were chosen for investigation; General Oxford Shoulder Questionnaire (GOSQ), Simple Shoulder Test Questionnaire (SST) and Hospital for Special Surgery System for Assessing Shoulder Function (HSS). Each was completed by 108 consecutive patients referred to our shoulder clinic, representing a spectrum of disease. These were compared with a pain and function score derived from the UK SF-36 Health Score. A subset of 27 patients repeated the questionnaires twenty four hours later to test repeatability of the scores. Agreement was calculated using Bland and Altman’s statistical method for assessing agreement between two methods of clinical measurement. This analysis was done both on the group as a whole and divided into five subgroups by diagnosis: instability (subgoup1), cuff tears and impingement (2), adhesive capsulitis (3), arthritis (4) and miscellaneous (5).

Reproducibility as a standard deviation (SD) of the difference between the scores after 24 hours: HSS 9.9, GOSQ 8.8, SST, 15.5 and SF-36 11.1.

Using the Bland and Altman method for assessing agreement, the scores both for repeatability and in comparison with the SF-36 are disappointing. It would appear that out of the three scores tested the HSS gives the most consistent results over a range of shoulder problems.

The aim of this study was to evaluate how three different scoring systems (Constant, Reichelt, and UCLA scores) perform in individuals with normal shoulder function. Scoring systems to evaluate the outcome of surgical treatment around the shoulder are well established. A total of 201 individuals were enrolled in this study. They were divided in four age groups and divided by sex: Group 1: Under 50 years of age: 25 female, 21 male; Group II: From 50 to 59 years of age: 17 female, 21 male; Group III: From 60 to 69 years of age: 18 female, 12 male; Group IV: 70 years of age and older: 24 female, 15 male. All underwent clinical examination, ultrasound examination for detection of cuff tears, and radiograph examination in three planes. In all cases the dominant arm was enrolled. Twelve patients were excluded from the study because ultrasound depicted cuff tear or radiograph showed more than mild osteoarthritis according to the criteria of Hawkins, et al. (1990). The main factor influencing the over-all score was the age-dependent decrease of muscle force measured in forward arm flexion (max. 12.5kp). The score was also influenced by the limitation of internal rotation (Group I: 13%, Group II: 26%, Group III: 40%, Group IV: 41%). According to the Reichelt and UCLA scores, males in Groups I, II and III reached a 100% top score in the UCLA and Reichelt scoring systems. In Group IV composed of older male patients, 20% scored less that the top score because of loss in active motion and muscle force. Only females in Groups I and II scored maximum results. Females in Group III scored 11% and in Group IV composed of older female patients, 50% scored less than the top score because of loss in active motion and muscle force. Due to the natural aging process, males and females in Group IV could not accomplish maximum scores. We recommend that the top scores for the oldest age group be adjusted in order to avoid drawing erroneous conclusions from the scores in this age group

Lumbar facet joint pain cannot be reliably diagnosed clinically, the International Spinal Injection Society recommends two diagnostic local anaesthetic blocks before radiofrequency (RF) denervation [. 1. ]. Scoring systems may improve diagnostic accuracy. The two most popular scores disagree on the interpretation of pain induced by extension/rotation:. ‘Cochin Criteria’ [. 2. ]: pain on extension/rotation _ not facet joint problem. Helbig & Lee [. 3. ]: pain on extension/rotation _ facet joint problem. Methods: Retrospective study of all patients who had RF denervations of the lumbar facet joints in 2004. Patients were selected clinically and did not undergo diagnostic blocks. Cochin criteria, Helbig & Lee scores, work status, and outcome were taken from the case notes. Likelihood ratios were calculated for the scores, their individual components, and work status. Results: 145 patients underwent RF facet joint denervation, for 127 all data was available. In 68 patients the procedure was successful (53.5%). Conclusion: Neither the Cochin Criteria nor the Helbig & Lee score can predict the response to radiofrequency denervation of the lumbar facet joints. Pain on extension/rotation weakly indicates a poor response to facet joint denervation. X-rays do not help with the diagnosis. Social factors may be more important than clinical signs

Introduction. The new Knee Society Score has been developed and validated, in part, to characterize better the expectations, components of satisfaction, and the physical activities of the younger, more diverse modern population of TKA patients. This study aims to reveal patients' activity levels' post-TKA and to determine how it contributes to their subjective evaluation of the surgery. Methods. As part of a multi-centered and regionally diverse study sponsored by the Knee Society, the new Knee Society Score (KSS) was administered 243 patients (44% male; avg 66.4years; 56% female, avg 67.7years) following primary TKA (follow up > 1year, avg. 25mos). The new, validated KSS questionnaire consists of a traditional objective component, as well as subjective components inquiring into patient symptoms, satisfaction, expectations and activity levels as well as a survey of three physical activities that are viewed as important to the patients. Responses were analyzed as a whole group and as subgroups of male and female and as younger (<65) and older (>65). Results. Post-TKA, knee function met or exceeded 84% of patients' expectations, with 49% of patients reporting that their knee always feels normal. While performing standard activities (eg turning, climbing stairs), the majority of patients (78%) experienced few symptoms referable to the knee. Fewer (47%) report that they remain asymptomatic while performing more demanding (‘advanced’) activities (eg squatting, running). Distance walking (52%), swimming (28%) and stationary biking (25%) were among activities that were most commonly selected as personally important. Activities such as golf (Male 39%; Female 6%; p<0.001) and road cycling (Male 19%; Female 4%; p<0.001) were important to more men than women, whereas for gardening (Female 44%; Male 32%; p=0.001) and stretching (Female 44%; Male 16%; p<0.001) the gender preference was reversed. Overall, 24% of patients experienced severe symptoms when performing at least one of their most important activities. Older patients experienced symptoms more than younger patients (26% vs 21%; p<0.01). As a whole, 93% of patients reported that they were satisfied with their knee post-operatively. However, satisfaction with TKA decreased significantly among patients who experienced severe or debilitating symptoms during of their most important activities, (at least one activity: 78% satisfied; p<0.001; during all 3 activities: 50%; p<0.001). Discussion. The New Knee Society Scoring System provides sufficient flexibility and scope to capture the diverse lifestyles and activities of contemporary TKR patients. Data collected by this assessment tool allow surgeons and affiliated personnel to appreciate differences in the priorities of individual patients and the interplay between function, expectation, symptoms, and satisfaction after TKR. A resounding conclusion of this new multi-dimensional analysis is that a critical factor in many patients' assessment of the value of this procedure is their restored ability to perform activities that they personally consider important

Introduction: Patello-femoral evaluation after total knee arthroplasty (TKA) is not addressed by most knee scoring systems. Patellar radiographic assessment after TKA is obtained with static, unloaded views that may not reproduce the in-vivo patello-femoral kinematics. The purpose of this study was to develop and validate new reliable and reproducible clinical and radiographic assessment tools for analysis of the patello-femoral joint in TKA. Materials and Methods: The existing axial Merchant view was modified by positioning the standing patient in the semi-squatted position with the knees at 45°. Relationship between X-ray source, the angle of incidence on the joint, and the cassette position, were kept unchanged from the original view. The standing position and consequent muscle involvement were the only differences. The quality of the view was confirmed on a cadaveric knee model with multiple markers. Safety, reproducibility and clinical reliability were obtained in 100 posterior-stabilized TKA’s. These patients were assessed by a new Patella Scoring System (0–100 points). This system considers anterior knee pain, crepitus, stair performance and quadriceps strength. Radiographic abnormalities are calculated as deductions. Intra- and inter-observer variability were obtained comparing the results of two different investigators. Results: The modified Merchant view showed significant patello-femoral tracking changes in 68% of patients. Twenty-one cases of bone-implant contact were observed when load was applied. Correlation between excellent-good clinical outcome and excellent patello-femoral performance was significantly higher for the Patellar Score compared to Knee Society Clinic or Function scores (p=.022, p=.014). Multivariate regression analysis of radiographic tilt, subluxation, and height, did not correlate with clinical outcomes, whilst bone-implant contact showed higher incidence of pain, particularly when associated with asymmetric patellar resection. Conclusion: These new patello-femoral clinical and radiological assessment methods employed in the study represent additional valuable tools for the comprehensive evaluation of results in TKA

Mirels’ score predicts the likelihood of sustaining pathological fractures using pain, lesion site, size and morphology. The aim is to investigate its reproducibility, reliability and accuracy in upper limb bony metastases and validate its use in pathological fracture prediction.

A retrospective cohort study of patients with upper limb metastases, referred to an Orthopaedic Trauma Centre (2013–18). Mirels’ was calculated in 32 patients; plain radiographs at presentation scored by 6 raters. Radiological aspects were scored twice by each rater, 2-weeks apart. Inter- and intra-observer reliability were calculated (Fleiss’ kappa test). Bland-Altman plots compared variances of individual score components &total Mirels’ score.

Mirels’ score of ≥9 did not accurately predict lesions that would fracture (11% 5/46 vs 65.2% Mirels’ score ≤8, p<0.0001). Sensitivity was 14.3% &specificity was 72.7%. When Mirels’ cut-off was lowered to ≥7, patients were more likely to fracture (48% 22/46 versus 28% 13/46, p=0.045). Sensitivity rose to 62.9%, specificity fell to 54.6%. Kappa values for interobserver variability were 0.358 (fair, 0.288–0.429) for lesion size, 0.107 (poor, 0.02–0.193) for radiological appearance and 0.274 (fair, 0.229–0.318) for total Mirels’ score. Values for intraobserver variability were 0.716 (good, 95% CI 0.432–0.999) for lesion size, 0.427 (moderate, 95% CI 0.195–0.768) for radiological appearance and 0.580 (moderate, 0.395–0.765) for total Mirels’ score.

We showed moderate to substantial agreement between &within raters using Mirels’ score on upper limb radiographs. Mirels’ has poor sensitivity &specificity predicting upper limb fractures - we recommend the cut-off score for prophylactic surgery should be lower than for lower limb lesions.

Proximal Humeral fractures are common injuries that are difficult to treat satisfactorily despite the variety of operative and conservative treatment options that are available. To make any real sense of the literature concerning the treatment of these injuries, it is important that the tools that clinicians use to assess clinical outcomes accurately reflect each patient’s level of symptoms and function. Aim: To assess how well commonly used subjective, and composite clinical scoring systems reflect patients’ perceptions of pain and functional recovery. Methods: We invited all patients who had sustained a proximal humeral fracture that had been treated using a PHILOS (Synthes) Locking plate to attend for review. All patients were reviewed at a minimum of 14 months following surgery by which time they had all been discharged from regular clinical review months before. All patients completed subjective Visual Numerical Scales (VNSs) for pain, and for function, that were used to compare more commonly used shoulder/upper limb scores (UCLA, Modified Constant, Oxford, and Quick DASH scores). Results: 33 patients were available for review. 55% were women. Age range 25–83 years (Ave. 57 years). Timing of review after index procedure (Range 14–58 months, ave. 30 months). Patients appeared to find the numerical VNSs easier to understand, and interestingly, analysis of the pain component of the each of the commonly used scores were answered inconsistently when the scores were compared. With respect to patient perception of pain and subjective level of function, both the Oxford and Quick DASH scores consistently overscored both parameters placing the majority of patients in higher (clinically better) categories, while the Constant score underscored the majority of patients placing them in lower categories (satisfactory or poor). The UCLA score was marginally better than the Constant score in relation to the VNSs for pain and function. Discussion: Despite our dependence upon the more commonly used Clinical Outcome Scoring systems to help guide us with choosing the best treatment options for our patients with proximal humeral fractures, our study confirms our suspicions that none of these outcome scores truly reflect our patients perception of function and pain. In addition, the terminology and sentence structure that is used in all of the commonly used scoring systems may bias the results by confusing many of our patients. Conclusion: Currently, none of our commonly used shoulder outcome scores truly reflect the clinical outcome of patients who have sustained proximal humeral fractures. Instead, it may be better to use subjective VNSs that are easy for patients to understand and are quick to use

Aims

The influence of identifiable pre-operative factors on the outcome of eccentric rotational acetabular osteotomy (ERAO) is unknown. We aimed to determine the factors that might influence the outcome, in order to develop a scoring system for predicting the prognosis for patients undergoing this procedure.

Early mortality in patients with hip fractures due to bony metastases is unknown. The aim was to quantify 30 and 90-day mortality in patients with metastatic hip fractures and identify markers associated with early death.

Consecutive patients referred to orthopaedics with a metastatic proximal femoral fracture/impending fracture over a six-year period were compared to a matched control group of non-malignant hip fractures. Minimum follow-up was 1 year and data was analysed using the student´s t-test (significance p<0.05).

From Jan 2010-Dec 2015, 163 patients were referred with metastatic proximal femoral lesions. 90-day mortality was three times higher than controls (44% 71/163 vs. 12% 4/33, p<0.01). Mean time from referral to surgery was longer in impending versus completed fractures (11 and 4 days respectively, p<0.05).

Multiple biochemical markers were associated with early mortality in the metastatic group. Patients who died early were more likely to demonstrate low haemoglobin and albumin, and high c-reactive protein, platelets, urea, alkaline phosphatase and calcium (p<0.05).

Several biochemical markers associated with early mortality reached clinical and statistical significance. These markers were combined into a score out of 7 and indicated a higher early mortality in metastatic patients compared to controls. Patients with a score of 5–6/7 were 31 times more likely to die within 90 days versus controls.

This scoring system could be utilised to predict early mortality and guide management. The average delay to surgery of 4 days (completed) and 11 days (impending fractures) identifies a window to intervene and correct these abnormalities to improve survival.

The ankle radiograph is a commonly requested investigation as the ankle joint is commonly injured. Each radiograph exposes 0.01 mSv of radiation to the patient that is equivalent to 1.5 days of natural background radiation [1]. The aim of the clinical audit was to use the Ottawa Ankle Rule to attempt to reduce the number of ankle radiographs taken in patients with acute ankle injuries and hence reduce the dose of ionising radiation the patient receives.

A retrospective audit was undertaken. 123 ankle radiograph requests and radiographs taken between May and July 2018 were evaluated. Each ankle radiograph request including patient history and clinical examination was graded against the Ottawa Ankle Rule. The rule states that 1 point(s) indicates radiograph series; (1) malleolar and/or midfoot pain; (1) tenderness over the posterior 6cm or tip of the lateral or medial malleolus (ankle); (1) tenderness over the navicular or the base of the fifth metatarsal (foot); (1) unable to take four steps both immediately and in the emergency department [2]. Patients who score 0 do not need radiograph series. Each radiograph was reviewed if a fracture was present or not.

The clinical audit identified 14 true positives where the Ottawa Ankle Rule scored 1 and the patient had an ankle fracture, and 2 false negatives (sensitivity 88%). There were 81 false positives, and 23 true negatives (specificity 22%). Therefore, a total of 23/123 ankle radiographs were unnecessary which is equivalent to 34.5 days of background radiation. The negative predictive value of the Ottawa Ankle Rule in this audit was 92%.

The low rate of Ottawa rule utilisation may unnecessarily cause patient harm that should be addressed. An educational intervention with physicians combined with integration of the Ottawa rule scoring in ankle radiograph requests is planned with re-audit in 6 months.

Introduction:

It has been shown that inadequate reduction of the sesamoids can lead to recurrent hallux valgus. It can be difficult however to assess the sesamoid position. We propose a simple method of grading sesamoid position; the sesamoid width ratio. We aim to assess for a difference in ratio between those with and without hallux valgus and subsequent correlation with increased deformity. The new grading system can then be tested for inter-observer reliability.