Musculoskeletal tumours are relatively rare and as such, they are not well known by the population and by general practicioners. We observed that an important proportion of our patients has seen major delays at diferent stages of their referral pathway. It is well recognised that such delays can cause avoidable loss of function, local and systemic recurrence and increase in health system costs. The main objective of this study was to prospectively assess the referral paterns of our patients to pinpoint the causes of the delays. This should allow the formation of strategies to minimise delas and their impact. The secondary objective was to assess the performance of our centre in comparaison to other centre with the goal of improving quality of care. Prospective follow up data is available for 457 patient referred to our musculoskeletal oncology team between july 2011 and november 2014. Every patients filled questionnaires on their initial referral patterns. Site specific function and quality of life are evaluated at baseline and at subsequent follow-up (six months, one year, three years and five years). The average delay between the first symptoms and the first medical consultation with a general practitioner was 37 weeks (CI: 27–46). The average delay between the first medical consultation and the referral to orthopaedic oncology was 54 weeks (CI: 43–65). The delay between the first consultation with a general practitioner and the first radiologic test was 31 weeks (CI: 22–39). The delay between the first radiologic test and the referral to orthopaedic oncology was 28 weeks (CI 24–32). The delay between the referral to orthopaedic oncology and the first appointment to our centre was three weeks (CI 2–4). Before the referral to our center, 23% of the patients met two general practitioners and 10% met with 3 or more general practitioner. Fifty-two pervent of the patients had a consultation with a specialist and 19% saw two or more specialists. It is imperative to raise awareness of musculoskeletal tumours and indication for early referral in general practitioners. One of the main problems in our actual referral patern is early access to appropriate imaging. The creation of a referral program with specific guidelines is, in our opinion, the best way to significantly reduce the delays for appropriate management of patients with suspiscion of musculoskeletal tumours

The progressive painful and disabling predicament of patients with severe osteoarthritis awaiting a total hip or knee arthroplasty (THA/TKA) results in a decline in muscle mass, strength and function also known as Sarcopenia. We conducted a cross-sectional, prospective study of patients on the waiting-list for a THA/TKA in the South Australian public healthcare system and compared the findings to healthy participants and patients newly referred from their general practitioners. Participants with a history of joint replacements, pacemakers and cancers were excluded from this study. Outcomes of this study included (i) sarcopenia screening (SARC-F ≥4); (ii) sarcopenia, defined as low muscle strength (hand grip strength M<27kg; F<16kg), low muscle quality (skeletal muscle index M<27%, F<22.1%) and low physical performance (short physical performance battery ≤8). Additional outcomes include descriptions of the recruitment feasibility, randomisation and suitability of the assessment tools. 29 healthy controls were recruited; following screening, 83% (24/29) met the inclusion criteria and 75% (18/24) were assessed. 42 newly referred patients were recruited; following screening, 67% (30/45) met the inclusion criteria and 63% (19/30) were assessed. 68 waiting list patients were recruited; following recruitment, 24% (16/68) met the inclusion criteria and 75% (12/16) were assessed. Preliminary data shows increasing waiting time is associated with higher SARC-F scores, lower hand grip strength and lower muscle quality. As a pilot study, preliminary data demonstrate that: (1) study subjects’ willingness to participate will enable a larger study to be conducted to establish the prevalence of sarcopenia and the diagnostic cut-off points for this patient group. (2) SARC-F is a suitable tool to screen for sarcopenia. (3) There is a positive correlation between waiting time for a THA/TKA and sarcopenia

Traumatic rotator cuff injuries can be a leading cause of prolonged shoulder pain and disability, and contribute to significant morbidity and healthcare costs. Previous studies have shown evidence of socio-demographic disparities with these injuries. The purpose of this nationwide study was to better understand these disparities based on ethnicity, sex, and socio-economic status, in order to inform future healthcare strategies. Accident Compensation Corporation (ACC) is a no-fault comprehensive compensation scheme encompassing all of Aotearoa/New Zealand (population in 2018, 4.7 million). Using the ACC database, traumatic rotator cuff injuries were identified between January 2010 and December 2018. Injuries were categorized by sex, ethnicity, age and socioeconomic deprivation index of the claimant. During the 9-year study period, there were 351,554 claims accepted for traumatic rotator cuff injury, which totalled over $960 million New Zealand Dollars. The greatest proportion of costs was spent on vocational support (49.8%), then surgery (26.3%), rehabilitation (13.1%), radiology (8.1%), general practitioner (1.6%) and “Other” (1.1%). Asian, Māori (Indigenous New Zealanders), and Pacific peoples were under-represented in the age-standardized proportion of total claims and had lower rates of surgery than Europeans. Māori had higher proportion of costs spent on vocational support and lower proportions spent on radiology, rehabilitation and surgery than Europeans. Males had higher number and costs of claims and were more likely to have surgery than females. There were considerably fewer claims from areas of high socio-economic deprivation. This large nation-wide study demonstrates the important and growing economic burden of rotator cuff injuries. Indirect costs, such as vocational supports, are a major contributor to the cost suggesting improving treatment and rehabilitation protocols would have the greatest economic impact. This study has also identified socio-demographic disparities which need to be addressed in order to achieve equity in health outcomes

The coronavirus pandemic has reduced the capability of Canadian hospitals to offer elective orthopaedic surgery requiring admission, despite ongoing and increasing demands for elective total hip and total knee arthroplasty surgery (THA and TKA). We sought to determine if the coronavirus pandemic resulted in more outpatient THA and TKA in Nova Scotia, and if so, what effect increased outpatient surgery had on 90 day post-operative readmission or Emergency Department/Family Doctor (FD) visits. The study cohort was constructed from hospital Discharge Abstract Data (DAD), inpatient admissions, and National Ambulatory Care Reporting System (NACRS) data, day surgery observations, using Canadian Classification of Health Intervention codes to select all primary hip and knee procedures from 2005-2020 in Nova Scotia. Emergency Department and General Practitioner visits were identified from the Physician Billings data and re-admissions from the DAD and NACRS. Rates were calculated by dividing the number of cases with any visit within 90 days after discharge. Chi-squared statistics at 95% confidence level used to test for statistical significance. Knee and hip procedures were modelled separately. There was a reduction in THA and TKA surgery in Nova Scotia during the coronavirus pandemic in 2020. Outpatient arthroplasty surgery in Nova Scotia in the years prior to 2020 were relatively stable. However, in 2020 there was a significant increase in the proportion and absolute number of outpatient THA and TKA. The proportion of THA increased from 1% in 2019 to 14% in 2020, while the proportion of TKA increased from 1% in 2019 to 11% in 2020. The absolute number of outpatient THA increased from 16 cases in 2019, to 163 cases in 2020. Outpatient TKA cases increased from 21 in 2019, to 173 in 2020. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED following TKA but not THA which was not statistically significant. For outpatient THA and TKA, there was a decrease in 90 day readmissions, and a statistically significant decrease in FD presentations. Outpatient THA and TKA increased significantly in 2020, likely due to the restrictions imposed during the coronavirus pandemic on elective Orthopaedic surgery requiring admission to hospital. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED for TKA, and a decrease in 90 day readmissions and FD presentations for THA and TKA. Reducing the inpatient surgical burden may result in a post-operative burden on ED, but does not appear to have caused an increase in hospital readmission rates

The purpose of this prospective pilot study is to examine the feasibility of a physiotherapist led rapid access shoulder screening clinic (RASC). The goal of this study is to assess for improvements in patient access to care, patient reported outcome measures, patient reported experience measures, and cost outcomes using time driven activity based costing methods. Patient recruitment began in January 2021. Consultation requests from general practitioners and emergency rooms are analyzed and triaged through a central system. One half of patients awaiting consultation were triaged to the traditional route used at our center while the other half were triaged to be assessed at the RASC. Outcome measures consisting of the Simple Shoulder Test and SF-12 were recorded at the initial consultation and at follow up appointments. Cost benefit analysis was conducted using time driven activity based costing methods (TD-ABC). From January to August of 2021, 123 new patients were triaged for RASC assessment. On average, the RASC gets 10 new referrals per month. As of September 2021, there are 65 patients still on waitlist for RASC assessment with 58 having been assessed. Of the 58, 11% were discharged through the RASC, 48% pursued private physiotherapy, 14% had injections, 19% proceeded on for surgical consultation, and 8% did not show. Over time same time period, approximately 15 new patients were seen in consultation by the surgeon's office. Thirty-five responses were obtained from RASC patients during their initial intake assessment. The average age of respondents was 54.7 with 21 females and 14 males. Median SF-12 scores in the physical dimension (PCS-12) for RASC patients were 36.82 and mental (MCS-12) 49.38927. Median Simple Shoulder Test scores measured 6. Of the patients who responded to the follow up questionnaires after completing physiotherapy at the RASC, both the SF-12 and Simple Shoulder Test scoring improved. Median PCS-12 measured 47.08, MCS-12 of 55.87, and Simple Shoulder Test measured 8. RASC assessments by PT saved $172.91 per hour for consultation and $157.97 per hour for patient follow ups. Utilization of a physiotherapy led rapid access shoulder clinic resulted in improvements in patient outcomes as measured by the SF-12 and Simple Shoulder Test as well as significant direct cost savings. Proper triage protocols to identify which patients would be suitable for RASC assessment, buy-in from physiotherapists, and timely assessment of patients for early initiation of rehabilitation for shoulder pain is paramount to the success of a RASC system at our centre. Future research direction would be geared to analyzing a larger dataset as it becomes available

Abstract. Introduction. Clinic letters to the general practitioner (GP) form an essential part of communication in a patient's care. One essential variable requiring 100% compliance is the laterality/side of the diagnosis. Rationale of this audit was to check compliance of the same in clinic letters, to implement changes within the department initially followed by trust wide change in policy to improve the same. Material and Methods. Clinic letters over a period of time were read through in retrospect to see for mention of side. The exclusion criteria were COVID consenting letters over phone, “did not attend” letters and letters for spinal pathology. After 1st limb of audit following actions were taken: doctor education, secretaries to remind the dictating doctor to mention side in the letter and putting up of laminated prompters in all T&O clinic rooms to remind doctors. Following this a 2nd limb was conducted with similar parameters. Results. 1st Limb:. Total letters 271: Fracture clinic- 126. Elective/orthopaedic clinic – 106. Excluded letters– 39. 2nd Limb:. Total letters 169: Fracture clinic- 91. Elective/orthopaedic clinic – 62. Excluded letters– 16. Letters without the mention of side of diagnosis. 1st Limb: Fracture clinic – 28 out of 126 (22.3%). Orthopaedic clinic – 12 out of 106 (11.3%). 2nd Limb: Fracture clinic – 2 out of 91 (2.2%). Orthopaedic clinic – 2 out of 62 (3.2%). Conclusion. With the changes there was an overall compliance of 97.8% in fracture clinic and 96.8% compliance elective clinic dictations

Knee arthroscopy with meniscectomy is the third most common Orthopaedic surgery performed after TKA and THA, comprising up to 16.6% of all procedures. The efficiency of Orthopaedic care delivery with respect to waiting times and systemic costs is extremely concerning. Canadian Orthopaedic patients experience the longest wait times of any G7 country, yet perioperative surgical care constitutes a significant portion of a hospital's budget. In-Office Needle Arthroscopy (IONA) is an emerging technology that has been primarily studied as a diagnostic tool. Recent evidence shows that it is a cost-effective alternative to hospital- and community-based MRI with comparable accuracy. Recent procedure guides detailing IONA medial meniscectomy suggest a potential node for OR diversion. Given the high case volume of knee arthroscopy as well as the potential amenability to be diverted away from the OR to the office setting, IONA has the potential to generate considerable improvements in healthcare system efficiency with respect to throughput and cost savings. As such, the purpose of this study is to investigate the cost savings and impact on waiting times on a mid-sized Canadian community hospital if IONA is offered as an alternative to traditional operating room (OR) arthroscopy for medial meniscal tears. In order to develop a comprehensive understanding and accurate representation of the quantifiable operations involved in the current state for medial meniscus tear care, process mapping was performed that describes the journey of a patient from when they present with knee pain to their general practitioner until case resolution. This technique was then repeated to create a second process map describing the hypothetical proposed state whereby OR diversion may be conducted utilizing IONA. Once the respective process maps for each state were determined, each process map was translated into a Dupont decision tree. In order to accurately determine the total number of patients which would be eligible for this care pathway at our institution, the OR booking scheduling for arthroscopy and meniscectomy/repair over a four year time period (2016-2020) were reviewed. A sensitivity analysis was performed to examine the effect of the number of patients who select IONA over meniscectomy and the number of revision meniscectomies after IONA on 1) the profit and profit margin determined by the MCS-Dupont financial model and 2) the throughput (percentage and number) determined by the MCS-throughput model. Based on historic data at our institution, an average of 198 patients (SD 31) underwent either a meniscectomy or repair from years 2016-2020. Revenue for both states was similar (p = .22), with the current state revenue being $ 248,555.99 (standard deviation $ 39,005.43) and proposed state of $ 249,223.86 (SD $ 39,188.73). However, the reduction in expenses was significant (p < .0001) at 5.15%, with expenses in the current state being $ 281,415.23 (SD $ 44,157.80) and proposed state of $ 266,912.68 (SD $ 42,093.19), representing $14,502.95 in savings. Accordingly, profit improvement was also significant (p < .0001) at 46.2%, with current state profit being $ (32,859.24) (SD $ 5,153.49) and proposed state being $ (17,678.82) (SD $ 2,921.28). The addition of IONA into the care pathway of the proposed state produced an average improvement in throughput of 42 patients (SD 7), representing a 21.2% reduction in the number of patients that require an OR procedure. Financial sensitivity analysis revealed that the proposed state profit was higher than the current state profit if as few as 10% of patients select IONA, with the maximum revision rate needing to remain below 40% to achieve improved profits. The most important finding from this study is that IONA is a cost-effective alternative to traditional surgical arthroscopy for medial meniscus meniscectomy. Importantly, IONA can also be used as a diagnostic procedure. It is shown to be a cost-effective alternative to MRI with similar diagnostic accuracy. The role of IONA as a joint diagnostic-therapeutic tool could positively impact MRI waiting times and MRI/MRA costs, and further reduce indirect costs to society. Given the well-established benefit of early meniscus treatment, accelerating both diagnosis and therapy is bound to result in positive effects

Identifying the core competencies of musculoskeletal medicine has been the basis for the development of the Australian Musculoskeletal Education Competencies (AMSEC) project. AMSEC aims to ensure Australian health professionals are suitably equipped through improved and appropriate education to address the increasing burden of both acute and chronic musculoskeletal disease. The AMSEC project has consisted of four distinct phases. The first two phases were consultative and highlighted concerns from medical educators, specialists and students that current curricula inadequately address the increasing scientific information base in MSK medicine and management. In phase three, Multidisciplinary Working Groups were established to detail competencies in MSK areas such as physical examination, red flag emergencies, basic and clinical science, patient education and self-management, procedural skills and rehabilitation and a web portal was developed. Phase four will see the core competencies completed, endorsed by the relevant professional colleges and integrated into Australian Medical School curricula. By bringing together experts from different groups involved in musculoskeletal education, it has been possible to agree on the core competencies required of a graduating medical student and from these determine the required underlying basic knowledge, skills and attitudes. These competencies are based on actual needs determined from current disease impact studies and the experience of professionals working in the various areas of musculoskeletal related clinical practice. This multidisciplinary and multi-professional approach, which includes consumer groups, has allowed a broader and more complete perspective of requirements. Both improved horizontal and vertical integration are facilitated and more efficient implementation is possible. By linking these core competencies to specific anatomy and basic science knowledge requirements, justification of the need to address current deficits in these areas was achieved. A standardised evidenced based approach to physical examination was developed allowing a unified approach to the resourcing and teaching of this skill by orthopaedic surgeons, rheumatologists and others. The ability to outline competency requirements vertically from medical student to resident, general practitioner and specialist is greatly facilitated by combining specialist educators with those of the universities and general practitioners. For the specialists, this approach yields excellent education leverage for very little additional effort. AMSEC has undertaken significant inter and intra disciplinary consultations to identify and classify core MSK competencies at a basic, median and advanced level of specialisation across professions. This novel national integrated model to address education needs offers many benefits and could be translated into other areas of medicine

Ten RCTs published between 2000 and 2013 support treating distal radius buckle fractures and other low-risk distal radius fractures with a removable splint and with no orthopaedic follow-up. Application of this evidence has been shown to be variable and suboptimal resulting in unnecessary costs to a strained healthcare system. The Canadian evidence on this topic has been generated by subspecialist physicians working in paediatric hospitals. It is unclear what factors affect the dissemination of this information. We investigated the association of hospital type and physician type with the application of best-evidence treatment for low-risk distal radius fractures in children with the goal of improving our understanding of evidence diffusion in Ontario for this common injury. We performed a retrospective population-based cohort study using linked health care administrative data. We identified all children aged 2–14 treated in Ontario emergency departments from 2003–2015 with distal radius fractures with no reduction and no operation within a six week period. We excluded refractures and children with comorbidities. We evaluated the followup received – orthopaedic, general practitioner, or none. We examined the data for trends over time. Multivariable log binomial regression was used to quantify associations between hospital and physician type and best-evidence treatment. We adjusted for patient-related variables including age, sex, rural or urban location, and socioeconomic status. 70,801 fractures were analyzed. Best-evidence treatment was more likely to occur in a small (RR 1.86, 95%CI 1.72–2.01), paediatric (RR 1.16, 95%CI 1.07–1.26), or community (RR 1.13, 95%CI 1.06–1.20) hospital compared with treatment in a teaching hospital. Best-evidence treatment was more likely if initial management was by a paediatrician with additional emergency medicine training (RR 1.73, 95%CI 1.56–1.92) or paediatrician (RR 1.22, 95%CI 1.11–1.34). Paediatric and teaching hospitals have improved their use of best-evidence over time while other hospital types have stagnated or deteriorated. Paediatricians, paediatricians with additional emergency medicine training, and emergency medicine residency trained physicians have improved their use of best-evidence over time, while other physician types have stagnated or deteriorated. Overall, only 20% of patients received best-evidence treatment and 70% had orthopaedic follow-up. Significant over-utilization of resources for low-risk distal radius fractures continues decades after the first randomized trials showed it to be unnecessary. Physician type and hospital rurality are most strongly associated with best-evidence treatment. Physician types involved in generating, presenting, and publishing best-evidence for this fracture type are successfully implementing it, while others have failed to change their practices. Rural hospitals are excellent resource stewards by necessity, but are deteriorating over time. Our results strongly indicate the need for targeted implementation strategies to explicitly apply clinical evidence in clinical practice Canada-wide, with the goal of providing more cost-effective care for common children's fractures

OBJECTIVES. The use of a mobile bearing has been suggested to decrease the rate of patellar complications after total knee arthroplasty (TKA). However, to resurface or retain the native patella remains debated. Few long-term results have been documented. The present retrospective study was designed to evaluate the long-term (more than 10 years) results of mobile bearing TKAs on a national scale, and to compare pain results and survivorship according to the status of the patella. The primary hypothesis of this study was that the 10 year survival rate of mobile bearing TKAs with patella resurfacing will be different from that of mobile bearing TKAs with native patella retaining. METHODS. All patients operated on between 2001 and 2004 in all participating centers for implantation of a TKA (whatever design used) were eligible for this study. Usual demographic and peri-operative items have been recorded. All patients were contacted after the 10 year follow-up for repeat clinical examination (Knee Society score (KSS), Oxford knee questionnaire). Patients who did not return were interviewed by phone call. For patients lost of follow-up, family or general practitioner was contacted to obtain relevant information about prosthesis survival. TKAs with resurfaced patella and TKAs with retained native patella were paired according to age, gender, body mass index and severity of the coronal deformation (with steps of 5°). Pain score, KSS and Oxford knee score were compared between two groups with a Student t-test at a 0.05 level of significance. Survival curve was plotted according to the actuarial technique, using the revision for mechanical reason as end-point. The influence of the patella status was assessed with a logrank test at a 0.05 level of significance. RESULTS. 1,604 TKAs were implanted during the study time-frame. 849 cases could be paired according to age, gender, BMI and severity of the pre-operative coronal deformation (2/1 ratio) into two groups: resurfaced patella (496 cases) and retained patella (243 cases). There was no difference in any baseline criteria between both groups. 150 patients deceased before the 10 year follow up (18%). Final follow-up was obtained for 489 cases (58%). 31 reoperations (prosthesis exchange or patellofemoral revision) were performed during the study time frame (4%), with 17 reoperations for mechanical reasons (3%). KSS and Oxford knee score were significantly higher for TKAs without patella resurfacing, there was a significant difference between the 13 year survival rates of TKAs with resurfaced patella (97%) and TKAs with retained native patella (93%). CONCLUSIONS. The primary hypothesis was confirmed: 10 year survival rate of mobile bearing TKAs with patella resurfacing was better than mobile bearing TKAs with native patella retaining. Patella resurfacing may lead to a better survival after mobile bearing TKA. However, the clinical results were better after patella resurfacing when the index TKA was not revised

INTRODUCTION. Unicompartmental knee arthroplasty (UKA) is considered a highly successful procedure. However, complications and revisions may still occur, and some may be related to the operative technique. Computer assistance has been suggested to improve the accuracy of implantation of a UKA. The present study was designed to evaluate the long-term (more than 10 years) results of an UKA which was routinely implanted with help of a non-image based navigation system. MATERIAL AND METHODS. All patients operated on between 2004 and 2005 for implantation of a navigated UKA were included. Usual demographic and peri-operative items have been record. All patients were prospectively followed with clinical and radiological examination. All patients were contacted after the 10 year follow-up for repeat clinical and radiological examination (KSS, Oxford knee questionnaire and knee plain X-rays). Patients who did not return were interviewed by phone call. For patients lost of follow-up, family or general practitioner was contacted to obtain relevant information about prosthesis survival. Survival curve was plotted according to Kaplan-Meier. RESULTS. 57 UKAs were implanted during the study time-frame. Final follow-up (including death or revision) was obtained for 50 cases (88%). Clinical status after 10 years was obtained for 45 cases (80%). 4 prosthetic revisions were performed for mechanical reasons during the follow- up time (7%). The 10 year survival rate was 94%. No component was considered loose at the final radiographic evaluation. No polyethylene wear was detected at the final radiographic evaluation. DISCUSSION. This study confirms our initial hypothesis, namely quite satisfactory results of a navigated implanted UKA after more than 10 years. Navigation, whose precision is no longer to be demonstrated, probably contributed to the quality of the results. A more consistent anatomical reconstruction and ligamentous balance of the knee should lead to more consistent survival of the UKA. However, superiority of navigated UKA in comparison to conventional implanted UKA is difficult to prove because of the subtle differences expected in mostly underpowered studies. Longer term follow-up may be required

INTRODUCTION. Total knee arthroplasty (TKA) is considered a highly successful procedure. Survival rates of more than 90% after 10 years are generally reported. However, complications and revisions may still occur for many reasons, and some of them may be related to the operative technique. Computer assistance has been suggested to improve the accuracy of implantation of a TKA (Jenny 2005). Short term results are still controversial (Roberts 2015). However, few long term results have been documented (Song 2016). The present study was designed to evaluate the long-term (more than 10 years) results of a TKA which was routinely implanted with help of a non-image based navigation system. The 5- to 8-year of this specific TKA has already been documented (Jenny 2013). The hypothesis of this study will be that the 10 year survival rate of this TKA will be improved in comparison to historical papers when analyzing survival rates and knee function as evaluated by the Knee Society Score (KSS). MATERIAL AND METHODS. All patients operated on between 2001 and 2004 for implantation of a navigated TKA were eligible for this study. Usual demographic and peri-operative items have been record. All patients were prospectively followed with clinical and radiological examination. All patients were contacted after the 10 year follow-up for repeat clinical and radiological examination (KSS, Oxford knee questionnaire and knee plain X-rays). Patients who did not return were interviewed by phone call. For patients lost of follow-up, family or general practitioner was contacted to obtain relevant information about prosthesis survival. Survival curve was plotted according to Kaplan-Meier. RESULTS. 247 TKAs were implanted during the study time-frame. 225 cases had an optimal lower limb axis (HKA angle between 177° and 183°) after TKA (91%). Final follow-up (including death or revision) was obtained for 200 cases (81%). Clinical status after 10 years was obtained for 146 cases (59%) (KSS, 102 cases – Oxford questionnaire, 146 cases – radiologic evaluation, 94 cases). 4 prosthetic revisions were performed for mechanical reasons during the follow-up time (1%). The 10 year survival rate was 98%. The mean KSS was 188 points. The mean Oxford score was 55 points. No component was considered loose at the final radiographic evaluation. No polyethylene wear was detected at the final radiographic evaluation. DISCUSSION. This study confirms our initial hypothesis, namely quite satisfactory results of navigated implanted TKA after more than 10 years. Navigation, whose precision is no longer to be demonstrated, probably contributed to the quality of the results. A more consistent anatomical reconstruction and ligamentous balance of the knee should lead to more consistent survival of the TKA. Other authors did observe similar results (Baumbach 2016). However, superiority of navigated TKA in comparison to conventional implanted TKA is difficult to prove because of the subtle differences expected in mostly underpowered studies. Longer term follow-up may be required

An osteoporosis screening service for patients presenting to the fracture clinic in Derriford Hospital Plymouth was established in February 2009. We report on the findings of the first year of patients referred for dual energy X-ray absorptiometry (DEXA) screening. Patients between 50 and 75 years of age, who sustained a fracture as a result of a fall from standing height or less, who had not previously had a DEXA scan within the last two years, were referred. Patients outside these age limits with other risk factors for osteoporosis were scanned at the discretion of the fracture clinic consultant. Of those patients who were referred, 96% subsequently attended for a scan timed to coincide with their scheduled fracture clinic follow-up appointment. 402 patients were scanned in total, of which 351 were female and 51 were male. The mean patient age was 65. The results for women were as follows: 21% normal, 45% osteopenic, 34% osteoporotic. The results for men were: 19% normal, 43% osteopenic, 38% osteoporotic. The scan results were forwarded to the patient's general practitioner for action as deemed necessary. These findings support the establishment of this screening service for both men and women

Using general practitioner records, hospital medical notes and through direct telephone conversation with patients, we investigated the accuracy of nine patient-reported complications after elective joint replacement surgery of the hip and knee. A total of 402 post-discharge complications were reported after 8546 elective operations that were undertaken within a three-year period. These were reported by 136 men and 240 women with an overall mean age of 71.8 years (34.3–93.2). A total of 319 (79.4%; 95% confidence interval, 75.4%–83.3%) reported complications were confirmed to be correct. Very high rates of correct reporting were demonstrated for infection (94.5%) and further surgery (100%), whereas the rates of reporting deep venous thrombosis (DVT), pulmonary embolism, myocardial infarct and stroke were lower (75%–84.2%). Dislocation, periprosthetic fractures and nerve palsy were associated with modest rates of correct reporting (36%–57.1%). More patients who had had knee surgery delivered incorrect reports of dislocation (p = 0.001) and DVT (p = 0.013). Despite these variations in accuracy, it appears that post-operative complications may form part of a larger patient-reported outcome programme for monitoring outcome after elective joint replacement surgery

Introduction:. South Africa has a very sports orientated population and a high blunt trauma prevalence. In August 2008, we re-established the soft tissue knee service at our academic hospital. Our clinic is staffed by a sessional Consultant, a Registrar, and is overseen by a senior honorary Consultant. Here we present a review of our first 2 years experience. Methods:. The clinic operates on a referral basis. All patients have all their clinical and demographic data and referral data entered into a Soft Tissue Database. The Data for 2009 and 2010 data were collated and analysed. Results:. A total of 346 patients were assessed and treated, of which 162 received surgery during this period. Patient referrals originated from both the state and independent sectors, and were made by hospital specialists, physiotherapists, and general practitioners. The mean delay from referral to first consultation was 9 days, and the mean wait from first consultation to surgery was 6 weeks. Our 162 procedures comprised of ACL reconstructions (52), PCL reconstructions (5), multiple ligament reconstructions (10), and osteotomies (4), as well as other procedures (91). There were 6 recorded major complications. Discussion:. A referral based specialist clinic can be successfully operated in a government hospital, and deliver both high quality clinical care, and valuable training opportunities to our trainees. Although currently staffed by part-time staff we believe that we have the capacity for many more patients and believe that we are only treating a small percentage of those in need. We want to increase awareness and referrals

Background. Steroid injections can be used safely to treat trigger fingers. We aimed to determine the accuracy of referring General Practitioner (GP) diagnoses of trigger finger made to an upper limb surgeon. We also aimed to determine the efficacy of a serial two steroid injection then surgery technique in the management of trigger fingers. Methods. Data was collected prospectively from a “one-stop” trigger finger clinic (based in a district general hospital). 200 trigger fingers identified from September 2005 to November 2008, giving a minimum 1 year follow-up. Data was analysed for correct referring diagnosis, resolution/recurrence rate following injection and the effect of age, injector grade, diabetes on the rate of recurrence. Results. GP diagnoses were correct in 94% of referrals. Recurrence free resolution after one steroid injection was achieved in 74% of cases, rising to 84% after a second injection. The grade of injector did not influence the rate of resolution (p=0.967) or recurrence (p=0.818). Age was the only statistically significant factor, with recurrences being 8.3 years younger (95% CI 4.1–12.6 yrs; p=0.0002). 15% required surgical release after failure of two steroid injections. Conclusions. Steroid injection for trigger finger is a safe, easily performed technique that can give recurrence free resolution in up to 84% using a serial two steroid injection technique. This is an easily acquired technique that has obvious potential to be performed in the primary care setting, thus reducing the burden on hospital based specialist upper limb services, as only 15% required surgical intervention

Orthopaedic International Medical Graduates (IMGs) have provided an invaluable service and source of workforce relief mainly in rural and outback Australia. Queensland has relied more heavily than any other state on overseas trained doctors to provide general practitioners and specialists around the state, particularly in areas deemed ‘an area of need’ (AON). The AON designation was seen to be a way of easy recruitment but is a two-edged sword for both the state government and for the IMG. While overseas trained doctors may be more compliant with administrators' wishes than what locally trained doctors might be, they have not necessarily passed a local medical examination or even sat a medical examination in English before coming to Australia. Meticulous and drawn out medical qualification checks, health and security checks are carried out which can take a long time to perform and could frustrate the end user who is often dependent on that doctor arriving by a certain date to cover a call roster and maintain a continuum of care for a specific district. The many and varied steps have been changing over the past few years and so this presentation is meant to clear up some of the misunderstandings that exist for the various parties involved. This would include some guidelines to the IMG and to the recipient hospital or practice recruiting that IMG, outlining some of the traps and pitfalls for all to consider. State government administrators also need to show leadership when advertising, interviewing and employing IMGs, as this may have implications for all of us into the next decade. A frank look at our present and future workforce needs by the whole Orthopaedic community is necessary. The challenges and solutions of how Orthopaedic Surgery will be provided both publically and privately into the future is resting with us now

Introduction. The Two Week Waiting Time Standard, which requires that patients with suspected cancer referred by general practitioners should be seen within 2 weeks, was introduced in 2000. We reviewed the performance of this standard with regards to proportion of patients seen and tumour detection rates. Methods and results. We reviewed all the referrals sent under the ‘two week’ rule from January 2004 to December 2005, to our bone and soft tissue sarcoma service. These referrals were evaluated for:. Whether or not the referral met established referral guidelines for bone and soft tissue tumours. The proportion of patients seen within two weeks. The proportion of patients referred under the guidelines that had malignant tumours. This was compared with the total number of referrals to the unit and their tumour detection rates. A total of 40 patients were referred under the ‘two week’ rule. 95% of these were seen within two weeks of referral. Of the 40 patients, three patients had soft tissue metastasis from a primary tumour elsewhere, and six had primary malignant soft tissue tumours. 13 had a benign bone/ soft tissue tumour. 18 (45%) patients had a non neoplastic pathology (6 Muscle tear/ herniation; 4 ganglion/bursa; 2 lumps that disappeared) During the same period a total of 507 patients were referred by other routes. Conclusion. Only 10 of 40 patients referred under the 2-week rule had malignant tumours. The majority of referrals to our service do not fall under this rule. Significant numbers of referral under the rule are not in line with the referral guidelines. It is our impression that the 2-week rule, whilst highlighting the need of these patients to be seen urgently, may distort clinical priorities and disadvantage patients referred from other sources

Background. The current treatment options available for Trapezio-metacarpal arthritis are injection, splint and ultimately surgery. The injections are predominantly done by General practitioners and no data is available to specialist. Aim. To investigate accuracy of injection and efficacy of injection in terms of short and long term pain relief. Methods. We recruited 25 patients during March 2010 - January 2011. All of these patients had AP, Lat, and special Roberts radiographs. The technique involved palpating and surface marking Trapezio-metacarpal joint in the theatre. Under fluoroscopy, needle placement was performed while the operator was blinded from the screen. The location of needle was confirmed and then operator was allowed visualize the position of needle. Every movement of needle or the thumb to get the needle in joint was considered as an attempt. All had premixed Local anaesthetic and Depomedrone injection in to the joint. Accuracy was confirmed by operator and patient. We recorded patient demographics, number of attempts required for correct needle placement, pre and 10 minutes post-injection visual analogue scale (VAS) pain score, and Nelson Score (NS)before and six weeks after injection. Results. Mean age was 60(range 46–90). M:F(23:2). Dominant hand was affected in 14 cases. CMC J OA ranged from grade 2–4. First attempt was successful in 6 cases. Mean attempts required for accurate injection was 3(range 0–4). Mean pain pre-injection VAS was 7(range 4–10), 10 minutes following injection 0.5(range 0–4) and at 6 weeks 5(range 3–10). Mean pre-operative NS was 29.6(range 14–65) and at 6 weeks 32.4(range 14–55). The difference was not statistically significant (paired t test, p=0.24). Conclusion. Our results suggest that blind injection of thumb CMCJ may not be accurate as it requires assessment and appreciation of surface anatomy. Accuracy can be definitely improved by radiological guided injection. Limitations. Small number and short follow up

Aims

Tuberculosis (TB) is one of the biggest communicable causes of mortality worldwide. While incidence in the UK has continued to fall since 2011, Bradford retains one of the highest TB rates in the UK. This study aims to examine the local disease burden of musculoskeletal (MSK) TB, by analyzing common presenting factors within the famously diverse population of Bradford.