The purpose of this study was to measure the effect of the implementation of a LEAN continuous process improvement initiative on the waitlist in an ambulatory pediatric orthopaedic clinic.

LEAN is a set of principles that guide organizational thinking and form a comprehensive approach to continuous process improvement. In 2016, our health centre began its journey towards becoming a LEAN organization. The health centre's Strategy and Performance portfolio collaborated with the Orthopaedic Clinic Team to facilitate a Value Stream Analysis, which mapped the clinic process from referral to discharge from care. This informed the plan for targeted improvement events designed to identify and reduce non-value added activity, while partnering with patients and families to share their experiences with care in the clinic. Improvement events included: In-Clinic Patient Flow; Scheduling Process Review; Standardized Triage Process; Clinician Schedule; 5-S Large Cast and Sample Exam Rooms; Booking Orthopedics Clinic; and Travelling and Remote Care. During each event, solutions were identified to improve the patient experience, access, and clinic flow. These solutions have been standardized, documented, and continuously monitored to identify additional improvement opportunities. Comparison of wait-list and percentage of new patients seen within target window was performed from August 2017 to December 2018.

The LEAN initiative resulted in a 48% decrease in wait-list for new patients, which translated to an improvement from 39% to 70% of new patients seen within their target window. There was a 19% decrease in the 3400+ patient wait-list for follow-up appointments, an 85% reduction in follow-up patients waiting past their target date for an appointment, and the number of patients waiting over a year beyond their target appointment improved from over 300 patients to 0 patients. There was a 15% improvement in average length of clinic visit.

Without the addition of new resources, the implementation of a LEAN continuous process improvement initiative improved the waitlist for new patients in an ambulatory pediatric orthopaedic clinic by almost 50%. Solutions identified and implemented through the LEAN process have contributed to unprecedented improvements in access to care. In fulfilling one of the LEAN theory principles to “pursue perfection”, the paediatric orthopaedic clinic team has embraced a culture of continuous improvement and continues to use LEAN tools such as daily huddles and visual management to monitor solutions and identify gaps.

Slipped capital femoral epiphysis (SCFE) is traditionally treated with in situ fixation using a threaded screw, leading to physeal arrest while stabilizing the femoral head. Recently, there has been interest in alternative methods of fixation for SCFE, aiming to allow growth and remodelling of the femoral neck postoperatively. One such option is the Free Gliding SCFE Screw (Pega Medical), which employs a telescopic design intended to avoid physeal compression. The objective of this study is to evaluate radiographic changes of the proximal femur following in situ fixation using the Free Gliding SCFE Screw.

This study retrospectively evaluated 28 hips in 14 consecutive patients who underwent in situ hip fixation using the Free Gliding SCFE Screw between 2014 and 2018. Initial postoperative radiographs were compared to last available follow-up imaging. Radiographic assessment included screw length, articulotrochanteric distance (ATD), posterior sloping angle (PSA), alpha angle, head-neck offset (HNO) and head-shaft angle (HSA).

Of the 28 hips reviewed, 17 were treated for SCFE and an additional 11 treated prophylactically. Average age at surgery was 11.7 years, with an average follow-up of 1.44 years. Screw length increased by 2.3 mm (p < 0.001). ATD decreased from 25.4 to 22.2 mm (p < 0.001). Alpha angle decreased from 68.7 to 59.8 degrees (p = 0.004). There was a trend towards an increase in HNO (p = 0.07). There was no significant change in PSA or HAS. There were three complications (two patients with retained broken guide wires, and one patient requiring screw removal for hip pain).

With use of the Free Gliding SCFE Screw, there was evidence of screw expansion and femoral neck remodelling with short-term follow-up. More research is required to determine the long-term impact of these changes on hip function, and to aid in patient selection for this technology.

Contrary to NICE guidance there remains a role for Austin-Moore hemiarthroplasty (AM) for patients with significant pre-existing comorbidities who are at higher risk of death and complications following cemented hemiarthroplasty.

We analysed prospectively-collected data comparing uncemented AM hemiarthroplasty in frail, poorly-mobile patients, and cemented hemiarthroplasty. We analysed age, pre-operative morbidity, duration of operation, death rate and complication rate.

AM patients were significantly older with significantly higher ASA grades. It took significantly longer to optimise them before surgery. AM was significantly shorter to perform. There was no significant difference in complications requiring re-operation. Twice as many AM patients developed post-operative pneumonia despite absence of cement. Twice as many AM patients died after surgery and a significant proportion died within the first month despite no increased risk of repeat operation, shorter operating time and no risk of cement-disease. We infer that these patients would likely have fared badly had they undergone a longer, cemented procedure. A modern cemented prosthesis costs £691 more than AM.

There exists a subset of patients within the neck of femur cohort who are significantly more unwell. Contrary to guidelines, we suggest that the cheaper, user-friendly Austin-Moore can be a reasonable prosthesis to use for this cohort.

Introduction

Pre-operative urine screening is accepted practice during pre-operative assessment in elective orthopaedic practice. There is no evidence surrounding the benefits, effects or clinical outcomes of such a practice.

Introduction: Abnormal hip morphology, seen with conditions such as slipped capital femoral epiphyses and femoral head necrosis, can lead to repetitive contact between the femoral neck and the acetabular rim. Impingement is a significant cause of hip pain in young adults and may be a mechanism for the development of early osteoarthritis. The senior surgeon has modified a technique to debride the pathology responsible for femoroacetabular impingement through a mini anterior approach, obviating the need to dislocate the hip. We describe this technique and present early clinical outcomes.

Method: Between Jan 2006 and June 2008, ‘notchplasty’ for the surgical treatment of femoroacetabular impingement was performed by the senior author (AHN) or directly under his supervision in 38 hips. There were 17 male patients and 21 female patients with an average age of 31 years. Patients have been followed according to a prospective protocol with Oxford and Iowa hip scores obtained pre-operatively, at 3 months and at 1 year.

Results: This study is still in progress. Twenty nine patients have had 3 month follow up and 13 of these have now been followed up to one year. Four patients are still less than 3 months post op. Data was unobtainable for 5 patients. 1 patient was excluded from the study.

The overall Oxford hip score improved significantly from a mean pre-operative value of 35 to a mean post operative value of 22.9 at 3 months (p< 0.001).

The mean score at 1 year increased slightly to 27.3 points but this remains lower than the pre operative average.

We report no cases of osteonecrosis. One patient has since been scheduled to undergo resurfacing arthroplasty.

Conclusions: The technique described is a new method for managing these patients whilst avoiding the pit-falls of current operative methods. The method avoids detaching the straight head of rectus, thereby tremendously improving postoperative mobilisation. However, the long term benefit of debridement of the head-neck junction for Cam-type femoroacetabular impingement remains to be seen.

Introduction: Infection remains the single most important complication in elective joint replacement. 1.1% of patients suffer early deep infection and 10–17% of patients superficial infection [1]. Antibiotic prophylaxis has been used extensively in elective orthopaedic practice, approximately halving the post-operative infection rate [2]. Cefuroxime is almost universally used in the UK. However there is an increased incidence of multiple drug resistant bacteria within the environment in addition cephalosporin use and resistance is widespread [3]. Many patients are treated pre-operatively for urinary tract infections with cephalosporins, and a further group of patients are already colonised with cephalosporin resistant staphylococcus. We have previously shown that 8.1% of patients fall into one or other of these categories.

Methods: We present a prospective series of 630 serial elective orthopaedic admissions from all orthopaedic disciplines. We have examined notes and reviewed lab records in order to determine outcomes. The centre for disease control [4] definition was used for suspected infections, and confirmed with wound swabs. 48 cases were confirmed infectious from a suspected 142 cases meeting this definition.

Results: We found a positive correlation between previous urine infection, MRSA status, revision surgery, and diabetes and wound infection. Nearly 35% of bacterium cultured were cephalosporin resistant, and 12% demonstrated multiple antibiotic resistance.

Discussion: It is good clinical practice to provide antibiotic prophylaxis in joint replacement, but the blind use of cephalosporins in all patients does not make sense because of increased incidence of antibiotic resistant bacteria. We present evidence based guidelines for the use of antibiotic prophylaxis in elective orthopaedic surgery and empirical antibiotic treatment in patients with wound infection before culture results are available.

Introduction: Tendon lengthening is an important cause of morbidity after Achilles tendon rupture. However, direct measurement of the tendon length is difficult. Ankle dorsiflexion has therefore been used as a surrogate measure, on the assumption that it is the Achilles tendon that limits this movement. The aim of this investigation was to assess the relationship between Achilles tendon length and ankle dorsiflexion. The primary research question was whether or not the Achilles tendon is the structure that limits ankle dorsiflexion. The secondary purpose was to quantify the relationship between Achilles tendon lengthening and dorsiflexion at the ankle joint.

Methods: Five cadaveric specimens were dissected to expose the tendons and capsular tissue of the leg and hindfoot. Fixed bony reference points were used as markers for the measurements. In the first specimen, the Achilles tendon was intact and the other structures that may limit ankle dorsiflexion were sequentially divided. In the other specimens the Achilles tendon was lengthened by 1cm intervals and the effect upon ankle dorsiflexion movement was recorded.

Results: Division of the other tendons and the capsular tissue around the ankle joint did not affect the range of ankle dorsiflexion. When the Achilles was divided the foot could be dorsiflexed until the talar neck impinged upon the anterior aspect of the distal tibia. There was a mean increase of 12 degrees of dorsiflexion for each centimetre increase in tendon length.

Conclusion: The Achilles tendon is the anatomical structure that limits ankle dorsiflexion, even when the tendon is lengthened. There was a linear relationship between the length of the Achilles tendon and the range of ankle dorsiflexion in this cadaveric model. Ankle dorsiflexion would appear to be a clinically useful indicator of tendon length.

Introduction and Aims: To evaluate the results of humeral nailing with the new Fixion inflatable humeral nail.

Method: We retrospectively studied 42 patients with acute humeral fractures (20), delayed and non-union (12) and pathological fractures (10), who where treated with an inflatable humeral nail and had a minimum follow-up of six months. Our primary outcome measures were clinical and radiological union. Secondary outcome measures were revision of the nail, screening time and operative time. We made a clinical assessment of the patients using the Constant score of the shoulder and a measure of health-related quality of life, using the EuroQol EQ-5D questionnaire.

Results: In patients with acute fractures 16/19 (84%) went on to clinical and radiological union (1/20 patients died four weeks post-operatively from bronchopneumonia). All of the patients with delayed and non-union of humeral fractures went on to clinical and radiological union. In the patients with pathological fractures, the nail provided good palliative symptom relief. Average screening time was 40.5 seconds (21–107). Average operative time was 71 minutes (26–142). Constant score of the shoulder had a median of 67 (SIQ 46.5–77.5) in the affected arm and 87 (SIQ 74–89) in the normal arm.

Conclusion: The treatment of humeral fractures using the inflatable intramedullary nail is a simple and safe technique, avoiding the time and complications associated with distal locking. Its seems to be an appropriate technique with excellent results in those patients with delayed and non-union of humeral fractures, and provides effective palliation in patients with pathological fractures. Its efficacy in patients with acute fractures is comparable to other intramedullary nails. In our experience, it is particularly effective in the multiply injured and the infirm because of the speed and ease of insertion.