A physiotherapy triage service for orthopaedic upper limb service: an effective way to reduce clinic visits and identify patients for operative intervention.

INTRODUCTION: Waiting times for orthopaedic outpatient clinics are steadily increasing over the past number of years worldwide. Physiotherapy triage clinics are being utilised to improve access for patients with non-urgent or routine musculoskeletal disorders, to be seen in a timely manner in specialised out-patient clinics. Using these clinics, the aim is to ultimately stratify patients into appropriate management pathways. The aim of our study is to review the effectiveness of a physiotherapy triage clinic run by advanced practitioner physiotherapists (APP), who specialise in the review of upper limb referrals from primary care physicians. METHODS: For this study, a prospective, observational design was used. Patients were referred to the Department of Orthopaedic Surgery, Upper Limb Service at a national elective Orthopaedic Unit. The patients' referrals were reviewed and allocated to a physiotherapy triage pathway if deemed routine, non-urgent cases. After assessment in the APP clinic, the physiotherapist made recommendations and highlighted patients who required review or case discussion with an orthopaedic surgeon. The discharge rate and outcome of patients referred on for further interventions or operative procedures was followed over a 3-year period. The outcomes for the patients were reviewed, including whether patients who met an orthopaedic surgeon went on to have surgical intervention. RESULTS: During the study, 646 patients were reviewed in an upper limb APP physiotherapy triage clinic. Of those reviewed, only 201 patients required review by an orthopaedic surgeon. Of those, 56 patients were scheduled for an operative procedure. Within the 3-year period, 50 patients of those scheduled underwent the procedure. The most commonly performed procedure being an arthroscopic subacromial decompression with or without acromioplasty or rotator cuff repair. A total of 145 patients referred by the physiotherapist had a shoulder injection including subacromial and glenohumeral intra-articular injection. The initial discharge rate was 68%. CONCLUSIONS: There is a high initial discharge rate after initial assessment by APP triage clinics for upper limb musculoskeletal pathology. This is beneficial in alleviating waiting list pressures allowing only those patients in need of intervention to be placed on the ever expanding waiting lists to see orthopaedic surgeons. This study shows a high proportion of patients being offered surgical intervention after being referred by the APP. We conclude from this that the agreement between the physiotherapist's initial diagnosis and that of the consultant surgeon being similar in identifying patients who would benefit from operative intervention.

Periprosthetic hip fractures: A review of the economic burden based on length of stay.

INTRODUCTION: With the increasing rates of total hip replacements being performed worldwide, there is an increasing incidence of periprosthetic fractures. As our patients' demographics change to include older patients with multiple medical co-morbidities, there is a concurrent increase in morbidity and mortality rates. This leads to longer hospital stays and increasing hospital costs. In the current economic climate, the cost of treating periprosthetic fractures must be addressed and appropriate resource and funding allocation for future provision of services should be planned. MATERIALS AND METHODS: All periprosthetic hip fractures that were admitted to a single trauma unit over a three-year period were reviewed. Independent chart review, haematological and radiological review was undertaken. All patients with a periprosthetic fracture associated with a total hip arthroplasty or hemiarthroplasty were included. Follow up data including complications were collated. Data from the hospital inpatient database and finance department was utilized for cost analysis. All statistical analysis was preformed using Minitab version 17. RESULTS: 48 patients were identified who met the inclusion criteria for review. The majority of participants were female with a mean age of 73.5 years. The mean time to fracture was 4.5 years (9 months-18.5 years). Periprosthetic fracture was associated with total hip arthroplasty in 24 cases and a Vancouver B2 classification was most common at n = 20. The majority of patients had revision arthroplasty, with a mean length of stay of 24 days for the whole cohort (9-42). Vancouver B3 fractures had the longest inpatient stay at a mean of 26 days. The mean cost of for a full revision of stem with additional plate and cable fixation was over €27000 compared to €14,600 for ORIF and cable fixation based on length of hospital stay. CONCLUSION: The prolonged length of stay associated with Vancouver B2 and B3 fractures leads to increased costs to the healthcare service. Accurately calculating the costs of total treatment for periprosthetic fractures is difficult due to a lack of transparency around implant and staffing costs. However, as we can expect increasing incidence of periprosthetic fractures presenting in the coming years it is paramount that we make financial provisions within healthcare budgets to ensure we can treat these patients appropriately.

Sprain of the Subaxial Cervical Spine in Childhood.

Posterior atlantoaxial ligament disruption in children is a rare diagnosis. We present a case of a young girl with cervical spine posterior atlantoaxial ligament disruption post a fall from a climbing frame. Presenting with minimal symptoms other than neck pain, this case highlights the diagnostic difficulty and need for further radiological imaging in paediatric patients with neck pain post trauma.

Malignant neuroendocrine tumour of the appendix in childhood with loco-regional lymph node invasion.

VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1006600359152743.