The clinical and cost effectiveness of a virtual fracture clinic service: An interrupted time series analysis and before-and-after comparison.

OBJECTIVES: To assess the clinical and cost-effectiveness of a virtual fracture clinic (VFC) model, and supplement the literature regarding this service as recommended by The National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association (BOA). METHODS: This was a retrospective study including all patients (17 116) referred to fracture clinics in a London District General Hospital from May 2013 to April 2016, using hospital-level data. We used interrupted time series analysis with segmented regression, and direct before-and-after comparison, to study the impact of VFCs introduced in December 2014 on six clinical parameters and on local Clinical Commissioning Group (CCG) spend. Student's t-tests were used for direct comparison, whilst segmented regression was employed for projection analysis. RESULTS: There were statistically significant reductions in numbers of new patients seen face-to-face (140.4, sd 39.6 versus 461.6, sd 61.63, p < 0.0001), days to first orthopaedic review (5.2, sd 0.66 versus 10.9, sd 1.5, p < 0.0001), discharges (33.5, sd 3.66 versus 129.2, sd 7.36, p < 0.0001) and non-attendees (14.82, sd 1.48 versus 60.47, sd 2.68, p < 0.0001), in addition to a statistically significant increase in number of patients seen within 72-hours (46.4% 3873 of 8345 versus 5.1% 447 of 8771, p < 0.0001). There was a non-significant increase in consultation time of 1 minute 9 seconds (14 minutes 53 seconds sd 106 seconds versus 13 minutes 44 seconds sd 128 seconds, p = 0.0878). VFC saved the local CCG £67 385.67 in the first year and is set to save £129 885.67 annually thereafter. CONCLUSIONS: We have shown VFCs are clinically and cost-effective, with improvement across several clinical performance parameters and substantial financial savings for CCGs. To our knowledge this is the largest study addressing clinical practice implications of VFCs in England, using robust methodology to adjust for pre-existing trends. Further studies are required to appreciate whether our results are reproducible with local variations in the VFC model and payment tariffs.Cite this article: A. McKirdy, A. M. Imbuldeniya. The clinical and cost effectiveness of a virtual fracture clinic service: An interrupted time series analysis and before-and-after comparison. Bone Joint Res 2017;6:-269. DOI: 10.1302/2046-3758.65.BJR-2017-0330.R1.

Cementless total hip replacement without femoral osteotomy in patients with severe developmental dysplasia of the hip: minimum 15-year clinical and radiological results.

We describe the clinical and radiological results of cementless primary total hip replacement (THR) in 25 patients (18 women and seven men; 30 THRs) with severe developmental dysplasia of the hip (DDH). Their mean age at surgery was 47 years (23 to 89). In all, 21 hips had Crowe type III dysplasia and nine had Crowe type IV. Cementless acetabular components with standard polyethylene liners were introduced as close to the level of the true acetabulum as possible. The modular cementless S-ROM femoral component was used with a low resection of the femoral neck. A total of 21 patients (25 THRs) were available for review at a mean follow-up of 18.7 years (15.8 to 21.8). The mean modified Harris hip score improved from 46 points pre-operatively to 90 at final follow up (p < 0.001). A total of 15 patients (17 THRs; 57%) underwent revision of the acetabular component at a mean of 14.6 years (7 to 20.8), all for osteolysis. Two patients (two THRs) had symptomatic loosening. No patient underwent femoral revision. Survival with revision of either component for any indication was 81% at 15 years (95% CI 60.1 to 92.3), with 21 patients at risk. This technique may reduce the need for femoral osteotomy in severe DDH, while providing a good long-term functional result.

A comparison of 2-octyl cyanoacrylate with nylon for wound closure of knee arthroscopy portals.

OBJECTIVE: To compare the cosmetic results, complications and patient satisfaction of 2-octyl cyanoacrylate (Dermabond, Ethicon Inc. Somerville, NJ, USA), a liquid bonding agent, with 3-0 nylon sutures (Ethilon, Ethicon Inc) skin closure in two groups of patients undergoing elective knee arthroscopy at 6 weeks. METHOD: The retrospective clinical audit recruited patients undergoing knee surgery for the first time between October 2010 and August 2011. The patients were either treated with the liquid bonding agent or nylon sutures. The patients in the bonding agent group were allowed to shower as normal on postoperative day one, while patients in the suture group kept their wounds dry for 2 weeks. RESULTS: Between the two groups (40 patients per group) there was no difference in the cosmetic outcome (p=0.285), patient satisfaction (p=0.29), pain scores (p=0.44) or wound complication rate (p<0.05). Patient satisfaction was high in both groups. Furthermore, 83.75% of all patients indicated they would prefer the liquid bonding closure over nylon sutures if undergoing the same procedure in the future as they could shower the next day and avoid suture removal. CONCLUSION: 2-octyl cyanoacrylate is safe to use in the short term in knee arthroscopy providing comparable results to nylon suture closure. Allowing patients to shower the next day appears to cause no adverse effects. DECLARATION OF INTEREST: The authors would like to state that they do not have any economic or social interest in any of the products used or mentioned. No grant or finance was received for this study, nor any input from other sources.

The S-ROM hydroxyapatite proximally-coated modular femoral stem in revision hip replacement: results of 397 hips at a minimum ten-year follow-up.

We report on 397 consecutive revision total hip replacements in 371 patients with a mean clinical and radiological follow-up of 12.9 years (10 to 17.7). The mean age at surgery was 69 years (37 to 93). A total of 28 patients (8%) underwent further revision, including 16 (4%) femoral components. In all 223 patients (56%, 233 hips) died without further revision and 20 patients (5%, 20 hips) were lost to follow-up. Of the remaining patients, 209 (221 hips) were available for clinical assessment and 194 (205 hips) for radiological review at mean follow-up of 12.9 years (10 to 17.7). The mean Harris Hip Score improved from 58.7 (11 to 92) points to 80.7 (21 to 100) (p < 0.001) and the mean Merle d'Aubigné and Postel hip scores at final follow-up were 4.9 (2 to 6), 4.5 (2 to 6) and 4.3 (2 to 6), respectively for pain, mobility and function. Radiographs showed no lucencies around 186 (90.7%) femoral stems with stable bony ingrowth seen in 199 stems (97%). The survival of the S-ROM femoral stem at 15 years with revision for any reason as the endpoint was 90.5% (95% confidence interval (CI) 85.7 to 93.8) and with revision for aseptic loosening as the endpoint 99.3% (95% CI 97.2 to 99.8). We have shown excellent long-term survivorship and good clinical outcome of a cementless hydroxyapatite proximally-coated modular femoral stem in revision hip surgery.

Difficulties encountered removing locked plates.

INTRODUCTION: Locked plates are commonly used to obtain fixation in periarticular and comminuted fractures. Their use has also gained popularity in repairing fractures in osteoporotic bone. These plates provide stable fixation and promote biological healing. Over the last 3 years, we have used over 150 locked plates with varying success to fix periarticular fractures involving mainly the knee and ankle. In this study, we report our clinical experience and the difficulties encountered when removing locked plates in adult patients with a variety of indications including implant failure, infection, non-union and a palpable symptomatic implant. METHODS: A retrospective analysis was performed of patients enrolled prospectively into a database. Included in the study were 36 consecutive adult patients who each underwent the procedure of locked plate removal in a single inner city level 1 trauma centre. Data collected included primary indication for fixation, indication for implant removal, time of the implant in situ, grade of operating surgeon and difficulties encountered during the procedure. RESULTS: Implant removal was associated with a complication rate of 47%. The major problems encountered were difficulty in removing the locked screws and the implant itself. A total of ten cold welded screws were found in eight cases. Removal was facilitated by high speed metal cutting burrs and screw removal sets in all but one case, where a decision was made to leave the plate in situ. CONCLUSIONS: The majority of studies investigating implant removal and problems encountered in doing so report a relatively high complication rate. With the advent of locking plates and their growing popularity, difficulties are now being seen intraoperatively when removing them. There is a paucity of data, however, specifically directed at locking plate removal. We recommend that surgeons should be aware of the potential complications while removing locked plates. Fluoroscopic control and all available extra equipment (mainly metal cutting burrs and screw removal sets) should be available in theatre.

Transphyseal reconstruction of the anterior cruciate ligament in prepubescent children.

We present the results of 17 children of Tanner stage 1 or 2 who underwent reconstruction of the anterior cruciate ligament between 1999 and 2006 using a transphyseal procedure, employing an ipsilateral four-strand hamstring graft. The mean age of the children was 12.1 years (9.5 to 14). The mean follow-up was 44 months (25 to 100). Survival of the graft, the functional outcome and complications were recorded. There was one re-rupture following another injury. Of the remaining patients, all had good or excellent results and a normal International Knee Documentation Committee score. The mean post-operative Lysholm score was 97.5 (SD 2.6) and the mean Tegner activity scale was 7.9 (SD 1.4). One patient had a mild valgus deformity which caused no functional disturbance. No other abnormality or discrepancy of leg length was seen. Measurements with a KT1000 arthrometer showed no significant difference between the normal and the operated legs. In this small series, transphyseal reconstruction of the anterior cruciate ligament appeared to be safe in these young children.