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The purpose of this paper is to investigate cost effectiveness, diagnostic rates, surgical percentage and appropriateness for orthopaedic referrals and number of patients able to be seen in orthopaedic triage from GP orthopaedic referrals.

The study involved triaging paper referrals for orthopaedic outpatients to an interface service, orthotics or continue normal route. Data were collected on outcome of the interface appointment and outcomes for those patients referred to orthopaedics from the appointment.

The study demonstrated a 27.3 per cent cost saving from the normal orthopaedic route with 86.1 per cent of patients able to be managed by an extended scope physiotherapist (ESP) without requiring orthopaedic assessment. Appropriateness of onward orthopaedic referrals was 80.5 per cent with surgery conversion rate of 75 per cent.

Although triage and ESP positions have been studied before, this is the first known study to look at cost effectiveness across the patient pathway despite this being a large reason for the creation of these positions. Further larger studies are required to build upon this base in terms of demonstrating the cost effectiveness of the value of these positions.

Historically, provision of orthopaedic services has been hospital based with GPs referring patients for specialist opinion. Growing demands on the service have led to new initiatives to reduce waiting times. One such initiative has been the introduction of orthopaedic assistants, usually physiotherapists, working with an extended scope of practice who see patients after referral to secondary care and determine the patients on‐going management. Studies to date have examined the effect of an orthopaedic assistant working alongside a consultant in the hospital environment. This study describes the impact on the management of the orthopaedic caseload in one general practice resulting from “screening” prior to referral to secondary care by a physiotherapist with an extended scope of practice. It demonstrates the successful management of the majority of patients within primary care.

The purpose of this paper is to discuss the scepticism that persists among medics regarding appropriateness of some aspects of services provided by extended scope physiotherapists (ESPs). This paper aims to highlight the extent and appropriateness of surgical and radiological referrals by ESPs working in an adult orthopaedic service.

The patient pathway following ESP assessment was audited over 31 months. Parameters explored included ESP referral rates to orthopaedic consultants; the percentage of patients where the entire episode of care was managed by the ESP; whether orthopaedic referrals were appropriate in terms of surgical interventions; and numbers of radiology referrals specifically for knee or lumbar complaints.

Of the patients, 79 per cent had their entire episode of care managed by ESPs. Of the patients, 9 per cent were referred on for a surgical opinion (of which 42 per cent knees, 20 per cent lumbar). 13 per cent were referred for x‐rays, 10 per cent for magnetic resonance imaging. Of the patients referred on for surgical opinion surgical intervention was appropriate in 89 per cent of cases.

Data from an ESP service with broad guiding protocols in a specific hospital are not readily extrapolated to ESPs elsewhere. Appropriateness of onwards referrals was based on the opinions of consultants to whom patients were referred. The potential benefit of a second opinion even if surgery is not offered is not taken into account by this model.

These audits reinforce the impact ESPs have on efficiency within orthopaedics. They document referral rates for x‐rays and magnetic resonance imaging by ESPs for lumbar and knee complaints that may benefit units proposing new ESP services.

This paper reinforces published data on ESP management of the entire episode of care of the majority of referrals to orthopaedics, and on the highly appropriate nature of onwards referrals. Documented for possibly the first time, data regarding investigations for lumbar and knee disorders highlight low referral rates.

The purpose of this paper is to improve surgical antimicrobial prophylaxis (SAP) prescribing in orthopaedic surgery using the model for improvement framework.

Orthopaedic patients receiving joint replacements, hip fracture repairs or open-reduction internal-fixation procedures were included. Antimicrobial(s); dose, time of administration and duration of SAP were evaluated for appropriateness based on the local SAP guidelines. After baseline data collection, a driver diagram was constructed with interventions devised for plan-do-study-act cycles. Data were fed back weekly using a point prevalence design (PPD). Interventions included SAP guideline changes, reminders and tools to support key messages.

SAP in 168 orthopaedic surgeries from 15 June 2016 to 31 January 2017 was studied. Prescribing appropriateness improved from 20 to 78 per cent. Junior doctor changeover necessitated additional education and reminders.

Due to constant staff changeover; continuous data collection, communication, education and reminders are essential to ensure continuous compliance with clinical guidance. Patients with hip fractures are difficult to weigh, requiring weight estimation for weight-based antimicrobial dosing. Unintended consequences of interventions included the necessity to change pre-operative workflow to accommodate reconstitution time of additional antimicrobials and inadvertent continuation of new antimicrobials post-operatively.

Rather than perform the traditional retrospective focused audit, we established a prospective, continuous, interventional quality improvement (QI) project focusing on internal processes within the control of the project team with rapid cyclical changes and interventions. The weekly PPD was pragmatic and enabled the QI project to be sustained with no additional resources.

Clinical specialist physiotherapy (CSP)-led musculoskeletal triage clinics have been established in the UK as a means of managing patients referred for outpatient orthopaedic consultation. The purpose of this paper is to determine if a CSP could allocate patients into distinct diagnostic triage categories in line with national and international guidelines. A second aim was to describe the CSPs clinical decision making.

A review of 100 spinal patients, consecutively referred between February and April 2013 to a CSP spinal triage clinic was undertaken. Patient demographics (age, gender, employment status), clinical diagnosis and diagnostic triage categories selected for each patient were recorded. Subsequently, if clinical triage led to further investigation or a consultant opinion then the onward management pathway was followed to calculate conversion to consultant surgical intervention.

In total, 69 per cent of patients were independently managed by the CSP and discharged back to the General Practitioner or on to therapy. In total, 30 per cent of patients (n=30) were referred for consultant opinion, of these 12 underwent intervention. This represents a conversion rate to consultant intervention of 40 per cent.

Findings suggest that a significant number of spinal patients referred for an orthopaedic consultation may be managed independently by a CSP. Referral for consultant review was deemed appropriate in terms of conversion to intervention, advice on further imaging, referral to other medical disciplines and patient counselling. This study suggests that CSPs can manage a significant number of patients with spinal conditions whilst providing high-quality referrals to surgical colleagues. This audit provides a novel insight into practitioner behaviour that supports the development of advanced practice for non-medical clinicians.

Human aging is becoming a common issue these days as it results in orthopaedic-related issues such as joints disorderness, bone-fracture. People with age = 60 years suffer more from these aforesaid issues. It is expected that these issues in human beings will ultimately reach 2.1 billion by 2050 worldwide. Furthermore, the increase in traffic accidents in young people throughout the world has significantly emerged the need for artificial implants. Their implantation can act as a substitute for fractured bones or disordered joints. Therefore, this study aims to focus on electron beam melted titanium (Ti)-based orthopaedic implants along with their recent trends in the field.

The main contents of this work include the basic theme and background of the metal-based additive manufacturing, different implant materials specifically Ti alloys and their classification based on crystallographic transus temperature (including α, metastable β, β and α + β phases), details of electron beam melting (EBM) concerning its process physics, various control variables and performance characteristics of EBMed Ti alloys in orthopaedic and orthodontic implants, applications of EBMed Ti alloys in various load-bearing implants, different challenges associated with the EBMed Ti-based implants along with their possible solutions. Recent trends and shortfalls have also been described at the end.

EBM is getting significant attention in medical implants because of its minor issues as compared to conventional fabrication practices such as Ti casting and possesses a significant research potential to fabricate various medical implants. The elastic modulus and strength of EBMed ß Ti-alloys such as 24Nb-4Zr-8Sn and Ti-33Nb-4Sn are superior compared to conventional Ti for orthopaedic implants. Beta Ti alloys processed by EBM have near bone elastic modulus (approximately 35–50 GPa) along with improved tribo-mechanical performance involving mechanical strength, wear and corrosion resistance, along with biocompatibility for implants.

Advances in EBM have opened the gateway Ti alloys in the biomedical field explicitly ß-alloys because of their unique biocompatibility, bioactivity along with improved tribo-mechanical performance. Less significant work is available on the EBM of Ti alloys in orthopaedic and orthodontic implants. This study is directed solely on the EBM of medical Ti alloys in medical sectors to explore their different aspects for future research opportunities.

The collection of complete and accurate data is an essential prerequisite of any study that aims to produce meaningful results. Much contemporary research in orthopaedic surgery has focused on proving the superiority of one implant or technique over another and relies on data which are currently being collected by various different methods. Modern joint replacement surgery is now successful with high implant survivorship at 10 and even 20 years and any new prosthetic design could be expected to result in only a modest improvement over current results. Complete follow‐up as well as optimum data collection are therefore of particular importance to detect any such benefit. Four methods commonly used for the collection of orthopaedic data were compared in this study with the aim of finding out which techniques would automatically result in the most reliable capture of complete data without the need for labour‐intensive supervision and the use of additional resources. The information obtained has been used to re‐define the audit methods for the North West Regional Arthroplasty Register.

The orthopaedic consultants at East Kent Hospitals NHS Trust had questioned whether the Extended Scope Practitioners (ESPs) and consultants were forming a comparable diagnosis and treatment plan. This audit aims to identify what percentage of patients received a comparable diagnosis from the ESPs and the orthopaedic consultant and to find out what percentage of patients referred from the ESP to the orthopaedic consultant for a surgical opinion underwent surgery.

The medical notes of a sample of patients from the ESP clinic who had been referred to the orthopaedic consultant were reviewed retrospectively and the following information was documented in a table: the ESP's diagnosis, the consultant's diagnosis and whether the patient underwent surgery.

The audit found a 31 per cent partially and 65 per cent fully comparable diagnosis rate between the consultant and the ESPs, and the ESPs predicted which patient would undergo surgery in 86 per cent of cases. The results of this audit compared favourably with the benchmarks set.

Audits such as this will hopefully help improve consultant, ESP, manager and patient confidence that the ESP is a valuable and effective member of the orthopaedic team.

A search for papers relating to ESP services on the healthcare databases AMED, BNI, CINAHL and MEDLINE found a number of articles which have reported on audits of ESP services but to date not with regard to shoulder problems. The paper may encourage other clinicians to do similar audits, supporting the expansion of ESP services within the NHS and ultimately improving patient care.

To describe orthopaedic surgical site infection (SSI) surveillance models at two English pilot sites, and to review their effectiveness and integration into clinical governance.

The different organisational models for orthopaedic SSI at two Trusts were examined and assessed.

Both sites recognised that regular feedback to clinical staff and clinical ownership are important determinants of success, and this was addressed by both models. Each site appointed a surveillance coordinator within the infection control service to oversee the programme, but tasked data collection to different staff groups directly involved with the care of orthopaedic patients. Feedback programmes to Clinical Governance Committees, clinical staff and managers were developed, reinforcing surveillance of SSI as a core component of surgical risk management and quality assurance, and an integral part of clinical governance. The pilots demonstrated the importance of a dedicated surveillance coordinator.

Infection following joint replacement surgery is associated with high morbidity and financial costs. In 2004 surveillance of orthopaedic SSI became mandatory in England. A description and assessment of these pilot sites will be of practical value to Trusts that must now implement SSI surveillance.

SSI surveillance is a corner‐stone of risk management and quality clinical care, yet little has been published on organisational frameworks needed for implementation, particularly in the context of clinical governance. This paper addresses these issues in describing and assessing the models at two English pilot sites.

The complications caused by metallic orthopaedic bone screws like stress-shielding effect, screw loosening, screw migration, higher density difference, painful reoperation and revision surgery for screw extraction can be overcome with the bioabsorbable bone screws. This study aims to use additive manufacturing (AM) technology to fabricate orthopaedic biodegradable cortical screws to reduce the bone-screw-related-complications.

The fused filament fabrication technology (FFFT)-based AM technique is used to fabricate orthopaedic cortical screws. The influence of various process parameters like infill pattern, infill percentage, layer height, wall thickness and different biological solutions were observed on the compressive strength and degradation behaviour of cortical screws.

The porous lattice structures in cortical screws using the rapid prototyping technique were found to be better as porous screws can enhance bone growth and accelerate the osseointegration process with sufficient mechanical strength. The compressive strength and degradation rate of the screw is highly dependent on process parameters used during the fabrication of the screw. The compressive strength of screw is inversely proportional to the degradation rate of the cortical screw.

The present study is focused on cortical screws. Further different orthopaedic screws can be modified with the use of different rapid prototyping techniques.

The use of rapid prototyping techniques for patient-specific bone screw designs is scantly reported. This study uses FFFT-based AM technique to fabricate various infill patterns and porosity of cortical screws to enhance the design of orthopaedic cortical screws.