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.

The Effect of Hand Dominance on Functional Outcome Following Single Row Rotator Cuff Repair.

INTRODUCTION: Rotator cuff tears are a common cause of shoulder disability and pain. Excellent outcomes can be obtained with surgical treatment although this outcome is affected by several factors. We sought to investigate the effect of hand dominance on subjective functional outcome post rotator cuff repair. METHODS: All patients who had rotator cuff repair over a calendar year were identified and followed up at 3 years post operatively. Patients were consented for inclusion in the study and demographic data, hand dominance and functional outcome data was collected. L'insalata shoulder questionnaire was used for outcome data collection. SPSS version 22 was used for statistical analysis where appropriate. RESULTS: 144 patients were included in this study. Mean age was 63 +/- 10.1 years in the dominant side group and 62 +/- 8.6 years in the non-dominant group. 92 patients had dominant side surgery and 52 had non-dominant side surgery. There was a statistically significant correlation between dominant hand and operated side (P=0.005). The mean overall outcome score was marginally higher in the dominant surgery group with a mean of 89.8 +/- 14.2 compared with a mean of 87.4 +/- 17.5 in the non-dominant group. Multi-variate linear regression analysis revealed this difference to be non-significant (p = 0.4). CONCLUSION: No difference was found in the functional outcome of rotator cuff repair between dominant and non-dominant side surgery. This information will help in counselling patients who are concerned about the potential impact of rotator cuff repair on the function of their dominant hand.

The natural history and clinical syndromes of degenerative cervical spondylosis.

Cervical spondylosis is a broad term which describes the age related chronic disc degeneration, which can also affect the cervical vertebrae, the facet and other joints and their associated soft tissue supports. Evidence of spondylitic change is frequently found in many asymptomatic adults. Radiculopathy is a result of intervertebral foramina narrowing. Narrowing of the spinal canal can result in spinal cord compression, ultimately resulting in cervical spondylosis myelopathy. This review article examines the current literature in relation to the cervical spondylosis and describes the three clinical syndromes of axial neck pain, cervical radiculopathy and cervical myelopathy.

Foot and ankle surgery--the Achilles heel of medical students and doctors.

BACKGROUND: Numerous studies have shown that deficiencies exist in orthopaedic and musculoskeletal medical training resulting in students and doctors regularly failing basic orthopaedic exams. However, there have not been any studies addressing the attitudes of medical students towards the orthopaedic subspecialties. OBJECTIVES: This study aimed (i) to determine if foot and ankle surgery was the orthopaedic specialty with which students and doctors have the most difficulty, (ii) to appraise attitudes towards teaching of foot and ankle surgery, and (iii) to suggest ways teaching might be improved. METHODS: A questionnaire on orthopaedic teaching was given to 238 medical students in Ireland. Perceived difficulties with foot and ankle surgery were compared to seven other orthopaedic subspecialties and the results were analysed. Other aspects of teaching were assessed including why foot and ankle surgery is perceived as difficult and ways teaching could be improved. RESULTS: Foot and ankle surgery is the orthopaedic subspecialty with which medical students and doctors have the most difficulty, least confidence and poorest knowledge in. This was due to: perceived complexity; insufficient exposure; and a lack of teaching. CONCLUSION: Foot and ankle surgery is the least popular of the orthopaedic subspecialties and considerable deficiencies exist in its education.