FRCSOrthExam Education Viva Topics

TRAUMA
1) Type 3 periprosthetic fracture
2) THR presents with a first time dislocation
3) Posterior dislocation with a fractured acetabulum
4) Osteochondral fracture of the knee
5) 15 year old boy club football player with acute ACL injury
6) Segmental tibial fracture with ipsilateral tibial plateau fracture
7) Open book pelvic fracture that is very haemodynamically unstable
8) Draw Hamilton Russell traction for a femoral fracture.
9) Diagram of oblique fracture, Where do you place the lag screw and why?
10) Pelvis fracture and inferior hip dislocation & pneumothorax
11) 18 year old with subtalar dislocation
12) 32 year old with midshaft tibial fracture and chest injury
13) Clavicle fracture mid shaft in a young adult, Non-union
14) Inferior shoulder dislocation
15) Burst fracture T12, no neurology
16) Treatment of distal biceps rupture and describe surgical approach.
17) Mangled extremity. Limitations of MESS
18) Spinal fracture. Need for steroids. NASCIS studies
19) IM nails biomechanics.
20) Displaced intracapsular NOF# in a 42 year old, classification (Garden & Pauwell's angle)
21) Lateral C-spine XR with C7/T1 subluxation, paraplegic, application of halo & discussion of
respiration in C-spine injuries
22) Pelvic fixator in place with pins not in the pelvis on one side
23) Anterior #-dislocation shoulder
24) Tibial tuberosity avulsion in a child
25) Salter Harris type II injury of proximal phalanx of little finger
26) Open comminuted tibial #
27) Midshaft ulna #
28) Volar Barton #
29) Torus versus greenstick #
30) Post fracture dislocation shoulder
31) Distal radius with scaphoid fracture
32) Segond #
33) Median nerve laceration
34) Comminuted proximal humerus fracture
35) Distal femoral fracture in elderly
36) Secondary prevention of osteoporosis and effects on bone healing
37) Clinical picture mangled leg
38) Segmental loss tibia, Limb salvage versus reconstruction
39) Weber C ankle
40) Displaced intracapsular fracture in young male
41) Elbow dislocation with radial head fracture
42) Intracapsular NOF in a 70 year old
43) Open supracondylar femoral fracture with pelvic fracture
44) Salter Harris type 4 fracture proximal phalanx great toe
45) Grade 3 (Ruedi's) tibial pilon fracture
46) Transverse humeral fracture in a 2 month old
47) Pelvic Fracture
48) Acetabular fracture
49) Distal Femoral fracture intra-articular
50) Supracondylar elbow fracture/Baumann’s angle
51) Compartment Syndrome
52) Open fracture Gustilo C
53) Lisfranc injury
54) Shaft femur with neck of femur
55) Periprosthetic fracture around knee
56) Ankle instability
57) Unstable inter-trochanteric fracture
58) Galeazzi #
59) Pathological # Humerus

ADULT PATHOLOGY
1) 50 year old man with symptomatic hip OA, failed conservative management. Which hip
would you do and can you support this with any literature or joint registry findings
2) Paget’s disease, THR
3) Valgus rheumatoid knee
4) X-ray appearances of OA, RhA and gout.
5) Infected THR
6) Osteochondroma proximal femur, differential, management, risks
7) Meniscal injury and repair
8) Ankylosing spondylitis with painful bilateral hips with 30 degrees FFD
9) Ewing’s sarcoma
10) Biopsy for a bone tumour
11) Isolated renal metastases in the femur
12) RSA analysis for implants
13) Guidelines for doing MIS for hip surgery
14) Bilateral mild hip dysplasia in 18 year old
15) Degenerative spine. What are worrying reg flag signs.
16) MRI of PCL deficient knee
17) 56 year old with OA hip. What implant are you going to use and why?
18) Conversion hip arthrodesis to THR
19) C-spine x-ray. Destroyed C5, no neurological signs in a 70 year old male (Myeloma)
20) Chronic osteomyelitis in adult tibia
21) Fibrous dysplasia with Shepherd's crook deformity
22) Freiberg's of a 2nd MT head
23) Unicortical # in a patient with Paget's disease. D/D & treatment (problems with nailing)
24) Loose Charnley THR. Discussion of diagnosis, investigations and treatment
25) Fibrous cortical defect in distal tibia
26) Pelvic X-ray with diffuse lytic pelvic lesion & a sclerotic iliac lesion
27) Bilateral varus knees, bone-on- bone
28) Correctable flat foot picture with 'too many toes' sign
29) Lytic lesion over greater trochanter
30) Foot photo 6 months after weber B fracture treated in POP with RSD/CRPS
31) Glass eye due to retinoblastoma as a child. X-ray of knee showed osteosarcoma
32) Elbow x-ray with multiple loose bodies
33) Rheumatoid forefoot
34) Lytic lesion femoral neck in a 32 year old woman
35) Young patient pelvis with Cemented THR one side & severe dysplastic OA hip on other
side
36) Mechanism of loosening / wear / osteolysis
37) Risks of allogenic bone graft
38) Rotator cuff tear
39) Rotator cuff arthropathy
40) Meniscal tears, MRI features, types, structure of meniscus and blood supply
41) Protrusio hip
42) Rheumatoid foot
43) Hallux valgus
 44) Dislocated MTPJ’s in Rheumatoid foot, management surgical options
45) Spondylolysis
46) Gangrenous foot post-op
47) Syme’s, Chopart’s and B/K amputation, design of B/K amputation prosthesis
48) Chondrosarcoma
49) Osteomyelitis
50) Septic loosening
51) Spondylolisthesis and Spondyloptosis
52) Acute calcific tendonitis of the shoulder
53) Psoas abscess (on CT)
54) AVN
55) Multiple Myeloma
56) Looser’ s zones
57) Synovial chondromatosis
58) Paget’s with THR and protrusion
59) Spinal stenosis
60) Fowler’s operation
BASIC SCIENCES
1) Draw a hip free body diagram
2) Posterior approach of the hip
3) Pathogenesis of osteoarthritis and rheumatoid arthritis
4) Biomechanics of hip fracture fixation devices
5) What would you do if you had 5 consecutive THR that became acutely infected whilst still
an inpatient.
6) Survivorship curve
7) Posterior approach to the knee
8) Indications for disarticulation of the knee as an amputation
9) Define wear and give me examples.
10) Define hoop stresses and give me some examples in the body
11) Biomechanical priciples and material properties of an Exeter & Charnley stem
12) Problem in the 3M capital hip disaster
13) Summary of the recent National Joint registry report and tell me the features of the NJR
compared with other joint registries
14) Draw the compressive and tensile trabecullae in the proximal femur
15) What is a hypothesis
16) How do you go about setting up a clinical trial
17) What does central tendency mean (mean, median, mode)
18) What is dispersion (Standard deviation, interquartile range)
19) Why do we use a P-value of 5%?
20) When do you use a parametric test and when do you use a non parametric test?
21) What is a meta analysis?
22) Given a diagram of a box and whisker plot, asked to describe all points , lines etc
23) What is your DVT prophylaxis and why. What is the evidence behind it.
24) Describe the different forms of lubrication.
25) What properties of ceramic make it good for lubrication.
26) How does MRI, X-ray, US, CT, bone scan, DEXA scan work?
27) X-ray on a 25 year old pregnant female, steps you take to reduce the dose
28) How do you do an arthrogram. What are the contra-indications to using the contrast.
29) Radiation dose they will get from an isotope bone scan
30) Design a new plate for fracture fixation. What features in the plate will you incorporate
into your design.
31) You have been asked to design a new hip replacement / knee replacement. What features
will you incorporate into your design.
32) DCP plate is very strong. Why does it need to be this strong.
33) What are the material properties of tendon & ligament
34) How is polyethelene manufactured.
35) Draw the structure of a nerve and what do you repair in a digital nerve repair and a
median nerve repair.
36) Name some outcome scores used in orthopaedics
37) What do you know about metal on metal articulation. How do the current generation of
implants differ from those used in the 70's (McKee-Farrar)
38) Tourniquets. How to apply & use.
39) Screws, describe different types and how they work etc
40) Locking plates, principles
41) Humeral plating, why done posteriorly, principles tension band
42) Draw brachial plexus
43) Set up a bone bank (Consent, testing, storage etc)
44) X-sectional anatomy of carpal tunnel
45) Chronic regional pain syndrome.
46) Creep and stress relaxation curves
47) Zones of growth plate, blood supply & relevance to osteomyelitis
48) Types of ossification & bones in which these occur
49) Shown unmarked axial drawing of a vertebra
50) Lumbar discogram with normal discogram at L3/4 & abnormal at L4/L5
51) Structure of intervertebral disc & what happened with age
52) Shown a drawing of the ulnar bursa of the hand
53) Hysteresis loops (one for elastin and one for collagen)
54) Cross section of nerve. Tell me about the structure of a nerve
55) How does the nerve vary along its course
56) Nerve Conduction Studies
57) Osteogenesis Imperfecta
58) Dwarfism
59) Torticollis
60) Osteoid Osteoma
61) Syringomyelia
62) Horner’s syndrome
63) Rickets
64) Fracture healing
65) Nerve injuries
66) Piriformis muscle anatomy
67) Prosthesis, A/K prosthesis
68) Bone grafts
69) Tourniquets
70) Screw design and function/ lag screw principle
71) Structure peripheral nerve/nerve conduction studies
72) Brachial plexus injury with Horner
73) Henry approach to radius
74) Course of nerves & muscles innervated in upper and lower limbs
75) Design of knee brace for valgus deformity
76) Four bar linkage mechanism of ACL/PCL
77) Difference between osteoporosis and osteomalacia
78) Causes of secondary tumours to bone and mechanism of metastases
79) Parts of a THR
80) Ceramic-mechanical properties
81) Stainless steel-mechanical properties, manufacture
82) Titanium -mechanical properties
83) Draw X-sectional anatomy at mid-thigh level
84) Course of the sciatic nerve from roots to foot
85) Course of the lateral cutaneous nerve of thigh
86) Draw articular cartilage, viscoelasticity, lubrication, effect of laceration, loading and
unloading
87) Articular cartilage defects and repair methods
88) Draw an osteoclast
89) Meniscus structure / function / biomechanics / discussion on hoop stresses
90) Structure of proteoglycan
91) Mendelian inheritance, sex-linked recessive/dominant
92) Theatre design (Laminar flow, Ex flow, air changes, HEPA filter, size of particles)
93) Failure mechanisms prostheses. Interfaces
94) Bacterial organisms. Use of prophylactic antibiotics and mechanism of action
95) Open fractures
96) Gas gangrene
97) Talus & calcaneum to describe anatomy
98) Bone graft substitutes properties
99) Confidence intervals and relative risk
100) Wear mechanisms
101) Subsurface delamination of polyethylene
102) Traction
103) MRI principle
104) Stress-strain curve
105) Phyeal injuries
106) Palacos cement
107) Highly Cross-Linked polyethylene
108) Ex-fix construct

HANDS & PAEDS

1) Finger tip injury with bone exposed
2) Radial club hand
3) Madelung’s deformity of distal radius
4) # 4th and 5th Metacarpals minimally displaced
5) Bilateral club foot
6) Neurofibromatosis (I & II) and pseudoarthrosis of tibia
7) Tibia vara
8) Blounts disease
9) Acute displaced scaphoid fracture
10) Kienbock’s disease
11) STT OA
12) Clinical slide of a hypothenar eminence haemangioma
13) Clinical slide of recurrent Dupuytren's contracture
14) Boutonniere deformity
15) Tibial spine avulsion
16) Arthrogram in an 18 month old DDH
17) Clinical picture of anterolateral bowing tibia in a toddler with café au lait spot
18) Clinical photograph of an adolescent pes planus
19) Calcaneonavicular tarsal coalition
20) Extra-articular distal radius fracture management options
21) Ulnar Collateral Ligament injury of the thumb and management options
22) Mucous cyst
23) Monteggia Fracture dislocation with unreduced radial head
24) Scapholunate ligament injury and management – acute vs chronic, Kirk-Watson’s
instability test
25) LLD and causes, Management of predicted 9cm LLD in a normal child
26) Management of missed DDH in 18 month old
27) DDH in newborn
28) Perthes’ disease
29) SUFE
30) CTEV
31) Cavovarus foot
32) Physiological variants
 33) Neuromuscular disease
34) Limb lengthening and deformity correction
35) Juvenile Arthritis
36) Non-accidental Injury
37) Paediatric knee
38) Skeletal Dysplasias
39) Spinal disorders
40) Oncology
41) Infection
42) Supracondylar fracture
43) Lateral condyle
44) Mallet finger
45) Fight bite

46) Fibular hemimelia

47) EPL rupture
48) De Quervain’s disease
49) Perilunate dislocation
50) Osteochondral defect of the knee
51)
52) Dorsal PIPJ fracture dislocation
53) Undisplaced scaphoid fracture
54) Pes cavus with claw toes
55) Grease gun injury
56) Old Monteggia's fracture
57) Bipartite patella
58) Galeazzi's fracture
59) Ewing’s sarcoma
60) Boutonniere and swan neck deformities
61) Examiner puts glove on. Draw on the glove and talk about incisions for the hand
62) Management of 1st MTPJ OA. Conservative and operative.
63) How do you repair a flexor tendon injury in Zone 2, different post-op regimes
64) Describe the zones for flexor and extensor tendon injuries of fingers and thumb
65) Picture of winging scapula. What are causes.
66) Menigococcal septicaemia
67) Diaphyseal aclasia
68) Scaphoid non union
69) Gross crush injury to hand. Management fasciotomies
70) Enchondroma of the proximal phalanx with #, Treatment
71) Climber with rupture of all flexor pulleys of finger. Reconstruction principles
72) Clinical photo of a nail bed injury
73) Malunited Frykman's type VIII distal radial #, options for DRUJ reconstruction
(osteotomies), Darrach's, Suave-Kapandji & ulnar head replacement
74) Clinical photo of a traumatic amputation through MCPJ's of all fingers
75) Asked about the different types of hand grip
76) Between proportionate and non proportionate dwarfism.
77) Principles in the management of CP
78) Three ways bone form and grow
79) Physes in the hand metacarpals, and phalanges
80) AVN rate in pavlic harness
81) Basic requirements for a good screening test.
82) What screening do we have for DDH in the UK
83) Gait analysis, gait cycle, and what are the prerequisites for normal gait
84) Causes of bowing of tibia
85) Osteogenesis imperfecta, and draw me a genetic table demonstrating the genetics
86) Differences in medial and anterior approaches for DDH
87) Setting up a pavlik harness
 88) Picture of congenital vertical talus. What are the associations
89) Cavo-varus foot
90) Changes in Child's knee varus and valgus with age (Selenius graph)
91) SUFE, causes, classification, management. Discussion about recent review
from Southampton
92) Fibular hemimelia and PFFD
93) Clinical photo of pair of varus knees in a 2 year old child
94) Picture of Gallow's traction

PPER LIMB SHORT CASES

 Massive rotator cuff tear

 Charcot-Marie-Tooth disease
 Cubital tunnel syndrome
 Popeye biceps (Ruptured Long Head of Biceps)
 Ulnar nerve palsy
 Frozen shoulder
 Shoulder instability with generalised ligamentous laxity
 Dupuytren’s contracture
 Rheumatoid hand
Bilateral median and ulnar nerve palsies
 EPL rupture following distal radial fracture
 Shoulder OA
 Deltopectoral scar, Post-Total Shoulder Replacement
 Postop Total Elbow Replacement
 Old supracondylar # with cubitus varus
 Tennis elbow
 Ganglion
 Median nerve palsy
 Radial nerve palsy
 CMC Thumb OA
 Carpal Tunnel syndrome
 Brachial plexus lesion
 Posterior Interosseous Nerve Palsy
 Elbow OA
 Cervical myelopathy
 POSTOP=Shoulder arthrodesis
FRCSOrthExam Education Clinical Cases
LOWER LIMB SHORT CASES

 Polio foot and hip

 Postop ankle arthrodesis
 Chronic osteomyelitis
 Leg length discrepancy (Pseudoarthrosis tibia due to neurofibromatosis)
 Pes cavus, CP and fredriech’s ataxia
 Sciatic nerve injury from hip injury/surgery
 Arthrodesed hip
 Diaphyseal aclasia
 HMSN/Charcot-Marie-Tooth disease
 ACL rupture
 Posterolateral corner injury
 Diabetic charcot hindfoot
 Postop open Tibial fracture with a flap
 Ankylosing spondylitis
 Valgus OA knee
 Clawed toes
 OA ankle
 Morton’s Neuroma
 OA Hip
 Hip arthrodesis
 Femoral nerve palsy
 PCL rupture
 OA Knee
 Patello-femoral instability
 Rheumatoid foot
 Cavo-varus foot
 Tarsal coalition
 Hallux valgus
 Hallux rigidus
 Lesser toe deformities (Hammer, mallet & claw toes)
 Tibialis posterior tendon rupture / Pes planus deformity
 Lateral ligament instability of ankle
 PFFD / Congenitally short lower limb
 Fibular hemimelia
 Leg nailing with fasciotomy scars
 Gout
 Postop A/K amputee in prosthesis
 Postop subtalar arthrodesis for previous calcaneal fracture
 Spinal stenosis
 CPN palsy

LONG CASES
 Secondary OA to previously treated DDH
 Hip primary OA
 Spinal stenosis
 AVN hip
 Postop TKR/THR with some complications
 AVN of hip secondary OA several years post-ORIF acetabular fracture
 Previous open tibial fracture with infected non-union
 Rheumatoid wrist & hands
 OA Knee
 Syndromic case
PAEDIATRIC CASES

 Scoliosis
 Arthrogryposis
 Cerebral palsy
 Osteogenesis imperfecta
  Spina bifida
 Hyperlaxity
 Multiple exostosis
 LLD

NICE guidelines (Website: www.nice.org.uk)

The use of routine preoperative tests for elective surgery June 2003

Head injury June 2003

Surgical site infection June 2008

Extracorporeal shock wave therapy for refractory tendinopathies 2004

Arthroscopic femoro-acetabular surgery for hip impingement syndrome March 2007

Artificial MCP and IP joint replacement for end-stage arthritis February 2005

Balloon kyphoplasty for vertebral compression fractures April 2006

Computed tomography (CT) guided thermocoagulation of osteoid osteoma March 2004

Endoscopic division of epidural adhesions September 2004

Endoscopic laser foraminoplasty 2005

Extra-corporeal shockwave lithotripsy for calcific tendonitis of the shoulder November 2003

Laser lumbar discectomy December 2003

Mosaicplasty for knee cartilage defects March 2006

Open femoro-acetabular surgery for hip impingement syndrome January 2007

Percutaneous endoscopic laser thoracic discectomy June 2004

Percutaneous intradiscal electrothermal therapy for lower back pain August 2004

Percutaneous intradiscal radiofrequency thermocoagulation for LBP August 2004

Percutaneous vertebroplasty September 2003

Prosthetic intervertebral disc replacement November 2004

Prosthetic intervertebral disc replacement in the cervical spine November 2005

Single mini-incision surgery for total hip replacement January 2006

Hip disease - replacement prosthesis April 2000

Cartilage injury - autologous chondrocyte implantation May 2005

Sarcoma: Improving outcomes for people with sarcoma March 2006

Audit process for acute back pain guidelines September 2001

BOA Guidelines (Website: www.boa.ac.uk)

Best Practice For Primary Isolated Anterior Cruciate Ligament Reconstruction July 2001

Better Care for the Severely Injured July 2000

Blood Conservation in Elective Orthopaedic Surgery April 2005

BOA Position on Decontamination April 2007

BOA Recommendation on Sterile Procedures in Operating Theatres December 1998

BOA Statement on Prophylaxis for Venous Thromboembolism May 2007

Children's Orthopaedics and Fracture Care July 2006

Knee Replacement - a guide to good practice December 1999

Metastatic bone disease: a guide to good practice December 2001

Primary Total Hip Replacement: A Guide to Good Practice August 2006

The Care of Patients with Fragility Fractures September 2007

The Initial Care and Transfer of Patients with Spinal Cord Injuries July 2006

The Management of Acute Bone and Joint Infection in Childhood September 2004

The Management of Open Tibial Fractures September 1997

The Management of Spinal Deformity in the UK: A Guide to Good Practice November 2003

Theatre Efficiency August 2003

Scottish Inter-collegiate Guideline Network (www.sign.ac.uk)

SIGN TOPIC
45 Antibiotic prophylaxis

48 Rheumatoid arthritis

54 Perioperative blood

56 Hip fractures

62 Venous thromboembolism

71 Osteoporosis

77 Postop management

Appraisal

It is a one to one discussion between the trainer and the trainee about goals to be set or those that have been
achieved. It is a two-way informal and confidential communication about feedback on past performance and to
identify educational and professional development needs.

Assessment

It is an objective standard setting exercise, with an integral element of performance review in the process.

Revalidation

It is a process whereby doctors will have to demonstrate regularly to the GMC that they are fit to practise
medicine. It would be done by repeated assessments.

Clinical governance

Formal definition by department of health (1988)-‘Framework through which NHS organizations are
accountable for continuously improving the quality of their services and safeguarding high standards of care by
creating an environment in which excellence in clinical care can flourish.’

Informal definition-‘Systems to ensure lessons learnt are implemented and mechanism to ensure systems are in
place and functioning effectively.’

Three basic things

-framework
-accountability
-aiming for excellence in clinical care

Building blocks are

-clinical audit,
-clinical effectiveness,
-clinical risk management,
-quality assurance,
-staff development,
-evidence based practice,
-CME,
-IT

Clinical effectiveness

It can be defined as the extent to which specific clinical interventions, when deployed in the field for a patient or
population,do what they are intended to do. It can be achieved by informing, changing and monitoring these
changes resulted in improvements.

Clinical negligence

It is said to be occurred when the doctor did something wrong (act of commission eg. wrong side or patient) or
failed to do something which they should have done (act of omission eg. minor sepsis leading to multiorgan
failure).

Clinical risk management

Steps taken to identify the risks of adverse events, assessing their frequency and severity, and reducing or
eliminating them in order to improve the quality of patient care.

Clinical audit

It is a systematic, critical analysis of the quality of clinical care, including the procedure used for diagnosis and
treatment, the use of resources and the resulting outcome and treatment.

Research

It is a process of going from known to unknown. It is a process of gathering data and information with an aim to
prove or disprove existing facts and genesis of neoconcepts.

Audit loop or cycle

It starts from observing the current practice, finding out the set standards of care, comparing the practice with
standards and implement the changes. It is an ongoing process and should be repeated to keep changes long-
lasting.

Audit versus research

Both involve gathering data and information. Local versus wider applicability. Known to unknown and vice-versa.
Audit is reviewing current medical practice to identify deficiencies which can be remedied, while purpose of
research is to enrich the medical knowledge.

Steps of Randomised controlled trial

-Hypothesis
-Literature review
-Statistical analysis
-Working protocol, patient advice sheet, consent form
-Ethical committee approval
-Funding
-Data collection, analysis and interpretation
-Writing up, submitting and milking

National Institute for Clinical Excellence (NICE) (Web: www.nice.org.uk)

 Established in 1999
 NICE works on behalf of the NHS and the people who use it
  NICE makes recommendations on treatments and care using the best available evidence
 NICE produces three kinds of guidance:
o Technology appraisals - guidance on the use of new and existing medicines and
treatments within the NHS in England and Wales.
o Clinical guidelines - guidance on the appropriate treatment and care of people with
specific diseases and conditions within the NHS in England and Wales.
o Interventional procedures - guidance on whether interventional procedures used for
diagnosis or treatment are safe enough and work well enough for routine use
in England, Wales and Scotland.

National Patients Safety Agency (NPSA)

Web: www.npsa.nhs.uk
 NPSA seeks to improve the safety and quality of care through reporting, analysing and
learning from adverse incidents and 'near misses' involving NHS patients.
 Its main role is to prevent accidents/incidents by
o collecting and analysing information on adverse incidents from local NHS organisations,
NHS staff, patients and carers
o by taking into account other safety-related information from a variety of existing reporting
systems
o by learning lessons and ensuring that they are fed back into health care and treatment is
organised and delivered
o by ensuring that where risks are identified, work is undertaken on producing solutions to
prevent harm, specify national goals and establish mechanisms to track progress

Commission for Health Improvement(CHI)

Web: www.chi.nhs.uk
 Ceased to exist on 31 March 2004. All functions have now been taken over by the Healthcare
Commission
 The CHI had four functions:
o Clinical Governance Review
o Monitoring and reviewing how the NHS meets the recommendation of National Service
Frameworks (NSF) and NICE
o Investigating serious service failures in the NHS
o Leading and reviewing NHS healthcare improvements

Healthcare Commission
Web: www.healthcarecommission.org.uk
 Its legal name is the "Commission for Healthcare Audit and Inspection. It became operational on 1
April 2004.
 It replaced CHI but also took over some responsibilities from other commissions. In particular:
o it takes over the private and voluntary healthcare function of the National Care Standards
Commission
 o it covers the elements of the Audit Commission's work which relate to efficiency,
effectiveness and economy of healthcare
 One of its main functions is to promote the quality of both the NHS and the private and voluntary
healthcare across England and Wales. In particular it takes over the handling of complaints if
they have not been successfully resolved at a local level

National Service Frameworks (NSF)

 NSFs started being implemented in 1999. They:

 Set national standards and identify key interventions for a defined service or care group

o put in place strategies to support implementation

o establish ways to ensure progress within an agreed time scale
o form one of a range of measures to raise quality and decrease variations in service,
introduced in The New NHS and A First Class Service. The NHS Plan re-emphasised the
role of NSFs as drivers in delivering the Modernisation Agenda.
 There will usually be only one new framework a year.
 Each NSF is developed with the assistance of an external reference group (ERG) which brings
together health professionals, service users and carers, health service managers, partner agencies,
and other advocates. ERGs adopt an inclusive process to engage the full range of views. The
Department of Health supports the ERGs and manages the overall process.
 NSFs implemented so far include
o Long-term conditions (due end 2004)
o Older people (March 2001)
o Coronary Heart Disease (March 2000)
o Mental Health (1999)
o Diabetes (1999)

Evidence-Based Medicine (EBM)

 The most common definition of EBM is "the conscientious, explicit and judicious use of current
best evidence in making decisions about the care of the individual patient. It means integrating
individual clinical expertise with the best available external clinical evidence from systematic
research." (Sackett, D.)
 The steps involved in EBM are:
o A clinical problem arises out of the care of a patient
o Construct a well defined clinical question from the case
o Conduct a search using the most appropriate resources
o Appraise that evidence for its validity (i.e. closeness to the truth) and applicability (i.e.
usefulness in clinical practice
o Integrate that evidence with clinical practice & patient preferences and apply it to practice
o Evaluate your performance with the patient

Opponents of EBM
EBM is "old hat". Clinicians have been using the literature to guide their decisions for a long time. The label is
new.

EBM is "cook book medicine". It suggests that decisions are based solely on the evidence, down playing sound
clinical judgement.

EBM is the mindless application of population studies to the treatment of the individual. It takes the results of
studies of large groups of people and tries to apply them to individuals who may have unique circumstances or
characteristics, not found in the study groups.

Often there is no randomised controlled trial or "gold standard" in the literature to address the clinical question.

There is often great difficulty in getting access to the evidence and in conducting effective searches to identify the
best evidence.

Proponents of EBM

The new focus on EBM "formalises" that "old hat" process and filters the literature so that decisions are made
based on "strong" evidence.

EBM should be one part of the process. Decisions must be blended with individual clinical expertise, patient
preferences and when available good evidence.

The last step in the EBM process is to decide whether or not the information and results are applicable to your
patient and to discuss the results with the patient.

Clinicians might consider the "evidence pyramid" and look for the next best level of evidence. Clinicians need to
understand that there may be no good evidence to support clinical judgement.

Librarians can help identify the best resources and teach clinicians effective searching skills.

Published Books

*1000 EMQs in Trauma and Orthopaedic Surgery

Turning point in FRCS(Tr & Orth) Part I Examination
(ISBN:978-0-9558458-0-2, £32)
*'Cross-Bridges'
FRCS(Tr & Orth) Part II Examination
How to get slick in the clinicals
(ISBN:978-0-9558458-2-6, £40)

*'Cross-Bridges'
FRCS(Tr & Orth) Part II Examination
Drawings & Classifications
(ISBN:978-0-9558458-1-9, £32)
*'Slippery Slope'
FRCS(Tr & Orth) Part I Mock Examination Papers
(ISBN:978-0-9558458-3-3, £32)

Forthcoming publications

*'Cross-Bridges'
FRCS(Tr & Orth) Part II Examination
How to get slick in the vivas
(ISBN:978-0-9558458-4-0)