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Background Virtual clinics have been shown to be safe and cost-effective in many specialties, yet barriers exist to their implementation in orthopaedics. Ankle fractures are common and therefore represent a significant clinical workload. The aim of this study was to evaluate the management of radiographically stable Weber B ankle fractures using a standardised treatment protocol in a virtual fracture clinic setting, to assess clinical outcomes, any complications and its cost effectiveness. Methods All patients referred to the VFC with an actual or suspected stable Weber B ankle fracture between September 2013 and September 2015 were identified. The primary outcome measure was successful fracture union. Any complications were noted and a cost analysis comparing the VFC and traditional fracture clinic models was undertaken. Results 314 patients referred with a radiographically stable Weber B ankle fracture were identified. Follow up was complete for 98.4% (309/314) of patients. The union rate was 99.4% (307/309) in patients where follow up was completed. 3.5% (11/309) of patients were underwent acute surgical intervention. Of these patients, 6 were identified as having an unstable injury on weight bearing radiographs at 2 weeks and underwent ORIF, 4 were identified as having an unstable injury on EUA and underwent ORIF and 1 had an EUA with no fixation. 2 patients required ORIF for radiographically confirmed non-union. A cost saving analysis comparing the traditional fracture clinic model and VFC model revealed a saving of £237 per patient (32% reduction) with a VFC model. This represents an estimated saving of almost £40,000 per year for the management of this injury alone in our institution. Conclusion Our study supports the use of a virtual fracture clinic model that is standardised, initiated in ED, and is both safe and cost-effective in the management of radiographically stable Weber B ankle fractures. Level of evidence Level III–Retrospective Cohort Study.

Objectives To report the early surgical outcome, risk of failure and predictive value of rhegmatogenous retinal detachment (RRD) classification based on all participants in the Scottish Retinal Detachment study. Methods Over 2 years, all incident cases of RRD in Scotland were approached for recruitment. Early postoperative success was defined as an attached retina following one procedure with a minimum follow-up of 6–8 weeks. Using a regression model, the influence of clinical factors on the failure risk was estimated and the sensitivity and specificity of the Royal College of Ophthalmologists (RCOphth) grading for RRD and the vitrectomy in retinal detachment stratification risk formula (VR-SRF) in predicting operative failure were assessed. Results Primary outcome data were available for 86.2% (975/1130) of patients. The overall primary success rate was 80.8% (95% CI 78.1 to 83.3%). The presence of preoperative proliferative vitreoretinopathy of any degree and each additional clock hour of detachment increased the risk of failure by an OR of 2.4 and 1.13 respectively (p 95% in predicting early surgical failure was noted for highly complex RRDs according to the VR-SRF formula and the RCOphth classification. Conclusions Consistent with previous series, the overall early success rate of RRD repair was 80% after one operation. The type of surgical repair did not influence overall success rates. Significant predictors of failure are the presence of preoperative proliferative vitreoretinopathy of any grade and the extent of detachment. The analytical value of current classification systems in predicting failure is most useful in complex RRDs.

Objectives To assess the effectiveness of combined ultrasound and biochemical (CUB) screening for chromosome abnormalities in singleton pregnancies in a routine antenatal clinic and laboratory setting. Methods Women whose pregnancies fell within the gestational age range of 11 to 14 weeks by ultrasound assessment were offered CUB screening on the basis of measurement of nuchal translucency (NT), maternal serum free beta-human chorionic gonadotrophin (FβhCG) and pregnancy-associated plasma protein A (PAPP-A). NT measurements were obtained using a standardised method defined by the Fetal Medicine Foundation and FβhCG, and PAPP-A were measured using the DELFIA immunoassay system. Each screening marker measurement was converted to a multiple of the appropriate gestational median and a risk was derived using previously published parameters for each marker in chromosomally abnormal and unaffected pregnancies. A combined risk of Down syndrome and of trisomy 18/13, incorporating the maternal age risk, was calculated for all women. Invasive diagnostic testing was offered to women whose combined risk exceeded the cut-off risk of 1 in 250 (term). Results Five thousand and eighty-four women accepted a first-trimester screening test for Down syndrome, representing 75% of the eligible booking population. Out of the population eligible for CUB screening at the time of booking, NT measurements were obtained from 93% at the first clinic visit and 7% had to return for a second attempt. After excluding women who defaulted on a return visit, satisfactory NT measurements were obtained in 99.5% of pregnancies. Fifteen cases of Down syndrome and eleven pregnancies with other chromosome abnormalities were ascertained. The detection rate for Down syndrome was 93% (14/15) at a false-positive rate of 5.9% and for all chromosome abnormalities it was 96% (25/26) at an overall false-positive rate of 6.3%. Conclusions CUB screening offers a significant improvement in sensitivity over second-trimester biochemical screening and is deliverable within a routine prenatal clinical setting. Copyright © 2004 John Wiley & Sons, Ltd.

Neck pain is a common presenting complaint, but the precise patho-aetiology is often unclear. Broadly speaking, the cause of neck pain can be considered as degenerative or non-degenerative (Table 1). While detailing the important non-degenerative causes the clinician should not miss, this article reviews the diagnosis and management of the common degenerative orthopaedic causes of neck pain.

Objectives: Nuchal translucency is known to be a sonographic marker of autosomal trisomy. First trimester screening for Down’s syndrome has been offered routinely since August 2000 in the Queen Mother’s Hospital. The screening programme involves measurement of maternal serum for free bhCG and PAPP-A and nuchal translucency (NT) between 11–14 weeks of gestation. Nuchal translucency is known to be a sonographic marker of autosomal trisomy. Nuchal translucency measurements need to be precise, accurate and reproducible when being used as part of a screening programme. A system of audit is therefore required to ensure that the operators carrying out these measurements are doing so to appropriate standards. Methods: A hard copy thermal image was saved from each nuchal translucency measurement taken. A scoring system was used to score the images. 10 random images from each operator were reviewed each month and scored by an independent assessor. In addition individual NT MOM (multiple of median) values were compared statistically. Scores were given to each operator for inter-operator agreement of the 95% and 99% confidence intervals. These scores and those from the assessment of images were combined to give results, which were given to each operator along with comments on how to improve the images. Results: Changes in the measurement of NT were assessed over a four-month period using the Mann-Whitney test for comparisons between groups of two operators. There was a significant difference between operator 1 and operator 2 in the first month (p = 0.001) but by the fourth month there was no significant difference (p = 0.858). Conclusions: The quality control cycle aids the improvement of NT images and reduces inter-operator variation.

The stress distribution in cylindrical web panels of horizontally curved girders subjected to an applied moment is studied analytically. Both the membrane state of stress in the plane of the web and the web bending stresses resulting from the curvature of the panel are considered. A simplified mathematical model which treats the web as a series of curved strips (arches) is used. Solutions for this model are obtained using the Rayleigh-Ritz method. The influence of curvature on the resulting stresses in curved webs is presented. Recommendations for the allowable bending stresses in curved beams expressed in terms of the web depth-to-thickness ratio as well as limiting web slenderness ratios are established.

Background: Modified Marshall criteria used for PFAPA syndrome have never been validated and are little used by the experts because the symptoms of monogenic fevers often overlap with PFAPA ones. A new set of classification criteria based on an international survey and a consensus conference in Genoa was developed in 2018. Objectives: Evaluate the performance of the new criteria in a real-life setting Methods: This is a multicentric, prospective and descriptive cohort study, through the recurrent fever module of the JIRcohorte platform. 417 patients diagnosed with PFAPA (187), monogenic fever syndromes (167) or unclassified recurrent fever syndrome (UPF=63) from Swiss and French centers were enrolled in the study. The new classification criteria were applied to this cohort and we calculated their performance. We then analyzed which of the criteria performed the less well. Results: One hundred fourteen from 187 (61%) PFAPA patients met the new criteria, as well as 20/230 non-PFAPA patients (FMF: 3, MKD: 4, UPF: 13); 73 PFAPA patients did not meet the criteria. We calculated a specificity of 91.3% and a sensitivity of 60.9%. The least satisfied criterion among PFAPA patients not meeting the criteria was “absence of skin rash”. By removing this criterion, the sensitivity improved (81.2%), but the specificity decreased slightly to 86%. Conclusion: Genoa 2017 classification criteria for PFAPA syndrome showed a good specificity but an insufficient sensitivity. Excluding the less satisfied criterion, the set reaches a sensitivity and specificity around 80% which could be a fair compromise for PFAPA classification criteria. Our study highlights the difficulty in establishing classification criteria due to the lack of gold standard for PFAPA diagnosis. References [1] Vanoni F, Federici S, Anton J, Barron K, Brogan P, De Benedetti F, Dedeoglu F, Demirkaya E, Hentgen V, Kallinich T, Laxer R, Russo R, Toplak N, Uziel Y, Martini A, Ruperto N, Gattorno M, Hofer M. An international Delphi survey for the definition of the variables for the development of new classification criteria for Periodic Fever Aphthous stomatitis Pharyngitis Cervical Adenitis (PFAPA). Pediatr Rheumatol Online J. 2018, 16(1):27. Disclosure of Interests: Fabio Crimi: None declared, Manel Mejbri: None declared, Veronique Hentgen Consultant for: SOBI, Novartis, Abbvie, Speakers bureau: Novartis, Glory Dingulu: None declared, Isabelle Kone-Paut Grant/research support from: SOBI has supported drug product (anakinra) for the presented study, Consultant for: SOBI, Novartis, Pfizer, Abbvie, UCB, CHUGAI, ROCHE, Sophie Georgin-Lavialle Consultant for: novartis, sobi, Speakers bureau: novartis, sobi, Pascal Pillet: None declared, michael hofer Grant/research support from: novartis, SOBI, Consultant for: Novartis, SOBI