Shared learning database

Maidstone and Tunbridge Wells NHS Trust
Published date:
January 2014

Implementation of the EXOGEN ultrasound bone healing system into the management of patients with delayed unions and non unions.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To introduce the EXOGEN ultrasound bone healing system into the management of patients with delayed unions and non unions.

Reasons for implementing your project

Bone fractures are very common with their calculated incidence in England being 3.6 fractures per 100 people per year. Hospital Episode Statistic data reveal that in 2012-2013 Accident and Emergency Services referred 727.698 patients to the fracture clinic. Non-union is a recognised complication of fracture and can occur in 5 - 10% of the patients.
Before the broad use of the EXOGEN ultrasound bone healing system, patients with non-unions had to go through surgery - often more than once. Bone grafts had to be taken from the patient frequently or alternatively expensive bone substitutes or allografts had to be used. EXOGEN is a portable device used by patients at home. It is a non-invasive self- administered treatment, which delivers low-intensity pulsed ultrasound when applied on the skin over the fracture. The duration of each treatment is 20 minutes.
Implementing the NICE guidance in relation to EXOGEN benefited our Trust financially and aided in the provision of better - high quality care to our patients. More specifically, the trust cut down on the costs of expensive surgery, theatre time, hospital stay and the use of bone substitutes. Most importantly patients avoided unnecessary operations with all their potential risks and complications.

How did you implement the project

We named a lead clinician. Initially funding requests were made on a case by case basis to the Primary Care Trust in line with the NICE guidelines. Once the benefits of EXOGEN became more obvious an agreement was reached with a limited number of patients allowed to be treated for the financial year. This covered about 50% of the total number needed during the year. Despite the obvious patient benefits and economical advantages to the NHS we still have to request funding for every case beyond the agreed number, adding to the overall bureaucracy and loosing some of the financial benefits for the NHS as an organisation. All patients are followed up until the end of the treatment cycle and the state of bone healing is critically assessed and recorded.

Key findings

Between July 2012 and September 2013, 43 patients received EXOGEN treatment in our institution. 1 patient subsequently died and 2 were lost to follow up and excluded. The final outcome for 7 patients is still pending. Out of the remaining 31 patients 24 (77%) have achieved union of their fractures and 7 (23%) have not. Union has been assessed both clinically and radiologically. More specifically, the patients were periodically examined for pain, tenderness and range of motion and assessed with radiographs and frequently with a CT - scan in order to confirm fracture healing.
Out of the 24 patients that reached union 8 female and 16 male. Their average age was 52.9 years (range 22 - 78 years). 14 out of these 24 patients had already a previous operation in order to achieve union. Out of the 7 patients that have not reached union 3 female and 4 male. Their average age was 42.5 years (range 18 - 87 years). 6 out of these 7 patients had already one operation in order to achieve union. The results certainly met our expectations as 77% of the patients avoided operative management with all the associated peri and post operative risks.
The Hospital Episode Statistic Data for the period 2010-2011 indicate that 88 patients were treated surgically for fracture non - union. Their average length of stay was 4.49 days, representing a total of 280 bed days. The average required operating time was 3 hours, representing 243 hours of theatre capacity. Taking into consideration the length of stay and theatre time and deducting the cost of EXOGEN the calculated financial benefit for the Trust is approximately £1164.00 per patient. This calculation does not take into consideration fracture clinic appointments and radiographs that are certainly more frequent with operative management of fracture non-unions, as well as the cost of managing any complications as a result of surgery.

Key learning points

Use of the EXOGEN system is something new both for patients and clinicians and relevant education is required. Orthopaedic surgeons together with managers have to look into this option, read the supporting literature and be prepared to use it for their patients. Also the local population has to be informed about this option, its benefit on avoiding unnecessary major operations and prolonged hospital stay. Finally, NHS Commissioners have to facilitate this effort which results in both financial benefits and better quality of care.

Contact details

Andreas Leonidou
Trauma and Orthopaedic Registrar - ST5
Maidstone and Tunbridge Wells NHS Trust

Secondary care
Is the example industry-sponsored in any way?