Open Access

Table A1

EXOGEN device suitability screening tool to be used to assess patient suitability prior to commencing EXOGEN and assessing for successful completion post-treatment.

EXOGEN® ultrasound bone healing system used for the management of long bone non union fractures
Patient NHS No. Trust: GP Name:
Patient Hospital Number: Consultant Making Request: GP code/Practice code:
Patient initials
Date of birth // GP Post code:
Please confirm the following
The patient is over 18 years old. Yes No
  • The patient has a non-union fracture or arthrodesis for > 9 months

  • The bones are well aligned, stable and the inter-fragment gap is < 10 mm.

  • Date of fracture // and type and location of long bone fracture

Yes No
  • The patient has been screened and referred by a Consultant Radiologist/Consultant Orthopaedic Surgeon following review on at least two occasions at least 4 weeks apart to allow examination of serial X-rays.

  • The patient has received a further assessment in a non-union clinic by surgeon with expertise of dealing with non-union of long bones; appropriateness of EXOGEN® has been determined through agreement of two specialist non-union Consultants.

Yes No
  • The patient has been counselled and has the ability to comply with usage protocol and criteria in line with the EXOGEN International* Performance Program which includes a 90% minimum adherence to the treatment regimen for minimum of 120 days

  • The patient is registered on the EXOGEN International* Performance Program.

    Purchaser Code

Yes No
For treatment failures, the provider will ensure that a reimbursement is obtained in accordance with the manufacturers “money back guarantee” arrangement; the CCG will not fund these patients.
I confirm that the patient meets the criteria for treatment I confirm that the patient meets the criteria for treatment
Name of consultant: Signature (or email confirmation) by Department Service Manager (or nominated deputy)
Signature: Name:
Date: // Signature: Date: //
Section below to be submitted on completion of treatment
Treatment was successful Yes No
If no, seek reimbursement from the manufacturer Cost of EXOGEN® claimed £
Time to heal/fail (weeks)  Date final assessment //
I confirm that the patient meets the criteria for treatment I confirm that the patient meets the criteria for treatment
Name of consultant: Signature (or email confirmation) by Department Service Manager (or nominated deputy)
Signature: Name:
Date: // Signature: Date: //

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