Autotransfusion drains in total knee replacement. Are they alternatives to homologous transfusion?

We prospectively randomised 104 consecutive patients undergoing primary cemented total knee arthroplasty into two groups of 52 patients each, with one group to receive a standard suction drain (Redivac) and the other, an autologous transfusion drain (Bellovac). Randomisation was achieved using the software programme MINIM: , which was set to randomly allocate patients to either of the two groups based on their age, sex and body mass index (BMI). All procedures were performed under pneumatic tourniquet. Drains were released in the recovery room 20 min after surgery and removed 24 h following surgery. Blood collected in the standard suction drain (control group) was discarded, while blood collected in the autologous transfusion drains (study group) was transfused unwashed back to the patient within 6 h of collection. Thirteen patients (25%) in the study group had two or more units of homologous blood transfused in addition to the blood collected postoperatively and re-transfused (average: 438 ml). Twelve patients (23%) in the control group had two or more units of homologous blood transfused. No sepsis, transfusion reactions or coagulopathies were associated with the autologous blood transfused in the study group. The use of the autologous transfusion system (Bellovac) proved to be safe but failed to reduce the need for postoperative homologous blood transfusion following uncomplicated total knee arthroplasty.

Retraining: Can do, will do? A practical guide to process and pitfalls

This article reports the lessons learnt from a period of retraining and from discussion with others who have been involved in a similar process. The conclusions are that retraining should only be undertaken once there is full agreement between all parties involved that it is necessary and feasible. There must also be agreement in advance of the criteria which will constitute successful retraining, and the actions which will be taken to ensure the rapid return of the retrainee to the type of practice which is being offered and has been accepted. The process of retraining requires especially close supervision and is very stressful for the retrainee. It is likely that this should only be undertaken in units specially staffed and funded to accommodate this type of work.

Assessment at the end of training — a necessity or a nuisance?

If the public are to be assured that surgeons are safe, then there must be some form of competence assessment on which a licence to practice is based. However, the assessment and the licence needs to be both appropriate to the training received by the surgeon and to the requirements of the post they propose to take up. The 'key-concept' described in this paper attempts to address this problem.

Selecting the best from the rest

The current method for selecting surgeons of the future is neither objective nor relevant to present day needs. An assessment is needed which ranks potential trainees according to aptitude, motivation and diligence, all of which is validated. This task should be a core duty for the Royal Colleges of Surgeons working in close co-operation with surgical specialty associations.

A randomised controlled trial comparing two methods of teaching medical students trauma and orthopaedics: traditional lectures versus the “donut round”

OBJECTIVE

To assess whether a new form of teaching, the 'donut round', is as good at imparting factual knowledge as interactive lectures in both the short-term and the long-term.

DESIGN

Randomised controlled trial.

SETTING

University of Oxford Medical School.

PARTICIPANTS

106 fifth year clinical medical students taught half of their A&E/trauma course by donut round and half by lecture.

MAIN OUTCOME MEASURES

The results of multiple choice questions (MCQs) divided according to how the material was taught. Three MCQ papers were set: one at the end of a four-week course, one approximately 10 weeks later and a final exam approximately 17 months after the first.

RESULTS

At the first MCQ, the average result for questions taught by donut round was 41.0 (out of 50) and for those taught by conventional lecture was 40.1. At 10 weeks these averages fell to 36.3 and 37.3 and at 17 months they were 38.7 and 38.1, respectively. None of these pairs were significantly different. Ratios were calculated for each candidate by dividing their donut round score by their lecture score. The average ratios for the first, second and third MCQ papers were: 1.029, 1.007 and 1.027, respectively, and were not significantly different. The individual ratios of all candidates in all three MCQs were plotted against their equivalent total mark. The calculated linear regression showed a statistically significant advantage of donut rounds over lectures in those candidates who scored a total mark less than 89 (n=260, p=0.02).

CONCLUSIONS

Donut rounds are at least as good as lectures in imparting factual knowledge and may provide a selective advantage to weaker students.

Training teachers--changing practice?

A three-day course was designed to improve the skills of those who provide clinical training to medical students. This long-term follow up of past participants shows a sustained improvement to their skills, especially in terms of involving students in their own learning, and giving them positive feedback.

Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study

OBJECTIVES

To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning.

DESIGN

Interrupted time series analysis of presentations for self poisoning at accident and emergency departments during three week periods before and after the broadcast. Questionnaire responses collected from self poisoning patients during the same periods.

SETTING

49 accident and emergency departments and psychiatric services in United Kingdom collected incidence data; 25 services collected questionnaire data.

SUBJECTS

4403 self poisoning patients; questionnaires completed for 1047.

MAIN OUTCOME MEASURES

Change in presentation rates for self poisoning in the three weeks after the broadcast compared with the three weeks before, use of paracetamol and other drugs for self poisoning, and the nature of overdoses in viewers of the broadcast compared with non-viewers.

RESULTS

Presentations for self poisoning increased by 17% (95% confidence interval 7% to 28%) in the week after the broadcast and by 9% (0 to 19%) in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty two patients who presented in the week after the broadcast and were interviewed had seen the episode-20% said that it had influenced their decision to take an overdose, and 17% said it had influenced their choice of drug. The use of paracetamol for overdose doubled among viewers of Casualty after the episode (rise of 106%; 28% to 232%).

CONCLUSIONS

Broadcast of popular television dramas depicting self poisoning may have a short term influence in terms of increases in hospital presentation for overdose and changes in the choice of drug taken. This raises serious questions about the advisability of the media portraying suicidal behaviour.

The role of MRI in the diagnosis of occult hip fractures

Undisplaced fractures of the hip can occasionally be difficult to diagnose on radiographs. We performed MRI scans on 33 patients who had post-traumatic painful hips but negative radiographs. Forty per cent of the patients had sustained a fractured neck of femur, 15 per cent had sustained an intertrochanteric fracture and 11 per cent had sustained other fractures around the hip; in one patient a tumour was demonstrated. No fracture was seen in 30 per cent of the patients scanned. MRI is well tolerated by elderly patients in pain, does not involve ionising radiation and provides early and accurate diagnosis in patients with X-ray negative post-traumatic hip pain.

Total hip replacement: the way forward

Images

Why do doctors find some patients difficult to help?

Almost all doctors encounter difficulties in managing some patients. Previous studies have examined the characteristics of such patients: we have additionally studied the reasons why hospital doctors find these patients 'difficult to help'. Three clinics (two medical and one surgical) were studied. The consultants rated 60 (22%) of 293 attenders s severely or extremely difficult to help. Difficulty was associated with greater patient distress (odds ratio 3.9; 95% CI 2.0-7.7), less patient satisfaction (2.6; 1.3-5.0) and chronic attendance (5.0; 1.4-17.3). An interview study of 40 'difficult' patients indicated that doctors considered psycho-social factors more important in difficult patients (3.2; 1.3-7.7). Objective differences between the doctor's and the patient's aims for care also occurred more frequently for difficult patients (2.8; 1.1-7.2). Three common types of difficulty were identified; medically unexplained symptoms; co-existing social problems; and severe untreatable illness. A review of the management aims for patients whom doctors find 'difficult to help', combined with improved access to psycho-social care, could improve both the quality and the cost-effectiveness of hospital out-patient services.

Survival analysis of joint replacements

Survival analysis is a powerful tool for analysing the results of total joint replacement, but it has major drawbacks when the failure rates are very low. We have reviewed 35 recent survival analyses of joint replacements to assess the magnitude of these problems and make recommendations as to how they may be avoided.

Elective total hip replacement: incidence, emergency readmission rate, and postoperative mortality

OBJECTIVES

To report the incidence of elective total hip replacement and postoperative mortality, emergency readmission rates, and the demographic factors associated with these rates in a large defined population.

DESIGN

Analysis of linked, routine abstracts of hospital inpatient records and death certificates.

SETTING

10 hospitals in six districts in Oxford Regional Health Authority covered by the Oxford record linkage study.

SUBJECTS

Records for 11,607 total hip replacements performed electively in 1976-85.

MAIN OUTCOME MEASURES

Incidence of operation, postoperative mortality, relative mortality ratios, and incidence of emergency readmission.

RESULTS

NHS operation rates increased over time from 43 to 58 operations/100,000 population. Variation in operation rates between districts reduced over time. Operation rates were on average 25% higher in women than men. There were 93 deaths (11/1000 operations) within 90 days of the operation and 208 emergency readmissions (28/1000 operations) within 28 days of discharge. Postoperative mortality and emergency readmission rates increased with age. No significant trend with time was found. Mortality in the 90 days after the operation was 2.5-fold higher (1.9 to 3.0) than in the rest of the first postoperative year. This represented an estimated excess of 6.5 (4.2 to 8.8) early postoperative deaths/1000 operations. Most deaths were ascribed to cardiovascular events. Thromboembolic disease was the commonest reason for emergency readmission.

CONCLUSIONS

The pronounced increase in operations in districts with initially low rates suggests a trend towards greater equity in the local provision of NHS hip arthroplasty. The early postoperative clusters of deaths attributed to cardiovascular disease and of readmissions for thromboembolic disease suggest that there is scope for investigating ways of reducing the incidence of major adverse postoperative events.

Percutaneous nucleotomy. An anatomic study of the risks of root injury

Fifteen cadaveric dissections have been performed to determine the anatomic relationships of nucleotomy guide wires. All the 44 guide wires inserted were found to be in contact with at least one nerve root (eight transfixed a root). Guide wires passing anterior to the nerve roots always passed anterior to the center of the disc. Lateral displacement of the skin entry point made safe entry to the center of the disc impossible. Nerve root transfixion is likely to be a significant complication in percutaneous nucleotomy. Entry to the center of the disc avoiding the nerve roots is simplest if the skin entry is as near to the midline as possible.

Avoidable causes of cancellation in elective orthopaedic surgery

As part of an audit of clinical practice in an orthopaedic unit for elective surgery, a study was made of the causes of cancellation of operations. Despite careful liaison with general practitioners, and a booked admission policy, over 6% of patients were cancelled as unsuitable. The results of this study suggest that the number of cancellations on medical grounds would be reduced by closer liaison with general practitioners, and the establishment of preadmission clinics. Ensuring that only consultants book patients for surgery would also reduce the number of cancellations due to incorrect indications for surgery.

Osteotomy for osteoarthritis of the hip. A survivorship analysis

We have reviewed 368 osteotomies carried out for osteoarthritis of the hip at the Nuffield Orthopaedic Centre. Survivorship analysis showed that 10 years after osteotomy 47% had required no further surgery, and even after 20 years 23% had still not had a hip replacement. Hips with moderate arthritic change showed significantly better results than those with more severe degeneration. Osteotomies with varus angulation as well as medial displacement showed longer survival.

What happens to wild animals with broken bones?

Orthopaedic teaching suggests that long-bone fractures in wild animals are not uncommon and that they can heal naturally. This paper investigates this statement. The unsystematic collection of specimens for museums has perpetuated the idea that these fractures are not uncommon. Many fractures in adult skeletons seem to have occurred while the animal was still young. A review of the original skeletons in two museums does not support the view that major long-bone fractures in adult wild animals heal well. Contemporary observations on primates in the wild over long periods show that fractures of long bones in adult wild primates are rare and usually fatal, while falls which might be associated with juvenile fractures are much more common and may well be the source of the many well-healed fractures found in museum collections.

Polylactate-coated carbon fiber in extra-articular reconstruction of the unstable knee

Fascia lata and carbon fiber were used in identical operations for the correction of a clearly defined knee instability in cases with a follow-up period of about one year. The early results suggest an improvement of the results in the carbon group, but free carbon has been found within the joint despite careful extra-articular implantation. The long-term consequences of this await evaluation.

Pseudo-malignant osseous tumour of soft tissue

A case of pseudo-malignant osseous tumour of soft tissue in the hand is described. The history was over two years with intractable pain becoming the dominant symptom. There was no history of trauma or infection initiating the condition. Local amputation provided complete relief of symptoms and there has been no recurrence in two years.