Abstract

Aim: To reduce the amount of blood wastage in our unit.

Method: In 72 patients, the number of blood units cross-matched and the haemoglobin/haematocrit fall were audited for primary total shoulder replacement (n=44), primary hemiarthroplasty (n=21), and revision shoulder replacement (n=7) over twelve months (January 2008 to December 2008). The amount of crossmatched blood was compared to the amount of blood transfused, pre-operative haemoglobin and fall in haemoglobin/haematocrit.

Results: 23 of 44 primary total shoulder replacements and 5 of 21 hemiarthroplasties were crossmatched 55 units preoperatively. 4 of the 7 revision arthroplasties were crossmatched 7 units preoperatively. No units were transfused. 4 patients were later transfused 2 units each for symptomatic low haemoglobin at day 3–5 postoperatively from postoperatively crossmatched blood. No correlation existed between preoperative haemoglobin and number of units blood ordered. A haemoglobin reduction of ~2.5 g/dl was seen for both primary and revision surgery. There was significant correlation between low preoperative haemoglobin and need for transfusion (p< 0.05). Nearly all patients in whom blood was crossmatched rather than group and saved, belonged to one consultant. No patients had an adverse outcome due to a lack of immediately available cross-matched blood.

Conclusion: A large amount of blood was crossmatched and no units used in primary and revision shoulder replacement surgery. We recommend group and save only in primary shoulder arthroplasty and crossmatch of 2 units for revision shoulder surgery. Providing pre-operative haemoglobin is > 11.5 g/dl, group and save is safe even for revision shoulder arthroplasty. Wastage of blood could be reduced to zero in our unit. We recommend regular audit as a tool to ensure compliance with guidelines, and for clinical governance purposes ensuring guidelines remain best practice.

Individuals learn to master new motor skills (such as learning a new surgical technique) by evaluating available feedback to alter future performance. Continuous concurrent augmented feedback is supplementary information presented to the learner throughout the performance of a task. An example of this type of feedback is the visual information provided by computer navigation during arthroplasty surgery. This type of feedback is a potentially powerful tool for learning because it theoretically guides the learner to the correct response, reduces errors, and reinforces correct actions. However, motor learning theory suggests that this type of feedback may impair learning because of development of dependence on the additional feedback or distraction from intrinsic feedback. In the current era of reduced number of training hours it is essential to assess the role of computer navigation on trainees.

Our objective was to determine whether computer navigation influences the learning curve of novices performing hip resurfacing arthroplasty. We conducted a systematic review and critical appraisal of the literature. There is some evidence from randomised controlled trials that navigation use by trainees facilitates accurate placement of arthroplasty components compared to conventional instrumentation. There is no evidence that training with computer navigation impairs performance in retention tests (re-testing on same task after an interval of time) or transfer tests (re-testing in different conditions i.e. without concurrent feedback).

We conclude that although there are significant limitations of the published literature on this topic there is no available evidence that supports concerns regarding the theoretical detrimental effects of computer navigation on the learning curve of arthroplasty trainees.