Day case surgery is commonplace in the field of orthopaedic surgery, being suitable for a wide range of both trauma &
elective procedures. It became apparent within our unit that an unacceptably high number of cases were being cancelled for a variety of reasons. We set out to identify these reasons and thereby develop a simple screening process to reduce the number of cancellations. Initial audit over a 1 year period showed 25% of the 907 day case patients were being cancelled. We subdivided the reasons for these cancellations at both pre-operative assessment and on the day of surgery into avoidable [e.g. no carer / telephone, uncontrolled BP, high BMI and ischaemic heart disease] and unavoidable [e.g. surgery no longer required, patient unwell, list cancelled for emergencies, patient DNA]. The majority of our cancellations fell into the “avoidable” category, predominantly at pre-operative assessment. Accordingly, we devised a simple screening questionnaire to be used by clinicians in out-patients at the time of listing for surgery, based on the RCS guidelines (1985). If any of the questions were answered “Yes”, the patient was not suitable for day case surgery. The patient information letter was also changed, informing patients that non-attendance would result in their removal from the waiting list. Re-audit of 727 patients over the next 12 months showed a fall in cancellations to only 11%, with the majority of these being for unavoidable reasons. Cancellations are a source of inconvenience, distress and frustration to both clinician and patient, are a waste of hospital time and resources, and lead to an increase in waiting lists. Our study demonstrates the value of closing the loop in audit, leading to a dramatic reduction in cancellations. Audit is a useful tool to improve patient care, and is not merely a “number-crunching” exercise.
Total knee arthroplasty is sometimes associated with excessive bleeding necessitating blood transfusion. Transfusion is associated with risk of disease transmission and immunological burden to the recipient.
We present the mid term results of 267, 3M Capital hip replacement performed in a single institution from 1991 to 1994. Patients were recalled back to clinic in April 1998 after the reported high failure rate of 3M hips. Fifty- nine hips were excluded from this study for various reasons. Average follow-up was 68.8 months. Nine (4.2%) have been revised for aseptic loosening at the time of review and further 10(4.8%) of the stems are radiologically loose. There was no statistical significant difference between hips that failed, regarding grade of the operating surgeon, surgical approach: trochanteric osteotomy or Hardinge, or type of prosthesis used: monoblock (stainless steel) or modular (titanium). Acetabular wear rate, width of medial cement mantle or cancellous bone at level of neck at Gruen zone7, or stems with canal fill index less than 50%, 7 cm below the level of the collar also showed no statistical difference. Male patients had higher incidence of loosening (p=0.001) which was statistically significant. Both varus and valgus alignment of the stem had higher failure rate which was significant. We could no find any obvious reason for failure in 10 of the 18 patients. The stem was either in varus or there was an inadequate cement mantle in 8 of the failed hips on the initial postoperative radiograph. A feature of this study was high incidence of endosteolysis and debonding of prosthesis from cement in the failed cases. The present series showed considerably lower revision and loosening rate of 3M stems compared to the published series, the reason for which is not clear. Only Palacos cement was used in this series, which may partly account for the lower failure rate. Surface finish of the stem leading to debonding of the prosthesis from cement along with different modulus of elasticity probably accounts for the higher rate. Technical failure is partly to blame for the higher failure rate.
