Time at the surgical ‘coal-face’ has been reduced by introduction of the European Working Time Directive (EWTD) significantly impacting training opportunity. Our null hypothesis was that duration of surgery is significantly longer if a trainee were performing the operation despite supervision or level of trainee experience. Cemented hip hemiarthroplasty was chosen as our index procedure as complexity is largely comparable between cases. 461 patients were identified on the hospital trauma database. Data were augmented by information regarding level of surgeon, assistant and time of surgery from the hospital theatre database. There was no significant difference in registrar and consultant operative times, mean time 69 and 72 minutes respectively. SHOs were significantly slower (mean 80 minutes, p=0.0006). Junior (ST5 or less) registrars were significantly slower (mean 81minutes, p=0.0002) whereas senior registrars were not. Supervision level had no effect on duration of senior registrar operations but when junior registrars were consultant supervised they were not significantly slower (mean 75 minutes, p=0.09). Supervised operating therefore reduces time variability and should be promoted within a climate of training. Increase in mean operative time in registrars and SHOs is insignificant within a day's operating and is unlikely to lead to cancellations of cases.
Early detection of Developmental Dysplasia of the Hip (DDH), and treatment, may prevent the need for surgical correction following late presentation. Neonatal examination, and ultrasound screening of at risk groups, does not detect all cases. Most neonates treated in the Intensive Care Unit (NICU) have abdominal radiographs performed during their stay. These include the hips but DDH is not routinely looked for. 50 neonatal abdominal films (five from patients who subsequently were found to have DDH, 45 from patients without this condition) were randomly shown to three paediatric orthopaedic surgeons and three paediatric radiologists on two separate occasions. Each was asked whether they would refer the patient for further investigation. An overall sensitivity of 25.5% (Range 0–60%) and specificity of 93.2% (Range 87–97%) was found with a positive predictive value (PPV) of 14.0% (Range 0–37%) and negative predictive value (NPV)of 96.3% (Range 95–98%). Although the low sensitivity and PPV make interpretation of these films a poor way to diagnose DDH, the high specificity and NPV suggest that they may be used as a prompt to further investigation. Therefore, we propose that DDH should be looked for on these films and, where there is radiological suspicion, ultrasound examination should be advised.
We carried out a comparison of the analgesic requirements, length of stay in hospital, complications and cost effectiveness of patients who had either a continuous disposable infusion pump or standard treatment for unicompartmental knee replacement. This study began as an audit. We completed the audit loop with a prospective study after implementing our recommendations. The device is a single use disposable elastometric pump, set immediately after surgery to deliver a continuous flow of 0.5% bupivacaine at a rate of 2mls per hour for 48 hrs into the knee joint via a fine catheter with a fenestrated tip. The case notes of all patients in the study were analysed to establish their total analgesic requirements for 48hrs following surgery. Complications and length of stay in hospital were recorded This has changed our clinical practice. Results of our study of 50 patients, 25 in each group (age and sex matched) confirmed that there was a significant reduction in opiate requirements after introduction of the pain pump. Length of stay in hospital was reduced from 5.7 to 3.9 days. Patients' requirements for NSAIDs were reduced. There were no significant complications in the pain pump group. The costs of the pump (£40) were offset by the reduction in analgesic requirements and shortened length of stay in hospital. We conclude this form of analgesia is safe, effective and cost effective. Our department has now changed to using the pump for all unicompartmental knee replacements.
Purpose We report the long term outcome of a minimally invasive technique avoiding the risks associated with open reduction and bone grafting in paediatric lateral condyle fracture non-unions. Methods The Toronto Hospital for Sick Children's radiology database was searched to isolate all those who sustained a lateral condyle elbow fracture and had developed a non-union between the years 1998 and 2008. This identified 16 patients who had undergone percutaneous fixation for the treatment of their non union. Each individuals clinical notes and radiographs were reviewed from presentation to final follow-up. Results Median age at injury was 5.1 (3.2, 7.2) in the successful and 2.8 (2.1, 4.7) in the unsuccessful groups (p=0.18). 11 patients (68.7%) had been initially managed non-operatively. Median time from injury to non-union diagnosis was 15.7 weeks in the successful, and 225.5 weeks in the unsuccessful group (p=0.039). Mean time to union post fixation was 16.2 weeks (+/- 6.74) and mean time to surgery was 5.2 weeks (+/- 4.11). Surgery was successful, defined as radiological and clinical union, in 12 of 16 patients (75%). 43.8% had metalwork removal and no cases of avascular necrosis were reported. Conclusion We have demonstrated this technique to be successful in those non-unions addressed within 16 weeks from initial injury to diagnosis. We had 4 failures, these occurred in patients whose non-unions were diagnosed more than 31 weeks from the time of injury (31; 68; 383; 427 weeks). Each of these failures had been managed non-operatively as part of their primary treatment plan. Percutaneous fixation is feasible and safe. Patients not achieving union were diagnosed significantly later. There was a trend towards successfully treated patients being younger.
There is little evidence from the literature regarding the timing of hip fracture surgery for patients who are on the antiplatelet agent clopidogrel bisulphate (Plavix) (1). We report the results of a retrospective case control study of 40 patients comparing the timing of surgery for patients taking clopidogrel against a control group of those not taking an antiplatelet agent. Time to surgery, length of stay, transfusion requirements, wound problems and other post operative complications were examined. Within the study group of patients taking clopidogrel, we also compared those who underwent surgery within four days of stopping the clopidogrel and after four days. The transfusion requirements were greater in those patients on clopidogrel prior to admission. Wound healing and post operative complications were similar between the two groups. Total length of hospital stay and post operative length of stay were longer in the clopidogrel group. There was an increase in transfusion requirements and post operative length of stay in patients on clopidogrel undergoing early surgery (within 4 days) compared to the group where surgery was delayed. We conclude that, in this small study, transfusion requirements and length of stay were greater in patients on clopidogrel. Transfusion requirements and post operative length of stay were also greater if surgery was performed within four days of omitting clopidogrel. Further studies are required to determine optimal timing of surgery following discontinuation of clopidogrel.
We have assessed the clinical and radiological outcome of traumatic knee injuries resulting in open reconstruction of the posterior cruciate ligament using synthetic ligaments at the University of Toronto, Ontario. Pre and post-operative stress radiographs at 30 and 90 degrees were performed, along with IKDC, Lysholm and Tegner scoring. Between 1995 and 2002, 11 patients were operated on. The average time to surgery was 42.3 months (range 1 to 252 months). The average age at time of surgery was 34.1 (26 – 48). The length of follow up ranged from 6 to 87 months. IKDC scoring showed that no patient returned to normal. 5 were nearly normal, 4 abnormal and 2 severely abnormal. The average Lysholm score was 83 (58 – 95). 2 scored excellent, 6 good, 2 fair and 1 poor. The average Tegner score pre-injury was 6.3, prior to surgery 1.8 and post-operatively 3.9 (twice weekly jogging). Stress radiographs showed a decrease in antero-posterior laxity at 30 and 90 degrees although statistical significance was not achieved (p = 0.229 and 0.474 respectively). We conclude that PCL reconstruction restores the normal biomechanics of the knee allowing a more normal function. The synthetic ligament allowed early weight bearing and range of movement mobilisation. The Tegner scores showed a considerable improvement from pre to post-operative values. The stress radiographs showed a decrease in the antero-posterior laxity. Although the IKDC scores did not show any normal knees post-operatively, this was expected due to the severity of the initial injuries. The authors recommend the use of synthetic ligaments to reconstruct the PCL.
