An Extended Scope Practitoner Physiotherapist (ESP) developed a problem shoulder clinic to support the physiotherapy management of patients with shoulder pathology across one healthcare trust. The impact of the clinic on the management of patients and their onward referral to a shoulder surgeon was evaluated. Physiotherapists had access to a problem shoulder clinic that was managed by an ESP with a special interest in shoulders. The clinic provided assessment and advice on the management of patients with shoulder pathology who were receiving physiotherapy treatment. Throughout a three-year period the opinion of the ESP was sought on 256 patients. 69 patients were seen in a face-to-face consultation, the remainder were diuscussed with their treating physiotherapist and advice was offered. 211 patients were managed and discharged through the physiotherapy service. The ESP referred 45 patients to the shoulder surgeon, of which 53% underwent surgery; 20% are awaiting investigations, 22% were managed with injection therapy and five per cent were discharged. The problem shoulder clinic was shown to be a valuable addition to the clinical mentoring system in physiotherapy. It proved to be an important gate-keeping mechanism between physiotherapy and consultant care as 82% of patients referred to the clinic were managed within physiotherapy. The clinic also proved to be an effective means of identifying patients requiring surgery. Of those that were referred to the shoulder surgeon only five per cent were discharged with no further intervention. A planned development as a consequence of this evaluation is a physiotherapy advocate for shoulders for each outlying hospital within the trust. The aim of this will be to strengthen communication links between the shoulder surgeon and physiotherapy departments over a wide geographic area and to facilitate prompt identification of patients in need of referral to the shoulder surgeon.

Introduction Blood loss and requirement for blood transfusion is a recognized and common complication of major joint replacement arthroplasty. In 2001, the authors began using an autologous blood transfusion (ABT) drainage system for total hip and knee arthroplasty. This paper illustrates changes in post-arthroplasty transfusion practice in a rural orthopaedic hospital.

Methods Retrospective review of all 289 patients undergoing 132 primary hip and 157 knee replacement arthroplasties in 2001 to 2002 was performed. ABT drainage was used in 187 patients (64%). Wound fluid collected during the first six post-operative hours was filtered by the ABT device and reinfused to the patient intravenously. The observational database was explored by general linear modeling to investigate whether using the reinfusion drain resulted in higher post-operative haemoglobin concentrations. Various multifactor models were explored, re-fitted and regressions diagnostics examined. A final model directed further prospective analysis.

Results Independent of all variables, post-operative haemoglobin was on average 0.3g/dl higher (p=0.0308) when ABT was used. Levels were significantly higher for knee compared with hip replacement (p=0.0083) and significantly higher by 0.55g/dl for uncemented compared to cemented/hybrid knee arthroplasty (p=0.0271). ABT reduced blood transfusion requirements from 46.5% to 22% following hip replacement and from 23.6% to 16.3% following knee replacement.

Conclusions Introduction of the ABT system resulted in significantly higher post-operative haemoglobin levels and decreased blood transfusion rates following hip and knee replacement arthroplasty. Uncemented component fixation further increased post-operative haemoglobin levels. The authors advise routine use of this system for joint replacement.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.