Assessing the performance and learning curve of orthopaedic surgical trainees in primary total hip arthroplasty.

INTRODUCTION: The aims of this study were threefold: first, to review the surgical performance of trainees in our departments by reviewing postoperative radiographs and operative times; second, to investigate the effect of supervision and assistant grade on postoperative radiographs and operative times; and third, to monitor trainees over a 6-month period looking for changes in postoperative radiograph appearances and operative times to assess whether these parameters reflect a trainee's learning curve. METHODS: A retrospective evaluation of a continuous series of primary hip arthroplasty procedures performed by 12 trainee orthopaedic surgeons (StR) during their arthroplasty rotation. In total, 348 primary total hip replacement (pTHR) operations were performed by StRs. Operative time, acetabular cup inclination, radiological leg length discrepancy (rLLD), femoral stem alignment (FSA) and the Barrack score for cementation were evaluated. The mean number of pTHRs performed per 6-month placement was 29 (range 15-51). Operative times were available for 292 cases and all postoperative imaging was evaluated. RESULTS: The mean operative time for StRs as first-surgeon was 84.3 minutes (range 42-174 minutes). Significant differences in operative times were observed between individual StRs. As a cohort, the operative times were not affected by the level of supervision but were significantly slower when StRs were assisted by other StRs. Significant differences in rLLD, FSA and Barrack score for cementation were observed across the cohort of StRs, although this did not change at a group or individual level between the first and second halves of the 6-month placement. CONCLUSIONS: Used in isolation, postoperative radiographs and operative time are not an effective measure of the learning curve in primary hip arthroplasty, however, they may be a useful adjunct in assessing the performance of orthopaedic trainees when learning primary hip arthroplasty.

The role of intra-operative cell salvage in patient blood management for revision hip arthroplasty: a prospective cohort study.

Cell salvage is an important component of blood management in patients undergoing revision hip arthroplasty surgery. However concerns regarding efficacy and patient selection remain. The aims of this study were to describe intra-operative blood loss, cell salvage re-infusion volumes and red blood cell transfusion rates for revision hip procedures and to identify factors associated with the ability to salvage sufficient blood intra-operatively to permit processing and re-infusion. Data were collected from a prospective cohort of 664 consecutive patients undergoing revision hip surgery at a single tertiary centre from 31 March 2015 to 1 April 2018. Indications for revision surgery were aseptic (n = 393 (59%)) fracture (n = 160 (24%)) and infection (n = 111 (17%)). Salvaged blood was processed and re-infused when blood loss exceeded 500 ml. Mean (SD) intra-operative blood loss was 1038 (778) ml across all procedures. Salvaged blood was re-infused in 505 of 664 (76%) patients. Mean (SD) re-infusion volume was 253 (169) ml. In total, 246 of 664 (37%) patients received an allogeneic red blood cell transfusion within 72 h of surgery. Patients undergoing femoral component revision only (OR (95%CI) 0.41 (0.23-0.73)) or acetabular component revision only (0.53 (0.32-0.87)) were less likely to generate sufficient blood salvage volume for re-infusion compared with revision of both components. Compared with aseptic indications, patients undergoing revision surgery for infection (1.87 (1.04-3.36)) or fracture (4.43 (2.30-8.55)) were more likely to generate sufficient blood salvage volume for re-infusion. Our data suggest that cell salvage is efficacious in this population. Cases where the indication is infection or fracture and where both femoral and acetabular components are to be revised should be prioritised.

Surgical management of the elderly elbow.

The elbow has a major role in helping with the positioning of the hand in space. Any pathology of the joint can result in pain, loss of function and difficulties with activities of daily living. With an increasingly elderly population the degenerative conditions affecting the elbow are becoming more prevalent. Besides traumatic injury, the more commonly encountered problems are osteoarthritis, inflammatory arthritis, nerve compression and stiffness. An awareness of these conditions is important for those who provide care to this patient group. Whilst many of these conditions can be managed conservatively in primary care, some patients are referred to secondary care and elect for surgical treatments. This review considers the surgical treatments for the common elbow pathologies in the elderly population, including the potential complications associated with such treatments.