Saving Blood and Reducing Costs: Updating Blood Transfusion Practice in Lower Limb Arthroplasty

Aim Our aim was to quantify blood transfusion rates in lower limb arthroplasty following the introduction of a multimodal enhanced recovery programme (ERP). We then sought to update the maximum surgical blood ordering schedule (MSBOS) and calculate cost savings achieved. Methods A retrospective cohort study was conducted of all patients who required blood transfusion following primary and revision total hip and knee arthroplasty in 2012 and 2015. A multimodal ERP was introduced in 2015. Cost savings were calculated following the introduction of a new MSBOS. Results During the two-year study period 1467 lower limb arthroplasty procedures were performed. The cross-match to transfusion ratio was 3.6:1 in 2012 and 9.9:1 in 2015. The updated MSBOS resulted in a 46% reduction of cross-matched blood and savings of €54,375 per annum. Conclusion Improved perioperative management in lower limb arthroplasty has reduced blood transfusion rates. Updating blood transfusion practice can result in considerable savings in blood, resources and costs.

Fracture Patients' Attitudes towards Online Health Information & a 'Prescribed' Fracture Website

Introduction Following musculoskeletal injury patient education is essential to help patients understand their treatment. Many attend the orthopaedic fracture clinic with multiple questions related to their diagnosis and treatment. Aim To assess trauma patients' attitudes towards online health information and a specific orthopaedic patient information website. Methods A validated questionnaire was distributed over 5 consecutive clinics, with questions based on previous online experiences & www.myorthoclinic.com. Results One hundred six patients completed the survey. Seventy-one percent trusted the internet whereas 83% trusted the information provided by the website. Eighty-three percent felt encouraged to take action to benefit their health. Eighty-seven percent felt that there was a wide range of information provided. Seventy-two percent agreed that they learnt something new. Discussion Patients attending the trauma clinic have benefited from the 'prescribing' of a dedicated orthopaedic trauma website. This low-cost concept utilises minimal resources, requires little effort to implement and is applicable to all specialties.

Absorbable Polydioxanone (PDS) suture provides fewer wound complications than polyester (ethibond) suture in acute Tendo-Achilles rupture repair.

We prospectively studied acute Achilles tendon rupture in patients over a two 2-year period and reviewed the causes, outcome and complications. There were 53 patients included with acute Achilles rupture with minimum follow up period of 6 months. We compared the outcomes including infection rate and Boyden score between the two groups repaired by Polydioxanone and Polyester respectively. All infected cases had a suture repair using the polyester suture. The difference in the infection rate was highly significant between the 2 groups (p=0.001). All 34 patients (100%) in the PDS group had good / excellent results based on the Boyden clinical assessment. Conversely, only 16 patients 9(68.4%) had good or excellent results IN Polyester repair group. Patients treated with a non- absorbable suture (ethibond) material for repair had a higher incidence infection and worse Boyden scores than the absorbable PDS group.

Enhanced recovery in lower limb arthroplasty in the Irish setting.

BACKGROUND: In the current economic climate of staff shortages and bed closures, orthopaedic surgeons must look for system efficiencies. Enhanced Recovery Programmes (ERP) have the potential not only to reduce length of stay (LOS) and concurrent costs but also to improve patient outcomes. The aim of this paper is to evaluate the effect of ERP for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) on length of stay (LOS) in the Irish Setting. METHODS: A single-surgeon retrospective case-control study was conducted comparing those who underwent primary lower limb arthroplasty before and after the introduction of an ERP. Patient medical and theatre records were used to determine the operation type, gender, age, LOS and readmission rates. RESULTS: Over the 2-year study period, a total of 310 patients underwent either THA (n = 244) or TKA (n = 66). The mean LOS was 8.79 days in the pre-ERP group and 5.1 days in the post-ERP group (p < 0.001). There was a significant correlation between LOS and age (p < 0.001). Gender or procedure type had no bearing on LOS for any of the subgroups (p > 0.1). CONCLUSIONS: ERP has the potential to significantly reduce overall length of stay after hip and knee arthroplasty and could have a considerable benefit in the Irish setting.

Outcomes of a patient recall following early failure of hip hemiarthroplasty.

BACKGROUND: Unexpected early loosening was noted in some patients who had bipolar hemiarthroplasties using aspecific combination of head and stem. AIM: A review of all patients who had received this implant combination was performed to establish whether there was a higher than expected failure rate and to identify those patients who had evidence of early loosening requiring further intervention or monitoring. METHODS: Theatre records were reviewed to identify those who had undergone bipolar hemiarthroplasty using these products. All surviving patients were contacted and offered an appointment at which they underwent clinical and radiological review. Following review, revision rates were compared to published Australian joint registry data. RESULTS: Of 247 eligible for recall, 139 attended for clinical and radiological review. The cumulative revision rate was 6.8 % at 4 years, with a mean time to revision of 26 months; however, there was a significantly higher revision rate of 12.1 % in those aged under 75 years at the time of surgery (p = 0.01). This is significantly higher than rates quoted for bipolar hemiarthroplasties in Australian joint registry data. CONCLUSION: Overall, higher than expected revision rates due to early loosening were seen for this product combination,especially in patients aged\75 years at the time of the initial surgery.

Preoperative estimation of tibial nail length--because size does matter.

INTRODUCTION: Selecting the correct tibial nail length is essential for satisfactory outcomes. Nails that are inserted and are found to be of inappropriate length should be removed. Accurate preoperative nail estimation has the potential to reduce intra-operative errors, operative time and radiation exposure. METHODS: We compared the most commonly used radiological, anthropometric and intra-operative techniques to determine ideal nail lengths for 16 paired cadaveric tibiae. Five different anthropometric measurements were taken from each intact cadaver including: knee joint line to ankle joint line distance (JJD), medial knee joint line to medial malleolus distance (MMD), tibial tuberosity to medial malleolus distance (TMD), olecranon to 5th metacarpal head distance (OMD) and body height (BHR). Each tibia also underwent antero-posterior (AP) and lateral scanograms. Computerised tomography was used to determine the ideal nail length for each tibia. Each anthropometric and radiological measurement was recorded by two orthopaedic surgeons independently. An expert tibial nail was then inserted after nail length estimation was performed using a guidewire technique and an intra-operative radiographic ruler. RESULTS: The AP scanogram was found to be 100% accurate in selecting ideal nail length. The lateral scanogram was also found to be reasonably accurate but in 19% (3/16) of cases it led to a nail being too long. The intra-operative radiographic ruler was found to give a good indication of the ideal nail size, as did the guidewire technique, with only 6% (1/16) of cases producing an incorrect nail size. In general, the anatomical measurements gave a poor indication of ideal nail size compared with the other techniques. The following accuracies were noted: JJD 56%, MMD 50%, TMD 38%, BHR 13% and OMD 56%. CONCLUSIONS: We found that radiological methods such as using an AP radiograph with known magnification and intra-operative radiographic ruler were able to predict nail length very accurately and we suggest that these measurements should be performed routinely. The guidewire technique was also effective but we recommend that it not be used in isolation as errors can occur. We found that anatomical measurements are not accurate for predicting tibial nail length.

Operative outcomes for cervical myelopathy and radiculopathy.

Cervical spondylotic myelopathy and radiculopathy are common disorders which can lead to significant clinical morbidity. Conservative management, such as physical therapy, cervical immobilisation, or anti-inflammatory medications, is the preferred and often only required intervention. Surgical intervention is reserved for those patients who have intractable pain or progressive neurological symptoms. The goals of surgical treatment are decompression of the spinal cord and nerve roots and deformity prevention by maintaining or supplementing spinal stability and alleviating pain. Numerous surgical techniques exist to alleviate symptoms, which are achieved through anterior, posterior, or circumferential approaches. Under most circumstances, one approach will produce optimal results. It is important that the surgical plan is tailored to address each individual's unique clinical circumstance. The objective of this paper is to analyse the major surgical treatment options for cervical myelopathy and radiculopathy focusing on outcomes and complications.

H1N1 infection in emergency surgery: A cautionary tale.

Pandemic 2009 influenza A H1N1 has spread rapidly since its first report in Mexico in March 2009. This is the first influenza pandemic in over 40 years and it atypically affects previously healthy young adults, with higher rates of morbidity and mortality. The medical literature has been inundated with reports of H1N1 infection, the majority found in critical care and internal medicine journals with a relative paucity in the surgical literature. Despite this, it remains an important entity that can impact greatly on acute surgical emergencies. We present a case of previously healthy 31-year-old male who underwent open appendectomy. His post-operative recovery was complicated by acute respiratory distress syndrome secondary to H1N1 infection. This case report highlights the impact that H1N1 virus can have on acute surgical emergencies and how it can complicate the post-operative course.

Neuroendoscopic laser-assisted ventriculostomy of the third ventricle.

Hydrocephalus is caused by an imbalance between the production and absorption of cerebrospinal fluid. Ventriculostomy of the third ventricle now is an acceptable treatment alternative for this problem. This procedure reduces costs over the course of the illness because the patient does not require subsequent shunt revisions throughout his or her life. The specialized care and the fear associated with the dependency on mechanical hardware also are eliminated if shunt placement is avoided. Postoperative complications may include increased intracranial pressure, bleeding, infection, and pain.

Midwifery in a family practice.

This study examined the effect on the type of maternity care given low-risk mothers in a family practice where approximately one-half of the patients were coached in labour by midwives. It was found that the same caregiver tended to make fewer obstetrical interventions with the midwife-coached patients. While the study was not methodologically rigorous, it nevertheless illustrated trends that the authors believed to be valid when midwives were involved. Future studies might document the trends more clearly and suggest areas for co-operation between family doctors and midwives.

Appendicular tremor as a late complication of intracerebral hemorrhage.

A 23-year-old woman without demonstrable risk factors for cerebral hemorrhage was admitted after the acute onset of hemiparesis of the left side. A computed tomography scan showed a small right thalamic hemorrhage. Cerebral angiography was normal, and she was managed conservatively. Three months after the original ictus the patient developed severe tremor on the left side. Angiography again revealed no abnormalities and the tremor was successfully treated with a stereotaxic thalamic lesion superimposed on the area of the hemorrhage. The patient's disease, its treatment, and the current knowledge of the anatomy and physiology of movement disorders are reviewed.

Prediction of the needed level of sympathectomy for posttraumatic reflex sympathetic dystrophy.

The course of 2 patients with posttraumatic reflex sympathetic dystrophy is presented and discussed. The importance of determining the exact level of sensory blockade in order to know the necessary level of the sympathectomy is emphasized. It is suggested that in patients with reflex sympathetic dystrophy, the diagnosis should include the exact upper anatomical level of sympathetic truncus involvement, which can be easily achieved with sensory epidural blockade.

Some clinical aspects of superficial temporal-middle cerebral artery bypass surgery.

Carotid occlusive disease may occur at the base of the skull and siphon without evidence of atheroma in the neck. Careful search for lesions in this location should be undertaken in any patients with TIAs or neurologic deficit when the extracranial carotid arteries appear normal. Unilateral frontotemporal headache may be an early symptom of stenosis in this location. Inaccessible lesions are often bilateral, although the symptoms may be unilateral. Superficial temporal-middle cerebral artery bypass on the symptomatic side affords relief of symptoms. Bypass on the contralateral side should be considered when and if symptoms subsequently develop related to the lesion on that side. The configuration of a carotid thrombus may enable one to determine that it is a retrograde rather than antegrade occlusion and hence is not amenable to endarterectomy, even in the acute situation. The use of a Fogarty catheter in such a setting would be ill-advised and potentially hazardous. Current experience suggests that risk of subsequent stroke is reduced after EC-IC bypass operation.

Parasellar epidermoid tumor presenting as painful ophthalmoplegia.

In 1964, a 51-year-old man experienced a right abducens nerve palsy, which resolved spontaneously. In 1978, he developed painful ophthalmoplegia on the right with paresis of the right oculomotor and trigeminal nerves. Neuroradiographic evaluation was reported unremarkable, and the painful ophthalmoplegia was attributed to the Tolosa-Hunt syndrome. High-dose corticosteroids were administered with transient improvement of signs and symptoms. In 1979, cranial computerized tomography demonstrated a low-density lesion adjacent to the right cavernous sinus, which at operation proved to be an epidermoid tumor.

Multiple myeloma masquerading as chromophobe adenoma.

A 62-year-old woman presenting with intracranial lesion eroding the sella with compression of optic chiasma was found to have plasmacytoma of the pituitary area. At the time of initial surgery, the patient had no biochemical, immunologic or marrow findings of multiple myeloma. The intracranial tumor was interpreted initially as chromophobe adenoma on light microscopy, but the diagnosis of plasmacytoma was established by electron microscopic examination of the tumor. The case illustrates the usefulness of electron microscopy as a diagnostic tool.