Training initiative list scheme (TILS) for minimal access therapy: the MATTUS experience.

The objective of the MATTUS intercollegiate exercise was to set up and audit a training initiative list scheme (TILS) by which funds are awarded to Trust hospitals for operative sessions used specifically for the training of staff in minimal access therapy (MAT). A prospective centralized audit of TILS involving nine Trust hospitals in Scotland over a 12-month period (1 March 1995-end of February 1996) was carried out. These hospitals had contracted for 510 4-h training sessions (389 for minimal access surgery, 121 for allied interventional techniques) by MATTUS accredited consultant tutors. The scheme covered training in technical competence for Minimal Access Surgery (MAS), interventional flexible endoscopy and interventional radiology within Scottish Hospitals. The main outcome measures used in the audit were trainee completion rates, conversion rates, morbidity and mortality, assessment of training received by trainees and assessment of aptitude by the trainers. The results were as follows. Of 510 sessions, 482 (95%) were completed within the deadline. Of these, 463 sessions were audited (367 for MAS, 69 for flexible endoscopy and 27 for interventional radiology). During these sessions, 817 operations/procedures were performed (781 training and 36 developmental). A total of 544 operations were performed during 339 MAS training sessions and 237 radiological/flexible endoscopy procedures in 96 MAT training sessions. The trainee was the principal operator in 643 (82%) procedures and completed the task in 581 (74%) cases. Four per cent of the MAS operations (22/544) required conversion. Post-operative complications occurred in 42 out of 817 patients (5%). Four patients, all with advanced malignancy, died within 30 days of the procedure. Trainees graded 355 sessions as excellent, 109 good, two as average and one as unsatisfactory. The tutors graded their trainees' aptitude to perform the operation as excellent in 34%, good in 53%, average in 11% and poor in < 1%. The training initiative list scheme which allows unhurried training in MAT by consultant tutors using operating sessions that are extra to the service lists is operationally and educationally viable. Furthermore, it can be implemented within a pre-determined budget. The audit of TILS has also demonstrated that the immediate clinical outcome of patients is not compromised by this type of training.

Reduction of a nonconcentrically relocated hip dislocation in a seven-year-old boy.

Traumatic dislocation of the hip in childhood is a rare injury. Treatment usually consists of a closed reduction and some form of immobilization. Inability to obtain a concentric reduction by closed means is commonly attributable to soft-tissue interposition. This is a report of a method not previously described for obtaining reduction of a nonconcentrically reduced traumatic hip dislocation without an open surgical procedure.

Arthroscopic evaluation of allograft anterior cruciate ligament reconstruction.

In a previous study, we evaluated the findings of arthroscopic second looks at open anterior cruciate ligament reconstructions using autogenous tissue. We were disappointed at the variable quality of the ligaments and the presence of articular cartilage lesions. These findings led us to change our treatment protocol. Since 1983, we have used freeze-dried allografts for arthroscopic intraarticular ACL reconstructions. We have started protected motion in a brace immediately postoperatively and delayed weightbearing for 12-16 weeks. A total of 54 patients with at least a 2-year follow-up were evaluated subjectively (Lysholm scale) and objectively (KT 1000). Some 78% were rated good or excellent, and 87% were satisfied with their surgery. Of these 54 patients, 28 underwent subsequent surgery for hardware removal, manipulation, or removal of adhesions. All 28 had an arthroscopy, and an evaluation of ligamentous tissue and articular cartilage at the time of the second surgery. The graft resembled a normal anterior cruciate ligament in 18 patients. The graft was slightly lax in two of these patients, but their clinical examination revealed normal stability. In six patients, the intercondylar notch was covered by a sheath of dense, fibrous tissue, but the knees were stable. In two cases, there was slight fraying of the lateral aspect of the graft from impingement on the lateral femoral condyle. In two cases the graft failed. The condition of the articular cartilage was documented and compared with the condition of the articular cartilage at the time of cruciate reconstruction. In 19 cases, the articular cartilage had been normal and remained normal at the time of reevaluation.(ABSTRACT TRUNCATED AT 250 WORDS)

Recent advances and perspectives on arthroscopic stabilization of the shoulder.

The goal of surgical stabilization of the unstable glenohumeral joint is to produce a stable yet mobile joint that can return to preinjury function. Open surgical procedures (in particular, the Bankart procedure) have evolved to a point where stability and mobility are being attained with a low complication rate, but the rate of return to preinjury function, particularly in overhead athletes, has not been ideal. Arthroscopic stabilization is an attractive alternative to open procedures, particularly in those patients who have a history of traumatic and unidirectional recurrent dislocations with a labral detachment. A variety of techniques for reattaching a detached labro-ligamentous complex have been described. Longer follow-up is needed to assess the efficacy of these procedures fully, particularly in light of the good results now being obtained with the open Bankart procedure. Longer-term studies have shown a higher rate of recurrence of dislocation with the arthroscopic technique than with the open technique. Arthroscopic stabilization offers the potential advantages of shorter hospitalization, less traumatic treatment of the soft tissues, more thorough examination of the glenohumeral joint and subacromial bursa, and greater cosmesis. It could also provide a means by which selective stabilization of those initial anterior dislocations that might be prone to recurrence could be performed. Long-term follow-up and randomized studies comparing open and arthroscopic techniques are needed to further define the best role of arthroscopic shoulder stabilization and to determine which of the several techniques described provides the best results with the fewest complications.

Chiari's osteotomy in the treatment of Perthes' disease.

Seventeen patients, with an average age of nine years 11 months, underwent 18 Chiari osteotomies for the treatment of painful subluxation of the hips following Perthes' disease. The average follow-up period was four years three months. The 13 patients reviewed clinically all did well and none complained of pain or instability. The radiographs were examined in all 17 cases. The average centre-edge angle and percentage femoral head cover were definitely improved by the operation. No significant medical displacement of the femoral head was achieved. The clinical success may result from improved femoral head coverage and diminished eccentricity. Chiari's osteotomy is recommended for adolescent patients with painful subluxation of the hip as a consequence of Perthes' disease.

Four-year average follow up of cemented PCA total knees: clinical and roentgenographic analysis.

Twenty patients with 25 consecutive primary-cemented Howmedica PCA total knee prostheses were clinically and roentgenographically reviewed. Twenty implants were placed in 16 women and five in four men. The average patient age at surgery was 68.0 years (range, 53 to 82), and average follow up was 51 months. Total knee replacement indication was degenerative joint disease in 21 knees and rheumatoid arthritis in four. Excellent or good results were seen in 22 of 25 knees (88%) at the early follow up examination and 18 of 25 knees (72%) at the most recent follow up examination.