The main purpose of preoperative blood tests is to provide information to reduce the possible harm or increase the benefit to patients by altering their clinical management if necessary. This information may help clinicians assess the risk to the patient, predict postoperative complications and establish a baseline measurement for later reference. National Institute of Clinical Excellence (NICE) has issued guidelines around the need for pre-operative blood tests related to the age of the patient, comorbidities and the complexity of the procedure they will undergo. We decided to retrospectively review the pre-operative blood requests for patients under the age of 65 who were admitted at our institution over a 2 month period for open reduction and internal fixation of the ankle or tibial plateau and manipulation under anaesthesia of the lower limb. Patients were divided into 2 groups, under the age of 40 and between 40-65 years old. Patients under the age of 18 were excluded. These surgical procedures were classified as ‘intermediate complexity’. Admission clerkings of our 63 patient cohort were reviewed to ascertain if any patients had a significant co-morbidity or past medical history. The pre operative blood tests requested for each patient were audited against the NICE recommendations. None of the patients under the age of 40 had any significant comorbidites, whilst 8 patients above the age of 40 suffered with hypertension. 95% of patients had at least one blood test carried out. All patients over the age of 40 had at least one blood test. Tests requested included full blood count (91%), urea and electrolytes (91%), coagulation (66%), liver function tests (67%), group and save (69%), CRP (70%), ESR (2%), thyroid function tests (5%) and CK (2%). Only 5 patients (5%) followed the guidelines correctly. The clinical value of testing healthy individuals before an operation is debatable. The possible benefits of routine preoperative investigations include identification of unsuspected conditions that may require treatment before surgery or a change in surgical or anaesthetic management. The American Society of Anaesthesiologists has stated that ‘routine preoperative tests (i.e. tests intended to discover a disease or disorder in an asymptomatic patient) do not make an important contribution to the process of perioperative assessment and management of the patient by the anaesthesiologist.’ The overzealous requesting of preoperative blood tests also has a financial burden upon individual institutions. Our study also showed that some blood tests, such as inflammatory markers and thyroid function tests, were inappropriately requested. Adherence to the NICE guidelines would have resulted in a significant financial saving. This review has shown that adopting the NICE guidelines may result in a decrease in the amount of unnecessary blood tests patients undergo when they attend hospital for routine, minor or intermediate surgical procedures. If these guidelines were implemented for all surgical procedures, this would undoubtedly result in a significant financial saving for the institution and the NHS as a whole. At our institution we have implemented surgical and anaesthetic team awareness and education around these guidelines in a bid to reduce the use of unnecessary testing.
Purpose: To determine if early MRI diagnosis in the acutely injured knee affects management, use of resources and patient satisfaction compared to conventional management with physiotherapy.
Methods: Patients referred to fracture clinic with acute knee injury in whom a specific clinical diagnosis could not be made were randomised to one of two groups. The MRI group had a scan within 2 weeks and were then reassessed in clinic with management according to the results. The control group received physiotherapy and then reassessed. Patients were assessed in clinic on presentation, at 2 weeks and then by a telephone questionnaire at 3 months. Electronic medical records were also reviewed.
Results: 48 patients were recruited in total: 23 in the MRI group (78.2% male, 21.8% female) and 25 in the control group (68% male, 32% female). The mean age was similar in the two groups (29 years (range 18–61) vs. 30 years (18–50)). The MRI group had significantly less physiotherapy appointments (5 ± 3.42 vs. 2.52 ±1.93, p=0.003) on average until definitive treatment but not outpatient appointments (2.72 ± 1.1 vs. 2.43 ±0.66, p=0.27). Median time to surgery was less in the MRI group (138 (31–199) vs.180 days (33–826) vs.) but not statistically significant (p=0.19). A similar number of patients returned to work in both groups (82.6% vs. 76%) but the MRI group had less time off work (15.82 ±22.26 vs. 20.56 ±25.38 days, p=0.48) and statistically better satisfaction scores (2 ±2.68 vs. 3.5 ±2.75, p=0.048) than the control group.
Conclusion: We have shown that early MRI in acute knee injury can provide early diagnosis of internal derangement and therefore allow targeted treatment. These patients had significantly less physiotherapy appointments and less time off work which may offset the cost of the MRI. Moreover these patients were significantly more satisfied with the service.
The early surgical management of the anterior cruciate ligament (ACL) tears in children remains controversial. The argument for nonoperative treatment is driven by concerns about the risk of growth arrest caused by a transphyseal procedure. On the other hand, early surgical reconstruction is favoured because of poor compliance with conservative treatment and increased risk of secondary damage due to instability. This paper reports a series of 39 very young children who had an ACL reconstruction using a transphyseal procedure with a hamstring graft. Patients were followed to skeletal maturity or for a minimum of three years. Only those patients with either a chronological age less than 14 years or with a Tanner stage of 1 and 2 of puberty were included in the study. Thirty children were Tanner 1 or 2 and nine were Tanner 3-4 but were younger than 14. The mean age at operation was 12.2 years (Range 9.5-14.2, Median 12.4). The mean follow up was 60.7 months (range 36-129, median: 51) months. Thirty four patients had attained skeletal maturity at the last follow up. The mean Lysholm score improved from 72.4 pre-operatively to 95.86 postoperatively (p
Purpose: To determine if early MRI diagnosis in the acutely injured knee affects management, use of resources and patient satisfaction compared to conventional management with physiotherapy.
Methods: Patients referred to fracture clinic with acute knee injury in whom a specific clinical diagnosis could not be made were randomised to one of two groups. The MRI group had a scan within 2 weeks and were then reassessed in clinic with management according to the results. The control group received physiotherapy and then reassessed. Patients were assessed in clinic on presentation, at 2 weeks and then by a telephone questionnaire at 3 months. Electronic medical records were also reviewed.
Results: 48 patients were recruited in total: 23 in the MRI group (78.2% male, 21.8% female) and 25 in the control group (68% male, 32% female). The mean age was similar in the two groups (29 years (range 18–61) vs. 30 years (18–50)). The MRI group had significantly less physiotherapy appointments (5 ± 3.42 vs. 2.52 ±1.93, p=0.003) on average until definitive treatment but not outpatient appointments (2.72 ± 1.1 vs. 2.43 ±0.66, p=0.27). Median time to surgery was less in the MRI group (138 (31–199) vs.180 days (33–826) vs.) but not statistically significant (p=0.19). A similar number of patients returned to work in both groups (82.6% vs. 76%) but the MRI group had less time off work (15.82 ±22.26 vs. 20.56 ±25.38 days, p=0.48) and statistically better satisfaction scores (2 ±2.68 vs. 3.5 ±2.75, p=0.048) than the control group.
Conclusion: We have shown that early MRI in acute knee injury can provide early diagnosis of internal derangement and therefore allow targeted treatment. These patients had significantly less physiotherapy appointments and less time off work which may offset the cost of the MRI. Moreover these patients were significantly more satisfied with the service.
Background: The evidence in favor of early surgical treatment of anterior cruciate ligament (ACL) injuries in children is increasing. However, the controversy regarding the safety of such a procedure in young athletes with wide open physes remains unresolved. Methods: We reviewed prospectively collected outcome data on consecutive patients who had undergone transphyseal ACL reconstruction at either (1) an age of less than fourteen years and Tanner stage 1 or 2, or (2) an age of less than twelve years and Tanner stage 3. Children who had less than four years of follow-up, who were younger than sixteen years at the time of final follow-up, or who had been at Tanner stage 4 at the time of surgery were excluded. Twenty-eight of the thirty-two included patients had been at Tanner stage 1 or 2 at the time of surgery, and the remaining four had been at Tanner stage 3 but had been younger than twelve years of age. The mean age at the time of the surgery was 11.25 years (range, 9.5 to 14.0 years; median, 12.1 years). The mean duration of follow-up was 72.3 months (range, forty-eight to 129 months; median, seventy-two months). Results: The mean Lysholm score improved from 71.5 preoperatively to 95.86 postoperatively (p < 0.0001). The mean Tegner activity scale score improved from 4.03 to 7.66 (p < 0.0001), which was comparable with the preinjury score of 8.0. One patient had a mild valgus deformity with no functional disturbance, and none had a limb-length discrepancy. One rerupture occurred, but all other patients had a good or excellent outcome. Conclusions: This case series indicates good long-term results of ACL reconstruction with use of a transphyseal technique in young children. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Abstract Background Carpal coalitions have an incidence of 0.1 to 1% in Caucasians and up to 8 to 9% in African populations. They rarely cause clinical problems requiring investigation or treatment, but are commonly identified on imaging obtained for other indications. Case Description We report a case of a 35-year-old male with progressive degenerative change of incomplete coalitions of the scaphotrapeziotrapezoid joint (STT) in the presence of bilateral complete osseous lunate–triquetral coalitions (Minnaar type 4). He was successfully treated with staged bilateral arthrodesis with excellent symptom resolution and preservation of function. Literature Review In patients with isolated STT coalition six reports of surgery exist, two of which were for arthrodesis. This is the first described case of STT arthrodesis in a patient with coexistent lunate–triquetral coalition. Clinical Relevance The STT arthrodesis remains a safe and effective treatment for STT pain even in cases of occult carpal coalition. Functional range of movement was well preserved. Level of evidence This is a Level V study.
Abstract This chapter reviews the management of complex intra-articular distal humeral fractures in the elderly population. It is a multicenter prospective randomized controlled trial comparing the treatment options of open reduction and internal fixation (ORIF) against total elbow arthroplasty (TEA). Twenty patients were randomized to each group with clear inclusion and exclusion criteria. The outcome measures included the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Complications, duration of procedure, and reoperations were reported with statistical analysis. Patients treated with TEA had significantly improved MEPSs at all time points in the follow-up period.
The purpose of preoperative investigations is to provide diagnostic and prognostic information. Preoperative tests requested for a cohort of patients admitted for simple trauma related procedures were retrospectively reviewed. Adherence to the NICE guidelines was found to be 5%. No result from a blood test led to a change in the management of the patient. The authors believe that implementation of the NICE guidelines will reduce clinical time and result in huge financial savings for individual institutions.
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