Peri-operative radiation exposure: Are overweight patients at increased risks?

The aim of this study was to identify if there was a correlation between body mass index (BMI) and intra-operative radiation exposure. A retrospective review of 81 patients who had sliding hip screw fixation for femoral neck fractures in one year was completed, recording body mass index (BMI), screening time, dose area product (DAP), American Society of Anesthesiologists (ASA) grade, seniority of operating surgeon and complexity of the fracture configuration. There was a statistically significant correlation between dose area product and BMI. There was no statistically significant relationship between screening time and BMI. There was no statistical difference between ASA grade, seniority of surgeon, or complexity of fracture configuration and dose area product. Simulated stochastic risks were increased for overweight patients. Overweight patients are exposed to increased doses of radiation regardless of length of screening time. Surgeons and theatre staff should be aware of the increased radiation exposure during fixation of fractures in overweight patients and, along with radiographers, ensure steps are taken to minimise these risks. Whilst such radiation dosages may have little adverse effect for individual patients, these findings may be of more relevance and concern to staff that will be exposed to increased radiation.

Use of radiology by general practitioners making orthopaedic referrals: a cross-sectional study.

BACKGROUND: In orthopaedic clinics, patients can be x-rayed during their visit to the surgeon. Could radiographs carried out in primary care be more efficiently carried out when the patient meets the surgeon? AIMS: To quantify and describe use of radiological investigations by general practitioners (GPs), when referring to orthopaedics. METHODS: We made a retrospective examination of 294 referral letters for detail regarding x-ray investigation of the condition prompting the letter. We used referral letters assessed by the recipient as 'routine'. We excluded those addressed to a particular surgeon because of subspecialty interest or prior care. RESULTS: Twenty one percent (62) of referrals described an investigation that did not contribute to management prior to the patient's clinic appointment. CONCLUSIONS: A significant number of patients travelled specifically for an x-ray. In some of these cases the radiographs could be delayed until the clinic visit without compromising care. DISCUSSION: We suggest that GPs seeing patients with musculoskeletal problems should consider referral to an orthopaedic surgeon prior to requesting x-rays. X-ray investigation in the orthopaedic clinic may be more convenient for the patient and surgeon.

Early mortality after surgical fixation of hip fractures in the elderly: an analysis of data from the scottish hip fracture audit.

We investigated the relationship between a number of patient and management variables and mortality after surgery for fracture of the hip. Data relating to 18,817 patients were obtained from the Scottish Hip Fracture Audit database. We divided variables into two categories, depending on whether they were case-mix (age; gender; fracture type; pre-fracture residence; pre-fracture mobility and ASA scores) or management variables (time from fracture to surgery; time from admission to surgery; grade of surgical and anaesthetic staff undertaking the procedure and anaesthetic technique). Multivariate logistic regression analysis showed that all case-mix variables were strongly associated with post-operative mortality, even when controlling for the effects of the remaining variables. Inclusion of the management variables into the case-mix base regression model provided no significant improvement to the model. Patient case-mix variables have the most significant effect on post-operative mortality and unfortunately such variables cannot be modified by pre-operative medical interventions.

Drop foot after high tibial osteotomy: a prospective study of aetiological factors.

Drop foot is not uncommon after high tibial osteotomy for genu varum. The authors report their results of a prospective study of 16 patients operated on between May 1990 and May 1991. All patients had medial femoro-tibial osteoarthritis with a constitutional genu varum. They all had a subtraction valgus high tibial osteotomy fixed by a blade plate. The experimental protocol included clinical review, antero-lateral compartment pressure measurements, intra- and post-operative electromyography, assessment of the post-operative drainage, serum estimation of muscle enzymes and post-operative arteriography. From their own results and a literature review, the authors consider successively the different aetiological factors for post-operative drop foot. Certain deficits occur due to direct trauma on the nerve during high osteotomy of the fibula, by local high pressure due to poor haemostasis or ineffective drainage. In addition, there are several related phenomena. The pneumatic tourniquet sensitises the nerve to trauma, and stretching of the nerve during correction of the deformation depends on the local anatomical factors and their marked variation. In order to diminish the frequency of these post-operative complications, the authors suggest limiting the surgical approach, and limiting as far as possible the traumatic manoeuvres on the nerve by using a tibial resection jig, which allows correction without forced manoeuvres. Finally, the authors discuss the benefits of using a pneumatic tourniquet.

Who actually does orthopaedic operating?

Recent correspondence in the British Medical Journal suggested that up to 80% of orthopaedic trauma surgery is carried out by unsupervised trainees. We examined our own experience by gathering theatre computer system data over a six month period and case note verification. Unsupervised trainees carried out 48% of the trauma surgery, but only 13% of the elective surgery. Case sheet review demonstrated that the computer system over-attributed operating to the senior surgeon, and under-recorded the presence of unscrubbed consultants. Supervision of trainees is important for both training and service provision, and needs to be tailored to the needs of individual trainees, but we were disappointed with our results. Theatre computer records may not be accurate enough to allow assessment of the level of supervision.

Screening times with image intensifier in orthopaedic trauma surgery.

Image intensifier technology has been of great benefit to orthopaedic, but not a benign aid. We have examined the image intensifier screening times for trainees and consultants over a seven month period. Consultants did not always have shorter screening times, and there were no differences between radiographers, Surgeons of all grades should depend more upon anatomical knowledge and spatial orientation, and less upon the image intensifier.

The long-term results of the Howse total hip arthroplasty. With particular reference to those requiring revision.

We present the results of 506 consecutive Howse hip arthroplasties with a minimum follow-up of 10 years. The mortality within one month of surgery was 0.79%. The early dislocation rate was 1.38%, two hips requiring revision. Nine hips developed deep sepsis (1.78%), eight of which required revision. At 10 years 42 hips (8.3%) had required revision, including 14 with aseptic acetabular loosening and 11 with femoral stem fractures. We feel that as judged by the dislocation rate and the need for subsequent revision, the Howse arthroplasty is an acceptable form of total hip replacement, particularly in the older patient and in those requiring total replacement for femoral neck fractures.