Complete excision of the infrapatellar fat pad is associated with patellar tendon shortening after primary total knee arthroplasty.

BACKGROUND: Patella baja is a potentially disabling and difficult-to-treat complication following total knee arthroplasty (TKA). We investigated whether complete or partial excision of the fat pad has an effect on the length of the patellar tendon following TKA. METHODS: A retrospective review of patient radiographs was performed. One hundred and eleven consecutive patients who underwent primary TKA for osteoarthritis using the same components by two consultants were selected. Seventy-two patients underwent complete excision of the fat pad, whilst 39 had partial excision as per consultant practice. Patellar height was measured using the Caton-Deschamps Index (CDI) on immediate postoperative radiographs and at a minimum follow-up of 1 year. RESULTS: In the complete excision group, the mean CDI changed from 0.54 immediately postoperatively to 0.45 at a minimum follow-up of 1 year (p < 0.0001) indicating shortening of the patellar tendon, and eight patients reported anterior knee pain. The partial excision group's mean CDI changed from 0.76 to 0.75 (p = 0.231). An analysis of variance showed that the effect of complete fat pad excision on patella tendon length was significant, F(1, 109) = 15.273, p < 0.001. CONCLUSION: At a minimum follow-up of 1 year, the patellar tendon length shortened significantly in the group of patients with complete fat pad excision. With partial excision, there was no significant change in tendon length. Complete excision of the fat pad should therefore be avoided wherever possible in an attempt to avoid patella baja. LEVEL OF EVIDENCE: II.

Variable life-adjusted display (VLAD) for hip fracture patients: a prospective trial.

PURPOSE: With restructuring within the NHS, there is increased public and media interest in surgical outcomes. The Nottingham Hip Fracture Score (NHFS) is a well-validated tool in predicting 30-day mortality in hip fractures. VLAD provides a visual plot in real time of the difference between the cumulative expected mortality and the actual death occurring. Survivors are incorporated as a positive value equal to 1 minus the probability of survival and deaths as a negative value equal to the probability of survival. Downward deflections indicate mortality and potentially suboptimal care. METHODS: We prospectively included every hip fracture admitted to UHW that underwent surgery from January-August 2014. NHFS was then calculated and predicted survival identified. A VLAD plot was then produced comparing the predicted with the actual 30-day mortality. RESULTS: Two hundred and seventy-seven patients have completed the 30-day follow-up, and initial results showed that the actual 30-day mortality (7.2 %) was much lower than that predicted by the NHFS (8.0 %). This was reflected by a positive trend on the VLAD plot. CONCLUSION: Variable life-adjusted display provides an easy-to-use graphical representation of risk-adjusted survival over time and can act as an "early warning" system to identify trends in mortality for hip fractures.

General practice registrar responses to the use of different risk communication tools in simulated consultations: a focus group study.

OBJECTIVES: To pilot the use of a range of complementary risk communication tools in simulated general practice consultations; to gauge the responses of general practitioners in training to these new consultation aids. DESIGN: Qualitative study based on focus group discussions. SETTING: General practice vocational training schemes in South Wales. PARTICIPANTS: 39 general practice registrars and eight course organisers attended four sessions; three simulated patients attended each time. METHOD: Registrars consulting with simulated patients used verbal or "qualitative" descriptions of risks, then numerical data, and finally graphical presentations of the same data. Responses of doctors and patients were explored by semistructured discussions that had been audiotaped for transcription and analysis. RESULTS: The process of using risk communication tools in simulated consultations was acceptable to general practitioner registrars. Providing doctors with information about risks and benefits of treatment options was generally well received. Both doctors and patients found it helped communication. There were concerns about the lack of available, unbiased, and applicable evidence and a shortage of time in the consultation to discuss treatment options adequately. Graphical presentation of information was often favoured-an approach that also has the potential to save consultation time. CONCLUSIONS: A range of risk communication "tools" with which to discuss treatment options is likely to be more applicable than a single new strategy. These tools should include both absolute and relative risk information formats, presented in an unbiased way. Using risk communication tools in simulated consultations provides a model for training in risk communication for professional groups.

Towards a feasible model for shared decision making: focus group study with general practice registrars.

OBJECTIVES: To explore the views of general practice registrars about involving patients in decisions and to assess the feasibility of using the shared decision making model by means of simulated general practice consultations. DESIGN: Qualitative study based on focus group interviews. SETTING: General practice vocational training schemes in south Wales. PARTICIPANTS: 39 general practice registrars and eight course organisers (acting as observers) attended four sessions; three simulated patients attended each time. METHOD: After an introduction to the principles and suggested stages of shared decision making the registrars conducted and observed a series of consultations about choices of treatment with simulated patients using verbal, numerical, and graphical data formats. Reactions were elicited by using focus group interviews after each consultation and content analysis undertaken. RESULTS: Registrars in general practice report not being trained in the skills required to involve patients in clinical decisions. They had a wide range of opinions about "involving patients in decisions," ranging from protective paternalism ("doctor knows best"), through enlightened self interest (lightening the load), to the potential rewards of a more egalitarian relationship with patients. The work points to three contextual precursors for the process: the availability of reliable information, appropriate timing of the decision making process, and the readiness of patients to accept an active role in their own management. CONCLUSIONS: Sharing decisions entails sharing the uncertainties about the outcomes of medical processes and involves exposing the fact that data are often unavailable or not known; this can cause anxiety to both patient and clinician. Movement towards further patient involvement will depend on both the skills and the attitudes of professionals, and this work shows the steps that need to be taken if further progress is to be made in this direction.

When is a shared decision not (quite) a shared decision? Negotiating preferences in a general practice encounter.

We consider whether there are situations in which 'shared decision making' in primary care is inherently problematic, such as in the demand for antibiotics to treat viral disorders. In such an instance there might be a lack of the equipoise necessary for a decision-making context in which apparent choices are genuine options. Using the techniques of discourse analysis on the transcript of a consultation with the parents of an infant with tonsillitis, we illustrate how a general practitioner's (GP's) efforts to reach a 'shared decision' come unstuck through a combination of the embedded power imbalance and the conflict between the GP's own prescription preferences and those of the parent.