The Consent Process for Elective Hip and Knee Arthroplasty: Does Information on Handwritten Forms Meet Prescribed Standards?

Introduction The process of informed consent is vital, not only to good clinical practice and patient care, but also to avoid negligence and malpractice claims. Elective hip and knee arthroplasty numbers are increasing globally, and the British Orthopaedic Association (BOA) has endorsed standards for obtaining written consent for these procedures. Many centres in the United Kingdom and globally, use handwritten consent forms to document informed consent, leaving open the potential for missing out important procedure and risk-related information. Our study aimed to assess whether information on handwritten consent forms was compliant with BOA standards for elective arthroplasty of the hip and knee. Methods We retrospectively reviewed 70 handwritten consent forms, across theatre lists of 12 arthroplasty consultants at our elective arthroplasty centre. These included 35 forms each for hip and knee arthroplasty respectively. We compared the information on these forms to the standards prescribed by the BOA. We assessed compliance of the forms with common, less common and rare risks of hip and knee replacement, as described by the BOA. We also noted the designation of the person filling out the form (consultant, registrar or nurse practitioner) and whether this affected information on the form. We assessed the forms for legibility issues, and whether the setting (clinic/pre-operative ward) affected information on the form. Results None of the 70 forms reviewed achieved full compliance with BOA standards. When assessed for common risks of hip and knee arthroplasty, the number of compliant forms was 25.7% and 42.8%, respectively. None of the forms mentioned all rare risks of either hip or knee arthroplasty. We identified legibility issues in 12 of 70 (17.1%) forms. There was no significant difference in information written on forms filled out by consultants, registrars or nurse practitioners, or between forms filled out in the clinic versus those on the pre-operative ward. Conclusion Handwritten forms lack compliance with prescribed standards for written informed consent in elective hip and knee arthroplasty. Ideally, a pre-written consent form should be used, but with the option of adding information individually tailored to the patients' background. This ensures that good clinical practice is optimally followed, and reduces the potential risk of any litigation.

Imageless navigation total hip arthroplasty - an evaluation of operative time.

INTRODUCTION: Imageless navigation has been successfully integrated in knee arthroplasty but its effectiveness in total hip arthroplasty (THA) has been debated. It has consistently been shown that navigation adds significant time and cost to the operation. Further, the relative success of traditional hip replacements has impeded the adoption of new techniques. METHODS: We compared the operative time between fifty total hip replacements with and without the use of imageless navigation by a single senior surgeon in a retrospective study. We employed standard statistical tools to compare the two methods. A correlation-based analysis was used to delimit the "learned" phase of imageless navigation to make comparisons meaningful. RESULTS: Contrary to what has previously been reported, there was no significant difference between operative time in navigated, when compared to traditional operations (p = 0.498). Only fourteen operations were required to delimit the learning phase of this operation. DISCUSSION: This is the first study that demonstrates no added operative time when using imageless navigation in THA, achieved with an improved workflow. The results also demonstrate a very reasonable learning curve.

Modeling Learning in Surgical Practice.

OBJECTIVE: Methods that model surgical learning curves are frequently descriptive and lack the mathematical rigor required to extract robust, meaningful, and quantitative information. We aimed to formulate a method to model learning that is tailored to dealing with the high variability seen in surgical data and can readily extract important quantitative information such as learning rate, length of learning, and learnt level of performance. METHODS: We developed a method where progressively more complex models are fitted to learning data. These include novel models that split the learning data into 2 linear phases and fit adjoining lines using least squares regression. The models were compared and the least complex model was selected unless a more complex one was significantly better. Significance was tested by Fischer tests. We applied this method to total hip and knee replacements using imageless navigation, analyzing the operative time for a surgeon's first 50 and 60 operations, respectively. This method was then tested against 4 sets of simulated learning data. RESULTS: The proposed method of progressive model complexity successfully modeled the learning curve among real operative data. It was also effective in deducing the underlying trends in simulated scenarios, created to represent typical situations that can practically arise in any learning process. CONCLUSIONS: The novel modeling method can be used to extract meaningful and quantitative information from learning data displaying high variability seen in surgical practice. By using simple and intuitive models, the method is accessible to researchers and educators without the need for specialist statistical knowledge.

Spontaneous fracture of diaphyseal stem of S-ROM femoral prosthesis.

We present two cases of spontaneous fractures of the S-ROM femoral stem prosthesis implanted by different surgeons within 5 years of implantation. Both the stems fractured in the mid-distal stem at the junction of the main body and the slotted portion. Both fractures affected the posterior tine only. Our aim in publication is to ensure that this is an isolated problem and not an under-reported phenomenon. We are not aware of any previous reports of spontaneous fracture of the distal stem.