Consultant Orthopaedic Surgeon Research Articles

Perioperative use of methotrexate--a survey of clinical practice in the UK.

We have surveyed the use of methotrexate in the perioperative period in patients with rheumatoid arthritis (RA) undergoing surgery. A total of 200 consultant rheumatologists and 200 consultant orthopaedic surgeons in the UK were sent a postal questionnaire. Thirty-five per cent of rheumatologists and 46% of orthopaedic surgeons were concerned that the drug may increase the risk of post-operative complications, although significantly less 'always' stopped the drug around the time of surgery. There was great variation in the timing of stopping the drug with most stopping treatment within 2 weeks before surgery and restarting within 2 weeks after surgery. The majority of clinicians surveyed (70%) felt that national guidelines for the perioperative use of methotrexate would be helpful.

Carpal tunnel decompression under local anaesthetic and tourniquet control

A postal survey within the North West Region (UK) revealed that 66% of the consultant orthopaedic surgeons did not use local anaesthesia routinely for carpal tunnel decompression. This prospective study was set up to assess the effectiveness, safety and patient tolerance of performing this procedure using local anaesthesia and upper arm tourniquet control. Eight-six carpal tunnel decompressions were performed on 75 consecutive and unselected patients with confirmed carpal tunnel syndrome over a 6-month period. Completed questionnaires were obtained before discharge. None or only slight discomfort was experienced for all aspects of the operation in at least 94%. None of the patients reported severe and unbearable discomfort. At review, 3 months postoperatively, all patients with the exception of two reported complete resolution of preoperative symptoms. The use of local anaesthesia and a tourniquet is safe, effective and well-tolerated in carpal tunnel decompressions.

Decline in the incidence of late diagnosed congenital dislocation of the hip.

We reviewed the incidence of early and late diagnosed CDH over a 13 yr period in a single maternity with a well established follow-up program and a stable population base. In March 1991, all newborn infants were nursed in the lateral or supine position, having previously been nursed prone. In addition, a dedicated hip screener was appointed in October 1992. We wished to determine whether these changes could have led to a reduction in late diagnosed CDH. Babies with suspected CDH were seen by a single consultant orthopaedic surgeon within 1 week of birth. Splints were not applied until diagnosis was confirmed by the orthopaedic surgeon. The study period was from January 1983 to December 1995, inclusive. 37,383 babies were born during the study period, an average of 2,876 births per annum. The average rate of babies referred to the orthopaedic surgeon was 12.8 per 1,000 (range 5.5-28.2 per 1,000). The average incidence of babies splinted early was 7.19 per 1,000 (range 4.0-14.1 per 1,000) with no discernible increase or decrease over the yrs. In contrast, there was a clear reduction in the incidence of late diagnosed CDH; 42/24,713 births (January 1983-February 1992) compared to only 2/12,673 births (March 1992-December 1995; p < 0.0001. Twelve of the 44 infants (27 per cent) diagnosed with late diagnosed CDH were discovered by the policy of routine hip radiographs at 6 months of age of all babies born by breech presentation (2/12) or those with a positive family history of CDH in a first degree relative (10/12). Six others had a diagnosis of CDH confirmed by X-rays done at 6 months of age because of doubts about their examination in the newborn period. Nursing infants in the supine or lateral position and the introduction of a single hip screener were associated with a reduction in the incidence of late diagnosed CDH. Routine hip radiographs of high risk infants at 6 months of age proved to be a valuable safety net in detecting a significant proportion of previously undetected infants with CDH.

Surgeon wins record libel damages

A British surgeon dubbed “Dr Dolittle” by the Daily Mirror after the death of a patient has won the fourth highest libel damages ever awarded in Britain. Mr Anthony Percy, a consultant orthopaedic surgeon at Queen Mary's Hospital in Sidcup, Kent, was awarded pounds sterling625000 ($938000) by a jury at the High Court in London after a three week trial. Mr Percy, who alleged that he was “framed and set up” by the Department of Health to divert attention from a shortage of neurosurgical beds, sued after a front page story last March blamed him for the death of 45 year old Mr Malcolm Murray. Mr Murray, who sustained a major brain injury in a hit and run accident, died at Leeds General Infirmary after having been flown …

British surgeon sues paper for libel

A British surgeon dubbed “Dr Doolittle” by the Daily Mirror after the death of a patient is suing the Mirror Group for libel in the High Court in London. The patient, who had incurred a severe head injury, had to be flown 300 km to a neurosurgical bed after none could be found in the south east. As we went to press, the Daily Mirror's lawyers had given notice that they will call the former health secretary, Virginia Bottomley, to give evidence before the trial ends next week. Anthony Percy, a consultant orthopaedic surgeon at Queen Mary's Hospital in Sidcup, Kent, claims that the paper suggested that he was guilty of gross dereliction of duty, bore some responsibility for the death of the patient, …

A survey of glove preferences of general and orthopaedic surgeons in North West Thames Regional Health Authority

The glove preferences of all the consultant surgeons and consultant orthopaedic surgeons in North West Thames were surveyed by questionnaire. Responses were received from 59 of 78 general surgeons and 47 of 55 orthopaedic surgeons. Twenty-two percent of general surgeons never double gloved compared with 4% of orthopaedic surgeons ( P < 0·01). Seventy-three percent of general surgeons double gloved for ‘high risk’ patients compared with 17% of orthopaedic surgeons ( P < 0·001). When double gloving the majority of surgeons (67%) used their normal sized glove inside and half a size larger on the outside.

Consultants do not want more structured career progression

The conference rejected overwhelmingly a motion calling for more structured career progression within the consultant grade. Proposing the motion, Mr Richard Rawlins, a consultant orthopaedic surgeon in Bedford, argued that consultants should have more opportunities for development and education throughout their careers. He …

Functioning multidisciplinary care and referral center for cerebral palsy children.

This presentation will attempt to give the history of the Developmental Neurology Service at the Istituto Neurologico, Milano, where children affected by cerebral palsy, spina bifida and other developmental disorders are followed up and treated. In order to achieve this goal, it is necessary to give a brief overview of the Italian Health Care System for handicapped children from 1950 to 1992, including the history of the service where I am working. During the first period, from 1950 to 1970, the Italian Health Care System for handicapped children was very poorly organized. There were residential centers, mainly managed by the Catholic Church, where children older than 3 years of age affected by cerebral palsy (CP) and other developmental diseases were admitted. Some of them provided rehabilitation treatment and special teaching; most of them provided only nursing care and assistance. There were also community centers for daily care; they were very few in number and 0nly located in big cities (e.g., Milan and Rome). The children with CP only went to the rehabilitation service and special classes during the day. At that time the approach to treating CP children was orthopedic and similar to the one used in children with poliomyelitis, i.e., orthesis and orthopedic operations. The history of the Developmental Neurology Service at the Istituto Neurologico in Milan, during this period (from 1950 to 1970) is characterized by an important step: in 1954 a Cerebral Palsy Center was founded by Prof. A. Grisoni Colli and was officialy recognized by the Ministry of Health for the treatment of handicapped children. The Center was the first Service in Italy for the treatment of outpatients and for children less than 3 years of age. CP children coming from various areas of northern Italy were treated and then followed up until 18 years of age. The rehabilitation program, in part using the Bobath approach and in part focusing on daily living activities, was explained to the family. The mothers had to treat their children at home. Family and psychosocial support was provided by a psychologist. The staff comprised a pediatric neurologist, 2 physiotherapists, 1 psychologist and 1 consultant orthopedic surgeon. All the members of the staff met weekly for a discussion of clinical problems in order to define rehabilitation plans. The following period, from 1970 to 1985, was characterized by a radical change in the Italian Health Care System for Handicapped Children. Between 1972 and 1974, following the new health political reforms, most of the residential centers for CP children and all the special classes were closed. From a theoretical point of view these reforms had many positive aspects. A new plan for a network of territorial rehabilitation service was designed with the aim of helping the families treat their children at home. A new law was passed that said that every handicapped child must be admitted to a normal school. From a practical point of view, our experience during this period showed had negative aspects. The new care system was introduced too suddenly: it took about ten years to organize the territorial services and to train physiotherapists, special teachers and social workers involved in the care and treatment of CP children. Very often at that time the family, therapists and teachers were left alone to cope with the various clinical and social problems of handicapped children. From 1970 to 1985 the knowledge and experience in diagnosis and rehabilitation of CP gained previously induced a modification in the function and organization of our service, which subsequently became a Referral Center Model for Multidisciplinary Care. The goals were as follows:

Hip Fracture Management

Martyn J Parker, Glyn A Pryor Blackwell Scientific, £ 69.50, pp 292 ISBN 0-632-03263-4 An ambitious undertaking, Hip Fracture Management represents the work of the Peterborough hip fracture project, which was set up by John Myles, formerly consultant orthopaedic surgeon at Peterborough District General Hospital. It is spectacularly successful. Fractures of the proximal femur …

The differential stress flow profile as a quality criterion of hip joint prostheses

Calcaneal osteotomies are used to correct hindfoot alignment. Traditional open procedures have been plagued with complications. Various minimally invasive techniques have been described but are laborious and time-consuming. A percutaneous technique using a side cutting “Shannon” burr offers a simple and reliable alternative; however, little evidence is available to address the safety concerns. The aim of the present study was to quantify the risk posed to the medial and lateral neurovascular structures using this technique. The study was performed at the anatomy department, University of Sussex, using 13 fresh-frozen, below-the-knee cadaveric specimens during a training session held by WG Healthcare UK, Ltd. (Letchworth, Herts). The participants were 11 consultant orthopedic surgeons, who were inexperienced in minimally invasive surgery, and 2 demonstrators. Each performed a chevron calcaneal osteotomy using a Shannon burr by way of a lateral percutaneous approach under fluoroscopic guidance. The authors subsequently dissected the specimens to identify the neurovascular structures, describe their anatomic relations and proximity to the burr, and note any damage incurred. No evidence was found of significant neurovascular injury. Two very small proximal branches of the sural nerve were transected, the nerve itself passing safely 9 to 21 mm anterosuperior to the entry point. The medial neurovascular bundle crossed the path of the osteotomy in 4 specimens but was protected by the medial head of the quadratus plantae muscle. In conclusion, the Shannon burr for calcaneal osteotomy has the potential to minimize the surgical morbidity and maximize surgical efficiency without compromising safety in all patients with normal anatomy of the quadratus plantae muscle.

Aspects of ‘safe’ surgery

The differing concern among surgeons regarding the blood-borne transmissible infections HIV and hepatitis B virus (HBV), has prompted a confidential questionnaire of 250 consultant orthopaedic surgeons on some aspects of their current practice of ‘safe’ surgery. Only 154 replied. Hepatitis B vaccine uptake by surgeons was 70 per cent in this sample. This compares favourably with two recently published figures (47 per cent and 24 per cent). Unfortunately, we do not fare as well on routine screening for HBV in known ‘at risk’ groups, although 92 per cent of surgeons felt confident that they would recognize the ‘inoculation risk’ categories. The response to sustaining a needlestick injury by the majority of surgeons (87 per cent), was to change the affeded glove. Only 7 per cent reported the incident as recommended to the Occupational Health Department and 6 per cent took no action at all. Current recommendations for ‘safe’ surgical practice as they apply to surgeons with regard to needlestick injury are discussed.

Referral letters and replies from orthopaedic departments: opportunities missed.

To study delays between sending referral letters and the outpatient appointment and to assess the content of referral and reply letters, their educational value, and the extent to which questions asked are answered by reply letters. Retrospective review of referrals to 16 consultant orthopaedic surgeons at five hospitals, comprising 288 referral letters with corresponding replies, by scoring contents of letters. Orthopaedic teaching hospitals in Nottingham, Derby, and Mansfield. Weighted scores of contents of referral and reply letters, assessment of their educational value, and responses to questions in referral letters. Median outpatient delay was 23.4 weeks. There was no significant decrease in waiting time if the referral letter was marked "urgent" but a significantly greater delay (p less than 0.01) if referrals were directed to an unnamed consultant. The content score was generally unsatisfactory for both referrals and replies, and there was no correlation for the content scores of the referral letter and its reply (r = 0.13). Items of education were rare in the referral letters (8/288; 3%) and significantly more common in replies (75/288; 26%) (p much less than 0.001). Senior registrars were significantly more likely to attempt education than other writers (p less than 0.02). Education in replies was significantly related to increased length of the letter (p less than 0.05) and was more likely to occur if the referral was addressed to a named consultant (p less than 0.03). 48 (17%) Referral letters asked questions, of which 21 (44%) received a reply. No factor was found to influence the asking of or replying to questions. The potential for useful communication in the referral letter and in the reply from orthopaedic surgeons is being missed at a number of levels. The content is often poor, the level of mutual education is low, and the use of the referral letter to determine urgency is deficient. Most questions asked by general practitioners are not answered.

Letters to the Editor

Consultant Orthopaedic Surgeon, Nufield Orthopaedic Centre, Oxford, United Kingdom Statistician Cheltenham, United Kingdom

Correction: The winter solstice phenomenon at Newgrange, Ireland: accident or design?

Nature 337, 343 (1989) OWING to circumstances beyond Nature's control, cooperation on the above project, an account of which appeared in our issue of 26 January 1989, was not acknowledged. Professor T. P. Ray would now like to correct this omission by stating that the name of T. M. O'Brien, consultant orthopaedic surgeon in Dublin, should be added to his own.

Prevention of haematogenous infection in prosthetic joints.

A survey was conducted to identify the attitude of consultant orthopaedic surgeons and rheumatologists in Scotland, North East England and Ireland, to the prevention of blood-borne infection in prosthetic joints. Of the 61% who completed the questionnaire, 65% gave advice about intercurrent infection, a similar number gave advice about the use of prophylactic antibiotics before certain surgical procedures, with less than half of the patients receiving any written instructions about inter-current infection, and less than a quarter of the patients receiving any written instructions about antibiotic prophylaxis. 36% of the respondents were confused as to what to advise or ignored the problem. The reality of late infection is discussed and a policy to minimise the risk of late infection in prosthetic joints is presented for consideration.

Non‐steroidal anti‐inflammatory agents in the management of Colles' fractures

International Journal of Clinical PracticeVolume 42, Issue 5 p. 184-189 Clinical Study Non-steroidal anti-inflammatory agents in the management of Colles' fractures T R C Davis BSc, FRCS, Corresponding Author T R C Davis BSc, FRCS Senior Registrar n/[email protected] University Department of Orthopaedics, Royal Victoria Infirmary, Newcastle-upon-TyneAddress correspondence to Mr T R C Davis, University Department of Orthopaedics, Royal Victoria Infirmary, Newcastle-upon-Tyne.Search for more papers by this authorC E Ackroyd MA, FRCS, C E Ackroyd MA, FRCS Consultant Orthopaedic Surgeon Southmead Hospital, BristolSearch for more papers by this author T R C Davis BSc, FRCS, Corresponding Author T R C Davis BSc, FRCS Senior Registrar n/[email protected] University Department of Orthopaedics, Royal Victoria Infirmary, Newcastle-upon-TyneAddress correspondence to Mr T R C Davis, University Department of Orthopaedics, Royal Victoria Infirmary, Newcastle-upon-Tyne.Search for more papers by this authorC E Ackroyd MA, FRCS, C E Ackroyd MA, FRCS Consultant Orthopaedic Surgeon Southmead Hospital, BristolSearch for more papers by this author First published: 01 May 1988 https://doi.org/10.1111/j.1742-1241.1988.tb08548.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Volume42, Issue5May 1988Pages 184-189 RelatedInformation

History of the establishment and development of the plastic surgical service in the city of Cork and surrounding province of Munster

Until the early 1960s no plastic surgery was available in the province of Munster, Republic of Ireland. The Author trained in Chepstow under Emlyn Lewis and Leonard Schofield, in Rookesdown House, Basingstoke under Sir Harold Gillies, Patrick Clarkson and Charles McCash, and was senior registrar both in the Birmingham Unit in Wordsley and at the Queen Elizabeth Hospital under Oliver Mansfield and John North. He took over a private general surgical practice in Tralee in the middle of 1960 as there appeared to be no prospect of a public plastic surgical appointment and with the intention of endeavouring to establish the speciality in his own University and Medical School at Cork. Colleagues in surgical practice in Cork were approached and, largely through the good offices first of St John O’Connell and Fred Moore, consultant orthopaedic surgeons, supported later by Maurice Hickey, consultant thoracic and general surgeon, a number of their cases were referred for plastic surgical attention. These cases were dealt with on an itinerant basis between Tralee and Cork (a distance of 75 miles) over a period of almost 10 years. A typical plastic surgical weekly Wednesday trip at that time would consist of the Author leaving Tralee at about 8 a.m., driving to Cork and starting an operating list at St Mary’s Orthopaedic Hospital at around 10 a.m. Three or four major cases, largely staged pedicle work to cover fractures of the lower limbs, congenital hand deformities and major hand injuries, would tend to occupy the morning. At around 2 p.m. an outpatient session would start in St Finbarr’s Hospital on the other side of Cork. When this was completed the main operating list would begin at St Finbarr’s at around 5 p.m., when burns, major hand injuries and facial carcinomata would be on the menu. This session usually finished around 10.30 p.m. so that Des Gaffney, consultant anaesthetist, and the Author could retire to the local for a badly needed pint before KCC set out on the road to Tralee at about midnight. (Not surprisingly, perhaps, the Author wrote off three cars in the course of these proceedings over a period of about six years; however, on each occasion, on the morning trip and not on the late night return journey !)

A Tribute to Sir John Charnley (1911???1982)

Consultant Orthopaedic Surgeon, Royal Surrey County Hospital, Guildford, King Edward VII Hospital, Midhurst, Research Fellow, University of Surrey, Great Britain.

The Severely Injured Limb. By Christopher E. Ackroyd, M.A., M.B., BChir, F.R.C.S., F.R.A.C.S., Consultant Orthopaedic Surgeon, Southmead General Hospital, Bristol; Brian T. O’Connor, M.S., MChOrth, F.R.C.S., F.R.A.C.S, Robert Jones Professor of Orthopaedics, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry; and Pieter F. de Bruyn, FRCS, Consultant Orthopaedic Surgeon, Tiel Hospital, Tiel. With 22 contributors. 19 × 25.5 cm. Pp

The Severely Injured Limb. By Christopher E. Ackroyd, M.A., M.B., BChir, F.R.C.S., F.R.A.C.S., Consultant Orthopaedic Surgeon, Southmead General Hospital, Bristol; Brian T. O’Connor, M.S., MChOrth, F.R.C.S., F.R.A.C.S, Robert Jones Professor of Orthopaedics, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry; and Pieter F. de Bruyn, FRCS, Consultant Orthopaedic Surgeon, Tiel Hospital, Tiel. With 22 contributors. 19 × 25.5 cm. Pp

A Colour Atlas of Minor Operations on the Hand By Geoffrey Hooper, M.M.Sc., F.R.C.S., F.R.C.S.Ed., Senior Lecturer in Orthopaedic Surgery, University of Edinburgh and Honorary Consultant Orthopaedic Surgeon Lothian Health Board. 62 pages, 80 illustrations many coloured, and index. Price £14.00, Wolfe Medical Publications Limited 1985 ISBN 0-7234 1018-6. Available in U.S.A. from Year Book Medical Publications Inc. 35 East

A Colour Atlas of Minor Operations on the Hand By Geoffrey Hooper, M.M.Sc., F.R.C.S., F.R.C.S.Ed., Senior Lecturer in Orthopaedic Surgery, University of Edinburgh and Honorary Consultant Orthopaedic Surgeon Lothian Health Board. 62 pages, 80 illustrations many coloured, and index. Price £14.00, Wolfe Medical Publications Limited 1985 ISBN 0-7234 1018-6. Available in U.S.A. from Year Book Medical Publications Inc. 35 East