Sixty patients undergoing total knee replacement were randomized to receive either a cold compression dressing (Cryo/Cuff, Aircast, UK) or a modified Robert Jones bandage immediately after surgery. The cold compression dressing was used for a minimum of 6 h per day throughout the hospital stay, and the modified Robert Jones bandage remained in place for 48 h from the time of operation. The 2 groups of patients were compared during their hospital stay for blood loss, range of movement, pain scores and need for analgesia. No difference was found between the 2 groups except for less blood loss in the surgical drains in the cold compression group (P<0.05). Postoperative complications were seen in both groups, but no complication was associated with either the cold compression dressing or the modified Robert Jones bandage. Résumé Etude randomisée de 60 patients qui, immédia-tement après une arthroplastie totale du genou ont eu soit un pansement compressif froid de type "Cryocuff" soit un pansement compressif de type Robert Jones. Le pansement froid a été utilisé 6 heures par jour pendant la durée de l'hospitalisation tandis que le pansement compressif de type Robert Jones a été laisse en place pendant 48 heures après l'opération. Aucune différence statistiquement significative n'a pu être mise en évidence entre les deux groupes, à l'exception des pertes sanguines dans le drainage, moins importantes dans le premier groupe de patients. Nous avons eu des complications post opératoires dans les deux groupes mais aucune corrélation n'a pu être établie entre ces complications et le type de bandage appliqué.

Ann R Coll Surg EnglThe aim of this study was to audit the activity of ESPs in our hospital. Benchmark standards were set as follows: (i) ESPs should independently assess 85% of patients appropriately referred to them; 2 (ii) the patient satisfaction rate should be 89%; 1 and (iii) no patient should be re-referred to an orthopaedic surgeon with the same complaint. Patients and Methods Extended scope physiotherapistsESPs had at least 5 years' clinical experience post qualification and at least 3 years' experience in the management of orthopaedic and musculoskeletal conditions as recommended by the guidelines produced by the Chartered Society of Physiotherapy. 4 ESPs had been seeing new orthopaedic referrals in clinic for at least 18 months before the period of the audit. TriageBased on the recommendations of Durrell, We undertook an audit of the activity of the extended scope physiotherapists (ESPs) in our unit. We assessed their activity against three benchmark data: (i) independent assessment and management by the ESP of 85% of patients seen by them; (ii) no patient to be re-referred to a surgeon with the same problem; and (iii) patient satisfaction rate of 89%.

Learning curves graphically represent the relationship between learning effort and learning outcome. Learning curves are increasingly used in research, the design of randomised controlled trials, the assessment of competency, healthcare education and training programme design. In this review we have outlined the principles behind plotting learning curves, described the common methods used to analyse learning curves, how to interpret learning curves, the multitude of learning models, their applications and potential pitfalls, and the importance of a mathematically rigorous approach to learning curve analytics.

INTRODUCTION This paper describes an audit loop. The aim of this study was to audit the effect of a specialised preoperative anaesthetic assessment clinic after hip and knee arthroplasty and revision arthroplasty. PATIENTS AND METHODS We studied patients undergoing hip and knee surgery (arthroplasty and revision arthroplasty). We collected data concerning postoperative admissions to the high dependency unit (HDU), intensive care unit (ICU) and post-anaesthesia care unit (PACU) (planned and unplanned rates of admission, length of stay). We also noted mortality. In the first part of the study (April 2005 to March 2006) we studied 298 patients. All patients were assessed independently by an anaesthetist on the day of surgery. A multidisciplinary preoperative assessment clinic commenced in April 2006. After this date all patients were assessed preoperatively by a multidisciplinary anaesthetic lead team. In the second part of the study (May 2006 to April 2009) a further 1,147 arthroplasty patients were studied. Data were again collected regarding HDU, ICU, PACU and mortality, as noted above. RESULTS We found statistically significant (p=0.001) reductions in the admissions to PACU (22% down to 10%) and in mortality (6.1% down to 1.2%) after the introduction of the pre-assessment clinic. There was also a statistically significant (p=0.01) reduction in the HDU length of stay (2.1 days to 1.6 days), ICU un-planned admissions (1.3% to 0.4%) and the ICU length of stay (2.3 to 1.9 days). We estimated cost savings of nearly £50,000 in the second part of the study. This is based on the average decrease in HDU and ICU length of stay. CONCLUSIONS We recommend the use of a multidisciplinary pre-assessment clinic for complex orthopaedic surgery.

We investigated the incidence of complications following childhood clavicle fractures and the necessity for follow-up in fracture clinic after the first orthopaedic consultation. We found that review in fracture clinic has no impact upon the outcome of clavicle fractures and complications such as non-union, mal-union or neurovascular problems are exceptionally rare. We concluded that there is no need for follow-up of children with isolated, uncomplicated clavicle fractures. These patients should be discharged after their first assessment in fracture clinic.

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We assessed the risk for refractures following removal of elastic nails and plates from paediatric forearms. Out of 82 children who had 112 plates removed, seven patients (8.5%) had refractures when removals were within 12 months of implantation. Those aged 12 years or older were at risk. Out of 24 patients who had 38 nails removed, four patients (16.7%) had refractures and the risk was high when nails were removed within 6 months of insertion. Children aged 9 years or older were at risk. We do not recommend removal of forearm plates within 12 months and nails within 6 months of implantation.

The World Health Organisation Surgical Safety Checklist (WHO SSC) is a validated tool for reducing in-patient surgical morbidity and mortality. It is not performed universally with full compliance. Two audit cycles were completed at two different trauma and orthopaedic units and compliance was measured. Site 1 was found to have a significantly lower compliance with the team-brief (p<0.001). Following a change in practice the compliance significantly increased (p>0.00001) at Site 1. The team de-brief was found to be consistently poorly complied with. We recommend regular audit of compliance and change in practice for all surgical units, and suggest national monitoring to ensure the benefits of the WHO checklist are applied to all in-patient surgery.