Aim

To construct and validate a simple patient related outcome measure scheme to quantify the disability caused by Dupuytren's Disease thus enabling prioritisation of treatment, allow reliable audit of surgical outcome and support future research.

Introduction: Pharmacological and mechanical methods are recommended to prevent venous thromboembolism (VTE) following hip replacement (THR). However, data on mechanical methods such as graduated compressive stockings (GCS) are limited. This study examined the efficacy and safety of GCS when added to fondaparinux.

Methods: The randomised treatments were 2.5 mg fondaparinux for 5–9 days starting postoperatively alone or with GCS for 42±7 days. The primary efficacy outcome was VTE or sudden death prior to Day 42±7. All patients were to have duplex USS at day 42 + 7. VTE was defined by verified symptomatic VTE or asymptomatic proximal DVT. The main safety outcomes were major and minor bleeding and VTE death.

Results: 856 patients were randomised, of which 799 were THR patients. Of these 756 (95%) were evaluable, 377 in the fondaparinux and 379 in the fondaparinux plus GCS groups. Risk factors for thrombosis were recorded (age > 75 in 20%, history of obesity in 21%, cancer in 6% and VTE in 3%). Compliance with GCS was high, with 85% wearing them continuously. The primary efficacy outcome of VTE or sudden death in THR patients was similar in each treatment group, the results were 5.5% in the fondaparinux only group and 5.3% in the fondaparinux with GCS group; odds ratio was 0.96, 95% confidence interval 0.50–1.83, p=0.91. Outcomes were not different for long-length and short-length stockings. Major bleeding occurred in one patient (< 1%), minor bleeding in 6.7%. No VTE deaths were reported.

Discussion: The addition of GCS to fondaparinux showed no benefit in thromboprophylaxis over fondaparinux alone in this large study of THR patients. Therefore GCS may not be indicated in patients receiving fondaparinux. Graduated compression stockings are time consuming to measure and fit, inconvenient and expensive; therefore we recommend a reconsideration of this current and commonly used practice in THR.

Efficient utilisation of the trauma list is an important aspect of trauma care in the NHS. An audit of the trauma theatre time utilisation was done from April 1999 to March 2000. Ideally the first case should start at 8:30 am. However, we found that the first patient was on the operating table only by 9:40 am (mean). The main reasons for the delay were the time required for the anaesthetist to see the patient and the other staff to set up the necessary equipments. We decided to identify the first case of the trauma list the day before, so that the anaesthetist can review the patient the previous day. We felt that this would also give adequate time for the theatre staff to set up their instruments. However, this did not improve the theatre timings.

We introduced the novel idea of performing a carpal tunnel decompression at the beginning of each trauma list to make use of the redundant time without an extra financial burden to the hospital. Carpal tunnel decompression can be performed under local anaesthetic by a basic grade surgeon. This would also give time for the anaesthetist and the consultant surgeon to review the patients on the trauma list.

The theatre time utilisation was re-audited a year following the introduction of carpal tunnel release. The patient for carpal tunnel decompression was on table at 8:44 am (mean). The first trauma case was on operating table at 9:46 am (mean). Therefore, in spite of performing an additional surgery on the list, there was a delay of only 6 minutes. This simple idea has helped us to do an additional case every day with only a 6 minute delay to the trauma list.