The reinfusion of perioperative cell salvage is one method employed to reduce exposure to donor blood. Data on the safety of this process, however, are scant. Notably, the effect of intraoperative, washed cell salvage reinfusion on prothrombotic markers has not been demonstrated. The risk of postoperative venous thromboembolism following major orthopaedic operations is not insignificant. The study objective was to assess the effect of cell salvage reinfusion on coagulation and platelet activation. Twenty-one patients undergoing elective primary hip operations were recruited. Nine patients received washed cell salvage intraoperatively, and were compared with 12 patients undergoing similar surgery that did not. Two patients in the cell salvage group also received postoperative, unwashed cell salvage. Blood samples were collected pre-operatively, immediately post-operatively, and one day post-operatively for assays of platelet activation markers, P-selectin expression and fibrinogen binding by flow cytometry in diluted whole blood; coagulation activation marker, thrombin-antithrombin complex (TAT); D-dimer by ELISA, thrombin generation by chromogenic assay, and full blood count. Samples of cell salvage material were also analysed for prothrombotic markers. There were no significant differences between the groups preoperatively. Postoperatively haemoglobin levels did not differ significantly between the cell salvage group and controls. Postoperative TAT and D-dimer were significantly higher in the cell salvage group compared with controls (p<0.05). One day postoperatively, there were significantly higher platelet P-selectin expression (p=0.006) and platelet fibrinogen binding (p=0.004) in the cell salvage group compared with controls. The white cell count (WCC) was also significantly higher (p=0.04). In the intraoperative washed cell salvage material, and in postoperative cell salvage, the platelet count was low, but significant proportions of platelets were activated, and levels of D-dimer were elevated compared with venous blood. The postoperative salvage material also contained high levels of TAT. The results from this pilot study show the induction of a prothrombotic state following reinfusion of intraoperative, washed cell salvage in recipients undergoing primary elective hip operations. An inflammatory response to reinfusion is also indicated by the raised WCC. Further investigation into the safety of cell salvage is indicated.
Shoulder pain represents a significant burden of disease in the general population, yet there is a lack of evidence about the effectiveness of routinely used interventions. Current management of ‘painful arc’ of the shoulder in Primary Care is not evidence-based. Over a six-month period patients with ‘painful arc’ of less than six months duration were recruited via their GPs. Eligible patients were consented to enter the trial and were then randomised, by sealed envelopes, to one of four arms of the study: control (normal analgesia and/or non-steroidal anti-inflammatory medication), a specified and repeatable Exercise and Manual Therapy Package (EMTP), a course of up to three subacromial steroid injections or both the EMTP and the steroid injections. The interventions and clinic follow-ups were over an 18-week period. A final postal questionnaire was sent out at one year. The progress of the patients was monitored using the Oxford Shoulder Score (OSS) and the SF36 general health questionnaire. Seventy-nine GPs referred 186 patients, of whom 112 were randomised (Control=27, EMTP=29, Injections=28, Both=28). 64 patients were female and 48 male. The mean age was 54.5 years (range 23-88 years). Ninety patients completed the trial (Control=20, EMTP=22, Injections=26, Both=22). Sixty-two returned the follow-up questionnaire. By paired sample t-tests, no significant differences were found between the OSS scores or SF-36 (physical health total) at the beginning and end of the intervention period, or at one year, in any group. There were no differences in changes in scores between groups. Two patients in the injection group went on to surgery, along with one each in the control and EMTP groups. We have found no significant differences in outcome between steroid injections, a physiotherapy package, both treatments, or symptomatic treatment in our group of patients presenting with symptoms of painful arc of the shoulder.
The aim of this randomised, controlled trial is to compare subacromial steroid injections, physiotherapy and both interventions with a control treatment in early painful arc of the shoulder. Over a six-month period patients with “painful arc”, of less than six months duration, were recruited via their GPs. Eligible patients were consented to enter the trial and were then randomised, by sealed envelopes, to one of four arms of the study: control (normal analgesia and/or non-steroidal anti-inflammatory medication), a specified and repeatable Exercise and Manual Therapy Package (EMTP), a course of up to three subacromial steroid injections or both the EMTP and the steroid injections. The interventions and clinic follow-ups were over an 18-week period. A final postal questionnaire was sent out at one year. The progress of the patients was monitored using the Oxford Shoulder Score (OSS) and the SF36 general health questionnaire. Seventy-nine GPs referred 186 patients, of whom 112 were randomised (Control=27, EMTP=29, Injections=28, Both=28). 64 patients were female and 48 male. The mean age was 54.5 years (range 23–88 years). Ninety patients completed the trial (Control=20, EMTP=22, Injections=26, Both=22). Sixty-two returned the follow-up questionnaire. By paired sample t-tests, no significant differences were found between the OSS scores or SF-36 (physical health total) at the beginning and end of the intervention period, or at one year. Two patients in the injection group went on to surgery, along with one each in the control and EMTP groups. We have found no significant differences in outcome between steroid injections, a physiotherapy package, both treatments, or symptomatic treatment in our group of patients presenting with symptoms of painful arc of the shoulder.
Eligible patients randomised to one of four arms of the study: control (normal analgesia and/or non-steroidal anti-inflammatory medication), a specified and repeatable Exercise and Manual Therapy Package (EMTP), a course of up to three subacromial steroid injections or both the EMTP and the steroid injections. Follow-up was for 18 weeks, with postal questionnaire at one year. The primary outcome measure was the Oxford Shoulder Score (OSS).
By analysis of covariance, no significant differences were found between the OSS scores or SF-36 (physical health total) at the beginning and end of the trial, or at one year. Two patients in the injection group went on to surgery, along with one each in the control and EMTP groups. No significant differences were found between treatment groups.
