Letters to the Editor

Sir,

Re: Primary total hip replacement Surg J R Coll Surg Edinb Irel., 1: 2003; 332-341

I am a Basic Surgical Trainee working at Rochdale Infirmary and intend to pursue a career in Orthopaedic Surgery. I am a regular reader of THE Surgeon and read with interest the article written by Mr G Bannister, Primary Total Hip Replacement, How I Do It published in Volume 01, No. 6, December 2003. It is very useful and informative to surgeons at my stage of training. However, I would like clarification of the following points:

Table 1 Prosthetic selection: Ceramic or metal bearings are selected for young patients less than 50 years of age. Is there any longterm in vivo human study to back up the above suggestion? There are several types of Calcium Phosphate Ceramic (CPC) prothseses which have been used to coat surfaces of total hip replacements. Concern has been expressed about the long-term in vivo fatigue strength of the substrate/coating interface. Biodegredation and the potential for generating ceramic particles is a matter of concern. Using CPC has shown promise but long-term data and longitudinal data are needed on the benefit-to-risk ratio of clinical outcome for these types of surface modifications.

Table 2 Planning for total hip replacement: The author stated that patients require large components. It is well known clinically that the size of the medullary canal often does not correlate well with the patient’s height. It would be impossible to insert large components in tall patients with narrow medullary canals.The aim of THR is to relieve the pain in the first place and, of course, restore the biomechanics of the diseased joint as closely as is practical.

In surgical exposure of the hip joint: While it is not always necessary to visualise the sciatic nerve in the posterior approach, it would have been helpful for a trainee at my stage of surgical training to describe ways of protecting this nerve.

I look forward to hearing from you. Thank you very much.

Yours sincerely, D. A. Beden Rochdale Infirmary Rochdale, Lancashire, UK

Sir,

I thank Dr Beden for his interest in the article. He raises four issues which I will address:

Bearings other than polyethylene for younger patients: The reason for selecting alternative bearings to polyethylene in patients under the age of 50 is cup wear and loosening. The only good results using polyethylene have been with the 22.25mm Charnley, but these results are poorer in patients with osteoarthritis than rheumatoid disease.

The ceramic on ceramic experience is predominantly French, and despite a titanium stem and cemented socket, these have fared better than high density polyethylene in this age group.

The metal on metal experience is based on long-term follow-up of uncemented ring prostheses implanted by Duke in Birmingham. The prostheses loosened but the bearing surfaces remained immaculate.

Biological surfacing of prostheses to enhance osseointegration is certainly effective as isotope bone scans around hydroxyapatite coated acetabular components cease to be hot after as little as 6 weeks, indicating that the prosthesis has stabilised within that time. The problem comes when the hydroxyapatite has been incorporated and replaced with bone, as potentially there is a smooth metal hemisphere which could loosen. The ABG 2 cup (Stryker Howmedica) is plasma coated titanium under the hydroxyapatite and the Birmingham Hip Resurfacing (MMT/ Smith & Nephew) has Harris-Galante mesh. Both of these surfaces afford reliable osseointegration. Mr Beden is quite correct, we need twenty year results of all these prostheses and they are only available at present for the Charnley prosthethis.

Component size related to height: Taller patients generally have a larger hip offset and larger bones. When planning an operation in such a patient it is wise to have a prosthesis available that will restore offset.

Hip replacement is for pain relief: I agree that the aim of hip replacement is to relieve pain but it is also to prevent premature revision. If the biomechanics of the joint is not restored there is increased joint reaction and excessive wear and premature failure.

Protection of the sciatic nerve: It has been suggested that the sciatic nerve can be protected by putting a suture through the short external rotators as this places a layer of muscle between the nerve and the posterior lip of the acetabulum. This is a useful but not infallible technique because the position of the sciatic nerve in relation to the posterior aspect of the capsule is variable and can be as close as 5mms. The sciatic nerve can also be anomalous and bifurcate into its lateral popliteal and posterior tibial components proximally. In such circumstances, the posterior inferior retractor may catch the sciatic nerve as it passes beneath the short external rotators. For what it is worth I generally pass a finger posterior to palpate the nerve, to ensure that it is well out of the way, before proceeding, although I do not dissect it out.

Yours sincerely, Gordon C. Bannister BUPA Glen Hospital Bristol, UK

I must commend Mr Older for his article Anatomy: A must for teaching the next generation, and thus attempting to stimulate the ongoing debate surrounding anatomy teaching to both medical undergraduates and postgraduates. As a surgical trainee who sat the now ‘old’ MRCS in 2002, I wholeheartedly agree that time spent teaching and working in an anatomy department is an invaluable part of surgical training and should be more actively encouraged. I currently hold the position of ‘Lecturer in Clinical Surgical Anatomy’ at the University of Aberdeen, a one-year post that was designed to give formal teaching experience, provide a clinical input to teaching, give time to undertake personal research and the opportunity to produce dissections for undergraduate teaching. Despite this excellent concept, and a local demand amongst surgical trainees, the post has been withdrawn after only one year due to ‘funding issues’ within NHS Education. I have been fortunate to occupy such a post that I feel will be of much benefit to me in my future practice.

With regard to the way that anatomy teaching is delivered, it is a reality that in many centres, much of the teaching time previously occupied by anatomy and many other clinical and non-clinical disciplines has been reallocated to other areas. This situation is unlikely to be reversed. It may be unrealistic to provide a dissection-based course, as students are unlikely to derive maximum benefit from personal dissection if time is very limited. Prosection-based courses retain many of the benefits of a dissection-based course, and while a properly resourced and timetabled dissection course may remain the ‘gold standard’ for teaching anatomy, it is surely better to continue a student’s exposure to human material through the use of high quality prosected specimens, than attempt a dissection course with insufficient time?

Yours sincerely, Stuart W. Waterston, Marischal College, Aberdeen, Scotland

Sir,

Thank you for the two important facts in your letter: the importance of demonstrator posts in Basic Surgical Training and the problem of time available for teaching personal dissecting versus prosection.

It is encouraging to have a current surgical trainee emphasise his own personal benefits from the post he held at Aberdeen. This reinforces the invaluable importance of demonstrator posts with experience in teaching, masterclass tutorials by senior staff, research and a period to reflect away from the ‘hurly-burly’ of the new NHS shift system. Demonstrators enhance their knowledge of anatomy and basic science for their future as surgeons.

Sad that administrators fail to appreciate these jobs and like in Aberdeen they are removed. The cost to Universities and the NHS can be minimal. Some are honary appointments, self-funding by the holder, others are funded by rotation.

I agree, small group teaching around a cadaver in the dissecting room is a ‘gold standard’ essential to enhance learning and confidence in the subject.¹

The performance of students who dissected compared with those who studied prosected specimens, has been assessed by many investigators. There was a small, but significant difference in favour of personal dissection in some studies.^2,3

You have correctly emphasised the importance of time for teaching. The stress of limited time must not allow active dissection to become useless, for it remains popular with students. In the academic Department of Anatomy, King’s College London, students benefit from active practical dissection before a prosected based tutorial.

Students themselves from many centres around the UK and Ireland are now requesting small group teaching around a cadaver in the dissection room.

1.Johnson JH. Importance of dissection in learning anatomy: personal versus peer teaching. Clin Anat 2002; 15: 38-44.

2.Yeager VL. Learning gross anatomy: dissection and prosection.  Clin Anat 1996; 9: 57 -59.

3.Dinsmore CE, Daugherty S, Zeitz JH. Teaching and learning gross anatomy: dissection, prosection or “both of the above?” Clin Anat 1999; 12 (2): 110-14.

Yours sincerely,

Sir,

We read with interest the above article by Morris-Stiff et al. They are propagating the long held assumption that quantity equates to quality in surgical training. Present consultants did operate long hours as trainees but many of these was unsupervised, giving rise to the axiom ‘see one, do one, teach one.’¹ In the age of clinical governance, this is no longer acceptable. The apprenticeship model of surgical training is dependent on learning by osmosis, i.e. by virtue of the length of training, it was hoped that appropriate surgical skills would be acquired, although this was not always so. Surgeons who learnt quickly still had to serve out a long apprenticeship because of the training system.

Competency-based assessment as proposed by Modernising Medical Careers is attractive since career progression is dependent on acquiring defined skills, not merely on the length of training.² However, the delivery of training has to be more focused in ensuring that trainees will be able to operate independently and safely as consultants in the future. NHS management has to provide dedicated operating lists for training. The penalty is withdrawal of Deanery money and training posts if there is no surgical training. Training will also need to take place outside of the operating theatre in wet labs and laparoscopic simulators. Out of hours service cover has to be modified if there is to be little operating opportunities available.³

In conclusion, surgical training is possible under the time constraints of Modernising Medical Career and European Working Time Directive, although both trainers and trainees have to accept that the traditional model of apprenticeship training may have to be abandoned in favour of the structured, competency-based training.

REFERENCES

1. Chikwe J, deSouza AC, Pepper JR. No time to train surgeons. BMJ 2004; 328:418-19.

2. Department of Health. Modernising Medical Careers: The response of the four UK Health Ministers to the consultation on unfinished business. London : DoH, February 2003.

3. Clarke MD, Anderson AGD, MacFie J. Training the higher surgical trainee within the EWTD framework. Ann R Coll Surg Engl (Suppl) 2004; 86: 82-84.

Yours sincerely,

Sir,

I would like to thank Miss Hindle and Miss Carney for their interest in our article. Our article was simply reporting trends in operating experience at our hospital over a 15-year period and we were not suggesting that we return to a 1:2 on-call system. Whilst we do concur with the authors that the ‘total’ number of procedures performed by trainees may not be a perfect reflection on the adequacy of training, since surgery is a practical craft, it must be concede that there is a good correlation between operative experience and expertise viz learning curves for complex operations and, thus, the more procedures performed the better!

Furthermore, we are not against improving surgical training, indeed we favour the move. However, what does concern us is the reason why, and the haste with which these changes have been implicated. In the era of evidence-based medicine, surely there should have been good evidence for restructuring training based maybe on increasing litigation, a high prevalence of suspensions for incompetence or a high percentage of examination failures in the old system. This certainly was not the case, indeed, there is increasing evidence to suggest the converse is true. The arguments put forward by Hindle and Carney for dedicated training lists, provision of surgical skills laboratories, modification of out of hours operating and competency-based training are all good ideas but most hospitals in the UK do not have the capabilities of providing these facilities. Indeed, as no comparison of ‘old and new’ has been made, there is no evidence that training in such an environment in the UK would be any more successful than training under the ‘old’ system.

Finally, I would take issue with the final paragraph which states ‘training is possible under the time constraints of Modernising Medical Care and European Working Time Directive’ as no trainees have passed through such a system and will not do so for six years. We will then have to wait for a few years to judge the competency levels of the ‘new’ consultant breed - maybe we will have to see how long it is before one of the trainees appears as a headline for the wrong reasons in our National tabloids!

Sir,

This article by Nambirajan et al has dealt with an important and pertinent issue in TRUS guided prostate biopsy. The authors and others have shown peri-prostatic nerve block (PPNB) to be the superior form of analgesia in prostate biopsy.¹ Local anaesthesia has become a necessity especially with extended systematic prostate biopsies.

The biopsy technique reported involved injecting lignocaine at four sites (base and apex). We suggest a two puncture technique involving either a bibasal or biapical PPNB, might be as effective or better analgesia. We have reported no significant difference in pain scores if the PPNB is bibasal or biapical.²

The authors have mentioned the pain on probe insertion but have omitted this from their study, reporting only the pain on biopsy. The insertion of the ultrasound probe is more painful in patients than the biopsy itself, albeit with local anaesthesia.² Studies by Obek et al (2004) have shown that PPNB with perianal/intrarectal lidocaine gel to be the superior form of pain relief.³

A number of studies have emphasised the importance of periprostatic nerve block in prostate biopsy. However, we feel the introduction of the probe remains a significantly more painful part of the procedure, an issue that the authors have failed to address. The four puncture technique is also unnecessary and a two puncture technique, as amptly demonstrated in our series, will suffice in the majority of cases.

REFERENCES

1. Addla SK, Adeyoju AA, Wemyss-Holden GD, Neilson D. Local anaesthestic for transrectal ultrasound-guided prostate biopsy: A prospective, randomised, double-blind, placebo-controlled study. Eur Urol 2003; 43(5): 441-43.

2. Philp J, Campbell IM, Samsudin A, Javle P. Site of periprostatic nerve block in prostatic biopsy: A prospective, randomised study. Eur Urol Suppl 2004; 3(2): 199.

3. Obek C, Ozcan B, Tunc B, Can G, Yalcin V, Solok V. Comparison of three different methods of anaesthesia before transrectal prostate biopsy: A prospective, randomised trial. J Urol 2004; 172(2):502-505.

Your faithfully,

Dear Sir,

There is no denying that the probe insertion remains a painful procedure. This was not assessed in this study, as one would not expect the periprostatic local anaesthetic to have any effect on this component of the pain.

Regarding the technique, the rationale for the technique used is discussed in detail in the discussion section. Various authors have reported good results from single site injection to six sites injection.^1-2 The larger the surface area of contacts between the local anaesthetic and nerve fibres, the quicker the onset of action. The four site injection achieves this effectively, as visualised by spread of the local anaesthetic under TRUS. What is not clear from the studies using single or two sites injections, is whether the authors waited before performing the biopsy. Mallick et al (2004) administered local anaesthetic five minutes before biopsy.3 What would one do in these five minutes? Taking the probe out and reinserting would inflict more pain and waiting with the probe inside the rectum would be equally unpleasant. We believe our technique offers the optimal pain relief, while minimising the duration of the procedure.

REFERENCES

1. Taverna G, Maffezzini M, Benetti A, Seveso M, Giusti G, Graziotti P. A single injection of lidocaine as local anaesthesia for ultrasound guided needle biopsy of the prostate. J Urol 2002;167(1):222-23.

2. Soloway MS, Obek C. Periprostatic local anaesthesia before ultrasound guided prostate biopsy. J Urol 2000;163(1):172-73.

3. Mallick S, Humbert M, Braud F, Fofana M, Blanchet P. Local anaesthesia before transrectal ultrasound guided prostate biopsy: comparison of 2 methods in a prospective, randomised clinical trial. J Urol 2004;171:730-33.

Yours Sincerely, 

T. Nambirajan Belfast City Hospital

Sir,

Re: Bannister GC. Letters. Surg J R Coll Edinb Irel 2004; 2 (4): 243.

Dr G C Bannister makes no sense at all. He operates for joint replacement at two different hospitals - at one he inserts a drain in every case, in the other he does not. “The results are very similar in both units.” So why does he subject his patients to the discomfort of a drain, wastes theatre and nursing time inserting and observing the drain and adds significantly to the cost of the procedure if the drain is unnecessary? What is the point of audit if you do not act on the findings? Do we just carry on with traditional operating methods even if we know they are useless?

A few years ago at the Royal College of Obstetricians and Gynaecologists issued a guideline suggesting that closure of the peritoneum was a waste of time and resources - so we stopped doing it, saved time, made progress in surgical development and eliminated yet another useless procedure. If wound drains and joint drains do not do any good, why use them?

Yours faithfully, 

G. Barker Consultant Gynaecologist and Obstetrician The Portland Hospital, London, England

Sir,

I thank Mr Barker for his comments.

I have not audited the outcome of drains in our major elective unit or the lack of them in our trauma unit. My subjective impression was that the results were very similar.

Mr Barker raises the importance of the issue of useless ritual in contrast to evidence-based practice. I entirely concur that evidence-based practice is preferable when the evidence is robust. When I have audited and found that drains make no difference, I will follow the evidence of the audit.

Yours sincerely, 

G. C. Bannister Consultant Orthopaedic Surgeon BUPA Glen Hospital Bristol, England

Sir,

Re: Luscombe KL, N Maffulli. The three-in-one procedure: How I do it. Surg J R Coll Edinb Irel 2004;1:32-36.

It was very interesting to read the above article. I would like to debate a number of aspects of the article.

Myer et al (1999), with the above procedure, have quoted a re-dislocation rate of nearly 10% with good to excellent result in only 76% of cases.¹ Similar results have been achieved by Miller D et al (1993) with closed lateral retinacular release. Do we have any improved results to promote this as a safe and reliable procedure?

In the beginning of the article you recommend this procedure for a ‘normally sited patella’. However, in the discussion it is advised for use only ‘in the patella with tilt and lateralisation’.

Besides radiographs you state ‘that CT can be used’. I think it is mandatory pre-operatively as femoral antetorsion and femorotibial rotation are increased in the pathological group.² In fact, pre-operative MRI scan to diagnose MPFL rupture/avulsion is advised to plan the necessary repair.

Recent literature suggests that lateral release has no role in the hyperlax patellofemoral joint and that repair of ‘passive retinacular restraints’ is as effective. More extensive procedures do not necessarily yield better results, compared with conservative treatment.³

Lastly, are we overdoing the reconstruction and realignment for the medial side? As medial patella dislocation after surgical repair, though rare, has been documented.

I agree that this procedure needs correct patient selection, but it is technically demanding and a very cautious approach to its practical application should be taken.

REFERENCES

1. Myers P, Williams A, Dodds R. The three-in-one proximal and distal soft tissue patellar realignment procedure. Results and its place in the management of patello femoral instability. Am J Sports Med 1999; 27(5): 575-79.

2. Airanow S, Zippel H. Femoro-tibial torsion in patella instability. Beitr Orthop Traumatol 1990;37(6):311-16 (German)

3. Fithian D, Paxton EW, Cohen AB. Indications in the treatment of patella instability. J Knee Surg 2004;17(1): 47-56.

Yours sincerely, 

A. P. Joshi Registrar in Orthopaedics, Gloucester Royal Hospital UK

Dear Sir,

We thank Mr Joshi for the attention that he has given to our contribution, and the Editorial Board for the opportunity to reply. We shall try and answer each query in the order in which it has been posed.

In our hands, the procedure has not resulted in a further re-dislocation.This is probably not an effect of what we do, but of the fact that we have not followed-up our patients for long enough. Regarding the indications for closed lateral retinacular release, the indications for this procedure are different than for the three in one procedure. I would suggest that Mr Joshi refers to the work by the Lyon group on this topic. Indeed, the patella should not be dislocated, though we consider that an indication for the procedure is given by its position in relative tilting and lateralisation to the femoral grove. We have described in details the methods that can be used for assessment of the condition We stress that, despite advanced imaging, accurate history taking and clinical examination still play the major role.

The issue raised in this point has been debated many times. As any form of soft tissue surgery, this procedure is more likely to fail in hyperlax patients (see, for example, multidirectional instability of the gleno-humeral joint). Indeed, we agree with Mr Joshi that, in such patients, conservative management should be the main intervention. Nevertheless, as in the shoulder, more and more surgeons are operating in patient in whom conservative measures fail. Myers et al (1999) went to great lengths to stress that the ‘three in one’ is not a ‘set menu’ approach to the problem, and that each step should be performed only if the surgeon deemed that what had been performed was not enough to stabilise the patella.3 We abide by the same principle. As in many other forms of surgery, the definitive answer to the query posed by Mr Joshi will only come from randomised controlled trials. It should be acknowledged, however, that given the selection criteria for this procedure and the numbers involved, such trials are not easy to plan, implement and conclude. No author would ever recommend that his/her procedure is adopted in a ‘carpet bombing’ fashion. If such an approach was adopted, a large number of problems would arise, and the procedure would fall into disrepute. The fact that a procedure should be offered for carefully selected indications and that it is technically demanding should prompt interested surgeons to study, train, and become proficient at it before offering it to their patients.

REFERENCES

1. Beaconsfield T, Pintore E, Maffulli N, Petri GJ. Radiological measurements in patellofemoral disorders. Clin Orthop 1994; 308:18-28.

2. Beaconsfield T, Maffulli N, Chan KM. Patello-femoral disorders: an imaging approach. In Controversies in Orthopedic Sports Medicine. Hong Kong: Williams and Wilkins Asia-Pacific Ltd; 1998. P. 256-71.

3. Myers P, Williams A, Dodds R. The three-in-one proximal and distal soft tissue patellar realignment procedure. Results and its place in the management of patello femoral instability. Am J Sports Med 1999; 27(5): 575-79.

Yours sincerely, 

Nicola Maffulli Professor of Trauma and Orthopaedic Surgery, Keele University School of Medicine Staffs, UK