Time delays, patient confusion regarding professional roles and diagnostic indecision are significant problems for patients referred to hospital orthopaedic clinics from MPTT clinics. This risks sub-optimal patient care and may lead to future medicolegal implications.

INTRODUCTION The correction of anaemia prior to total hip arthroplasty reduces surgical risk, hospital stay and cost. This study considers the benefits of implementing a protocol of identifying and treating pre-operative anaemia whilst the patient is on the waiting list for surgery.PATIENTS AND METHODS From a prospective series of 322 patients undergoing elective total hip arthroplasty (THA), patients identified as anaemic (haemoglobin (Hb) <1 2g /dl) when initially placed upon the waiting list were appropriately investigated and treated. Pre-and postoperative Hb levels, need for transfusion, and length of hospital stay were collated for the entire patient cohort.RESULTS Of the cohort, 8.8% of patients were anaemic when initially placed upon the waiting list for THA and had a higher transfusion rate (23% versus 3%; P < 0.05) and longer hospital stay (7.5 days versus 6.6 days; P < 0.05). Over 40% of these patients responded to investigation and treatment whilst on the waiting list, showing a significant improvement in Hb level (10.1 g/dl to 12.7 g/dl) and improved transfusion rate.CONCLUSIONS Quantifying the haemoglobin level of patients when initially placed on the waiting list helps highlight those at risk of requiring a postoperative blood transfusion. Further, the early identification of anaemia allows for the utilisation of the waiting-list time to investigate and treat these patients. For patients who respond to treatment, there is a significant reduction in the need for blood transfusion with its inherent hazards.

INTRODUCTION Deliberate self-harm is a common problem that often requires orthopaedic treatment. Patients with injuries due to deliberate self-harm are often referred to our unit. This study assessed the type of treatment required and the cost of treatment. PATIENTS AND METHODS We undertook a retrospective survey of deliberate self-harm patients with known ICD-10 psychiatric disorders admitted for orthopaedic care from a medium-secure, female-only, psychiatric unit. Data were collected on admission rate, duration of stay, surgical interventions and complications. RESULTS Over a 36-month period there were 73 admissions for 15 patients (mean age, 25.1 years) requiring 65 operative interventions, a mean of 4.3 (range, 0-9) per patient. Over 50% of patients were admitted more than 3 times, totalling 416 hospital bed-days and 80% had methicillin-resistant Staphylococcus aureus (MRSA) isolated. The orthopaedic treatment costs for these patients was £453,000 during the period studied. DISCUSSION The significant resources required to manage this patient cohort demonstrates the need for a co-ordinated management policy. We recommend day-case surgery for infected wounds only. Postoperatively, wounds should be protected with plaster of Paris. All patients with deliberate self-harm should be regarded as being infected with MRSA.

INTRODUCTIONThe peak incidence of venous thrombo-embolism (VTE) occurs 3 weeks following hip arthroplasty surgery and current guidelines proposing VTE prophylaxis continuing for 4 weeks after surgery. This study first compares the duration of treatment and satisfaction between patients prescribed low molecular weight heparin (LMWH) and rivaroxaban, a new oral Factor Xa inhibitor, following elective hip arthroplasty; and second, surveys the duration of LMWH use in other units. SUBJECTS AND METHODS An international survey detailing the use of LMWH was performed. A prospective audit was performed of 100 hip replacements, with 50 prescribed 40 mg once daily of subcutaneous enoxaparin and subsequently 50 patients prescribed 10 mg once daily of oral rivaroxaban. The duration of treatment, patient satisfaction and complications for both cohorts was quantified and compared against published evidence-based guidelines. RESULTS The survey demonstrated that four out of 39 (10.2%) units that routinely prescribe LMWH do so for at least 4 weeks following surgery. The audit demonstrated that rivaroxaban afforded a superior mean duration of postoperative VTE prophylaxis (35 days vs 5.4 days; P < 0.05) and superior patient satisfaction. There was no difference in the incidence of bleeding, wound infection or thrombotic complications. CONCLUSIONS This study demonstrates that patients are exposed to an increased VTE risk following hip replacement surgery due to the inadequate prescription of LMWH. This is poor clinical practice, contrary to current evidence-based guidelines and has potential medicolegal implications. The prescription of rivaroxaban affords a superior patient compliance compared with subcutaneous LMWH, thus ensuring that patients receive VTE prophylaxis for the current recommend period of time.

INTRODUCTION This prospective audit studies the use of cross-matched blood in 301 patients over a 1-year period undergoing total knee (TKR) and total hip replacement (THR) surgery in an orthopaedic unit. PATIENTS AND METHODS Analysis over the first 6 months revealed a high level of unnecessary cross-matched blood. The following interventions were introduced: (i) to cease routine cross-matching for THR; (ii) all patients to have a check full blood count on day 2 after surgery; and (iii) Hb < 8 g/dl to be considered as the trigger for transfusion in patients over 65 years and free from significant co-morbidity. RESULTS In the next 6 months, the number of units cross-matched but not transfused fell by 96% for THR, and the crossmatch transfusion (C:T) ratio reduced from 3.21 to 1.62. Reductions were also observed for the TKR cohort. These results provide evidence of a substantial risk and cost benefit in the use of this limited resource. A telephone survey of 44 hospitals revealed that 20 hospitals routinely cross-matched blood for THR and 11 do so for TKR.CONCLUSIONS Changes can be made to the Maximum Surgical Blood Ordering Schedules (MSBOS) in other orthopaedic units according to national guidelines. KEYWORDSTotal hip replacement -Total knee replacement -Cross-match transfusion ratio (C/T) -Maximum Surgical Blood Ordering Schedule (MSBOS)