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Aspects of Current Management: A. J. Timperley and S. L. Whitehouse Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur J Bone Joint Surg Br 2009; 91-B: 851-854 [Abstract] [Full text] [PDF]

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Cementing the evidence to deliver safer patient care

Sukhmeet S Panesar, Philip Roberts, John Scarpello, Kevin Cleary, Mohit Bhandari, and Aziz Sheikh   (7 August 2009)

Cementing the evidence to deliver safer patient care 7 August 2009
Sukhmeet S Panesar, Clinical Advisor to the Medical Director National Patient Safety Agency, Philip Roberts, John Scarpello, Kevin Cleary, Mohit Bhandari, and Aziz Sheikh Send letter to journal: Re: Cementing the evidence to deliver safer patient care sukhmeet.panesar{at}npsa.nhs.uk Sukhmeet S Panesar, et al.	Sir, We welcome the article by Timperley et al which acknowledges the recommendations made by the recent National Patient Safety Agency (NPSA) Rapid Response Report (RRR).1 In undertaking this work, it was clear that there was plurality of discourse on the issue of cemented versus non-cemented arthroplasties within the orthopaedic community. We agree with the value of specialised protocols where and when cement is used. These, together with other points that provide guidance on mitigating the risk in patients undergoing hip arthroplasty, are mentioned in our report.1 Whereas Timperley et al correctly point out the low number of deaths reported to the National Reporting and Learning System (NRLS), a voluntary reporting system, this figure may conceal a higher number which have not been reported. These deaths are likely to have occurred during the early peri-operative phase and we doubt that current research methodologies will ever pick up the true impact of the problem. Higher quality evidence remains conspicuously absent. 2-4 The question remains regarding the 26 deaths. Do we accept these as an insignificant number and consider them as expected surgical mortality or do we try and prevent future recurrences? The Chief Medical Officer’s annual report (2007) stressed the need to find ways of reducing bone-cement implantation syndrome.5,6 One way of facilitating greater clarity about safety considerations would be for orthopaedic surgeons and anaesthetists to continue reporting possible safety incidents related to bone cement to the NPSA in as much detail as possible, to allow meaningful interrogation of these data.1 Perhaps the orthopaedic community would also consider using innovative research methodologies to assess the complications of cemented versus uncemented prostheses? We look forward to working with other stakeholders such as the National Joint Registry (NJR), quality control bodies such as the National Institute for Health and Clinical Excellence (NICE) that are in a position to recommend on the best form of fixation and the orthopaedic community to promote the development of a robust evidence base in this neglected area. S.S. Panesar, Clinical Advisor to the Medical Director, P. Roberts, J. Scarpello, K. Cleary, M. Bhandari, A. Sheikh, National Patient Safety Agency, London, UK. 1. National Patient Safety Agency. Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur. http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/mitigating-risks -when-using-bone-cement-in-hip-surgery/ (accessed 30/07/09) 2. Parker MJ, Gurusamy K. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2006;3:CD001706. 3. Ahn J, Man LX, Park S, Sodl JF, Esterhai JL. Systematic review of cemented and uncemented hemiarthroplasty outcomes for femoral neck fractures. Clin Orthop 2008;466:2513-8. 4. Cai XZ, Chen XZ, Yan SG. Letter to the editor: cemented hemiarthroplasty confers less pain and better mobility than uncemented hemiarthroplasty. Clin Orthop 2009;467:582-4. 5. Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome. Br J Anaesth 2009;102:12-22. 6. Department of Health. On the state of public health: annual report of the Chief Medical Officer 2007. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/AnnualReports/DH_086176 (accessed 30/07/09).