25, 50 and 75 years ago

Increasing emphasis has recently been placed on quality assurance in surgical treatment and care. To provide the necessary basis for these evaluations, measures of outcome such as clinical indicators have been proposed. Thus, working with the Australian Council on Healthcare Standards (ACHS) Care Evaluation Programme, the Royal Australasian College of Surgeons (RACS) introduced ~50 clinical indicators for surgical practice in 1996. Clinical indicators address early outcomes of acute care and are intended to act as flags to promote internal review of performance in hospital. They do not stand alone as absolute measures of the quality of medical care. Excellence in medical care is generally reflected in a low incidence of adverse outcomes. Adverse outcomes are thus often employed in designating clinical indicators. It is at present unclear what measures of outcome might most appropriately be used as clinical indicators for orthopaedic surgery. Clinical indicators should be simple to define clearly, specific, independent and easy to record. Provision should be made for periodic updating and revision of indicators according to changing needs and the work of the institution. Based on the prospective recording of possible clinical indicators for orthopaedic surgery at Nepean Hospital, we recommend dislocation of a hip arthroplasty, DVT, and development of heel pressure areas as useful clinical indicators in orthopaedic surgery. These clinical indicators should serve as measures of outcome for each of the important aspects of patient care in orthopaedics, namely surgical, general medical and nursing care. The outcome of surgical repair for recurrent anterior instability of the shoulder at the Wellington Hospital was reviewed. A retrospective review was undertaken of patients undergoing surgical repair for recurrent anterior instability of the shoulder at Wellington Hospital between October 1989 and November 1996. Patients were asked to complete two shoulder-specific ques-questionnaires, and the range of motion, stability, and strength was evaluated clinically. A total of 37 patients (38 shoulders) who had recurrent anterior dislocation of the shoulder that was unresponsive to a physician-directed rehabilitation programme were managed with open surgical repair. Procedures included the Putti–Platt, Bristow, Magnuson–Stack, Botychev, and Bankart repairs. The mean age at the time of surgery was 24 years and the male-to-female ratio was 11.3:1. Surgery was performed on the dominant side in 63.2% of shoulders. The postoperative redislocation rate was 39.4% at an average of 4.6 years follow-up. Three patients have since required revision of their surgical repair and one patient is awaiting revision. A total of 63.2% of patients were unable to return to their previous level of sports. Differences existed between the motion in the surgically treated shoulder when compared with the contralateral side. Patients reported the most functional difficulty in throwing, working overhead, pulling, and working at shoulder level. The results of the present study indicate a high redislocation rate, and highlight the challenges in restoring a stable, mobile, functional shoulder. This very erudite and comprehensive account of sympathectomy from a historical perspective highlights the Australian contribution to the operation, particularly from Norman Royle (lumbar sympathectomy), Bernard O'Brien (digital vessel sympathectomy) and John Royle (laparoscopic lumbar sympathectomy). Post-mortem examination of 130 subjects demonstrated a relatively high incidence of ulcerated atherosclerotic lesions of the aortic arch and proximal great vessels. The most commonly affected location was the origin of the brachiocephalic artery (Fig. 1). Two patients are described in whom retinal embolism probably originated from this source. Ulceration of the brachiocephalic artery and other proximal great vessels may be an important source of ocular and neurological disability, as well as constituting a hazard for arteriographic catheters negotiating these arteries, such as occurs during arch aortography and selective catheterization of the brachiocephalic artery. A review of 11 patients with 19 popliteal aneurysms is presented. Seven episodcs of acute ischaemia due to thrombosis of the popliteal aneurysm necessitated major limb amputation in five patients in spite of attempts to save the limb by sympathectomy or vein-bypass grafting. Conversely, in 11 limbs with asymptomatic aneurysms, large aneurysms causing pressure symptoms, or aneurysms with distal embolization, all aneurysms were reconstructed with a bypass graft. All but one limb survived for periods ranging from 4 months to 4 years. One patient was considered unfit for surgery on medical grounds. Our experience shows that once acute ischaemia has occurred as a result of a popliteal aneurysm, the results of treatment are bad, and amputation is likely. If the limb survives, there is usually (1) persistent ischaemia. Small aneurysms, as well as large ones, are liable to complications. We recommend that all popliteal aneurysms should be treated prophylactically by saphenous vein bypass, provided that there is no medical contraindication. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians.