of 2 /2
848 sealed ruptures are likely to proceed to uncontrolled rupture.7,8 These findings in symptomatic aneurysms show that aortic rupture can be recognised at an earlier stage and much more frequently than hitherto. Surgical repair in this category of chronic contained ruptured aneurysms can be achieved safely, with a mortality approaching that of elective operations in symptom-free patients. Some vascular surgeons regard back and abdominal pain in aneurysm patients as such ominous signs that they operate on the day of diagnosis.9 Others will prefer to take their time with preoperative assessments of pulmonary, cardiac, and renal function since incompletely assessed patients undergoing emergency graft replacement have a four-fold higher operative mortality than those having similar operations done electively. 10 SURGICAL MANPOWER RESTRAINT of public expenditure has lately been the leading concern of Government policy. As a component of this policy, public sector managers have come under increasing pressure to operate at minimum cost and, in the NHS, to reduce activities to whatever can be afforded and no more. To facilitate control over expenditure the number of clinical service posts with tenure (consultants) has been more or less held constant for some years. Promised consultant expansion has conveniently become lost in committees whose delay in reaching decisions is a more respectable manpower control than straight political refusal to fund posts. The acute specialties, and especially surgery, have historically not been so underprovided as the so-called "caring services". But this is changing. A survey of general surgical manpower within the UK commissioned by the Royal College of Surgeons of Englandl confirms the shortfall in numbers of consultant surgeons and their uneven distribution, and comments on Britain’s adverse position by comparison with its Western neighbour nations. Britain is bottom of the league for provision of surgeons—eg, Britain has 1 general surgeon per 100 000 population, whereas West Germany has 12, and similarly 1 ophthalmologist whereas Belgium has 6. The statistics speak for themselves but graphic representation of these facts as serried ranks of surgical homunculi in the report gives the following positions in the league table: Belgium 11, West Germany 12, Netherlands 6, Italy 9, USA 11, and UK 2. However coloured, this diagram would make a poor election poster for any party manifesto! It is worth recalling that the paucity of surgical manpower is as much a product of the parsimony of the past as it is of the perfidy of the present. Ministers constantly remind us of the extra resources available and how much more work is being done each year in the NHS; the RCS report confirms, in the light of such boasts of increased output, how efficient British surgeons really are to achieve all they have. British surgery has much to commend it. Despite the lack of 7. Darling RC. Ruptured artenosclerotic abdominal aortic aneurysms: A pathologic and clinical study. Am J Surg 1970; 119: 397-401. 8. Szilagyi DE, Smith RF, Macksoon AJ, et al. Expanding and ruptured abdominal aortic aneurysm. Arch Surg 1961; 83: 83-96. 9. Lawne GM, Moms GC, Crawford ES, et al. Improved results of operation for ruptured abdominal aortic aneurysms. Surgery 1979; 85: 483-88. 10 Johnson G, McDeVitt NB, Proctor HJ, et al. Emergent or elective operation for symptomatic abdominal aortic aneurysm. Arch Surg 1980; 115: 51-53. 1. Royal College of Surgeons of England. Commission on the provision of surgical services General surgical manpower within the United Kingdom. London: RCS, 1986. 2. Anonymous. Surgical supply and demand. RCS concerned at widening gap. Lancet 1986; i: 1511. personnel, surgeons in the UK work harder and do more operations than their counterparts abroad. Nevertheless, it seems doubtful that they can become any more efficient or even do any more operating and hope to maintain standards. Taken together with a report on outpatient services3 which presses for more new patients to be seen in surgical clinics, the average surgeon must be wondering how reasonable standards of work, how reasonable hours of work, and how more work can all be accomplished without more resources. Sausage machine surgery, either "quantity" or "efficiency", is no substitute for the individualised consultant care, "quality", that the NHS should provide. Relentless pursuit of this efficiency is beginning to challenge the previously high standards of care of which British surgery was rightly proud. The adverse situation is further compounded by local initiatives which have organised iinproved surgical services in some districts, and thereby raised public expectations locally to the envy of less fortunate districts elsewhere. Action is needed; the ratio of general surgical consultants to population of 1 to 27 000 in Scotland, 1 to 27 900 in Northern Ireland, 1 to 44 600 in Wales, and 1 to 47 900 in England needs balancing. And the huge discrepancies between regions and districts need evening out too. Subtraction from the better off (who are poorly off by international standards) will not improve the situation for anyone. The case for more surgical provision is now formidably made. Government should be haunted by the diminutive size of the UK surgical battalion compared with its NATO partners. BIOCOMPATIBLE IMPLANTS FOR RECONSTRUCTION OF THE EAR EARLIER this year an entire meeting of the Section of Otology of the Royal Society of Medicine was given over to a discussion of techniques for reconstruction of the ossicular chain, reflecting continued interest in new methods and materials for use in ossiculoplasty. Since this type of surgery was introduced in the 1950s, natural materials have been most widely used. Bone chips’ and cartilage, either autoge- nous tragal car-tilages°6 or homograft nasal septum,6,7 gave good results initially. However, homograft or autograft ossicles have proved more satisfactory in the long term, and must now be regarded as the standard materials for ossicular reconstruction.7-10 Homograft ossicles must be harvested and stored in suitable solutions, and resorption or ankylosis may be. a long-term complications In addition, it may be difficult to fashion the ossicles to fit the defect accurately.13 Because of these drawbacks the search for suitable alloplastic implants continues. In the past otologists have used 3. Institute of Health Services Management. Action on outpatient services—time to move. London: IHSM, 1986. 4. Bauer RR. Autografts for ossicular reconstruction. Arch Otolaryngol 1966; 83: 335-38. 5. Shea JJ, Glasscock ME III. Tragal cartilage as an ossicular substitute. Arch Otolaryngol 1967; 86: 308-17. 6. Jansen C. Cartilage tympanoplasty. Laryngoscope 1963; 73: 1288-302. 7. Smyth GDL, Jones JH, Kerr AG. Management of ossicular chain defects. J Laryngol Otol 1967; 81: 1325-35. 8. Guildford FR. Tympanoplasty: Use of prostheses in the conduction mechanism. Arch Otolaryngol 1964; 80: 80-86. 9. Campbell EE. Tympanoplasty using homograft tympanic membrane and ossicles. Laryngoscope 1978; 88: 1363-77. 10. Lang J, Kerr AG Smyth, GDL. Long term viability of transplanted ossicles. J Laryngol Otol 1986; 100: 741-47. 11 Brackman DE, Sheehy JL. Tympanoplasty: PORPS and TORPS. Laryngoscope 1979; 89: 108-14. 12. Grote JJ. Reconstruction of the ossicular chain with hydroxyapatite implants Ann Otol Rhinol Laryngol 1986; 95 (suppl 123): 10-12. 13. Reck R. Bioactive glass ceramics in ear surgery: Animal studies and clinical results. Laryngoscope 1984; 94 (suppl 33): 1-54.

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Page 1: BIOCOMPATIBLE IMPLANTS FOR RECONSTRUCTION OF THE EAR

848

sealed ruptures are likely to proceed to uncontrolled

rupture.7,8These findings in symptomatic aneurysms show that

aortic rupture can be recognised at an earlier stage and muchmore frequently than hitherto. Surgical repair in this

category of chronic contained ruptured aneurysms can beachieved safely, with a mortality approaching that of electiveoperations in symptom-free patients. Some vascular

surgeons regard back and abdominal pain in aneurysmpatients as such ominous signs that they operate on the dayof diagnosis.9 Others will prefer to take their time withpreoperative assessments of pulmonary, cardiac, and renalfunction since incompletely assessed patients undergoingemergency graft replacement have a four-fold higheroperative mortality than those having similar operationsdone electively. 10

SURGICAL MANPOWER

RESTRAINT of public expenditure has lately been theleading concern of Government policy. As a component ofthis policy, public sector managers have come under

increasing pressure to operate at minimum cost and, in theNHS, to reduce activities to whatever can be afforded andno more. To facilitate control over expenditure the numberof clinical service posts with tenure (consultants) has beenmore or less held constant for some years. Promisedconsultant expansion has conveniently become lost incommittees whose delay in reaching decisions is a more

respectable manpower control than straight political refusalto fund posts. The acute specialties, and especially surgery,have historically not been so underprovided as the so-called"caring services". But this is changing.A survey of general surgical manpower within the UK

commissioned by the Royal College of Surgeons of

Englandl confirms the shortfall in numbers of consultantsurgeons and their uneven distribution, and comments onBritain’s adverse position by comparison with its Westernneighbour nations. Britain is bottom of the league forprovision of surgeons—eg, Britain has 1 general surgeon per100 000 population, whereas West Germany has 12, andsimilarly 1 ophthalmologist whereas Belgium has 6. Thestatistics speak for themselves but graphic representation ofthese facts as serried ranks of surgical homunculi in thereport gives the following positions in the league table:Belgium 11, West Germany 12, Netherlands 6, Italy 9, USA11, and UK 2. However coloured, this diagram would makea poor election poster for any party manifesto!

It is worth recalling that the paucity of surgical manpoweris as much a product of the parsimony of the past as it is ofthe perfidy of the present. Ministers constantly remind us ofthe extra resources available and how much more work is

being done each year in the NHS; the RCS report confirms,in the light of such boasts of increased output, how efficientBritish surgeons really are to achieve all they have. Britishsurgery has much to commend it. Despite the lack of

7. Darling RC. Ruptured artenosclerotic abdominal aortic aneurysms: A pathologic andclinical study. Am J Surg 1970; 119: 397-401.

8. Szilagyi DE, Smith RF, Macksoon AJ, et al. Expanding and ruptured abdominalaortic aneurysm. Arch Surg 1961; 83: 83-96.

9. Lawne GM, Moms GC, Crawford ES, et al. Improved results of operation forruptured abdominal aortic aneurysms. Surgery 1979; 85: 483-88.

10 Johnson G, McDeVitt NB, Proctor HJ, et al. Emergent or elective operation forsymptomatic abdominal aortic aneurysm. Arch Surg 1980; 115: 51-53.

1. Royal College of Surgeons of England. Commission on the provision of surgicalservices General surgical manpower within the United Kingdom. London: RCS,1986.

2. Anonymous. Surgical supply and demand. RCS concerned at widening gap. Lancet1986; i: 1511.

personnel, surgeons in the UK work harder and do moreoperations than their counterparts abroad. Nevertheless, itseems doubtful that they can become any more efficient oreven do any more operating and hope to maintain standards.Taken together with a report on outpatient services3 whichpresses for more new patients to be seen in surgical clinics,the average surgeon must be wondering how reasonablestandards of work, how reasonable hours of work, and howmore work can all be accomplished without more resources.Sausage machine surgery, either "quantity" or "efficiency",is no substitute for the individualised consultant care,

"quality", that the NHS should provide. Relentless pursuitof this efficiency is beginning to challenge the previouslyhigh standards of care of which British surgery was rightlyproud. The adverse situation is further compounded bylocal initiatives which have organised iinproved surgicalservices in some districts, and thereby raised publicexpectations locally to the envy of less fortunate districtselsewhere.

Action is needed; the ratio of general surgical consultantsto population of 1 to 27 000 in Scotland, 1 to 27 900 inNorthern Ireland, 1 to 44 600 in Wales, and 1 to 47 900 inEngland needs balancing. And the huge discrepanciesbetween regions and districts need evening out too.

Subtraction from the better off (who are poorly off byinternational standards) will not improve the situation foranyone. The case for more surgical provision is now

formidably made. Government should be haunted by thediminutive size of the UK surgical battalion compared withits NATO partners.

BIOCOMPATIBLE IMPLANTS FORRECONSTRUCTION OF THE EAR

EARLIER this year an entire meeting of the Section ofOtology of the Royal Society of Medicine was given over to adiscussion of techniques for reconstruction of the ossicularchain, reflecting continued interest in new methods andmaterials for use in ossiculoplasty. Since this type of surgerywas introduced in the 1950s, natural materials have beenmost widely used. Bone chips’ and cartilage, either autoge-nous tragal car-tilages°6 or homograft nasal septum,6,7 gavegood results initially. However, homograft or autograftossicles have proved more satisfactory in the long term, andmust now be regarded as the standard materials for ossicularreconstruction.7-10Homograft ossicles must be harvested and stored in

suitable solutions, and resorption or ankylosis may be. along-term complications In addition, it may be difficultto fashion the ossicles to fit the defect accurately.13 Becauseof these drawbacks the search for suitable alloplasticimplants continues. In the past otologists have used

3. Institute of Health Services Management. Action on outpatient services—time tomove. London: IHSM, 1986.

4. Bauer RR. Autografts for ossicular reconstruction. Arch Otolaryngol 1966; 83: 335-38.5. Shea JJ, Glasscock ME III. Tragal cartilage as an ossicular substitute. Arch

Otolaryngol 1967; 86: 308-17.6. Jansen C. Cartilage tympanoplasty. Laryngoscope 1963; 73: 1288-302.7. Smyth GDL, Jones JH, Kerr AG. Management of ossicular chain defects. J Laryngol

Otol 1967; 81: 1325-35.8. Guildford FR. Tympanoplasty: Use of prostheses in the conduction mechanism. Arch

Otolaryngol 1964; 80: 80-86.9. Campbell EE. Tympanoplasty using homograft tympanic membrane and ossicles.

Laryngoscope 1978; 88: 1363-77.10. Lang J, Kerr AG Smyth, GDL. Long term viability of transplanted ossicles.

J Laryngol Otol 1986; 100: 741-47.11 Brackman DE, Sheehy JL. Tympanoplasty: PORPS and TORPS. Laryngoscope

1979; 89: 108-14.12. Grote JJ. Reconstruction of the ossicular chain with hydroxyapatite implants Ann

Otol Rhinol Laryngol 1986; 95 (suppl 123): 10-12.13. Reck R. Bioactive glass ceramics in ear surgery: Animal studies and clinical results.

Laryngoscope 1984; 94 (suppl 33): 1-54.

Page 2: BIOCOMPATIBLE IMPLANTS FOR RECONSTRUCTION OF THE EAR

849

polyethylene,8,14,ls ’Teflon’ ,8,15 ‘Proplast’,16 and ’Plas-

tipore’. 11,17 These materials usually give good short-term (upto six months) hearing results, but longer term follow-upreveals a progressively increasing extrusion rate. They allconstitute foreign bodies which are inert and become

encapsulated in soft tissue without exciting a tissue responsefor good or ill.

In 1971 Hench’Il introduced a bioactive vitreous sili-

cophosphate glass ceramic implant material which hassubsequently been used in various types of surgery,including otology. This substance, which is known as’Ceravital’ (Xomed) differs from the earlier implant mater-ials in that it interacts with bone, so that new bone is formedat the bone-implant interface. As a result, a bond is formedbetween the implant and the patient’s remaining ossicles.Such bonding does not, however, occur between theimplant and intact epithelial surfaces and so fixation to othermiddle-ear structures is avoided.13 Satisfactory hearingresults, which are maintained for up to eighteen months,have been reported.13 More recently, a new ceramic

material, composed of hydroxyapatite, has been introduced.This material has a chemical structure which closelyresembles that of bone and is easier to shape with a burr thanceravital. 12 It also bonds to bone by means of new boneformation.19 Results of a clinical trial of hydroxyapatiteimplants in ossicular chain reconstruction have now beenpublished and indicate satisfactory results which may bemaintained for up to four years.’2Ceramic protheses have also been used in another area of

reconstructive ear surgery-to make good defects in theposterior meatal wall produced by mastoid surgery. Open-cavity mastoid operations continue to be widely practised forcholesteatoma as they provide dependable elimination ofdisease. However, mastoid cavities may be complicated bytroublesome discharge and even those which remain dryrequire regular removal of wax. In addition, they areassociated with a significant conductive hearing loss in mostcases. For these reasons attempts have been made toreconstruct mastoid cavities. The mastoid bowl may beobliterated with a temporalis muscle flap,20 a postauricularsoft-tissue flap,21 bone paté,21 or rnethacrylate.22 Alterna-tively, the posterior canal wall may be replaced by anautogenous bone graft,23 cartilage,24 or an artificial materialsuch as proplast.16 These latter techniques have the

advantage that an aerated mastoid bowl can be maintainedand this in turn may facilitate middle-ear reconstruction, if

14. House HP. Polyethylene in middle ear surgery. Arch Otolaryngol 1960; 71: 926-31.15. Portmann M. Management of ossicular chain defects. J Laryngol Otol 1967; 81:

1039-324.16. Shea J, Homsby CA. The use of Proplast (TM) in otologic surgery. Laryngoscope

1974; 84: 1835-45.17. Shea J. Plastipore total ossicular replacement prosthesis. Laryngoscope 1976, 86:

239-40.18. Hench LL, Splinter RS, Allen WC, et al. Bonding mechanisms at the interface of

ceramic prosthetic materials. J Biomed Mater Res 1971, 5 (symposium rep part 2):117-41

19 Grote JJ, Van Blitterswijk CA, Kuijpers W. Hydroxyapatite ceramic as middle earimplant material: animal experiment results. Ann Otol Rhinol Laryngol 1986; 95(suppl 123): 1-5

20 Rambo JHT. Musculoplasty, a new operation for suppurative middle ear deafness.Trans Am Acad Opthalmol Otolaryngol 1958; 62: 166-77.

21 Palva T. Operative technique in mastoid obliteration. Acta Otolaryngol 1973; 75:289-90.

22 Meuser W. Permanent obliteration of old radical cavities combined with tympano-plasty J Laryngol Otol 1984; 98: 31-35

23 Wigand ME, Weidenbecher M, Bumin P, Mollenhauer HW. Tympanoplastik nachRadikaloperation: Mit Konchen oder Knorpel? Arch Otolaryngol 1974; 207:542-44

24 Wehrs R. Reconstructive mastoidectomy with homograft knee cartilage. Laryngoscope1972; 82: 1177-88.

this is being carried out as well. Both ceravital and

hydroxyapatite have been used for posterior wall recon-struction with encouraging early results.13’zsThese new material show promise, but long-term clinical

trials are needed to confirm their place in otological surgery.

WHERE TO DRAW THE LINE

Dear Dr,—Apothicon cordially invites you to attenda 3-day informal workshop on Tranquilliton, thelatest addition to its well-established range of

anxiolytics, to be held in Bermuda, Feb 12-14.

Tempted? The answer to such a clear example ofunwarranted largesse, according to a report from the RoyalCollege of Physicians,l is a firm "no". But what of moresubtle lures?

In February, 1984, it was agreed that a College workingparty should examine the relationship between physiciansand the pharmaceutical industry; 21 years later publicationof its conclusions was greeted in The Times (Oct 3) with theheadline "Keep drug companies at bay, study says". Rathera strange comment when the report declares that "a close

relationship between doctors and the pharmaceuticalindustry is important for the treatment of patients and forthe future development of new drugs", and the President ofthe College has taken pains to stress that the report is notintended as an attack on the industry. Offered is a guide topractising physicians, with the somewhat cosy conclusionthat the recommendations substantially represent the

present practice of most physicians and physicians-in-training.From the report it is far easier to be sure of the permissible

than the impermissible. Small gifts such as diaries and pensare deemed acceptable, for example, as is reasonable (howdefined?) payment for giving ad hoc expert opinion to acompany if the physician takes time and trouble over thematter. The advice on sponsored meetings is to attend onlythose of educational or scientific value, the content of whichhas been selected independently of the sponsor; fees fortravel and other expenses are acceptable, but the primaryinvitation should come from the organising body. Thefrequent provision of light refreshments at postgraduatecentre educational meetings is deemed regrettable (but doesit really "degrade" the profession?), however the suggestionthat Health Authorities should step in and provide thesandwiches is unlikely to be popular with financiallybeleagured HAs. Surely doctors can afford to eat.The guidelines cover many aspects of the physician-

pharmaceutical company relationship with respect to

prescribing and clinical research and trials. The overridingprinciple is that "any benefit in cash or kind, any gift, anyhospitality or any subsidy received from a pharmaceuticalcompany must leave the doctor’s independence ofjudgement manifestly unimpaired"-which seems to

indicate that all drug companies should adopt the policy ofnot providing alcohol at meetings. A useful criterion ofacceptability is suggested: "Would you be willing to havethese arrangements generally known?" Some would saythis leaves plenty of scope for the pachyderms.

25 Grote JJ, Van Blitterswijk CA Reconstruction of the posterior auditory canal wall witha hydroxyapatite prosthesis Ann Otol Rhinol Laryngol 1986; 95 (suppl 123): 6-9.

1. The relationship between physicians and the pharmaceutical industry. A report ofthe Royal College of Physicians London. Royal College of Physicians, 1986