Regional nerve block for upper limb surgery is an established procedure. Our study was undertaken to look at the patient experience of this. We prospectively studied 59 consecutive patients undergoing shoulder arthroscopic surgery under regional anaesthesia in our department. They completed a questionnaire which they brought back at their first follow up appointment. The questionnaire gathered information of their experience of anaesthesia and surgery, adequate postoperative information. We reviewed if intra-operative pain occurred and if the patients would undergo such a procedure again. All surgeons were upper limb specialists.3 out of 59 patients required conversion to general anaesthetic (5%) due to failure of the block. The introduction of the block was mainly painless;with patients giving a mean scoring of 0.59 on the visual analog pain score (VAS, range 0–5). 26 patients (44%) expressed interest and watched their operation. Of those, 7 patients felt anxious after having the proceedings explained.1 patient discontinued to watch due to this. 10 patients experienced intraoperative pain, 2 requiring local anaesthetic, 8 receiving sedation, giving a mean score of 3.2 on the VAS. 81.4% of patients would have surgery with regional anaesthetic again, 85% would recommend to others. 83% of patients received adequate information. Overall satisfaction of the experience was rated out of 10, with a mean score of 8.7 (median 9). Regional blocks are an established technique. Since patients are awake and can watch their surgery, it is important to consider the patients perception of this experience. The majority of viewing patients were reassured by explanations of their pathology. Most patients would undergo another procedure with regional anaesthesia and would recommend it, suggesting that this is an effective and popular choice. The overall experience is positive. This supports our intention of offering regional blocks for all upper limb surgery, facilitating increasing use of day case facilities, reducing inpatient stays

Aim. To see if minor upper limb surgery procedures like CTR, Trigger release, Joint injections are safe for a remote telephonic review by specialist nurse. This arrangement was to help maintain our current agreed departmental New to Follow up ratio of 1:1.56 and also to improve access to specialist clinics. Methods. This was a prospective study. Patients undergoing minor procedures were informed about the remote follow up arrangements when placed on waiting list and on the day of surgery. Patients were assured access to clinic up to 3 months after procedure. A specialist nurse undertook a telephone consultation at 2 and 6 weeks using a proforma provided by the Consultant. Results. From Dec 2012 to June 2014, we have undertaken a total of 155 minor procedures in 134 patients. We were unable to contact 15 (11%) patients for remote review. Twelve of 39 (30%) in injection subgroup requested repeat injections, they were added to the waiting list saving OPD visit 3(8%) based on response to treatment. In Procedure subgroup 20 needed review of which 15 were reassured and discharged. Only 5 needed further investigations and follow ups. Twenty-three (15%) out of 155 procedures needed review in clinic. We used available resources prudently avoiding follow up without clinical benefit for 85% of our patients. Five adverse reactions were reported but none of them had complications related to procedure nor did we receive any complaints. Conclusion. Based on our pilot study “Remote Review” of patients is safe in carefully selected procedures. This innovative arrangement helped us improve the specialist access for more new patients without compromising the patient safety

Introduction. Brachial plexus blocks are used widely to provide intra-operative and post-operative analgesia. Their efficacy is well established, but little is known about discharging patients with a numb or weak arm. We need to quantify the risk of complications for improved informed consent. Objectives. To assess whether patients can be safely discharged from hospital before the brachial plexus block has worn off and record any complications and concerns. Study design. Prospective cohort study. Methods. 319 consecutive patients who had a brachial plexus block alone or combined with a general anaesthetic for upper limb surgery were assessed. The adequacy of the block and the outcome of the block was assessed. Results. 238 patients received a general anaesthetic as well as the block and 81 patients received a brachial plexus block alone. The mean time to discharge was 27.5 hours (2-308 hours). Sensation recovered in 15.8 hours (SD- 15.9) and motor power recovered in 15.6 hours (SD- 13.3). The most frequent complication was swelling of the limb which occurred in 8 patients. 7 patients (2.2%) developed Horner's syndrome, 4 patients (1.3%) developed phrenic nerve anaesthesia and 2 patients (0.6%) developed a pneumothorax. Eleven patients had prolonged numbness of >24 hours following the block without any untoward effect. 287 patients (90%) were happy to care for themselves following discharge. Conclusion. Patients can be discharged before the brachial plexus block has worn off with good advice. Patients should be warned of symptoms of Horner's syndrome and phrenic nerve anaesthesia

Used routinely in maxillofacial reconstructive surgery, the chondrocostal graft is also applied to hand surgery in traumatic or pathologic indications. The purpose of this overview was to analyze at long-term follow-up the radiological and histological evolution of this autograft, in hand and wrist surgery. We extrapolated this autograft technique to the elbow by using perichondrium.

Since 1992, 148 patients have undergone chondrocostal autograft: 116 osteoarthritis of the thumb carpometacarpal joint, 18 radioscaphoid arthritis, 6 articular malunions of the distal radius, 4 kienbock's disease, and 4 traumatic loss of cartilage of the proximal interphalangeal (PIP) joint. Perichondrium autografts were used in 3 patients with elbow osteoarthritis.

Magnetic Resonance Imaging (MRI) was performed in 19 patients with a mean follow-up of 68 months (4–159). Histological studies were performed on: i) perioperative chondrocostal grafts (n=3), ii) chondrocostal grafts explanted between 2 and 48 months after surgery (n=10), and iii) perioperative perichondrium grafts (n=2).

Whatever the indication, the reconstruction by a chondrocostal/ostochondrocostal or perichondrium graft yielded satisfactory clinical results at long-term follow-up. The main question was the viability of the graft.

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For rib cartilage grafting: The radiological study indicated the non-wear of the graft and a certain degree of ossification. The MRI and histology confirmed a very small degree of osseous metaplasia and graft viability. The biopsies showed neo-vascularization of the cartilage that had undergone morphological, constitutional and architectural changes. Comparison of these structural modifications with perioperative chondrocostal graft histology is in progress.

Despite the strong mechanical strain in the hand and wrist, chondrocostal graft is a biological arthroplasty that is trustworthy and secure over the long term, although it can cause infrequent complications inherent to this type of surgery. Despite the inevitable histological modification, the cartilage remains alive and is of satisfactory quality at long term follow-up and fulfills the requirements for interposition and reconstruction of an articular surface.

The perichondrium graft constitutes a new arsenal to cure cartilage resurfacing. The importance of perichondrium for the survival of the grafted cartilage, as previously reported, as well as its role in resurfacing, is being investigated.

Various kinds of bone have been used as a donor for vascularised bone grafts (VGF) to the upper extremities; among them the fibula has been widely used because of its structural characteristics and low donor site morbidity. Vascularised fibular graft is indicated in patients with large bone defects, bone tumour resection, established or infected non-union, congenital pseudarthrosis, avascular necrosis or bone defects surrounded by scarred, infected and poorly vascularised soft tissue or failure of conventional techniques.

Between 1994 and 2003 nine patients were treated with vascularised fibular graft (VFG) and five for reconstruction of upper extremities defects, following trauma of the forearm with failure of conventional treatments. Four were male and one were female; the mean age was 32 years; the reconstructed sites were four radius and one ulna. The mean lengths of the bone defect was 9 cm. All patients were evaluated pre-operatively with angiography and/or magnetic resonance imaging. Two patients had a concomitant arthrodesis of the wrist. The bone graft was stabilised with plates (AO/LCP), screws, K-wires and the forearm was immobilised in plaster or with external fixation for several months. Cancellous iliac bone graft was packed about the proximal and distal junctions. In two recent cases autologous platelet gel was added at the sites of fixation.

Bone healing was assessed clinically by the absence of pain and mobility on stress, and radiologically. Patients’ satisfaction and function results were assessed by the DASH questionnaire. After an average duration of follow-up of 48 months (from December 1996 to December 2003), all but one of the patients had radiographic evidence of osseous union of both bone junctions. All wounds healed primarily and no patient had problems related to the donor leg. Three patients had returned to their pre-injury occupation.

Vascularised fibula transfer is a valuable technique for the reconstruction of extensive long-bone defects in the upper extremities. The fibula allows a transfer of a bone that is structurally similar to the radius and is of sufficient length for the reconstruction of most skeletal defects in the forearm. In these serious forearm injuries, rapidity of fracture healing is not the primary issue, but rather control of infection and bone stability. The only disadvantage of VFG is that it is more costly; because more technical expertise is required for the microvascular work and the operating time is extended. The reliability and the value of vascularised fibula transfer will increase, with further experience, careful patient selection and appropriate pre and post-operative technical details.

In the last few years the study of the biology of fracture repair processes has isolated chemical mediators that induce and modulate bone repair. In orthopaedic surgery and traumatology, in cases of unsuccessful fracture setting, loss of bone and in the treatment of bone cavities it is advisable to associate a biological substitute in order to restore bone continuity and to maintain the mechanical properties of the skeletal segment.

Platelets contain several growth factors (PDGF, TGFβ, EGF, IGF) capable of stimulating the proliferation of mesenchymal and mature cells such as fibroblasts and osteoblasts. The autologous platelet gel is obtained by separating and concentrating platelets from 450 ml of a patient’s blood. This procedure is simple, with a low risk of infections. It is free of immunogenic risk and it is comparatively cheap, considering the risk connected with a possible graft of homologous bone or with the use of allo- or xenograft.

From 2003 we applied autologous platelet gel in eight patients: two cases of humerus pseudoarthrosis for exposed and plurifragmentary fractures, one with vascular and nerve injury; one forearm infected pseudoar-throsis with loss of bone and soft tissues caused by local drug injections; one infected ulnar pseudoarthrosis for high energy exposed proximal forearm and elbow fracture; one distal radius non-union after sub-amputation of distal forearm; one distal radius resection for TGC and implant of allograft epiphysis; one massive osteomyelitis of entire forearm after exposed distal radius fracture; and one humerus fracture in re-implanted arm with elbow arthrodesis.

The patients were treated with surgical curettage of bone, iliac bone graft and autologous platelet gel; two received a vascularised fibular graft, all stabilised with internal fixation and six stabilised also with external fix-ation. They were immobilised for a mean of 3 months; then with a partial tutor they started physiotherapy. At the follow-up they were evaluated clinically and radiologically and with the DASH score.

None of the patients had local or general post-operative complications; X-ray showed the restoration of regular skeletal filling. Only in one case was bone reabsorption seen in the distal humerus. All patients were satisfied and four of them returned to their pre-surgical occupation.

The results of this application are difficult to standardise because of the complexity of each case. Imaging techniques are currently the only means to validate the remodelling process and to demonstrate its faster pace with platelet gel application. We are satisfied by the use of autologous platelet gel as a possible co-treatment in cases characterised by multiple surgical treatments with inactive pseudarthrosis and osteoepenia. The application is also simple, and the cost is relatively low with respect to the results obtained.

Periprosthetic joint infections (PJIs) and osteosynthesis-associated infections (OSIs) present significant challenges in trauma and orthopaedic surgery, substantially impacting patient morbidity, mortality, and economic burden. This concern is heightened in patients with pre-existing comorbidities, such as diabetes mellitus, which are not always modifiable at presentation. A novel intraoperative strategy to prevent these infections is the use of Defensive Antibacterial Coating (DAC), a bio-absorbable antibiotic-containing hydrogel applied to implant surfaces at implantation, acting as a physical barrier to prevent infection. The purpose of this study is to assess the use of a commercially available hydrogel (DAC), highlighting its characteristics that make it suitable for managing PJIs and OSIs in orthopaedics and traumatology. Twenty-five patients who underwent complex orthopaedic procedures with intraoperative application of DAC between March 2022 and April 2023 at a single hospital site were included. Post-operative assessment encompassed clinical, laboratory, and radiographic examinations. In this study, 25 patients were included, with a mean age of 70 ± 14.77 years and an average ASA grade of 2.46 ± 0.78. The cohort presented an average Charleston Comorbidity score of 5.45 ± 2.24. The procedures included 8 periprosthetic fractures, 8 foot and ankle surgeries, 5 upper limb surgeries, and 4 elective hip and knee surgeries. Follow-up assessments at 6 weeks and 6 months revealed no evidence of PJI or OSI in any patients, nor were any treatments for PJI or OSI required during the interim period. DAC demonstrated efficacy in preventing infections in high-risk patients undergoing complex orthopaedic procedures. Our findings warrant further investigation into the use of DAC in complex hosts with randomized control trials

Yes the paradigm is changing!!!. Refinement of surgical techniques, anesthesia protocols, and patient selection has facilitated this transformation to same day discharge for arthroplasty care. The trend for early discharge has already happened for procedures formerly regarded as “inpatient” procedures such as upper extremity surgery, arthroscopy, ACL reconstruction, foot and ankle procedures, and rotator cuff repair. Our program began focused on Partial Knee Arthroplasty (PKA) and has now expanded to primary TKA and THA, and select revision cases. Over the past few years we have performed: 138 TKA, 111 THA, 244 Partial KA, 6 RevTKA, and 6 RevTHA with no readmissions for pain control. With preoperative Hgb above 11 combined with Tranexamic Acid we have had no transfusions. Medical optimization is critical to the safety and success of patient selection for same day discharge. We utilise a standardised format for preadmission testing. The program centers on the patient, their family, home recovery, preoperative education, efficient surgery, and represents a shift in the paradigm of arthroplasty care. It can be highly beneficial to patients, surgeons, anesthesia, facility costs, and payors as arthroplasty procedures shift to the outpatient space

Refinement of surgical techniques, anesthesia protocols, and patient selection has facilitated this transformation to same day discharge for arthroplasty care, most notably Partial Knee Arthroplasty (PKA). The trend for early discharge has already happened for procedures formerly regarded as “inpatient” procedures such as upper extremity surgery, arthroscopy, ACL reconstruction, foot and ankle procedures, and rotator cuff repair. Our program began focused on PKA and has now expanded to primary TKA and THA, and select revision cases. Over the past few years we have performed 1,230 knee arthroplasty procedures with no readmissions for pain control. Average age and age range is identical to our inpatient cohort for our partial knee cases. Patient selection is based on medical screening criteria and insurance access. PKA is the ideal procedure to begin your transition to the outpatient space. We currently perform medial PKA, lateral PKA, and patellofemoral arthroplasty as an outpatient. The program centers on the patient, their family, home recovery, preoperative education, efficient surgery, and represents a shift in the paradigm of arthroplasty care. It can be highly beneficial to patients, surgeons, anesthesia, facility costs, and payors as arthroplasty procedures shift to the outpatient space. Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay in the inpatient hospital environment opening the opportunity for cost savings and even outpatient joint replacement surgery for appropriately selected patients. The hallmark of this program is meticulous protocol execution. Preemptive pain control with oral anti-inflammatory agents, gabapentin, regional anesthetic blocks that preserve quad function for TKA (adductor canal block) and pericapsular long acting local anesthetics with the addition of injectable ketorolac and IV acetaminophen are key adjuncts. Over the past two years utilizing this type of program over 60% of our partial knee replacement patients are now returning home the day of surgery. Concerns over readmission are appropriate. The rates of complications and readmissions are less than our inpatient cohort in appropriately selected cases with a standardised care map. We believe this brings the best VALUE to the patients, surgeons, and the arthroplasty system

Refinement of surgical techniques, anaesthesia protocols, and patient selection have facilitated this transformation to same day discharge for arthroplasty care, most notably Partial Knee Arthroplasty (PKR). The trend for early discharge has already happened for procedures formerly regarded as “inpatient” procedures such as upper extremity surgery, arthroscopy, ACL reconstruction, foot and ankle procedures, and rotator cuff repair. Our program began focused on Partial Knee Arthroplasty (PKA) and has now expanded to primary TKA and THA, and select revision cases. Over the past few years we have performed 1,230 Knee Arthroplasty procedures with no readmissions for pain control. Average age and age range is identical to our inpatient cohort for our partial knee cases. Patient selection is based on medical screening criteria and insurance access. PKA is the ideal procedure to begin your transition to the outpatient space. We currently perform medial PKA, lateral PKA, and patellofemoral arthroplasty as outpatient cases. The program centers on the patient, their family, home recovery, pre-operative education, efficient surgery, and represents a shift in the paradigm of arthroplasty care. It can be highly beneficial to patients, surgeons, anaesthesia, facility costs, and payors as arthroplasty procedures shift to the outpatient space. Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay in the inpatient hospital environment opening the opportunity for cost savings and even outpatient joint replacement surgery for appropriately selected patients. The hallmark of this program is meticulous protocol execution. Pre-emptive pain control with oral anti-inflammatory agents, gabapentin, regional anesthetic blocks that preserve quad function for TKA (adductor canal block) and pericapsular long acting local anesthetics with the addition of injectable ketorolac and IV acetaminophen are key adjuncts. Over the past two years utilizing this type of program over 60% of our partial knee replacement patients are now returning home the day of surgery. Concerns over readmission are appropriate. The rates of complications and readmissions are less than our inpatient cohort in appropriately selected cases with a standardised care map. We believe this brings the best VALUE to the patients, surgeons, and the arthroplasty system

Length of hospital stay has been decreased to the point where the next logical progression in arthroplasty surgery is outpatient arthroplasty procedures. This trend has already happened for procedures formerly regarded as “inpatient” procedures such as upper extremity surgery, arthroscopy, anterior cruciate ligament reconstruction, foot and ankle procedures, and rotator cuff repair. Refinement of surgical techniques, anesthesia protocols, and patient selection has facilitated this transformation. Today, hip, knee and shoulder arthroplasty can be performed safely as outpatient procedures by implementing surgical and protocol refinements. Understanding and addressing, safely, the reasons that surgeons and patients believe they “need” a hospital admission is the cornerstone to outpatient arthroplasty. This program can be highly beneficial to patients, surgeons, anesthesia, ambulatory surgery centers, and payors as arthroplasty procedures shift to the outpatient space. It will always cost more to perform these procedures in hospitals therefore opening up significant opportunities. The less efficiently run hospital in-patient setting demands over-treatment of each patient to fit him or her into the mold of inpatient surgery. Patient satisfaction is very high in the outpatient setting. Patients can recover in their own home with reduced inpatient services and by utilizing outpatient physical therapy. The surgeon efficiently controls the local environment, and thus the overall patient experience and satisfaction are improved in the outpatient setting. The surgeon's role changes from commoditised technician in the hospital setting to coordinator of the entire care experience including pre-operative care, imaging, anesthesia, peri-operative care mapping, post-operative care, and enhanced coordination with therapy providers. An outpatient arthroplasty program involves multiple individuals and specialised protocols for pre-operative, peri-operative, and post-operative care. These include patient selection and education, anesthesia and analgesia, and minimally invasive surgical techniques. By implementing these protocols and a minimally invasive Watson-Jones approach, one study has reported 77% utilization of outpatient THA, 99% success with day of surgery discharge, and a 1% readmission or complication rate. Outpatient arthroplasty is safe, it's better for us and our patients, and it is here now. In an outpatient environment the surgeon actually spends more time with the patients and family in a friendly environment. Patients feel safe and well cared for, and are highly satisfied with their arthroplasty experience. In a typical day a surgeon can perform 6–8 outpatient arthroplasty procedures with multiple interactions with each patient and their family throughout the day. Avoidance of narcotics with peripheral and local blocks will increase the eligibility for outpatient surgery and decrease the need for overnight hospitalization. The singular focus on the patient and the avoidance of over-treatment will become the standard of care for total hip and total knee arthroplasty in much the same way as for other procedures once deemed “inpatient” surgeries

Intra-operative fluoroscopy in thumb metacarpophalangeal joint arthrodesis has been recommended as a means of achieving optimal alignment more consistently. This is not our current practice. A patient attending dissatisfied with an arthrodesis in excessive flexion performed outwith our unit highlighted the potential for problems, and we therefore elected to review our own outcomes. An evaluation of the alignment achieved in thumb metacarpophalangeal joint arthrodeses, to determine if current outcomes satisfactory or if fluoroscopic assistance should be considered. Radiological review of alignment of thumb metacarpophalangeal joint arthodeses carried out by two Consultant Surgeons with specialist interests in upper limb surgery in a District General hospital. Cases were predominantly identified retrospectively from sequential review of operating lists. The radiological images were, or had been taken, as part of routine follow-up and were not standardised. The alignment was also assessed independently by a junior doctor with no involvement in the patient's surgical treatment and no knowledge of the intended alignment. Recommended positions for arthrodesis have covered a range from 0 to 30 degrees, so for the purposes of analysis that range was considered acceptable. 14 cases had an average fusion position of 18 degrees flexion (range 6 to 30 degrees). 6 underwent concurrent ipsilaterel trapeziectomy. The series achieved satisfactory alignment radiologically without the routine use of intra-operative fluoroscopy

Aims

Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma.

Aims

The use of 3D printing has become increasingly popular and has been widely used in orthopaedic surgery. There has been a trend towards an increasing number of publications in this field, but existing literature incorporates limited high-quality studies, and there is a lack of reports on outcomes. The aim of this study was to perform a scoping review with Level I evidence on the application and effectiveness of 3D printing.

Definitions and perceptions of good and poor outcome vary between patients and surgeons, and perceived inadequate outcome can lead to litigation. We investigated outcomes of litigation claims relating to non-union and deformity following lower limb long bone fractures from 1995 to 2010. The database of all 10456 claims related to Trauma and Orthopaedic Surgery was obtained from the NHS Litigation Authority. Data was searched for “deformity, non-union and mal-union”, excluding spine, arthroplasty, foot and upper limb surgery. The type of complaint, whether defended or not, and costs was analysed. 241 claims met our criteria, 204 of which were closed, and 37 unsettled. Deformity/mal-union constituted 97, and non-union 143. Coronal/sagittal deformity cost £4.2 million, mean £45,487 (60% received compensation). Rotational mal-unions cost £1.6 million, mean £114,263 (87% received compensation). Non-union cost £5.3 million, mean £75,866 (60% received compensation). Mean legal fees for coronal/sagittal deformity was £18,772, rotational deformity £37,384, and non-union £24,680. The total cost of litigation was £12.2 million, with a mean of £59,597 per settled claim. The mean pay-out for all confirmed negligence/liability was £56,046 (£1,300–£500,000, median £21,500) per case. Non-union is an accepted complication following fracture surgery. However, this does not mitigate against non-union being seen as representing a poor standard of care. While it is unclear whether the payouts reflect a defensive culture or were due to avoidable errors, and notwithstanding the limitations of the database, we argue that failure of the index surgery should prompt a referral to a specialist centre. The cosmetic appearances of rotational malalignment results in higher compensation, reinforcing outward perception of outcome as being more important than harmful effects. We also note that the database sometimes contained conflicting and incomplete data, and make a case for standardisation of this component of the outcome process to allow for learning and reflection

The use of regional anaesthesia for upper limb surgery has been increasing in popularity recently. It is safe, effective and has financial benefits. We report the activity in a tertiary hand surgery unit over one year. This department performs elective and trauma surgery between 8am and 7pm. Out of hours surgery is performed in main theatres. A total of 3335 cases were performed in Hand Surgery theatres between 1st August 2008 and 1st August 2009. Of these, 1791 had a regional block. The ages of these patients ranged from 13 to 92 years (Median = 46 years, Mean = 47 years). 1030 were male and 761 were female. 1011 regional block procedures were performed by a Consultant Anaesthetist, with 266 performed by a trainee and 472 by non-career grade. 646 procedures were for trauma surgery with 1145 for elective surgery. 87 procedures were arthroscopic. A vast range of surgery was safely performed under regional block. There were no significant complications. All regional nerve blocks were performed with the aid of ultrasound. Training of junior anaesthetists was benefited by performing the nerve blocks. Patients required very little time to recover following nerve block when compared to recovery after general anaesthesia, with resultant reduction in resource requirements. We conclude that the use of regional nerve block anaesthesia for hand surgery benefits both the patient and the hospital

Background: Diagnostic and operative codes are routinely collected on every patient admitted to hospital in England and Wales (hospital episode statistics, HES). Linked data allows post-operative complications to be associated with the primary operative procedure, even if patients are re-admitted following a successful discharge. Morbidity and mortality data on shoulder surgery have not previously been available in large numbers. Methods: All HES data for a 42-month was analysed and divided into three groups – elective shoulder replacement (total or hemiarthroplasty), shoulder arthroscopy (all procedures), and proximal humerus fracture surgery (internal fixation or replacement). Incidence of pulmonary embolism (PE), deep venous thrombosis (DVT) and mortality within 90 days was established. Results: For elective shoulder replacement (10735 patients), 90-day DVT, PE and mortality rates were 0.07%, 0.11% and 0.36% respectively. Mortality in patients over 75 years was 0.9%. For arthroscopic procedures (66344 patients), 90-day DVT, PE and mortality rates were 0.01%, 0.01% and 0.03%. For proximal humerus fracture surgery (internal fixation or replacement, 4968 patients) 90-day DVT, PE and mortality rates were 0.20%, 0.38% and 2.98%. Mortality in patients over 75 years old was 6.6%. Discussion: Venous thromboembolic (VTE) prophylaxis is rarely used for upper limb surgery. PE and mortality rates for shoulder replacement and proximal humerus fracture surgery are lower those for patients receiving chemical prophylaxis after hip replacement. Further investigation into the cause of high mortality rates following fracture surgery in patients over 75 years old is required. VTE prophylaxis may be required in this age group

Background. Thrombosis is a rare complication for the single orthopaedic surgeon. The objective for this study was to determine the incidence of thromboembolism after orthopaedic surgery at Söder Hospital. Methods. All patients operated on during 1997–2000 (n= 25284) were given a short questionnaire regarding postoperative complications. The patients were asked to return the form at 6 weeks. About 50% of the forms were returned spontaneously. A research nurse contacted the rest of the patients. The questionnaires were compared with patient’s charts. An orthopaedic surgeon judged if the complication was related to surgery. Results. 99.5% of the surveys were returned. 0.78% deep vein thrombosis (DVT) and 0.20% pulmonary emboli (PE) were radiographically diagnosed. DVT mean age was 59.6 and PE 74.7 years. Median DVT detection time was 18.0 and PE 20.6 days. DVT and PE incidence was higher in lower extremity compared to upper extremity surgery. DVT incidence in Achilles tendon ruptures (9.5%), knee replacement (5.8%), pelvic fractures (4.8%) was high. Conclusions. Thromboembolism incidence in orthopaedic surgery was low. However, some surgical procedures had a high DVT incidence. The results of this study imply the need for adjusting thromboprophylaxis according to the surgical procedure

Introduction: Diabetes mellitus is a systemic disease affecting peripheral nerves and the use of regional anaesthesia in diabetic patients undergoing surgery could be unpredictable. We investigated the efficacy of brachial plexus block in diabetic patients undergoing upper limb surgery compared to normal individuals. Method: Four hundred and fifty-two patients had a brachial plexus block performed under ultra-sound guidance by senior anaesthetists. There were 221 males and 231 females. Fifty-five patients were diabetic (mean age of 61 years, SD 12), 24 with type 1 and 31 with type 2 diabetes. Mean age of non-diabetic patients was 55 years (SD 15). A mixture of 0.5% Bupivacaine and 1% Prilocaine was used for the block. Post-operative proximal and distal motor and sensory functions were assessed. The assessment was conducted at a mean of 4.6 hours (SD 2.2 hours) post-operatively. MRC grading system was used to asses motor function while sensory function was assessed subjectively using a graded scale between 0, absent sensation, 1, altered sensation and 2, normal sensation. Results: Brachial plexus block was as efficient in diabetic patients proximally for motor and sensory functions compared to non-diabetic patients. There was significant difference in the efficacy of the block distally between diabetic and non-diabetic patients in both motor (P< 001) and sensory function (P< 0001). Furthermore, in diabetic patients the response to the block between type 1 and type 2 was statistically significant (P< 001). Conclusion: In diabetes, the efficacy of brachial plexus block is different compared to normal individuals. This study showed that brachial plexus block can be used efficiently in shoulder surgery in patients with diabetes. In more distal surgery, orthopaedic surgeons as well as anaesthetists should be prepared to either reinforce the block by using a local anaesthetic or to convert to general anaesthesia, if necessary, in diabetic patients

This clinical study was performed to establish the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) after shoulder surgery. The incidence of venous thrombo-embolism complicating shoulder surgery is poorly described in literature. As VTE is a potentially fatal condition we wanted to make surgeons aware of the problem and to try to establish any risk factors contributing to it. We reviewed retrospectively clinical records of all patients who had any procedure performed on their shoulder between 2001 and 2009 in our institution. In operating theatre coding database we identified 920 patients. Their records were assessed for any admissions due to proven DVT or PE; we looked for any radiological results suggestive of or confirming venous thromboembolism. We identified 920 patients who had surgical procedure under GA on their shoulder. 126 patients had shoulder arthroplasty, other procedures commonly undertaken were: subacromial decompression, shoulder stabilization and shoulder manipulations. There was 1 fatal PE in this group – patient died within 48 hours following total shoulder replacement, post mortem revealed massive pulmonary embolism with no sing of neither upper nor lower limb DVT. There were 3 cases of symptomatic DVT confirmed by USS Doppler. No upper limb symptomatic DVT was identified. There were 7 patients who had negative tests for suspected thrombosis (2 negative tests for suspected PE, 5 negative tests for suspected DVT). There is very limited evidence in literature on VTE following upper limb surgery. Recent studies suggest that DVT incidence following arthroplasty is as high as 13%, with further 3% incidence of PE. In our study we examined occurrence of symptomatic VTE only. According to our results the incidence of symptomatic DVT following shoulder surgery is about 0.35% and symptomatic PE about 0.1 %. We did not manage to show any risk factors associated strongly with post operative DVT in our group. The prevalence of asymptomatic VTE is probably much higher and further research needs to be undertaken in that area. On base of our experience we would not recommend routine anticoagulation as a DVT prophylactic after shoulder surgery unless there are additional risk factors