Aims. The purpose of this study was to assess the prevalence of depression and anxiety symptoms in patients undergoing shoulder surgery using the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and Anxiety computer adaptive tests, and to determine the factors associated with more severe symptoms. Additionally, we sought to determine whether PROMIS Depression and Anxiety were associated with functional outcomes after shoulder surgery. Methods. This was a retrospective analysis of 293 patients from an urban population who underwent elective shoulder surgery from 2015 to 2018. Survey questionnaires included preoperative and two-year postoperative data. Bivariate analysis was used to identify associations and multivariable analysis was used to control for confounding variables. Results. Mean two-year PROMIS Depression and Anxiety scores significantly improved from preoperative scores, with a greater improvement observed in PROMIS Anxiety. Worse PROMIS Depression and Anxiety scores were also significantly correlated with worse PROMIS Physical Function (PF) and American Shoulder and Elbow Surgeons scores (ASES). After controlling for confounding variables, worse PROMIS Depression was an independent predictor of worse PROMIS PF, while worse PROMIS Anxiety was an independent predictor of worse PROMIS PF and ASES scores. Conclusion. Mean two-year PROMIS Depression and Anxiety scores improved after elective shoulder surgery and several patient characteristics were associated with these scores. Worse functional outcomes were associated with worse PROMIS Depression and Anxiety; however, more severe two-year PROMIS Anxiety was the strongest predictor of worse functional outcomes. Cite this article: Bone Joint J 2022;104-B(4):479–485

The risk of falls in patients undergoing orthopedic procedures is particularly significant in terms of health and socioeconomic effects. The literature analyzed closely this risk following procedures performed on the lower limb, but the implications following procedures on the upper limb remain to be investigated. Interestingly, it is not clear whether the increased risk of falling in patients undergoing shoulder surgery is due to preexisting risk factors at surgery or postoperative risk factors, such as anesthesiologic effects, opioid medications used for pain control, or brace use. Only one prospective study examined gait and fall risk in patients using a shoulder abduction brace (SAB) after shoulder surgery, revealing that the brace adversely affected gait kinematics with an increase in the risk of falls. The main purpose of the study was to investigate the influence of SAB on gait parameters in patients undergoing shoulder surgery. Patients undergoing elective shoulder surgery (arthroscopic rotator cuff repair, reverse total shoulder arthroplasty, and Latarjet procedure), who used a 15° SAB in the postoperative period, were included. Conversely, patients age > 65 years old, with impaired lower extremity function (e.g., fracture sequelae, dysmorphism, severe osteo-articular pathology), central and peripheral nervous system pathologies, and cardiac/respiratory/vascular insufficiency were excluded. Participants underwent kinematic analysis at four different assessment times: preoperative (T0), 24 hours after surgery (T1), 1 week after surgery (T2), and 1 week after SAB removal (T3). The tests used for kinematic assessment were the Timed Up and Go (TUG) and the 10-meter test (10MWT), both of which examine functional mobility. Agility and balance were assessed by a TUG test (transitions from sitting to standing and vice versa, walking phase, turn-around), while gait (test time, cadence, speed, and pelvic symmetry) was evaluated by the 10MWT. Gait and functional mobility parameters during 10MWT and TUG tests were assessed using the BTS G-Walk sensor (G-Sensor 2). One-way ANOVA for repeated measures was conducted to detect the effects of SAB on gait parameters and functional mobility over time. Statistical analysis was performed with IBM®SPSS statistics software version 23.0 (SPSS Inc., Chicago, IL, USA), with the significant level set at p<0.05. 83% of the participants had surgery on the right upper limb. A main effect of time for the time of execution (duration) (p=0.01, η2=0.148), speed (p<0.01, η2=0.136), cadence (p<0.01, η2=0.129) and propulsion-right (R) (p<0.05, η2=0.105) and left (L) (p<0.01, η2=0.155) in the 10MWT was found. In the 10MWT, the running time at T1 (9.6±1.6s) was found to be significantly longer than at T2 (9.1±1.3s, p<0.05) and at T3 (9.0±1.3s, p=0.02). Cadence at T1 (109.7±10.9steps/min) was significantly lower than at T2 (114.3 ±9.3steps/min, p<0.01) and T3 (114.3±9.3steps/min, p=0.02). Velocity at T1 (1.1±0.31m/s) was significantly lower than at T2 (1.2± 0.21m/s, p<0.05). No difference was found in the pelvis symmetry index. No significant differences were found during the TUG test except for the final rotation phase with T2 value significantly greater than T3 (1.6±0.4s vs 1.4±0.3s, p<0.05). No statistically significant differences were found between T0 and T2 and between T0 and T3 in any of the parameters analyzed. Propulsion-R was significantly higher at T3 than T1 (p<0.01), whereas propulsion-L was significantly lower at T1 than T0 (p<0.05) and significantly higher at T2 and T3 than T1 (p<0.01). Specifically, the final turning phase was significantly higher at T2 than T3 (p<0.01); no significant differences were found for the duration, sit to stand, mid-turning and stand to sit phases. The results demonstrated that the use of the abduction brace affects functional mobility 24 hours after shoulder surgery but no effects were reported at longer term observations

Introduction and Objective. Postoperative pain control in shoulder surgery is challenging even in arthroscopic procedures. Acute postoperative pain can last up to 48hrs despite using multimodal analgesia. Different techniques have been used to control acute pain following shoulder surgery. The most common technique currently used in shoulder surgery at the elective orthopaedic centre in Leeds is a combination of general anaesthetic (GA) and interscalene block (ISB). ISB maybe very effective, however, carries many risks and potential side effects such as brachial plexus injury and paralysis of the vagus and laryngeal recurrent nerves as well as cervical sympathetic nerve and pneumothorax. ISB can also be associated with higher incidence of neurological deficit compared to other peripheral nerve blocks; up to 14% at 10 days in some cases. As such we decided to examine the use of ISB for achieving pain control in our elective unit. Materials and Methods. A prospective consecutive series of 217 patients undergoing shoulder surgery were studied. These were grouped into 10 groups. All procedures were arthroscopic apart from shoulder arthroplasty procedures such as hemiarthroplasty and total shoulder replacements (TSRs). The choice of regional anaesthesia was ISB with GA as standard practice. Visual analogue scores (VAS) at 0hrs, 1hr, 2hrs, 4hrs and 6hrs; and total opiates intake were recorded. A one-way single factor ANOVA was used as preferred statistical analytical method to determine whether there is a difference in VAS scores and total opiates intake amongst the groups. Postoperative analgesics were used for pain relief, although these were not standardised. Results. In total shoulder replacement group, although the RSR group used more morphine on average compared to the ASR group (Mean morphine intake 6.5mg vs 3mg), this was not statistically significant (F<Fcrit; p value= 0.19). When comparing all the arthroplasty groups, the difference in mean morphine intake was also statistically not significant (F<Fcrit; p value=0.24). However, when comparing all 10 groups’ morphine intake there was a statistically significant difference amongst these groups (F>F crit; p value=0.03). Interestingly, there was a statistically significant difference in VAS at 0hrs (F>Fcrit p value=0.01); 1hrs (F>Fcrit; p value=0.00), and at 6hrs (F>Fcrit; p value=0.02) when comparing all 10 groups. Conclusions. ISB is an effective technique in achieving pain control in shoulder surgery; however, there are still variations in analgesic needs amongst groups and the use of alternative techniques should be thus explored. A future prospective study looking at acute pain for a longer period of time after shoulder surgery would explore the effectiveness of ISB in achieving pain control consistent with rehabilitation requirements

Emerging evidence suggests preoperative opioid use may increase the risk of negative outcomes following orthopedic procedures. This systematic review evaluated the impact of preoperative opioid use in patients undergoing shoulder surgery with respect to preoperative clinical outcomes, postoperative complications, and postoperative dependence on opioids. EMBASE, MEDLINE, CENTRAL, and CINAHL were searched from inception to April, 2021 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use. The search, data extraction and methodologic assessment were performed in duplicate for all included studies. Twenty-one studies with a total of 257,301 patients were included in the final synthesis. Of which, 17 were level III evidence. Of those, 51.5% of the patients reported pre-operative opioid use. Fourteen studies (66.7%) reported a higher likelihood of opioid use at follow-up among those used opioids preoperatively compared to preoperative opioid-naïve patients. Eight studies (38.1%) showed lower functional measurements and range of motion in opioid group compared to the non-opioid group post-operatively. Preoperative opioid use in patients undergoing shoulder surgeries is associated with lower functional scores and post-operative range of motion. Most concerning is preoperative opioid use may predict increased post-operative opioid requirements and potential for misuse in patients

Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon's visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is a safe alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization. The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week. One hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p < 0 .001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p < 0 .001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups. Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone

Adequate visual clarity is paramount to performing arthroscopic shoulder surgery safely, efficiently, and effectively. The addition of epinephrine in irrigation fluid, and the intravenous or local administration of tranexamic acid (TXA) have independently been reported to decrease bleeding thereby improving the surgeon's visualization during arthroscopic shoulder procedures. No study has compared the effect of systemic administered TXA, epinephrine added in the irrigation fluid or the combination of both TXA and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. The purpose of this study is to determine if intravenous TXA is a safe alternative to epinephrine delivered by a pressure-controlled pump in improving arthroscopic shoulder visualization during arthroscopic procedures and whether using both TXA and epinephrine together has an additive effect in improving visualization. The design of the study was a double-blinded, randomized controlled trial with four 1:1:1:1 parallel groups conducted at one center. Patients aged ≥18 years undergoing arthroscopic shoulder procedures including rotator cuff repair, arthroscopic biceps tenotomy/tenodesis, distal clavicle excision, subacromial decompression and labral repair by five fellowship-trained upper extremity surgeons were randomized into one of four arms: Pressure pump-controlled regular saline irrigation fluid (control), epinephrine (1ml of 1:1000) mixed in irrigation fluid (EPI), 1g intravenous TXA (TXA), and epinephrine and TXA (EPI/TXA). Visualization was rated on a 4-point Likert scale every 15 minutes with 0 indicating ‘poor’ quality and 3 indicating ‘excellent’ quality. The primary outcome measure was the unweighted mean of these ratings. Secondary outcomes included mean arterial blood pressure (MAP), surgery duration, surgery complexity, and adverse events within the first postoperative week. One hundred and twenty-eight participants with a mean age (± SD) of 56 (± 11) years were randomized. Mean visualization quality for the control, TXA, EPI, and EPI/TXA groups were 2.1 (±0.40), 2.1 (±0.52), 2.6 (±0.37), 2.6 (±0.35), respectively. In a regression model with visual quality as the dependent variable, the presence/absence of EPI was the most significant predictor of visualization quality (R=0.525; p < 0 .001). TXA presence/absence had no effect, and there was no interaction between TXA and EPI. The addition of MAP and surgery duration strengthened the model (R=0.529; p < 0 .001). Increased MAP and surgery duration were both associated with decreased visualization quality. When surgery duration was controlled, surgery complexity was not a significant predictor of visualization quality. No adverse events were recorded in any of the groups. Intravenous administration of TXA is not an effective alternative to epinephrine in the irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries although its application is safe. There is no additional improvement in visualization when TXA is used in combination with epinephrine beyond the effect of epinephrine alone

Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (-1.9-3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery

Introduction and Objective. Tranexamic acid (TXA) is used across surgical specialties to reduce perioperative bleeding. It has been shown to be effective in trauma, spinal surgery, and lower limb arthroplasty. The aim of this study is to investigate the clinical effectiveness of TXA in all types of shoulder surgery on bleeding and non-bleeding related outcomes. Materials and Methods. This study was registered prospectively on the PROSPERO database (ref: CRD42020185482). A systematic review and meta-analysis of randomised controlled trials (RCTs) investigating intra-operative use of TXA versus placebo in any type of surgery to the shoulder girdle. Electronic databases searched included MEDLINE, EMBASE, PsychINFO, and the Cochrane Library. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and Jadad score. Certainty of findings were reported using the GRADE approach. The primary outcome was total blood loss. Secondary outcomes included patient reported outcome measures, adverse events, and rate of blood transfusion. Results. Eight RCTs were included in the systematic review and data from 7 of these studies pooled in the meta-analysis. A total of 708 patients were randomized across the studies (406 received TXA, 302 received placebo). Studies included patients undergoing anatomic or reverse total shoulder arthroplasty, open Latarjet surgery, and arthroscopic rotator cuff repair. Pooled analysis demonstrated significant reduction in perioperative bleeding with TXA compared to controls; estimated total blood loss (mean difference [MD], −209.66; 95% CI −389.11 to −30.21; p=0.02), and post-operative blood loss (via drain output) (MD, −84.8ml; 95% CI, −140.04 to −29.56; p=0.003). A mean difference in Visual Analogue Scale (VAS) of 2.93 was noted in favour of TXA (95% CI 0.2 to 5.66; p=0.04). Conclusions. Whilst noting some risk of bias within the studies, TXA was effective in reducing blood loss and pain in shoulder surgery. There may be a benefit of TXA use in both open and arthroscopic shoulder procedures. Larger, low risk of bias, RCTs for specific surgical shoulder procedures are required

Introduction. The impact of prior ipsilateral shoulder surgery on outcomes following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) is unknown. The purpose of this study was to determine the impact of prior shoulder surgery on patients undergoing TSA and RSA compared to patients without prior shoulder surgery. The hypothesis was that patients undergoing arthroplasty after prior ipsilateral shoulder surgery would have inferior outcomes with higher complication rates compared to patients undergoing arthroplasty without having undergone prior surgery. Materials and Methods. Seven-hundred fifteen consecutive patients undergoing TSA or RSA between 1/2010 and 5/2014 with a minimum 2-year follow-up were prospectively analyzed. All patients were evaluated with the American Shoulder and Elbow Society (ASES), Simple Shoulder Test (SST), Functional Score, Visual Analog Scale (VAS) outcomes assessments, as well as with physical examination including range of motion assessments. Outcomes in patients undergoing prior ipsilateral shoulder surgery (PS group) were compared to those in patients without history of prior surgery (NPS group). Statistical analysis was performed using one-way univariate and multivariate analysis of covariates (ANCOVA/MANCOVA) adjusting for age, Whitney-Mann U tests, and Chi-square or Fisher's exact test, with P<0.05 considered significant. Results. Of the 715 patients, 506 (263 TSA, 243 RSA) were available for analysis (71% follow-up rate). A total of 144 patients (29%) underwent an average of 2.0±1.1 ipsilateral shoulder surgeries, prior to arthroplasty while 362 (71%) did not undergo prior surgery. In the PS Group, rotator cuff repair (RCR) accounted for 67% of the prior surgeries. PS group patients were significantly younger at the time of arthroplasty compared to the NPS group (61.6±10.2 vs. 68.2±8.6 years, P=0.035). At an average follow-up of 42.8±16.4 months, both groups had significant improvements in ASES, SST, and VAS outcomes scores and range of motion values (P<0.05 for all). All outcomes scores in the PS group were significantly lower compared to the NPS group (P≤0.005 for all). Within the PS group, there were no significant differences detected in outcome scores or magnitudes of change in outcomes between patients undergoing RCR or any other procedure. There were 41 total complications (8.1%) and 17 total reoperations (3.4%) following shoulder arthroplasty, and there was a significantly higher rate of complications in the PS Group (18.1%) versus the NPS Group (4.1%, P<0.001). There were no significant differences between the PS and NPS groups with respect to the number of postoperative infections (P=0.679), reoperations (P=0.553), or transfusions (P=0.220). Conclusions. While patients who have undergone prior ipsilateral shoulder surgery derive benefit from shoulder arthroplasty, these patients are significantly younger, have significantly more complications, and their magnitude of improvement and final scores are significantly lower than patients without prior surgery. This information can be used to counsel this challenging patient population on expected outcomes following shoulder arthroplasty procedures

The primary objectives of this study were to: 1) identify risk factors for subsequent surgery following initial treatment of proximal humerus fractures, stratified by initial treatment type; 2) generate risk prediction tools to predict subsequent shoulder surgery following initial treatment; and 3) internally validate the discriminative ability of each tool. We identified patients ≥ 50 years with a diagnosis of proximal humerus fracture from 2004 to 2015 using linkable health datasets in Ontario, Canada. We used procedural and fee codes within 30 days of the index fracture to classify patients into treatment groups: 1) surgical fixation; 2) shoulder replacement; and 3) conservative. We used intervention and diagnosis codes to identify all instances of complication-related subsequent shoulder surgery following initial treatment within two years post fracture. We developed logistic regression models for randomly selected two thirds of each treatment group to evaluate the association of patient, fracture, surgical, and hospital variables on the odds of subsequent shoulder surgery following initial treatment. We used regression coefficients to compute points associated with each of the variables within each category, and calculated the risk associated with each point total using the regression equation. We used the final third of each cohort to evaluate the discriminative ability of the developed risk tools (via the continuous point total and a dichotomous point cut-off value for “higher” vs. “lower” risk determined by Receiver Operating Curves) using c-statistics. We identified 20,897 patients with proximal humerus fractures that fit our inclusion criteria for analysis, 2,414 treated with fixation, 1,065 treated with replacement, and 17,418 treated conservatively. The proportions of patients who underwent subsequent shoulder surgery within two years were 13.8%, 5.1%, and 1.3%, for fixation, replacement, and conservative groups, respectively. Predictors of reoperation following fixation included the use of a bone graft, and fixation with a nail or wire vs. a plate. The only significant predictor of reoperation following replacement was poor bone quality. The only predictor of subsequent shoulder surgery following conservative treatment was more comorbidities while patients aged 70+, and those discharged home following initial presentation (vs. admitted or transferred to another facility) had lower odds of subsequent shoulder surgery. The risk tools developed were able to discriminate between patients who did or did not undergo subsequent shoulder surgery in the derivation cohorts with c-statistics of 0.75–0.88 (continuous point total), and 0.82–0.88 (dichotomous cut-off), and 0.53–0.78 (continuous point total) and 0.51–0.79 (dichotomous cut-off) in the validation cohorts. Our results present potential factors associated with subsequent shoulder surgery following initial treatment of proximal humerus fractures, stratified by treatment type. Our developed risk tools showed good to strong discriminative ability in both the derivation and validation cohorts for patients treated with fixation, and conservatively. This indicates that the tools may be useful for clinicians and researchers. Future research is required to develop risk tools that incorporate clinical variables such as functional demands

This study was performed to evaluate the efficacy of interscalene block combined with general anaesthetic for common surgical procedures of shoulder and the potential of this procedure for providing day case shoulder surgery. 114 consecutive patients undergoing shoulder surgery were audited using a questionnaire immediately after operation and at 6, 12 and 48 hours after operation. Pain scores were recorded based on visual analogue scale, type of operation, duration of operation, postoperative stay and complications. At 48 hours overall pain control was assessed and patients were asked about having their operation done as a day case. 104 patientswho responded to the questionnaire were included in the study. There were 52 males and 52 females with overall mean age of 49 years (range 18–85). 75 patients underwent arthroscopic decompression, 15 patients underwent arthroscopy assisted mini open cuff repair, 9 underwent open glenohumeral stabilisation and the rest five underwent open Mumford procedure. Mean operation time was 47 minutes (range 25–90). 97 (93%) patients had no pain immediately postoperatively, 76 (73%) patients were pain free at 6 hours and 39 (38%) were pain free at 12 hours. Mean pain scores art 6 hours was 3 and at 12 hours were 4. 101 patients said their pain was well controlled throughout the first 48 hours by simple oral analgesics. 84 (83%) patients expressed an opinion that they could have been managed as day case provided they were adequately counselled about the procedure. 6(5.7 %)patients showed signs of Horner’s syndrome that resolved by 12 hours. No other complications related to inter scalene block occurred. This study has shown that interscalene block is a safe procedure providing sustained adequate pain relief after shoulder surgery. It could allow a high percentage of patients undergoing shoulder surgery to be discharged home on the day of surgery

Blood transfusion requirement in shoulder surgery has been reported from 8.1% to up to 15%. Our observation was that blood transfusion rarely required after open shoulder surgery. We therefore decided to conduct a retrospective case notes study to look at the crossmatch-transfusion ratio for shoulder surgery. A total of 211 patients were included in the study. Results were analysed using paired T-test from SPSS (15.0). There were 63 elective procedures and 148 trauma procedures during that period. Ten patients (4.8%) required intra-operative or post operative transfusion. Crossmatch-transfuison ratio was 21. There should be a clear equation between crossmatch and its use, intra-operatively and post operatively. This study highlighted unnecessary cross-matching for shoulder operations which puts extra pressure on the laboratory staff, the blood bank and also has financial implications

Background. This clinical study was performed to establish the prevalence of deep vein thrombosis and pulmonary embolism after shoulder surgery. The incidence of VTE complicating shoulder surgery is poorly described in literature. Methods. We reviewed retrospectively clinical records of all patients who had any surgical procedure performed on their shoulder between 2001 and 2009.‘Patients’ records were assessed for any admissions due to proven VTE; we looked for any radiological results suggestive of venous thromboembolism. Results. We identified 920 patients who had surgical procedure under GA on their shoulder; including 113 patients had shoulder arthroplasty. There was 1 fatal PE in this group – patient died within 48 hours following reverse shoulder replacement, post mortem revealed massive pulmonary embolism. There were 2 cases of symptomatic DVT of lower limb, both treated successfully with anticoagulation. No upper limb DVT was identified. There were 7 patients who had negative tests for suspected thrombosis. Discussion. Recent studies suggest that DVT incidence following arthroplasty is as high as 13%. In our study we examined occurrence of symptomatic VTE only. According to our results the incidence of symptomatic DVT following shoulder surgery is about 0.3% and symptomatic PE about 0.1 %. The prevalence of asymptomatic VTE is probably much higher and further research needs to be undertaken in that area. We would advice to think carefully about risk of thrombosis and use mechanical prophylaxis in shoulder surgery. We would not recommend routine postoperative anticoagulation as a DVT prophylaxis unless there are additional risk factors

The evaluation of our results from the use of transscalen block in shoulder surgery. During September 2008 – March 2009, in our institution 25 patients underwent different types of shoulder surgery. Fifteen patients were male and ten female with mean age 56 y.o. Shoulder pathology included fractures, rotator cuff tears, subacromial decompression. Two of the patients received general anaesthesia because of anatomic variations to the neck and the rest twenty three of them underwent a transcalen block as method for anaesthesia. For the block all the patients received 20 ml Naropeine 7.5% and 10 ml NaCl 0. Two out of twenty three patients received, during the beginning of surgery, general anaesthesia because of pain. There were no other complications, regarding the anaesthesia, during the surgery. The postoperative analgesia was 8.5 hours in average. None of the patients received postoperatively any strong analgetics. We believe that the use of transcalen block is a safe and secure method of anaesthesia for the shoulder surgery with excellent analgetics results

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

Challenging cases in shoulder surgery emphasizing joint reconstruction will be presented to a distinguished panel of experts. Audience participation will be encouraged. Preoperative assessment, imaging, operative techniques, and postoperative care will be emphasised. Special focus will be on shoulder replacement, especially reverse shoulder arthroplasty

Thirty years ago, rotator cuff surgery was exceedingly uncommon and shoulder arthroplasty almost unknown. Surgery for shoulder instability was largely empirical, non-anatomical and frequently unsuccessful. With the help of arthroscopy and MR scanning, a complex array of labral, ligament and tendon pathologies can now be recognised and treated, precisely and predictably. Anatomy-restoring arthroscopic techniques have largely replaced open stabilisation surgery. As life expectancy rises and citizens remain active into their seventh and eighth decades, the call for rotator cuff surgery has risen dramatically. Complex tendon transfers have expanded the indications for cuff surgery. Open repair has in part been supplanted by increasingly sophisticated arthroscopic techniques. The potential use of orthobiologics and stem cells promises further advances in the foreseeable future. Following the successful development of humeral hemiarthroplasty, and later of total shoulder replacement, surgical techniques and clinical indications for arthroplasty are now well refined. Predictable outcomes have been further enhanced by the present generation of ‘anatomic’ prostheses. More recently, the ‘rediscovery’ and improvement of semi-constrained (reverse) prostheses has transformed the previously dismal outlook for sufferers of cuff arthropathy and similar conditions. Many Australian Orthopaedic Association trainees undertake post-specialisation fellowships in shoulder surgery, both at home and abroad, and there is a steady flow of young overseas fellows through Australian shoulder units. The Shoulder and Elbow Society of Australia, founded in 1990 as a loose grouping of interested colleagues, now boasts over 70 active members. Australian surgeons and researchers are well represented in the prestigious Journal of Shoulder and Elbow Surgery and Australian shoulder surgery has come of age

Background: Proprionibacterium acnes (P. acnes) is a skin commensal which is often interpreted as a contaminant when found in cultures of surgical specimens. However, recent reports suggest that P. acnes can be identified as the causative micro-organism of infection. Furthermore P. acnes infections occur more often after shoulder surgery than after surgery of the lower extremities or spine. The aim of this study was to identify how frequent P. acnes was responsible for infection after orthopaedic surgery of the shoulder, lower extremity and spine in a single centre. Patients and Methods: Inclusion criteria were the occurrence of infection after surgery of the shoulder, lower extremity (hip and knee), or spine in a 100-bed orthopaedic hospital. The inclusion period was between January 2000 and May 2008. Infection was defined when two or more cultures were positive with the same microorganism in the presence of clinical signs and symptoms. The first goal was to identify the incidence of infection due to P. acnes amongst all infections. The secondary outcome was the incidence of infection versus contamination amongst all cases with positive cultures for P. acnes. Both outcomes were compared for surgery of the shoulder, lower extremity and spine. Results: A total of 3703 surgeries of the shoulder were performed, compared to 19906 lower extremity- and 5687 spine surgeries. The incidence of infection after surgery of the shoulder was 1.4% (52 cases; prosthesis [n=23], fractures [n=5], soft tissue surgery [n=16] and others [n=8]). After surgery of the lower extremity and spine this was 2.8% (548 cases) and 3.1% (177 cases), respectively. The incidence of infection due to P. acnes after shoulder surgery (23%) was significantly greater then after surgery of the lower extremity (1.3%; p < 0.001) or spine (0%; p < 0.001). Furthermore, in cases where P. acnes was cultured after surgery of the shoulder it was more often identified as the causative pathogen of infection than when P. acnes was cultured after surgery of the lower extremity or spine (71% vs 22%; p < 0.05 and 71% vs 0%; p < 0.01). Conclusion: The low virulent P. acnes can cause orthopaedic surgical infections and should not be regarded a priori as a contaminant in cultures. This is especially true for shoulder surgery, where P. acnes infections occur frequently and significantly more often than in surgery of other joints

Aim. This study was performed to evaluate the efficacy of a balanced interscalene and general anaesthetic and its potential for use in increasing the provision of day case shoulder surgery. Patients and Methods. 104 patients undergoing shoulder surgery were audited using a questionnaire immediately postoperatively, and at 6, 12 and 48 hours. Pain scores were recorded using a visual analogue scale. Operative details including operation time, postoperative stay and complications have also been recorded. At 48 hours patients were asked about having their operation as a day case and their pain control was assessed. Results. 52 males and 52 females mean age 49 years (range 18–85) completed the questionnaire. 90 responded to a 48-hour interview. 75 arthroscopic decompressions, 15 arthroscopically assisted mini open cuff repairs, 9 open glenohumeral stabilisations and 5 open Mumford procedures were performed. Mean operation time was 47 minutes (range 25–90) and 101 patients were discharged after one (86 patients) or two (15 patients) postoperative nights. 97 patients had no pain immediately postoperatively, 76 were pain free at 6 hours and 39 were pain free at 12 hours. Mean pain scores at 6 and 12 hours were 3 and 4. 101 patients said that their pain was well controlled throughout the first 48 hours with simple oral analgesics. 83% of patients expressing an opinion on day case treatment (69 out of 83) could have been managed as day cases provided that they were adequately counseled about the procedure. 6 patients showed signs of Horner’s syndrome that resolved fully by 12 hours. No other complications related to the inter-scalene block occurred. Conclusion. This study has shown that interscalene anaesthesia is a safe procedure providing sustained and adequate pain relief. In association with oral analgesia and patient counselling it allows a high percentage of patients undergoing shoulder surgery to be discharged home on the day of surgery

Post-operative pain is well recognised in patients undergoing shoulder surgery. With the recent advances in arthroscopic shoulder surgery over the last decade, a larger number of cases are being performed in day surgery units. These procedures are generally performed under general anaesthetic with either an interscalene or suprascapular nerve block or local anaesthetic infiltration. The aim of our prospective audit was to investigate the adequacy of analgesia provided for patients, undergoing day case arthroscopic shoulder procedures in a rural district general hospital, to ensure best medical care and to tailor certain procedures to appropriate analgesic pathways in the future. Fifty consecutive patients, who underwent day case arthroscopic shoulder surgery, were contacted by telephone one week post surgery, to assess their post-operative pain scores and analgesic requirements. Patients who received a nerve block were found to have a significantly longer duration of pain relief (p < 0.001). These patients also had significantly less pain performing their usual activities of daily living in the immediate post-operative period (p = 0.05), compared to patients who only had local anaesthetic infiltration. There was no trend found between the type of procedure and post-operative pain scores. Our audit has confirmed that nerve blocks provide longer pain relief, but has also highlighted the need to take into consideration pre-operative pain and pain perception to enable analgesia to be tailored