Venous thromboembolic events are rare after shoulder surgery: analysis of a national database.

BACKGROUND: Data on venous thromboembolic (VTE) events after different types of shoulder surgery have not previously been available in large numbers in the United Kingdom. We aimed to determine baseline postoperative complication rates with reference to national thromboembolic prophylaxis guidelines. METHODS: Diagnostic and operative codes are routinely collected on every patient admitted to the hospital in the English NHS. Data for a 42-month period were analyzed for planned shoulder surgery (total replacement, hemiarthroplasty, or arthroscopy) and proximal humeral fracture surgery (internal fixation or replacement). In addition, complications during the two 6-month periods before and after the implementation of national thromboprophylaxis guidelines were compared. Rates of symptomatic deep venous thrombosis, pulmonary embolism, and mortality within 90 days were extracted. RESULTS: For total shoulder replacement (4,061 patients), deep venous thrombosis, pulmonary embolism, and mortality rates were 0%, 0.20%, and 0.22%, respectively. For arthroscopic procedures (65,302 patients), the rates were less than 0.01%, 0.01%, and 0.03%, respectively. For proximal humeral fracture surgery (internal fixation or replacement, 4,696 patients), the rates were 0.19%, 0.40%, and 3.02%, respectively. There was no significant difference in the VTE event or mortality rates before and after the introduction of the 2007 National Institute for Health and Clinical Excellence guidelines after arthroscopy or proximal humeral fracture surgery. A statistically significant decrease in total shoulder replacement-related mortality was found, from 0.72% (5 patients) to 0%. DISCUSSION: VTE disease is not a significant problem after shoulder surgery, and thromboprophylaxis may not be required, even in high-risk patients. National thromboprophylaxis guidelines did not affect VTE event rates.

Injury to the lateral femoral cutaneous nerve during minimally invasive hip surgery: a cadaver study.

INTRODUCTION: A smaller skin incision as part of minimally invasive surgery (MIS) for total hip arthroplasty (THA) is thought to reduce local tissue trauma. Preservation of cutaneous nerves may reduce postoperative pain and improve rehabilitation. The standard lateral approach (SLA) and two MIS approaches (anterolateral [ALA] and posterior [PA]) were compared to determine which incision preserved cutaneous nerves. PATIENTS AND METHODS: Fifteen cadaveric hip specimens were dissected to establish the course of branches of the lateral femoral cutaneous nerve. The number of branches divided by each of the three incisions was recorded. RESULTS: The MIS incisions resulted in significantly less nerve division compared with the SLA. The mean difference between the SLA and the ALA was 4.4 (P < 0.0001), and between the SLA and the PA was 1.4 (P = 0.0005). The ALA divided significantly fewer nerves compared with the PA (mean difference = 3; P = 0.0001). DISCUSSION: There is little evidence of the benefit of one MIS approach over another in the literature. The ALA preserved significantly more cutaneous nerves in this study. These results need corroboration with clinical outcomes to determine their significance.

Internal fixation of proximal humeral fractures.

We discuss the appropriate assessment and treatment options available for proximal humeral fractures. Important factors to consider are the fracture pattern, the bone quality and any co-morbidities. These are common injuries and are increasing in incidence due to an ageing population. The management of displaced 3- and 4-part fractures remains controversial. The ideal is anatomic reduction and stable internal fixation of the fractures especially the tuberosities to allow early mobilisation. The recent introduction of fixed angle locking plates allows stable fixation even in markedly osteoporotic bone. The early results are encouraging however there are presently no randomised trials comparing these devices to conservative treatment, conventional plating or hemiarthroplasty.