Predictors of mortality following shoulder arthroplasty.

INTRODUCTION: This study aims to determine 30-day, 90-day and 1 year mortality following shoulder arthroplasty and identify predictors of mortality. MATERIALS AND METHODS: All shoulder arthroplasty cases performed at the host institution, between 2012 and 2018 were included. A review of patient records was completed to identify demographic data, Charlson comorbidity index, date of death and factors associated with mortality.Mortality analysis was undertaken using 1-Kaplan Meier estimates with 95% confidence intervals. Comparative analysis was performed for mortality following shoulder arthroplasty for elective vs. trauma and for primary vs. revision surgery. A multiple regression analysis was conducted to determine which factors were associated with increased mortality risk. RESULTS: 640 shoulder arthroplasty cases were performed in 566 patients. There were 44 deaths, 1 occurred within 90 days and 13 within 1 year. Trauma procedures had a hazard ratio of 5.3 (95% CI 1.9 to 15.0) for mortality compared to elective procedures (5 year survival trauma 78.6% (95% CI 60.7 to 89.0); elective 91.8% (95% CI 88.1 to 94.4). 1-year mortality was predicted by presence of malignancy, liver failure, cardiac failure, peptic ulcer, trauma surgery, revision surgery, intra-operative complication, transfusion and increased length of stay. DISCUSSION: 30-day, 90-day and 1-year mortality following shoulder arthroplasty were 0%, 0.16% and 2%; trauma procedures had a hazard ratio of 5.3 for 1-year mortality when compared to elective surgery. Malignancy, cardiac failure, liver failure, peptic ulcer and trauma surgery are associated with an increased risk of 1-year mortality.

Predictors of length of stay following shoulder arthroplasty in a high-volume UK centre.

INTRODUCTION: Shoulder arthroplasty rates are increasing in the UK. No data have been published from a UK centre on predictors of length of inpatient stay following shoulder arthroplasty. This study analyses the length of inpatient stay following shoulder arthroplasty in a high-volume UK centre and identifies predictors of prolonged inpatient stay. MATERIALS AND METHODS: All shoulder arthroplasty cases performed between 2012 and 2018 were identified. A review of case notes and electronic patient records was completed to identify demographic data, Charlson comorbidity score, length of inpatient stay and factors associated with length of stay. Multiple linear regression analysis was conducted to determine which factors were independently associated with length of inpatient stay. RESULTS: A total of 640 shoulder arthroplasty cases were performed in 566 patients. Median length of stay was two days. Length of stay was predicted by age, sex, chronic kidney disease, congestive cardiac failure, previous myocardial infarction, intraoperative complication and postoperative transfusion. DISCUSSION: Increasing age, female sex, chronic kidney disease, congestive cardiac failure, previous myocardial infarction, intraoperative complication and transfusion were independent predictors of increased length of stay. Strategies to reduce perioperative complication and transfusion, and to optimise renal and cardiac comorbidities may reduce overall length of stay for shoulder arthroplasty patients.

Blood transfusion rates following shoulder arthroplasty in a high volume UK centre and analysis of risk factors associated with transfusion.

AIMS: To determine the blood transfusion rates following shoulder arthroplasty and to establish risk factors associated with increased risk of transfusion. MATERIALS AND METHODS: All shoulder arthroplasty cases performed between January 2012 and March 2017 in a tertiary upper limb unit were identified. Patients who received perioperative tranexamic acid were excluded. Retrospective review of case notes was completed to identify transfusion rate and risk factors. Univariate and multivariate analysis were performed to analyse the association between risk factors and transfusion rate. RESULTS: Five hundred and thirty-seven shoulder arthroplasties performed in 474 patients were included. Peri- or post-operative transfusion was required in 21 cases (3.9%). Univariate analysis suggested significant association with age (p = 0.005), female sex (0.015), preoperative haemoglobin/haematocrit (p < 0.001), perioperative drop in haemoglobin (p < 0.001), ASA grade (p < 0.001) and transfusion rate. Only perioperative drop in haemoglobin (p < 0.001) and American Society of Anaesthesiologist score (ASA) grade (p = 0.039) retained significance on multivariable analysis. CONCLUSIONS: The blood transfusion rate following shoulder arthroplasty was 3.9%. Greater perioperative drop in haemoglobin and higher ASA grade were associated with increased risk of transfusion on multivariate analysis.

Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial.

BACKGROUND: There is a growing trend to treat displaced midshaft clavicular fractures with primary open reduction and plate fixation; whether such treatment results in improved patient outcomes is debatable. The aim of this multicenter, single-blinded, randomized controlled trial was to compare union rates, functional outcomes, and economic costs for displaced midshaft clavicular fractures that were treated with either primary open reduction and plate fixation or nonoperative treatment. METHODS: In a prospective, multicenter, stratified, randomized controlled trial, 200 patients between sixteen and sixty years of age who had an acute displaced midshaft clavicular fracture were randomized to receive either primary open reduction and plate fixation or nonoperative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores. Union was evaluated with use of three-dimensional computed tomography. Complications were recorded, and an economic evaluation was performed. RESULTS: The rate of nonunion was significantly reduced after open reduction and plate fixation (one nonunion) as compared with nonoperative treatment (sixteen nonunions) (relative risk = 0.07; p = 0.007). Group allocation to nonoperative treatment was independently predictive of the development of nonunion (p = 0.0001). Overall, DASH and Constant scores were significantly better after open reduction and plate fixation than after nonoperative treatment at the time of the one-year follow-up (DASH score, 3.4 versus 6.1 [p = 0.04]; Constant score, 92.0 versus 87.8 [p = 0.01]). However, when patients with nonunion were excluded from analysis, there were no significant differences in the Constant scores or DASH scores at any time point. Patients were less dissatisfied with symptoms of shoulder droop, local bump at the fracture site, and shoulder asymmetry in the open reduction and plate fixation group (p < 0.0001). The cost of treatment was significantly greater after open reduction and plate fixation (p < 0.0001). CONCLUSIONS: Open reduction and plate fixation reduces the rate of nonunion after acute displaced midshaft clavicular fracture compared with nonoperative treatment and is associated with better functional outcomes. However, the improved outcomes appear to result from the prevention of nonunion by open reduction and plate fixation. Open reduction and plate fixation is more expensive and is associated with implant-related complications that are not seen in association with nonoperative treatment. The results of the present study do not support routine primary open reduction and plate fixation for the treatment of displaced midshaft clavicular fractures.

Does pulse lavage reduce hip hemiarthroplasty infection rates?

This paper reports a prospective randomized trial involving four hospitals in the south of England, in which every hemiarthroplasty (American Association of Anaesthetists grade IV and above) was randomized to one of two limbs. In the first group, the patients received a 2-L pulse lavage normal saline washout; in the second group, they received a 2-L normal saline washout via a jug or a syringe. All wounds were reviewed during their time in hospital up to 30 days post surgery or discharge (using criteria from the Nosocomial Infection National Surveillance Survey). Any re-admissions for infection were recorded. The pulse lavage group had a significantly lower total infection rate and, specifically, a decreased 'joint space' or deep infection rate.

Pelvic and acetabular fractures in the United Kingdom: a continued public health emergency.

In 1996 the quality of the early management of 100 consecutive patients referred to the SW Thames regional pelvic and acetabular unit between 1989 and 1992 was studied. The management of these patients was assessed in four specific areas, and guidelines were laid down. It was found that in 56% of patients the early management did not meet these suggested standards, with 34% having deficiencies in more than one area. These results were presented and published. Five years later, the early management of a further 100 consecutive referrals was assessed using these same guidelines, in order to close the audit loop. The treatment of 57% of patients still did not reach the guideline standards, but the number with problems in more than one area fell to 20%. There has been improvement in the early management of pelvic and acetabular injuries. The use of external fixation in cases of severe haemorrhage increased, but frames were often poorly applied. Early communication with the specialist centre was encouraged but unfortunately there was still an unacceptable delay in referral. The frequency of delayed referral actually increased during the 5 years between study groups.

Pre-vascular hernia: a rare cause of chronic obscure groin pain after inguinal hernia repair.

A rare case of pre-vascular hernia is reported in a woman complaining of chronic obscure groin pain following an inguinal hernia repair. The condition was only diagnosed by means of a herniogram, emphasising the value of this investigation in unexplained groin pain. The hernia was successfully repaired using a polypropylene mesh plug, a simple technique widely employed in both femoral and recurrent inguinal hernia, but never before described in pre-vascular hernia.

The contribution of bone densitometry to the diagnosis and treatment of osteoporosis.

OBJECTIVE: It has recently been proposed that a specialist osteoporosis service, including bone densitometry, should be made available to those most at risk in the UK population. The aim of this study was to evaluate such a service, and in particular the role of bone densitometry, in terms of its effect on the diagnosis of osteoporosis and clinical management of the disease. METHODS: A retrospective data abstraction study was performed to investigate the diagnosis and management of patients referred to the Metabolic Clinic, City Hospital Nottingham, with a potential diagnosis of osteoporosis. Hospital records were available for 117 patients, aged between 45 and 59, who had attended the Clinic in a given time period and undergone bone mineral density measurement. RESULTS: Forty-eight patients (41.0%) had osteoporosis of the lumbar spine. The final diagnosis of osteoporosis after attending the clinic was different from that on referral in a substantial proportion (62.6%) of cases. Only 48.9% of patients with spinal osteoporosis were identified by their referring doctor. The percentage of patients receiving treatment for osteoporosis increased from 34.2% to 72.6% after attending the clinic. CONCLUSIONS: Measurement of bone mineral density identifies cases of osteoporosis who would not otherwise be detected and as a consequence contributes to the proportion of patients receiving treatment after referral. The osteoporosis service provided by the Metabolic Clinic including measurement of bone mineral density was thus found to have a considerable impact on the diagnosis and treatment of patients with osteoporosis.