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Background: Shoulder arthroplasty surgery carries the risk of blood loss. The antifibrinolytic tranexamic acid (TXA) is effective in reducing blood loss in lower limb arthroplasty. The purpose of this study was to assess blood loss and associated complications following shoulder arthroplasty performed with and without TXA for both elective and trauma indications. Methods: A cohort study was performed to assess blood loss, transfusion requirements and post-operative venous thromboembolic events (VTE) following shoulder arthroplasty undertaken with and without the use of intravenous TXA. Results: The study consisted of 67 patients (n = 36 with TXA; n = 31 without TXA). Type of arthroplasty included reverse-shoulder arthroplasty, total-shoulder arthroplasty and hemiarthroplasty. There was no significant difference between TXA and non-TXA groups regarding blood loss (TXA group haemoglobin drop 20.6 mg/dL; non-TXA group haemoglobin drop 20.5 mg/dL; p = 0.978). There was no significant difference in measured outcomes with or without TXA use for elective or trauma indications, nor regarding type of arthroplasty. Discussion: The use of intravenous TXA in shoulder arthroplasty was not associated with a significant reduction in blood loss or post-operative transfusion rates, nor did it impact on VTE. This result was not affected by the indication being elective or trauma nor the type of arthroplasty surgery performed.

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BACKGROUND: Lateral end clavicle fractures can be challenging due to the small and often comminuted lateral fragment, problems with union and stability and implant morbidity. We retrospectively reviewed outcomes of Tightrope device in isolation to treat lateral end clavicle fractures. METHODS: Subjective and objective measures were assessed for 29 patients. The subjective comprised of functional clinical scores: Oxford shoulder score and EuroQoL5D. The objective measures were maintenance of fracture reduction, bone healing and complications. RESULTS: Median age was 36 years and 72% of cases were male patients. Average clinical follow up time was 21 months. Evaluation of latest radiographs showed that all reductions were maintained post-operatively. Twenty-two fractures had united and one patient had established non-union. Functional outcomes showed predominantly good results with Oxford shoulder score average of 41, EuroQoL5D index score of 0.78 and EuroQol Visual Analogue Scale 76. The overall post-operative complication rate was 10%; only one case requiring a secondary procedure. DISCUSSION: In our series, using the Tightrope as the sole device to treat displaced lateral end of clavicle fractures resulted in good radiological and functional outcomes, with minimal complications requiring secondary procedures. We believe the Tightrope device is a good method of fixing these challenging fractures and advocate its use.

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The use of robots in orthopaedic surgery is an emerging field that is gaining momentum. It has the potential for significant improvements in surgical planning, accuracy of component implantation and patient safety. Advocates of robot-assisted systems describe better patient outcomes through improved pre-operative planning and enhanced execution of surgery. However, costs, limited availability, a lack of evidence regarding the efficiency and safety of such systems and an absence of long-term high-impact studies have restricted the widespread implementation of these systems. We have reviewed the literature on the efficacy, safety and current understanding of the use of robotics in orthopaedics.

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INTRODUCTION: The referral of a lateral malleolus fracture is one of the commonest orthopaedic trauma presentations. Failure to fully assess the patient and radiography can lead to missing associated injuries in the hindfoot. CASE REPORT: We describe an unusual hindfoot injury with an atypical combination of lateral subtalar dislocation and calcaneal fracture with associated lateral malleolus fracture that was initially not appreciated by the referring emergency department. This case is of particular interest as subtalar dislocation is a rare injury and lateral subtalar dislocation is even rarer. CONCLUSION: Failure to fully assess such injuries and manage non-operatively leads to early degenerative tibia-talar, hindfoot and midfoot changes and a difficult situation for the surgeon to salvage. We advocate early CT scan and open reduction with fixation for such cases.

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BACKGROUND: Day surgery trauma lists are becoming an increasingly popular and widespread approach to address the inpatient trauma demand on NHS services. A 'Rapid Access' list initiative was set-up to book patients from an emergency pathway who require surgery and also fulfilled the standard day case patient criteria but for whom it was safe to wait for over 24 h before going to theatre. MATERIALS & METHODS: We performed a prospective audit of the cases undertaken on the day surgery trauma list over a 12-month period and analysed the number of cases, spectrum of procedures, complications and the cost benefits. RESULTS: A total of 119 day surgery trauma cases were performed (42 lists; average of 3 cases per list; upper limb procedures accounted for 60%.). The overall cost benefit for day surgery was calculated as the difference between the tariff and the costs for day surgery and inpatient procedures. A cost benefit of £617 per case for day surgery over inpatient surgery was noted with a total saving of £67,450 for the performed procedures. DISCUSSION: We demonstrate day trauma surgery to be a safe and cost effective method of optimising the management of the appropriate trauma case workload. Further it reduces demand for inpatient beds, provides significant cost savings for the trust and improves patient satisfaction.

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We performed a prospective cohort comparative analysis of simple trapezectomy and trapezectomy with pyrocarbon interposition in 38 consecutive patients with trapeziometacarpal joint osteoarthrosis. Patients were assessed preoperatively, at six and 12 months postoperatively using subjective and objective tools. Subjective assessment was performed using the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire and the visual analogue score. Objective assessment was performed with grip strength measurements. At each time interval, statistical differences were sought between the two subgroups. No significant difference between the two subgroups was noted at any time interval on subjective or objective assessment. A significant difference (p < 0.05) was found on comparing the respective preoperative and 12-month subjective scores in both subgroups. Of the pyrocarbon subgroup seven had related complications. We suggest that pyrocarbon interposition does not significantly improve postoperative function, requires a longer operation with a high postoperative risk of pyrocarbon displacement and need for revision surgery.

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The aim of this study was to establish a classification system for the acromioclavicular joint using cadaveric dissection and radiological analyses of both reformatted computed tomographic scans and conventional radiographs centred on the joint. This classification should be useful for planning arthroscopic procedures or introducing a needle and in prospective studies of biomechanical stresses across the joint which may be associated with the development of joint pathology. We have demonstrated three main three-dimensional morphological groups namely flat, oblique and curved, on both cadaveric examination and radiological assessment. These groups were recognised in both the coronal and axial planes and were independent of age.

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A consecutive series of 372 patients who underwent surgery for disorders of the rotator cuff involving arthroscopic subacromial decompression and open or arthroscopic repairs of the cuff were prospectively investigated as to the comparability of subjective and objective assessment scores of shoulder function. Assessments were made before operation and at 3, 6, 12, 18 and 24 months after surgery using the Disabilities of the Arm, Shoulder, and Hand score, the Oxford shoulder score and the Constant-Murley score, which was used as a reference. All scores were standardised to a scale of 0 to 100 for comparison. Statistical analysis compared the post-operative course and the mean score for the subjective Disabilities to the Arm, Shoulder and Hand score and Oxford shoulder score, with the objective Constant score at each interval. A strong correlation was evident between both subjective scores and the Constant score. We concluded that both the subjective scores would be useful substitutes for the Constant score, obviating the need for a trained investigator and the specialist equipment required to perform the Constant score.

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To investigate the relationship between age, gender and the Constant score. Two hundred and seventy Healthy volunteers (527 normal shoulders) from our local population with no previous history of shoulder disease were assessed using the Constant score. The mean age was 43.9 years (16-86) and the mean Constant score 85.9 (56-100). The mean score was 88.1 (range 56-100) for men and 83.7 (range 60-100) for women. A mixed regression model estimated that, for the male population, the Constant score falls by 0.15 points per annum between the ages of 50 and 70 and by 1.3 points per year after the age of 70. Similarly, for the female population, the fall is of 0.25 per year between 60 and 70 and 0.35 after the age of 70. The changes are statistically significant (P < 0.01) and clinically important when comparing patients of different age groups.

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The purpose is to perform a comparative analysis of mini-open and arthroscopic rotator cuff repairs through the use of subjective and objective scoring tools. We conducted a prospective comparative cohort study that evaluated 123 consecutive patients who underwent rotator cuff repairs (arthroscopic and 31 mini-open repair). Subjective and objective functional assessment was performed preoperatively and postoperatively at 3, 6, 12, 18 and 24 months using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Oxford Shoulder Score (OSS) and the Constant-Murley score. Statistical analysis was performed on the datasets assessing the Pearson correlation coefficients and any significant differences present at each respective time point. At every time point the arthroscopic group scored better than the mini-open group, regardless of the assessment tool employed. The percentage recovery from the baseline measured at 1 year was similar with either treatment option. A significant difference was found between the arthroscopic and mini-open groups for the Constant-Murley, DASH and OSS scoring systems preoperatively (P < 0.05), reflecting a difference in tear severity. Arthroscopic rotator cuff repair is comparable with the mini-open technique with well correlated postoperative rates recovery. Subjective scoring provides an accurate and potentially easier method of postoperative assessment for long-term follow-up of rotator cuff repairs.

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A case is reported in which endoscopic trans-anal rectal mucosal ablation (ETARMA) was employed in combination with laparoscopic partial proctectomy in order to decrease complications associated with open surgery.

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BACKGROUND: Herniorrhaphy is one of the most commonly performed operations in the UK. Approximately 1 per 1,000 of the population has a groin hernia. METHOD AND RESULT: We report on a rare complication following laparoscopic inguinal herniorrhaphy of bladder stone formation and its management. CONCLUSION: To our knowledge a combined laparoscopic repair of the urinary bladder wall, following iatrogenic injury by a mesh fixation clip and retrieval of bladder stone (induced through the misplacement of the clip) has not been described previously.

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