Intraoperative and early postoperative complications of reverse shoulder arthroplasty: A current concepts review

Background

Reverse shoulder arthroplasty is a common procedure performed for a variety of shoulder pathologies.

Aims and objectives

This current concept review evaluates the intraoperative and early postoperative complications, with a specific focus given to neurological and vascular injury, fracture, dislocation and venous thromboembolism.

Conclusion

A detailed knowledge of potential complications will allow surgeons to mitigate risk and maximise outcomes.

Do we achieve the Montgomery standard for consent in orthopaedic surgery?

AIMS/BACKGROUND

The Montgomery v Lanarkshire Health Board (2015) case set a precedent that has driven the modernisation of consenting practice. Failure to demonstrate informed consent is a common source of litigation. This quality improvement project aimed to provide pragmatic guidance for surgeons on consent and to improve the patient experience during decision making.

METHODS

Elective orthopaedic patients were assessed and the quality of documented consent was recorded. Data were collected over two discrete cycles, with cycle 1 used as a baseline in practice. The following criteria were reviewed: grade of consenting clinician, alternative treatment options, description of specific risks, place and timing of consent and whether the patient received written information or a copied clinic letter. Cycle 1 results were presented to clinicians; a teaching session was provided for clinicians on the standard of consent expected and implementation of a change in practice was established with a re-audit in cycle 2.

RESULTS

There were 111 patients included in cycle 1, and 96 patients in cycle 2. Consent was undertaken mostly by consultants (54%). Specific patient risks were documented in 50% of patients in cycle 1 and 60% in cycle 2. Risks associated with a specific procedure were documented in 42% in cycle 1 and 76% in cycle 2, alternative options in 48% (cycle 1) and 66% (cycle 2). A total of 14% of patients in cycle 1 and 8% in cycle 2 had documented written information provision. Copied letters to patients was only seen in 12% of all cycles. Documentation from dedicated consenting clinics outperformed standard clinics.

CONCLUSIONS

Highlighting poor documentation habits and refining departmental education can lead to improvements in practice. The use of consenting clinics should be considered and clinicians should individually reflect on how to address their own shortcomings. Other units should strongly consider a similar audit. This article provides stepwise advice to improve consent and specifics from which to audit.

A radiological study to define safe zones for drilling during plating of clavicle fractures

This study investigated the anatomical relationship between the clavicle and its adjacent vascular structures, in order to define safe zones, in terms of distance and direction, for drilling of the clavicle during osteosynthesis using a plate and screws following a fracture. We used reconstructed three-dimensional CT arteriograms of the head, neck and shoulder region. The results have enabled us to divide the clavicle into three zones based on the proximity and relationship of the vascular structures adjacent to it. The results show that at the medial end of the clavicle the subclavian vessels are situated behind it, with the vein intimately related to it. In some scans the vein was opposed to the posterior cortex of the clavicle. At the middle one-third of the clavicle the artery and vein are a mean of 17.02 mm (5.4 to 26.8) and 12.45 mm (5 to 26.1) from the clavicle, respectively, and at a mean angle of 50° (12 to 80) and 70° (38 to 100), respectively, to the horizontal. At the lateral end of the clavicle the artery and vein are at mean distances of 63.4 mm (46.8 to 96.5) and 75.67 mm (50 to 109), respectively.

An appreciation of the information gathered from this study will help minimise the risk of inadvertent iatrogenic vascular injury during plating of the clavicle.

A prospective randomised trial of absorbable versus non-absorbable sutures for wound closure after fasciectomy for Dupuytren's contracture

After fasciectomy for Dupuytren's contracture the wound has traditionally been closed with non-absorbable sutures. A prospective randomised study of 59 patients was undertaken to compare wound closure after fasciectomy with irradiated polyglactin 910 absorbable sutures and non-absorbable sutures. The outcomes studied were: time spent attending to the wound at the first postoperative visit; the patient's pain score at that visit; and any complications. Wound care required significantly more time when non-absorbable sutures were used. There was no significant difference in pain scores or in complications between the two groups. We recommend the use of irradiated polyglactin 910 absorbable sutures for wound closure after fasciectomy as it saves time and resources without compromising wound healing.

Pain as a presenting feature of acute abdomen in spinal injuries

The diagnosis of acute abdomen can be difficult in patients with spinal injuries. We reviewed all the 1039 case records of patients admitted with spinal injuries to the Queen Elizabeth National Spinal Injuries Unit, Glasgow over a 7-year-period and found 5 (0.48%) cases of acute abdomen that required surgical intervention and were not caused by original injury. Their presenting signs and symptoms were analysed. Pain was found to be an unreliable symptom in these patients.

Bilateral coexistent calcaneonavicular and talocalcaneal tarsal coalition: a case report

Tarsal coalition refers to a union of two or more tarsal bones. The union may be fibrous, cartilaginous, or bony. The most common sites of tarsal coalition reported in the literature are the calcaneonavicular, the talocalcaneal, and, less commonly, the talonavicular areas. Bilateral coexistent multiple tarsal coalitions are a rare occurrence. The authors present a case report of a 17-year-old boy with bilateral coexistent calcaneonavicular and talonavicular bars. The diagnosis was established by radiographs and CT scanning. The patient was treated conservatively with immobilization of the foot in a below-knee walking plaster cast followed by the use of an orthosis with a lateral iron and a medial T strap. The patient was pain-free at 2-year follow-up.