Background: Published scoping review has identified evidence paucity related to long-term follow-up of shoulder arthroplasty. We aim to report effectiveness of elective primary shoulder arthroplasty surveillance in identifying failing implants requiring revision. Methods: A prospective database recording shoulder arthroplasty and subsequent follow-up surveillance in a shoulder unit was analyzed. Shoulder arthroplasty was performed by 4 fellowship-trained shoulder surgeons for accepted elective indications including the use of anatomic arthroplasty in arthritic shoulders with intact rotator cuff and a reverse prosthesis being used in rotator cuff-deficient shoulders and rotator cuff-competent arthritic shoulders when deemed preferable by the treating surgeon. All shoulder arthroplasty implants used had achieved a minimum 7A Orthopaedic Data Evaluation Panel (ODEP) rating. The included shoulder arthroplasties were performed between May 1, 2004, and December 31, 2021, with minimum 1-year follow-up. Surveillance program involves specialist physiotherapist review at 1, 2, 3, 5, 8, 10, and 15 years postoperatively, including clinical examination, outcome scoring, and radiographs. Patient-initiated review occurred between time points if a patient requested assessment because of symptoms. Outcome measures include ratio of failing implants identified by surveillance and patient-initiated review, with number of surveillance reviews offered and proportion that identified a failing implant requiring revision calculated. Results: A total of 1002 elective primary shoulder arthroplasty with minimum 1-year follow-up were performed (547 reverse total shoulder arthroplasty [rTSA], 234 anatomic total shoulder arthroplasty [aTSA], and 221 hemiarthroplasty [HA]). A total of 238 patients died prior to December 31, 2022, resulting in 4019 surveillance appointments offered. Thirty-eight prostheses required revision >= 1 year postoperatively (6 rTSA, 9 aTSA, and 23 HA), with surveillance identifying requirement in 53% (33% rTSA, 56% aTSA, and 57% HA) and patient-initiated review in 47%. Mean years from implantation to revision was 5.2 (2.7 rTSA, 3.6 aTSA, and 6.6 HA). Revision indications included rotator cuff failure (56% aTSR and 43% HA) and glenoid erosion (57% HA). Conclusion: This is the first series reporting effectiveness of shoulder arthroplasty surveillance in identifying implants requiring revision. Surveillance identified more than half of implants requiring revision, although only 0.5% of appointments identified revision requirement. Surveillance enrolment may influence patient-initiated review utilization; therefore, similar studies using only patient- initiated follow-up would help inform recommendations. Level of evidence: Level III; Retrospective Cohort Comparison; Treatment Study (c) 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background Shoulder arthroplasty incidence is projected to continue its exponential growth and the resultant burden of monitoring patients with shoulder arthroplasty implants creates significant pressure on orthopaedic services. Surveillance offers the opportunity to study implant longevity, detect failing implants and potentially perform revision at lower morbidity and cost. There is a paucity of evidence to support recommendations on long-term follow-up in shoulder arthroplasty. Prospective studies comparing long-term follow-up and structure are impractical from time, resource and cost perspectives. A real-time Delphi technique represents a mechanism by which experts involved in long-term follow-up of primary shoulder arthroplasty can formulate recommendations via a transparent, reproducible and efficient process. We outline the protocol for a real-time Delphi study seeking consensus on long-term follow-up and surveillance of primary shoulder arthroplasty .Methods A real-time Delphi technique will be used. A planning committee will design the Delphi statements. A steering committee will supervise and monitor the real-time Delphi process. Participants will be asked to rate their agreement with statements using a 5-point Likert scale. The Delphi statements will be derived from review of published literature, and the strength of evidence available for each statement will be provided. We will offer participation to all surgeons and extended-scope practitioners who are current members of the British Elbow & Shoulder Society (BESS) and have clinical practice involving shoulder arthroplasty follow-up. The questionnaire will be active for 4 weeks and requires a minimum of 20 participants. Consensus agreement is defined as 70% of participants selecting at least a 4-point on a 5-point Likert scale.Discussion We anticipate the outlined study will achieve consensus on long-term follow-up and surveillance of primary shoulder arthroplasty. We intend to use the expert consensus recommendations achieved, in addition to the limited applicable published evidence available, to produce BESS-affiliated guidelines on long-term follow-up and surveillance of primary shoulder arthroplasty.EthicsEthical approval is not required for the real-time Delphi study.We expect the results of this initiative will be published in a peer-reviewed, high-impact journal.

Background: The Discovery Elbow System (DES) utilizes a polyethylene bearing within the ulnar component. An exchange bearing requires preoperative freezing and implantation within 2 minutes of freezer removal to allow insertion. We report our outcomes and experience using this technique.Methods: This was an analysis of a two-surgeon consecutive series of DES bearing exchange. Inclusion criteria included patients in which exchange was attempted with a minimum 1-year follow-up. Clinical and radiographic review was performed 1, 2, 3, 5, 8 and 10 years postoperative. Outcome measures included range of movement, Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), complications and requirement for revision surgery.Results: Eleven DESs in 10 patients were included. Indications were bearing wear encountered during humeral component revision (n=5); bearing failure (n=4); and infection treated with debridement, antibiotics and implant retention (DAIR; n=2). Bearing exchange was conducted on the first attempt in 10 cases. One case required a second attempt. One patient developed infection postoperatively managed with two-stage revision. Mean follow-up of the bearing exchange DES was 3 years. No further surgery was required, with no infection recurrence in DAIR cases. Mean elbow flexion-extension and pronosupination arcs were 107° (±22°) and 140° (±26°). Mean OES was 36/48 (±12) and MEPS was 83/100 (±19).Conclusions: Our results support the use of DES bearing exchange in cases of bearing wear with well-fixed stems or acute infection. This series provides surgeons managing DES arthroplasty with management principles, successful and reproducible surgical techniques and expected clinical outcomes in performing DES polyethylene bearing exchange.Level of evidence: IV.

Aims Long-term follow-up and monitoring of asymptomatic shoulder and elbow arthroplasty remains contentious, with a wide spectrum of non-evidence-based mechanisms used. This scoping review aims to outline related evidence, thereby informing research requirements. Methods Studies relevant to shoulder and elbow arthroplasty follow-up, surveillance and time-related failure were included. The review included randomised controlled trials, systematic reviews and economic studies indexed in MEDLINE, Embase, Cochrane CDSR and Cochrane CENTRAL since 1 January 2012. In addition, all registry studies, follow-up studies, cohort studies and case reports indexed in MEDLINE since 1 January 2020 were included. The screening was undertaken by two reviewers. Key characteristics of each study were described, alongside a narrative review. Results Twenty-one articles were included. We were unable to identify evidence that long-term follow-up and monitoring of asymptomatic shoulder and elbow arthroplasty identifies failure or leads to a revision that is of reduced patient morbidity and cost. In addition, no evidence was apparent to inform whether patients will self-present with a failing implant. Several surveillance mechanisms were identified. Conclusion This scoping review highlights the paucity of evidence related to long-term follow-up and monitoring of shoulder and elbow arthroplasty, and the need for high-quality data to inform the development of evidence-based care pathways.

We report our medium-term outcomes of the balloon spacer in treating irreparable massive rotator cuff tears (MRCT). Twenty-two patients (17 male:5 female; mean age 68.2 years) had a balloon spacer arthroscopically inserted between September 2013–May 2017 after failing non-surgical management or rotator cuff repair. Oxford Shoulder Scores (OSS) were collected prospectively at baseline and prior to reverse total shoulder replacement (rTSR) or at most recent follow up for those with the balloon spacer still in-situ. A significant OSS improvement at mean follow-up 31.4 months (5–63) was found analysing all patients who had a balloon inserted (23.6 vs 29.6; p < 0.02). However, 6 patients (27%) converted to rTSR at a mean time of 11 months post balloon insertion with a mean OSS deterioration of 1.1. Six patients with the balloon still in-situ demonstrated either a deterioration or an OSS improvement less than the minimal clinically important difference (MCID). Three patients had an OSS improvement greater than the MCID but remained symptomatic. Seven patients (32%) had a successful clinical outcome. Patients converting to rTSR or with poor clinical outcomes were significantly older with significantly lower baseline OSS compared to those with the best outcomes. The balloon spacer is effective in a minority of patients in the medium term. The majority either convert to rTSR or remain symptomatic with the risk of failure higher in those who are older with a low baseline OSS.

PURPOSE:Stiffness is a sequelae of elbow trauma. Arthrolysis may be considered to increase range of movement (ROM). Little is published on the outcomes/complications of elbow arthrolysis. We present our series of primary open arthrolysis in posttraumatic elbow stiffness.METHODS:A consecutive series of patients that underwent primary open arthrolysis for posttraumatic elbow stiffness in our unit (2011-2018) were analysed. All procedures were performed by an elbow surgeon. Postoperative rehabilitation followed protocol with early motion; continuous passive motion (CPM) was utilised if requested. Data collected included patient demographics, traumatic injury type, arthrolysis technique, preoperative, intraoperative and postoperative elbow ROM, complications and postoperative Oxford Elbow Score (OES).RESULTS:41 patients were included. 59% were male. Mean age at time of arthrolysis was 43 years (range 12-79 years). Mean duration of follow-up was 53 months (range 8-100 months). Median duration from time of injury to arthrolysis was 11 months (range 2-553 months). Mean preoperative flexion-extension arc (FEA) was 70°, improving to 104° postoperatively (p < 0.001). Mean preoperative pronosupination arc (PSA) was 125°, improving to 165° postoperatively (p < 0.001). Mean postoperative OES was 37 (n = 28). Complication rate was 24% with 7 recurrence requiring surgery, 2 nerve injuries and 1 infection. CPM, 10 patients, saw mean FEA improvement of 56°. Mean PSA improvement was 36°. Complication rate for these patients was 40%. Severe traumatic injury was associated with increased preoperative stiffness (FEA 61° vs 84°, PSA 111° vs 149°) but larger improvements in ROM (postoperative FEA 98° [p < 0.001], PSA 165° [p < 0.001]).CONCLUSION:This series demonstrates improvement in elbow ROM following open arthrolysis with significantly higher gain in pronosupination for those withsevere injury. Moderate results were seen in a patient reported outcome measure. Patients considering arthrolysis should be counselled regarding expectations/complication rate.

There are few studies reporting the outcomes from arthroscopic shoulder stabilisation using all-suture soft anchors. The aim of this study was to assess the clinical outcomes and failure rate for arthroscopic shoulder stabilisation using these anchors. A retrospective cohort analysis of a consecutive series of patients in a single unit undergoing arthroscopic shoulder stabilisation using JuggerKnot all-suture soft anchors by four consultant shoulder surgeons was performed. Exclusion criteria were revision procedures, engaging Hill-Sachs lesions and glenoid bone loss greater than 20%. The primary outcome measure was failure (dislocation or subluxation as perceived by the patient with subsequent revision surgery). The secondary outcome measure was function as assessed by the Oxford Shoulder Instability Score (OSIS). 67 patients with a mean age at the time of surgery of 32.6 years (range 15–55 years) met the inclusion criteria. Median follow up was 34.5 months (minimum 13 months). No patient experienced a postoperative dislocation. However, three patients experienced painful subluxations; two underwent revision arthroscopic stabilisation and one required open stabilisation due to glenoid bone loss. Consequently, failure rate was 4.5%. Mean post-operative OSIS was 39/48 (n = 49). This series supports the use of all-suture soft anchors in arthroscopic shoulder stabilisation. The failure rate compares favourably with that previously reported in literature for conventional anchors. Level IV: Case series with no comparison group.

Aim: The British Orthopaedic Association introduced an Audit Standard for Trauma (BOAST) related to the management of ankle fractures in 2016. We aim to audit Royal Derby Hospital compliance with a specified standard for practice – ‘early fixation (on the day or day after injury) is recommended in the majority of patients under 60 years’. We also compare compliance with that of a local district general hospital. Method: Retrospective analysis of patients presenting to Royal Derby Hospital with unstable ankle fractures from 29/01/2018-03/06/2018. Pilon, open and skeletally immature fractures and patients >60 years were excluded. Data related to time of presentation and fixation was collected. Casenotes were reviewed in patients with fixation delay to clarify cause. Length of inpatient stay was also recorded. Identical data was obtained at King’s Mill Hospital. Results: 53 patients presented to Royal Derby Hospital; of which 27 fulfilled our inclusion criteria. 14 patients (52%) fulfilled audit standard of undergoing fixation on the day or day after injury. Mean number of days between presentation and fixation was 4 (median 1; range 1-17). 62% (n=34) fulfilled audit standard at King’s Mill Hospital. Of those patients that did not fulfil the audit standard, 46% remained an inpatient whilst awaiting optimisation of their soft tissue status. 39% had had an initial trial of non-operative treatment. 15% were granted home leave and attended fracture clinic for a preoperative swelling check. At King’s Mill Hospital 40% of those that did not fulfil audit standard remained an inpatient. Conclusion: Audit compliance at Royal Derby Hospital is comparable to that of a local district general hospital. Recommendations: Endeavour to prioritise early fixation of unstable ankle fractures. However, when surgical intervention is delayed due to capacity issues, suitable patients should be discharged home with advice to strictly elevate the injured limb. The patient can then be readmitted on an urgent elective basis for fixation.

An arthroscopic shoulder posterior stabilisation is indicated in symptomatic patients with an isolated posterior labral tear. We present our surgical technique and perioperative management.

The shoulder is the least constrained of all joints of the body and is more susceptible to injury including dislocation. The rate of recurrent instability following primary stabilization procedure at 10 years of follow-up ranged from 3.4 to 20%. There is a lack of evidence in the literature regarding use of labral tape and anchors for anterior stabilization despite the growing market for this product. We describe the outcomes of 67 patients who underwent knotless arthroscopic anterior stabilisation under awake anaesthesia using 1.5 mm LabralTape with 2.9 mm Pushlock anchors for primary anterior instability by a single surgeon.

Prophylactic antibiotics can decrease the risk of wound infection and have been routinely employed in orthopaedic surgery for decades. Despite their widespread use, questions still surround the selection of antibiotics for prophylaxis, timing and duration of administration. The health economic costs associated with wound infections are significant, and the judicious but appropriate use of antibiotics can reduce this risk. This review examines the evidence behind commonly debated topics in antibiotic prophylaxis and highlights the uses and advantages of some commonly used antibiotics. Cite this article: Bone Joint J 2016;98-B:1014-19.

INTRODUCTION:English Major Trauma Centres (MTCs) were established in April 2012. Increased case volume and complexity has influenced trauma and orthopaedic (T&O) core surgical training in these centres.OBJECTIVES:To determine if T&O core surgical training in MTCs meets Joint Committee on Surgical Training (JCST) quality indicators including performance of T&O operative procedures and consultant supervised session attendance.METHODS:An audit cycle assessing the impact of a weekly departmental core surgical trainee rota. The rota included allocated timetabled sessions that optimised clinical and surgical learning opportunities. Intercollegiate Surgical Curriculum Programme (ISCP) records for T&O core surgical trainees at a single MTC were analysed for 8 months pre and post rota introduction. Outcome measures were electronic surgical logbook evidence of leading T&O operative procedures and consultant validated work-based assessments (WBAs).RESULTS:Nine core surgical trainees completed a 4 month MTC placement pre and post introduction of the core surgical trainee rota. Introduction of core surgical trainee rota significantly increased the mean number of T&O operative procedures led by a core surgical trainee during a 4 month MTC placement from 20.2 to 34.0 (p<0.05). The mean number of hip hemiarthroplasty procedures led by a core surgical trainee during a 4 month MTC placement was significantly increased (0.3 vs 2.4 [p=0.04]). Those of dynamic hip screw fixation (2.3 vs 3.6) and ankle fracture fixation (0.7 vs 1.6) were not. Introduction of a core surgical trainee rota significantly increased the mean number of consultant validated WBAs completed by a core surgical trainee during a 4 month MTC placement from 1.7 to 6.6 (p<0.0001).CONCLUSIONS:Introduction of a departmental core surgical trainee rota utilising a 'problem-based' model can significantly improve T&O core surgical training in MTCs.

PURPOSE:To highlight missed training opportunities in daycase surgery for trainees to acquire competency in vascular anastomosis by performing arteriovenous fistula (AVF) formations.METHODS:Operative Room Management Information System records were reviewed for AVF procedures in daycase and general theatres at a UK Foundation Trust between 2007 and 2012. Data collected included procedure, procedure time (PT), patient length of stay (LOS), readmissions within 30 days of procedure and lead and assistant surgeons involved.RESULTS:Of 199 daycase AVF procedures reviewed, 59.3% (n=118) were brachiocephalic formations and 34.2% (n=68) radiocephalic formations. Trainees attended 41.2% of daycase AVF procedures and were lead surgeon in 7.3% of these. Mean PT was 64 minutes for consultants compared with 56 minutes for trainees, with no significant difference (p=0.297). Median patient LOS was less than 24 hours for both groups. Six daycase AVF procedures resulted in patient readmission within 30 days; five of these were operated on by consultants and one by a staff grade. During the same period, 258 AVF procedures were performed in general theatres. Trainees attended 64.3% of AVF formations performed in general theatres and were lead surgeon in 5.8% of these.CONCLUSIONS:Trainees attended and led few daycase AVF formations despite no significant difference in PT, patient LOS or readmission rate between consultant-led and trainee-led cases. Trainees attended more AVF formations performed in general theatres than daycase. However, trainees led a greater proportion of daycase AVF formations, possibly due to a less complex case mix that is more suitable for training.

Introduction: Traditionally uncomplicated elective hernia operations were performed by surgical trainees; allowing them to develop key competencies and skills transferable to emergency hernia surgery. Daycase surgical units (DCU) are increasingly accommodating operations that traditionally contributed to operating lists in general elective theatres. We aim to assess whether DCU could help improve training in hernia surgery.Subjects and methods: Operative Room Information System (ORMIS) data was collected retrospectively to identify hernia operations performed at a large NHS hospital between January 2007 and 2012. Data collected included operating surgeon(s), procedure performed and procedure time (PT). Hospital coding records were used to collect data related to patient length of stay (LOS), complications, readmissions and deaths within 30 days of procedure.Results: 4668 hernia operations were performed; 3063 in DCU. 91.5% (n = 2803) were open and 8.5% (n = 260) laparoscopic repairs. Trainees assisted in 24.6% (n = 752) and led 7.8% (n = 238) of cases. Overall, the mean PT for consultant led open hernia operations was 37.44 min (95% CI 36.75-38.12) and 43.07 min (95% CI 40.99-45.16) for trainees (p < 0.05). Subgroup analysis of all hernia operations performed showed no significant difference in PT between consultants and trainees when performing open bilateral inguinal, femoral, epigastric, incisional and laparoscopic hernia operations. There were no differences in LOS, readmissions and death rates within 30 days of the operation.Conclusions: DCU are an underutilised opportunity for trainees to acquire experience of hernia operations. When given the opportunity to lead hernia operations in DCU, trainees have similar PT and complication rates to consultants in many instances. Trainees should be encouraged to assist and lead hernia cases in DCU under adequate supervision to ensure appropriate competency is achieved and high standards are maintained. (C) 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Colorectal DiseaseVolume 15, Issue 12 p. 1544-1544 Correspondence Day-case training in coloproctology A. El-Sharkawy, A. El-Sharkawy Upper G.I. Surgery, Queens Medical Centre, Nottingham, UKSearch for more papers by this authorB. Grewal, B. Grewal ballyg88@gmail.com Vascular Surgery, Royal Derby Hospital, Derby, UKSearch for more papers by this authorD. Morris, D. Morris King's Mill Hospital, Kirkby in Ashfield, UKSearch for more papers by this authorJ. Quarmby, J. Quarmby Vascular Surgery, Royal Derby Hospital, Derby, UKSearch for more papers by this authorT. Rowlands, T. Rowlands Vascular Surgery, Royal Derby Hospital, Derby, UKSearch for more papers by this author A. El-Sharkawy, A. El-Sharkawy Upper G.I. Surgery, Queens Medical Centre, Nottingham, UKSearch for more papers by this authorB. Grewal, B. Grewal ballyg88@gmail.com Vascular Surgery, Royal Derby Hospital, Derby, UKSearch for more papers by this authorD. Morris, D. Morris King's Mill Hospital, Kirkby in Ashfield, UKSearch for more papers by this authorJ. Quarmby, J. Quarmby Vascular Surgery, Royal Derby Hospital, Derby, UKSearch for more papers by this authorT. Rowlands, T. Rowlands Vascular Surgery, Royal Derby Hospital, Derby, UKSearch for more papers by this author First published: 12 August 2013 https://doi.org/10.1111/codi.12374Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume15, Issue12December 2013Pages 1544-1544 RelatedInformation

Dear Sir, Recent changes prompted by the 2003 European Working Time Directive (EWTD) have impacted surgical training in a number of ways. Although the EWTD has decreased trainee fatigue and improved work–life balance, it has led to decreased theatre exposure for surgical trainees. The knock-on effect has been to reduce trainee opportunities to learn and consolidate their surgical technique. Bariatric surgery is complex, requiring a high level of skill with a laparoscopic approach at the heart of such operations. In order to ensure competence, trainees need to utilise all available opportunities to learn and perform parts or indeed all of the operation appropriate to their grade and ability. We reviewed electronic database records detailing daycase operations between 1 January 2007 and 1 January 2012 at a large NHS foundation trust, in order to investigate the availability of opportunities for trainees to develop laparoscopic skills in bariatric procedures. There were 92 daycase bariatric procedures performed during this time, including gastric band portreplacement and laparoscopic band-adjustment procedures. All these cases were performed by consultants with trainees assisting in only 20 % (n=18) of cases. Possible reasons for poor trainee participation include trainees not wishing to utilise such an opportunity or trainees being timetabled to attend other activities. Relatively minor operations such as daycase bariatric procedures provide trainees with opportunity to develop a solid technical foundation from which to progress to more complex procedures in the future. The laparoscopic skills developed by performing these subspecialty procedures are core and transferable to other surgical specialties. In order for standards of surgical excellence within the UK to be maintained, trainees must utilise all such available opportunities.

1 Wijffels N, Cunningham C, Dixon A, Greenslade G, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete?. Colorectal Dis 2011; 13: 561–6. 2 Collinson R, Wijffels N, Cunningham C, Lindsey I. Laparoscopic ventral rectopexy for internal rectal prolapse: short-term functional results. Colorectal Dis 2010; 12: 97– 104. 3 Powar M, Ogilvie J, Stevenson A. Day-case laparoscopic ventral rectopexy: an achievable reality. Colorectal Dis 2013; 15: 700–706.