Aims: To assess shoulder function and pain following open reduction and internal fixation of displaced 2, 3 & 4 part fractures of the proximal humerus, using a new fixation plate designed to provide rotation and angle stability.

Method: Patients treated by open reduction and internal fixation with a PlantTan Plate (PTP) were followed-up for a minimum period of 12 months from time of surgery. Post-operatively Constant-Murley (CMS) and visual analogue (VAS) scoring systems were used to assess function and pain at 2, 6 and 12 months post-operatively. Complications have been recorded.

Results: 48 patients have been treated by 4 surgeons with a PTP. Mean patient age was 65 (32 – 89), 17 male, 31 female. Six operations were undertaken for non-union and 42 for acute fractures. At 12 months the mean CMS was 70 (19 – 95) for the fractured side compared to 86 (75 – 100) for the uninjured side, with a mean VAS of 20 (0–68). Six patients have died (unrelated causes). Screws have cut out in 6 (12.5%) patients with 1 requiring implant removal, 1 requiring revision and 1 requiring removal of a head screw. One screw cut out was due to the only case of AVN to date. There have been 5 (10.4%) superficial wound infections (resolved with oral antibiotics) and no deep infections. One patient had a postoperative CVA and one case developed a compartment syndrome due to intra-operative vascular injury; treated successfully with fasciotomies and vascular repair.

Conclusion: We believe the PTP is a useful implant for the management of displaced proximal humeral fractures. We will report on a minimum 2 year follow-up in the near future.

We prospectively audited 79 patients undergoing primary knee or hip arthroplasty (38 knees, 41 hips) and found that 66% (58% of knees, 73% of hips) had at least one unit of blood transfused postoperatively, with a mean transfusion requirement of 1.3 units per patient (1.1 for knees, 0 to 6; 1.5 for hips, 0 to 4).

We then established a new protocol for postoperative blood transfusion. This requires the calculation of the maximum allowable blood loss (MABL) that each individual patient can safely lose based upon their weight and preoperative haematocrit. The total blood loss up to this volume is replaced with colloid. When a patient’s total blood loss reaches their MABL their haematocrit is measured at the bedside using the Microspin system (Bayer plc, Newbury, UK). If their haematocrit is low (< 0.30 for men, < 0.27 for women), blood is transfused. As a safety net all patients have their haemoglobin formally checked on days 1, 2, and 3 after surgery and have a transfusion if the haemoglobin levels are less than 8.5 g/dl.

We conducted a further audit of 82 patients (35 knees, 47 hips) after the introduction of this protocol. Under the new protocol only 24% of patients required blood (11% of knees, 34% of hips) with a mean transfusion requirement of 0.56 units per patient (0.26 for knees, 0 to 4; 0.79 for hips, 0 to 4).

The use of clinical audit and the introduction of strict guidelines for transfusion can change transfusion practice and result in improved patient care. Our transfusion protocol is a simple and effective method of keeping transfusion to a minimum and is particularly useful in departments which do not have the facility to use autologous blood or reinfusion drains for elective orthopaedic surgery.

Blood is a costly commodity with side-effects that can be avoided by eliminating unnecessary transfusion. The purpose of this study was to prospectively audit the amount of blood we were transfusing in elective joint surgery and to then institute a new, more scientifically based post-operative protocol to see if we could reduce our transfusion requirements.

We prospectively audited 79 patients undergoing primary knee or hip arthroplasty (38 knees and 41 hips) in our unit and found that 66% (58% of knees and 73% of hips) had at least one unit of blood transfused postoperatively, with a mean transfusion requirement of 1. 3 units per patient (1. 1 for knees, range 0–6; 1. 5 for hips, range 0–4).

We then devised a new protocol for post-operative blood transfusion. This new protocol requires the calculation of the volume of blood that each individual patient can safely lose (maximum allowable blood loss – MABL) based upon their weight and pre-operative haematological indices. Total blood loss up to this volume is replaced with colloid. In the first 24 hours, if a patient’s total blood loss reaches their MABL they have their haematocrit measured at the bedside using the Microspin™ system. If their haematocrit is low (< 0. 30 for males, < 0. 27 for females) they are transfused blood. We set our ‘transfusion trigger’ after the first 24 hours at 8. 5 g/dl. Blood is transfused if the formal haemoglobin check on days 1, 2 or 3 is less than this.

We conducted a further audit of 82 patients (35 knees, 47 hips) following the institution of this protocol. Under the new protocol only 24% of patients required blood (11 % of knees, 34% of hips) with a mean transfusion requirement of 0. 56 units per patient (0. 26 for knees, range 0–4; 0. 79 for hips, range 0–4).

The use of clinical audit and the institution of strict guidelines for transfusion can effectively change transfusion practice and result in the delivery of improved patient care. Our transfusion protocol is a simple and effective method of keeping blood transfusion to a minimum and is particularly useful in a unit that does not have the facility to use autologous blood or re-infusion drains for elective orthopaedic surgery.