To determine whether pre-operative cessation of anticoagulant or antiplatelet medication is necessary for patients undergoing total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA).

A prospectively maintained database was used to identify 213 consecutive patients treated with TSA or RTSA performed by a single surgeon across 3 centres. This cohort included 24 patients on an anticoagulant agent (warfarin, apixaban, rivaroxaban, dabigatran), 52 patients on an antiplatelet agent (aspirin, clopidogrel), and a control group of 137 patients not on anticoagulant or antiplatelet medication. Patients on anticoagulant or antiplatelet medications continued these agents peri-operatively. Outcomes included haemoglobin drop, intra-operative blood loss, operative time, transfusion requirements and post-operative complications.

The mean age of the cohort was 74.3 years (range 47 – 93) and 75 (35.2%) of the patients were male. TSA was performed in 63 cases and RTSA in 150 cases. The mean haemoglobin drop in the control group was 17.3 g/L, compared to 19.3 g/L in the anticoagulant group (p = 0.20) and 15.6 g/L in the anti-platelet group (p = 0.14). The mean intra-operative blood loss in the control group was 107.8 mL, compared to 143.0 mL in the anticoagulant group (p = 0.03) and 134.3 mL in the anti-platelet group (0.02). The mean operative time in the control group was 49.3 minutes, compared to 47.1 minutes in the anticoagulant group (p = 0.56) and 50.3 minutes in the anti-platelet group (p = 0.78). Post-operatively no patients developed a wound infection or haematoma requiring intervention. Three patients not on anticoagulant or antiplatelet medication developed pulmonary embolism.

Continuing anticoagulant or antiplatelet medication was associated with higher intra-operative blood loss, but produced no statistically significant differences in haemoglobin drop, operative time, transfusion requirements or post-operative complications. We now do not routinely stop any anticoagulant or antiplatelet medication for patients undergoing total shoulder arthroplasty.

Midshaft clavicle fractures can be classified into simple or complex/comminuted. The hardest fracture to treat is the severely comminuted and displaced fracture. We retrospectively compared 286 consecutive operatively treated simple (2 and 3 part) fractures with the more complex comminuted (>=4 part) midshaft clavicle fractures, looking at outcome, complication rate and union rate.

Between 2008 and 2010 the senior author operated on 286 displaced midshaft clavicle fractures using a plate and screws. In this cohort there were 173 simple (2 and 3 part) fractures and 99 complex (>=4 part) fractures. The operation was performed through a limited incision technique and was standardized. All fractures were fixed with at least 3 screws on either side of the comminution. All patients were up until radiological and clinical union. A standardized questionnaire was used to assess patient satisfaction, return to work, sport and outcome at each postoperative visit. All complications were documented.

All fractures eventually went onto union. There were 242 males and 44 females with the average age being 33. The complex fractures had a larger scar, took longer to return to normal motion, work and sport, and took on average 10 weeks to unite compared to 6 weeks in the simple fractures. The infection rate in the simple fractures was 1% and in the complex fractures was 2%. The big difference was the incidence of non union in the complex fractures of 10% compared to 1%; the other main difference was postoperative shoulder stiffness of 3% at 3 months in the complex fractures compared to 1 % in the simple fractures. Plate elevation/irritation was also more prevalent in the complex fractures of 10% compared to 3%.

This study clearly shows there is a higher complication rate in complex fractures. Particular attention must be placed on surgical technique and anatomical reduction of these difficult fractures followed closely by postoperative rehabilitation. Future studies of clavicle fractures should specify the type of fracture being treated to give a better understanding of the potential outcome.