This randomized controlled study aimed to compare surgical duration, intra-operative blood loss, and fluoroscopy time between the suprapatellar and infrapatellar approaches for intramedullary interlocking nailing of tibia. We included 40 adult patients with tibial shaft fractures, excluding those with non-union, revision surgery, or polytrauma. Patients were divided equally into two groups using block randomization: Group A (20 patients) underwent the infrapatellar approach, and Group B (20 patients) underwent the suprapatellar approach. Blood loss was measured using gravimetric method and by changes in pre-operative and post operative haemoglobin levels. Surgical duration was estimated by calculating the time elapsed between the start and end of the procedure and fluoroscopy time was logged from the fluoroscopy machine. In group A, blood loss averaged 154±30.98ml, slightly more than in group B (150±32.92ml), though the difference was not statistically significant (p>0.05). Group A also showed a higher difference in haemoglobin levels (2.20±1.13 gm/dl) compared to group B (1.15±0.93 gm/dl), which was statistically significant (p=0.02). Fluoroscopy time and surgery duration were slightly longer in group A compared to group B but not statistically significant(p=0.693). The suprapatellar approach results in lesser blood loss, potentially promoting faster recovery, reduced need for blood transfusions and shorter hospital stays. It also entails shorter fluoroscopy time and surgical duration (though not statistically significant) which may reduce radiation exposure for the surgical team

Aims

Frailty has been gathering attention as a factor to predict surgical outcomes. However, the association of frailty with postoperative complications remains controversial in spinal metastases surgery. We therefore designed a prospective study to elucidate risk factors for postoperative complications with a focus on frailty.

Aims

For displaced femoral neck fractures (FNFs) in geriatric patients, there remains uncertainty regarding the effect of total hip arthroplasty (THA) compared with hemiarthroplasty (HA) in the guidelines. We aimed to compare 90-day surgical readmission, in-hospital complications, and charges between THA and HA in these patients.

Aims

For rare cases when a tumour infiltrates into the hip joint, extra-articular resection is required to obtain a safe margin. Endoprosthetic reconstruction following tumour resection can effectively ensure local control and improve postoperative function. However, maximizing bone preservation without compromising surgical margin remains a challenge for surgeons due to the complexity of the procedure. The purpose of the current study was to report clinical outcomes of patients who underwent extra-articular resection of the hip joint using a custom-made osteotomy guide and 3D-printed endoprosthesis.

Aims

Lower limb fractures are common in low- and middle-income countries (LMICs) and represent a significant burden to the existing orthopaedic surgical infrastructure. In high income country (HIC) settings, internal fixation is the standard of care due to its superior outcomes. In LMICs, external fixation is often the surgical treatment of choice due to limited supplies, cost considerations, and its perceived lower complication rate. The aim of this systematic review protocol is identifying differences in rates of infection, nonunion, and malunion of extra-articular femoral and tibial shaft fractures in LMICs treated with either internal or external fixation.

The October 2024 Arthroplasty Roundup³⁶⁰ looks at: Breaking the mould: female representation in arthroplasty surgery remains low, with elbow leading the way; Post COVID-19: where are we with the 'catch up' in England and Wales?; Prevalence and clinical impact of sarcopenia in patients undergoing total joint replacement: a systematic review and a meta-analysis; Total joint replacement and sleep: the state of the evidence.

Aims

Closed suction subfascial drainage is widely used after instrumented posterior spinal fusion in patients with a spinal deformity. The aim of this study was to determine the effect of this wound drainage on the outcomes in patients with adolescent idiopathic scoliosis (AIS). This was a further analysis of a randomized, multicentre clinical trial reporting on patients after posterior spinal fusion using segmental pedicle screw instrumentation. In this study the incidence of deep surgical site infection (SSI) and chronic postoperative pain at two years’ follow-up are reported.

Aims

This study aimed to assess the risk of acute kidney injury (AKI) associated with combined intravenous (IV) and topical antibiotic therapy in patients undergoing treatment for periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA), utilizing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for classification.

The October 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Does the primary surgical approach matter when choosing the approach for revision total hip arthroplasty?; Time to achieve the minimal clinically important difference in primary total hip arthroplasty: comparison of anterior and posterior surgical approaches; To scope or not to scope: arthroscopy as an adjunct to PAO does not provide better clinical outcomes at one year than PAO alone; Re-exploring horizons in hip resurfacing: two-year results of a ceramic-on-ceramic hip resurfacing; Association between tranexamic acid and decreased periprosthetic joint infection risk in patients undergoing total hip and knee arthroplasty; Octogenarians fare well: in revision for infection age is not a bar.

The growth of life expectancy during the last decades has led to an increment in age-related conditions such as hip arthritis and fractures. On the other hand, these elderly patients will present a higher incidence of mental diseases which, in some studies, have been associated with inferior results. This study aims to evaluate the differences in early complication rates between patients with cognitive impairment compared with those without this condition following total hip replacement for osteoarthritis or fracture in the context of contemporary perioperative care protocols. We conducted a retrospective cohort study where cognitively-impaired patients who required primary hip arthroplasty were compared to a propensity-score matched cohort of patients without cognitive alterations. Early major complications were measured and analyzed in order to determine significant differences. Screening and matching. 1196 patients were identified during the study period. After screening for inclusion and exclusion criteria and matching, two cohorts comprising 65 patients each were compared. After performing the propensity-score match, no significant differences were found in covariates between the two groups. Outcomes. The occurrence of delirium was more frequent in patients with cognitive deficit (27.5%) than in the control group (9%), p<0.001. No significant differences were found among groups regarding myocardial infarction, venous thromboembolism, blood transfusion requirement, 30-day readmission, in-hospital death, 90-days death, dislocation or surgical site infection. The composite outcome of any adverse event did not exhibit a significant difference either. To our knowledge, this is the first study which demonstrates similar outcomes between patients with cognitive impairment and those without these alterations. Our results might indicate that contemporary protocols and implants are bridging the traditional gap between these two populations. These findings support the use of total hip arthroplasty in patients with mental alterations when indicated, especially in those institutions with strict perioperative protocols

The August 2024 Knee Roundup³⁶⁰ looks at: Calcification’s role in knee osteoarthritis: implications for surgical decision-making; Lower complication rates and shorter lengths of hospital stay with technology-assisted total knee arthroplasty; Revision surgery: the hidden burden on surgeons; Are preoperative weight loss interventions worthwhile?; Total knee arthroplasty with or without prior bariatric surgery: a systematic review and meta-analysis; Aspirin triumphs in knee arthroplasty: a decade of evidence; Efficacy of DAIR in unicompartmental knee arthroplasty: a glimpse from Oxford.

Shoulder replacement surgery is a well-established orthopaedic procedure designed to significantly enhance patients’ quality of life. However, the prevailing preoperative admission practices within our tertiary shoulder surgery unit involve a two-stage group and save testing process, necessitating an admission on the evening before surgery. This protocol may unnecessarily prolong hospital stays without yielding substantial clinical benefits. The principal aim of our study is to assess the necessity of conducting two preoperative group and save blood tests and to evaluate the requirement for blood transfusions in shoulder arthroplasty surgeries. A secondary objective is to reduce hospital stay durations and the associated admission costs for patients undergoing shoulder arthroplasty. We conducted a retrospective observational study covering the period from 1st January 2023 to 31st August 2023, collecting data from shoulder arthroplasty procedures across three hospitals within the Aneurin Bevan University Health Board. Our analysis included 21 total shoulder replacement cases and 13 reverse shoulder replacement cases. Notably, none of the patients required postoperative blood transfusions. The mean haemoglobin drop observed was 14 g/L for total shoulder replacements and 15 g/L for reverse shoulder replacements. The mean elective admission duration was 2.4 nights for total shoulder replacements and 2 nights for reverse shoulder replacements. Our data indicated that hospital stays were extended by one night primarily due to the preoperative group and save blood tests. In light of these findings, we propose a more streamlined admission process for elective shoulder replacement surgery, eliminating the need for the evening-before-surgery group and save testing. Hospital admissions in these units incur a cost of approximately £500 per night, while the group and save blood tests cost around £30 each. This revised admission procedure is expected to optimise the use of healthcare resources and improve patient satisfaction without compromising clinical care

Aims. Transfusion after primary total hip arthroplasty (THA) has become rare, and identification of causative factors allows preventive measures. The aim of this study was to determine patient-specific factors that increase the risk of needing a blood transfusion. Methods. All patients who underwent elective THA were analyzed retrospectively in this single-centre study from 2020 to 2021. A total of 2,892 patients were included. Transfusion-related parameters were evaluated. A multiple logistic regression was performed to determine whether age, BMI, American Society of Anesthesiologists (ASA) grade, sex, or preoperative haemoglobin (Hb) could predict the need for transfusion within the examined patient population. Results. The overall transfusion rate was 1.2%. Compared to the group of patients without blood transfusion, the transfused group was on average older (aged 73.8 years (SD 9.7) vs 68.6 years (SD 10.1); p = 0.020) and was mostly female (p = 0.003), but showed no significant differences in terms of BMI (28.3 kg/m. 2. (SD 5.9) vs 28.7 kg/m. 2. (SD 5.2); p = 0.720) or ASA grade (2.2 (SD 0.5) vs 2.1 (SD 0.4); p = 0.378). The regression model identified a cutoff Hb level of < 7.6 mmol/l (< 12.2 g/dl), aged > 73 years, and a BMI of 35.4 kg/m² or higher as the three most reliable predictors associated with postoperative transfusion in THA. Conclusion. The possibility of transfusion is predictable based on preoperatively available parameters. The proposed thresholds for preoperative Hb level, age, and BMI can help identify patients and take preventive measures if necessary. Cite this article: Bone Jt Open 2024;5(7):560–564

The Cochrane Collaboration has produced five new reviews relevant to bone and joint surgery since the publication of the last Cochrane Corner These reviews are relevant to a wide range of musculoskeletal specialists, and include reviews in Morton’s neuroma, scoliosis, vertebral fractures, carpal tunnel syndrome, and lower limb arthroplasty.

The June 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Machine learning did not outperform conventional competing risk modelling to predict revision arthroplasty; Unravelling the risks: incidence and reoperation rates for femoral fractures post-total hip arthroplasty; Spinal versus general anaesthesia for hip arthroscopy: a COVID-19 pandemic- and opioid epidemic-driven study; Development and validation of a deep-learning model to predict total hip arthroplasty on radiographs; Ambulatory centres lead in same-day hip and knee arthroplasty success; Exploring the impact of smokeless tobacco on total hip arthroplasty outcomes: a deeper dive into postoperative complications.

Aims

This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days.

Aims. Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures. Methods. We identified all periprosthetic fractures around a hip or knee arthroplasty from our prospectively collated database between 2012 and 2021. Patients were categorized into early or delayed intervention based on time from admission to surgery (early = ≤ 36 hours, delayed > 36 hours). Patient demographics, existing implants, Unified Classification System fracture subtype, acute medical issues on admission, preoperative haemoglobin, blood transfusion requirement, and length of hospital stay were identified for all patients. Complication and mortality rates were compared between groups. Results. A total of 365 patients were identified: 140 in the early and 225 in the delayed intervention group. Mortality rate was 4.1% at 30 days and 19.2% at one year. There was some indication that those who had surgery within 36 hours had a higher mortality rate, but this did not reach statistical significance at 30 days (p = 0.078) or one year (p = 0.051). Univariate analysis demonstrated that age, preoperative haemoglobin, acute medical issue on admission, and the presence of postoperative complications influenced 30-day and one-year mortality. Using a multivariate model, age and preoperative haemoglobin were independently predictive factors for one-year mortality (odds ratio (OR) 1.071; p < 0.001 and OR 0.980; p = 0.020). There was no association between timing of surgery and postoperative complications. Postoperative complications were more likely with increasing age (OR 1.032; p = 0.001) and revision arthroplasty compared to internal fixation (OR 0.481; p = 0.001). Conclusion. While early intervention may be preferable to reduce prolonged immobilization, there is no evidence that delaying surgery beyond 36 hours increases mortality or complications in patients with a femoral periprosthetic fracture. Cite this article: Bone Jt Open 2024;5(6):452–456

Introduction. Distal femur fractures have traditionally been stabilized with either lateral locking plate or retrograde intramedullary nail. Dual-plates and nail-plate combination fixation have the theoretical biomechanical advantage, faster union and allows patients to weight bear immediately. The aim of this study is to compare single vs combination fixation, and evaluate outcomes and complications. Method. We retrospectively reviewed all patients over 60, admitted to Christchurch Hospital, between 1st Jan 2016 and 31st Dec 2022, with an AO 33A/33B/33C distal femur fracture. Patient demographics, fracture characteristics, operation details, and follow up data were recorded. Primary outcomes are union rate, ambulatory status at discharge, and surgical complications. Secondary outcomes include quality of reduction, operation time and rate of blood transfusions. Results. 114 patients were included. (92 single fixation, 22 combination fixation). Baseline demographic data and fracture characteristics did not differ between the cohorts. There was no difference in the rate of union or time to union between the two cohorts. Combination fixation patients were allowed to weight-bear as tolerated significantly more than single fixation patients (50% vs 18.9%, p=0.003). There was no difference in length of hospital stay, transfusion, complication and mortality rates. Medial translation of the distal articular block was significantly lower in the combination fixation cohort (1.2% vs 3.4%, p=0.021). Operation time was significantly longer in the combination fixation cohort (183mins vs 134mins, p<0.001). Discussion. The results show no difference in achieving union or time to union, despite better quality of fracture reduction with dual fixation. This differs to previously published literature. The clear benefit of combination fixation is immediate weight-bearing. As expected, operation times were longer with combination fixation, however this did not translate to more complications. Conclusion. Combination fixation allows earlier weight bearing, at the cost of longer operation times

Preoperative anaemia and intraoperative blood loss result in ∼90% of individuals being anaemic following hip and knee arthroplasty. Reducing blood loss offers the opportunity to improve outcomes and reduce the risk of transfusion and costs. This review's aim was to determine the effectiveness of drugs for preventing blood loss, and identify optimal dose, route, and timing of administration. Cochrane network meta-analysis of randomised controlled trials was conducted. Inclusion criteria: adults undergoing primary or revision elective hip or knee arthroplasty. Drugs studied: tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid, desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. Primary outcomes: need for allogenic blood transfusion, all• cause mortality (within 30 days). Secondary outcomes: mean number of transfusion episodes, re-operation, length of hospital stay and adverse events (DVT, PE, CVA, MI). 102 studies with 8418 participants. Trials included more women (63%). 47 studies (4398 participants) were included within the blood transfusion NMA. TXA given intra-articularly and orally at a total dose of greater than 3g pre-incision, intraoperatively and postoperatively ranked the highest, with anticipated absolute effect of 147 fewer transfusions per 1000 (53% chance ranking 1st) (relative risk(RR) 0.02, 95% credible interval(CrI) 0–0.31); moderate-certainty). Aprotinin (RR 0.59, 95%:CrI 0.36–0.86; low certainty evidence), fibrin (RR 0.86, CrI 0.25–2.93; very-low certainty) and EACA (RR 0.60, 95%:CrI 0.29–1.27; very-low certainty) were not shown to be as effective as TXA. TXA was the most effective drug for preventing bleeding in lower limb arthroplasty. Aprotinin and EACA were not as effective. Currently, the optimal dose, route and timing of administration of TXA is unclear. However, TXA given at higher doses and via mixed routes ranked higher in the treatment hierarchy. Oral TXA may be as effective as intavenous. There was no evidence of harm associated with higher doses of TXA