Joint-Preserving Surgery in Varus Ankle Osteoarthritis.

Ankle deformity is a disabling condition especially if concomitant with osteoarthritis (OA). Varus ankle OA is one of the most common ankle OA deformities. This deformity usually leads to unequal load distribution in the ankle joint and decreases joint contact surface area, leading to a progressive degenerative arthritic situation. Varus ankle OA might have multiple causative factors, which might present as a single isolated factor or encompassed together in a single patient. The etiologies can be classified as post-traumatic (e.g., after fractures and lateral ligament instability), degenerative, systemic, neuromuscular, congenital, and others. Treatment options are determined by the degree of the deformity and analyzing the pathology, which range from the conservative treatments up to surgical interventions. Surgical treatment of the varus ankle OA can be classified into two categories, joint-preserving surgery (JPS) and joint-sacrificing surgery (JSS) as total ankle arthroplasty and ankle arthrodesis. JPS is a valuable treatment option in varus ankle OA, which should not be neglected since it has showed a promising result, optimizing biomechanics and improving the survivorship of the ankle joint.

Clinical Effectiveness of Various Surgical Procedures Addressing Long Head of Biceps Pathology: Protocol for a Systematic Review and Meta-Analysis.

INTRODUCTION: The long head of biceps tendon is a common source of anterior shoulder pain and impaired function. Multiple surgical procedures are available as treatment options, but the optimal procedure is not known. The aim of this systematic review and meta-analysis is to review the literature to assess the clinical effectiveness of various surgical procedures to treat pain arising from the long head of biceps. METHODS: The study protocol was designed and registered prospectively on PROSPERO (International prospective register for systematic reviews). Electronic databases used for the literature search will include MEDLINE, EMBASE, PsycINFO, and The Cochrane Library. Randomised controlled trials (RCTs) evaluating surgical procedures on the long head of biceps will be included. Our primary outcome is any functional patient-reported outcome measure related to the shoulder. Secondary outcomes will include the rate of 'Popeye' deformity, the rate of biceps cramping pain, the rate of complications, objective measurements of strength testing such as dynamometer, and other patient-reported outcome measures not specific to the shoulder such as the Visual-Analog Scale (VAS) for pain. Methodological quality of included studies will be assessed using The Cochrane Risk of Bias Tool 2.0 and the Jadad score. Inconsistency and bias across included studies will be assessed statistically. Comparable outcome data will be pooled and analysed quantitatively or qualitatively as appropriate. ETHICS AND DISSEMINATION: No ethical clearances required for this study. We plan to publish this systematic review and meta-analysis in a peer-reviewed journal. It will also be presented at various national and international conferences. HIGHLIGHTS: Evaluating the clinical effectiveness of surgical procedures for long head of biceps pathology.Randomised controlled trials.Biceps tenodesis and biceps tenotomy.Systematic review compliant with the PRISMA guideline.

The use of low intensity pulsed ultrasound in the foot and ankle.

Low intensity pulsed ultrasound (LIPUS) therapy has demonstrated clinical effectiveness in achieving union in a variety of fracture situations.Few studies have investigated the effectiveness of LIPUS therapy in foot and ankle surgery.The overall rate of union in all published studies relating to the use of LIPUS in a variety of foot and ankle fracture and fusion situations is 95%.Some studies suggest lower healing rates (~ 67%) when LIPUS therapy is used to treat hindfoot fusion nonunion.A well-powered, high-quality, randomized controlled trial is needed to demonstrate the clinical and cost effectiveness of LIPUS therapy in foot and ankle surgery. Cite this article: EFORT Open Rev 2021;6:217-224. DOI: 10.1302/2058-5241.6.200045.

Clinical Effectiveness of Intraoperative Tranexamic Acid Use in Shoulder Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Tranexamic acid (TXA) is widely used across surgical specialties to reduce perioperative bleeding. It has been shown to be effective in spinal surgery and lower limb arthroplasty. Among all languages, there are no systematic reviews or meta-analyses investigating its clinical effectiveness for all types of shoulder surgery. PURPOSE: To investigate the clinical effectiveness of TXA in all types of shoulder surgery, including open and arthroscopic procedures. To investigate the effect of TXA on bleeding and non-bleeding-related outcomes. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A protocol for the study was designed and registered with PROSPERO (CRD42020185482). The literature search included the MEDLINE, Embase, PsycINFO, and Cochrane Library databases. All randomized controlled trials evaluating the use of TXA against placebo, in all types of shoulder surgery, were included. Assessments were undertaken for risk of bias and certainty of evidence. The primary outcome was total blood loss. Secondary outcomes included those not directly related to bleeding. Data from comparable outcomes were pooled and analyzed quantitatively or descriptively, as appropriate. RESULTS: Eight randomized controlled trials were included in the systematic review, and data from 7 of these studies were pooled in the meta-analysis. Pooled analysis demonstrated a significant reduction in 2 of 3 outcomes measuring perioperative bleeding with TXA compared with controls: estimated total blood loss (mean difference, -209.66 mL; 95% CI, -389.11 to -30.21; P = .02) and postoperative blood loss as measured by drain output (mean difference, -84.8 mL; 95% CI, -140.04 to -29.56; P = .003). Hemoglobin reduction was reduced but not statistically significant (mean difference, -0.33 g/dL; 95% CI -0.69 to 0.03; P = .07). This result became significant with sensitivity analysis excluding arthroscopic procedures. CONCLUSION: This systematic review and meta-analysis indicated that TXA was effective in reducing blood loss in shoulder surgery. Larger randomized controlled trials with low risk of bias for specific surgical shoulder procedures are required. CLINICAL RELEVANCE: TXA can be used across shoulder surgery to reduced perioperative blood loss. The use of TXA may have other beneficial features, including reduced postoperative pain and reduced operative time.

The use of intra-operative tranexamic acid in shoulder surgery: Protocol for a systematic review and meta-analysis.

INTRODUCTION: Blood loss is an important consideration in all types of shoulder surgery. Excessive bleeding is associated with increased morbidity. Tranexamic acid (TXA) is an antifibrinolytic agent. It has been demonstrated to be effective in reducing blood loss across multiple surgical specialties. The aim of this systematic review and meta-analysis is to review the literature evaluating clinical outcomes associated with the use of TXA in shoulder surgery. METHODS: The study protocol was designed and registered prospectively on PROSPERO (International prospective register for systematic reviews). Literature search will include the MEDLINE, EMBASE, PsycINFO, and Cochrane Library databases. Randomised controlled trials (RCTs) evaluating the use of TXA against placebo, in all types of shoulder surgery, will be included. Our primary outcome is total blood loss (ml). Secondary outcomes include patient-reported outcome measures (PROMs), adverse events, and number of blood transfusions required. Risk of bias will be assessed within each study using The Cochrane Risk of Bias Tool 2.0 and the Jadad score. Inconsistency and bias across included studies will be assessed statistically. Data from comparable outcomes will be pooled and analysed quantitatively or descriptively as appropriate. ETHICS AND DISSEMINATION: No ethical clearances required for this study. This systematic review and meta-analysis will be published in a peer-reviewed journal. It will be presented a various national and international conferences.

Can we reduce the number of MRSA screening site swabs in elective orthopedic patients?

BACKGROUND: Deep infection after routine elective orthopedic procedures can be catastrophic, leading to further surgery, loss of limb, disability, and risk of mortality. Ring-fencing elective orthopedic ward has been shown to significantly reduce the incidence of all postoperative infections especially with methicillin-resistant Staphylococcus aureus (MRSA). Our hospital's current MRSA screening is a four-site MRSA swabs. OBJECTIVES: This study evaluates the possibility of reducing the number of MRSA swab sites as part of a quality improvement project. STUDY DESIGN AND METHODS: Patients on the waiting list for elective orthopedic procedure in our trust who had an MRSA-positive swab from either four sites were analyzed over the time period from January 2012 to December 2014. Those without swabs from all four areas (nose, throat, axilla, and groin) were excluded. Positive swabs of different regions were recorded and compared. RESULTS: There were 138 MRSA-positive patients, giving an incidence of 31 per 10,000 screen/year over that time period. Some patients ( n = 31, 22.5%) had a positive swab in more than one site. The positive sites were as follows: nose (69.60%, n = 96), groin (26.10%, n = 36), throat (25.30%, n = 35), and axilla (8.70%, n = 12). In our cohort, we would miss a significant proportion of positive patients if we change it to a two swab screening policy (26.8% for nose and axilla combination; 18.10% for nose and groin combination; and 15.20% for nose and throat). However, we would only miss 2.2% of cases for a nose, groin, and throat three-swab policy. There were also 11 instances, where a previously negative site become positive in the next swab. CONCLUSION: A three-swab combination of nasal, throat, and groin swabs improves pickup rate of MRSA significantly compared to a two-swab policy and misses only 2.2% compared to a four-swab policy. Axilla swabbing does not make a significant difference to the results. Based on this study, the policy has now been changed from a four-swab to three-swab screening in our trust. This has now been audited four times and they were all negative. This has helped to reduce cost in terms of staff time and resources. We would not recommend screening only the previous positive site for the next repeat screening swabs as there is an 8% chance of missing MRSA carrier status.

Mid-term clinical results of the cementless R3 cup and Polarstem total hip arthroplasty.

BACKGROUND: There has been a shift from cemented to uncemented hip arthroplasty. One popular uncemented combination is the R3 acetabular cup with Polarstem, having the lowest revision rate in the UK National Joint Registry. However, there are no medium-term clinical outcomes on this combination in the literature. The aim of this study is to review our centre's outcomes with this combination using conventional bearings with a minimum of 7-year follow-up. METHODS: Using our centre's arthroplasty database, we identified all patients that underwent a total hip arthroplasty using these implants from August 2009 to December 2010. One hundred and forty-four procedures were performed. The primary outcome was revision rate, and the secondary outcomes were clinical and radiological evaluation. RESULTS: The mean cohort age at surgery was 68.3 years. There were three revisions, of which only one underwent a cup revision. The mean Oxford Hip Score at 7-year follow-up was 38. Radiological evaluation of both acetabular and stem component did not show any radiolucency at 7-year follow-up. Kaplan-Meier survivorship analysis showed an implant survival rate of 97.69% at 7 years using revision for all causes as endpoint. The risk of revision was 1.47% at 7 years. CONCLUSION: Our revision rates are comparable to the UK's National Joint Registry, with excellent clinical and radiological outcome. Our results correlate with the allocated rating of 7A* by the Orthopaedic Data Evaluation Panel for both R3 acetabular cup and Polarstem.

A Comparative Study Between Uncemented and Hybrid Total Hip Arthroplasty in Octogenarians.

BACKGROUND: The aim of this prospective cohort study is to evaluate the outcome of octogenarian patients undergoing uncemented total hip arthroplasty (THA) with a control group of similarly aged patients undergoing hybrid THA with a minimum 5-year follow-up. METHODS: Clinical outcomes including intraoperative and postoperative complications, blood transfusion, revision rate, and mortality were recorded. Radiological analysis of preoperative and postoperative radiographs assessed bone quality, implant fixation, and any subsequent loosening. RESULTS: One hundred forty-three patients (mean age 86.2 years) were enrolled in the study. Seventy-six patients underwent uncemented THA and 67 underwent hybrid THA. The uncemented cohort had a significantly lower intraoperative complication rate (P = .017) and also a lower transfusion rate (P = .002). Mean hospital stay (P = .27) was comparable between the 2 groups. Two patients underwent revision surgery in each cohort. CONCLUSION: Our study demonstrates that uncemented THA is safe for the octogenarian patient and we recommend that age should not be a barrier to the choice of implant. However, intraoperative assessment of bone quality should guide surgeons to the optimum decision regarding uncemented and hybrid implants. LEVEL OF EVIDENCE: 3.

R3 Cup Does Not Have a High Failure Rate in Conventional Bearings: A Minimum of 5-Year Follow-Up.

BACKGROUND: The R3 cementless acetabular system was first marketed in Australia and Europe in 2007. Previous papers have shown high failure rates of the R3 cup with up to 24% with metal-on-metal bearing. There are currently no medium term clinical results on this cup. The aim of the study is to review our results of the R3 acetabular cup with conventional bearings with a minimum of 5-year follow-up. METHODS: Patients who were implanted with the R3 acetabular cup were identified from our center's arthroplasty database. A total of 293 consecutive total hip arthroplasties were performed in 286 patients. The primary outcome was revision. The secondary outcomes were the Oxford Hip Scores (OHS) and radiographic evaluation. RESULTS: The mean age of the patients was 69.4 years. The mean preoperative OHS was 23 (range 10-34) and the mean OHS was 40 (range 33-48) at the final follow-up. Radiological evaluation showed an excellent ARA score in all patients at 5 years. None of the R3 cups showed osteolysis at the final follow-up. There were 3 revisions in our series, of which 2 R3 cups were revised. The risk of revision was 1.11% at 5 years. CONCLUSION: Our experience of using the R3 acetabular system with conventional bearings showed high survivorship and is consistent with the allocated Orthopaedic Data Evaluation Panel rating of 5A* as rated in 2015 in the United Kingdom.

Our early experience of the Corin Minihip prosthesis.

PURPOSE: Although there have been several varieties of short-stem hip prosthesis in the market, there have been no published clinical results of the Corin MiniHip (Corin, Cirencester, UK) to date. The aim of this study is to describe our early results and experience of this stem in a nondesigner, single-surgeon series; calculate 5-year survival with stem revision as an endpoint; evaluate complications and early revisions; and assess radiolucency and stem subsidence at the latest follow-up review. METHODS: Over a 5-year period, 275 MiniHip were implanted in 239 patients. The mean age of the patients was 63 years (range 20-84); mean follow-up was 37 months (range 12-72 months). RESULTS: The mean Harris Hip Score and Oxford Hip Score improved significantly to 87 (range 49-100) and 41 (range 32-48) at the final follow-up (p = 0.038; p = 0.017). There were 9 intraoperative calcar fractures (3%) of which only 1 required cerlage wiring. 10 patients died in our series and none were lost to follow-up. 2 patients had their stem revised for failure of fixation (secondary to possible undersizing) and sink. The risk of revision was 0.73% at 5 years. The Kaplan Meier estimate of survivorship of cumulative failure gave an implant survival rate of 99.3% (95% confidence interval [CI], 27.0-100) at 5 years for revision for any reason as the endpoint. CONCLUSIONS: This novel, short-stem prosthesis has shown good survival in the short term, similar to other short-stem prostheses currently available. We describe the largest series in the literature of this prosthesis.

Do magnetic growing rods have lower complication rates compared with conventional growing rods?

BACKGROUND CONTEXT: The main advantage cited for the use of the magnetic controlled growing rod (MCGR) system over the conventional growing rod (CGR) in early-onset scoliosis is avoiding repeated invasive surgical procedures for lengthening, thus reducing, complications. PURPOSE: The study aimed to evaluate the complications of the MCGR system against the CGR system in our center. STUDY DESIGN/SETTING: This is a retrospective case control series. PATIENT SAMPLE: The sample includes patients with early-onset scoliosis treated with MCGR or CGR. OUTCOME MEASURES: Complications and unplanned return to theater were the outcome measures. RESULTS: Of the 37 patients (MCGR, N=10; CGR, N=27) in our cohort, 28 patients (76%) had at least one complication. Taking into account the follow-up period, MCGR had a higher complication rate than CGR group (0.32 complication per patient per year vs. 0.15 complication per patient per year). The use of MCGR was associated with a lower risk of deep infection (odds ratio [OR]: 0.22; p=.22) and superficial infection (OR: 0.07, p=.017) but increased risk of metalwork problems (OR: 4.67; p=.045) and unplanned return to theater (OR: 2.92; p=.05) compared with CGR. CONCLUSIONS: Although MCGR has a lower rate of both deep and superficial infections when compared with CGR, it does not completely avoid repeated invasive surgical procedures as previously suggested. It does have a significant increased risk of metalwork problems and unplanned return to theater.

Long-term results following polydioxanone sling fixation technique in unstable lateral clavicle fracture.

Neer type II (Edinburgh type 3B) fractures of the lateral clavicle are unstable fractures. The optimal management of these fractures remains controversial with many surgical techniques described in the literature. Our study reports the long-term results of a modified suture (1.5-mm polydioxanone cord) and sling technique for these fractures to avoid complications associated with current techniques in the literature. Over a 5-year period, 23 patients who were (12 males, 11 females; 14 left, 9 right) with a mean age of 42 years were treated with this technique. At last follow-up, the mean Oxford score was 45.1 (range 36-48); the mean SPADI score was 7.4 (range 0-32.3); and the mean Constant score was 91.5 (range 71-100). There were one non-union and no malunion. All patients in our series, except one, returned to their pre-injury activity level. This modified suture fixation technique is safe, technically simple to perform and cheap. It achieves excellent rates of fracture union without the complications associated with other fixation methods in the literature.

Methicillin-resistant Staphylococcus aureus infection of the subacromial bursa: an unusual complication following subacromial corticosteroid injection (a report of two cases).

Subacromial corticosteroid injections are frequently used for both diagnostic and therapeutic purposes in shoulder pain. Subacromial septic bursitis is a recognized but rare complication. There have been no reports of methicillin-resistant Staphylococcus aureus infections of the subacromial bursa after subacromial injections in the literature. We describe case reports of two patients who presented with subacromial methicillin-resistant Staphylococcus aureus septic bursitis following subacromial corticosteroid injections in the community and highlight the diagnostic and management challenges of this condition.

Fractures of the lesser tuberosity of the humerus.

BACKGROUND: Fractures of the lesser tuberosity are rare injuries, and little is known of their epidemiology. Operative treatment is generally recommended for displaced fractures; however, the outcome of this method of treatment has not previously been studied. The aims of our study were to determine the approximate incidence of lesser tuberosity fractures, as well as the functional outcome following operative treatment in a consecutive series of patients. METHODS: Over an eight-year period, we studied the demographic details of a consecutive series of twenty-two adult patients who had a fracture of the lesser tuberosity. We used age and sex-specific local census data to estimate the annual incidence of this injury in our local population. Seventeen of the original cohort of twenty-two patients, who were medically fit and had a displaced (two-part) fracture, were treated with open reduction and internal fixation of the fracture. We assessed the outcome using the Short Form-36 (SF-36) general health measure, the Constant score, and the Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: The estimated annual incidence of these fractures was low at 0.46 per 100,000 population per year during the study period. There were fifteen men and seven women, with a median age of forty-three years. There was an even distribution of fractures across the age cohorts, and most fractures were sustained from a high-energy transfer mechanism. The median Constant score was 95 points at two years, and the median DASH score was 12 points at two years after the injury. Most patients regained nearly normal range of motion in the affected shoulder by three months. One patient had development of posttraumatic shoulder stiffness, which responded to arthroscopic release. All patients who were in regular employment prior to the injury returned to their jobs within six months. There were no significant differences between each component of the SF-36 at two years compared with age and sex-matched controls. CONCLUSIONS: A lesser tuberosity fracture, without an associated humeral head or greater tuberosity fracture, is a rare injury. Open reduction and internal fixation provides excellent restoration of function and range of shoulder movement, with a low risk of complications.