A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials Comparing Treatments for Displaced Radial Head Fractures.

Background: The aim of this study is to compare the surgical and non-operative management of displaced radial head fractures via a network meta-analysis of randomised controlled trials (RCTs). Methods: RCTs comparing management of isolated, displaced radial head fractures in adults were included in our review and statistical analysis. A systematic review of electronic databases (Medline, Embase and Cochrane Library) were screened for comparative RCTs reporting on the management of displaced radial head fractures in August 2021. Two investigators independently reviewed studies for eligibility and an assessment of bias was performed for each study. A Bayesian network meta-analysis of the included RCTs was performed. Results: Five RCTs (326 patients) were included in our meta-analysis. Treatment methods included radial head arthroplasty (RHA), open reduction internal fixation (ORIF) with metal implants (ORIF-M), ORIF with biodegradable implants (ORIF-B) and non-operative management. In our network meta-analysis of 'good' or 'excellent' patient-reported outcome measures (PROMs), RHA was significantly favourable to ORIF-M (OR: 0.04, CrI: 0.0011, 0.87), ORIF-B (OR: 0.1 CrI: 0.00076, 6.37). Nonoperative treatment was not shown to be significantly worse than RHA (OR: 0.01 CrI: 2.5e-0.5, 3.61). Conclusions: This network meta-analysis shows that in displaced radial head fractures, RHA is associated with significantly superior functional PROMs than ORIF-M based on the evidence available. Nonoperative management has not been shown to be significantly worse. Level of Evidence: Level III (Therapeutic).

Whole-body vibration decreases delayed onset muscle soreness following eccentric exercise in elite hockey players: a randomised controlled trial.

BACKGROUND: Delayed onset muscle soreness (DOMS) is a common non-structural muscle injury which can disrupt training and impair performance in elite athletes. Vibration therapy reduces inflammation and improves neuromuscular efficiency, leading to reductions in pain and stiffness, and may be effective for the prevention or treatment of DOMS. However, the effect of whole-body vibration (WBV) used after sport in elite athletes has not been reported. METHODS: A randomised, controlled trial was performed. Participants were elite (national or international level) hockey players and underwent an eccentric exercise protocol previously shown to produce clinical DOMS. After exercise, one group underwent static stretching with WBV therapy, and the other performed stretching only. Baseline and serial post-exercise pain scores and measurements of quadriceps tightness were obtained. RESULTS: Eleven participants were recruited into each study arm. There were no significant differences in baseline group characteristics. Participants receiving WBV had significant reductions in both pain (p = 0.04) and quadriceps tightness (p = 0.02) compared with stretching only. CONCLUSIONS: Post-exercise WBV is effective in elite hockey players to reduce DOMS after eccentric exercise. Elite athletes in multi-sprint sports are at risk of DOMS during training and competition, and its reduction could contribute to reduced injury risk and improved performance. This treatment modality is favourable because it can be incorporated with minimal disruption into the recovery section of existing training regimes. These findings may also be extrapolated to other multi-sprint sports.

Novel clinical and radiological measures of lower limb obesity.

Osteoarthritis of the knee is strongly associated with central obesity, and the prevalence of obesity in patients undergoing knee arthroplasty procedures is expected to increase. Central obesity is associated with multiple adverse outcomes after knee arthroplasty, but the impact of obesity specifically around the operated knee is poorly understood. One reason for this is the absence of a standardized measure, analogous to BMI for central obesity, to facilitate research. The aim of this study was to develop a radiological limb obesity scoring system which reliably corresponds with anthropometric measurements. Detailed anthropometric and radiological measurements were taken from patients undergoing total and unicompartmental knee replacement. Anthropometric measurements were combined into a composite score using principal components analysis. Different radiological scoring methods were evaluated against the anthropometric measure using correlation and regression analyses. Intraclass correlation coefficients were used to evaluate intra- and inter-observer reliability of the radiographic measurements. Measurements were obtained from fifty patients. There was a significant correlation between the composite anthropometric score and unadjusted radiological soft tissue width at the level of the femoral condyles (p < 0.001). There was also a significant correlation with the ratio of tissue to bone widths at the same level (p < 0.001), and fit was improved by including variables coding for soft tissues overlapping the medial or lateral boundaries of the radiograph. We have demonstrated a methodology for producing standardized radiological limb obesity scores which are strongly correlated with anthropometric measurements, and which can be easily applied in diverse clinical and research settings.

Preoperative sizing of hip hemiarthroplasties to accurately estimate head size from non- standardised pelvic radiographs: Can it be done?

BACKGROUND: Preoperative sizing of implants for hip fracture patients requiring a hemiarthroplasty is difficult due to non-standardised radiographs, absence of sizing marker, variable patient position and body habitus. We investigated whether a simple tool could help predict femoral head size, allowing surgeons to safely proceed with surgery when implant stocks are limited, and to potentially improve theatre efficiency. METHODS: Three independent reviewers measured the maximum width of the contralateral (intact) femoral head using PACS software in 50 cases of intracapsular hip fracture. This was linearly regressed on actual implant size to calculate the average magnification coefficient. Inter- and intra-rater reliability were evaluated using intraclass correlation coefficients (ICC). RESULTS: The best fitting magnification constant was 118% (95% confidence interval 16.0-19.7%), which achieved a mean error of 1.7 mm. Prediction accuracy was significantly improved by allowing a constant (intercept) as a second parameter in the regression model (p = 0.01), which achieved a mean error of just 1.4 mm from the implant used. The inclusion of the constant reduces errors at the upper and lower extremes of head sizes. ICCs for inter- and intra-rather agreement were 0.94 and 0.98 respectively. CONCLUSION(S): We have shown that hip hemiarthroplasty head sizes can be reliably and accurately predicted from non-standardised pre-operative radiographs. We have devised a method which can easily be adopted by other centres and tailored to the characteristics of their radiology department.

Should surgery be delayed in patients taking direct oral anticoagulants who suffer a hip fracture? A retrospective, case-controlled observational study at a UK major trauma centre.

OBJECTIVE: To determine whether not waiting for the elimination of direct oral anticoagulants (DOACs) has an effect on the amount of perioperative bleeding in patients who undergo operative treatment of a hip fracture. DESIGN: Observation, retrospective case-control study. SETTING: A single UK major trauma centre. PARTICIPANTS: Patients who sustained a hip fracture were identified using the National Hip Fracture Database (NHFD). All those found to be taking a DOAC at the time of fracture were identified (n=63). A matched group not taking a DOAC was also identified from the NHFD (n=62). MAIN OUTCOME: Perioperative drop in haemoglobin concentration. RESULTS: There was no relationship between admission to operation interval and perioperative change in haemoglobin concentration in patients taking DOACs (regression coefficient=-0.06 g/L/hour; 95% CI -0.32-0.20; p=0.64). No relationship was found between the time from admission to operation interval and the probability of transfusion (OR=0.94; 95% CI 0.85 to 1.90; p=0.16) or reoperation (OR=1.04; 95% CI 0.93 to 1.16; p=0.49). One mortality was recorded in the DOAC group within 30 days of admission, and this compared with five in the matched group of patients (p=0.2). CONCLUSIONS: Delaying surgery in patients who sustain a hip fracture who are taking a DOAC drug has not been shown to reduce perioperative bleeding or affect their mortality in this study.

A descriptive study of potential participant preferences for the design of an incentivised weight loss programme for people with type 2 diabetes mellitus attending a public hospital in Lima, Peru.

Background: Weight loss is important for the control of type 2 diabetes mellitus but is difficult to achieve and sustain. Programmes employing financial incentives have been successful in areas such as smoking cessation. However, the optimum design for an incentivised programme for weight loss is undetermined, and may depend on social, cultural and demographic factors. Methods: An original questionnaire was designed whose items addressed respondent personal and health characteristics, and preferences for a hypothetical incentivised weight loss programme. One hundred people with type 2 diabetes mellitus were recruited to complete the questionnaire from the endocrinology clinic of a public hospital in Lima, Peru. A descriptive analysis of responses was performed. Results: Ninety-five percent of subjects who had previously attempted to lose weight had found this either 'difficult' or 'very difficult'. Eighty-five percent of subjects would participate in an incentivised weight loss programme. Median suggested incentive for 1 kg weight loss every 2 weeks over 9 months was PEN 100 (~USD $30). Cash was preferred by 70% as payment method. Only 56% of subjects would participate in a deposit-contract scheme, and the median suggested deposit amount was PEN 20 (~USD $6). Eighty percent of subjects would share the incentive with a helper, and family members were the most common choice of helper. Conclusions: The challenge of achieving and sustaining weight loss is confirmed in this setting. Direct cash payments of PEN 100 were generally preferred, with substantial scope for involving a co-participant with whom the incentive could be shared. Employing direct financial incentives in future weight loss programmes appears to be widely acceptable among people with type 2 diabetes mellitus.

Risk of Surgical Site Infection in Elective Hip and Knee Replacements After Confirmed Eradication of MRSA in Chronic Carriers.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is globally endemic and is a leading cause of surgical site infection (SSI). The purpose of this study was to evaluate the incidence of SSI in MRSA carriers undergoing elective hip or knee arthroplasty, who had confirmed eradication and to compare it with incidence of SSI in non-MRSA carriers. METHODS: This is a retrospective analysis of 6613 patients who underwent elective total hip arthroplasty (THA; n = 3347) and total knee arthroplasty (TKA; n = 3266) at our institution. A cohort of patients who were preoperatively colonized with MRSA was identified. We compared the infection rates with non-MRSA carriers. RESULTS: We had a colonization rate of 1.3% (83 patients). A total of 79 patients had confirmed eradication of carrier status before surgical intervention. Of these, 38 were THAs and 41 were TKAs. Five of 79 patients (6.32%; 95% confidence interval [CI]: 2.35%-14.79%) had "deep SSI" within 1 year of surgery. There were 2 MRSA infections in THAs (relative risk 4.46; 95% CI: 1.12-17.82). There were 2 MRSA and 1 methicillin-sensitive Staphylococcus aureus infections in TKAs (relative risk 5.61; 95% CI: 1.81-17.38). A significant statistical difference in infection rates from MRSA negative control group was noted, which had a deep sepsis rate of 1.17% in THAs and 1.3% in TKAs over the same period. CONCLUSION: In spite of a selective treatment program for carriers and confirmed eradication, there is still a significantly increased risk of SSI in MRSA-colonized patients undergoing hip or knee arthroplasties.

Virtual fracture clinic management of fifth metatarsal, including Jones', fractures is safe and cost-effective.

Virtual clinics have been shown to be safe and cost-effective in many specialties, yet barriers exist to their implementation in orthopaedics. The aims of this study were to look at whether the management of 5th metatarsal fractures using a virtual fracture clinic model is safe, cost effective and avoids adverse outcomes whilst being acceptable to patients using the service. All patients with a fifth metatarsal fracture between September 2013 and September 2015 had a standardised management plan initiated (blackboot, full weightbearing) in the emergency department (ED). 663 patients met inclusion criteria, 251 (37.5%) Type 1, 111 (17%) Type 2 (Jones'), 281 (42%) Type 3 or distal, 20 (3%) were misdiagnosed, and 4 (0.5%) patient's images were unavailable. 499 (75%) patients were discharged immediately, 47 (7%) had further imaging, 114 (17%) had either ESP or consultant clinic review, and 3 (<1%) transferred their care privately. The average number of clinic visits per patient was 0.17. At a conservative estimate of 1.3 visits per patient in a traditional pathway this saved 779 clinic visits with a cost saving of £60,000 on clinic visits alone. There were 8 (7%) asymptomatic non-unions in Type 2 (Jones') fractures. One patient required surgical intervention. Fifth metatarsal fractures have excellent outcomes with conservative management yet traditionally have required clinic visits to confirm the diagnosis and explain the management and prognosis. Our study supports the use of a virtual fracture clinic model that is standardised, initiated in ED, that is both safe and cost-effective.

Delay to surgery does not affect survival following osteoporotic femoral fractures.

AIMS: Fragility femoral fractures occur in a similar group of patients to hip fractures but they are not routinely managed along standardised guidelines. This study looked specifically at whether delay to surgery has an impact on mortality and morbidity. PATIENTS AND METHODS: An international, multi-centre retrospective review was carried including all patients over 60 years with fragility femoral fractures, including most periprosthetic fractures, between December 2008-2014. RESULTS: 243 patients met the inclusion criteria with mean follow-up 25 months. 197 (81%) were female with mean age 81 years. Median time to surgery was 2 days; 39% were operated on <24h, 23% 24-48h, and 37% at >48h. 3- and 12-month mortality were 14% (95% CI: 9-18%) and 26% (20-31%) respectively. On Kaplan-Meier plotting, relationships were apparent between survival and sex, and ASA grade, but not delay to surgery or fracture type. CONCLUSION: Fragility femoral fractures have equivalent mortality to hip fractures but we found no link between delay to surgery and mortality. We believe it is safe to delay surgery, within reason, whilst their acute and chronic medical problems are optimised. We believe this information will help develop guidelines similar to hip fracture pathways.

Minimally Invasive and Open Distal Chevron Osteotomy for Mild to Moderate Hallux Valgus.

BACKGROUND: Minimally invasive surgical (MIS) techniques are increasingly being used in foot and ankle surgery but it is important that they are adopted only once they have been shown to be equivalent or superior to open techniques. We believe that the main advantages of MIS are found in the early postoperative period, but in order to adopt it as a technique longer-term studies are required. The aim of this study was to compare the 2-year outcomes of a third-generation MIS distal chevron osteotomy with a comparable traditional open distal chevron osteotomy for mild-moderate hallux valgus. Our null hypothesis was that the 2 techniques would yield equivalent clinical and radiographic results at 2 years. METHODS: This was a retrospective cohort study. Eighty-one consecutive feet (49 MIS and 32 open distal chevron osteotomies) were followed up for a minimum 24 months (range 24-58). All patients were clinically assessed using the Manchester-Oxford Foot Questionnaire. Radiographic measures included hallux valgus angle, the intermetatarsal angle, hallux interphalangeal angle, metatarsal phalangeal joint angle, distal metatarsal articular angle, tibial sesamoid position, shape of the first metatarsal head, and plantar offset. Statistical analysis was done using Student t test or Wilcoxon rank-sum test for continuous data and Pearson chi-square test for categorical data. RESULTS: Clinical and radiologic postoperative scores in all domains were substantially improved in both groups (P < .001), but there was no statistically significant difference in improvement of any domain between open and MIS groups (P > .05). There were no significant differences in complications between the 2 groups ( > .5). CONCLUSION: The midterm results of this third-generation technique show that it was a safe procedure with good clinical outcomes and comparable to traditional open techniques for symptomatic mild-moderate hallux valgus. LEVEL OF EVIDENCE: Level III, retrospective comparative study.