Effectiveness of suture anchor and transosseous suture technique in arthroscopic foveal repair of the triangular fibrocartilage complex: a systematic review.

BACKGROUND: Currently, there were two major surgical methods for arthroscopic triangular fibrocartilage complex (TFCC) foveal repair: suture anchor (SA) and transosseous suture (TOS). The purpose of this systematic review is to examine the relevant outcome improvement and safety of SA and TOS technique. METHODS: Literature review of electronic databases for studies investigating the effects of SA and TOS in patients undergoing arthroscopic TFCC foveal repair was performed. We compared the pre-operative and postoperative functional outcomes, clinical outcomes [pain, range of motion (ROM) and grip strength], and complications of two methods. Minimal clinically important difference (MCID) was used to determine clinically meaningful improvement. RESULTS: There were 1263 distinct studies identified, with 26 (904 patients) meeting the inclusion criteria. The mean age of participants ranged from 21.4 to 41 years, and the mean follow-up time ranged from 6 to 106 months. Both SA and TOS groups reported significant improvement in the modified mayo wrist score, the disabilities of the arm, shoulder, and hand (DASH) score, quick DASH score, patient-reported wrist evaluation (PRWE) score, and the visual analog scale (VAS) score. According to MCID, all the studies from both groups reporting DASH, quick DASH, PRWE and VAS score achieved clinically meaningful improvement. (MCID: 10 for DASH, 14 for quick DASH, 14 for PRWE and 1.6-18 for VAS). The ROM changes in both groups varied from improvement to deterioration. Grip strength improved in both SA and TOS group. Most complications were self-limited. The reoperation rates in SA and TOS ranged from 0 to 20% and 0 to 27.3%, respectively. CONCLUSIONS: Both SA and TOS technique for arthroscopic TFCC foveal repair could achieve improvement in postoperative functional outcomes, pain, and grip strength with low reoperation rate. However, the ROM improvement was still inconclusive. LEVEL OF EVIDENCE IV: Systematic review of level III and IV studies.

The safety and cost-analysis of simultaneous versus staged bilateral total knee arthroplasty in a Taiwan population.

BACKGROUND: In patients with advanced osteoarthritis (OA) of the bilateral knees, uncertainty remains as to whether simultaneous bilateral total knee arthroplasty (SiTKA) or staged TKA (StTKA) is the treatment of choice. The purpose of this study was to investigate the safety and relative cost of SiTKA vs StTKA in Taiwan patients. METHODS: Using the Big Data Center of Taipei Veterans General Hospital, we retrospectively reviewed all patients who underwent SiTKA or StTKA due to OA or spontaneous osteonecrosis of the knee from January 2011 to December 2016. We assessed length of stay, transfusion rate, early postoperative complications, 30- and 90-day readmission rate, 1-year reoperation rate, and the indication for reoperation. Furthermore, we analyzed the total cost of the two groups, including reimbursement from the national health insurance (NHI), cost of the procedures, and net income from each case. RESULTS: A total of 2016 patients (1565 SiTKA and 451 StTKA) were included in this study. The two groups had no significant differences in rates of complications, 30- and 90-day readmission, or 1-year reoperation. The length of stay was on average 5.0 days longer for StTKA ( p < 0.01). In terms of cost, all categories of medical costs were significantly lower for SiTKA, while the net hospital income was significantly higher for StTKA. CONCLUSION: SiTKA is a safe and cost-effective surgery. Both SiTKA and StTKA have similar rates of postoperative complications, readmission and reoperation, but SiTKA significantly reduces medical expenses for both the patient and the NHI.

Does the Addition of iPACK Block to Adductor Canal Block Provide Improved Analgesic Effect in Total Knee Arthroplasty? A Systematic Review and Meta-Analysis.

The interspace between popliteal artery and the capsule of posterior knee (iPACK) block was proposed in recent years to relieve posterior knee pain. Since adductor canal block (ACB) and iPACK involve different branches of the sensory nerves, it is theoretically feasible to combine iPACK block and ACB to relief pain after total knee arthroplasty (TKA). We aim to validate the efficacy of adding iPACK block to ACB in the setting of a multimodal pain management protocol following TKA. A comprehensive literature review on Web of Science, Embase, the Cochrane Library, and PubMed was performed. Eight studies (N = 1,056) that compared the efficacy of iPACK block + ACB with ACB alone were included. Primary outcomes consisted of Visual Analogue Scale (VAS) score at rest or during activity at various time points. Secondary outcomes include opioids consumption, walking distance, and length of hospital stay (LOS). Compared to ACB alone, VAS scores at rest (standardized mean difference [SMD]: -1.18; 95% confidence interval [CI]: -2.05 to -0.30) and during activity (SMD: -0.26; 95% CI: -0.49 to -0.03) on the day of surgery were lower in the iPACK block + ACB group. However, the difference did not reach the minimal clinically important difference. Opioids consumption at postoperative 24 hours was lower in the iPACK + ACB group (SMD: -0.295; 95% CI: -0.543 to -0.048). VAS score on postoperative day (POD) 1 and POD2, opioids consumption from 24 to 48 hours, walking distance, and LOS were not different. In conclusion, the addition of iPACK block to ACB in a multimodal pain management protocol can effectively reduce opioids consumption in the early postoperative period. This is a level III, meta-analysis study.

The benefits of a percutaneous supplemental screw to reinforce the hinge of a medial open wedge tibial osteotomy.

INTRODUCTION: Our earlier studies reported that an additional lag screw placed from the opposite side increases the stability of the fixation construct in medial open wedge high tibia osteotomy (MOWHTO). The aim of the study was to evaluate the clinical relevance of the use of a supplemental screw with immediate post-operative full weight-bearing and its benefits in terms of functional outcome, radiographic outcome and complications. MATERIALS AND METHODS: A retrospective study was performed comparing the historical cohort (MOWHTO without opposite screw) (group A) with the current cohort (MOWHTO with opposite screw) (group B). The patients underwent clinical and radiological assessments. We evaluated the WOMAC (The Western Ontario and McMaster Universities) score, IKDC (International Knee Documentation Committee) scores, and Lysholm knee score. Patients' return to sports and work were also recorded. RESULTS: We included 123 knees receiving MOWHTO alone (group A) with 114 knees (group B) receiving MOWHTO with an opposite screw. A shorter bone union time (18.3 ± 2.1 weeks v.s. 11.5 ± 2.6 weeks, p < 0.001), earlier return to sports (6.1 months vs. 4.6 months, p < 0.001) and return to works (3.2 months vs. 2.3 months, p < 0.001) and better 6-month functional outcomes were found in group B (p < 0.001). The complications were similar in both groups. One patient experienced irritation at the site of the screw entrance and the screw was removed after union. CONCLUSION: The current study evaluated the clinical efficacy of a supplemental lag screw placed from the opposite side in MOWHTO. Comparing to the plate alone, the additional opposite screw improved the implant and fixation stability under immediate weight-bearing without causing complications. A shorter time for returning to sports and work was noted, and a better functional outcome at 6-month follow-up was registered.

Is double-crossed retrograde elastic stable intramedullary nailing an alternative method for the treatment of diaphyseal fractures in the adult humerus?

BACKGROUND: The aim of this study was to compare two techniques for the surgical treatment of diaphyseal fractures in the adult humerus: double-crossed retrograde elastic stable intramedullary nailing (DCR-ESIN) and limited-contact dynamic compression plate (LC-DCP). METHODS: This was a retrospective study conducted at a single hospital. We included 122 patients with diaphyseal fractures of the humerus who had received DCR-ESIN or LC-DCP from January 2011 to January 2017. We compared union rates, union times, disabilities of the arm, shoulder, and hand (DASH) scores at the postoperative 1-year follow-up, and complications between the two groups. RESULTS: Plating management was performed in 63 patients, while DCR-ESIN was performed in 59 patients. The union rate was higher in the DCR-ESIN group than in the LC-DCP group (100% vs. 90.5%; p = 0.052). The union time was shorter in the DCR-ESIN group than in the LC-DCP group (12.0 weeks vs. 14.8 weeks; p < 0.001). The intraoperative blood loss and operative time were less in the DCR-ESIN group than in the LC-DCP group (76.4 min vs. 129.5 min; p < 0.001; 60.9 ml vs. 244.8 ml; p < 0.001, respectively). The DCR-ESIN had superior results for the rate of overall complications (p = 0.006). At the 1-year follow-up, the DCR-ESIN group had better DASH scores than the LC-DCP group (p = 0.014). CONCLUSIONS: The DCR-ESIN technique, used to treat diaphyseal fractures of the humerus, has shorter operative times, less intra-operative blood loss, shorter union times, and better functional outcomes at 1-year follow-up than the LC-DCP technique. DCR-ESIN may be an alternative method for the surgical treatment of diaphyseal humeral fractures in adults.

Cementless primary or revision stem in revision hip arthroplasty for aseptic stem loosening with Paprosky type I/II femoral defect?

BACKGROUND: The use of primary or revision stem during revision total hip arthroplasty (THA) for aseptic stem loosening with Paprosky type I/II femoral defect remains controversial. The aim of this study was to compare the outcomes of patients who underwent revision THA with a primary or revision stem. METHODS: We retrospectively reviewed 78 patients who received revision THA for aseptic stem loosening using primary (N = 28) or revision stems (N = 50). The bone defects were classified as Paprosky type I or II. The mean follow-up duration was 72.3 ± 34.7 months. The primary outcome domains included surgical complications and implant failures. The secondary outcome domains included medical complications, 30- and 90-day readmission, and Harris hip score (HHS). RESULTS: The use of revision stem was associated with a higher incidence than primary stem of patient complications (60.0% vs. 32.1%, p = 0.018), including intraoperative femur fracture (28.0% vs. 7.1%, p = 0.029) and greater trochanter fracture (16.0% vs. 0%, p = 0.045). The implant survival rate was comparable between groups. HHS at the final follow-up was similar. CONCLUSION: With a lower risk of surgical complications and a similar rate of mid-term implant survival, cementless primary stem appears superior to revision stem in revision THA for aseptic stem loosening with Paprosky type I/II femoral defect.

Radial distraction may reduce the incidence of ulnar-sided wrist pain in ulna-plus morphology intraoperatively following distal radius fractures fixation.

INTRODUCTION: Fixed-angle plate fixation can be an effective treatment for distal radius fractures (DRFs). However, patients with existing ulnar positive variance might be at risk of developing symptoms of ulnar-sided wrist pain (USWP). Ulnar shortening osteotomy (USO) is one of the main treatment options for USWP. We hypothesized that a limited radial distraction at the fracture site at the time of surgery for DRF would be functionally equivalent to an indirect USO and that if this were done in a patient with an ulnar plus morphology it could potentially decrease the risk of USWP. METHODS: This retrospective study was conducted at a single institution and all the surgeries were performed by single surgeon. A total of 136 patients (92 women and 44 men) with a mean age of 55 years were enrolled with 57 patients in the distraction group (from 2014 to 2017) and 79 patients (from 2011 to 2013) in the non-distraction group. Patients were assessed USWP. Functional outcomes were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Visual Analogue Scale (VAS) for pain, grip strength, and range of motion for the wrist. RESULTS: The mean follow-up was 37.9 months (range, 28-61 months). The radiographs at postoperative 2-year follow-ups showed the mean ulnar positive variance was 1.3 mm (range, 1-2 mm) in the distraction group and 3.5 mm (range, 2-5 mm) in the non-distraction group. The average of the distraction length was 2.32 mm (range, 2-3 mm). At the 2-year follow-ups, USWP presented in 7% (four patients) in the distraction group, which was significantly less than the incidence of 28% (22 patients) in the non-distraction group. The distraction group exhibited significantly better DASH scores and grip strength and less subsequent ulnar-shortening osteotomy for ulnar-sided wrist pain. CONCLUSIONS: The radial distraction procedure performed during DRFs fixation could possibly reduce the occurrence of postoperative USWP and improve the functional outcomes. LEVEL OF EVIDENCE: Level III, Therapeutic.

Does suprascapular nerve release provide additional benefits for rotator cuff repair: a systematic review and meta-analysis.

BACKGROUND: There is still a lack of consensus regarding whether suprascapular nerve decompression should be routinely performed with rotator cuff repair. Therefore, this meta-analysis aimed to evaluate whether additional suprascapular nerve release (SSNR) could improve shoulder functional outcomes and pain relief more than rotator cuff repair alone. MATERIALS AND METHODS: We performed a literature review of electronic databases for noncomparative and comparative studies investigating the effect of SSNR in patients undergoing rotator cuff repair. The primary outcome was the change in shoulder function scores from the preoperative status, and the secondary outcome was the change in the visual analog scale (VAS) score of pain after surgery. A subgroup analysis was conducted based on the study design (noncomparative studies vs. comparative studies). RESULTS: Nine studies comprising 279 participants were included. Our analysis demonstrated that the group that underwent SSNR had a better shoulder functional score after surgery than at preoperative assessment (standardized mean difference [SMD], 1.333, 95% confidence interval [CI], 0.708-1.959). No significant differences were identified in shoulder function improvement between those with and without SSNR, with an SMD of 0.163 (95% CI, -0.091 to 0.418). Likewise, the group with SSNR showed a decreased VAS score after surgery compared to their preoperative status (SMD, 0.910; 95% CI, 0.560-1.260). However, there was no significant difference in VAS change between those with and without SSNR, with an SMD of 0.431 (95% CI, -0.095 to 0.956). CONCLUSION: The present meta-analysis revealed that SSNR might not be routinely needed in rotator cuff tendon repair as no additional benefits in functional improvement or pain relief were identified compared to rotator cuff tendon repair alone.

Is there a role for cementless primary stem in hip arthroplasty for early or late fixation failures of intertrochanteric fractures?

BACKGROUND: The choice of femur stems during the hip arthroplasty procedures for patients with treatment failure of intertrochanteric fractures (ITF) remains controversial. We aimed to compare the surgical complication and reoperation rates between cementless primary and revision stems in the early (≤3 months) and late (> 3 months) fixation failures of ITF. METHODS: This was a retrospective, cohort study conducted in a single, tertiary referral hospital of Taipei, Taiwan. We included hip arthroplasty procedures for failed ITF using cementless primary or revision stems. There were 40 and 35 patients who had early and late fixation failure of ITF, respectively. The patient demographics, time to fixation failure, surgical complications and medical complications were recorded for analysis. RESULTS: We included 75 patients that underwent hip arthroplasty procedure for failed ITF using cementless primary (n = 38) or revision (n = 37) stems. The mean age was 79.3 years and 56% of the patients were female. In the early fixation failure group, the complication rate was similar between the primary and revision stems (44% vs. 29%, p = 0.343). However, there was a trend toward a higher reoperation rate (31% vs. 8%, p = 0.061) of using the primary stem, compared with the revision stem. In the late fixation failure group, the rate of complication and reoperation was similar between the two stem types. CONCLUSION: For early fixation failures of ITFs, we caution against the use of cementless primary stems due to a trend towards an increased risk of reoperations compared to the use of cementless revision stems. However, in late fixation failures of ITFs, there is a role for cementless primary stems. LEVEL OF EVIDENCE: III, retrospective cohort study.

Efficacy of Povidone Iodine Solution in the Prevention of Surgical Site Infections in Minimally Invasive Instrumented Spinal Fusion Surgery.

STUDY DESIGN: A retrospective case-controlled study. OBJECTIVES: To evaluate overall infection rate and adverse event after harvesting bone graft soaking and surgical wound irrigation by povidone iodine solution (PVI) in the minimally invasive instrumented spinal fusion surgery. In order to reduce the rate of surgical site infection in spinal surgery, surgical wound irrigation by povidone iodine solution has been well-established. However, the efficacy of autologous bone graft soaking by PVI has not been evaluated before. METHODS: This is a retrospective cohort study. 120 patients were enrolled in the PVI group and compared with 124 patients in the historical cohort. In the PVI group, the harvesting autologous bone graft was soaking and the surgical wound was also irrigated by diluted PVI solution. The outcome measures were overall infection rate, superficial wound infection and deep infection. In addition, the delayed union of the fusion mass was also evaluated through the radiograph evaluation. RESULTS: Both groups shared similar patient demographics instead of body mass index. The use of PVI solution had decreased the overall infection rate (0% versus 4.03%, p = 0.026) and deep infection rate (0% versus 3.23%, p = 0.047). In addition, there was no delayed bone healing in the PVI group after autologous bone graft soaking. CONCLUSIONS: In this study, we conclude that harvested autologous bone graft after PVI soaking in spinal fusion surgery can decrease the incidence of deep infection.

Comparing radial lengthening osteotomy with ulnar shortening osteotomy to treat ulnar impaction syndrome after distal radius fracture malunion.

INTRODUCTION: Distal radius mal-unions often cause radius shortening and ulnar impaction syndrome. The modern treatments of ulnar impaction syndrome following distal radius mal-union are ulnar shortening osteotomy (USO) and distal radius lengthening osteotomy (DRLO). However, there are few studies to compare long-term outcomes of these two treatments. This study compares isolated USO to DRLO for the treatment of ulnar impaction syndrome following distal radius mal-union. MATERIALS AND METHODS: We retrospectively reviewed 68 patients with extra-articular distal radius mal-unions treated by isolated USO in 36 patients and DRLO in 32 patients. Pain visual analog scale (VAS), wrist motion, grip strength, radiographic parameters including sigmoid inclination, DASH score, and perioperative complications were analyzed. Mean follow-up was 62.6 months. RESULTS: The postoperative VAS scores for pain on exertion were less in the DRLO group than the USO group (1.2 vs. 2.8, p = 0.02). The DASH scores were 16.7 and 29.8 in the DRLO and USO groups, respectively (p = 0.02). The reduction of pain and improvement of function showed significantly better in the DRLO group. The mean operative time was shorter in the USO group. Most of the sigmoid inclinations were changed in DRLO. There were two re-operations following USO for painful nonunion and two patients had subsequent DRUJ osteoarthritis at the last follow-up. CONCLUSION: Although both treatments improved range of motion, grip strength, and VAS for pain, DRLO was found in better reduction of pain and improvement of function. USO is a simpler procedure with a shorter operative time but it has an increased potential to cause subsequent osteoarthritis of the DRUJ as its incongruity of DRUJ after USO especially in reverted inclination. DRLO can be a preferred method for treating USWP in relevant distal radial mal-union.

Dialysis patients have comparable results to patients who have received kidney transplant after total joint arthroplasty: a systematic review and meta-analysis.

Patients with end-stage renal disease (ESRD) have inferior outcomes after hip and knee total joint arthroplasty (TJA), with higher risk for surgical site complications (SSC) and periprosthetic joint infection (PJI).We conducted a systematic review and meta-analysis regarding outcomes after hip and knee TJA in ESRD patients who have received dialysis or a kidney transplant (KT) using PubMed, MEDLINE, Cochrane Reviews, and Embase in order to: (1) determine the mortality and infection rate of TJA in patients receiving dialysis or KT and (2) to identify risk factors associated with the outcome.We included 22 studies and 9384 patients (dialysis, n = 8921, KT, n = 463). The overall mortality rate was 14.9% and was slightly higher in KT patients (dialysis vs. KT, 13.8% vs. 15.8%). The overall SSC rate was 3.4%, while dialysis and KT patients each had an incidence of 3.3% and 3.6%, respectively. For PJI, the overall rate was 3.9%, while the incidence for dialysis patients was 4.0% and for KT patients was 3.7%.Using multi-regression analysis, age, sex, the type of arthroplasty (knee or hip) performed, and the form of renal replacement therapy (dialysis or KT) were not significant risk factors.In patients on dialysis or who had received a KT, TJA is associated with a slight increase in mortality, SSC and PJI rates. Cite this article: EFORT Open Rev 2021;6:618-628. DOI: 10.1302/2058-5241.6.200116.

Are functional outcomes and reoperation rates really better than those of cementless stems in displaced femoral neck fractures? An updated systematic review and meta-analysis of randomized controlled trials in current-generation stem designs.

BACKGROUND: The aim of the study was to conduct a systematic review and meta-analysis to compare the functional outcomes and reoperation rates of cemented and cementless hip arthroplasty for treating displaced femoral neck fractures in elderly patients. METHODS: Systematic searches were conducted of literature up to December 2018 on PubMed, Embase, Cochrane, and Web of Science for randomized controlled trials (RCTs) concerning current-generation stem designs only. Two reviewers independently determined eligibility, extracted the outcome data and assessed the risk of bias of eligible studies. The follow-up data and complication rates were pooled by using random-effects models and fixed-effects models, with mean differences and risk ratios for continuous and dichotomous variables, respectively. RESULTS: Eight RCTs involving 1361 patients (1361 hips) were included in the meta-analysis. Cemented stems were associated with fewer implant-related complications (odds ratio [OR] = 0.303; 95% confidence interval [CI], 0.185%-0.496%; p < 0.001) and reoperations (OR = 0.492; 95% CI, 0.247%-0.977%; p = 0.043). There were no statistically significant differences between groups in functional outcomes, including those assessed by the EuroQol(EQ)-5D and Harris Hip Score, mortality rates, major systemic complications, minor local complications, operation times, intraoperative blood losses, and lengths of hospital stays. CONCLUSION: In treating displaced femoral neck fracture in elderly patients with hip arthroplasty with current-generation stems, cemented stems were found to have fewer implant-related complications and reoperations than those of cementless stems. Functional outcomes and mortality rates were similar between the groups.

The influence of proximal femur canal size on reduction of intertrochanteric fracture with cephalomedullary nail.

BACKGROUND: Malalignment is the most important risk factor for fixation failure after intertrochanteric fracture treated with a cephalomedullay nail (CMN). Malalignment continues to occur despite advances in surgical techniques. HYPOTHESIS: We hypothesized that small femur canal size causes intra-operative reduction loss during cephalomedullary nail insertion. METHODS: A retrospective study was performed from 2014 to 2017. Patients with acute intertrochanteric fracture implanted with the same sized CMN (Stryker, Mahwah, NJ, USA, diameter: 10mm, length: 170mm, degree 130) were included. Evaluated radiographic parameters included femoral canal size, corrected neck-shaft angle, and calcar reduction. RESULTS: The study totally included and analyzed the data from 108 patients. Patients with smaller femoral canal size tended to have increased calcar distance according to Pearson's correlation coefficient analysis (r(106)=-0.805, p<0.001). Patients with calcar mal-reduction had higher corrected neck-shaft angle post-operatively. This observed correction tended to be lost during follow up. CONCLUSIONS: Small femoral canal size resulted in poorer reduction quality. Reduction loss during nail insertion may be due to the whole proximal fragment instead of the superolateral femoral neck. Reaming the isthmus before nail insertion or choosing a smaller sized CMN is indicated in this patient population to prevent intra- or post-operative loss of reduction. LEVEL OF EVIDENCE: III; retrospective study.

Postoperative spinal orthosis may not be necessary for minimally invasive lumbar spine fusion surgery: a prospective randomized controlled trial.

BACKGROUND: With the progress and success in minimally invasive surgery of transforaminal lumbar interbody fusion (MIS TLIF), the musculoskeletal injury was minimized. However, the role of postoperative orthosis in MIS TLIF has not been established and there is little evidence supporting the routine use of orthosis in MIS TLIF. METHODS: This is a prospective randomized clinical study. 90 patients who underwent MIS TLIF were randomly divided into groups A (with postoperative spinal orthosis) and B (without postoperative spinal orthosis). Patients were followed up for an average of 12.6 months. Clinical outcome was assessed using the Oswestry disability index (ODI) and visual analogue scale (VAS). Fusion rate was classified with the BSF scale system at postoperative 6-month, and 12-month. RESULTS: Both groups had similar patient demographics. The use of postoperative spinal orthosis had no significant influence on instrumentation-related complications or radiological parameters at each follow-up. CONCLUSIONS: In this study, we conclude that postoperative spinal orthosis is not necessary for MIS TLIF. Patients without postoperative spinal orthosis had the same fusion rates and improvement of VAS and ODI scores.

Risk factors and modes of failure in the modern dual mobility implant. A systematic review and meta-analysis.

BACKGROUND: The aims of this meta-analysis were to: (1) validate the outcome of modern dual mobility (DM) designs in patients who had undergone primary and revision total hip arthroplasty (THA) procedures and (2) to identify factors that affect the outcome. METHODS: We searched for studies that assessed the outcome of modern DM-THA in primary and revision procedures that were conducted between January, 2000 to August, 2020 on PubMed, MEDLINE, Cochrane Reviews and Embase. The pooled incidence of the most common failure modes and patient reported outcomes were evaluated in patients who have received: (1) primary THA, (2) revision THA for all causes or (3) for recurrent dislocation. A meta-regression analysis was performed for each parameter to determine the association with the outcome. The study design of each study was assessed for potential bias and flaws by using the quality assessment tool for case series studies. RESULTS: A total of 119 studies (N= 30016 DM-THAs) were included for analysis. The mean follow-up duration was 47.3 months. The overall implant failure rate was 4.2% (primary: 2.3%, revision for all causes: 5.5%, recurrent dislocation: 6.0%). The most common failure modes were aseptic loosening (primary: 0.9%, revision for all causes: 2.2%, recurrent dislocation: 2.4%), septic loosening (primary:0.8%, revision for all causes: 2.3%, recurrent dislocation: 2.5%), extra-articular dislocation (primary:0.6%, revision for all causes:1.3%, recurrent dislocation:2.5%), intra-prosthetic dislocation (primary:0.8%, revision for all causes:1.0%, recurrent dislocation:1.6%) and periprosthetic fracture (primary:0.9%, revision for all causes:0.9%, recurrent dislocation:1.3%). The multi-regression analysis identified younger age (ß=-0.04, 95% CI -0.07 - -0.02) and female patients (ß=3.34, 95% CI 0.91-5.78) were correlated with higher implant failure rate. Age, gender, posterolateral approach and body mass index (BMI) were not risk factors for extra-articular or intra-prosthetic dislocation in this cohort. The overall Harris hip score and Merle d'Aubigné score were 84.87 and 16.36, respectively. Level of evidence of this meta-analysis was IV. CONCLUSION: Modern dual-mobility designs provide satisfactory mid-term implant survival and clinical performance. Younger age and female patients might impact the outcome after DM-THA. Future research directions should focus on, (1) long-term outcome of modern dual-mobility design, including specific concerns such as intra-prosthetic dislocation and elevated metal ion, and (2) cost-effectiveness analysis of dual-mobility implant as an alternative to conventional THA for patients who are at high risk of dislocation.

An opioid-sparing protocol with intravenous parecoxib can effectively reduce morphine consumption after simultaneous bilateral total knee arthroplasty.

Multimodal pain management protocol effectively relieves pain following simultaneous bilateral total knee arthroplasty (SBTKA) but is associated with administration of large amounts of opioids in the perioperative period. In this prospective, randomized, assessor-blinded, single-surgeon clinical trial, the goal was to validate the efficacy of an opioid-sparing protocol for SBTKA with a reduced opioid dose, while achieving similar pain relief with few adverse events. Fifty-six patients who had undergone SBTKA were randomly allocated to receive either an opioid-sparing or opioid-based protocol. The primary outcome parameters were visual analogue scale (VAS) scores at rest, with movement, and cumulative morphine dose, through time. Secondary outcome parameters included drug-related adverse events and range of motion with continuous passive motion device, through time. In the opioid-sparing group, a lower VAS score with movement at postoperative 24 and 72 h was observed compared with the opioid-based group, but the difference did not reach the minimal clinically importance difference. A reduced cumulative morphine dose was noted in the opioid-sparing group at postoperative 24, 48 and 72 h. In conclusion, the opioid-sparing protocol may be used as an alternative modality for pain management following SBTKA. Similar pain relief effects may be achieved utilizing a reduced cumulative opioid dose, with few opioid related adverse events.

The efficacy of periarticular injection intraoperatively for mini-open rotator cuff repair: A comparative study.

BACKGROUND: The optimal postoperative analgesia after open rotator cuff repair surgery remains unclear. This study compared the use of a multimodal pain regimen including periarticular injection (PAI), with a control condition. We hypothesized that PAI leads to decreased opioid consumption and lower pain scores. METHODS: The perioperative analgesic regimen was standardized and implemented from January 1, 2017 to December 31, 2017. The PAI was administered from July 1, 2017 to December 31, 2017. The historical control group was enrolled from January 1, 2017 to June 30, 2017. The evaluation items included assessments of pain using a 10-point visual analog scale (VAS) before and after the mini-open rotator cuff repair and on postoperative days 1, 2, and 3. The dose of ketorolac suppository and its side effects were also evaluated. RESULTS: The VAS score on the day of the operation was significantly low in the PAI group and less incidence of night pain. The time point of the rescue drug was longer in the PAI group than the control group (12.7 hours vs. 0.62 hours; p < 0.01). No cardiac or central nervous system toxicity was observed. DISCUSSION: In our study, PAI in the shoulder after mini-open rotator cuff repair showed effective pain control on the day of the surgery, postponed the time of the first dosage of intravenous pain medication, and reduced the total dosage of the intravenous pain medication.

Uncemented femoral stem design might have an impact on postoperative periprosthetic femur fracture pattern. A Comparison between flat-wedge and dual-wedge stems.

INTRODUCTION: Type I, flat-wedge and type II, dual-wedge stems are currently two common stem types used in primary, uncemented hip arthroplasty. The prevalence of periprosthetic femur fracture is higher in type I stems, possibly because of the different shapes and areas of bone contact. We aimed to compare the fracture pattern, stem stability during the fracture and type of subsequent procedures in periprosthetic femur fractures between type I and II stems. MATERIALS AND METHODS: This was a retrospective, cross-sectional study conducted in a single tertiary referral hospital of Taipei, Taiwan. We included primary hip arthroplasty procedures using type I or type II stems complicated with postoperative periprosthetic femur fractures. We recorded the age, sex, ASA grade, index procedure, institution of where the index procedure was performed, trauma mechanism, time from index procedure to fracture, procedure for periprosthetic fracture and radiographic parameters including Dorr type, Vancouver classification, stem stability, fracture pattern, type and brand of the stems for analysis. RESULTS: We included 132 patients who had undergone surgery for periprosthetic femur fracture for type I (N = 46) or type II (N = 86) stems. The mean age was 74.5 years and 52.3% of the patients were female. Type I stems were associated with a higher proportion of a complex fracture pattern (52.2% vs. 8.2%), femoral stem loosening (78.2% vs. 60.4%) and a higher rate of revision stem procedures (69.6% vs. 50.0%) compared with type II stems. Using multivariate analysis, type I stem was the only factor for a complex fracture pattern in the overall population (aOR: 23.60, 95% CI: 6.54-85.16), hemiarthroplasty (aOR: 160.50, 95% CI: 9.77-2635.95) and total hip arthroplasty (aOR: 14.17, 95% CI: 2.92-68.79) subgroups. CONCLUSION: We observed a difference in fracture patterns between type I and type II stems. Type I stems appear to be an independent risk factor for a complex fracture pattern in patients who had undergone primary hip arthroplasty.