Higher rate of progesterone receptor positivity in skeletal metastases of breast cancer with a pathological fracture vs those without fracture.

Identifying risk factors for fracture occurrence in breast cancer (BC) skeletal metastases (SM) may guide the management of such bone deposits. There is sparse evidence regarding receptor status in SM and their relationship to fracture occurrence. Our study aimed to determine the relationship between estrogen (ER), progesterone (PR) and HER2 receptor status and Ki-67 index and fracture occurrence in SM of BC. Exactly 152 samples of SM of BC obtained from individual patients were evaluated. The status of the aforementioned receptors and Ki67 index were determined in SMs samples. Their expression was compared between SM that did and did not develop a fracture. Ninety-one cases sustained a pathological fracture at the SM site, and 61 did not. Patients who sustained a pathological fracture had a higher rate of PR positivity at their SMs as compared to those with no fracture. There was no significant difference between the two groups concerning ER, HER2+ or Ki67 status. SMs secondary to BC with a fracture are more likely to be PR positive than those with no fracture. Determining the receptor status in SMs may identify high-risk groups for fracture occurrence, and determining the PR status may also guide surgical and hormonal therapy.

Editorial Commentary: Double-Pulley Remplissage Using Transtendon Anchors: Keep It Simple.

A large Hill-Sachs lesion that engages the glenoid rim and predisposes to recurrent anterior instability confers a substantial management challenge. Arthroscopic remplissage, either in isolation or combined with anterior labral repair, gives the arthroscopic surgeon a tool to stabilize the shoulder without reverting to more extensive open procedures or bone block reconstructions. In arthroscopic remplissage, the posterior capsule and infraspinatus are sutured into the humeral defect to limit such engagement between the HilleSachs lesion and the glenoid rim. The double-pulley technique using 2 transtendon anchors makes arthroscopic remplissage technically simpler, and potentially more reproducible, than earlier techniques. As we refine remplissage techniques, we need to further explore issues such as the optimal distance between the 2 anchors (and hence the resultant tendon bridge) as this distance-along with the pliability of the tendon-potentially determines how much compression against the bone can be achieved. Furthermore, as remplissage techniques are proven to be effective in restoring shoulder stability and conferring successful clinical function, there is even more need for high-quality comparative studies to define their role versus that of more extensive open stabilization procedures. Mechanistic studies are also needed to define the fill-effect versus the possible check-rein and neuromuscular control activation components of remplissage.

Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial.

BACKGROUND: Manipulation under anaesthesia and arthroscopic capsular release are costly and invasive treatments for frozen shoulder, but their effectiveness remains uncertain. We compared these two surgical interventions with early structured physiotherapy plus steroid injection. METHODS: In this multicentre, pragmatic, three-arm, superiority randomised trial, patients referred to secondary care for treatment of primary frozen shoulder were recruited from 35 hospital sites in the UK. Participants were adults (≥18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation (≥50%) in the affected shoulder. Participants were randomly assigned (2:2:1) to receive manipulation under anaesthesia, arthroscopic capsular release, or early structured physiotherapy. In manipulation under anaesthesia, the surgeon manipulated the affected shoulder to stretch and tear the tight capsule while the participant was under general anaesthesia, supplemented by a steroid injection. Arthroscopic capsular release, also done under general anaesthesia, involved surgically dividing the contracted anterior capsule in the rotator interval, followed by manipulation, with optional steroid injection. Both forms of surgery were followed by postprocedural physiotherapy. Early structured physiotherapy involved mobilisation techniques and a graduated home exercise programme supplemented by a steroid injection. Both early structured physiotherapy and postprocedural physiotherapy involved 12 sessions during up to 12 weeks. The primary outcome was the Oxford Shoulder Score (OSS; 0-48) at 12 months after randomisation, analysed by initial randomisation group. We sought a target difference of 5 OSS points between physiotherapy and either form of surgery, or 4 points between manipulation and capsular release. The trial registration is ISRCTN48804508. FINDINGS: Between April 1, 2015, and Dec 31, 2017, we screened 914 patients, of whom 503 (55%) were randomly assigned. At 12 months, OSS data were available for 189 (94%) of 201 participants assigned to manipulation (mean estimate 38·3 points, 95% CI 36·9 to 39·7), 191 (94%) of 203 participants assigned to capsular release (40·3 points, 38·9 to 41·7), and 93 (94%) of 99 participants assigned to physiotherapy (37·2 points, 35·3 to 39·2). The mean group differences were 2·01 points (0·10 to 3·91) between the capsular release and manipulation groups, 3·06 points (0·71 to 5·41) between capsular release and physiotherapy, and 1·05 points (-1·28 to 3·39) between manipulation and physiotherapy. Eight serious adverse events were reported with capsular release and two with manipulation. At a willingness-to-pay threshold of £20 000 per quality-adjusted life-year, manipulation under anaesthesia had the highest probability of being cost-effective (0·8632, compared with 0·1366 for physiotherapy and 0·0002 for capsular release). INTERPRETATION: All mean differences on the assessment of shoulder pain and function (OSS) at the primary endpoint of 12 months were less than the target differences. Therefore, none of the three interventions were clinically superior. Arthoscopic capsular release carried higher risks, and manipulation under anaesthesia was the most cost-effective. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Arthroscopic "Remplissage" for shoulder instability: a systematic review.

PURPOSE: Large Hill-Sachs lesions engaging the glenoid rim predispose to recurrent anterior instability and failure of isolated labrum repairs. In arthroscopic remplissage, the posterior capsule and infraspinatus are sutured into the humeral defect to limit such engagement. This systematic review assessed the outcomes and complications of arthroscopic remplissage for anterior shoulder instability. METHODS: A search of the MEDLINE, EMBASE and evidence-based medicine Cochrane databases was conducted. Data were extracted by two reviewers in a standardised manner. Redislocation, instability and complication rates were calculated and expressed as percentages with 95 % confidence intervals. RESULTS: Of 4,284 studies identified, eight articles with a total of 207 patients were analysed. Mean redislocation rate was 4.2 ± 3.9 % (range 0-15 %), and mean recurrent instability rate 3.2 ± 3.8 % (0-15 %). Posterosuperior shoulder pain and stiffness were the only complications described. Overall, there was a mean reduction in external rotation in adduction of 5.6° (-40 to +30), reduction in external rotation in abduction of 11.3° (-50 to +7) and reduction in internal rotation of 0.9 (-4 to 0) vertebral levels. CONCLUSIONS: Arthroscopic remplissage alongside anterior labrum repair seems successful in treating recurrent shoulder instability in the presence of large or engaging Hill-Sachs lesion. However, the available literature consists mainly of heterogeneous case series. There is a need for a high-quality randomised trial to compare remplissage with other commonly used techniques for recurrent instability associated with substantial Hill-Sachs defects such as the Latarjet procedure. LEVEL OF EVIDENCE: Systematic review, Level IV.

Ultrasound-guided barbotage for calcific tendonitis of the shoulder: a systematic review including 908 patients.

PURPOSE: A systematic review was performed to assess the outcomes and complications of ultrasound-guided barbotage (repeated injection and aspiration) for calcific tendonitis of the shoulder. METHODS: A literature search of the Medline, Embase, and Cochrane databases using all relevant keywords found 1,454 original articles. After removal of duplicates and application of inclusion criteria, 13 original articles were selected for review. Articles that used fluoroscopic guidance rather than ultrasound guidance were excluded from the review. All studies analyzed except 1 were case series, with no comparative studies being available. RESULTS: Thirteen articles with a total of 908 patients were analyzed. In all articles reviewed, the authors reported a good clinical outcome, with many achieving marked improvement in clinical scores or overall satisfaction with the treatment. CONCLUSIONS: Ultrasound-guided barbotage is a safe technique, with a high success rate and low complication rate. There is no evidence assessing its effectiveness compared with other major treatment modalities; a randomized trial comparing ultrasound-guided barbotage, extracorporeal shock wave therapy, and arthroscopic calcific deposit excision would be of great value. However, while awaiting such a trial, on the basis of the results of this systematic review, we can recommend ultrasound-guided barbotage. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Do intra-articular steroid injections increase infection rates in subsequent arthroplasty? A systematic review and meta-analysis of comparative studies.

Intra-articular steroid injections are widely used in joint arthritis. The safety of such injections has been questioned as they may increase infection rates in subsequent arthroplasty. We carried out a meta-analysis of studies examining the relation between intra-articular steroid injections and infection rates in subsequent joint arthroplasty. A literature search was undertaken. Eight studies looking at hip and knee arthroplasties were analyzed. Meta-analysis showed that steroid injection had no significant effect on either deep (risk ratio = 1.87; 95% CI 0.80-4.35; P = 0.15) or superficial infection rates (risk ratio = 1.75; 95% CI 0.76-4.04; P = 0.19) of subsequent arthroplasty. Further large cohort studies would be of value in further examining whether steroid injections close to the time of arthroplasty are safe.

The SAInT study: a protocol for a randomized controlled trial of steroid injection for subacromial pain syndrome using the anterolateral versus posterior approach.

Aims: Steroid injections are used for subacromial pain syndrome and can be administered via the anterolateral or posterior approach to the subacromial space. It is not currently known which approach is superior in terms of improving clinical symptoms and function. This is the protocol for a randomized controlled trial (RCT) to compare the clinical effectiveness of a steroid injection given via the anterolateral or the posterior approach to the subacromial space. Methods: The Subacromial Approach Injection Trial (SAInT) study is a single-centre, parallel, two-arm RCT. Participants will be allocated on a 1:1 basis to a subacromial steroid injection via either the anterolateral or the posterior approach to the subacromial space. Participants in both trial arms will then receive physiotherapy as standard of care for subacromial pain syndrome. The primary analysis will compare the change in Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include the change in OSS at six and 12 months, as well as the Pain Numeric Rating Scale (0 = no pain, 10 = worst pain), Disabilities of Arm, Shoulder and Hand questionnaire (DASH), and 36-Item Short-Form Health Survey (SF-36) (RAND) at three months, six months, and one year after injection. Assessment of pain experienced during the injection will also be determined. A minimum of 86 patients will be recruited to obtain an 80% power to detect a minimally important difference of six points on the OSS change between the groups at three months after injection. Conclusion: The results of this trial will demonstrate if there is a difference in shoulder pain and function after a subacromial space steroid injection between the anterolateral versus posterior approach in patients with subacromial pain syndrome. This will help to guide treatment for patients with subacromial pain syndrome.

Radiological outcomes following surgical fixation with wires versus moulded cast for patients with a dorsally displaced fracture of the distal radius: a radiographic analysis from the DRAFFT2 trial.

Aims: The primary aim of this study was to report the radiological outcomes of patients with a dorsally displaced distal radius fracture who were randomized to a moulded cast or surgical fixation with wires following manipulation and closed reduction of their fracture. The secondary aim was to correlate radiological outcomes with patient-reported outcome measures (PROMs) in the year following injury. Methods: Participants were recruited as part of DRAFFT2, a UK multicentre clinical trial. Participants were aged 16 years or over with a dorsally displaced distal radius fracture, and were eligible for the trial if they needed a manipulation of their fracture, as recommended by their treating surgeon. Participants were randomly allocated on a 1:1 ratio to moulded cast or Kirschner wires after manipulation of the fracture in the operating theatre. Standard posteroanterior and lateral radiographs were performed in the radiology department of participating centres at the time of the patient's initial assessment in the emergency department and six weeks postoperatively. Intraoperative fluoroscopic images taken at the time of fracture reduction were also assessed. Results: Patients treated with surgical fixation with wires had less dorsal angulation of the radius versus those treated in a moulded cast at six weeks after manipulation of the fracture; the mean difference of -4.13° was statistically significant (95% confidence interval 5.82 to -2.45). There was no evidence of a difference in radial shortening. However, there was no correlation between these radiological measurements and PROMs at any timepoint in the 12 months post-injury. Conclusion: For patients with a dorsally displaced distal radius fracture treated with a closed manipulation, surgical fixation with wires leads to less dorsal angulation on radiographs at six weeks compared with patients treated in a moulded plaster cast alone. However, the difference in dorsal angulation was small and did not correlate with patient-reported pain and function.

Arthroscopic coracoid transfer in the treatment of recurrent shoulder instability: a systematic review of early results.

PURPOSE: Systematic review of the literature to characterize safety profile and complication rates associated with arthroscopic coracoid transfer procedures. METHODS: We conducted a combined search of Medline, EMBASE, and the CINAHL databases from 1985 to November 2012. Articles were selected and data extracted according to standard criteria. RESULTS: Only 3 studies met the inclusion criteria, and these originated from the pioneers of this technique. These studies described the results of 172 arthroscopic coracoid transfer procedures with an overall complication rate of 19.8% ± 5.6%. Conversion to open surgery was necessary in 6/172 (3.5%) patients. Repeated surgery was described in 5/172 (2.9% ± 2.5%) cases, all for screw removal. The overall rate of recurrent instability was 3/172 cases (1.7% ± 2%). Hardware-related complications occurred in 4/172 patients (2.3% ± 2.3%). Coracoid grafts failed to unite in 14/172 patients (8.1% ± 4.1%); graft osteolysis was seen in 7/172 patients (4.1% ± 2.6%). The coracoid graft fractured in 2/172 cases (1.2% ± 1.6%); one of these occurred intraoperatively and one occurred early postoperatively. There was one transient nerve palsy (0.6% ± 1.1%). CONCLUSIONS: Results of arthroscopic coracoid transfer surgery for anterior shoulder instability are sparse, with the available studies originating from the pioneers of this technique. Early results suggest that arthroscopic coracoid transfer is a technically feasible procedure that is able to restore shoulder stability. However, this technique seems to be associated with a high complication rate and a steep learning curve. Results from the wider orthopaedic shoulder arthroscopic community are awaited. Extensive cadaveric training and experience with the open technique is recommended before performing the arthroscopic procedure. LEVEL OF EVIDENCE: Systematic review of Level IV studies.

Cementing Techniques In Knee Surgery (CeTIKS): a UK expert consensus study.

Aims: Aseptic loosening is the most common cause of failure following cemented total knee arthroplasty (TKA), and has been linked to poor cementation technique. We aimed to develop a consensus on the optimal technique for component cementation in TKA. Methods: A UK-based, three-round, online modified Delphi Expert Consensus Study was completed focusing on cementation technique in TKA. Experts were identified as having a minimum of five years' consultant experience in the NHS and fulfilling any one of the following criteria: a 'high volume' knee arthroplasty practice (> 150 TKAs per annum) as identified from the National joint Registry of England, Wales, Northern Ireland and the Isle of Man; a senior author of at least five peer reviewed articles related to TKA in the previous five years; a surgeon who is named trainer for a post-certificate of comletion of training fellowship in TKA. Results: In total, 81 experts (round 1) and 80 experts (round 2 and 3) completed the Delphi Study. Four domains with a total of 24 statements were identified. 100% consensus was reached within the cement preparation, pressurization, and cement curing domains. 90% consensus was reached within the cement application domain. Consensus was not reached with only one statement regarding the handling of cement during initial application to the tibial and/or femoral bone surfaces. Conclusion: The Cementing Techniques In Knee Surgery (CeTIKS) Delphi consensus study presents comprehensive recommendations on the optimal technique for component cementing in TKA. Expert opinion has a place in the hierarchy of evidence and, until better evidence is available these recommendations should be considered when cementing a TKA.

Vancomycin Graft Presoaking in Anterior Cruciate Ligament Reconstruction Surgery Is Associated with a Lower Risk of Graft Rerupture as Compared With No Vancomycin Presoaking: Systematic Review and Meta-analysis.

BACKGROUND: To determine whether there is any difference in graft rerupture rates and clinical outcomes between cases having vancomycin graft presoaking vs. no vancomycin presoaking in anterior cruciate ligament (ACL) reconstruction (ACLR). METHODS: Systematic review and meta-analysis. PubMed, Embase, CINAHL, and Cochrane CENTRAL were searched. Full published studies reporting on the relation between vancomycin graft presoaking and rates of graft rerupture and/or clinical outcomes in ACLR surgery vs. no vancomycin graft presoaking were included. Data extraction and quality appraisal were performed. Meta-analysis was conducted using a random effects model. The study's protocol was prospectively registered with PROSPERO (CRD42021290608). RESULTS: The literature search identified 907 records. After removing duplicates and those not meeting inclusion criteria, 8 studies were included. Meta-analysis showed that the estimated risk of hamstring graft rerupture was lower in cases presoaked with vancomycin vs. those having no presoaking (3.2% vs. 6.2% rerupture rate, risk ratio [RR] = 0.507, 95% CI, 0.39-0.737, p < 0.001). Similarly, the estimated risk of graft rerupture was lower in cases presoaked with vancomycin vs. those having no presoaking when the analysis included various ACL graft types (2.7% vs. 3.9% rerupture rate, RR = 0.557, 95% confidence interval [CI], 0.403-0.771, p < 0.001). Meta-analysis also showed that vancomycin graft presoaking was associated with similar International Knee Documentation Committee scores as compared with no presoaking when looking at hamstring grafts (estimated mean difference 0.112, 95% CI, -2.359 to 2.582, p = 0.929) or when considering various graft types (estimated mean difference 0.933, 95% CI, -0.140 to 2.006, p = 0.088). CONCLUSION: Vancomycin graft presoaking is a safe practice and does not compromise ACL graft rerupture rates or clinical outcomes. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does correction of carpal malalignment influence the union rate of scaphoid nonunion surgery?

The aim of this retrospective study was to assess the relation between carpal malalignment correction and radiological union rates in surgery for scaphoid nonunions. A total of 59 scaphoid waist fracture nonunions treated with open reduction and palmar tricortical autograft were divided according to their pre- and postoperative scapholunate (SL) and radiolunate (RL) angles. We found that carpal malalignment failed to correct in 32 of 59 (54.2%) patients despite meticulous surgical technique and placement of an appropriately sized wedge-shaped graft. In total, 43 (72.9%) fractures united at a mean of 4.47 months (range 3-11). Of the 27 fractures with postoperative SL and RL angles within the normal range, 21 united, whereas 22 of the 32 remaining fractures that failed to achieve postoperative angles within the normal range went on to union. The postoperative SL and RL angles were not related to union. Our findings suggest that in scaphoid fracture nonunion surgery, carpal malalignment may not be corrected in a substantial proportion of patients, but such correction may not be essential for bony union. Our findings also show that there is no marked collapse of the scaphoid graft in the early postoperative period. LEVEL OF EVIDENCE: IV.

Anatomic Monopolar Press-fit Radial Head Arthroplasty; High Rate of Loosening at Mid-Term Follow Up.

Introduction: Radial head arthroplasty (RHA) is used for the management of unstable or unreconstructable injuries of the radial head. Our aim was to investigate clinical and radiographic outcomes in patients treated with the Acumed anatomic radial head press-fit system for trauma. Methods: Clinical and radiographic assessment of RHAs undertaken for trauma with minimum 2-year follow-up. Results: 16 consecutive patients, mean age 53 (21-82) and 66 month ± 27 (26-122) clinical follow-up were included. There were marked radiographic changes with 11/16 showing periprosthetic lucent lines and 13/16 showing subcollar osteolysis. Radiographic changes occurred early post-surgery. Stem loosening was associated with larger cantilever quotients (0.47 vs 0.38, p = 0.004). Overall survivability was 81.2%, with 3 RHAs removed. Clinical outcomes for the retained RHAs were acceptable with mean flexion 134°, extension deficit of 10°, pronation of 82°, and supination of 73°. Mean VAS scores were 8.5 ± 14.4, QuickDASH 13.8 ± 18.9, Mayo Elbow Performance Scores were 91.5 ± 12.5 with no poor scores. Conclusion: Mid-term clinical functional outcomes following the Acumed anatomic RHA are acceptable in most cases. However, in view of the extensive periprosthetic lucencies and surgical removal due to loosening, patients should be cautioned when consented for implantation of the prosthesis, especially if a large collar is anticipated.

High rate of radiolucent lines following the cemented original design of the ATTUNE total knee arthroplasty.

Aims: Loosening of components after total knee arthroplasty (TKA) can be associated with the development of radiolucent lines (RLLs). The aim of this study was to assess the rate of formation of RLLs in the cemented original design of the ATTUNE TKA and their relationship to loosening. Methods: A systematic search was undertaken using the Cochrane methodology in three online databases: MEDLINE, Embase, and CINAHL. Studies were screened against predetermined criteria, and data were extracted. Available National Joint Registries in the Network of Orthopaedic Registries of Europe were also screened. A random effects model meta-analysis was undertaken. Results: Of 263 studies, 12 were included with a total of 3,861 TKAs. Meta-analysis of ten studies showed high rates of overall tibial or femoral RLLs for the cemented original design of the ATTUNE TKA. The overall rate was 21.4% (95% confidence interval (CI) 12.7% to 33.7%) for all types of design but was higher for certain subgroups: 27.4% (95% CI 13.4% to 47.9%) for the cruciate-retaining type, and 29.9% (95% CI 15.6% to 49.6%) for the fixed-bearing type. Meta-analysis of five studies comparing the ATTUNE TKA with other implants showed a significantly higher risk of overall tibial or femoral RLLs (odds ratio (OR) 2.841 (95% CI 1.219 to 6.623); p = 0.016) for the ATTUNE. The rates of loosening or revision for loosening were lower, at 1.2% and 0.9% respectively, but the rates varied from 0% to 16.3%. The registry data did not report specifically on the original ATTUNE TKA or on revision due to loosening, but 'all-cause' five-year revision rates for the cemented ATTUNE varied from 2.6% to 5.9%. Conclusion: The original cemented ATTUNE TKA has high rates of RLLs, but their clinical significance is uncertain given the overall low associated rates of loosening and revision. However, in view of the high rates of RLLs and the variation in the rates of loosening and revision between studies and registries, close surveillance of patients who have undergone TKA with the original ATTUNE system is recommended.

A randomized clinical trial of glenohumeral joint steroid injection versus suprascapular nerve block in patients with frozen shoulder: a protocol for the Therapeutic Injections For Frozen Shoulder (TIFFS) study.

Frozen shoulder is a common, painful condition that results in impairment of function. Corticosteroid injections are commonly used for frozen shoulder and can be given as glenohumeral joint (GHJ) injection or suprascapular nerve block (SSNB). Both injection types have been shown to significantly improve shoulder pain and range of motion. It is not currently known which is superior in terms of relieving patients' symptoms. This is the protocol for a randomized clinical trial to investigate the clinical effectiveness of corticosteroid injection given as either a GHJ injection or SSNB. The Therapeutic Injections For Frozen Shoulder (TIFFS) study is a single centre, parallel, two-arm, randomized clinical trial. Participants will be allocated on a 1:1 basis to either a GHJ corticosteroid injection or SSNB. Participants in both trial arms will then receive physiotherapy as normal for frozen shoulder. The primary analysis will compare the Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include OSS at six and 12 months, range of shoulder movement at three months, and Numeric Pain Rating Scale, abbreviated Disabilities of Arm, Shoulder and Hand score, and EuroQol five-level five-dimension health index at three months, six months, and one year after injection. A minimum of 40 patients will be recruited to obtain 80% power to detect a minimally important difference of ten points on the OSS between the groups at three months after injection. The study is registered under ClinicalTrials.gov with the identifier NCT04965376. The results of this trial will demonstrate if there is a difference in shoulder pain and function after GHJ injection or SSNB in patients with frozen shoulder. This will help provide effective treatment to patients with frozen shoulder.

Complications associated with open coracoid transfer procedures for shoulder instability.

BACKGROUND: Interest has been maintained in the use of coracoid transfer procedures for recurrent shoulder instability despite the significant potential for serious complications. A comprehensive systematic review of the literature was performed to quantify and characterize the complication rate associated with these procedures to better inform practicing surgeons and their patients. MATERIALS AND METHODS: Medline, Excerpta Medica Database (EMBASE), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched for therapeutic studies published between 1985 and 2011. Data regarding complications was extracted from selected articles in a standardized manner. Complication rates were determined and expressed as percentages with 95% confidence intervals. RESULTS: Included were 30 studies describing the results of 1658 coracoid transfer procedures. Repeat surgery was documented in 4.9% ± 1.0% of cases. Recurrent instability occurred in 6.0% ± 1.2%. Hardware complications occurred in 6.5% ± 1.3%. Collectively, the rate of graft nonunion, fibrous union, or postoperative graft migration was 10.1% ± 1.6%; graft osteolysis occurred in 1.6% ± 0.7%. There was a 1.2% ± 0.8% rate of nerve palsy. Surgical site infection occurred in 1.5% ± 0.7%. Intraoperative fractures occurred in 1.1 ± 0.6%. CONCLUSION: Coracoid transfers for shoulder instability can improve shoulder stability with acceptable recurrence rates. They are challenging procedures associated with a broad range and significant incidence of complications. A detailed appreciation of anatomy and meticulous attention to technical detail, particularly graft placement, is key to reducing complications. These procedures may be best indicated in the setting of glenoid or humeral bony deficiency, although efficacy over open capsular procedures remains equivocal.

Greater length of hospital stay for concurrent hip and upper limb fractures compared to isolated hip fractures: a systematic review of 13 studies including 210,289 patients and meta-analysis.

BACKGROUND: The impact of concurrent upper limb and fragility hip fractures has not been well defined. A greater understanding of this can guide decision making in the early peri-operative period and subsequent rehabilitation of such patients. AIMS: To identify if patients with concurrent upper limb and fragility hip fractures have different outcomes and demographics than those with an isolated hip fracture. METHODS: A search of MEDLINE and EMBASE was performed to identify cohort and case-control studies, comparing concurrent hip and upper limb fractures with isolated hip fractures. Meta-analysis was conducted using RevMan 5.4. Subgroup analyses were performed for concurrent distal radius and concurrent proximal humerus fractures. RESULTS: 13 studies were included reporting on 196,916 patients with an isolated hip fracture and 13,373 with concurrent hip and upper limb fractures. Patients with concurrent upper limb fractures had a significantly longer length of hospital stay (mean difference: 3.97 days, 95% CI: 1.36, 6.57, P=0.003) as compared to those with isolated hip fractures. Patients with concurrent upper limb fractures were significantly more likely to be female (OR: 0.57, 95% CI: 0.46, 0.70, P<0.00001), reside at home pre-injury (OR: 0.6, 95% CI: 0.37, 0.96, P=0.03) and have no cognitive impairment (OR: 0.54, 95% CI: 0.35, 0.84, P=0.006). Patients with concurrent distal radius fractures had significantly lower 90-day mortality (OR: 0.70, 95% CI: 0.49, 0.99, P=0.04) and 1-year mortality (OR: 0.68, 95% CI: 0.51, 0.90, P=0.008). CONCLUSIONS: Concurrent fragility hip and upper limb fractures are associated with increased length of hospital stay. We recommend early, aggressive, individualised rehabilitation to help improve outcomes and early hospital discharge in this highly vulnerable patient group.

Comparison of Acorn and Fluted Reamers on Tibial Tunnel Outer Aperture Dimensions in ACL Reconstruction.

The aim of this study was to determine if the type of reamer used in tibial tunnel creation during anterior cruciate ligament (ACL) reconstruction influences the dimensions of the tunnel's outer aperture. Tibial tunnels were created in tibial saw bones by reaming over a guidewire using an 8 mm acorn or fluted reamer in an antegrade manner. Reaming was aimed either in line with the guidewire, or with 10-degree inferior/superior deviation in relation to the wire. The shape and size of the outer aperture of the tibial tunnel were compared between the two reamers. When using the acorn reamer, a 10-degree deviation in relation to the guidewire resulted in minimal change in outer aperture length (mean 13.6 vs. 15.6 mm, p = 0.11) and width (11.6 vs. 11.1 mm, p = 0.51). However, when using the fluted reamer, although the aperture width showed no substantial change with reamer/guidewire deviation (11.4 vs. 11.2 mm, p = 0.71), the mean length almost doubled (14.7 vs. 28.1 mm, p = 0.002). The use of a fluted reamer when reaming the tibial tunnel creates a distal aperture which is inconsistently sized, larger, and of oblong shape compared with an acorn-shaped reamer. This should be taken in consideration when using a fluted reamer for creating the tibial tunnel in ACL reconstruction.

Perioperative Hypothermia Is Associated With Increased 30-Day Mortality in Hip Fracture Patients in the United Kingdom: Α Systematic Review and Meta-analysis.

OBJECTIVES: To undertake a systematic review and meta-analysis to determine the relationship between perioperative hypothermia and mortality after surgery for hip fracture. DATA SOURCES: A systematic literature search of Medline, EMBASE, CINAHL, and Cochrane CENTRAL databases was performed using the Cochrane methodology for systematic reviews with no publication year limit. Only studies available in the English language were included. STUDY SELECTION: Predetermined inclusion criteria were patients of any age with a hip fracture, exposure was their body temperature and outcome was mortality rate. Any comparative study design was eligible. DATA EXTRACTION: The quality of selected studies was assessed according to each study design with the Methodological Index for Non-Randomised Studies (MINORS) used for all the retrospective comparative studies. The GRADE approach was used to assess the quality of evidence. DATA SYNTHESIS: A meta-analysis was conducted using a random-effects model. RESULTS: The literature search identified 1016 records. After removing duplicates and those not meeting inclusion criteria, 3 studies measuring 30-day mortality were included. All included studies were carried out in the United Kingdom. The mortality rate was higher in the hypothermic groups as compared with the normothermic group in all the studies, with the difference being significant in 2 of the studies (P < 0.0001). The meta-analysis showed that low body temperature was associated with an increased mortality risk (estimated odds ratio: 2.660; 95% confidence interval: 1.948-3.632; P < 0.001) in patients undergoing surgery for hip fracture. CONCLUSIONS: This study shows that low body temperature in hip fracture patients is associated with an increased 30-day mortality risk in the United Kingdom. Randomized control trials are required to determine whether the association between perioperative hypothermia in hip fracture patients and mortality is causal. Nevertheless, based on this analysis, we urge the maintenance of normal body temperature in the perioperative period to be included in national hip fracture guidelines. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Additional Imaging is of Limited Value in Traumatic Hip Fractures With a History of Distant Malignancy and No Suspicious Lesion on Plain Radiographs.

OBJECTIVE: To determine the value of obtaining additional preoperative imaging in patients with a traumatic hip fracture and a history of malignancy in whom plain radiographs show no lesion suspicious for metastases. DESIGN: Retrospective review. SETTING: Teaching NHS Trust in the United Kingdom, over an 8-year period treating 4421 hip fractures. PATIENTS/PARTICIPANTS: Three hundred sixty-seven patients with hip fracture and a history of malignancy at a site distant to the hip. Three hundred thirty patients had a history of trauma and no lesion on the plain radiograph suspicious for metastases. MAIN OUTCOMES MEASUREMENTS: Whether obtaining additional imaging preoperatively (MRI, CT, and bone scan) identified metastases or affected management. RESULTS: 32/330 patients had further preoperative imaging, none of which demonstrated a pathological fracture secondary to malignancy. On follow-up, 3/330 (0.9%) cases were found to have occult metastasis at the hip fracture site. All 3 had only plain radiographs before surgery. In 2, this was identified on histological examination of intraoperative samples, and in 1, radiologically as a metastatic metaphyseal lesion 18 months after a hemiarthroplasty. Only in the latter case, preoperative identification of hip metastasis could have altered surgical management. Patients undergoing further preoperative imaging waited significantly longer for surgery (35 ± 26 vs. 51 ± 26 hours, P = 0.0011). CONCLUSIONS: In the absence of a suspicious metastatic lesion on initial plain radiographs, further preoperative imaging is unlikely to identify a lesion that will affect management and confers significant delays to surgery. Sending intraoperative histological samples may help guide postoperative oncological management, but further work is needed to prove its utility. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.