RECITAL: a non-inferiority randomised control trial evaluating a virtual fracture clinic compared with in-person care for people with simple fractures (study protocol).

INTRODUCTION: Most simple undisplaced fractures can be managed without surgery by immobilising the limb with a splint, prescribing medication for pain, and providing advice and early rehabilitation. Recent systematic reviews based on retrospective observational studies have reported that virtual fracture clinics can deliver follow-up care that is safe and cost-effective. However, no randomised controlled trial has investigated if a virtual fracture clinic can provide non-inferior physical function outcomes compared with an in-person clinic for patients with simple fractures. METHODS AND ANALYSIS: 312 participants will be recruited from 2 metropolitan hospitals located in Sydney, Australia. Adult patients will be eligible if they have an acute simple fracture that can be managed with a removable splint and is deemed appropriate for follow-up at either the virtual or in-person fracture clinic by an orthopaedic doctor. Patients will not be eligible if they have a complex fracture that requires a cast or surgery. Eligible participants will be randomised to receive their follow-up care either at the virtual or the in-person fracture clinic. Participants at the virtual fracture clinic will be reviewed within 5 days of receiving a referral through video calls with a physiotherapist. Participants at the in-person fracture clinic will be reviewed by an orthopaedic doctor within 7-10 days of receiving a referral. The primary outcome will be the patient's function measured using the Patient-Specific Functional Scale at 12 weeks. Secondary outcomes will include health-related quality of life, patient-reported experiences, pain, health cost, healthcare utilisation, medication use, adverse events, emergency department representations and surgery. ETHICS AND DISSEMINATION: The study has been approved by the Sydney Local Health District Ethics Review Committee (RPAH Zone) (X23-0200 and 2023/ETH01038). The trial results will be submitted for publication in a reputable international journal and will be presented at professional conferences. TRIAL REGISTRATION NUMBER: ACTRN12623000934640.

Overlapping surgery in arthroplasty - a systematic review and meta-analysis.

BACKGROUND: Planned overlapping surgery can improve efficiency, reduce costs and help manage long waiting lists; yet, this practice has been questioned due to patient safety concerns. A systematic review and meta-analysis were performed to answer the question: (1) are there any differences in the risk of postoperative adverse outcomes; and (2) are there any differences in length of stay or length of surgery, in elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed either as non-overlapping surgery (NOS) or overlapping surgery (OS). PATIENTS AND METHODS: A systematic search of literature in the databases of MEDLINE, PubMed, Embase and Cochrane from dates of inception was performed. All studies published in English were included. Risk of Bias in Non-randomised Studies-of Interventions (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05. RESULTS: A total of nine studies with 120,625 patients were included for analyses. There were no statistically significant differences for overall rates of postoperative complications, dislocations, fractures, infections, readmissions or revision surgery nor with length of stay or length of surgery (p>0.05). Patient characteristics between groups were similar (p>0.05). DISCUSSION: There were no differences in postoperative adverse outcomes for elective orthopaedic THA and TKA performed as NOS when compared to OS. Operating schedules for OS in elective lower limb arthroplasty appear to be safe, given appropriate patient selection processes and may be a useful method to improve hospital efficiency. Informed consent and preoperative patient education should remain paramount. LEVEL OF EVIDENCE: IV.

Fibular fixation in mid and distal extra-articular tibia fractures - A systematic review and meta-analysis.

BACKGROUND: The surgical management of extra-articular mid and distal tibia fractures has primarily focused on reducing rates of non-union and malunion, preserving hip-knee-ankle alignment and improving functional outcomes. Fibular fractures commonly accompany these injuries and the contributory role of fixation of these fractures has been increasingly studied. A systematic review and meta-analysis were performed to determine whether concurrent fibular fixation (FF) during extra-articular mid and distal tibia fracture fixation (AO/OTA 42 and 43-A) altered the risk of malunion, non-union and post-operative complications when compared to no fibular fixation (NF). METHODS: A systematic search of literature in the databases of MEDLINE (via OvidSP), PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) from the dates of inception was performed for randomised and non-randomised controlled trials. All studies published in English were included. Risk of Bias in Non-randomised Studies (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05. RESULTS: A total of ten studies with 1174 patients were included for analysis. There was a statistically significant reduced risk of overall malunion in the FF group compared to the NF group (11.8% vs 21.9%, RR 0.63, 95% CI: 0.41-0.98, p = 0.04) and this was supported through a sensitivity analysis of only randomised controlled trials (21.8% vs 40.3%, RR 0.37, 95% CI: 0.18-0.76, p = 0.006). There was no statistically significant difference in rates of non-union between groups (p > 0.05). Overall, there were similar incidences of diabetes, open fractures and smoking history between groups (p > 0.05). Detailed information regarding methods of tibial fixation were not available for subgroup analysis. CONCLUSION: In conclusion, in extra-articular mid and distal tibia (AO/OTA 42 and 43-A) fracture fixation, additional fibular fixation (FF) appears to significantly reduce the risk of overall malunion (RR, 0.37, 95% CI: 0.18-0.76, p = 0.006) without increasing the risk of non-union. These results should be interpreted with caution given the lack of subgroup analysis for methods of tibial fixation. Future high-quality randomised controlled trials should therefore delineate between types of tibial fixation.

Hip fracture surgery performed out-of-hours-A systematic review and meta-analysis.

INTRODUCTION: . Early hip fracture surgery (<48 hours) has shown to improve mortality for geriatric patients and is recommended in national hip fracture guidelines. However, this may be at the expense of surgery being performed out-of-hours where concerns about mortality risk exist. A systematic review and meta-analysis were performed to determine the mortality risk for hip fracture surgery performed in-hours (IH) compared to out-of-hours (OH), and on weekdays (WD) compared to weekends (WE). MATERIALS AND METHODS: . A systematic search of literature in the databases of MEDLINE, PubMed, Embase and Cochrane from the dates of inception was performed. All studies published in English were included. Risk of Bias in Non-randomised Studies (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05. RESULTS: . A total of 13 studies with 177,090 patients were included for analysis. Overall, there was no statistically significant difference for 30-day or inpatient mortality in IH vs OH groups (RR 0.93, p=0.46 and RR 1.16, p=0.63) and for WD vs WE groups (RR 0.98, p=0.73 and RR 0.76, p=0.67). There was no difference in length of stay between groups (p>0.05). The number of patients with American Society of Anaesthesiology (ASA) physical status classification ≥3 and male gender between the groups were similar (p>0.05). CONCLUSION: . Performing hip fracture surgery OH or on the WE does not appear to increase the risk of 30-day or inpatient mortality or post-operative complications. Consideration should be given to performing hip fracture surgery out-of-hours to meet national guidelines (<48 hours).

Subacromial analgesia via continuous infusion catheter vs. placebo following arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized trials.

BACKGROUND: Subacromial analgesia (SAA) is hypothesized to reduce pain after arthroscopic shoulder surgery by delivering a continuous infusion of local anesthetic directly to the surgical site. The purpose of this systematic review and meta-analysis was to evaluate the efficacy of SAA vs. placebo for pain relief after arthroscopic subacromial shoulder procedures. METHODS: MEDLINE, Embase, PubMed, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials comparing SAA with placebo after arthroscopic shoulder surgery. Outcomes collected included pain scores (converted to equivalent ordinal visual analog scores; minimal clinically important difference 1.4 cm), oral morphine equivalents used postoperatively, and catheter-related complications. Meta-analysis was performed via a random-effects model. Included trials underwent a risk of bias and quality of evidence assessment. RESULTS: Nine studies involving 459 participants were included. There were no clinically significant changes for pain scores in SAA at 6-, 12-, 24-, and 48-hour postoperative timepoints. Patients receiving SAA used less morphine equivalents of pain medication at 12 hours only (-0.37 mg, 95% confidence interval: -0.63 to -0.11), but there was no significant difference at 24 and 48 hours. There were no major complications (infection or reoperation). Included trials demonstrated a moderate risk-of-bias, and low to very low quality of evidence for primary outcomes. CONCLUSION: Subacromial continuous infusion of local anesthetic does not provide a clinically significant benefit compared with placebo as part of a multimodal analgesia regime after arthroscopic subacromial surgical procedures. Future, high-quality trials are required to further assess the efficacy of SAA against placebo.