Outcomes of perioperative intravenous iron infusion in femoral fracture surgery: A systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Patient blood management recommends the use of intravenous (IV) iron infusion to reduce inappropriate blood transfusion perioperatively for anaemic surgical patients. However, evidence regarding its use in urgent femoral fracture surgery is limited. This systematic review aims to collate the current evidence regarding the utilisation of IV iron in femoral fracture surgery. METHOD: MEDLINE, Embase, Cochrane CENTRAL, Clinicaltrials.gov, and the WHO ICTRP databases were systematically searched for randomised controlled trials (RCT) comparing the outcomes of perioperative IV iron infusion with placebo in adults requiring surgical management for femoral fractures. Risk ratios (RR) were calculated using the Mantel-Haenszel method for dichotomous outcomes, and mean differences (MD) were calculated with the inverse-variance method for continuous outcomes. RESULTS: Six RCTs with 1292 patients were included. No statistically significant difference was found in the proportion of patients receiving red blood cell (RBC) transfusion (RR = 0.87, 95%CI: 0.75; 1.01, p = 0.058) between groups. Statistically significant difference in postoperative haemoglobin concentration was found between groups measured between day 4-7 of admission (MD = 1.93 g/L, 95%CI: 0.48; 3.39, p = 0.024), but not clinically significant. No statistically significant differences were found between groups in mortality rate, length of hospital stay, infection rate, or return to home rate. CONCLUSION: Current evidence indicates that IV iron infusion alone does not provide any clinically significant benefit in femoral fracture surgery. Further high-quality RCTs are needed to explore its synergistic potential when used in combination with other perioperative optimisation methods, including tranexamic acid, erythropoietin and cell salvage.

Artificial intelligence in orthopaedics surgery: transforming technological innovation in patient care and surgical training.

Artificial intelligence (AI) is an exciting field combining computer science with robust data sets to facilitate problem-solving. It has the potential to transform education, practice and delivery of healthcare especially in orthopaedics. This review article outlines some of the already used AI pathways as well as recent technological advances in orthopaedics. Additionally, this article further explains how potentially these two entities could be combined in the future to improve surgical education, training and ultimately patient care and outcomes.

Evaluation of first ray instability using the double dorsiflexion test: A prospective observational case-controlled study.

BACKGROUND: First-Ray (FR) stability allows for foot propulsion in-stance, taking 60% weight. First-ray instability (FRI) is associated with middle column overload, synovitis, deformity and osteoarthritis. Clinical detection can still be challenging. We propose to develop a clinical test that helps identify FRI using two simple manual manoeuvres. METHODS: 10 patients with unilateral FRI were recruited. Unaffected contralateral feet were used as controls. Stringent exclusion criteria were applied including hallux MTP pain, laxity, inflammatory arthropathy and collagen disorders. A Klauemeter directly measured the sagittal plane dorsal first metatarsal head translation of affected vs unaffected feet. Maximum passive proximal phalanx 1st MTP joint dorsiflexion was measured using a video capture and Tracker motion software analysis with and without applying a dorsal force at the 1st metatarsal head using a Newton meter. Proximal phalanx motion was compared in affected vs unaffected feet with and without dorsal metatarsal head force application and compared to direct measurements using the Klaumeter. P value of < 0.05 was considered significant. RESULTS: FRI feet had dorsal translation greater than 8 mm (median, 11.94; interquartile range [IQR], 10.23-13.81) vs 1.77 for unaffected control feet was (median, 1.77; interquartile range [IQR], 1.23-2.96) using the Klauemeter. The percentage reduction in 1st MTP joint dorsiflexion ROM when applying the double dorsiflexion test FRI (mean reduction of 67.98%) when compared to control feet (mean reduction of 28.44%)(P < 0.01). Receiver operating characteristic (ROC) analysis showed that a 50% reduction in dorsiflexion ROM of 1st MTPJ when performing the double dorsiflexion test achieved a specificity of 100% and sensitivity of 90% (AUC =0.990, 95%CI [0.958-1.000], P > 0.0001). CONCLUSION: The double dorsiflexion (DDF) is easy to perform with two relatively simple manual manoeuvres that avoids the need for complex instrumented and radiation-based assessment. Greater than 50% decrease in proximal phalanx motion has an over 90% sensitivity in identifying feet with FRI. LEVEL OF EVIDENCE: This was a prospective case-controlled study of consecutive cases of a level II evidence.

CRP monitoring in fractured neck of femur. A waste of resource?

AIM: We aim to assess post-operative CRP serum values in a cohort of patients who underwent surgical treatment for neck of femur fracture (NOF#), and whether CRP is a valid tool for the assessment of these patients post-operatively. STUDY DESIGN AND METHODS: Retrospective analysis was carried out on all NOF#'s admitted for surgical fixation between August 2015 and July 2016 in a district general hospital. Primary analysis included serum CRP levels until day 7 post-operatively, with secondary analysis of any documented evidence of post-operative complications (medical and surgical) within 30 days post-operatively. RESULTS: A total of 365 patients were surgically treated for NOF#'s over the study period. CRP serum levels peaked over the first two days post-operatively to median (IQ range) of 226 mg/L (158-299 mg/L), decreasing to 67 mg/L (45.5-104 mg/L) by day 7 post-operatively. 116 patients had documented post-operative complications within 30 daysof operation. CRP levels in patients with and without complications showed no statistical significance in day-1, day-2 and day-3 post-operatively. However, a significant difference was demonstrated on day-4 (p = 0.017), day-5 (p = 0.003), day-6 (p = 0.02) and day-7 (p = 0.031). CONCLUSIONS: During the first three days of the postoperative period we cannot recommend routine CRP serum blood test monitoring in NOF# patients, as it is not diagnostic in the acute inflammatory phase for medical or surgical complications.

Requesting spinal MRIs effectively from primary care referrals.

OBJECTIVE: To define if MRI scans can accurately be requested based on information provided in the primary care referral and, therefore, streamline the patient journey. The demand for outpatient spinal appointments significantly exceeds our services' ability to provide efficient, high-quality patient care. Currently, magnetic resonance imaging (MRI) of the spine is requested following first consultation. METHODS: During routine vetting of primary care referral letters, three consultant spinal surgeons recorded how likely they thought each patient would be to have an MRI scan. Following the first consultation with the spinal service, the notes of each patient were reviewed to see if an MRI was requested. We measured the positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity of ordering MRI scans based on primary care referral letters. RESULTS: 149 patients were included [101 females, 48 males, mean age 49 (16-87)]. There were 125 routine, 21 urgent, and 3 'urgent-suspected cancer' referrals. The PPV of ordering MRIs before first consultation was 84%, NPV was 56% with the sensitivity and specificity being 82 and 59%, respectively. Ordering MRIs during initial vetting could shorten the patient journey with potential socioeconomic benefits. CONCLUSIONS: MRI scans can be effectively ordered based on the information provided by the primary care referral letter. Requesting MRI scans early in the patient journey can save considerable time, improve care, and deliver cost savings. These slides can be retrieved under Electronic Supplementary Material.

Novel technique to accurately measure femoral diameter using a Thomas splint.

INTRODUCTION: During surgical management of femoral shaft fractures, difficulties arise when treating patients with narrow femoral diaphyseal canals, such as young patients and those with dysplastic femurs secondary to underlying pathology. Accurate pre-operative assessment of the femoral diaphyseal canal diameter would allow the surgeon to plan surgical technique and ensure appropriate equipment was available, such as narrow, unreamed or paediatric sized nails. TECHNIQUE: When secured to the patient both longitudinal rods of the main Thomas Splint component lie parallel with the femoral shaft and horizontal to the radiographic x-ray plate. The diameter of these rods are 13mm (Adult and paediatric). Using the calibration tool, we calibrate the diameter of the Thomas Splint to 13mm, accurately measuring any further detail on that radiograph, such as the diaphyseal canal diameter. CONCLUSION: Accurate knowledge pre-operatively of radiographic measurements is highly valuable to the operating surgeon. This technique can accurately measure femoral canal diameter using the Thomas splint, negates the requirement for a calibration marker, is reproducible, easy to perform, and is indispensible when faced with a patient with a narrow femoral canal in a diaphyseal femoral fracture. (181 words).