Does Hyaluronan improve pain or function following Arthroscopic Subacromial decompression (ASD) surgery of Shoulder? Results of a level 1 RCT.

BACKGROUND: Sodium hyaluronate (hyaluronan) can be used as a synovial fluid substitute following arthroscopic surgery. In this study, we examined its effect on pain and function following arthroscopic subacromial arthroscopic decompression (ASAD). METHODOLOGY: A prospective, randomized, and single-blinded design was used (13/LO0427) to compare the effect of a single postprocedure subacromial instillation of 10 ml hyaluronan, against 10 ml saline control. All patients had interscalene block along with general anesthesia and followed standard postoperative rehabilitation protocol. A power calculation for a 6-point difference in Oxford Shoulder Score (OSS) indicated a minimum sample size of 44. Participants were assessed preoperatively, and at 12 weeks using the following outcome measures -Oxford Shoulder Score (OSS), visual analog score (VAS), European quality of life score (EUROQOL), and Disability of the arm, shoulder, and hand (DASH) scores. RESULTS: 46 patients were included for analysis. Both groups showed a mean improvement in OSS of 9 points (P = 0.0001), DASH (10 points, P < 0.05), and EUROQOL (0.13, P < 0.05). No significant difference was observed between groups in any of the recorded outcomes. Apart from one case of frozen shoulder in each group, no other complications were noted. CONCLUSION: While both groups showed improved pain and function scores after ASAD, no significant difference was seen between groups receiving placebo or hyaluronan. The intervention is safe but, in this study, has not been shown to improve postoperative pain or function over ASAD alone. Level of evidence: I.

Lateral Clavicle Fractures with Coracoclavicular Ligament Disruption (Neer's Type IIB): Review of Literature and a New Technique for All-Suture Fixation.

BACKGROUND: All-suture fixation for the treatment of Neer's Type IIB lateral clavicle fractures by coracoclavicular (CC) ligament reconstruction has become popular in the past decade. Results of modified under-coracoid-around-clavicle (UCAC) technique are reported in this paper. METHODOLOGY AND RESULTS: Nineteen consecutive patients with minimum 6-month followup (FU) were identified. Average FU was 23 months (6-47 m), mean age was 38 years (16-81), and male-to-female ratio was 2:1. The time to surgery varied from 4 days to 12 weeks. Two patients had primary lateral end excision; of the rest, all but one healed fully. Average time to regain full range of motion was 4 weeks; postoperative Oxford Shoulder Score at 6 months was 43. All the patients returned to their previous occupation. One patient showed mild osteolysis on the last X-rays. There were no cases with infections or stiffness. DISCUSSION: CC ligament reconstruction converts the unstable Type IIB fracture into stable Type I; therefore, it is unnecessary to fix the distal fragment separately. Standard plating procedures are technically challenging due to small lateral fragment and frequently require a second operation for implant removal. The cost of commercially available implants vary from ≤750 to ≤1450. This technique is quick, easy to perform, provides good primary stability, and comparable union rates with other techniques at an implant cost of <£120. CONCLUSION: This is a reproducible and efficient technique that provides comparable results with other established procedures at a fraction of the cost of the next cheapest implant. It is recommended for the treatment of displaced Type II clavicle fractures. LEVEL OF EVIDENCE: Level IV.

Conservative management of psoas haematoma following complex lumbar surgery.

We report psoas hematoma communicating with extradural hematoma and compressing on lumbar nerve roots during the postoperative period in a patient who underwent L3/4 level dynamic stabilization and L4/5 and L5/S1 posterior lumbar interbody fusion. Persistent radicular symptoms occurring soon after posterior lumbar surgery are not an unknown entity. However, psoas hematoma communicating with the extradural hematoma and compressing on L4 and L5 nerve roots soon after surgery, leading to radicular symptoms has not been reported. In addition to the conservative approach in managing such cases, this case report also emphasizes the importance of clinical evaluation and utilization of necessary imaging techniques such as computed tomography (CT) scan and magnetic resonance imaging (MRI) scan to diagnose the cause of persistent severe radicular pain in the postoperative period.

Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total knee replacement: a randomized controlled trial (TRANX-K).

BACKGROUND: Approximately one-third of patients undergoing total knee replacement require one to three units of blood postoperatively. Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that has been successfully used intravenously to stop bleeding after total knee replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid. METHODS: A double-blind, randomized controlled trial of 157 patients undergoing unilateral primary cemented total knee replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Knee Score, length of stay, a cost analysis, and complications as per the protocol definitions. RESULTS: Tranexamic acid reduced the absolute risk of blood transfusion by 15.4% (95% confidence interval [CI], 7.5% to 25.4%; p = 0.001), from 16.7% to 1.3%, and reduced blood loss by 168 mL (95% CI, 80 to 256 mL; p = 0.0003), the length of stay by 1.2 days (95% CI, 0.05 to 2.43 days; p = 0.041), and the cost per episode by £333 (95% CI, £37 to £630; p = 0.028). (In 2008, £1 = 1.6 U.S. dollars.) Oxford Knee Scores and EuroQol EQ-5D scores were similar at three months. CONCLUSIONS: Topically applied tranexamic acid was effective in reducing the need for blood transfusion following total knee replacement without important additional adverse effects. LEVEL OF EVIDENCE: Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total hip replacement: a randomized controlled trial (TRANX-H).

BACKGROUND: Approximately one-third of patients undergoing total hip replacement surgery require one to three units of blood postoperatively. Tranexamic acid is a synthetic antifibrinolytic agent that has been successfully used intravenously to control bleeding after total hip replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid. METHODS: A double-blind, randomized controlled trial of 161 patients undergoing unilateral primary total hip replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Hip Score, length of stay, a cost analysis, and complications. RESULTS: Tranexamic acid reduced the absolute risk of blood transfusion by 19.6% (95% confidence interval [CI], 6.9% to 32.1%; p = 0.004), from 32.1% to 12.5%, and reduced blood loss by 129 mL (95% CI, 47 to 211 mL; p = 0.002), the hemoglobin concentration drop by 0.84 g/dL (95% CI, 0.41 to 1.27; p < 0.0001), the length of stay by 1.0 days (95% CI, -0.2 to 2.3 days; p = 0.109), and the cost per episode by £305 (95% CI, £0 to £610; p = 0.05). (In 2010, £1 = 1.5 U.S. dollars.) Oxford Hip Scores and EuroQol scores were similar at three months. CONCLUSIONS: Topically applied tranexamic acid was effective in reducing blood loss and the need for blood transfusion following total hip replacement, avoiding the potential complications of intravenous tranexamic acid administration. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Distal biceps tendon rupture: current concepts.

BACKGROUND: Distal biceps tendon rupture is not a very common injury and the literature remains scarce, mainly limited to case series. While surgical repair has become popular, it is not universally accepted and there are insufficient data regarding patient satisfaction following repair. The purpose of this study was to assess the results of anatomical reinsertion according to objective muscle strength testing and patient-reported outcome measures. PATIENTS AND METHODS: Twenty-four patients underwent surgical repair over the last 10 years. All patients underwent clinical assessment using the Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score and Oxford Elbow score. Measurement of range of motion, supination and flexion strength testing was done using a Biodex isokinetic dynamometer. RESULTS: Ninety-five percent of the patients had good or excellent results following surgery as defined by Mayo and Oxford Elbow scores. The average DASH score following surgery was 7.1, nearly the same as the score of 6.2 in the normal population. The mean elbow flexion arc was 134° ± 10.8 (range, 125-150°; 95% confidence interval (CI) 129.6-137.8) with no flexion contractures in the operated side compared with the unaffected elbow. The range of pronation-supination was also comparable in both sides. The average torque in flexion improved by 19.8% (p = 0.25) while supination torque was reduced by 4% (p = 0.12) when compared to the uninjured side. There was 8% incidence of persistent neuropraxia of the antebrachial cutaneous nerve of the forearm and 4% incidence of asymptomatic heterotopic ossification. CONCLUSION: Surgical repair of distal biceps ruptures provides consistently good results in terms of patient-scored outcomes. Objective muscle strength testing does not reveal statistical difference between the injured and the opposite side.