Treatment of External Fixator Pin Tract Deep Infections With an Antibiotic "Sparkler".

Pin tract infections are virtually universal complications with the use of external fixation. While most are superficial and respond to oral antibiotics and local care, septic loosening may occur at the bone-pin interface, which may lead to instability of the fixator, catastrophic failure, fracture, and long-term osteomyelitis. Classification systems and prevention protocols have been developed to address this ubiquitous complication. Treatment of severe pin tract infections often requires debridement, parenteral antibiotics, and removal of the offending pin or the entire external fixator. In cases of osteomyelitic pin tracks, a sizable cavity is often present. We describe a simple technique for treatment of deep bone pin tract infection through the use of debridement, irrigation, and an antibiotic "sparkler," which is a specially prepared percutaneous implant of antibiotic laden bone cement.Levels of Evidence: Level 5.

Neuraxial versus general anesthesia in elderly patients undergoing hip fracture surgery and the incidence of postoperative delirium: a systematic review and stratified meta-analysis.

BACKGROUND: Evidence-based effect of anesthetic regimens on postoperative delirium (POD) incidence after hip fracture surgery is still debated. Randomized trials have reported inconsistent contradictory results largely attributed to small sample size, use of outdated drugs and techniques, and inconsistent definitions of adverse outcomes. The primary objective of this meta-analysis was to investigate the impact of different anesthesia regimens on POD, cognitive impairment, and associated complications including mortality, duration of hospital stay, and rehabilitation capacity. METHODS: We identified randomized controlled trials (RCTs) published from 2000 to December 2021, in English and non-English language, comparing the effect of neuraxial anesthesia (NA) versus general anesthesia (GA) in elderly patients undergoing hip fracture surgery, from PubMed, EMBASE, Google Scholar, Web of Science and the Cochrane Library database. They were included if POD incidence, cognitive impairment, mortality, duration of hospital stay, or rehabilitation capacity were reported as at least one of the outcomes. Study protocols, case reports, audits, editorials, commentaries, conference reports, and abstracts were excluded. Two investigators (KYC and TXY) independently screened studies for inclusion and performed data extraction. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. The quality of the evidence for each outcome according to the GRADE working group criteria. The odds ratio (OR) and 95% confidence intervals (CI) were calculated to assess the pooled data. RESULTS: A total of 10 RCTs with 3968 patients were included in the present analysis. No significant differences were found in the incidence of POD comparing NA vs GA [OR 1.10, 95% CI (0.89 to 1.37)], with or without including patients with a pre-existing condition of dementia or delirium, POD incidence from postoperative day 2-7 [OR 0.31, 95% CI (0.06 to -1.63)], in mini-mental state examination (MMSE) score [OR 0.07, 95% CI (-0.22 to 0.36)], or other neuropsychological test results. NA appeared to have a shorter duration of hospital stay, especially in patients without pre-existing dementia or delirium, however the observed effect did not reach statistical significance [OR -0.23, 95% CI (-0.46 to 0.01)]. There was no difference in other outcomes, including postoperative pain control, discharge to same preadmission residence [OR 1.05, 95% CI (0.85 to 1.31)], in-hospital mortality [OR 1.98, 95% CI (0.20 to 19.25)], 30-day [OR 1.03, 95% CI (0.47 to 2.25)] or 90-day mortality [OR 1.08, 95% CI (0.53-2.24)]. CONCLUSIONS: No significant differences were detected in incidence of POD, nor in other delirium-related outcomes between NA and GA groups and in subgroup analyses. NA appeared to be associated with a shorter hospital stay, especially in patients without pre-existing dementia, but the observed effect did not reach statistical significance. Further larger prospective randomized trials investigating POD incidence and its duration and addressing long-term clinical outcomes are indicated to rule out important differences between different methods of anesthesia for hip surgery. TRIAL REGISTRATION: 10.17605/OSF.IO/3DJ6C.

The Zadek Osteotomy for Surgical Management of Insertional Achilles Tendinopathy: A Systematic Review.

BACKGROUND: The calcaneal dorsal closing wedge osteotomy, otherwise known as the Zadek or Keck and Kelly osteotomy, is used to treat insertional Achilles tendinopathy. The purpose of this study is to investigate the clinical outcomes affiliated with the Zadek technique for insertional Achilles tendinopathy (IAT) as reported in the literature. METHODS: An English literature search on PubMed was performed yielding 8 level IV retrospective case series. RESULTS: The weighted mean of preoperative and postoperative Victorian Institute of Sports Assessment-Achilles Questionnaire (VISA-A) scores was 52.7 and 87.8, respectively. The weighted mean of preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores was 56.3 and 92.9, respectively. Majority of the reported complications were minor events, including symptomatic hardware (2.8%; n = 7/247), sural nerve paresthesia (2%; n = 5/247), and superficial infection (3.2%; n = 8/247). There was 1 reported event of hardware failure resulting in re-operation. Deep vein thrombosis occurred at a rate of 0.8% (n = 2/247), complex regional pain syndrome at 0.4% (n = 1/247) and nonunion at a rate of 1.2% (n = 3/247). CONCLUSION: The Zadek osteotomy is a viable option for insertional Achilles tendinopathy based on significantly improved outcome measures and minor complication rates. LEVEL OF EVIDENCE: 4.

Wear and tear of the intestinal visceral musculature by intrinsic and extrinsic factors.

BACKGROUND: The gut visceral musculature plays essential roles in not only moving substances through the lumen but also maintaining the function and physiology of the gut. Although the development of the visceral musculature has been studied in multiple model organisms, how it degenerates is poorly understood. RESULTS: Here, we employ the Drosophila midgut as a model to demonstrate that the visceral musculature is disrupted by intrinsic and extrinsic factors, such as aging, feeding, chemical-induced tissue damage, and oncogenic transformation in the epithelium. Notably, we define four prominent visceral musculature disruption phenotypes, which we refer as "sprout," "discontinuity," "furcation," and "crossover" of the longitudinal muscle. Given that the occurrence of these phenotypes is increased during aging and under various stresses, we propose that these phenotypes can be used as quantitative readouts of deterioration of the visceral musculature. Intriguingly, administration of a tissue-damaging chemical dextran sulfate sodium (DSS) induced similar visceral musculature disruption phenotypes in zebrafish larvae, indicating that ingestion of a tissue-damaging chemical can disrupt the visceral musculature in a vertebrate as well. CONCLUSIONS: Our study provides insights into the deterioration of the gut visceral musculature and lays a groundwork for investigating the underlying mechanisms in Drosophila as well as other animals.

Postoperative Infection Rates After Total Ankle Arthroplasty: A Comparison With and Without the Use of a Surgical Helmet System.

Following total joint arthroplasty, surgical site infections (SSI) and periprosthetic joint infections (PJI) are associated with increased patient morbidity and healthcare utilization. Current positive-pressure surgical sterile helmet system (SHS) were developed as a feasible, useful version of the body exhaust system.The use of SHS has not yet been proven to decrease infection rates in the orthopedic literature. The primary purpose of this study is to compare the infection rates between patients who underwent total ankle arthroplasty (TAA) with a surgical team wearing SHS versus without SHS.A retrospective chart review in patients undergoing primary TAA with the surgeon wearing SHS (Group 1) or standard surgical attire (Group 2) was conducted. The primary outcome was postoperative SSI and PJI. The rate of wound complications, revision rates, and associated procedures were also analyzed. We identified 109 patients in Group 1 and 151 patients in Group 2. The rate of SSI was 12.8% in Group 1 and 14.6% in Group 2 (p = .411). The rate of PJI was 0.92% in Group 1 and 2.6% in Group 2 (p = .411). There was no difference in revision rates between the two groups. This study suggests that SHS does not appear to protect against postoperative SSI or PJI after TAA. Conversely, we did not find a higher infection rate compared to standard surgical attire despite recent in-vitro studies suggesting SHS as a source of wound contamination. The utility of SHS does not appear to influence the prevalence of postoperative SSI or PJI.

The Role of Secondary Imaging Techniques for Assessing Bone Mineral Density in Elderly Ankle Fractures.

Elderly ankle fractures in the elderly represent a substantial healthcare burden. Dual-energy x-ray absorptiometry (DXA) is the gold standard for diagnosis of osteoporosis. However, there is emerging research regarding secondary imaging techniques to evaluate bone mineral density (BMD). The purpose of this systematic review was to summarize the role of secondary imaging techniques for measuring BMD in elderly ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Eight studies were included in the systematic review. Computed tomography (CT) may have a role in preoperative surgical planning, provide an explanation for injury patterns in elderly patients, and may be correlated with clinical outcomes. High-resolution peripheral quantitative CT may be better suited than DXA for the assessment of ankle fractures due to the resolution of the image and its ability to distinguish between bone compartments, as well as provide a more accurate estimation of bone quality. Quantitative ultrasound has shown promise as a tool for measuring BMD in patients with osteoporosis, but is not able to detect osteoporosis in patients with ankle fractures. This paper helps define the role of each modality in the spectrum of care in the evaluation of osteoporosis as it pertains to elderly ankle fractures.

Surgical Takedown Approaches to Insertional Achilles Tendinopathy: A Systematic Review.

Various techniques of surgical detachment for treatment of insertional Achilles tendinopathy have been described, including lateral release, medial release, central tendon splitting (CTS), and complete detachment. A systematic review of electronic databases was performed, encompassing 17 studies involving 703 patients and 746 feet, to compare outcomes associated with surgical takedown techniques. Observed results include wound complication rates (CTS 2.8%; Lateral 0%; Medial 0.4%; Complete 1.3%), postoperative rupture rates (CTS 0.7%; Lateral 0.8%; Medial 0.7%; Complete 2.6%), rate of revision (CTS 0.4%; Lateral 0.9%; Medial 4.2%; Complete 2.6%), rate of infection (CTS 1.1%; Lateral 1.7%; Medial 3.7%; Complete 6.5%). Lateral takedown group was found to have a statistically significant lower rate of complications compared to the complete takedown group (p = .0029). In light of these results, it is recommended that patient characteristics such as case specific tendon pathology and calcaneal morphology take precedent in determining the surgical approach to Achilles takedown.

Outcomes of Ankle Arthrodesis Conversion to Total Ankle Arthroplasty: A Systematic Review.

Ankle arthrodesis (AA) provides reliable pain relief, good patient satisfaction scores, and improved overall function. However, this procedure has been associated with numerous complications and sequelae, such as pseudoarthrosis, malunion, gait abnormalities, increased demand on surrounding joints, and a long period of convalescence. Conversion to total ankle arthroplasty (TAA) is a potential option in the management of these complex and challenging situations. The purpose of this study is to investigate the outcomes of AA conversion to TAA. A systematic review of electronic databases was performed. Six studies involving 172 ankles met inclusion criteria. The weighted mean preoperative Visual Analogue Scale (VAS) score at the time of TAA conversion was 7.8 and the weighted mean postoperative VAS score at the time of final follow-up was 2.5. The weighted mean preoperative AOFAS score at the time of TAA conversion was 32 and the weighted mean postoperative AOFAS score at the time of final follow-up was 72.4. The rate of salvage tibiotalocalcaneal arthrodesis was 2.3% and rate of transtibial amputation was also 2.3% after attempted conversion from initial AA to TAA. Conversion of AA to TAA appears to be a viable option to improve patient outcomes and prevent extensive hindfoot arthrodesis and transtibial amputation. More prospective studies with consistent reporting of outcomes, complications, and revision rates with long-term follow-up are needed.

Bone Mineral Density Testing in Patients Undergoing Total Ankle Arthroplasty: Should We Pay More Attention to the Bone Quality?

Total ankle arthroplasty (TAA) has become one of the standard treatments for end-stage ankle arthritis. Long-term TAA survivorship is reported from 63% to 95%, with aseptic loosening being the most common mode of failure. Several studies have shown that low bone mineral density (BMD) of the hip affects the longevity of prosthetic implants. The role of Dual energy X-ray absorptiometry for TAA has not been established. The purpose of this review was to define the role of BMD in TAA outcomes and the role of Dual energy X-ray absorptiometry in measuring periprosthetic BMD. There is a paucity of information and published literature regarding the relationship between BMD and TAA. From attempting this systematic review, we hope to highlight that much of the focus in total ankle arthroplasty has emphasized implants and relatively little has focused on the quality of bone into which the prostheses are implanted.

Outcomes and Incidence of Complications Following Endoscopic Gastrocnemius Recession: A Systematic Review.

Introduction: Equinus contracture of the ankle can lead to a multitude of foot and ankle pathologies. The gastrocnemius recession has been used to address equinus deformity via various methods, including either an open or an endoscopic approach. Open techniques require increased intraoperative time and complication risks of sural nerve injury, wound complications, and poor cosmesis. Resultantly, the aim of the current study is to review the complications and outcomes of the endoscopic gastrocnemius recession. Methods: A systematic review of electronic databases was performed. The authors compiled data from retrospective and prospective patient studies including general patient demographics, outcomes, qualitative scoring measures, complications, and surgical technique. Results: Eleven studies met our inclusion criteria. A total of 697 feet in 627 patients were included in the current systematic review. The weighted mean age was 45.3 years and weighted mean follow-up was 18.4 months. The most common indication for an endoscopic gastrocnemius recession was equinus contracture. The weighted mean preoperative ankle range of motion was -2.3° and the weighted postoperative ankle range of motion was 10.9°. The most common complications included plantarflexion weakness of the ankle at 3.5%, a sural nerve injury of 3.0% and wound complication rate was 1.0% with no deep infection. The overall complication rate was 7.5%. Conclusion: The endoscopic gastrocnemius recession is a valuable surgical tool in the treatment of ankle equinus. The endoscopic approach has satisfactory outcomes including low incidence of plantarflexion weakness and sural neuritis. Patients should be counseled on these risks preoperatively. Compared with previously reported systematic review of the open technique, the endoscopic approach has a lower overall incidence of complications. Prospective clinical trials comparing open and endoscopic techniques are warranted.Levels of Evidence: Level IV.

Opioid prescribing habits of podiatric surgeons following elective foot and ankle surgery.

Prescription of opioids following surgery is commonplace in the United States, but with that has come increases in misuse, overdose and death. Evaluating prescribing habits in efforts to reduce the opioid epidemic is becoming more frequent. The purpose of the present study was to examine the self-reported practices of podiatric surgeons regarding their methods of post-operative pain management in adult, sensate patients, as well as assessing the frequency of use of adjunctive pain control modalities. A survey was created and distributed to Podiatric Surgeons electronically, across the United States. Results of this study show that Podiatric Surgeons prescribe hydrocodone/acetaminophen most commonly after surgery, with most prescribing opioids for less than 2 weeks. With regards to adjunctive pain management, two-thirds of respondents use regional anesthesia blocks, with only 13% using post-anesthesia delivery devices (PADD). Interestingly, those using PADDs prescribed significantly more opioids at the first prescription and were more likely to refill the prescription. Podiatric Surgeons are concerned with various negative outcomes for their patients when taking opioids, including addiction, non-adherence, and motor vehicle accidents. Podiatric Surgeons are less concerned about negative outcomes for themselves when prescribing opioids. This study is in agreement with previously published studies in other medical specialties regarding opioid prescribing habits and concerns. However, further research is needed to fully understand the role PADDs and regional anesthesia blocks play in reducing the amount of opioids prescribed following surgery. The Opioid Epidemic in the United States is multi-faceted, but over-prescription by providers is part of it. Continuing to assess and understand how opioids are prescribed will be paramount to curb the epidemic.

A Comparison of Outcomes of Revision Surgical Options for the Treatment of Failed Bulk Talar Allograft Transfer: A Systematic Review.

Talar bulk osteochondral allograft transplantation is a useful treatment strategy for large, uncontained osteochondral lesions of talus. Complications and high revision rates from osteochondral talar allograft transfer can be common. Talar graft failure is a devastating complication that results from failure of allograft incorporation within the host bone and subsequent resorption and sometimes subsidence can occur. Treatment options and outcomes for graft failure have rarely been reported. The purpose of this study is to evaluate treatment options and their outcomes for treating talar allograft failure. A systematic review was completed to find all reports of salvage treatments for talar graft failure and outcomes of these reports were analyzed. Eleven studies involving a total of 522 ankles, in 520 patients, met the inclusion criteria. The allograft failure rate was 11.5% in these studies with a reoperation rate of 18.9%. With limited reports, satisfactory outcomes for treatment of graft failure with ankle arthrodesis were 77.3%, 50% for revision allograft procedures, and 50% for total ankle arthroplasty. Considering the large failure rate and reoperation rate for bulk talar allograft transplantations, superior revision, and salvage options are needed. More prospective cohort studies focusing on consistent and standard outcome measures are needed to further assess revision options for failed talar allograft procedures.

Association Between Bone Mineral Density and Elderly Ankle Fractures: A Systematic Review and Meta-Analysis.

Ankle fractures are becoming increasingly more common in the elderly population and present a significant burden to the United States health care system. Many factors have been associated with fragility ankle fractures including age, gender, body mass index, diabetes, tobacco use, and osteoporosis. However, the literature is inconsistent regarding the relationship between ankle fractures and osteoporosis. The primary aim of this meta-analysis was to quantify the relationship between bone mineral density (BMD) in elderly patients with ankle fractures compared with BMD in elderly patients without ankle fractures. A literature search was undertaken using relevant search terms. Articles were screened for suitability and data extracted where studies met inclusion criteria and were of sufficient quality. Data were combined using standard meta-analysis methods. Seven studies were used in the final analysis. A small-pooled effect size was found indicating the control group had increased BMD regardless of measurement used (95% confidence interval 0.09-0.58; I2 = 98.39%). Lower femoral neck BMD showed a small-pooled effect size (femoral neck 0.36; 95% confidence interval 0.00-0.73; I2 = 94.91%) with the ankle fracture cohort. This is the first meta-analysis to quantify the relationship between BMD and ankle fractures in the elderly population. Elderly ankle fractures showed a significant association with femoral neck BMD. The current data can be used in orthopedic clinics and Fracture Liaison Service programs to assign the appropriate subgroup of ankle fracture patients to investigative and treatment groups, assess fracture risk, and serve as an indication for secondary fracture prevention by stimulating an osteoporosis prevention workup. There may be a role for a team approach to fracture care including metabolic optimization.

Internal Amputation in Charcot Neuroarthropathy Complicated by Diabetic Foot Osteomyelitis.

Studies have demonstrated the importance of preserving plantar surface area, lever arm length, and plantar soft tissues in affording patients a plantigrade, stable, and functional limb. We describe a case of a patient who underwent internal pedal amputation that was amenable to functional bracing. The purpose of this case study is to present internal pedal amputation as a viable option to eradicate infection and produce a plantigrade, stable foot that is amenable to custom bracing.

Complications of En Bloc Osteochondral Talar Allografts and Treatment of Failures: Literature Review and Case Report.

Reoperation rates and complication rates can be high for patients receiving an osteochondral talar allograft transplant. Complications can include graft failure, delamination of the graft, arthrofibrosis, advancing osteoarthritis, nonunion of malleolar osteotomies, and partial or complete osteonecrosis of the talus. Graft failure refers to failure of graft incorporation with subsequent necrosis and subsidence. Treatment options for talar graft failure are limited, and outcomes for these treatments have rarely been reported. We present a review of the published data on the complications and treatments for failed talar allograft transplantation. A case report is presented on a young woman who experienced graft failure and osteonecrosis of her talar allograft transplant. Because of the size of the present osteonecrosis, an ankle arthrodesis was performed as the initial revision procedure. Talar necrosis was removed and revascularized from the ankle fusion with solid fusion was confirmed with computed tomography. Symptomatic adjacent joint pain quickly developed in the hindfoot after the ankle fusion, and 12 months later an ankle fusion conversion to total ankle arthroplasty was performed. The patient has returned to normal activity with significant reduction in pain at most recent follow-up visit. This patient was followed for 7 years from initial osteochondral talar allograft transplantation and for 2 years from conversion of ankle fusion to total ankle arthroplasty. It is important to understand the techniques, indications, and outcomes for the various revision options for talar allograft failure. This case report illustrates how multiple revision options can be used to provide the best outcome for the patient.

Surgical Treatment of Subtalar Joint Instability: Safety and Accuracy of a New Technique in a Cadaver Model.

New surgical strategies to treat symptomatic subtalar joint (STJ) instability are evolving. We modified a previously described reconstruction strategy and then refined our new surgical technique through simulated surgery and subsequent cadaver dissections. Our purpose was to show that a tunnel intended to facilitate STJ stabilization surgery could safely be drilled across the footprints of the interosseous talocalcaneal ligament (ITCL). A percutaneous fluoroscopically guided tunnel for the purpose of ITCL reconstruction was created in 10 cadaveric below-knee specimens. Accuracy of the tunnel with relation to the anatomic boundaries of the ITCL attachment sites as well as damage to relevant structures at risk were recorded. Two sets of 5 surgeries were performed to assess for improvement in technique. Mean distances from the tunnel to the ITCL on the calcaneus improved between groups 1 and 2: 4.04 and 1.80 mm, respectively (p = .04). Mean distances from the tunnel to the ITCL on the talus improved between groups 1 and 2: 6.2 and 1.8 mm, respectively (p = .08). With information obtained from this study, an osseous tunnel can be safely placed within 2 mm of the ITCL footprints.

Conversion of First Metatarsophalangeal Joint Arthrodesis to Interpositional Arthroplasty With Acellular Dermal Matrix for First Ray Ulceration: A Case Report.

The purpose of this study is to report the outcome of the conversion of a first metatarsophalangeal (MTP) joint arthrodesis to an interpositional arthroplasty with an acellular dermal matrix for a chronic nonhealing first ray wound. To our knowledge, this is the first case report converting a first ray arthrodesis to an interpositional arthroplasty to heal a chronic ulceration. A 78-year-old female developed a chronic neuropathic ulceration under the first metatarsal head and hallux after a first MTP joint arthrodesis. The patient failed local wound care and underwent gastrocnemius recession, hallux interphalangeal joint fusion, and an interpositional arthroplasty with the use of an acellular dermal matrix. Bone tunnels were placed proximal to the metatarsal neck, where absorbable sutures affixed to the dermal matrix were passed from plantar to dorsal, and the graft was secured to the reamed metatarsal head and associated capsule. Postoperative radiographs revealed improved alignment of the first MTP joint. Complete reepithelialization of the plantar ulceration occurred within 2 weeks postoperatively. At the 16-month follow-up, the patient was ambulating without restriction and continued to be free of first ray ulceration and infection. This case study details the use of an acellular dermal matrix in an interpositional arthroplasty to offload a chronic nonhealing ulceration secondary to elevated first ray pressure associated with first MTP joint arthrodesis. The goal of this treatment is to reduce pain, heal the ulceration, and prevent its recurrence.

Gouty Achilles Tendinopathy: A Case Report.

Tendinopathy in the presence of gouty arthropathy is relatively common, yet the clinical suspicion for gout involvement in acute tendon pain remains low. A 49-year-old man presented with an acute, tender, erythematous mass to the right posterior heel. A computed tomographic scan was obtained, which revealed a septated fluid collection superficial to the Achilles tendon. The patient was taken to the operating room for an incision and drainage with debridement, and the abscess was found to be filled with caseous material. The diagnosis of gout was confirmed with pathology. The calcaneus was submitted to biopsy, and the results were negative for osteomyelitis. The patient was returned to the operating room for repair of the Achilles tendon with flexor hallucis longus tendon transfer. Postoperatively, the patient was nonweightbearing for 6 weeks. Oral colchicine was used perioperatively, and a steroid taper was administered. The patient was started on allopurinol and colchicine for chronic treatment. At 14 months, the patient was walking without pain or recurrence of the mass. Although the relationship between hyperuricemia and tendinopathy is not completely understood, it is apparent that tendon involvement may be a sequela in patients with gout. When a patient presents with acute tendon pain, gout should be considered in the differential diagnosis.

How Does A Structured Review Instrument Impact Learning at Resident Journal Club?

Journal club article review is an integral aspect of graduate medical education. A structured review instrument (SRI) is a checklist form that serves to guide through critical appraisal of the literature. The goal of this study was to objectively evaluate the effect of an SRI on journal critical appraisal in foot and ankle residency programs. A prospective study evaluated resident critical appraisal of journal club articles at 2 residency sites. Baseline resident critical appraisal scores were obtained the first 5 months of the academic year. The SRI form was then implemented into journal club sessions starting the sixth month until the end of the academic year. Resident critical appraisal scores were then compared. The use of SRI significantly improved resident scores compared with pre-SRI assessment scores (p < .001). The SRI tool is easily implemented and makes measurable improvement in resident critical appraisal of the reviewed literature. The use of an SRI tool should be considered in all residency programs to improve resident critical appraisal skills. Further study is warranted to determine specific competencies in which SRI provide the most benefit.

Pre-operative intravenous steroid improves pain and joint mobility after total knee arthroplasty in Chinese population: a double-blind randomized controlled trial.

INTRODUCTION: This study aims to investigate the effect of pre-operative intravenous methylprednisolone on post-operative pain control and joint mobility in Chinese patients undergoing single primary total knee arthroplasty. METHODS: This is a prospective, randomized, double-blinded, placebo-controlled single-centre trial. Sixty subjects were randomized into intervention and control group. The peri-operative anaesthetic and analgesic regimes were standardized. The intervention group received 125 mg methylprednisolone intravenously on the induction of anaesthesia. Subjects were assessed at 24, 30 and 48 h after surgery and upon discharge for pain scores and range of movement from the operated knee. Change in C-reactive protein level was calculated. Patient's satisfaction was recorded. Adverse reactions were documented. Subjects were followed up at 6 weeks, 4 months and 1 year. RESULTS: Rest pain and pain on movement were significantly reduced in the methylprednisolone group at 24 and 30 h after surgery (ANOVA p = 0.030, p = 0.003, p = 0.032, p = 0.010). The methylprednisolone group demonstrated a greater range of movement from the operated knee up to 30 h after surgery (ANOVA p = 0.031). Post-operative C-reactive protein level was significantly less in the methylprednisolone group (p < 0.001). Methylprednisolone group had a higher patient's satisfaction than the control group (p < 0.01). No adverse effects were noted at the 1-year follow-up. CONCLUSION: Pre-operative intravenous methylprednisolone improves post-operative pain and joint mobility after total knee arthroplasty up to 30 h after operation. It results in a higher patients' satisfaction. It can act as an effective adjunct in the multimodal analgesic regime. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03082092.