Intra-articular versus intravenous administration of tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomised clinical trials.

AIM: The ideal route of tranexamic acid (TXA) administration in total hip arthroplasty (THA) or total knee arthroplasty (TKA) remains controversial. This study aims to identify the optima route of TXA administration in THA or TKA. METHODS: PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched until 4 August 2021 for randomised studies that compared intravenous (IV) or intra-articular (IA) administration of TXA in THA or TKA. RESULTS: Sixty-seven studies enrolling 8335 patients (IA: 4162; IV: 4173) were eligible for quantitative and qualitative analysis. Comparable results were demonstrated in the incidence of venous thromboembolisation (OR:0.96, p = 0.84), total blood loss (MD: - 9.05, p = 0.36), drain output (MD: - 7.36, p = 0.54), hidden blood loss (MD: - 6.85, p = 0.47), postoperative haemoglobin level (MD: 0.01, p = 0.91), haemoglobin drop (MD: - 0.10, p = 0.22), blood transfusion rate (OR: 0.99, p = 0.87), total adverse events (OR: 1.12, p = 0.28), postoperative range of motion (MD: 1.08, p = 0.36), postoperative VAS pain score (MD: 0.13, p = 0.24) and postoperative D-dimer level (MD: 0.61, p = 0.64). IV route of TXA administration was associated with significantly longer length of hospital stay compared to IA route of administration (MD: - 0.22, p = 0.01). CONCLUSION: In this meta-analysis, both IV and IA route of TXA administration were equally effective in managing blood loss and postoperative outcomes in lower limb joints arthroplasty. LEVEL OF EVIDENCE: Level 1. PROSPERO Registration CRD42021271355.

Tetrahedral Pegs in Square Holes: Stereochemistry of Diboron Porphyrazines and Phthalocyanines.

The first examples of diboron complexes of the tetrapyrroles octaethylporphyrazine (OEPz) and 2,9,16,23-tetra-t-butyl-phthalocyanine (Pc) are reported, counterpoints to the better known monoboron tripyrroles, subporphyrazine and subphthalocyanine. Two stereochemical possibilities are observed, with cisoid-B2 OF2 (OEPz), both cisoid-B2 OPh2 (OEPz) and transoid-B2 OPh2 (OEPz), transoid-B2 OF2 (Pc) and cisoid-B2 OPh2 (Pc) having been isolated and characterised, including structure determinations for the OEPz complexes. This variation in stereochemistry, which can be extended to include the previously reported transoid-B2 OF2 (porphyrin), cisoid-[B2 OF2 (corrole)]- , and both transoid- and cisoid-B2 OF2 (calixphyrin), prompted a wider DFT study to elucidate the factors influencing the stereochemical preferences. This shows that the cisoid/transoid preference is correlated to the ease with which the macrocycle accommodates a rectangularly distorted N4 cavity.

Are Psychologic Factors Associated With Shoulder Scores After Rotator Cuff Surgery?

BACKGROUND: Psychologic factors are associated with pain and disability in patients with chronic shoulder pain. Recent research regarding the association of affective psychologic factors (emotions) with patients' pain and disability outcome after surgery disagrees; and the relationship between cognitive psychologic factors (thoughts and beliefs) and outcome after surgery is unknown. QUESTIONS/PURPOSES: (1) Are there identifiable clusters (based on psychologic functioning measures) in patients undergoing shoulder surgery? (2) Is poorer psychologic functioning associated with worse outcome (American Shoulder and Elbow Surgeons [ASES] score) after shoulder surgery? METHODS: This prospective cohort study investigated patients undergoing shoulder surgery for rotator cuff-related shoulder pain or rotator cuff tear by one of six surgeons between January 2014 and July 2015. Inclusion criteria were patients undergoing surgery for rotator cuff repair with or without subacromial decompression and arthroscopic subacromial decompression only. Of 153 patients who were recruited and consented to participate in the study, 16 withdrew before data collection, leaving 137 who underwent surgery and were included in analyses. Of these, 124 (46 of 124 [37%] female; median age, 54 years [range, 21-79 years]) had a complete set of four psychologic measures before surgery: Depression, Anxiety and Stress Scale; Pain Catastrophizing Scale; Pain Self-Efficacy Questionnaire; and Tampa Scale for Kinesiophobia. The existence of clusters of people with different profiles of affective and cognitive factors was investigated using latent class analysis, which grouped people according to their pattern of scores on the four psychologic measures. Resultant clusters were profiled on potential confounding variables. The ASES score was measured before surgery and 3 and 12 months after surgery. Linear mixed models assessed the association between psychologic cluster membership before surgery and trajectories of ASES score over time adjusting for potential confounding variables. RESULTS: Two clusters were identified: one cluster (84 of 124 [68%]) had lower scores indicating better psychologic functioning and a second cluster (40 of 124 [32%]) had higher scores indicating poorer psychologic functioning. Accounting for all variables, the cluster with poorer psychologic functioning was found to be independently associated with worse ASES score at all time points (regression coefficient for ASES: before surgery -9 [95% confidence interval {CI}, -16 to -2], p = 0.011); 3 months after surgery -15 [95% CI, -23 to -8], p < 0.001); and 12 months after surgery -9 [95% CI, -17 to -1], p = 0.023). However, both clusters showed improvement in ASES score from before to 12 months after surgery, and there was no difference in the amount of improvement between clusters (regression coefficient for ASES: cluster with poorer psychologic function 31 [95% CI, 26-36], p < 0.001); cluster with better psychologic function 31 [95% CI, 23-39], p < 0.001). CONCLUSIONS: Patients who scored poorly on a range of psychologic measures before shoulder surgery displayed worse ASES scores at 3 and 12 months after surgery. Screening of psychologic factors before surgery is recommended to identify patients with poor psychologic function. Such patients may warrant additional behavioral or psychologic management before proceeding to surgery. However, further research is needed to determine the optimal management for patients with poorer psychologic function to improve pain and disability levels before and after surgery. LEVEL OF EVIDENCE: Level II, therapeutic study.

Optimal screw length in volar locking plate osteosynthesis for distal radius fractures: a systematic review.

BACKGROUND: Fractures of the distal radius represent the most common fracture of the upper limb, and can be managed surgically with volar locking plate osteosynthesis (VLPO). Uncertainty remains regarding the optimal length of the distal locking screws. The aim of this study was to determine the optimal VLPO screw length which provided adequate stability while minimizing complications. METHODS: A systematic review of relevant literature published within Cochrane, PubMed, MEDLINE and Embase, including studies up to April 2020, was performed using the Preferred Reporting Items for Systemic Reviews and Meta-analysis (PRISMA) guidelines. Studies were included if they investigated distal radius fracture fixation with VLPO, screw lengths, complications, and associated imaging. RESULTS: Search results identified 664 relevant studies, of which 14 studies examining 926 radii were included for review. Synthesis revealed that unicortical locking fixation with screws ~75% the depth of the radius, or 2 mm short of the dorsal cortex, provided equivalent stability to bicortical fixation. The lunate may be used as a proxy to determine radial depth at each quartile column. Inadvertent screw protrusion can be assessed by taking four images intra-operatively; anteroposterior (AP), lateral, 45° supinated and dorsal tangential views (DTVs). Radial shaft screws can have up to 2 mm prominence with no clinical significance. CONCLUSION: Unicortical locking fixation at least 75% the depth of the distal radius provides equivalent stability to bicortical fixation in extra-articular fractures with lower complication rates. Imaging should be used to confirm that penetration of the dorsal cortex has not occurred.

A ten-year radiologic comparison of two-all polyethylene glenoid component designs: a prospective trial.

BACKGROUND: Aseptic glenoid component loosening remains a common problem in total shoulder arthroplasty (TSA). This study presents long-term prospective follow-up of 2 cemented all-polyethylene glenoid components with different backside design geometry and the effect on the presence and progression of radiolucent lines (RLLs). MATERIALS AND METHODS: Fifty-six TSAs were performed for primary osteoarthritis. Two surgeons used an identical technique to implant 32 flat-back and 24 convex-back glenoids. In particular, the glenoid components were cemented after a minimal reaming and bone compaction. Standardized postoperative radiologic and clinical follow-up was at 2 and 10 years. Three independent observers evaluated the x-ray images for RLLs around the base plate and keel. The results were analyzed for progression and influencing factors. RESULTS: At 10 years, progression of RLL was seen in both components, but there was no difference between the 2 glenoid designs (P = .16). Younger patient age (P = .03), hand dominance (P = .017), and presence of early RLLs (P = .018) were significant factors for progression of RLLs. Constant scores deteriorated with progression of RLLs (P = .006). The glenoid revision rate at 10 years was 5%. CONCLUSION: At 10 years there was no difference in the presence or progression of RRLs between a flat-back and a convex-back glenoid all-polyethylene design. Young age, hand dominance, and poor implantation technique influence glenoid RLLs and affect the clinical result of TSA.

The Use of High Strength Sutures and Anchors in Olecranon Fractures: A Systematic Review.

PURPOSE/BACKGROUND: Olecranon fractures are common, particularly in the elderly osteoporotic population. Although various techniques of fixation are available, the gold standard-tension band wiring (TBW)-has high complication and reoperation rates. We sought to identify current evidence for the use of high-strength suture tension banding methods to determine whether they reduce complications and reoperation rates while maintaining fixation. METHODS: A systematic review of several databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases included Cochrane, PubMed, MEDLINE and Embase. We searched for evidence of at least Level I to IV (according to NHMRC) of the use of tension band suturing or anchors in the surgical treatment of displaced olecranon fractures. We also analyzed the cost of fixation in our institute. RESULTS: Four hundred and forty articles were identified. Of these, 9 met the inclusion criteria. One hundred thirty-one subjects had an average age of 66 years. All the studies showed that high-strength suture tension banding/anchoring maintained fixation with displaced olecranon fractures, reducing the complication rates and showed minimal reoperation rates. There was also a significant cost advantage of the suture tape construct mainly due to avoiding subsequent removal of metal. CONCLUSION: Tension band suturing or anchoring displaced olecranon fractures may be an alternative cost effective method to TBW in maintaining fixation, reducing metalware complications and reducing re-operation rates. LEVEL OF EVIDENCE: IV.

Boron calixphyrin complexes: exploring the coordination chemistry of a BODIPY/porphyrin hybrid.

Boron complexes of calix[4]phyrins (1.1.1.1) were prepared by reacting the free-base ligands with BF3·Et2O. The reaction conditions can be efficiently tailored to produce mono- or di-boron calixphyrins. Mono-BF2 calixphyrins with boron coordinating to either the dipyrrin, BF2[H(Calix)], or dipyrromethane, BF2[H(Calix)] and BF2[H2(Calix)]+, bonding sites were isolated. The dipyrromethane isomer, BF2[H(Calix)], isomerises into BF2[H(Calix)] which kinetic studies and DFT calculations indicate is an intramolecular process. Two isomers of B2OF2(Calix) were isolated, one isomer bonding via the dipyrrin sites with the FBOBF moiety in cisoid geometry, and the second isomer bonding via the dipyrromethane sites with the FBOBF moiety in transoid geometry. Although the cisoid/dipyrrin isomer was calculated to be most energetically favourable for B2OF2(Calix), the isolation of the transoid/dipyrromethane isomer is postulated to occur via the presumed intermediate (BF2)2(Calix), for which DFT indicated a preference for transoid/dipyrromethane geometry.

Osteotomy and Re-fixation for treatment of Malunited Greater Tuberosity of Humerus.

INTRODUCTION: Most greater tuberosity humerus fractures can be treated successfully with either surgical or conservative methods and good results can be expected if fracture heals anatomically but a displaced fracture or an improperly reduced fracture can lead to a symptomatic mal-union. CASE PRESENTATION: 36years old man with mal-united greater tuberosity fracture presented to us 18 months following injury and percutaneous screw fixation and 9 months after screw removal. She complained of severe restriction of shoulder movements. A good result was achieved after corrective open reduction and fixation of the greater tuberosity and rotator cuff repair. CONCLUSION: Open reduction, re-fixation and soft tissue reconstruction can give excellent results in cases of malunited greater tuberosity fractures even as late as 20 months after trauma.

Complications associated with treatment of multiple ligament injured (dislocated) knee.

Multiple ligament injured knee is a heterogenous group of injuries, which remains a challenging entity for physicians to manage. Complications that are associated with this severe injury can occur from the injury itself or can arise from emergency or definitive treatment. The development of these complications can alter management options and compromise patient outcomes.