Lower Risk of Revision With 32- and 36-Millimeter Femoral Heads Compared With 28-mm Heads in Primary Total Hip Arthroplasty: A Comparative Single-Center Study (10,104 Hips).

BACKGROUND: We aimed to compare the clinical outcomes of different head sizes (28-, 32-, and 36- millimeter) in primary total hip arthroplasty (THA) at mean 6 years follow-up (range, 1 to 17.5 years). METHODS: This was a retrospective consecutive study of primary THA at our institution (2003 to 2019). Demographic and surgical data were collected. The primary outcome measures were all-cause revision, revision for dislocation, and all-cause revision excluding dislocation. Continuous descriptive statistics used means, median values, ranges, and 95% confidence intervals, where appropriate. Kaplan-Meier survival curves were used to estimate time to revision. Cox proportional hazard regression analyses were used to compare revision rates between the femoral head size groups. Adjustments were made for age at surgery, sex, primary diagnosis, American Society of Anesthesiologists score, articulation type, and fixation methods. There were 10,104 primary THAs included; median age was 69 years (range, 13 to 101) with 61.5% women. A posterior approach was performed in 71.6%. There were 3,295 hips with 28-mm heads (32.6%), 4,858 (48.1%) with 32-mm heads, and 1,951 (19.3%) with 36-mm heads. RESULTS: Overall rate of revision was 1.7% with the lowest rate recorded for the 36-mm group (2.7 versus 1.3 versus 1.1%). Cox regression analyses showed a decreased risk of all-cause revision for 32 and 36-mm head sizes as compared to 28-mm; this was statistically significant for the 32-mm group (P = .01). Risk of revision for dislocation was significantly reduced in both 32-mm (P = .03) and 36-mm (P = .03) head sizes. Analysis of all cause revision excluding dislocation showed no significant differences between head sizes. CONCLUSIONS: We found a significantly reduced risk of revision for all causes, but particularly revision for dislocation with larger head sizes. Concerns regarding increased risk of early revision for aseptic loosening, polyethylene wear, or taper corrosion with larger heads appear to be unfounded in this cohort of 10,104 patients with up to 17 years follow-up.

Abdominal arterial lesions associated with antiphospholipid antibodies: a comparative cross-sectional magnetic resonance angiography study.

OBJECTIVE: Case reports and small case series suggest that stenotic lesions of the renal, coeliac and mesenteric arteries may occur in the antiphospholipid syndrome (APS) resulting in clinical consequences such as hypertension and abdominal angina. The objective was to determine the prevalence of stenotic lesions in arteries arising from the middle aorta in patients with antiphospholipid antibodies (aPL) compared with healthy, hypertensive and atherosclerotic controls. METHODS: In a cross-sectional comparative radiological study using magnetic resonance angiography (MRA), we assessed five groups of subjects for the prevalence of stenotic lesions in arteries arising from the middle aorta: APS/aPL positive, healthy renal donors, patients with hypertension, patients with atherosclerosis defined radiologically and patients with systemic lupus erythematosus and vasculitis who were negative for aPL. All subjects underwent MRA in suspended respiration and images were assessed by two senior radiologists blinded to the clinical details. RESULTS: In the atherosclerosis group, vascular stenotic lesions were more prevalent (71%) than in any other group (P ≤0.000002). The prevalence of all stenotic lesions in aPL positive patients (33%) was significantly higher than in the renal donors (18%) and hypertensive patients (19%) (P ≤0.009). Renal artery stenosis was significantly more prevalent in aPL positive patients than in renal donors (P ≤0.0006) but similar to the prevalence in hypertensive patients. Coeliac and/or mesenteric lesions were significantly more common in aPL positive patients vs hypertensive patients (P ≤0.001). Stenoses did not correlate with traditional risk factors. CONCLUSION: Arterial stenotic lesions in arteries arising from the middle aorta were highly prevalent in atherosclerotic subjects and were more common in aPL-positive patients than in hypertensive patients and healthy renal donors.

Long-Term Survivorship of Modular Cementless Femoral Stem in Complex Primary Total Hip Arthroplasty: A Concise Minimum 15-Year Follow-Up Report.

BACKGROUND: S-ROM hip is a well-established and versatile prosthesis that offers extensive metaphyseal and diaphyseal geometries providing solutions for a variety of surgical scenarios. The aim of this study is to report on long-term survivorship and radiographic outcomes of complex primary total hip arthroplasty (THA) using a modular cementless stem (S-ROM). METHODS: Retrospective consecutive study was conducted of 167 patients (167 hips): 97 males and 70 females with average age at the time of surgery of 55 years (range 22-76). All patients underwent complex THA by the senior author from 1987 to 1999. Patients were identified using a prospective database. Demographic, clinical, and surgical data were collected from health records. All patients received a cementless acetabular component with a standard polyethylene liner. The primary outcome measure was survivorship beyond 15 years using stem revision for any cause as an end point. Secondary outcome measure was rate of radiographic loosening using Engh classification. RESULTS: Only 3 patients required stem revision for aseptic loosening and 1 for periprosthetic fracture. Isolated acetabular revision was undertaken in 23 of 167 patients (13.8%) due to polythene wear, osteolysis, and aseptic loosening. Proximal femoral stress shielding (zone 1, 7) was noted in 34 of 167 hips (20.4%). Stable bony ingrowth was noted in 144 hips (86.2%) and the remaining 23 hips had stable fibrous ingrowth (13.8%). Using stem "any-cause revision" as an endpoint, the mean stem survivorship was 31.5 years (95% confidence interval 31.007-31.985) with 30-year estimated survivorship of 97.6%. CONCLUSION: In a single designer surgeon series, S-ROM stem has stood the test of time with long-term, 30-year survivorship of 97.6% and continues to play an important role in modern hip surgery providing longevity and versatility. However, further comparative long-term studies from independent centers are needed for a definitive conclusion. LEVEL OF EVIDENCE: IV.

High Survivorship of Short-Cemented Femoral Stems in Condylar Revision Total Knee Arthroplasty Without Significant Metaphyseal Bone Loss: Minimum 5-Year Follow-Up.

BACKGROUND: We aimed to evaluate the outcomes of hybrid fixation technique in condylar revision total knee arthroplasty (rTKA) using cementless metaphyseal tibial sleeves and short-cemented femoral stems with a rotating platform articulation. METHODS: Retrospective consecutive study of all condylar rTKAs with a cemented femoral stem between 2009 and 2016 was conducted. Patients were identified using a local prospective database and linkable data obtained from the National Joint Registry for rTKA. Demographic, clinical, and surgical data were collected from patients' electronic health records. The primary outcome measure was mechanical failure and implant survivorship using a nationally collected data, complications, re-operations, and "any-cause revision" were also recorded. RESULTS: There were 72 consecutive patients (72 knees) with minimum 5-year follow-up: 33 (45.8%) females and 39 (54.2%) males with a median age of 70 years (range 47-88). The indication for revision surgery was aseptic loosening (n = 34, 47.2%), instability (n = 17, 23.6%), infection (n = 14, 19.5%) with 10 patients having 2-stage approach and 4 patients with single-stage approach, stiffness (n = 4, 5.6%), and malalignment (n = 3, 4.1%). At mean follow-up of 6.87 years (median 6.7; range 5-11.8), only 2 patients required revision for infection. Using "any-cause implant revision" as an end point, implant survivorship for this construct was 97.2% at median 6.7 years. To date, none of the femoral stems have been revised for mechanical failure. CONCLUSION: In rTKA with good femoral condylar bone stock, we have shown excellent survivorship with a short-cemented femoral stem, in conjunction with a mobile-bearing and a tibial sleeve. This has the advantage of reducing the length of the revision construct of this complex surgery. LEVEL OF EVIDENCE: Level IV.

Septic Revision Total Knee Arthroplasty Is Associated With Significantly Higher Mortality Than Aseptic Revisions: Long-Term Single-Center Study (1254 Patients).

BACKGROUND: The aim of this study is to examine the differences in long-term mortality rates between septic and aseptic revision total knee arthroplasty (rTKA) in a single specialist center over 17-year period. METHODS: Retrospective consecutive study of all patients who underwent rTKA at our tertiary center between 2003 and 2019 was carried out. Revisions were classified as septic or aseptic. We identified patients' age, gender, American Society of Anesthesiologists grade, and body mass index. The primary outcome measure was all-cause mortality at 5 years, 10 years, and over the whole study period of 17 years. Death was identified through both local hospital electronic databases and linked data from the National Joint Registry/NHS Personal Demographic Service. Kaplan-Meier survival curves were used to estimate time to death. RESULTS: In total, 1298 consecutive knee revisions were performed on 1254 patients (44 bilateral revisions) with 985 aseptic revisions in 945 patients (75.4%) and 313 septic revisions in 309 patients (24.6%). Average age was 70.6 years (range 27-95) with 720 females (57.4%). Septic revisions had higher mortality rates; patients' survivorship for septic vs aseptic revisions was 77.6% vs 89.5% at 5 years, 68.7% vs 80.2% at 10 years, and 66.1% vs 75.0% at 17 years; these differences were all statistically significant (P < .0001). The unadjusted 10-year risk ratio of death after septic revision was 1.59 (95% confidence interval 1.29-1.96) compared to aseptic revisions. CONCLUSION: rTKA performed for infection is associated with significantly higher long-term mortality at all time points compared with aseptic revision surgery. LEVEL OF EVIDENCE: Level IV.

The Association Between Surgeon Age and Early Surgical Complications of Elective Total Hip Arthroplasty: Propensity-Matched Cohort Study (122,043 Patients).

BACKGROUND: The aim of this study was to examine the relationship between surgeon age and early surgical complications following primary total hip arthroplasty (THA), within a year, in Ontario, Canada. METHODS: In a propensity-matched cohort, we defined consecutive adults who received their first primary THA for osteoarthritis (2002-2018). We obtained hospital discharge abstracts, patient's demographics and physician claims. Age of the primary surgeon was determined for each procedure and used as a continuous variable for spline analysis, and as a categorical variable for subsequent matching (young <45; middle-age 45-55; older >55). The primary outcome was early surgical complications (revision, dislocation, infection). Secondary analyses included high-volume vs low-volume surgeons (≤35 THA per year). RESULTS: We identified 122,043 THA recipients, 298 surgeons with median age 49 years. Younger, middle-aged, and older surgeons performed 39%, 29%, and 32% THAs, respectively. Middle-aged surgeons had the lowest rate of complications. Younger surgeons had a higher risk of composite complications (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.09-1.44, P = .002), revision (OR 1.28, 95% CI 1.07-1.54, P = .007), and infection (OR 1.39, 95% CI 1.12-1.71, P = .003). Older surgeons also had higher risk for composite complications (OR 1.18, 95% CI 1.03-1.36, P = .019), revision (OR 1.33, 95% CI 1.10-1.62, P = .004), and dislocation (OR 1.37, 95% CI 1.08-1.73, P = .009). However, when excluding low-volume surgeons, older high-volume surgeons had similar complications to middle-aged surgeons. CONCLUSION: Younger surgeons (<45 years) had the highest recorded complications rate while the lowest rate was for surgeons aged 45-55. Volume rather than age was more important in determining rate of complications of older surgeons. LEVEL OF EVIDENCE: IV.

Overview of randomised controlled trials in hallux valgus surgery (2,184 patients).

BACKGROUND: The aim of this study is to provide an overview of randomised controlled trials (RCTs) in hallux valgus correction surgery summarising the available high-quality evidence. METHODS: Following PRISMA guidelines, we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE (1946 to 1 February 2020) and Embase (1980 to 1 February 2020). We excluded non-randomised trials, systematic reviews and case-series. We also excluded trials of MTPJ arthrodesis. Trials that met our inclusion criteria were assessed by two authors using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to intervention groups. RESULTS: 32 RCTs met the inclusion criteria and were included. The total number of patients in those trials was 2,184. Only 4 RCTs (12.5%) reported significant differences between the intervention and the control groups. The remaining trials evaluated scarf or chevron osteotomies in 18 RCTs, and 10 RCTs compared other osteotomies or technical aspects of hallux valgus surgery using functional and radiological outcome measures with none reporting significant differences. CONCLUSION: Evidence from RCTs of hallux valgus surgery suggest that scarf and chevron osteotomies are the most popular techniques and lead to similar clinical outcomes.

Satisfactory medium-term outcomes with lateral condylar sliver osteotomy to correct valgus deformity in total knee replacements.

PURPOSE: To describe a surgical technique in correcting valgus deformity during total knee replacement and evaluate medium-term clinical outcomes. METHODS: This was a retrospective consecutive series of total knee replacement for severe valgus deformity of patients who underwent a lateral ligament complex release with a sliver osteotomy of the lateral femoral condyle with a minimum 1-year follow-up and recording objective and patient-reported outcome measures. RESULTS: Twenty-three patients (25 knees) were included with median follow-up of 5 years (range 1-15 years) and average age 67.7 years (range 43-87). The primary diagnosis was osteoarthritis in 14 patients (61%) and inflammatory arthritis in 9 patients (39%). At final follow-up, the median mechanical tibiofemoral angle was restored to 4° (range 2-7) compared with a median valgus of 20° (range 13-30) preoperatively. This was statistically significant (P < 0.00001). Median Oxford Knee Score at final follow-up was 43 (range 36-48) indicating satisfactory outcomes. There were no revisions for any cause with a mean arc range of movement 110° (range 85-120). CONCLUSION: This study shows that a technique utilising the familiar medial parapatellar approach, staged soft tissue releases, and a novel sliver lateral femoral condylar osteotomy with intact periosteum to release the lateral ligament complex leads to satisfactory medium-term outcomes, improved range of movement and patients' reported outcome measures. Sliver osteotomy is a useful technique in correcting valgus deformity in total knee replacements at medium-term follow-up. LEVEL OF EVIDENCE: IV.

Overview of Randomized Controlled Trials in Total Knee Arthroplasty (47,675 Patients): What Have We Learnt?

BACKGROUND: The aim of this study is to provide an overview of randomized controlled trials (RCTs) in primary total knee arthroplasty summarizing the available high-quality evidence. METHODS: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2019, Issue 3), Ovid MEDLINE, and Embase. We excluded nonrandomized trials, trials on unicompartmental knee arthroplasty or revision surgery, systematic reviews, and meta-analyses. Trials that met our inclusion criteria were assessed using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to the intervention groups (surgical approach, tourniquet use, design, etc.). RESULTS: Four hundred and three RCTs met the inclusion criteria and were included. The total number of patients in those 403 RCTs was 47,675. Only 33 RCTs (8.2%) reported significant differences between the intervention and the control groups. The trials were grouped into surgical approach 34, tourniquet 31, minimally invasive surgery 13, patient specific instrumentation 30, knee design 37, fixation 27, mobile bearing 47, navigation 50, polyethylene 19, technique 27, patella resurfacing 26, drain 19, closure 16, and others 27 RCTs. CONCLUSION: For the vast majority of patients, a standard conventional total knee arthroplasty with a surgical approach familiar to the surgeon using standard well-established components, with or without tourniquet, without surgical drain leads to satisfactory long-term clinical outcomes.

Early Surgical Complications of Total Hip Arthroplasty in Patients With Morbid Obesity: Propensity-Matched Cohort Study of 3683 Patients.

BACKGROUND: The aim of this study is to determine whether the high risk of surgical complications within 1 year of total hip arthroplasty (THA) is due to associated comorbidities or morbid obesity alone as measured by body mass index (BMI ≥ 40 kg/m2). METHODS: Population-based retrospective cohort study was conducted of all adults in Ontario undergoing primary THA for osteoarthritis (2012-2018). All patients were followed for 1 year. Outcomes were compared among matched groups (hypertension, diabetes, chronic obstructive pulmonary disease, frailty, congestive heart failure, coronary artery disease, asthma, and Charlson score). Primary outcome measure was major surgical complications within 1 year (composite of deep infection requiring surgery, dislocation requiring closed or open reduction, and revision surgery). RESULTS: A total of 3683 patients with morbid obesity were matched and had a significantly greater risk of major complications within 1-year (132 [3.6%] vs 54 [1.5%]; hazard ratio [HR] 2.54, 95% confidence interval [CI]; 1.98-3.25). This included greater risk for deep infection requiring surgery (100 [2.8%] vs 26 [0.7%]; HR 3.85, 95% CI; 2.70-45.48) and revision arthroplasty (86 [2.4%] vs 34 [0.9%]; HR 2.61, 95% CI; 1.92-3.55). Operative time was also longer with a median 116 (99-138) vs 102 (87-121) minutes. There were no significant differences in hospital stay, cost of acute care episode, or medical complications. CONCLUSION: Patients' large body habitus seems to contribute to the increased risk of surgical complications within 1-year of THA. Future research is needed to identify ways of mitigating surgical complications such as centralizing care for this complex group of patients in specialist centers.

Fractured Femoral Stems in Primary and Revision Hip Arthroplasties Revisited: Wrightington Experience.

BACKGROUND: The aim of this study is to present our experience in managing fractured femoral stems over the last 10 years for both primary and revision stems at our tertiary unit focusing on modes of failure and operative techniques. METHODS: This is a retrospective consecutive study of all patients with fractured femoral stems that were operatively managed in our unit between 2008 and 2018. Detailed radiographic evaluation (Paprosky classification) was undertaken and data collected on operative techniques used to extract distal fractured stem fragments. RESULTS: Thirty-five patients (35 hips) were included (25 men/10 women) with average age at time of presentation of 68 years (range, 29-93). Average body mass index was 30 (standard deviation, 3.8; range, 22.5-39). There were variety of stems both contemporary and historical, primary and revision cases (15 hips polished tapered cemented stems, 10 hips composite beam and miscellaneous stems, and 10 revision hip stems). The predominant mechanism of failure was fatigue due to cantilever bending in distally fixed stems. Surgical techniques used to extract distal fragment were drilling technique in 2 hips, cortical window in 13 hips, extended trochanteric osteotomy (ETO) in 5 hips, and proximal extraction in 15 hips. CONCLUSION: When faced with a contemporary fractured stem, drilling techniques into the distal fragment are unlikely to succeed. If a trochanteric osteotomy had been used at time of index surgery, this could be used again to aid proximal extraction with conventional revision instrumentations. The cortical window technique is useful but surgically demanding technique that is most successful in extracting polished tapered fractured stems particularly when an ETO is not planned for femoral reconstruction. Use of trephines can be useful for removal of longer, uncemented stems. Finally, an ETO might be necessary when other techniques have failed.

Higher failure rate of two-stage revision for infected knee arthroplasties in significantly compromised (host-C) patients.

PURPOSE: To evaluate clinical outcomes of two-stage revision arthroplasty for managing infected knee arthroplasties in significantly compromised patients (host-C). METHODS: This was a prospective consecutive series of two-stage revisions of infected total knee arthroplasties in host-C-type patients with a minimum 2-year follow-up using objective and patient-reported outcome measures. Thirteen consecutive patients were included and prospectively followed with a median 5-year follow-up (range 2-10). Median age was 68 years (range 59-73) at time of initial presentation. All patients were type-C host using McPherson classification system. All patients had primary arthroplasties in situ with confirmed chronic infections; the infecting pathogens were Staphylococcus aureus in 5/13 patients, coagulase-negative Staphylococci in 5/13, and the remaining three patients had mixed growth. All patients underwent two-stage revision protocol. RESULTS: At the final follow-up, 9/13 patients were infection free achieving satisfactory outcomes. Two patients had recurrent infections with different organisms and treated with suppressive antibiotics and salvage knee arthrodesis, respectively. Furthermore, two patients had chronic pain and poor functional outcomes with deficient extensor mechanism and significant bone loss; later underwent salvage knee arthrodesis. The preoperative knee society score (median 35.5; range 22-51; n = 10) showed a statistically significant improvement at the final follow-up (median 79.5; range 49-87; n = 10) p < 0.05. Patients reported outcome scores at the final follow-up were WOMAC-knee (median 59.1; range 47.7-94.7; n = 13) and Oxford knee score (median 26; range 11 to 43; n = 13). CONCLUSION: This study highlights the challenge of treating infected knee arthroplasties in physiologically compromised patients with 9/13 (69%) having satisfactory clinical outcomes. LEVEL OF EVIDENCE: Case series, level IV.

Overview of randomised controlled trials in orthopaedic research: search for significant findings.

BACKGROUND: The majority of recent orthopaedics randomised controlled trials (RCTs) have been non-inferiority trials with no significant clinical or statistical differences between treatment groups. The aim of this study was to evaluate randomised trials for significant findings in the orthopaedic literature based on the main elective procedures undertaken across different subspecialties. METHODS: We evaluated the following procedures: anterior cervical discectomy and fusion (ACDF), subacromial decompression (SAD), carpal tunnel decompression (CTD), total hip replacement (THR), anterior cruciate ligament reconstruction (ACLR), total knee replacement (TKR) and hallux valgus correction (HVC). Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2018, Issue 1), Ovid MEDLINE (1946 to 12 January 2018) and Embase (1980 to 12 January 2018). Trials that met our inclusion criteria were assessed using a binary outcome measure of whether they reported statistically significant findings. RESULTS: We included 1078 RCTs across seven most commonly performed elective procedures. Of those, only 16% (172/1078) reported significant findings [ACDF 26/77 (33.8%); SAD 2/22 (9%); CTD 11/72 (15.3%); THR 52/281 (18.5%); ACLR 21/239 (8.8%); TKR 55/357 (15.4%); HVC 5/30 (16.7%)]. The number of RCTs per year of publication has increased dramatically particularly since early 2000s-with over 100 RCTs of those seven procedures published in 2017 alone. CONCLUSIONS: This is the first study to undertake a comprehensive review of orthopaedic RCTs in elective practice. The number of RCTs in orthopaedic research is steadily increasing. However, only 16% of trials reports significant differences between interventions. CLINICAL RELEVANCE: For trials comparing different surgical techniques, this evidence provides treating surgeons with the flexibility to utilise available resources and infrastructure to deliver patients care without compromising clinical outcomes. Further, for trials comparing different treatment modalities, this study helps to inform the shared decision-making process when counselling patients on the effectiveness of surgical interventions.

Fluphenazine (oral) versus placebo for schizophrenia.

BACKGROUND: Fluphenazine is one of the first drugs to be classed as an 'antipsychotic' and has been widely available for five decades. OBJECTIVES: To compare the effects of oral fluphenazine with placebo for the treatment of schizophrenia. To evaluate any available economic studies and value outcome data. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Trials Register (23 July 2013, 23 December 2014, 9 November 2016 and 28 December 2017 ) which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. There is no language, date, document type, or publication status limitations for inclusion of records in the register. SELECTION CRITERIA: We sought all randomised controlled trials comparing oral fluphenazine with placebo relevant to people with schizophrenia. Primary outcomes of interest were global state and adverse effects. DATA COLLECTION AND ANALYSIS: For the effects of interventions, a review team inspected citations and abstracts independently, ordered papers and re-inspected and quality assessed trials. We extracted data independently. Dichotomous data were analysed using fixed-effect risk ratio (RR) and the 95% confidence interval (CI). Continuous data were excluded if more than 50% of people were lost to follow-up, but, where possible, mean differences (MD) were calculated. Economic studies were searched and reliably selected by an economic review team to provide an economic summary of available data. Where no relevant economic studies were eligible for inclusion, the economic review team valued the already-included effectiveness outcome data to provide a rudimentary economic summary. MAIN RESULTS: From over 1200 electronic records of 415 studies identified by our initial search and this updated search, we excluded 48 potentially relevant studies and included seven trials published between 1964 and 1999 that randomised 439 (mostly adult participants). No new included trials were identified for this review update. Compared with placebo, global state outcomes of 'not improved or worsened' were not significantly different in the medium term in one small study (n = 50, 1 RCT, RR 1.12 CI 0.79 to 1.58, very low quality of evidence). The risk of relapse in the long term was greater in two small studies in people receiving placebo (n = 86, 2 RCTs, RR 0.39 CI 0.05 to 3.31, very low quality of evidence), however with high degree of heterogeneity in the results. Only one person allocated fluphenazine was reported in the same small study to have died on long-term follow-up (n = 50, 1 RCT, RR 2.38 CI 0.10 to 55.72, low quality of evidence). Short-term extrapyramidal adverse effects were significantly more frequent with fluphenazine compared to placebo in two other studies for the outcomes of akathisia (n = 227, 2 RCTs, RR 3.43 CI 1.23 to 9.56, moderate quality of evidence) and rigidity (n = 227, 2 RCTs, RR 3.54 CI 1.76 to 7.14, moderate quality of evidence). For economic outcomes, we valued outcomes for relapse and presented them in additional tables. AUTHORS' CONCLUSIONS: The findings in this review confirm much that clinicians and recipients of care already know, but they provide quantification to support clinical impression. Fluphenazine's global position as an effective treatment for psychoses is not threatened by the outcome of this review. However, fluphenazine is an imperfect treatment and if accessible, other inexpensive drugs less associated with adverse effects may be an equally effective choice for people with schizophrenia.

Surgical treatment of Monteggia variant fracture dislocations of the elbow in adults: surgical technique and clinical outcomes.

PURPOSE: Monteggia variant defined as Monteggia fracture dislocation with radial head or neck fracture, coronoid fracture, ulnohumeral joint dislocation or combination of these injuries. The aim of this study was to evaluate clinical outcomes of surgical treatment of Monteggia variant fracture dislocations with focus on the operative technique and management of associated radial head fractures. METHODS: Between January 2008 and January 2014, 22 patients (7 men, 15 women) with a mean age of 58.9 years (45-77 years) and unilateral Monteggia variant were included. The mean follow-up was 4.1 years (2.2-6.6 years). Patients underwent clinical and functional assessment using the Mayo Elbow Performance Index and the Oxford Elbow Score. RESULTS: Eighteen patients had radial head fractures; in five patients the fracture fragment involved less than one-third of the radial head and the fragment was excised, in four patients the radial head fracture was fixed with headless screws and in nine patients the radial head was replaced. At review the mean Mayo Elbow Performance Index was 76.6 (20-100) and the Oxford Elbow Score 35 (4-48). CONCLUSIONS: Our experience suggests that satisfactory outcomes can be obtained in the treatment of the complex Monteggia variant fracture dislocations by recognising the injury pattern and addressing all components of the injury in order to achieve elbow stability.

Social skills programmes for schizophrenia.

BACKGROUND: Social skills programmes (SSP) are treatment strategies aimed at enhancing the social performance and reducing the distress and difficulty experienced by people with a diagnosis of schizophrenia and can be incorporated as part of the rehabilitation package for people with schizophrenia. OBJECTIVES: The primary objective is to investigate the effects of social skills training programmes, compared to standard care, for people with schizophrenia. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Trials Register (November 2006 and December 2011) which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. We inspected references of all identified studies for further trials.A further search for studies has been conducted by the Cochrane Schizophrenia Group in 2015, 37 citations have been found and are currently being assessed by review authors. SELECTION CRITERIA: We included all relevant randomised controlled trials for social skills programmes versus standard care involving people with serious mental illnesses. DATA COLLECTION AND ANALYSIS: We extracted data independently. For dichotomous data we calculated risk ratios (RRs) and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD) and 95% CIs. MAIN RESULTS: We included 13 randomised trials (975 participants). These evaluated social skills programmes versus standard care, or discussion group. We found evidence in favour of social skills programmes compared to standard care on all measures of social functioning. We also found that rates of relapse and rehospitalisation were lower for social skills compared to standard care (relapse: 2 RCTs, n = 263, RR 0.52 CI 0.34 to 0.79, very low quality evidence), (rehospitalisation: 1 RCT, n = 143, RR 0.53 CI 0.30 to 0.93, very low quality evidence) and participants' mental state results (1 RCT, n = 91, MD -4.01 CI -7.52 to -0.50, very low quality evidence) were better in the group receiving social skill programmes. Global state was measured in one trial by numbers not experiencing a clinical improvement, results favoured social skills (1 RCT, n = 67, RR 0.29 CI 0.12 to 0.68, very low quality evidence). Quality of life was also improved in the social skills programme compared to standard care (1 RCT, n = 112, MD -7.60 CI -12.18 to -3.02, very low quality evidence). However, when social skills programmes were compared to a discussion group control, we found no significant differences in the participants social functioning, relapse rates, mental state or quality of life, again the quality of evidence for these outcomes was very low. AUTHORS' CONCLUSIONS: Compared to standard care, social skills training may improve the social skills of people with schizophrenia and reduce relapse rates, but at present, the evidence is very limited with data rated as very low quality. When social skills training was compared to discussion there was no difference on patients outcomes. Cultural differences might limit the applicability of the current results, as most reported studies were conducted in China. Whether social skills training can improve social functioning of people with schizophrenia in different settings remains unclear and should be investigated in a large multi-centre randomised controlled trial.

Retrograde Intramedullary Nailing for Femoral Shaft Fractures in Elderly Patients with Previous Ipsilateral Dynamic Hip Screw Fixation.

PURPOSE: We present our experience in managing femoral shaft fractures in elderly patients with previous ipsilateral dynamic hip screw fixation for extracapsular neck of femur fractures using retrograde intramedullary nailing implants. METHODS: This was a prospective consecutive study of patients presenting with a femoral shaft fracture and an ipsilateral dynamic hip screw fixation treated with unreamed retrograde femoral nailing. The Wilde modification of the Neer knee score was used as a primary outcome measure. RESULTS: A total of 16 patients were included (5 males, 11 females), with a mean age of 82 years (range 74-101). All fractures were closed and were due to low-energy trauma. There were 7 patients with 32-A1 fractures, 5 patients with 32-A2 fractures and 4 patients with 32-B1 fractures. All patients had an ipsilateral 4-hole plate dynamic hip screw implant. Minor surgical complications were recorded in 5 patients. Two patients died due to medical complications and were excluded from the final analysis. All remaining 14 patients achieved satisfactory outcomes at 12 months of follow-up with a mean Wilde modification of the Neer knee score of 15.5 (SD 2.53; range 13-20). CONCLUSIONS: Unreamed retrograde femoral nailing can achieve good functional recovery in elderly patients with a femoral shaft fracture and a previous ipsilateral dynamic hip screw fixation.

Pericyazine for schizophrenia.

BACKGROUND: Pericyazine is a 3-cyano-10 (3-4'-hydroxypiperidinopropyl) phenothiazine. It is overall pharmacologically similar with chlorpromazine, though particularly sedating. Dopamine receptor subtype analysis has not been performed for pericyazine, but the drug appears to induce greater noradrenergic than dopaminergic blockade. Compared to chlorpromazine, pericyazine reportedly has more potent antiemetic, antiserotonin, and anticholinergic activity. OBJECTIVES: To evaluate the clinical effects and safety of pericyazine in comparison with placebo, typical and atypical antipsychotic agents and standard care for people with schizophrenia. SEARCH METHODS: We searched the Cochrane Schizophrenia Group Trials Register (February 2013) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. We inspected references of all identified studies for further trials. SELECTION CRITERIA: All relevant randomised controlled trials focusing on pericyazine for schizophrenia and other types of schizophrenia-like psychoses (schizophreniform and schizoaffective disorders). We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS: Data were extracted independently from included papers by at least two review authors. Risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated. We assessed risk of bias for included studies and used GRADE to judge quality of evidence. MAIN RESULTS: We could only include five studies conducted between 1965 and 1980. Most of the included studies did not report details of randomisation, allocation concealment, details of blinding and we could not assess the impact of attrition due to poor reporting.For the primary outcome of Global state - not improved, the confidence interval was compatible with a small benefit and increased risk of not improving with pericyazine compared with typical antipsychotics (2 RCTs, n = 122, RR 1.24 CI 0.93 to 1.66, very low quality of evidence) or atypical antipsychotics (1 RCT, n = 93, RR 0.97 CI 0.67 to 1.42, very low quality of evidence).When compared with typical antipsychotics relapse was only experienced by one person taking pericyazine (1 RCT, n = 80, RR 2.59 CI 0.11 to 61.75, very low quality of evidence).Pericyazine was associated with more extrapyramidal side effects than typical antipsychotics (3 RCTs, n = 163, RR 0.52 CI 0.34 to 0.80, very low quality of evidence) and atypical antipsychotics (1 RCT, n = 93, RR 2.69 CI 1.35 to 5.36, very low quality of evidence).The estimated risk of leaving the study early for specific reasons was imprecise for the comparisons of pericyazine with typical antipsychotics (2 RCTs, n = 71, RR 0.46 CI 0.11 to 1.90, very low quality of evidence), and with atypical antipsychotics (1 RCT, n = 93, RR 0.13 CI 0.01 to 2.42, very low quality of evidence). AUTHORS' CONCLUSIONS: On the basis of very low quality evidence we are unable to determine the effects of pericyazine in comparison with typical or atypical antipsychotics for the treatment of schizophrenia. However, there is some evidence that pericyazine may be associated with a higher incidence of extrapyramidal side effects than other antipsychotics, and again this was judged to be very low quality evidence. Large, robust studies are still needed before any firm conclusions can be drawn.

Surgical interventions for treating fractures of the olecranon in adults.

BACKGROUND: Fractures of the olecranon (the bony tip of the elbow) account for approximately 1% of all upper extremity fractures. Surgical intervention is often required to restore elbow function. Two key methods of surgery are tension band wire fixation and plate fixation. OBJECTIVES: To assess the effects (benefits and harms) of different surgical interventions in the treatment of olecranon fractures in adults. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (22 September 2014), the Cochrane Central Register of Controlled Trials (CENTRAL, 2014, Issue 8), MEDLINE (1946 to September week 2 2014), EMBASE (1980 to 19 September 2014), trial registers, conference proceedings and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials (RCT) and quasi-RCTs that compared different surgical interventions for the treatment of olecranon fractures in adults. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment and data extraction. The primary outcomes of this review were function, pain and adverse events. MAIN RESULTS: We included six small trials involving 244 adults with olecranon fractures. Of these, four were RCTs and two were quasi-RCTs; both of were at high risk of selection bias. All six trials were at high risk of performance bias, reflecting lack of blinding, and four trials were at high risk of detection bias. The quality of the evidence for most outcomes was generally very low because of limitations in study design and implementation, and either imprecision of the results or inadequate outcome measures. Thus, we are very uncertain about the estimates of effect.One trial (41 participants) comparing plate fixation with standard tension band wiring provided very low quality evidence at 16 to 86 weeks' follow-up of a better clinical outcome after plate fixation (good outcome (little pain or loss of elbow motion): 19/22 versus 9/19, risk ratio (RR) 1.82 favouring plate fixation, 95% confidence interval (CI) 1.10 to 3.01). There was very low quality evidence of less symptomatic prominent metalwork after plate fixation (1/22 versus 8/19; RR 0.11, 95% CI 0.01 to 0.79). The results for other adverse effects (infection and delayed or non-union) were inconclusive. Evidence is pending from a newly (September 2014) completed trial (67 participants) making the same comparison.Four trials compared four different modified techniques of tension band wiring (i.e. additional intramedullary screw fixation, biodegradable pins, Netz pins and cable pin system) versus standard tension band wiring. There was very low quality evidence of little difference at six to 14 months in function assessed by a non-validated scoring tool from the addition of an intramedullary screw. However, there were fewer cases of metalwork prominence in the intramedullary screw group (1/15 versus 8/15; RR 2.00, 95% CI 1.15 to 3.49; one trial; 30 participants). There was very low quality evidence from one trial (25 participants) of little difference in subjectively or objectively assessed good outcome at a mean of 20 months between tension band wiring with biodegradable implants versus metal implants. There were no adverse events, either non-union or sinus or fluid accumulation, reported. All 10 participants in the metalwork group had an extra operation to remove their metalwork at one year. One trial, which did not report on function or pain, provided very low quality evidence of lower rates of metalwork for any reason or for symptoms after Netz pin tension band wiring compared with standard tension band wiring (11/21 with Netz pin versus 17/25 with standard tension band wiring; RR 0.77, 95% CI 0.47 to 1.26; 46 participants); this evidence also supports the possibility of higher rates of metalwork removal for Netz pins. Two intra-operative complications occurred in the Netz pin group. The fourth trial, which compared the cable pin system with standard procedure, found low quality evidence that cable pin improved functional outcome at a mean of 21 months (Mayo Elbow Performance Score (MEPS), range 0 to 100: best outcome: mean difference (MD) 7.89 favouring cable pin, 95% CI 3.14 to 12.64; one trial; 62 participants). It also found low quality evidence of fewer postoperative complications in the cable pin group (1/30 with cable pin system versus 7/32 standard tension band wiring; RR 0.15, 95% CI 0.02 to 1.17), although the evidence did not rule out the converse.One trial provided very low quality evidence of similar patient-reported function using the Disabilities of the Arm, Shoulder and Hand questionnaire (0 to 100: worst function) at two or more years after fixation using a novel olecranon memory connector (OMC) compared with locking plate fixation (MD -0.70 favouring OMC, 95% CI -4.20 to 2.80; 40 participants). The only adverse event was a superficial infection in the locking plate group. AUTHORS' CONCLUSIONS: There is insufficient evidence to draw robust conclusions on the relative effects of the surgical interventions evaluated by the included trials. Further evidence, including patient-reported data, on the relative effects of plate versus tension band wiring is already pending from one recently completed RCT. Further RCTs, using good quality methods and reporting validated patient-reported measures of function, pain and activities of daily living at set follow-ups, are needed, including checking positive findings such as those relating to the use of an intramedullary screw and the cable pin system. Such trials should also include the systematic assessment of complications, further treatment including routine removal of metalwork and use of resources.