The effect of tranexamic acid and epinephrine on visual clarity during arthroscopic shoulder surgery: A meta-analysis of RCTs.

INTRODUCTION: Visual clarity in arthroscopic rotator cuff repair is essential to reduce the operative time and for efficiency of repair. Tranexamic acid (TXA) in open shoulder surgery has been shown to reduce blood loss but its use in shoulder arthroscopy for rotator cuff repair for improved clarity is not understood. The purpose of this SR is to determine the effect of TXA and epinephrine on visual clarity in shoulder arthroscopy for rotator cuff repair. HYPOTHESIS: We hypothesise that visual clarity should improve in those that have TXA compared to those who do not receive TXA. METHODS: A review of the online databases MEDLINE and Embase was conducted on 8th October 2022 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Randomised clinical trials reporting visual clarity and/or, operative time, volume of irrigation fluid used and mean arterial pressure were included. The studies were appraised using the CONSORT tool. RESULTS: Seven studies met eligible criteria, all of which were double-blinded RCTs. Five studies reported no difference in visual clarity between TXA vs. saline, while two reported a significant improvement with TXA. Pooling of data showed that visual clarity was significantly better in the TXA group vs. saline, on a standardised 10-point Likert scale (mean difference 0.73 points, p=0.03). However, the use of epinephrine was reported in two studies and its administration offered significantly better visual clarity than TXA (mean difference 0.9 points, p=0.02). There was no significant difference with TXA use in MAP (mean difference 1.2mmHg, p=0.14), operative time (mean difference 6.8minutes, p=0.11), irrigation volume used (mean difference 0.2L, p=0.88), or postoperative pain (mean difference 3.89 on a 0-100 VAS, p=0.34). CONCLUSION: The use of TXA in shoulder arthroscopy has shown to have significantly improved visual clarity in comparison to saline irrigation alone. This may not necessarily result in a significant clinical difference and may not translate to significantly less operative time or postoperative pain score. Furthermore, epinephrine use alone offers significantly better clarity than TXA. There may not be an added benefit to give both, but this area requires further research. LEVEL OF EVIDENCE: II; systematic review.

Are displaced distal clavicle fractures associated with inferior clinical outcomes following nonoperative management? A systematic review.

BACKGROUND: Management of displaced distal clavicle fractures remains a topic of discussion because of notoriously high nonunion rates, but there is little documented in the literature as to what effect this may have on patient-reported function. The aim of this systematic review was to look at nonoperative management following displaced distal clavicle fractures to determine union rates, complications, and patient-reported outcome measures. METHODS: A review of the online databases MEDLINE and Embase was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Clinical studies that included a cohort of nonoperatively managed displaced distal clavicle fractures and reported on union rate, complications, and patient-reported functional scores were included. RESULTS: Eleven studies were eligible for inclusion (2 randomized controlled trials, 1 prospective noncomparative cohort study, 5 retrospective comparative cohort studies, and 3 case series) with a total of 779 patients included in this review. Average union rate was 63.2% (22.2%-94.4%) in nonoperatively managed patients, compared with 96.3% (87.9%-100%) in operatively managed patients. The Constant-Murley score and Disabilities of the Arm, Shoulder, and Hand questionnaire were the most frequently used outcome measure tools. No study demonstrated any significant difference in any outcome measure when comparing nonoperative with operative treatment. Complication rate (including nonunion) in nonoperatively managed patients was 45.1%, with 11.1% requiring delayed surgery. Average complication rate in the operatively managed groups was 41.2%, with 40.1% requiring a second operation. CONCLUSION: Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates, but shoulder function remains excellent, and risk of complications and delayed surgery are low. Decision making must take into account patient factors and expectations to provide high-quality, individualized care.

Endoscopic Tendon Release for Iliopsoas Impingement After Total Hip Arthroplasty-Excellent Clinical Outcomes and Low Failure Rates at Short-Term Follow-Up.

PURPOSE: To investigate the clinical effectiveness of endoscopic iliopsoas tendon release (IPR) at the lesser trochanter (LT) in patients with iliopsoas impingement (IPI) after total hip arthroplasty (THA). METHODS: Between November 2017 and March 2021, a consecutive series of 36 patients were treated with endoscopic IPR for diagnosed IPI. Patients included had acetabular cup position confirmed by functional imaging (OPS, Corin, Pymble, NSW), typical clinical symptoms of IPI, and a positive response to diagnostic injection. Clinical assessment included validated patient-reported outcome measures (PROMs) along with hip flexion strength and active range of motion at different time marks up to 2-year follow-up, as well as surgical complications. RESULTS: Overall, 36 consecutive patients (11 males) with a mean age of 62 ± 12 years were included. All patients had failed nonoperative management. Dynamic computed tomography assessment was available in 89% of the patients, edge loading was reported in 10%, and variable cup overhang was reported in 50%. Clinically, PROMs were significantly improved at every time mark when compared with preoperative values (P < .001), showing the biggest improvement within the first 4 weeks after surgery. At the 6-month follow-up, peak isometric hip flexion strength on the operated side was 20% lower than the contralateral side (P < .001). Failure rate of the procedure was 2.8% (1 case). Linear regression showed no association between cup overhang and clinical outcomes. CONCLUSIONS: Endoscopic IPR at the LT is a safe and reproducible technique associated with significant and immediate improvement in pain, functional outcomes, and high patient satisfaction. With minimal short-term weakness, no complications, and only a single revision, even in cases with cup malposition and/or edge loading, we believe that endoscopic IPR can be considered as one of the first-line operative options in patients with symptomatic IPI, irrespective of component position. LEVEL OF EVIDENCE: Level IV, case series.

No clinical advantage with customized individually made implants over conventional off-the-shelf implants in total knee arthroplasty: a systematic review and meta-analysis.

INTRODUCTION: Total knee arthroplasty (TKA) can be performed with either conventional off-the-shelf (OTS) or customized individually-made (CIM) implants. The evidence for CIM implants is limited and variable, and the aim of this review was to compare clinical and radiological outcomes between CIM and OTS implants. METHODS: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Studies reporting on clinical, radiological, or alignment outcomes for CIM and OTS implants were selected. The studies were appraised using the Methodical index for non-randomized studies tool. RESULTS: Twenty-three studies fulfilled the inclusion criteria. The studies comprised 2856 CIM and 1877 OTS TKAs. Revision rate was higher with CIM (5.9%) compared to OTS (3.7%) implants [OR 1.23(95% CI 0.69-2.18)]. Manipulation under anesthesia (MUA) was higher in CIM (2.2%) compared to OTS (1.1%) group [OR 2.95(95% CI 0.95-9.13)] and complications rate was higher in CIM (5%) vs. OTS (4.5%) [OR 1.45(95% CI 0.53-3.96)] but neither reached statistical significance. Length of stay was significantly shorter in CIM group 2.9 days vs. 3.5 days [MD - 0.51(95% CI - 0.82 to - 0.20)]. Knee Society Score showed no difference between CIM and OTS groups for Knee 90.5 vs. 90.6 [MD - 0.27(95% CI - 4.27 to 3.73)] and Function 86.1 vs. 83.1 [MD 1.51(95% CI - 3.69 to 6.70)]. CONCLUSION: CIM implants in TKA have theoretical benefits over OTS prostheses. However, in this present review, CIM implants were associated with higher revisions, MUA, and overall complication rates. There was no difference in outcome score and CIM implants did not improve overall target alignment; however, more CIM TKAs were found to be in the HKA target zone compared to OTS TKAs. The findings of this review do not support the general utilization of CIM over OTS implants in TKA.

Pyrocarbon radial head arthroplasty offers satisfactory clinical and radiological outcomes with low revision rate: A systematic review.

INTRODUCTION: Pyrocarbon promises to be an optimal material choice for radial head arthroplasty (RHA) due to an elastic modulus comparable to the radial diaphysis and thus providing higher biocompatibility. Primary objective was to determine the complications and revision rates related to the usage of these prostheses. The secondary objective was to assess the clinical and radiological outcomes of Pyrocarbon RHAs. HYPOTHESIS: Pyrocarbon RHAs have good clinical and radiological outcomes with low complications and revisions. METHODS: Ovid MEDLINE and Embase databases were used to search for studies on outcomes and complications of the RHAs using Pyrocarbon radial head prostheses. The systematic review was designed in accordance with the PRISMA guidelines and included studies were appraised using the MINORS tool. Complications and RHA revision rates were assessed. Functional outcomes were reviewed using PROMs (like MEPI, DASH and BMS), post-op range of motion (using goniometer) and grip strength (using the dynamometer). Postoperative radiological outcomes like peri-prosthetic lucency, radial neck osteolysis, radio-capitellar congruence, capitellar erosion, overstuffing/understuffing and osteoarthritis were reported using radiographs. RESULTS: A total of 12 studies cumulatively reporting 353 patients who underwent Pyrocarbon RHAs were included in the review. The mean age of patients across the studies ranged from 47 to 54 years of which 50.5% were males. The majority of radial head replacements were done for acute trauma (87.5%) with the remainder done for arthritis (1.7%) and trauma sequelae (10.8%). Mean follow-up period in the selected studies ranged from 18 to 110 months with minimum follow-up across all studies being 12 months. Modular Pyrocarbon (MoPyC, Tornier™) was the implant of choice in ten studies while two studies used the Ascension Pyrocarbon radial head (Ascension Orthopaedics™). Ten studies demonstrated mean MEPI ranging from 75.5 to 96. Mean extension deficit ranged from 6 to 19 degrees, mean flexion from 120 to 140 degrees, mean pronation from 71 to 87 degrees and mean supination from 63 to 85 degrees. Relative grip strength ranged from 69 to 96% of the contralateral limb. Revisions due to implant-related reasons (intra-prosthetic dissociation, prosthetic fracture, peri-prosthetic loosening, radio-capitellar subluxation and understuffed/overstuffed elbow) was 6.8% (24/353). Radial stress shielding and peri-prosthetic lucency was reported in 10 to 100% of patients across different studies but symptomatic implant loosening leading to revision remained rare (2%, 7/353). Radio-capitellar congruence was reported in 81% to 100% cases while capitellar erosion ranged from 0% to 89%. Pyrocarbon implants specific complications included head-neck intra-prosthetic decoupling (1.1%) and pyrocarbon head fractures (0.9%). In total, 5.7% cases underwent re-surgery due to non-RHA related reasons. DISCUSSION: The pyrocarbon RHA shows good functional outcome, range of motion and low revision rates. This aligns with the working hypothesis of this review. However, pyrocarbon radial head implants have implant-specific complications like pyrocarbon radial head fractures and intra-prosthetic decoupling between stem and head. Despite promising in vitro biomechanical properties, capitellar wear is still a common finding with pyrocarbon RHAs. Despite these factors, pyrocarbon radial head implants are a viable option for radial head arthroplasty. LEVEL OF EVIDENCE: II; Systematic review.

Suture Button Fixation in Latarjet Has Similar Load to Failure and Clinical Outcomes but Lower Bone Resorption Compared With Screw Fixation: A Systematic Review.

PURPOSE: To compare the 2 Latarjet fixation techniques-screw fixation (SF) versus suture button (SB) -for clinical, biomechanical, and radiologic outcomes. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic and Meta-Analyses guidelines using MEDLINE and Embase databases and was prospectively registered on PROSPERO. Only comparative clinical and biomechanical studies of Latarjet with SF and SB were included. Studies were appraised using the Methodical Index for Non-Randomised Studies (MINORS) tool. RESULTS: Eleven studies met eligible criteria: 7 clinical studies (SB, n = 279; SF, n = 845) and 4 biomechanical. In total, 80.9% (SB) and 84.2% (SF) of patients were male. Follow-up ranged from 6 to 63.6 months. The overall recurrent instability rate for SB ranged from 0 to 8.3% and for SF ranged from 0 to 2.75%. Only one study demonstrated a greater recurrent instability rate with SB (P = .02). Overall SB complication rates ranged from 0 to 12.5% and SF ranged from 0 to 27%. Two studies reported greater complications and reoperations with SF related to hardware. Summary forest plots from 4 studies showed no significant difference in Walch Duplay score (mean difference, range -5.00 to 1.20 [95% confidence interval {CI} -12.13 to 8.56], I2 inconsistency = 0%), Rowe score (mean difference, range -2.00 to 4.00 [95% CI -7.37 to 7.66], I2 inconsistency = 45%), and VAS for pain (mean difference, range -0.10 to 0.60 [95% CI -0.72 to 1.33], I2 inconsistency = 0%). There was no statistically significant difference between SB and SF in the postoperative range of motion. Radiologically, there was no significant difference in graft positioning and union at final follow-up, but graft resorption was greater in SF (range 25.2%-47.6%) compared with SB (range 10.1%-18.5%). Biomechanical studies showed no significant difference in maximum load to failure (SB, range 184-266 N vs SF, range 148-288 N). CONCLUSIONS: Clinically, SB fixation demonstrated similar functional outcome and range of motion when compared with SF, with the potential benefit of lower rates of graft resorption and hardware-related complications. Biomechanically there was no difference in maximum load to failure. LEVEL OF EVIDENCE: Level III, cohort studies (all clinical studies were Level III cohort studies).

Functional assessment of component positioning in patients with groin pain after total hip arthroplasty as a tool to guide management.

BACKGROUND: Persisting groin pain post total hip arthroplasty (THA) is a common and complex issue that can be difficult to diagnose and manage. Acetabular component positioning is often implicated. AIMS AND METHODS: We used a previously well described and validated functional positioning protocol to determine if functional acetabular malpositioning was a factor in groin pain post THA and hence to determine if acetabular revision would be indicated. We compared patient-specific functional acetabular positioning to traditional CT evaluation of cup position and assessment of anterior cup overhang. RESULTS: 39 patients with groin pain post-THA were investigated. Functional acetabular malpositioning was diagnosed in 31% (12/39). Revision THA was performed in those 12 patients, resulting in resolution of functional malpositioning (100%), with an overall accuracy of 5.6° (range 1-12), and resolution of groin pain in 67% (8/12). 33% (4/12) of the revised implants had functional positioning located outside the traditional "40/20 zone". Comparison with CT indicated that 40% (4/10) of implants with anterior overhang were well positioned, however only 50% (6/12) of functionally malpositioned implants had CT evidence of anterior cup prominence. Of the 8/12 revision patients who had resolution of their groin pain, only 1 had cup prominence. CONCLUSIONS: This study suggests that the utilisation of a patient specific functional positioning algorithm in the analysis of persistent groin pain following THA can assist in identifying the underlying cause of pain and help to guide treatment. For a functionally malpositioned acetabulum, revision surgery offers a potential resolution of groin pain.

Defining Cephalomedullary Nail Breakage Rates: A Systematic Review and Meta-Analysis.

OBJECTIVE: To establish the background rate of breakage of cephalomedullary nails. DATA SOURCES: MEDLINE, PubMed, and Web of Science were searched on April 3, 2023. STUDY SELECTION: All English-language studies that examined trochanteric with or without subtrochanteric fractures and identified cephalomedullary nail breakage as an outcome measure and a breakage rate could be derived were included. Implants captured were predominantly the TFNA, TFN, and PFN by DePuy Synthes, various versions of the Gamma nail by Stryker, the Zimmer Natural Nail by Zimmer Biomet, and the Intertan by Smith and Nephew. DATA EXTRACTION: The author, year of publication, dates of implant insertion, study design, method of detection of breakages, implant used, number of implant breakages, number of implants inserted, breakage rate, and follow-up were extracted. DATA SYNTHESIS: Meta-analysis of included studies used descriptive nonparametric statistics and a noncomparative proportion for the pooled result. Differences in results between study design types were compared using the mean breakage rate per study design. CONCLUSIONS: Cephalomedullary nail breakage is a rare complication with a median reported rate of 0.6% and a pooled result rate of 0.4%. Ninety-five percent of studies had a breakage rate of 1.3% or less, which sets a benchmark from the reported literature for future studies. There is wide variability in rates of breakage reported between different types of study designs with single-center review studies reporting breakage rates nearly 4-fold greater than large-scale administrative database reviews. The rate of implant breakage should not be used in isolation to judge an implant's performance. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical treatment of high-grade acute intramuscular hamstring tendon injuries in athletes leads to predictable return to sports and no re-injuries.

PURPOSE: The purpose of this study was to assess the post-operative return to sport and re-injury rates following surgical repair of acute, first-time, high-grade intramuscular hamstring tendon injuries in high level athletes. METHODS: Patients were identified using the databases of two sports surgeons. Once patients were identified their clinical notes and imaging were reviewed to confirm that all patients had injuries to the intramuscular portion of the distal aspect of the proximal biceps femoris tendon. All imaging was reviewed by an experienced musculoskeletal radiologist to confirm diagnosis. Surgery for such injuries was indicated in high-level athletes presenting with acute hamstring injuries. All patients were operated on within 4 weeks. Outcomes included Tegner scores, return to sport, Lower Extremity Functional Score (LEFS), current hamstring symptoms and complications including re-injury. RESULTS: Eleven injuries (10 patients) were included in the study. All patients were male and Australian Rules Football players. Six patients were professional athletes and 4 semi-professional athletes. Median age was 24.5 (range 21-29) and median follow-up period was 33.7 months (range; 16-65). 91% were British Athletic Muscle Injury Classification (BAMIC) 3c and 9% were BAMIC 4c. 91% were classed as MR2 and 9% as MR3 on the simplified four-grade injury classification. Athletes achieved return to play (RTP) at an average of 3.1 months (SD 1.0) post repair. All but one patient achieved a Tegner score equal to pre-injury levels. Maximum LEFS was achieved by all patients. Minor pain scores (all with VAS < 1/10) on sciatic and functional stretch were recorded in 36% and 27% of patients respectively, with subtle neural symptoms (9%) and subjective tightness (36%) also noted. There were no surgical complications in our patient cohort. No patients had a re-injury or re-operation. CONCLUSIONS: Surgical repair of high-grade intramuscular tendon injuries of the biceps femoris hamstring muscle in athletes resulted in high levels of return to pre-injury sporting levels and no re-injuries. The intra-muscular tendon should be scrutinized when assessing hamstring injuries in elite sport and offer surgery in high-grade cases. LEVEL OF EVIDENCE: IV.

Combined quadriceps medial patellofemoral ligament reconstruction and osteochondral fixation offers good patient-reported outcomes and low rates of recurrent instability for osteochondral defects secondary to acute patella dislocation.

PURPOSE: Chondral injuries secondary to traumatic patella dislocation are common, and a subgroup of these are significant defects with fragments amenable to fixation. There is a paucity of published evidence assessing patients managed with combined acute patellofemoral stabilisation and osteochondral fixation. The purpose of this study is to report the outcomes of patients with osteochondral injuries secondary to acute traumatic patella dislocation treated with combined early fragment fixation and MPFL reconstruction using a quadriceps tendon turndown technique which has distinct advantages for this cohort, including preventing chondral overloading and non-violation of the patella bone. METHODS: Patients who underwent combined quadriceps tendon MPFL reconstruction and osteochondral fixation were included. Patient demographics, defect characteristics, complications and reoperations were evaluated. Patients were assessed with Lysholm, Kujala, KOOS-PF scores and satisfaction scale at follow up. Pre-operative MRI was assessed for presence of radiological risk factors for patella dislocation and post-operative MRI was used to assess cartilage quality with MOCART 2.0 score. RESULTS: A total of 19 patients (63.2% female) were included. The mean age was 17.4 ± 4.8 years and patients were followed up at a mean 15.8 ± 5.1 months post-surgery. The mean defect size was 2.4 cm2 ± 1.3 cm2, with the most common defect location being the patella (13/19; 68.4%) followed by the lateral femoral condyle (5/19; 26.3%). At final follow up, the overall mean Lysholm, Kujala, and KOOS-PF scores were 84.9 ± 11.1, 89.7 ± 5.8 and 80.6 ± 13.6, respectively. Seventeen patients (89.5%) were satisfied with their outcome. The mean MOCART 2.0 score at final follow-up was 72.5. One patient required medial capsular plication with removal of a loose chondral body and microfracture and 3 knees required minor reoperations. CONCLUSION: Combined acute osteochondral fragment fixation and MPFL reconstruction using a quadriceps tendon graft offers good radiological and patient-reported outcomes with high satisfaction and low rates of recurrent patella dislocation. To our knowledge, this is currently the largest series of its kind in the literature and the results of this study provide a rationale for a combined approach using a quadriceps tendon graft for this cohort. LEVEL OF EVIDENCE: Level IV.

The relationship between exposure to noise and hearing loss in orthopaedics.

Aims: In the UK, the agricultural, military, and construction sectors have stringent rules about the use of hearing protection due to the risk of noise-induced hearing loss. Orthopaedic staff may also be at risk due to the use of power tools. The UK Health and Safety Executive (HSE) have clear standards as to what are deemed acceptable occupational levels of noise on A-weighted and C-weighted scales. The aims of this review were to assess the current evidence on the testing of exposure to noise in orthopaedic operating theatres to see if it exceeds these regulations. Methods: A search of PubMed and EMBASE databases was conducted using PRISMA guidelines. The review was registered prospectively in PROSPERO. Studies which assessed the exposure to noise for orthopaedic staff in operating theatres were included. Data about the exposure to noise were extracted from these studies and compared with the A-weighted and C-weighted acceptable levels described in the HSE regulations. Results: A total of 15 studies were deemed eligible. These included a total of 386 orthopaedic operations and the use of 64 orthopaedic instruments. A total of 294 operations (76%) and 45 instruments (70%) exceeded the regulations on an A-weighted scale, and 22% (10 of 46) of operations exceeded the maximum C-weighted peak acceptable level of noise. Noise-induced hearing loss was reported in 28 of 55 orthopaedic staff members (50.9%). Conclusion: Safe levels of noise can be exceeded in orthopaedic operations, and when using orthopaedic instruments. Employers have clear policies about exposure to noise in the workplace but have yet to identify orthopaedic theatres as a potential at-risk area. Orthopaedic staff need education, monitoring, and protection, while employers should consider regular assessments of staff in orthopaedic theatres and offer methods to prevent noise-induced hearing loss.

The Effect of a Formal Nonoperative Management Program Combining a Hip Injection With Structured Adjunctive Exercise Rehabilitation in Patients With Symptomatic Femoroacetabular Impingement Syndrome.

BACKGROUND: Although the initial treatment recommendations for femoroacetabular impingement syndrome (FAIS) may include nonsurgical therapies such as injections and rehabilitation, many patients undergo isolated injections or a rudimentary exercise regimen. PURPOSE: To investigate the benefit of an intra-articular hip injection and concomitant structured exercise rehabilitation program in patients with symptomatic FAIS ≥6 months. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: For this study we recruited 49 patients with a mean age of 32.8 years (range, 16-56 years) and symptoms ≥6 months (range, 6-250 months) associated with FAIS, as confirmed via magnetic resonance imaging and radiography. After a guided intra-articular injection of corticosteroid and local anesthetic, patients underwent a structured 12-week rehabilitation program. Patients were assessed before and after injection (8 weeks and 4, 6, 12, and 24 months) with a range of patient-reported outcome measures (PROMs), including the 33-item International Hip Outcome Tool, Hip Outcome Score, modified Harris Hip Score, the Tegner Activity Score, a visual analog scale assessing the frequency and severity of hip pain, and a Global Rating of Change scale. Range of motion, peak isometric hip strength, and hop tests were assessed. Absolute scores and limb symmetry indices were calculated. The percentage of patients transitioning toward surgery over the period was evaluated. RESULTS: Of the 44 patients who underwent the injection and completed the initial 8-week rehabilitation component, 14 (31.8%) progressed toward surgical intervention over the 24-month postinjection period owing to dissatisfaction and/or symptom recurrence. Patients who progressed toward surgery, as compared with those who did not, reported significantly worse (P < .05) PROMs presurgery and more pain within the first 4 weeks after injection. In the nonoperative cohort, a significant improvement (P < .05) in all PROMs was observed, with 93% of these patients satisfied overall. The Global Rating of Change did not improve, although this was measured only after the injection, reflecting no further significant perceived global change from 8 weeks to 24 months. A significant increase (P < .05) in all hip range of motion and most isometric strength measures was observed at 8 weeks after injection, with these improvements largely sustained until 24 months. Bilateral improvements in hop capacity were observed, with hop test LSIs significantly improving for the single (p = 0.009), triple (p = 0.029) and triple crossover (p = 0.005) hop tests for distance. CONCLUSION: Although 32% of patients progressed toward surgery, significant improvement in hip pain, symptoms, and physical function was observed in the majority of patients with symptomatic FAIS as a result of a targeted nonoperative management pathway consisting of an intra-articular injection and a structured exercise program.

Open coraco-clavicular ligament reconstruction (CCLR) in treatment of displaced distal clavicle fractures has low complication rate and excellent union rate: a systematic review.

BACKGROUND: It is well established that non-operative treatment of displaced distal clavicle fractures (DDCF) leads to a high non-union rate. A number of open surgical treatments in the past have shown good to excellent outcomes including shoulder function and union rate. Despite this there is no consensus on the outcome of open coraco-clavicular ligament reconstruction (CCLR). The aim of this systematic review was to assess the union rate, complications and shoulder function of open CCLR techniques in the treatment of DDCF. PATIENTS AND METHODS: A review of the online databases MEDLINE and Embase was conducted on 1 January 2021 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting union rate, complications and shoulder function were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS: The search strategy identified 18 studies eligible for inclusion with a total of 330 patients. These included 12 retrospective case series and 5 nonrandomized retrospective comparative studies and one RCT. All but one study reported on shoulder function, while all the studies reported on union rate and complications. The overall shoulder function was good to excellent using Constant-Murley score. The overall union rate was 97.6% and complication rate was 7.6%. CONCLUSION: Open CCLR for displaced distal clavicle fractures that have a disruption of CC ligament, is a reliable treatment with excellent union rate and good to excellent shoulder functional scores. LEVEL OF EVIDENCE: IV; Systematic review.

Preoperative topical benzoyl peroxide treatment is effective in reducing Cutibacterium acnes in shoulder surgery: a systematic review.

BACKGROUND: Cutibacterium acnes (C acnes) colonization can have a significant impact on patients undergoing both arthroscopic and open shoulder surgery with regard to postoperative infection. Its resistance to standard preoperative skin preparations and prophylactic antibiotics has led to a need for a more targeted therapy. Topical benzoyl peroxide (BPO) has been used by dermatologists in the treatment for acnes due to its bactericidal and penetrative effects through the dermal layer. The aim of this systematic review is to review the effectiveness of topical BPO preoperatively in shoulder surgery in reducing C acnes colonization and postoperative infection. METHODS: A review of the online databases Medline and Embase was conducted on December 15, 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting superficial and deep sample microbiology and postoperative complications were included. The studies were appraised using the revised Cochrane Risk of Bias 2 (ROB 2) tool for randomized studies and the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS: The search strategy identified 10 studies for inclusion (6 randomized control trials, 2 prospective cohort studies, and 2 case series), including a total of 482 patients. Seven studies were comparable, testing BPO against alternative standard skin preparations. Of the 10 studies, 7 showed a decrease in the load of C acnes on the skin and/or deep tissues, of which 6 demonstrated statistical significance. Men were shown to have a statistically significant increase in the colonization rate of C acnes. Scheer et al (2021) demonstrated 4500 colony-forming units/mL in males and 900 colony-forming units/mL in females. In studies where the number of BPO applications was higher, BPO appeared more effective. Dizay et al demonstrated C acnes elimination in 78.9% with more than 1 application compared with 66.7% if only applied once. Three studies looked at the effectiveness of BPO during the operative timeline with 1 demonstrating its statistically significant effectiveness at reducing colonization 2 hours into the operation (P = .048). CONCLUSION: BPO is effective as a topical treatment at reducing C acnes colonization before shoulder surgery. However, the relationship between duration of treatment, frequency of application, and gender requires further research.

Open and arthroscopic posterior bone block with iliac crest autograft for posterior shoulder instability - systematic review of clinical and radiological outcomes.

INTRODUCTION: Posterior shoulder instability (PSI) is a rare and challenging pathology to manage. The aim of this review was to assess and compare whether open and arthroscopic iliac crest bone graft (ICBG) bone block procedures succeeded in improving functional and clinical outcomes as well as radiological outcomes of union and graft resorption. HYPOTHESIS: We hypothesised that there will be no difference in recurrence rate and functional outcome between open and arthroscopic procedures but there will be a higher complication rate with open bone block procedures. METHODS: A systematic review was conducted in accordance with PRISMA guidelines using the online databases MEDLINE and Embase. The review was registered on the PROSPERO database. Studies of open or arthroscopic ICBG bone block procedures reporting patient reported outcome measures, recurrence, complications and progression to osteoarthritis and radiological outcomes of graft union and resorption were selected. Studies were appraised using the Methodical index for non-randomised studies (MINORS) tool. RESULTS: 14 studies satisfied the inclusion criteria; five studies were arthroscopic and nine used open techniques. A total of 183 patients and 201 shoulders were included, mean age was 25 years range (14-75 years). Recurrent instability ranged from 0% to 12.5% for arthroscopic and 0% to 36.4% for open studies. Arthroscopic studies had statistically significant increases in numerous functional outcome scores but there was no evidence for similar improvements in open studies. Osteoarthritis at follow-up ranged from 12.5% to 47% in arthroscopic and 0% to 81.8% for open studies. Arthroscopic complication rate ranged from 6.7% to 75% compared to 0% to 80% for open studies. Majority of complications were metalware related requiring surgical intervention. Partial graft resorption ranged from 7.7-100% after arthroscopic and 4.8-100% after open procedures. High union rates were seen with both open and arthroscopic techniques. CONCLUSION: This study highlights a lack of high-level evidence for arthroscopic and open posterior bone block procedures using ICBG to manage PSI. Functional and instability outcome scores showed significant improvement with arthroscopic ICBG bone block procedures however limited evidence was available for open studies. Metalwork related complications requiring revision and radiographic progression to osteoarthritis was high in both arthroscopic and open studies. LEVEL OF EVIDENCE: IV, systematic review.

A systematic review on management and outcome of irreducible knee dislocations.

BACKGROUND: Irreducible knee dislocations (IKD) are rare and can often be missed or misdiagnosed. The incidence of knee dislocation is quoted between 0.01% and 0.2% of all orthopaedic injuries, with up to 4% of these dislocations sub-classified as irreducible. The primary aim of this systematic review was to analyse cases of IKD described in the literature, with a secondary aim of producing a streamlined approach for managing these patients. PATIENTS AND METHODS: A systematic review of the literature was conducted on 1st September 2021 in accordance with the PRISMA guidelines using the online databases Medline and EMBASE. The review was registered prospectively in the PROSPERO database. Case reports or clinical studies or reporting on IKD were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool and Newcastle-Ottawa quality assessment scale. RESULTS: The search strategy identified 60 studies eligible for inclusion, giving a total of 114 cases of IKD. Posterolateral dislocation was most common, seen in 85% of cases. The dimple sign was present in 70%. All cases required surgical intervention to achieve joint reduction. The most commonly involved structure blocking reduction was the medial collateral ligament (MCL)±medial structures, seen in 52.4%. MCL reconstruction or repair was carried out in 32.3% cases. The overall incidence of neurovascular injury was 9% and the overall complication rate was 14.4%. CONCLUSION: Based on the findings of this SR we conclude that: the most common type of IKDs are PL dislocations, and the MCL, medial retinaculum and capsule and vastus medialis oblique form the most common structures involved in block to reduction and often will require open reduction and repair in acute setting if arthroscopic reduction fails. The most common pattern of injury to ligament is likely to be ACL, PCL, MCL±other structures but the MCL will be the most commonly repaired ligament. The dimple sign is often present and is highly pathognomonic of IKD. The incidence of neurovascular injury is uncommon. The most common post-operative complications likely to be encountered is medial skin necrosis and postoperative knee stiffness. Therefore, patients should be mobilised as early as possible with ROM in hinge brace. LEVEL OF EVIDENCE: IV.

The use of the internal joint stabiliser for elbow instability Report of two cases and systematic review.

The management of elbow fracture-dislocations is challenging. The internal joint stabiliser (IJS) (Skeletal Dynamics, Miami, FL) has been advocated as an alternative to traditional techniques. This article shares our initial clinical experience and provide a systematic review analysing the ability of the IJS to maintain radiographic joint reduction and the associated complication profile. Two cases of elbow fracture-dislocations treated at our centre using the IJS are presented. A systematic review of the literature was conducted using the online databases Medline, Scopus and EMBASE. Clinical studies reporting the maintenance of joint reduction after the use of IJS in patients with acute or chronic elbow instability were included. The two cases reported remained radiographically concentric at 6 months follow up without complications. 5 studies met the inclusion criteria and were included in the systematic review (total n=65). Only two patients across the studies had ongoing radiological instability (3%) and both were associated with coronoid insufficiency. The mean flexion-extension arc ranged from 106° to 135° and pronation- supination arc ranged from 138° to 151°. The mean DASH scores ranged from 16 to 37.3 and the mean Broberg and Morrey Functional score from 68.2 to 93. Complication rates in the case series ranged from 21% to 40%, the commonest complications were heterotopic ossification, neuropathy and infections. Initial reports into the use of the Internal Joint Stabiliser for elbow instability have shown a low incidence of residual radiological joint incongruency.