Addition of liposomal bupivacaine to standard bupivacaine versus standard bupivacaine alone in the supraclavicular brachial plexus block: a randomized controlled trial.

BACKGROUND: The analgesic effect of adding liposomal bupivacaine to standard bupivacaine in supraclavicular brachial plexus block is not known. We hypothesized that addition of liposomal bupivacaine would reduce acute postoperative pain compared to standard bupivacaine alone. METHODS: A randomized controlled trial was conducted. Patients and outcome assessors were blinded. Eighty patients undergoing distal radial fracture fixation under regional anesthesia with supraclavicular brachial plexus block were randomized into two groups. The liposomal bupivacaine (LB-BPB) group received 10ml of 0.5% plain bupivacaine immediately followed by 10ml of 1.33% liposomal bupivacaine (n=40). The standard bupivacaine (S-BPB) group received 20ml of 0.5% plain bupivacaine (n=40). The primary outcome was weighted area under curve (AUC) numerical rating scale (NRS) pain score at rest over the first 48 hours after surgery. Secondary outcomes included AUC scores for pain with movement, overall benefit with analgesia score (OBAS) and other functional scores. RESULTS: For the primary outcome, LB-BPB group was associated with statistically significantly lower AUC pain score at rest (0.6 vs 1.4, p-value < 0.001) in the first 48 hours. Of the secondary outcomes, no difference between treatment groups reached statistical significance with the exception of AUC score for pain with movement (2.3 vs 3.7, adjusted p-value < 0.001) and OBAS (1.1 vs 1.7, adjusted p-value = 0.020) in the first 48 hours, as well as NRS pain score at rest (0.5 vs 1.9, adjusted p-value < 0.001) and with movement (2.7 vs 4.9, adjusted p-value < 0.001) on postoperative day (POD) 1. Differences in NRS pain scores on POD2, POD3 and POD4 did not reach the level of statistical significance. There were no statistically significant differences in sensory function. CONCLUSION: Liposomal bupivacaine given via supraclavicular brachial plexus block reduced pain at rest in the early postoperative period.

Determination of the ideal plate for medial femoral condyle fracture fixation: an anatomical fit and biomechanical study.

BACKGROUND: The aim of this study is to determine the best plate to use as a substitute to fix a medial femoral condyle fracture. MATERIALS AND METHODS: The first part is to measure the best fit between several anatomical plates including the Proximal Tibia Anterolateral Plate (PT AL LCP), the Proximal Tibia Medial Plate (PT M LCP), the Distal Tibia Medial Locking Plate (DT M LCP) and the Proximal Humerus (PHILOS) plate against 28 freshly embalmed cadaveric distal femurs. Measurements such as plate offset and number of screws in the condyle and shaft shall be obtained. The subsequent part is to determine the compressive force at which the plate fails. After creating an iatrogenic medial condyle fracture, the cadavers will be fixed with the two plates with the best anatomical fit and subjected to a compression force using a hydraulic press. RESULTS: The PT AL LCP offered the best anatomical fit whereas the PHILOS plate offered the maximal number of screws inserted. The force required to create 2 mm of fracture displacement between the two is not statistically significant (LCP 889 N, PHILOS 947 N, p = 0.39). The PT AL LCP can withstand a larger fracture displacement than the PHILOS (LCP 24.4 mm, PHILOS 17.4 mm, p = 0.004). DISCUSSION AND CONCLUSION: Both the PT AL LCP and the PHILOS remain good options in fixing a medial femoral condyle fracture. Between the two, we would recommend the PT AL LCP as the slightly superior option.

Rehabilitation progress following reverse total shoulder replacement and internal fixation for geriatric three and four-part proximal humerus fractures - a propensity score matched comparison.

BACKGROUND: Proximal humerus fracture is one of the most common fractures in the elderly population. However, in patients with complex fracture patterns, there is still no general consensus in the best treatment method. This study aims to evaluate the outcomes between those treated with reverse total shoulder arthroplasty (rTSA) and open reduction internal fixation (ORIF). METHODS: All geriatric patients (> 60 years of age) with proximal humerus fractures undergoing surgical treatment were analysed. There were 25 patients treated with rTSA and 75 with ORIF. Propensity score matching was used to select 25 matching patients from the ORIF group according to age and gender. All patients underwent surgical intervention within 7 days (mean 3.8 days). All patients followed a protocol-driven rehabilitation programme with outcome assessment at 3, 6, 12 and 24 months. Constant score, qDASH, range of motion, rate of complications and revision surgery were recorded and compared. RESULTS: Twenty-five rTSA were age and gender matched with 25 ORIF patients. The average age of patients in rTSA and ORIF groups were 77.0 years and 75.2 years respectively. At 3 months, mean Constant score was 37.7 (rTSA) vs 45.5 (ORIF) (p = 0.099). Mean qDASH score was 50.6 (rTSA) vs 29.4 (ORIF) (p = 0.003). Mean forward flexion range was 72.9° (rTSA) vs 94.4° (ORIF) (p = 0.007). Mean abduction range was 64.0° (rTSA) vs 88.6° (ORIF) (p = 0.001). At 2 years, mean Constant score was 72.8 (rTSA) vs 70.8 (ORIF) (p = 0.472). Mean qDASH score was 4.50 (rTSA) vs 11.0 (ORIF) (p = 0.025). Mean forward flexion range was 143° (rTSA) vs 109° (ORIF) (p < 0.001). Mean abduction range was 135° (rTSA) vs 110° (ORIF) (p = 0.025). There was a higher number of complications observed for ORIF (3) than rTSA (1) (p = 0.297) and a higher number of re-operations for ORIF (3) than rTSA (1) (p = 0.297), which was not statistically significant. CONCLUSION: rTSA appears to yield a slower recovery at 3 months but a better outcome at 2 years. It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome.

Recommendations on the post-acute management of the osteoporotic fracture - Patients with "very-high" Re-fracture risk.

Osteoporosis is a systemic skeletal disease where there is low bone mass and deterioration of bone microarchitecture, leading to an increased risk of a fragility fracture. The aim of this clinical guideline from Fragility Fracture Network Hong Kong SAR, is to provide evidence-based recommendations on the post-acute treatment of the osteoporotic fracture patient that presents for clinical care at the Fracture Liaison Service (FLS). It is now well established that the incidence of a second fracture is especially high after the first 2 years of the initial osteoporotic fracture. Therefore, the recent osteoporotic fracture should be categorized as "very-high" re-fracture risk. Due to the significant number of silent vertebral fractures in the elderly population, it is also recommended that vertebral fracture assessment (VFA) should be incorporated into FLS. This would have diagnostic and treatment implications for the osteoporotic fracture patient. The use of a potent anti-osteoporotic agent, and preferably an anabolic followed by an anti-resorptive agent should be considered, as larger improvements in BMD is strongly associated with a reduction in fractures. Managing other risk factors including falls and sarcopenia are imperative during rehabilitation and prevention of another fracture. Although of low incidence, one should remain vigilant of the atypical femoral fracture. The aging population is increasing worldwide, and it is expected that the treatment of osteoporotic fractures will be routine. The recommendations are anticipated to aid in the daily clinical practice for clinicians. The Translational potential of this article: Fragility fractures have become a common encounter in clinical practise in the hospital setting. This article provides recommendations on the post-acute management of fragility fracture patients at the FLS.

Operative management of midshaft clavicle fractures demonstrates better long-term outcomes: A systematic review and meta-analysis of randomised controlled trials.

INTRODUCTION: Midshaft clavicular fractures are common amongst young adults. Conservative or surgical treatment for definitive fracture management has been widely debate, both with their pros and cons. Previous meta-analyses compared the clinical outcomes between conservative and surgical treatment options of midshaft clavicular fractures but failed to elucidate any difference in functional improvement. We postulate that functional improvement after fracture union plateaus and the clinical outcome after treatment varies at different time points. This meta-analysis will focus on the synthesis comparison of outcomes at early, short-term results (3 months), intermediate-term (6 to 12 months) and long-term (>24 months) clinical outcomes. METHODS: A systematic search was done on databases (Pubmed, Embase, Medline, Cochrane) in June 2021. Search keywords were: midshaft clavicular fractures and clinical trials. Clinical trials fulfilling the inclusion criteria were selected for comparison and the clinical outcomes of midshaft clavicular fractures using surgical and non-surgical interventions in terms of improvement in the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley Score (CMS), time to union and risk ratio of treatment related complications were analysed in correlation with post-treatment timeframe. RESULTS: Of the 3094 patients of mean age 36.7 years in the 31 selected studies, surgical intervention was associated with improved DASH score (standard-mean difference SMD -0.22, 95% CI -0.36 to -0.07, p = 0.003; mean difference MD -1.72, 95% CI -2.93 to -0.51, p = 0.005), CMS (SMD 0.44, 95% CI 0.17-0.72, p = 0.001; MD 3.64, 95% CI 1.09 to 6.19, p = 0.005), time to union (non-adjusted SMD -2.83, 95% CI -4.59 to -1.07, p = 0.002; adjusted SMD -0.69, 95% CI -0.97 to -0.41, p<0.001) and risk ratio of bone-related complications including bone non-union, malunion and implant failure (0.21, 95% CI 0.1 to 0.42; p<0.001). Subgroup analysis based on time period after treatment showed that surgical intervention was far superior in terms of improved DASH score at the intermediate-term results (6-12 months later, SMD -0.16, 95% CI -0.30 to -0.02, p = 0.02; and long term results (>24 months SMD -4.24, 95% CI -7.03 to -1.45, p = 0.003) and CMS (>24 months, SMD 1.03, 95% CI 0.39 to 1.68, p = 0.002; MD 5.77, 95% CI 1.63 to 9.91, p = 0.006). Surgical outcome is independent of fixation with plates or intra-medullary nails. CONCLUSION: Surgical intervention was associated with better clinical outcomes compared with non-surgical approach for midshaft clavicular fractures in terms of improvement in functional scores DASH, CMS, time to union and fracture related complications, although not to the minimal clinically significant difference. Benefits in the long-term functional improvements are more pronounced.

A review of the manufacturing process and infection rate of 3D-printed models and guides sterilized by hydrogen peroxide plasma and utilized intra-operatively.

3D printing in the context of medical application can allow for visualization of patient-specific anatomy to facilitate surgical planning and execution. Intra-operative usage of models and guides allows for real time feedback but ensuring sterility is essential to prevent infection. The additive manufacturing process restricts options for sterilisation owing to temperature sensitivity of thermoplastics utilised for fabrication. Here, we review one of the largest single cohorts of 3D models and guides constructed from Acrylonitrile butadiene styrene (ABS) and utilized intra-operatively, following terminal sterilization with hydrogen peroxide plasma. We describe our work flow from initial software rendering to printing, sterilization, and on-table application with the objective of demonstrating that our process is safe and can be implemented elsewhere. Overall, 7% (8/114 patients) of patients developed a surgical site infection, which was not elevated in comparison to related studies utilizing traditional surgical methods. Prolonged operation time with an associated increase in surgical complexity was identified to be a risk factor for infection. Low temperature plasma-based sterilization depends upon sufficient permeation and contact with surfaces which are a particular challenge when our 3D-printouts contain diffusion-restricted luminal spaces as well as hollows. Application of printouts as guides for power tools may further expose these regions to sterile bodily tissues and result in generation of debris. With each printout being a bespoke medical device, it is important that the multidisciplinary team involved in production and application understand potential pitfalls to ensuring sterility as to minimize infection risk.

The status of triangular fibrocartilage complex after the union of distal radius fractures with internal plate fixation.

PURPOSE: Distal radius fractures are associated with a high incidence of triangular fibrocartilage complex (TFCC) tears. This study aims to evaluate the status of TFCC after the healing of distal radius fractures, and its clinical significance. METHODS: Wrist arthroscopies were performed on 43 distal radius fractures, with an average age of 54 years old. RESULTS: Twenty-six complete tears and 15 partial healed tears were noted. Five out of eight patients with intact TFCC tears had neither signs nor symptoms, while eight patients with TFCC tears had no complaint. While no association was found between ulnar wrist pain and TFCC tears, there was association between DRUJ instability and TFCC tears and fovea tears. The function outcome did not differ with respect to the integrity of TFCC. CONCLUSIONS: A large majority of TFCC tears remained unhealed after the union of distal radius fractures. However, not all patients with tear were symptomatic.

Comparison between patient-specific instruments and conventional instruments and computer navigation in total knee arthroplasty: a randomized controlled trial.

PURPOSE: The current study investigated the accuracy in achieving proper lower limb alignment and individual component positions after total knee arthroplasty (TKA) with 3 different instrumentation techniques. It was hypothesized that patient-specific instruments (PSI) would achieve more accurate lower limb alignment and component positions compared to conventional instruments (CON). METHODS: Ninety knees in 81 patients were randomized in 1:1:1 ratio into CON, computer navigation (NAV) and PSI groups to receive TKA. The surgical routines were standardized. The lower limb mechanical axis and individual component positions were assessed on standard radiographs. Tourniquet time, operation time and patients' functional scores were documented. RESULTS: Conventional instruments and PSI were more likely to result in an excessively flexed femoral component (p = 0.001) compared to NAV. Number of outliers in postoperative lower limb alignment, and other components positions in the coronal and sagittal plane showed no statistically significant difference. The mean tourniquet time and operation time was significantly shorter in CON and PSI groups than NAV group (p < 0.001). Four early complications occurred in the PSI group (p = 0.015). At 3-month follow-up, there was no difference in terms of the knee range of motion and patients' function among the 3 groups. CONCLUSION: No significant radiological and clinical benefit could be demonstrated in using PSI over CON or NAV in TKA. Routine use of PSI is not recommended because of the extra cost and waiting time. LEVEL OF EVIDENCE: I.