Outcomes of perioperative intravenous iron infusion in femoral fracture surgery: A systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Patient blood management recommends the use of intravenous (IV) iron infusion to reduce inappropriate blood transfusion perioperatively for anaemic surgical patients. However, evidence regarding its use in urgent femoral fracture surgery is limited. This systematic review aims to collate the current evidence regarding the utilisation of IV iron in femoral fracture surgery. METHOD: MEDLINE, Embase, Cochrane CENTRAL, Clinicaltrials.gov, and the WHO ICTRP databases were systematically searched for randomised controlled trials (RCT) comparing the outcomes of perioperative IV iron infusion with placebo in adults requiring surgical management for femoral fractures. Risk ratios (RR) were calculated using the Mantel-Haenszel method for dichotomous outcomes, and mean differences (MD) were calculated with the inverse-variance method for continuous outcomes. RESULTS: Six RCTs with 1292 patients were included. No statistically significant difference was found in the proportion of patients receiving red blood cell (RBC) transfusion (RR = 0.87, 95%CI: 0.75; 1.01, p = 0.058) between groups. Statistically significant difference in postoperative haemoglobin concentration was found between groups measured between day 4-7 of admission (MD = 1.93 g/L, 95%CI: 0.48; 3.39, p = 0.024), but not clinically significant. No statistically significant differences were found between groups in mortality rate, length of hospital stay, infection rate, or return to home rate. CONCLUSION: Current evidence indicates that IV iron infusion alone does not provide any clinically significant benefit in femoral fracture surgery. Further high-quality RCTs are needed to explore its synergistic potential when used in combination with other perioperative optimisation methods, including tranexamic acid, erythropoietin and cell salvage.

Standard setting for orthopaedic trauma competencies in postgraduate specialty training- catching those falling behind the curve.

BACKGROUND: The Curriculum for Trauma and Orthopaedics focuses on producing competent Day-One Consultants. However, the expected development trajectory is not clear. It is important, yet difficult to objectively identify trainees who are "falling behind". This project proposes practical, consensus-based thresholds of Operative Trauma Competence at each Waypoint stage of training. METHODS: 32 trainers and 73 trainees in one Deanery were identified. The trainers and trainees were asked their PBA level expectation of a trainee at ST4, ST6 and ST8 for nine trauma competencies. Lower quartile values were calculated providing thresholds. RESULTS: 53 (72%) trainees and 22 (69%) trainers responded. At ST8, the lower quartile threshold was level 4 for all procedures. At ST6, three operation groups became apparent: Group 1 (hip hemiarthroplasty, Dynamic hip screw; k-wire distal radius fracture and Weber C Ankle open reduction, internal fixation (ORIF)) Group 2 (Tibial Nail; Olecranon Tension band wire, ORIF radial shaft; distal radius plate fixation)- Group 3 (supracondylar fracture fixation)Threshold levels for procedures were: Group 1- 4a; Group 2-3b and Group 3- 3a.At ST4, there was more variation and spread in responses, however, expectations could still be similarly grouped: Group 1- 3a; Group 2- 2b and Group 3- 2a. CONCLUSION: In an increasingly competency-based training environment we provide tangible thresholds for expectations of orthopaedic trainees' progression and development. We identified two groups: basic trauma (Group 1 where level 4 competencies should be attained by ST6) and intermediate trauma (Groups 2 and 3 where level 4 competencies should be attained by ST8.).

Cessation of Pulsed Lavage During the SARS-CoV-2 Pandemic: The Effect on Hip Hemiarthroplasty Cement Mantles.

Background With the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, we were issued with guidance to minimize aerosol-generating procedures and discontinued the use of pulsed lavage for hip hemiarthroplasty. Instead, we used a bladder syringe to wash the femoral canal. The aim of this study was to assess whether this change in practice had a detrimental effect on the quality of the bone cement mantles in patients undergoing cemented hip hemiarthroplasty. Methodology We performed a retrospective review of all patients treated at a tertiary teaching hospital in the United Kingdom (Addenbrookes, Cambridge University Hospitals) presenting with a neck of femur fracture requiring a hemiarthroplasty between October 2019 and June 2020. We retrospectively assessed 100 post-operative radiographs for patients who had received hip hemiarthroplasty following neck of femur fragility fracture (50 before the service change and 50 after). The Barrack classification was used to assess the quality of the bone cement mantle. Results Pre-SARS-CoV-2, 30% of hemiarthroplasties were deemed as being "at risk" of aseptic loosening. During SARS-CoV-2, 64% of hips were deemed as being "at risk." This represents a statistically significant absolute increase of 34% (P < 0.05, the P value is 0.000645). Both clinicians agreed on the classification of hips "at risk" or "not at risk" (i.e., grades C/D and A/B, respectively) in 85% of the cases. Cohen's kappa coefficient was calculated as 0.68, indicating substantial agreement. Conclusions Following our experience of this forced service change, we would discourage abandoning the use of pulsed lavage in future pandemics. We have demonstrated an association between abandoning pulsed lavage and detrimental effects on the procedural quality for hip hemiarthroplasty. Patients treated over this time period will be closely monitored for operative complications. As this was the only equipment change made for this procedure, we have demonstrated its detrimental effect on the procedural quality. Should pulsed lavage be discontinued, patients may need to be counseled for higher risk of early failure and revision surgery and may require long-term radiographic follow-up. In SARS-CoV-2-positive patients, Surgeons should carefully consider the risks and benefits of using pulsed lavage in accordance with the personal protective equipment they have available and the consequential impact on the bone cement mantle quality.

Management of a Complex, Multioperated Intra-Articular Distal Radius Fracture.

Background Intra-articular distal radius fractures can have many complications, including radiocarpal osteoarthritis and distal radioulnar joint (DRUJ) dysfunction leading to pain and restricted wrist function. Case Description We describe the case of a 38-year-old patient who sustained a left distal radius intra-articular fracture, which was treated with volar plating. She developed pain from the radiocarpal joint as a result of intra-articular malunion and was listed for total wrist fusion. On the day of surgery this was converted to a Darrach procedure for minor DRUJ symptoms. This resulted in pain from the DRUJ as a result of instability, in addition to persisting radiocarpal arthritis pain. Due to her subsequent poor wrist function, she presented to the authors and underwent DRUJ arthroplasty with a proximally placed Scheker prosthesis to deal with her DRUJ symptoms and, later, a KinematX radiocarpal hemiarthroplasty for her radiocarpal symptoms. She remains happy with her outcome at 36-month follow-up. Literature Review The complications of the Darrach procedure include painful radioulnar convergence and wrist instability. The Scheker prosthesis allows restoration of stability of the DRUJ with good outcomes and 100% 5-year survival in one series. Sparing the midcarpal joint, the KinematX hemiarthroplasty allows preservation of the dart thrower's motion arc, which is key in many complex wrist movements and functions. Clinical Relevance This case highlights the negative consequences of distal ulna resection and shows both the Scheker and KinematX prostheses as viable, effective means to restore function to young, active patients with posttraumatic radiocarpal arthritis and/or instability.

Horner's syndrome secondary to intervertebral disc herniation at the level of T1-2.

A 54-year-old Caucasian woman presented with a 6 week history of periscapular pain and a T1 radiculopathy associated with Horner's syndrome. MRI of her cervicothoracic spine revealed an intervertebral disc herniation at the level of T1-2. During investigation she experienced some improvement in her symptoms and a conservative approach was pursued. At 6 months her pain and radiculopathy had resolved, and there was mild residual ptosis.