The MAGIC trial: a pragmatic, multicentre, parallel, noninferiority, randomised trial of melatonin versus midazolam in the premedication of anxious children attending for elective surgery under general anaesthesia.

BACKGROUND: Child anxiety before general anaesthesia and surgery is common. Midazolam is a commonly used premedication to address this. Melatonin is an alternative anxiolytic, however trials evaluating its efficacy in children have delivered conflicting results. METHODS: This multicentre, double-blind randomised trial was performed in 20 UK NHS Trusts. A sample size of 624 was required to declare noninferiority of melatonin. Anxious children, awaiting day case elective surgery under general anaesthesia, were randomly assigned 1:1 to midazolam or melatonin premedication (0.5 mg kg-1, maximum 20 mg) 30 min before transfer to the operating room. The primary outcome was the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF). Secondary outcomes included safety. Results are presented as n (%) and adjusted mean differences with 95% confidence intervals. RESULTS: The trial was stopped prematurely (n=110; 55 per group) because of recruitment futility. Participants had a median age of 7 (6-10) yr, and 57 (52%) were female. Intention-to-treat and per-protocol modified Yale Preoperative Anxiety Scale-Short Form analyses showed adjusted mean differences of 13.1 (3.7-22.4) and 12.9 (3.1-22.6), respectively, in favour of midazolam. The upper 95% confidence interval limits exceeded the predefined margin of 4.3 in both cases, whereas the lower 95% confidence interval excluded zero, indicating that melatonin was inferior to midazolam, with a difference considered to be clinically relevant. No serious adverse events were seen in either arm. CONCLUSION: Melatonin was less effective than midazolam at reducing preoperative anxiety in children, although the early termination of the trial increases the likelihood of bias. CLINICAL TRIAL REGISTRATION: ISRCTN registry: ISRCTN18296119.

Mixed manufacturer dual mobility bearing and the Exeter V40 Stem: is it safe? Short-term results in primary and revision hip replacement.

The aim is to review clinical and radiological outcomes for all cases of primary and revision THA, combining a cemented stem (Exeter V40) with a dual mobility component from a different manufacturer (SERF Novae), to evaluate whether concerns regarding mixing components from different manufacturers are justified. We identified 72 hip replacements performed between May 2010 and December 2015 using the SERF Novae dual mobility cup with an Exeter V40 stem, the majority of which were cemented (90%) and revisions (58%). Patients were evaluated clinically and radiologically at a minimum of two years. There were five (6.9%) dislocations; three (4.2%) requiring revision - one of which was an intra-prosthetic disarticulation and two infections. No cases were lost to follow-up and 49 surviving cases were reviewed at a mean of 4.0 (range 1.8-8.1) years following surgery. Pain and functional outcome scores all improved. There were no radiological failures and no revisions for aseptic loosening of stem or cup. The combination of Exeter cemented stem with a dual mobility bearing from a different manufacturer results in acceptable short-term outcomes in terms of hip stability, revision rates and patient-reported measures.

Interleukin-1 receptor antagonist, mode of analgesia and risk of Caesarean delivery after onset of labour: a Mendelian randomisation analysis.

BACKGROUND: Lower circulating levels of the anti-inflammatory cytokine interleukin-1 receptor antagonist (IL-1ra) are associated with intrapartum inflammation and epidural analgesia-related maternal fever, both of which increase the rate of obstetric interventions. We hypothesised that genetic variants determining IL-1ra levels would be associated with Caesarean delivery rates after the onset of labour. METHODS: We performed Mendelian randomisation analyses in parous women ≥16 yr old who received either non-neuraxial or neuraxial analgesia for their first two labours (UK Biobank). We used an established genetic score (calculated as 0-4, determined by the presence/absence of rs6743376 and rs1542176 alleles), in which the complete absence of both alleles causes the lowest IL-1ra levels. The primary outcome was Caesarean delivery after the onset of labour (odds ratio [OR]: 95% confidence intervals). RESULTS: There were 7731 women (mean [standard deviation] age at first birth: 25 [5] yr) who had complete genetic scores and delivery data. For women who received non-neuraxial analgesia, Caesarean delivery rates were different across allele scores (χ2=12.4; P=0.015): 104/596 (17.4%) women with zero allele score underwent Caesarean delivery, compared with 654/5015 (13.0%) with allele score ≥1 (OR 1.41; 1.12-1.77). For women who had neuraxial analgesia, Caesarean delivery was not different across allele scores, ranging from 18.1% to 20.8% (χ2=0.29; P=0.99). Caesarean delivery was independent of type of analgesia for 818/7731 (10.6%) women with zero allele scores (OR 0.93; 0.63-1.39), but was higher in women receiving neuraxial analgesia with allele scores ≥1 (OR 1.55; 1.35-1.79; P<0.001). CONCLUSIONS: Mendelian randomisation analysis suggests that higher IL-1ra levels are associated with reduced Caesarean delivery rate. Neuraxial analgesia appears to disrupt this link. CLINICAL TRIAL REGISTRATION: UK Biobank study 62745.

Remote Ischemic Preconditioning in Non-cardiac Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: Remote ischemic preconditioning (RIPC) may mitigate physiological stress related to surgery. There is no clear consensus on conduct of RIPC studies, or whether it is effective. The aim of this study was to (i) assess delivery of RIPC, (ii) identify reported outcomes, (iii) measure effect on key clinical outcomes. METHODS: This review was registered on PROSPERO (CRD:42020180725). EMBASE and Medline databases were searched, and results screened by two reviewers. Full-texts were assessed for eligibility by two reviewers. Data extracted were methods of RIPC and outcomes reported. Meta-analysis of key clinical events was performed using a Mantel-Haenszel random effects model. The TIDieR framework was used to assess intervention reporting, and Cochrane risk of bias tool was used for all studies included. RESULTS: Searches identified 25 studies; 25 were included in the narrative analysis and 18 in the meta-analysis. RIPC was frequently performed by occluding arm circulation (15/25), at 200 mmHg (9/25), with three cycles of 5 min ischemia and 5 min of reperfusion (16/25). No study fulfilled all 12 TIDieR items (mean score 7.68). Meta-analysis showed no benefit of RIPC on MI (OR 0.71 95% CI 0.48-1.04, I2 = 0%), mortality (OR 0.56, 95% CI 0.31-1.01, I2 = 0%), or acute kidney injury (OR 0.72 95% CI 0.48-1.08). CONCLUSIONS: RIPC could be standardized as 200 mmHg pressure in 3 × 5 min on and off cycles. The signal of benefit should be explored in a larger well-designed randomized trial.

Long-Term Survival of the Cemented Exeter Universal Stem in Patients 50 Years and Younger: An Update on 130 Hips.

BACKGROUND: There is variable evidence regarding survivorship beyond 20 years of total hip arthroplasties in young patients. We report the long-term results of the Exeter cemented hip system in patients ≤50 years at minimum of 20 years. METHODS: Clinical and radiological outcomes of 130 consecutive total hip arthroplasties in 107 patients aged 50 years or younger at primary operation were reviewed; 77% had a diagnosis other than osteoarthritis. All patients were followed at 5-year intervals, no patients were lost to follow-up, and the status of every implant is known. RESULTS: Mean age at surgery was 41.8 (17-50) years. Mean follow-up was 22.0 (20.0-26.1) years. There were 79 hips surviving, 14 hips (11 patients) deceased, and 37 hips revised. Reasons for revision: 29 hips for aseptic cup loosening (26 stems revised using cement-in-cement, three left in-situ); three stems for femoral osteolysis, two related to acetabular polyethylene wear (14.1 and 17.0 years), one with Gaucher's disease (21.1 years); one broken stem (12.9 years); one cup for instability (4.3 years-stem revised using cement-in-cement); and two hips with infection (8.5 and 23.8 years). There were no cases of aseptic loosening of the Exeter stem. There were no radiologically loose stems although eight patients had radiological evidence of loosening of the cemented cup. Survivorship at 22 years was 74.9% for revision for all causes and 96.3% for revision of the stem for aseptic loosening or lysis. CONCLUSION: The Exeter cemented stem has excellent survivorship at minimum 20 years in young patients. Acetabular component survivorship was less favorable, but the advent of highly cross-linked polyethylene may improve this in the long term.

Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial.

BACKGROUND: About a third of women receiving pethidine for labour pain subsequently require an epidural, which provides effective pain relief but increases the risk of instrumental vaginal delivery. Remifentanil patient-controlled analgesia (PCA) in labour is an alternative to pethidine, but is not widely used. We aimed to evaluate epidural analgesia progression among women using remifentanil PCA compared with pethidine. METHODS: We did an open-label, multicentre, randomised controlled trial in 14 UK maternity units. We included women aged 16 years or older, beyond 37 weeks' gestation, in labour with a singleton cephalic presentation, and who requested opioid pain relief. We randomly assigned eligible participants (1:1) to either the intravenous remifentanil PCA group (40 µg bolus on demand with a 2 min lockout) or the intramuscular pethidine group (100 mg every 4 h, up to 400 mg in 24 h), using a web-based or telephone randomisation service with a minimisation algorithm for parity, maternal age, ethnicity, and mode of labour onset. Because of the differences in routes of drug administration, study participants and health-care providers were not masked to the group allocation. The primary outcome was the proportion of women who received epidural analgesia after enrolment for pain relief in labour. Primary analyses were unadjusted and analysed by the intention-to-treat principle. This study is registered with the ISRCTN registry, number ISRCTN29654603. FINDINGS: Between May 13, 2014, and Sept 2, 2016, 201 women were randomly assigned to the remifentanil PCA group and 200 to the pethidine group. One participant in the pethidine group withdrew consent, leaving 199 for analyses. The proportions of epidural conversion were 19% (39 of 201) in the remifentanil PCA group and 41% (81 of 199) in the pethidine group (risk ratio 0·48, 95% CI 0·34-0·66; p<0·0001). There were no serious adverse events or drug reactions directly attributable to either analgesic during the study. INTERPRETATION: Intravenous remifentanil PCA halved the proportion of epidural conversions compared with intramuscular pethidine. This finding challenges routine pethidine use as standard of care in labour. FUNDING: National Institute for Health Research Clinician Scientist Award.

Atrial Fibrillation After Gastrointestinal Surgery: Incidence and Associated Risk Factors.

BACKGROUND: Atrial fibrillation (AF) is a common dysrhythmia that can occur after major physiological stress including surgery (postoperative AF). There are few data on postoperative AF after abdominal surgery. We set out to define the incidence of de novo postoperative AF after abdominal surgery and associated risk factors. METHODS: The Patient History Integrated Data store administrative database was interrogated for patients aged ≥65 y undergoing abdominal surgery from April 2012 to April 2014. Patients with pre-existing AF were excluded. The primary outcome was diagnosis of AF. RESULTS: Two thousand nine hundred and sixty-seven cases were included of whom 187 developed postoperative AF within 90 d (6.3%). The rate of postoperative AF varied by operation and was highest in small bowel resection (17.2%) and lowest in biliary surgery (4.8%). Median time to detection of postoperative AF was 32 d. Patients who developed postoperative AF were significantly older than those who did not develop AF (median age 75.3 y versus 72.4 y, P < 0.01). Logistic regression modeling found increasing age (odds ratio [OR] 1.03 [confidence interval {CI} 1.01-1.06], hypertension OR 1.73 [CI 1.19-2.51]), congestive cardiac failure (OR 3.04 [CI 1.88-4.92], and vascular disease OR 2.29 [CI 1.39-3.37]) were predictive of the development of postoperative AF within 30 d. The area under the curve for this model was 0.733. CONCLUSIONS: Postoperative AF affects a significant number of patients after abdominal surgery. Demographics such as history of cardiovascular disease might aid prediction of postoperative AF. Postoperative AF is mostly identified after discharge, suggesting the need for postoperative screening.

The Exeter Short Revision Stem for Cement-in-Cement Femoral Revision: A Five to Twelve Year Review.

BACKGROUND: Cement-in-cement femoral revision is a proven technique in revision total hip arthroplasty, with excellent results reported using standard-sized Exeter stems. The Exeter 44/00/125 short revision stem was introduced in 2004 to facilitate cement-in-cement revision. The stem is 25-mm shorter and has a slimmer body than standard stems to facilitate adjustment of depth of insertion and stem version. It is not known if this change in stem size affects its long-term performance. We therefore reviewed the outcome of all Exeter short revision stems used for cement-in-cement revision in our unit, with a minimum of 5 years of follow-up. METHOD: One hundred sixty-six cases were performed between 2004 and 2010. Mean follow-up of surviving patients was 8.1 years (range 5.0-11.7). The fate of all 166 hips were known and included in the survival analysis. RESULTS: Median clinical scores improved significantly. Sixteen hips required re-revision (infection 6, loose cup 3, periprosthetic fracture 3, instability 2, stem fracture with chronic infection 1, and pain 1). Kaplan-Meier survival analysis at 10 years revealed 100% survival for aseptic stem loosening, 96.8% survival for stem failure, and 88.9% survival for all causes. CONCLUSION: The Exeter short revision stem performed as well as standard length stems for cement-in-cement revision in this the largest and longest review of their use. Larger registry-based studies may provide additional information on the performance of this stem.

Cell salvage and donor blood transfusion during cesarean section: A pragmatic, multicentre randomised controlled trial (SALVO).

BACKGROUND: Excessive haemorrhage at cesarean section requires donor (allogeneic) blood transfusion. Cell salvage may reduce this requirement. METHODS AND FINDINGS: We conducted a pragmatic randomised controlled trial (at 26 obstetric units; participants recruited from 4 June 2013 to 17 April 2016) of routine cell salvage use (intervention) versus current standard of care without routine salvage use (control) in cesarean section among women at risk of haemorrhage. Randomisation was stratified, using random permuted blocks of variable sizes. In an intention-to-treat analysis, we used multivariable models, adjusting for stratification variables and prognostic factors identified a priori, to compare rates of donor blood transfusion (primary outcome) and fetomaternal haemorrhage ≥2 ml in RhD-negative women with RhD-positive babies (a secondary outcome) between groups. Among 3,028 women randomised (2,990 analysed), 95.6% of 1,498 assigned to intervention had cell salvage deployed (50.8% had salvaged blood returned; mean 259.9 ml) versus 3.9% of 1,492 assigned to control. Donor blood transfusion rate was 3.5% in the control group versus 2.5% in the intervention group (adjusted odds ratio [OR] 0.65, 95% confidence interval [CI] 0.42 to 1.01, p = 0.056; adjusted risk difference -1.03, 95% CI -2.13 to 0.06). In a planned subgroup analysis, the transfusion rate was 4.6% in women assigned to control versus 3.0% in the intervention group among emergency cesareans (adjusted OR 0.58, 95% CI 0.34 to 0.99), whereas it was 2.2% versus 1.8% among elective cesareans (adjusted OR 0.83, 95% CI 0.38 to 1.83) (interaction p = 0.46). No case of amniotic fluid embolism was observed. The rate of fetomaternal haemorrhage was higher with the intervention (10.5% in the control group versus 25.6% in the intervention group, adjusted OR 5.63, 95% CI 1.43 to 22.14, p = 0.013). We are unable to comment on long-term antibody sensitisation effects. CONCLUSIONS: The overall reduction observed in donor blood transfusion associated with the routine use of cell salvage during cesarean section was not statistically significant. TRIAL REGISTRATION: This trial was prospectively registered on ISRCTN as trial number 66118656 and can be viewed on http://www.isrctn.com/ISRCTN66118656.

Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews.

BACKGROUND: The rate of elective Caesarean Section (CS) is rising in many countries. Many obstetric units in the UK have either introduced or are planning to introduce enhanced recovery (ER) as a means of reducing length of stay for planned CS. However, to date there has been very little evidence produced regarding the necessary components of ER for the obstetric population. We conducted a rapid review of the composition of published ER pathways for elective CS and undertook an umbrella review of systematic reviews evaluating ER components and pathways in any surgical setting. METHODS: Pathways were identified using MEDLINE, EMBASE and the National Guideline Clearing House, appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and their components tabulated. Systematic reviews were identified using the Cochrane Library and Database of Abstracts of Reviews of Effects (DARE) and appraised using The Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two reviewers aggregated summaries of findings for Length of Stay (LoS). RESULTS: Five clinical protocols were identified, involving a total of 25 clinical components; 3/25 components were common to all five pathways (early oral intake, mobilization and removal of urinary catheter). AGREE II scores were generally low. Systematic reviews of single components found that minimally invasive Joel-Cohen surgical technique, early catheter removal and post-operative antibiotic prophylaxis reduced LoS after CS most significantly by around half to 1 and a half days. Ten meta-analyses of multi-component Enhanced Recovery after Surgery (ERAS) packages demonstrated reductions in LoS of between 1 and 4 days. The quality of evidence was mostly low or moderate. CONCLUSIONS: Further research is needed to develop, using formal methods, and evaluate pathways for enhanced recovery in elective CS. Appropriate quality improvement packages are needed to optimise their implementation.

Return to Sporting Activity After Total Hip Arthroplasty-A Survey of Members of the British Hip Society.

BACKGROUND: Total hip arthroplasty is increasingly performed in younger, more active patients. Thirty-five percent of patients are involved in sports preoperatively, and a desire to return to sporting activity is now a major expectation. Sporting activity potentially risks premature failure of the implant, and there is no consensus or guidelines among British or European surgeons performing total hip arthroplasty in sporting patients. METHODS: The current practice of British Hip Society members was explored through a Web-based survey. Of the 260 members surveyed, 109 responded. RESULTS: The majority of respondents (33%) would perform uncemented, 29.1% would perform hybrid, 15.5% would perform fully cemented, and 11.7% would perform a resurfacing hip arthroplasty for sporting patients. The preferred approach is the standard posterior (68.9%) and preferred bearing couples are ceramic-on-ceramic (39.8%) and ceramic-on-polyethylene (36.9%). Half of respondents would opt for a femoral head smaller than 36 mm, whereas 22.3% would use a head 36 mm or larger. A third would allow patients to return to sports between 6 and 12 weeks after surgery, whereas 43.7% advise patients to wait until 3 months postoperatively. All respondents allow patients to return to low-impact activities, but significant caution is exercised with regard to taking part in high-impact activities. CONCLUSION: We report the practice of a specialist group of hip surgeons, the majority of which consider themselves young adult hip specialists. We believe that these data may be of use to help inform the practice of our colleagues when performing arthroplasty in sporting patients and may serve to inform future consensus guidelines.

An Analysis of Reported Cases of Fracture of the Universal Exeter Femoral Stem Prosthesis.

BACKGROUND: Between 1991 and 2008, approximately 80 cases of fracture (neck or stem) have been reported. This study aimed at determining factors predisposing to implant fracture. METHODS: Clinical, surgical, radiological, and retrieval data were collated. Risk factors associated with fracture were categorized to patient related (weight and activity levels), surgical related (poor medial support, component size, and placement), and anatomic/implant related (head size/offset). RESULTS: Data was available on 60 patients (32 stem and 28 neck fractures). Mean patient age at fracture was similar for both neck and stem fractures (69 years, 67 years, respectively). Also, 77% neck and 52% stem fractures occurred in men. Mean weight was 107 kg in neck and 96.5 kg in stem fractures with 68% neck and 38% stem fractures either obese or morbidly obese. Mean time to fracture was 78 months (range, 36-144 months) for neck and 76 months (range, 2-155 months) for stem fractures. 44#2 and 44#3 were the most common sizes associated with neck fractures. Stem fractures occurred more commonly (84%) in the smaller sizes (35.5 to 44#1). Elongated femoral heads were used in 69% neck and 14% stem fractures. CONCLUSION: Neck fractures were most commonly associated with patient-related (increased weight and activity) and implant-related (use of an elongated femoral head) factors. Stem fractures were most commonly associated with correctable surgical-related causes, predominantly secondary to stem undersizing or inadequate medial support (84%).

Detailed Analysis of High Frequency Auditory Brainstem Response in Patients with Tinnitus: A Preliminary Study.

ABSTRACT: Increased spontaneous activity and aberrant neural synchrony is thought to be the underlying cause of tinnitus. The perceived pitch of tinnitus may be dictated by frequency specific neural fibers of the subcortical pathway, or the projection of altered cortical activity by-way-of tonotopic reorganizations. Subcortical neural activity in relation to tinnitus was characterized using ABR measurements. In the present study, 11 patients (21 ears) with constant tonal tinnitus underwent a two-part experiment. Experiment 1 involved click ABR measurements and included two experimental groups: tinnitus with normal hearing from 2000-4000 Hz (GI) and tinnitus with hearing loss within the range of 2000-4000 Hz (GII). Experiment 2 utilized tone burst ABRs matched to each participant's perceived tinnitus pitch and included two experimental groups: tinnitus with normal hearing at the tinnitus pitch (GIa) and tinnitus with hearing loss at the tinnitus pitch (GIIa). These groups were compared to a control group (GIII) of ten monaurally tested (10 ears) participants with normal hearing thresholds at 250-20000 Hz and no tinnitus. Click ABR results indicate significantly prolonged V-III IPLs for GI and GII and a significantly extended absolute V latency for GII only. Tone burst ABRs matched to tinnitus pitch revealed significantly prolonged absolute latencies and IPLs at three of the seven frequencies for GIIa. ABR threshold seeking was completed and revealed negative eHL values for two of the four different stimuli for GI and GIa and four of the eight stimuli for GII and GIIa. Click ABRs results are suggestive of upper brainstem abnormalities for both groups. While GI demonstrated prolonged V-III IPLs, no significant differences were found for GIa. This suggests that there is no frequency specific subcortical characteristic associated with tinnitus with normal hearing. Frequency specific properties for subcortical activity could not be characterized due to varying results of GIIa.

Paravertebral block versus thoracic epidural for patients undergoing thoracotomy.

BACKGROUND: Operations on structures in the chest (usually the lungs) involve cutting between the ribs (thoracotomy). Severe post-thoracotomy pain can result from pleural (lung lining) and muscular damage, costovertebral joint (ribcage) disruption and intercostal nerve (nerves that run along the ribs) damage during surgery. Poor pain relief after surgery can impede recovery and increase the risks of developing complications such as lung collapse, chest infections and blood clots due to ineffective breathing and clearing of secretions. Effective management of acute pain following thoracotomy may prevent these complications and reduce the likelihood of developing chronic pain. A multi-modal approach to analgesia is widely employed by thoracic anaesthetists using a combination of regional anaesthetic blockade and systemic analgesia, with both non-opioid and opioid medications and local anaesthesia blockade.There is some evidence that blocking the nerves as they emerge from the spinal column (paravertebral block, PVB) may be associated with a lower risk of major complications in thoracic surgery but the majority of thoracic anaesthetists still prefer to use a thoracic epidural blockade (TEB) as analgesia for their patients undergoing thoracotomy. In order to bring about a change in practice, anaesthetists need a review that evaluates the risk of all major complications associated with thoracic epidural and paravertebral block in thoracotomy. OBJECTIVES: To compare the two regional techniques of TEB and PVB in adults undergoing elective thoracotomy with respect to:1. analgesic efficacy;2. the incidence of major complications (including mortality);3. the incidence of minor complications;4. length of hospital stay;5. cost effectiveness. SEARCH METHODS: We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 9); MEDLINE via Ovid (1966 to 16 October 2013); EMBASE via Ovid (1980 to 16 October 2013); CINAHL via EBSCO host (1982 to 16 October 2013); and reference lists of retrieved studies. We handsearched the Journal of Cardiothoracic Surgery and Journal of Cardiothoracic and Vascular Anesthesia (16 October 2013). We reran the search on 31st January 2015. We found one additional study which is awaiting classification and will be addressed when we update the review. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) comparing PVB with TEB in thoracotomy, including upper gastrointestinal surgery. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors (JY and SG) independently assessed the studies for inclusion and then extracted data as eligible for inclusion in qualitative and quantitative synthesis (meta-analysis). MAIN RESULTS: We included 14 studies with a total of 698 participants undergoing thoracotomy. There are two studies awaiting classification. The studies demonstrated high heterogeneity in insertion and use of both regional techniques, reflecting real-world differences in the anaesthesia techniques. Overall, the included studies have a moderate to high potential for bias, lacking details of randomization, group allocation concealment or arrangements to blind participants or outcome assessors. There was low to very low-quality evidence that showed no significant difference in 30-day mortality (2 studies, 125 participants. risk ratio (RR) 1.28, 95% confidence interval (CI) 0.39 to 4.23, P value = 0.68) and major complications (cardiovascular: 2 studies, 114 participants. Hypotension RR 0.30, 95% CI 0.01 to 6.62, P value = 0.45; arrhythmias RR 0.36, 95% CI 0.04 to 3.29, P value = 0.36, myocardial infarction RR 3.19, 95% CI 0.13, 76.42, P value = 0.47); respiratory: 5 studies, 280 participants. RR 0.62, 95% CI 0.26 to 1.52, P value = 0.30). There was moderate-quality evidence that showed comparable analgesic efficacy across all time points both at rest and after coughing or physiotherapy (14 studies, 698 participants). There was moderate-quality evidence that showed PVB had a better minor complication profile than TEB including hypotension (8 studies, 445 participants. RR 0.16, 95% CI 0.07 to 0.38, P value < 0.0001), nausea and vomiting (6 studies, 345 participants. RR 0.48, 95% CI 0.30 to 0.75, P value = 0.001), pruritis (5 studies, 249 participants. RR 0.29, 95% CI 0.14 to 0.59, P value = 0.0005) and urinary retention (5 studies, 258 participants. RR 0.22, 95% CI 0.11 to 0.46, P value < 0.0001). There was insufficient data in chronic pain (six or 12 months). There was no difference found in and length of hospital stay (3 studies, 124 participants). We found no studies that reported costs. AUTHORS' CONCLUSIONS: Paravertebral blockade reduced the risks of developing minor complications compared to thoracic epidural blockade. Paravertebral blockade was as effective as thoracic epidural blockade in controlling acute pain. There was a lack of evidence in other outcomes. There was no difference in 30-day mortality, major complications, or length of hospital stay. There was insufficient data on chronic pain and costs. Results from this review should be interpreted with caution due to the heterogeneity of the included studies and the lack of reliable evidence. Future studies in this area need well-conducted, adequately-powered RCTs that focus not only on acute pain but also on major complications, chronic pain, length of stay and costs.

Effect of Repetitive, Subconcussive Impacts on Electrophysiological Measures of Attention.

OBJECTIVES: In this preliminary study, the auditory P3b response, when measured during a visually distracting task, was investigated as an index of change in cognitive function resulting from exposure to subconcussive impacts (SCIs) in collision sports over time. METHODS: Both pre- and postseason P3b responses were examined in seven first-year collegiate-level American football players. Comparisons were made between a group of seven third- and fourth-year players and a control group of seven noncontact athletes. RESULTS: No difference in P3b amplitude was revealed in pre- versus postseason data of the first-year players. Furthermore, no P3b amplitude differences were found when comparing first-year players with controls. P3b amplitudes of third- and fourth-year players versus first-year players were smaller along the midline electrode sites. CONCLUSIONS: Preliminary results suggest exposure to SCIs during the course of a season does not affect brain function negatively, as measured by the P3b response; however, differences between first-year players and the group of third- and fourth-year players suggest that exposure to hundreds of SCIs in multiple seasons leads to changes in brain activation patterns. Subtle effects such as difficulty with attentional resource allocation may develop. Longitudinal studies are necessary before definitive conclusions can be drawn.

Management of periprosthetic joint infection after total hip arthroplasty using a custom made articulating spacer (CUMARS); the Exeter experience.

Periprosthetic joint infection (PJI) after THA is a major complication with an incidence of 1%-3%. We report our experiences with a technique using a custom-made articulating spacer (CUMARS) at the first of two-stage treatment for PJI. This technique uses widely available all-polyethylene acetabular components and the Exeter Universal stem, fixed using antibiotic loaded acrylic cement. Seventy-six hips were treated for PJI using this technique. Performed as the first of a two-stage procedure, good functional results were commonly seen, leading to postponing second stage indefinitely with retention of the CUMARS prosthesis in 34 patients. The CUMARS technique presents an alternative to conventional spacers, using readily available components that are well tolerated, allowing weight bearing and mobility, and achieving comparable eradication rates.

The Exeter-Trident THA with ceramic-on-ceramic-bearings: 10-year outcomes in 275 total hip arthroplasties.

AIMS: This study reports on the Exeter-Trident total hip arthroplasty (THA) using an alumina ceramic-on-ceramic bearing with 10-year clinical and radiographic follow-up. PATIENTS AND METHODS: Between January 2001 and January 2006, 275 THAs were performed. Mean age at surgery was 52.7 (17-86) years, with 84 patients (33.6%) aged <50 years. The primary outcome was all-cause construct survival at minimum 10 years. Secondary outcomes included functional and noise scores. Radiographs were compared between baseline and latest follow-up and assessed for component loosening, migration and lysis. RESULTS: No patient was lost to follow-up. Mean follow-up for surviving patients was 12.5 (9.5-15.6) years. Kaplan-Meier survival for all-cause revision was 94.0% (95% CI, 90.5-97.5) at 14.3 years. 2 patients had a femoral component fracture. All scores improved significantly at latest follow-up. HSS-NQ for 247 hips (90.2%) at mean 9.1 (7.0-14.4) years post implantation showed most hips (93.1%) reported no more than occasional noise. At minimum 5 years, radiolucency around the acetabular component was observed in 2 hips (0.8%), and lysis at the interface in 1 hip (0.4%). On the femoral side, endosteal lysis was observed in 7 hips. CONCLUSIONS: The Exeter-Trident THA with alumina ceramic-on-ceramic bearings performed well in this population. Patients are at low risk of revision in the first decade. However, there is a small risk of stem fracture as a late complication and some patients experience significant noise.

Revision of metal-on-metal hip replacements with dual-mobility bearings and acetabular component retention.

Aims: In metal-on-metal (MoM) hip arthroplasties and resurfacings, mechanically induced corrosion can lead to elevated serum metal ions, a local inflammatory response, and formation of pseudotumours, ultimately requiring revision. The size and diametral clearance of anatomical (ADM) and modular (MDM) dual-mobility polyethylene bearings match those of Birmingham hip MoM components. If the acetabular component is satisfactorily positioned, well integrated into the bone, and has no surface damage, this presents the opportunity for revision with exchange of the metal head for ADM/MDM polyethylene bearings without removal of the acetabular component. Methods: Between 2012 and 2020, across two centres, 94 patients underwent revision of Birmingham MoM hip arthroplasties or resurfacings. Mean age was 65.5 years (33 to 87). In 53 patients (56.4%), the acetabular component was retained and dual-mobility bearings were used (DM); in 41 (43.6%) the acetabulum was revised (AR). Patients underwent follow-up of minimum two-years (mean 4.6 (2.1 to 8.5) years). Results: In the DM group, two (3.8%) patients underwent further surgery: one (1.9%) for dislocation and one (1.9%) for infection. In the AR group, four (9.8%) underwent further procedures: two (4.9%) for loosening of the acetabular component and two (4.9%) following dislocations. There were no other dislocations in either group. In the DM group, operating time (68.4 vs 101.5 mins, p < 0.001), postoperative drop in haemoglobin (16.6 vs 27.8 g/L, p < 0.001), and length of stay (1.8 vs 2.4 days, p < 0.001) were significantly lower. There was a significant reduction in serum metal ions postoperatively in both groups (p < 0.001), although there was no difference between groups for this reduction (p = 0.674 (cobalt); p = 0.186 (chromium)). Conclusion: In selected patients with Birmingham MoM hips, where the acetabular component is well-fixed and in a satisfactory position with no surface damage, the metal head can be exchanged for polyethylene ADM/MDM bearings with retention of the acetabular prosthesis. This presents significant benefits, with a shorter procedure and a lower risk of complications.

The results of acetabular impaction grafting in 129 primary cemented total hip arthroplasties.

Between 1995 and 2003, 129 cemented primary THAs were performed using full acetabular impaction grafting to reconstruct acetabular deficiencies. These were classified as cavitary in 74 and segmental in 55 hips. Eighty-one patients were reviewed at mean 9.1 (6.2-14.3) years post-operatively. There were seven acetabular component revisions due to aseptic loosening, and a further 11 cases that had migrated >5mm or tilted >5° on radiological review - ten of which reported no symptoms. Kaplan-Meier analysis of revisions for aseptic loosening demonstrates 100% survival at nine years for cavitary defects compared to 82.6% for segmental defects. Our results suggest that the medium-term survival of this technique is excellent when used for purely cavitary defects but less predictable when used with large rim meshes in segmental defects.