Objective To assess the effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery. Design Phase III, randomised, double blind, placebo controlled trial. Setting 34 centres in France, December 2017 to March 2019. Participants 1222 adults (>50 years) requiring major non-cardiac surgery with an expected duration of more than 90 minutes. The anticipated time frame for recruitment was 24 months. Interventions Participants were randomised to receive either dexamethasone (0.2 mg/kg immediately after the surgical procedure, and on day 1) or placebo. Randomisation was stratified on the two prespecified criteria of cancer and thoracic procedure. Main outcomes measures The primary outcome was a composite of postoperative complications or all cause mortality within 14 days after surgery, assessed in the modified intention-to-treat population (at least one treatment administered). Results Of the 1222 participants who underwent randomisation, 1184 (96.9%) were included in the modified intention-to-treat population. 14 days after surgery, 101 of 595 participants (17.0%) in the dexamethasone group and 117 of 589 (19.9%) in the placebo group had complications or died (adjusted odds ratio 0.81, 95% confidence interval 0.60 to 1.08; P=0.15). In the stratum of participants who underwent non-thoracic surgery (n=1038), the primary outcome occurred in 69 of 520 participants (13.3%) in the dexamethasone group and 93 of 518 (18%) in the placebo group (adjusted odds ratio 0.70, 0.50 to 0.99). Adverse events were reported in 288 of 613 participants (47.0%) in the dexamethasone group and 296 of 609 (48.6%) in the placebo group (P=0.46). Conclusions Dexamethasone was not found to significantly reduce the incidence of complications and death in patients 14 days after major non-cardiac surgery. The 95% confidence interval for the main result was, however, wide and suggests the possibility of important clinical effectiveness. Trial registration ClinicalTrials.gov NCT03218553 .

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Background?Open reduction with internal fixation (ORIF) is currently the gold standard treatment of acute perilunate injuries (PLIs). Less invasive surgery, including arthroscopic techniques, has recently emerged in the hope that results similar to those of ORIF could be obtained with less tissue disturbance. Our purpose was to review retrospectively a series of selected PLIs treated with arthroscopic assistance over the past 10 years. Materials and Methods?Between 2004 and 2014, a total of 135 acute PLIs were surgically treated in our unit. A total of 27 patients were treated with arthroscopic assistance, among whom 18 were reviewed clinically and radiologically. Description of Technique?After an initial closed gross reduction, radio- and midcarpal arthroscopy were performed to clean up the debris and assess the cartilaginous, bony, and ligamentous damage. In 22 cases arthroscopy was followed by either radiolunate and lunotriquetral pinning, scapholunate ligament repair, and SL joint pinning or ORIF of a scaphoid fracture through a mini-invasive dorsal approach. In the remaining six cases, fixation of the ligamentous and/or bony injuries was done using arthroscopy alone. Results?Arthroscopic findings are presented as well as the clinical results in a subgroup of patients. At final follow-up, visual analog scale (VAS) pain was rated 18/100 on average (minimum 0, maximum 50). If we consider only the patients without reflex sympathetic dystrophy (RSD; n?=?14), the average active wrist flexion-extension was 87? (58% of the normal contralateral side) and the average grip strength was 30?kg (71% of the normal contralateral side). Conclusions?Although no statistical comparisons were made, we found that the results were similar to those of ORIF. The results of our study suggest that the use of arthroscopy to treat selected PLIs may be a reliable adjunct either alone or in combination with a dorsal mini-open approach.

Background?Volar plating for acute distal radius fractures (DRF) in the elderly has been recommended. Some studies have suggested that open reduction with internal fixation (ORIF) in this situation results in frequent complications. Our purposes were to provide a definition of irreparable DRF in independent elderly patients and to review the results of a preliminary retrospective series of wrist hemiarthroplasty (WHA) in this patient population. Materials?Between 2011 and 2014, 11 consecutive independent elderly patients (12 wrists) with irreparable intra-articular DRF were treated with primary WHA at the acute stage. A resection of the ulnar head was associated in nine wrists. A total of 11 wrists with more than 2 years of follow-up form the basis of this paper. Description of Technique?The approach was dorsal longitudinal. An osteotome longitudinally entered the dorsal aspect of the fracture medial to the Lister tubercle. Two thick osteoperiosteal flaps were elevated radially and ulnarly in a fashion similar to opening a book. The distal radius articular surface was excised. The implant was pressed into the radial canal with attention to restoring distal radius length. The two osteoperiosteal flaps were brought back together and sutured so as to close, again like a book, the osseous and soft tissues around the implant. Results?At mean follow-up of 30 months, average visual analog scale (VAS) pain was 1/10. Mean QuickDASH (Disabilities of the Arm, Shoulder and Hand) score was 32, and mean Patient-Rated Wrist Evaluation (PRWE) score was 24. Mean forearm rotation arc was 151?. Mean active flexion-extension arc was 60?. Mean active extension was 34?. Mean grip strength was 14?kg (64% of contralateral wrist). Mean Lyon wrist score was 73%. Bone healing around the implants was satisfactory in all but one case. Conclusions?Out data suggest that treatment of irreparable DRF in the independent elderly patient with a bone-preserving WHA may be a viable option. Longer-term follow-up and comparative studies are needed to confirm the validity of this concept.

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