III.

Introduction Total knee arthroplasty (TKA) surgery can be associated with significant blood loss. Among the problems associated with such blood loss is the need for transfusions of banked blood [ 1 ]. Transfusions not only have a financial consequence but also carry a small risk of disease transmission to the patient. Antifibrinolytics have been successfully used to reduce transfusion requirements in elective arthroplasty patients. The objective of this meta-analysis is to determine which of tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) is more effective for reducing peri-operative blood loss, and lessening the need for blood transfusion following knee arthroplasty surgery. Materials and methods MEDLINE, Embase and CINAHL databases were searched for relevant articles published between January 1980 to January 2018 for the purpose of identifying studies comparing TXA and EACA for TKA surgery. A double-extraction technique was used, and included studies were assessed regarding their methodological quality prior to analysis. Outcomes analysed included blood loss, pre- and post-operative haemoglobin, number of patients requiring transfusion, number of units transfused, operative and tourniquet time, and complications associated with antifibrinolytics. Results Three studies contributed to the quantitative analysis of 1691 patients, with 743 patients included in the TXA group and 948 in the EACA group. Estimated blood loss was similar between the two groups [95% confidence interval (CI) −0.50, 0.04; Z = 1.69; P = 0.09]. There were no differences between the two groups regarding the percentage of patients requiring transfusion (95% CI 0.14, 4.13; Z = 0.31; P = 0.76). There was no difference in the pre- and post-operative haemoglobin difference between the two groups (95% CI −0.36, 0.24; Z = 0.38; P = 0.70). There was no difference in the average number of transfused units (95% CI −0.53, 0.25; Z = 0.71; P = 0.48). There was no difference in the operative (95% CI −0.35, 0.36; Z = 0.04; P = 0.97) or tourniquet time (95% CI −0.16, 0.34; Z = 0.72; P = 0.47). Similarly, there was no difference in the percentage of venous thromboembolism between the two groups (95% CI 0.17, 2.80; Z = 0.51; P = 0.61). Conclusions This study did not demonstrate TXA to be superior to EACA. In fact, both antifibrinolytic therapies demonstrated similar efficacy in terms of intra-operative blood loss, transfusion requirements and complication rates. Currently EACA has a lower cost, which makes it an appealing alternative to TXA for TKA s...

Introduction Internal fixation of undisplaced intracapsular femoral neck fractures with cannulated hip screws is a widely accepted surgical technique, despite reported failure rates of 12%-19%. This study determined whether preoperative serum albumin levels are linked to fixation failure. Methods We retrospectively reviewed 251 consecutive undisplaced intracapsular femoral neck fracture patients treated with cannulated hip screws in a district general hospital. Preoperative albumin levels were measured, and the fixation technique, classification and posterior tilt on radiography assessed. Fixation failure was defined as a screw cut, avascular necrosis (AVN) or non-union. Results Of the patients, 185 were female and 66 male. The mean age was 77 years (range 60-101 years). Thirty seven (15%) patients had fixation failure: 10 (4%) due to AVN; 12 (5%) due to non-union; and 15 (6%) due to fixation collapse. Low serum albumin levels were significantly associated with failure (p=0.01), whereas gender (p=0.56), operated side (p=0.62), age (p=0.34) and screw configuration (p=0.42) were not. A posterior tilt angle greater than 20° on lateral radiography significantly predicted failure (p=0.002). Conclusions Preoperative serum albumin is an independent predictor of cannulated hip screw fixation failure in undisplaced femoral neck fractures. Nutritional status should therefore be considered when deciding between surgical fixation and arthroplasty to avoid the possibility of revision surgery, along with an increased risk of morbidity and mortality.

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BackgroundThe aim of our study was to determine the rate and preoperative predictors of intraoperative fracture (IOF) during hip hemiarthroplasty (HA) in patients who have sustained a fragility hip fracture injury.MethodsWe reviewed 626 patients who underwent HA at our institution using the National Hip Fracture Database. Various patient- and surgery-related data including demographic information, cement usage, surgeon grade, time to surgery, and operative duration were collected. The metaphyseal diaphyseal index and modified canal bone ratio were measured on preoperative radiographs. We compared patients with and without IOF with respect to all variables collected. Multivariate regression modeling was used to identify significant preoperative risk factors for IOF.ResultsThere was a 7% incidence of IOF in our cohort exclusively comprising of Vancouver A fractures. The majority of these complications were treated nonoperatively (52%). There was no statistically significant difference with respect to cement usage, surgeon grade, operative duration, time to surgery, and radiographic parameters collected. Increasing age was found to be the most significant preoperative risk factor for predicting IOF (p = 0.024, overall relative risk = 1.06).ConclusionsOur identified predictor of increasing age is nonmodifiable and illustrates the importance of meticulous surgical technique in older patients. Furthermore, its independence from fixation methods or prosthesis design as a predictor of IOF may support using an uncemented prosthesis in patients at risk from cement implantation.

Objective. Iliotibial band friction syndrome (ITBFS) is the second most common cause of knee pain in runners, and the most common cause of lateral knee pain. This systematic review and meta-analysis evaluates 1) lower-limb biomechanics and 2) conservative interventions in ITBFS. Methods. The MEDLINE, CINAHL, SPORTSDiscus, Web of Science, and Google Scholar databases were searched in April 2018 for studies investigating lower limb biomechanics and conservative treatment in iliotibial band friction syndrome. Results. Eighteen studies were identified. Moderate evidence from prospective studies indicate 1) greater hip adduction and knee internal rotation (IR) at footstrike and through stance, and 2) greater rearfoot eversion at foot strike represent possible mechanisms for ITBFS. Moderate evidence from case-control studies indicate ITBFS participants exhibit 1) reduced hip adduction, 2) greater knee and hip IR at footstrike and through stance, and 3) reduced rearfoot eversion at foot strike. Moderate evidence indicates that a six-week rehabilitation programme involving NSAID prescription, ITB stretching, and hip abductor strengthening reduces knee pain during physical activity, and prevents ITBFS recurrence in the medium term (≤ 6 months). Conclusion. Greater hip adduction, knee IR, and rearfoot eversion represent possible risk factors for ITBFS. Greater hip adduction and rearfoot eversion appear to be risk factors which are reduced by ITBFS patients, to lower pain associated with ITB strain, ITB friction and compression. Addressing the absence of research evaluating lower limb electromyography is needed to understand the influence of muscle function on ITBFS. A six-week rehabilitation programme involving NSAID prescription, ITB stretching, and hip abductor strengthening effectively reduces pain and prevents recurrence for up to six months.

Background Osteopenia is a known risk factor for sustaining skeletal fractures. Prevention of fragility fractures has obvious clinical and economic advantages, however screening all patients using a dual energy X-ray absorptiometry (DXA) is controversial not only because of the cost implications but also because it would potentially involve exposing a percentage of normal patients to unnecessary radiation. We wished to assess whether a simple hand X-ray measuring the 2nd metacarpal cortical index (2MCI) could be used as a simple screening tool for identifying patients with osteopenia. Methods We retrospectively collected the radiographic data of 206 patients who had a simple radiograph of the hand and a DXA scan within one year of each other from our picture archiving and communication system database. The 2MCI was calculated for all patients. As data was parametric, a Pearson’s correlation was performed to assess association between T-scores and 2MCI. Further analysis involved the construction of receiver operating characteristic (ROC) curves to identify a 2MCI index, which would give the most appropriate sensitivity and specificity values for identifying the presence of osteopenia. Results A statistically significant and moderate correlation between DXA T-scores and 2MCI values was found (r=0.54, n=206, P <0.001). Further ROC curve analysis of normal and osteopenic subjects identified that a 2MCI of 41.5 had a sensitivity of 100% and specificity of 53% for detecting osteopenia. Conclusions Our results support the use of the 2MCI as a simple screening tool for identifying patients with osteopenia.