Aims The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip. Methods In this single-centre, randomized controlled trial, elderly patients undergoing surgery for a hip fracture, either hemiarthroplasty for a subcapital fracture or intramedullary nailing for an IT fracture, were screened for inclusion. Patients were randomly allocated to a study group using a sealed envelope. The TXA group consisted of 77 patients, (35 with a subcapital fracture and 42 with an IT fracture), and the control group consisted of 88 patients (29 with a subcapital fracture and 59 with an IT fracture). One dose of 15 mg/kg of intravenous (IV) TXA diluted in 100 ml normal saline (NS,) or one dose of IV placebo 100 ml NS were administered before the incision was made. The haemoglobin (Hb) concentration was measured before surgery and daily until the fourth postoperative day. The primary outcomes were the total blood loss and the rate of transfusion from the time of surgery to the fourth postoperative day. Results Homogeneity with respect to baseline characteristics was ensured between groups. The mean total blood loss was significantly lower in patients who received TXA (902.4 ml (-279.9 to 2,156.9) vs 1,226.3 ml (-269.7 to 3,429.7); p = 0.003), while the likelihood of requiring a transfusion of at least one unit of red blood cells was reduced by 22%. Subgroup analysis showed that these differences were larger in patients who had an IT fracture compared with those who had a subcapital fracture. Conclusion Elderly patients who undergo intramedullary nailing for an IT fracture can benefit from a single dose of 15 mg/kg TXA before the onset of surgery. A similar tendency was identified in patients undergoing hemiarthroplasty for a subcapital fracture but not to a statistically significant level. Cite this article: Bone Joint J 2021;103-B(3):442–448.

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Reconstruction of the central band of the interosseous membrane is an emerging procedure implemented in the treatment of longitudinal radioulnar dissociation (LRUD), usually in its chronic setting, after Essex-Lopresti injuries of the forearm. There are no sufficient clinical data to support reconstruction of the central band of the interosseous membrane in acute LRUD injuries. Clinical and cadaveric studies comparing autografts (palmaris longus, flexor carpi radialis and bone-patellar-bone), allografts (Achilles tendon) and synthetic ligaments have not shown superiority of one technique versus another; however, they have shown special concerns with respect to the use of synthetic grafts. Latrogenic fracture, decrease of rotational range of movement, iatrogenic nerve injury (superficial radial and median nerve), donor site morbidity with autografts and recurrent instability are the complications reported in literature after interosseous membrane reconstruction. Cite this article: EFORT Open Rev 2019;4:143-150. DOI: 10.1302/2058-5241.4.180072

Reconstruction of the interosseous membrane has the potential to re-establish a normal loading pattern through the forearm and enhance stability after an Essex-Lopresti lesion. The aim of our study was to assess the capacity of three different techniques, which all use a regionally harvested autograft, to restore longitudinal stability. Simulation of the Essex-Lopresti lesion was done by excising the radial head and sectioning the interosseous membrane in seven cadaveric specimens. Each technique was used in each specimen consecutively, using the pronator teres, the brachioradialis and the flexor carpi radialis tendons, respectively. The specimens were submitted to mechanical testing by applying proximally migratory forces to the radius and radioulnar displacement was assessed fluroscopically at wrist level. The pronator teres tendon achieved the greatest reduction (94% correction with respect to the intact interosseous membrane/radial head out state, followed by brachioradialis (92%) and flexor carpi radialis (85%). However, no statistically significant differences in displacement data or strength were detected between the techniques.

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The reconstruction of the hip joint in patients suffering from developmental hip dysplasia (DDH) is a demanding procedure and presents many challenges to the reconstructive surgeon. Higher rates of mechanical complications are present in this group of patients. The results of cemented and uncemented implants used in DDH patients are very promising, according to recent outcomes. However, the surgeon has to be aware of several complications, in order to establish an uneventful surgical management of DDH. The specific article investigates the technical challenges and clinical results of total hip arthroplasty in patients with DDH.

To assess the interobserver agreement of the most widely used classification systems (Schatzker, AO Foundation-Orthopaedic Trauma Association (AO-OTA), and Luo) and investigate the impact of multiplane CT scans on their reliability. MethodsTwelve raters (seven consultants and five senior trainees) were invited to classify 25 cases of tibial plateau fracture randomly selected out of a large database. Initially, they were asked to classify the fracture according to Schatzker, AO-OTA, and Luo based on plain anteroposterior (AP) X-ray and axial CT images. This procedure was applied for 25 cases consecutively. Next, the raters are given access to the multiplanar CT views of the same cases and were requested to reclassify each case. The interobserver agreement was calculated using the Fleiss kappa coefficient. ResultsAn overall fair inter-rater agreement was observed for the Schatzker classification based on the plain AP Xray (k=0.361) with a slight improvement after three-dimensional (3D) plane CT views (X-ray: k=0.361; 3D CT: k=0.364). For the AO-OTA classification, the relevant values were 0.204 and 0.231 based on plain X-ray and multiplanar CT, respectively. Finally, the Luo classification achieved the highest scores among the three classification systems (k=0.498), but its inter-rater agreement can still be characterized as moderate. No statistically significant improvement in the interobserver agreement was found for any classification even if only the consultants' subgroup was included in the data analysis. ConclusionAll three classification systems failed to achieve a substantial agreement among the raters, with only a nonsignificant improvement after providing advanced imaging. This finding reflects the intrinsic weaknesses of the classification systems themselves rather than the disagreement on the fracture pattern due to unsatisfactory imaging.

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