Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures.

BACKGROUND: Pelvic, hip, and long bone fractures can result in significant bleeding at the time of injury, with further blood loss if they are treated with surgical fixation. People undergoing surgery are therefore at risk of requiring a blood transfusion and may be at risk of peri-operative anaemia. Pharmacological interventions for blood conservation may reduce the risk of requiring an allogeneic blood transfusion and associated complications. OBJECTIVES: To assess the effectiveness of different pharmacological interventions for reducing blood loss in definitive surgical fixation of the hip, pelvic, and long bones. SEARCH METHODS: We used a predefined search strategy to search CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Transfusion Evidence Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) from inception to 7 April 2022, without restrictions on language, year, or publication status. We handsearched reference lists of included trials to identify further relevant trials. We contacted authors of ongoing trials to acquire any unpublished data. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of people who underwent trauma (non-elective) surgery for definitive fixation of hip, pelvic, and long bone (pelvis, tibia, femur, humerus, radius, ulna and clavicle) fractures only. There were no restrictions on gender, ethnicity, or age. We excluded planned (elective) procedures (e.g. scheduled total hip arthroplasty), and studies published since 2010 that had not been prospectively registered. Eligible interventions included: antifibrinolytics (tranexamic acid, aprotinin, epsilon-aminocaproic acid), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. We did not perform a network meta-analysis due to lack of data. MAIN RESULTS: We included 13 RCTs (929 participants), published between 2005 and 2021. Three trials did not report any of our predefined outcomes and so were not included in quantitative analyses (all were tranexamic acid versus placebo). We identified three comparisons of interest: intravenous tranexamic acid versus placebo; topical tranexamic acid versus placebo; and recombinant factor VIIa versus placebo. We rated the certainty of evidence as very low to low across all outcomes. Comparison 1. Intravenous tranexamic acid versus placebo Intravenous tranexamic acid compared to placebo may reduce the risk of requiring an allogeneic blood transfusion up to 30 days (RR 0.48, 95% CI 0.34 to 0.69; 6 RCTs, 457 participants; low-certainty evidence) and may result in little to no difference in all-cause mortality (Peto odds ratio (Peto OR) 0.38, 95% CI 0.05 to 2.77; 2 RCTs, 147 participants; low-certainty evidence).  It may result in little to no difference in risk of participants experiencing myocardial infarction (risk difference (RD) 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 199 participants; low-certainty evidence), and cerebrovascular accident/stroke (RD 0.00, 95% CI -0.02 to 0.02; 3 RCTs, 324 participants; low-certainty evidence).  We are uncertain if there is a difference between groups for risk of deep vein thrombosis (Peto OR 2.15, 95% CI 0.22 to 21.35; 4 RCTs, 329 participants, very low-certainty evidence), pulmonary embolism (Peto OR 1.08, 95% CI 0.07 to 17.66; 4 RCTs, 329 participants; very low-certainty evidence), and suspected serious drug reactions (RD 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 185 participants; very low-certainty evidence). No data were available for number of red blood cell units transfused, reoperation, or acute transfusion reaction. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures), and upgraded the evidence for transfusion requirement for a large effect.  Comparison 2. Topical tranexamic acid versus placebo We are uncertain if there is a difference between topical tranexamic acid and placebo for risk of requiring an allogeneic blood transfusion (RR 0.31, 95% CI 0.08 to 1.22; 2 RCTs, 101 participants), all-cause mortality (RD 0.00, 95% CI -0.10 to 0.10; 1 RCT, 36 participants), risk of participants experiencing myocardial infarction (Peto OR 0.15, 95% CI 0.00 to 7.62; 1 RCT, 36 participants), cerebrovascular accident/stroke (RD 0.00, 95% CI -0.06 to 0.06; 1 RCT, 65 participants); and deep vein thrombosis (Peto OR 1.11, 95% CI 0.07 to 17.77; 2 RCTs, 101 participants).  All outcomes reported were very low-certainty evidence. No data were available for number of red blood cell units transfused, reoperation, incidence of pulmonary embolism, acute transfusion reaction, or suspected serious drug reactions. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), inconsistency (moderate heterogeneity), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures, and high risk of attrition and reporting biases in one trial). Comparison 3. Recombinant factor VIIa versus placebo   Only one RCT of 48 participants reported data for recombinant factor VIIa versus placebo, so we have not presented the results here. AUTHORS' CONCLUSIONS: We cannot draw conclusions from the current evidence due to lack of data. Most published studies included in our analyses assessed the use of tranexamic acid (compared to placebo, or using different routes of administration).  We identified 27 prospectively registered ongoing RCTs (total target recruitment of 4177 participants by end of 2023). The ongoing trials create six new comparisons: tranexamic acid (tablet + injection) versus placebo; intravenous tranexamic acid versus oral tranexamic acid; topical tranexamic acid versus oral tranexamic acid; different intravenous tranexamic acid dosing regimes; topical tranexamic acid versus topical fibrin glue; and fibrinogen (injection) versus placebo.

Distal third clavicle fractures : a nationwide trainee-led collaborative review of current practice.

AIMS: Distal third clavicle (DTC) fractures are increasing in incidence. Due to their instability and nonunion risk, they prove difficult to treat. Several different operative options for DTC fixation are reported but current evidence suggests variability in operative fixation. Given the lack of consensus, our objective was to determine the current epidemiological trends in DTC as well as their management within the UK. METHODS: A multicentre retrospective cohort collaborative study was conducted. All patients over the age of 18 with an isolated DTC fracture in 2019 were included. Demographic variables were recorded: age; sex; side of injury; mechanism of injury; modified Neer classification grading; operative technique; fracture union; complications; and subsequent procedures. Baseline characteristics were described for demographic variables. Categorical variables were expressed as frequencies and percentages. RESULTS: A total of 859 patients from 18 different NHS trusts (15 trauma units and three major trauma centres) were included. The mean age was 57 years (18 to 99). Overall, 56% of patients (n = 481) were male. The most common mechanisms of injury were simple fall (57%; n = 487) and high-energy fall (29%; n = 248); 87% (n = 748) were treated conservatively and 54% (n = 463) were Neer type I fractures. Overall, 32% of fractures (n = 275) were type II (22% type IIa (n = 192); 10% type IIb (n = 83)). With regards to operative management, 89% of patients (n = 748) who underwent an operation were under the age of 60. The main fixation methods were: hook plate (n = 47); locking plate (n = 34); tightrope (n = 5); and locking plate and tight rope (n = 7). CONCLUSION: Our study is the largest epidemiological review of DTC fractures in the UK. It is also the first to review the practice of DTC fixation. Most fractures are being treated nonoperatively. However, younger patients, suffering a higher-energy mechanism of injury, are more likely to undergo surgery. Hook plates are the predominantly used fixation method followed by locking plate. The literature is sparse on the best method of fixation for optimal outcomes for these patients. To answer this, a pragmatic RCT to determine optimal fixation method is required.Cite this article: Bone Jt Open 2022;3(12):953-959.

Elbow conditions: research priorities setting in partnership with the James Lind Alliance.

OBJECTIVE: To undertake a UK-based James Lind Alliance (JLA) Priority Setting Partnership for elbow conditions and be representative of the views of patients, carers and healthcare professionals (HCPs). SETTING: This was a national collaborative study organised through the British Elbow and Shoulder Society. PARTICIPANTS: Adult patients, carers and HCPs who have managed or experienced elbow conditions, their carers and HCPs in the UK involved in managing of elbow conditions. METHODS: The rigorous JLA priority setting methodology was followed. Electronic and paper scoping surveys were distributed to identify potential research priority questions (RPQs). Initial responses were reviewed and a literature search was performed to cross-check categorised questions. Those questions already sufficiently answered were excluded and the remaining questions were ranked in a second survey according to priority for future elbow conditions research. Using the JLA methodology, responses from HCP and patients were combined to create a list of the top 18 questions. These were further reviewed in a dedicated multistakeholder workshop where the top 10 RPQs were agreed by consensus. RESULTS: The process was completed over 24 months. The initial survey resulted in 467 questions from 165 respondents (73% HCPs and 27% patients/carers). These questions were reviewed and combined into 46 summary topics comprising: tendinopathy, distal biceps pathology, arthritis, stiffness, trauma, arthroplasty and cubital tunnel syndrome. The second (interim prioritisation) survey had 250 respondents (72% HCP and 28% patients/carers). The top 18 ranked questions from this survey were taken to the final workshop where a consensus was reached on the top 10 RPQs. CONCLUSIONS: The top 10 RPQs highlight areas of importance that currently lack sufficient evidence to guide diagnosis, treatment and rehabilitation of elbow conditions. This collaborative process will guide researchers and funders regarding the topics that should receive most future attention and benefit patients and HCPs.

Accuracy of placement of ultrasound-guided corticosteroid injection for subacromial pain (impingement) syndrome does not influence pain and function: Secondary analysis of a randomised controlled trial.

OBJECTIVES: To investigate whether the accuracy of placement of ultrasound-guided (US-guided) corticosteroid injections for subacromial pain (impingement) syndrome (SAPS) influences pain and function outcomes. METHODS: This was a secondary analysis of data collected in a previous randomised controlled trial (RCT). Video images of US-guided subacromial corticosteroid injections delivered in the RCT were reviewed to categorise injection accuracy into three groups: definitely/probably not in the subacromial bursa (Group 1); probably in the subacromial bursa (Group 2); and definitely in the subacromial bursa (Group 3). The primary outcome was the Shoulder Pain and Disability Index (SPADI) total score. Secondary outcomes included SPADI pain and function subscales and participants' self-reported global impression of change. Outcomes were compared between the accuracy groups after adjusting for pre-selected baseline characteristics. RESULTS: US-guided injection accuracy data were available for 114 participants: 22 categorised into Group 1, 21 into Group 2 and 71 into Group 3. There were no significant differences in mean total SPADI scores between the three injection accuracy groups at 6 weeks (Group 2 vs. 1: 8.22 (95% CI -4.01, 20.50); Group 3 versus 1: -0.57 (95% CI -10.27, 9.13) or 6 months (Group 2 vs. 1: 12.38 (95% CI -5.34, 30.10); Group 3 versus 1: 3.10 (95% CI -11.04, 17.23). CONCLUSIONS: The accuracy of injection placement in SAPS did not influence pain and function, suggesting that improvements in patients' outcomes using subacromial corticosteroid injections can be achieved without US guidance.

Preoperative partial-thickness rotator cuff tears do not compromise anatomic total shoulder replacement outcomes: medium-term follow-up.

BACKGROUND: Reverse total shoulder replacement (TSR) in elderly patients with primary osteoarthritis (OA) and rotator cuff pathology is increasingly being performed. The purpose of our study was to determine the medium-term results of anatomic TSR for OA in patients with established preoperative partial-thickness rotator cuff tears on magnetic resonance imaging (MRI) scans. METHODS: We reviewed a cohort of patients who had undergone anatomic TSR for OA with a preoperative MRI diagnosis of partial-thickness rotator cuff tear. Patients were assessed with preoperative and post operative Oxford Shoulder Scores, evaluation of their range-of-movement and clinical rotator cuff assessment. Anteroposterior and axillary radiographs were used to assess for any proximal humeral migration (using the Torchia classification) and any evidence of loosening. The Lazarus score was used to grade glenoid radiolucencies. RESULTS: The study comprised 36 patients (14 men and 22 women) who underwent TSR and had partial-thickness rotator cuff tears on MRI; preoperatively, all showed mild to moderate fatty infiltration. The mean age of the patients was 79.2 years (range, 75-88 years); the mean follow-up period was 5.8 years (range, 5-9 years). Significant improvements in pain and range of movement were reported in all cases. At the final follow-up, the mean Oxford Shoulder Score was 42 points (range, 32-46 points), with a minimum improvement of 14 points (P = .001). External rotation (20° vs. 40°, P = .001), forward flexion (80° vs. 140°, P = .015), abduction (45° vs. 90°, P = .015), and internal rotation also improved. Lucencies were observed in 8 glenoids, with 6 showing grade 1 Lazarus changes, 2 showing grade 2, and none showing grade 3. There were no cases of implant loosening. Clinically, 4 patients had rotator cuff weakness but only 2 showed evidence of proximal migration. One patient remained satisfied, whereas the other patient, with moderate-grade proximal migration according to the Torchia classification, underwent revision for rotator cuff failure; one further patient underwent washout and DAIR (débridement, antibiotics, and implant retention) for infection. DISCUSSION: There is a paucity of literature on whether a preoperative partial-thickness rotator cuff tear has an adverse effect on the outcome of TSR. Our results show that the presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic TSR in the medium term. With anatomic TSR having less morbidity for patients and allowing greater potential options for revision, we believe that the use of reverse shoulder arthroplasty in this cohort of patients, with partial rotator cuff tears, may not be necessary and we advocate consideration of anatomic TSR in this patient group.

Patient compliance with venous thromboembolism prophylaxis (VTE).

Venous thromboembolic disease (VTE) comprises pulmonary embolism (PE) and deep vein thrombosis (DVT), and causes morbidity and mortality, particularly in trauma and orthopaedic patients. Prevalence of 0.9% and 1.2% respectively are reported, with mortality rates up to 13.8%. Chemical thromboprophylactic agents including low molecular weight heparin (LMWH) are considered cost effective in reducing VTE risk. Evidence for anti-platelets including Aspirin for VTE prophylaxis is less compelling and is not supported as monotherapy. There has been no published data on patient compliance with LMWH in trauma outpatients. We aimed to determine whether trauma outpatients accept LMWH after discussing their VTE risk and the evidence for prophylaxis. For those accepting prophylaxis, we also investigated their compliance for the duration of immobilisation. Lower limb injured patients treated with external immobilisation over a 6 month period at our major trauma centre were included. On completion of immobilisation, they were requested to complete a 17-point questionnaire. Patients declining injectable subcutaneous LMWH as prophylaxis were offered Aspirin 75 mg as a second line agent. Seventy-five questionnaires were completed and five were excluded. Nineteen patients required surgical intervention for their injury, 51 were managed non-operatively. Thirty-one patients accepted LMWH and 30 chose Aspirin as an alternative. Nine patients declined or were not commenced on prophylaxis. Nineteen reported no missed Aspirin doses and 25 reported no missed LMWH doses. No patients reported missed doses due to pain, side effects or cessation of treatment for another reason. The mean average pain score recorded on the VAS was 3.8. No patients in the study were diagnosed with a VTE. LMWH is a recognised chemical thromboprophylactic and is well tolerated by patients for VTE risk reduction in lower limb immobilised outpatients. With poor evidence supporting Aspirin as a solo prophylactic agent, our local policy has withdrawn Aspirin for this purpose.

Avascular necrosis complicating chondral resurfacing techniques.

Autologous chondrocyte implantation (ACI) and mosaicplasty have become established operations used to treat full-thickness chondral lesions in the knee and elsewhere. Although complications of both have been documented, there are no previous reports of avascular necrosis (AVN) complicating these procedures. Awareness of AVN as a complication of ACI might have prompted an earlier diagnosis, with possible non-surgical treatment or more minor surgery being possible. At the very least, an appropriate form of management could have been initiated earlier, so shortening the period of disability and suffering for the patient.

Rare and unusual metastases of a gastrointestinal stromal tumour.

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract, histological and immunohistochemistry findings help to differentiate such tumours from other gastrointestinal malignancies. Metastasis is common to the stomach and small bowel and often presents with gastrointestinal bleeding. This is a case of an 82 year old man with an inguinal mass that following exploratory examination was found on histology to be a GIST metastases, imaging also showed pulmonary metastases. Following colonoscopy the primary caecal mass was found. Such metastatic presentations are extremely rare for this type of tumour. This case report highlights these unusual findings.