Introduction:Finger amputation significantly impairs hand function and self-image. When surgical reconstruction or replantation is not possible, a finger prosthesis can provide cosmetic and functional benefits. However, conventional prostheses are limited by poor retention and lack of sensation. In this study, we evaluate an alternative method using osseointegrated dental implants to anchor finger prostheses, which provide stable fixation and, in turn, improve function and sensory feedback. Method:Four patients with traumatic amputations of a single finger each (thumb, index, middle, and ring fingers) underwent a two-stage surgical procedure. In the first stage, a titanium dental implant was placed into the medullary canal of the residual bone. After a three-month osseointegration period, a second-stage surgery attached a skin-penetrating abutment. Finally, a custom-made, color-matched silicone prosthesis was secured to the abutment. Outcomes were evaluated through clinical and radiographic follow-up, along with patient-reported satisfaction. Results:Three of four patients achieved successful osseointegration by three months. One thumb reconstruction was complicated by nonunion and implant loosening, requiring implant removal. One superficial abutment-site infection resolved with conservative treatment. Functional outcomes were favorable, with improved grip and pinch strength, preserved joint motion, enhanced sensibility, and high patient satisfaction with cosmetic and functional results. Conclusion:Osseointegrated dental implants may offer a feasible option for retention of digital prostheses in selected patients. Although short-term outcomes were encouraging, complications can occur, and careful patient selection and biomechanical planning are essential. Larger studies with longer follow-up are needed to confirm long-term safety, durability, and implant survival.
Purpose:Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, with surgical decompression as the definitive treatment for refractory or severe cases. With the evolution of surgical techniques, from open carpal tunnel release (OCTR) to endoscopic (ECTR) and ultra-minimally invasive ultrasound-guided approaches, there remains a need for a comprehensive comparative evaluation. This review aims to critically assess contemporary surgical modalities for CTS and to provide an evidence-based framework for patient-centered surgical decision-making. Methods:A structured narrative review was conducted using PubMed/MEDLINE, Scopus, Cochrane Library, and Web of Science, covering studies from 1985 to February 2026. Eligible studies included randomized controlled trials, cohort studies, systematic reviews, and meta-analyses reporting clinical outcomes of OCTR, ECTR, and ultrasound-guided techniques. Outcomes assessed included symptom relief, functional scores, complications, recurrence, return to work, and cost-effectiveness. Data were synthesized thematically due to heterogeneity. Results:OCTR and ECTR demonstrate comparable long-term symptom relief and functional outcomes. ECTR offers advantages in early postoperative recovery, including reduced pain and faster return to work. Ultra-minimally invasive ultrasound-guided techniques show promising early outcomes and accelerated recovery in selected patients, though long-term data remain limited. Complication rates are low across techniques and are influenced more by surgical expertise and completeness of release than by approach alone. Economic analyses suggest early recovery may offset higher procedural costs in working populations. Conclusion:Long-term outcomes of CTS surgery are broadly equivalent across techniques when adequate decompression is achieved. The surgical approach should be individualized based on disease severity, patient factors, occupational demands, and surgeon expertise. Further high-quality, long-term comparative studies are needed to define the role of emerging ultra-minimally invasive techniques.
Introduction:Diagnosis-Related Groups (DRGs) have become the basis of the Center of Medicare & Medicaid Services (CMS) hospital reimbursement system. Wide variability of patient factors and procedures bundled into a single DRG may contribute to significant cost variation and limited usefulness when analyzing economic performance. This investigation sought to analyze variation in hip and femur fracture inpatient costs as assessed by DRG and Current Procedural Terminology (CPT) codes. Materials and Methods:Patients age ≥ 18 treated with operatively managed fractures of the hip and femur at a Level 1 trauma center from 2019 to 2021 were retrospectively reviewed. Patients categorized as DRG 480, with major comorbidity/complication; 481, with comorbidity/complication; and 482, without comorbidity/complication were eligible. Seven common CPT codes were analyzed after exclusion of patients with low frequency CPT codes (< 50 instances). The primary outcome was total direct costs by DRG and CPT codes. Total direct costs were compared among CPT codes within each DRG using an ANOVA model. Costs were also compared among DRGs for each CPT code. Secondary outcomes include comparison of total direct costs by surgeon within DRG and within each CPT code. Results:A total of 896 patients were analyzed. Significant variation in costs was observed among different DRGs for specific CPTs (p < 0.001). Similarly, notable variation in total direct costs was recorded among different CPTs within each given DRG (p < 0.001). Although cost variations were observed between surgeon and DRG (p < 0.001), no significant interaction was observed once specific procedural (CPT) data were included in the model (CPT 27245: F = 1.077, p = 0.378; CPT 27506: F = 0.934, p = 0.504). Conclusions:While direct costs are influenced by the complexity of DRG assignment within the hip and femur fracture DRG family, the data may be limited in its applicability given the heterogeneity of patients and procedures captured within each DRG. Evaluating costs using a DRG-CPT combination, instead of DRG alone, may provide a more comprehensive and accurate understanding of costs of care. Level of Evidence:Economic and Decision Analyses Level III.
Background:Periprosthetic joint infection (PJI) is a severe complication after total joint arthroplasty (TJA). Inflammatory bowel disease (IBD) may plausibly increase this risk because of chronic systemic inflammation, intestinal barrier dysfunction, malnutrition, and exposure to immunosuppressive therapies; however, the available orthopedic literature is sparse and heterogeneous. Methods:This systematic review was revised in accordance with PRISMA 2020 principles and the PRISMA 2020 for Abstracts recommendations. The primary review question was whether patients with IBD undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) are at increased risk of PJI or septic revision. Cohort and case-control studies reporting arthroplasty-related infectious outcomes in patients with Crohn's disease, ulcerative colitis, or unspecified IBD were eligible for the primary analysis. To ensure the study is scientifically sound, case reports describing nonprosthetic osteomyelitis were excluded from the primary quantitative analysis and evaluated separately using CARE principles as contextual qualitative evidence. No prospective protocol registration was completed before the original review process. Results:The revised review identified two retrospective cohort studies suitable for the primary analysis and two case reports retained in a separate qualitative appendix. The primary analysis included 22,320 arthroplasty patients with IBD studied against much larger non-IBD comparator cohorts. One THA registry study found a higher risk of septic revision in patients with IBD, whereas one TKA database study found higher postoperative PJI odds in both Crohn's disease and ulcerative colitis. Direct quantitative pooling was considered inappropriate because the studies differed in joint type, follow-up duration, and outcome definition. Conclusions:The currently available evidence suggests that IBD may be associated with an increased risk of infection-related failure after arthroplasty, but the certainty of evidence is low to very low because only two retrospective cohort studies directly addressed this question. Future research should use standardized PJI definitions, report disease activity and immunosuppressive treatment in detail, and prospectively evaluate whether the excess risk is related to IBD itself or to modifiable perioperative factors.
Background:Calcaneal fractures are complex injuries associated with a high risk of postoperative complications, including infections and wound healing difficulties. Surgical treatment focuses on restoring anatomical alignment and joint congruency, but these fractures remain challenging to manage. The purpose of this study was to assess the epidemiology, postoperative complications, and surgical outcomes, specifically by evaluating changes in Böhler and Gissane angles in patients with calcaneal fractures. Materials and Methods:This is a retrospective single-center cohort study that included 202 patients with 221 calcaneal fractures, 19 of whom had bilateral fractures, treated at Rigshospitalet, Denmark, between 2012 and 2016. Patients were evaluated at 8, 26, and 52 weeks postoperatively. Böhler and Gissane angles were measured preoperatively and postoperatively. Epidemiological data, postoperative complications, and multitrauma cases were recorded. Results:Of the 221 fractures included, 217 were treated surgically. Among the surgically treated cases, 83% were intra-articular (n = 181) and 17% were extra-articular (n = 36). Twelve patients (6%) had open fractures, and 58 patients (27%) sustained additional trauma-related injuries, with five classified as multitrauma cases. Preoperative Böhler angles averaged 9.4° (range: -20°-40°), improving to 27.7° postoperatively (range: 10°-45°) (p < 0.001). The mean preoperative Gissane angle was 107.4° (range: 52°-147°), improving to 124.1° (range: 102°-147°) postoperatively (p < 0.001). Conclusion:This single-center study demonstrated significant improvements in Böhler and Gissane angles following surgical intervention for calcaneal fractures. However, postoperative complications, particularly related to soft-tissue management, remain a significant challenge.
Background:Total knee arthroplasty (TKA) in the fixed valgus knee is technically demanding due to lateral soft-tissue contractures and the risk of peroneal nerve injury. This study evaluates the clinical and radiographic outcomes of a manual "inside-out" soft-tissue balancing algorithm for Ranawat Grade II and III valgus deformities. Materials and Methods:We prospectively evaluated 30 knees (24 patients) with advanced arthritis and valgus deformity (> 10°) treated between 2016 and 2019. Surgical correction followed a sequential "inside-out" protocol: posterior cruciate ligament (PCL) resection, posterolateral capsule (PLC) release, and selective iliotibial band (ITB) pie-crusting within a strict 1-cm safety zone. Clinical outcomes were measured using the Knee Society Score (KSS). Radiographic analysis focused on the tibiofemoral angle and component alignment. Results were compared with traditional manual techniques and novel robotic-assisted data. Results:The mean KSS improved significantly from 19.63 preoperatively to 87.17 at the final follow-up (p < 0.001). The mean tibiofemoral valgus angle was corrected from 24.28° to 4.97°. Absolute medial stability was achieved in 96.6% of cases. Notably, in our series, no cases of peroneal nerve palsy were observed (0%; 95% CI: 0.0%-11.6%), suggesting a high safety profile for the inside-out technique. Two intraoperative periprosthetic fractures (6.6%) occurred and were managed successfully. Discussion:Our manual algorithm achieved safety and alignment outcomes comparable to novel robotic-assisted TKA series. The "inside-out" approach provides excellent exposure and controlled lengthening of contracted structures while protecting neurovascular anatomy. Conclusion:The manual "inside-out" technique is a safe, reproducible, and cost-effective method for correcting severe valgus deformity. It provides high precision in gap balancing and effectively eliminates the risk of peroneal nerve palsy in Ranawat Grade II and III cases. It ensures high precision in gap balancing and effectively minimizes the risk of peroneal nerve palsy, providing a reliable alternative in settings where robotic technology is inaccessible.
Objective: To compare short-term clinical outcomes between mini-incision carpal tunnel release (MCTR) using the ProMIS kit and conventional open carpal tunnel release (OCTR) in patients with carpal tunnel syndrome (CTS). Methods: In this single-center, prospective randomized trial, 90 adults with idiopathic CTS were allocated 1:1 to OCTR or MCTR. All procedures were performed by a single fellowship-trained hand surgeon, and postoperative care was standardized. The primary endpoint was change in Boston Carpal Tunnel Questionnaire (BCTQ) symptom severity and functional status scores at 2 months. Secondary outcomes were visual analog scale (VAS) pain, Patient-Rated Wrist Evaluation (PRWE), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, grip strength, scar length, and procedure-related complications. Analyses followed the intention-to-treat principle. Results: Forty-five participants were randomized to each group; most were middle-aged women. Baseline clinical characteristics were comparable. At 2 weeks, the MCTR group reported lower VAS pain and better PRWE and QuickDASH scores than the OCTR group, indicating faster early functional recovery. By 1 and 2 months, between-group differences in pain, BCTQ, PRWE, QuickDASH, and grip strength were small and not clinically important. No major complications, including iatrogenic nerve or tendon injury, wound infection, or reoperation, occurred in either group. Conclusion: MCTR using the ProMIS kit offered modestly faster early recovery than conventional OCTR while providing similar short-term symptom relief, functional improvement, and safety. MCTR appears to be a reasonable alternative to standard open release for CTS, but larger trials with longer follow-up are warranted.
Purpose: Disparities in primary total shoulder arthroplasty (TSA) care have been established based on insurance status and patient socioeconomic status; however, there is a paucity of data regarding TSA performed at "safety-net" hospitals (SNHs). This study sought to describe differences in surgical indications, perioperative complication rates, and follow-up rates for patients who underwent TSA at a large SNH compared to those who underwent surgery at a private academic hospital (PAH). Materials and methods: A retrospective review of adult patients undergoing TSA by a single surgeon at both a large, public SNH and an affiliated PAH between November 2011 and April 2023 was conducted. Patient demographic data, operative indications, and complication data were collected and compared between cohorts. Data were tested for normality via the Shapiro-Wilk test, and then Mann-Whitney U or Student's t-testing was conducted as indicated. Significance was defined as p < 0.05. Results: A total of 344 patients underwent TSA during the study period, with 92 patients presenting to the SNH and 252 patients presenting to the PAH. Patients presenting to the SNH were younger (63 vs. 70 years) and were more likely to undergo reverse TSA (90.2% vs. 75.8%). The average follow-up period was significantly shorter at the SNH (319.9 vs. 653.8 days, p = 0.002), with only 29.3% of SNH patients having a clinic visit beyond one year postoperatively versus 45.2% of the PAH patients (p = 0.008). Infection was the most common complication at the SNH and occurred more frequently than in PAH patients (4.3% vs. 0.4%, p = 0.007). Conclusion: TSA may be conducted in SNHs with low rates of early complications. However, surgeons should be aware of high rates of loss to follow-up and a potentially higher rate of postoperative infection.
BackgroundBone mechanical properties, including strength and stiffness, influence intraoperative fracture risk and implant stability in hip arthroplasty. Surgeons frequently utilize radiographic metrics to evaluate bone quality and inform surgical strategies. This study investigates the correlation between radiographic bone metrics and the mechanical properties of the femoral neck.MethodsFemoral neck cortical bone samples from 23 patients undergoing elective hip arthroplasty were subjected to mechanical compression testing to measure elastic modulus and ultimate strength. Density was also measured. Radiographic metrics, including cortical thickness index, canal flare index, canal-bone ratio and canal-calcar ratio, were determined from preoperative radiographs. The correlations between these metrics and bone mechanical properties were analysed using linear regression, with intra- and interobserver reliability assessed.ResultsAnalysis included 19 of the 23 participants. Whilst cortical thickness index measurements demonstrated a weak positive correlation with bone density (R2 = 0.291; p = 0.013) and ultimate strength (R2 = 0.279; p = 0.015), canal-bone ratio showed a weak negative correlation with both factors (R2 = 0.291; p = 0.013 and R2 = 0.279; p = 0.015, respectively). Both cortical thickness index and canal-bone ratio demonstrated excellent inter- and intraobserver reliability. Neither canal flare index nor canal-calcar ratio correlated with any mechanical properties, and none of the radiographic metrics correlated with elastic modulus.ConclusionsCortical thickness index and canal-bone ratio correlate weakly with bone strength and density but not with elastic modulus. Given their limited utility, radiographs should be used with caution in surgical decision-making regarding impaction force and implant fixation strategy.
Objective Total hip arthroplasty (THA) is a widely performed surgical intervention for managing severe hip pathologies. However, this procedure is often associated with substantial blood loss and an increased need for blood transfusion. Tranexamic acid (TXA), a synthetic antifibrinolytic agent, is frequently administered to mitigate perioperative bleeding. Despite its widespread use, the comparative efficacy and safety of intravenous (IV) and topical TXA administration remain subjects of ongoing debate in the literature. Materials and Methods This retrospective, single-center study evaluated 45 patients who underwent primary THA between 2020 and 2024. The patients were divided into three groups based on TXA administration: IV TXA (n = 15), topical TXA (n = 15), and a control group without TXA (n = 15). Outcomes assessed included perioperative blood loss, transfusion requirements, postoperative hemoglobin decrease, and thromboembolic complications. Group comparisons were further adjusted for baseline confounders using analysis of covariance and multivariable logistic regression. Statistical significance was set at p < 0.05. Results Both IV and topical TXA administration significantly reduced perioperative blood loss compared with the control group. Transfusion rates were numerically lower in the TXA groups, although these differences did not reach statistical significance after adjustment. Mean blood loss was recorded as 820 mL in the IV TXA group, 840 mL in the topical TXA group, and 1100 mL in the control group. No significant difference was found between the IV and topical TXA groups, while both were superior to the control group in terms of hemoglobin decline. Thromboembolic complications and surgical site infection rates were comparable across all groups. Discussion The findings of this study demonstrate that both IV and topical TXA administration provide effective and safe control of perioperative bleeding in THA. The low incidence of thromboembolic events supports the safe use of TXA in clinical practice. Selection of the TXA administration route can be tailored based on patient-specific clinical conditions and the surgeon's preference. Conclusion In conclusion, the appropriate use of TXA during THA effectively reduces the need for blood transfusion and contributes to improved surgical outcomes. These results highlight the value of TXA as a reliable hemostatic agent in modern orthopedic surgery.
Background: Scapulothoracic abnormal motion (STAM) describes any abnormal scapular position or movement that results in pain and dysfunction, commonly referred to as dyskinesia or scapular winging. These abnormalities may arise from musculoskeletal, neurological, or genetic etiologies. Subtype 3 (STAM 3) is characterized by weakness and functional impairment of the serratus anterior (SA) muscle, typically due to injury of the long thoracic nerve (LTN) and the brachial plexus upper trunk (BPUT). Objectives: Reporting on our experience in surgical restoration of STAM 3 in 270 patients with serratus anterior palsy. Patients and Methods: We report outcomes of surgical decompression and microneurolysis of the LTN and BPUT in 270 STAM 3 patients unresponsive to prior interventions. The average time between the onset of injury and surgery was 3.8 years. Results: STAM 3 was fully corrected in 194 shoulders (70%), while 80 (29%) recovered well with minimal winging after surgery (a mean follow-up of 1 year; range 3 months to 9 years). The extent of the scapular winging (ESW) grading scale (range 1-4) significantly improved postoperatively to a median score of 4 (IQR = 3-4) from the preoperative median score of 2 (IQR = 1-2). Two hundred and seventy-four of 278 STAM 3 (99%) had excellent or good improvement. The overall improvement in shoulder forward flexion and abduction (mean 169 degrees +/- 24 degrees and 167 degrees +/- 27 degrees) after surgery was statistically significant compared to the preoperative mean of 127 +/- 41 degrees and 122 +/- 42 degrees, respectively (p < 0.0001). Conclusions: Decompression and microneurolysis of the LTN and BPUT reduced the severity of STAM 3 and/or improved active shoulder range of motion in 99% of patients (274 of 278 shoulders). We demonstrate that the extent of internal and external microneurolysis maintained the BPUT and LTN healthy in their course to supply the serratus anterior muscle and its function by improving the axonal transport of the cofounding neurotrophic factors and motor signals from the cerebral cortex.
Background:Lateral plate fixation, the current standard for fixation of unstable distal fibular fractures, can compromise the minimal soft tissue envelope resulting in poorer postoperative outcomes. Isolated lag screw fixation represents a novel method of distal fibula fixation. Methods:Two independent reviewers conducted a literature search of PubMed, EMBASE, Google Scholar and MEDLINE (Ovid) in February 2024. Randomised control trials (RCTs), non-randomised control trials and cohort studies were included. Risk of bias was assessed with the ROBINS-I tool. PRISMA guidelines were followed. This systematic review was prospectively registered in the PROSPERO register (CRD42024521746). Results were synthesised by structured qualitative analysis. Results:Four studies (207 patients) were included. Compared to lateral plate fixation, lag screw-only fixation for distal fibula fractures resulted in reduced operative times, incision lengths, costs, hardware-related issues, ankle symptomatology, and complications, with comparable or improved functional outcomes and similar radiographic healing under equivalent postoperative care. These findings were applicable to patients under 60 years old with noncomminuted, oblique, or spiral unstable distal fibula fractures. Conclusion:Isolated lag screw fixation represents a novel method of distal fibular fracture fixation in select patients. Reducing hardware burden on the soft tissue envelope improved operative and patient outcomes without compromising standard postoperative care. The methodological and clinical differences among the included studies limited this review. Additionally, only four eligible studies were included, all with significant bias.
Introduction: The knee and extensor mechanism receives a rich blood supply from the anastomosis of multiple genicular arteries. We hypothesized that meticulous hemostasis of the suprapatellar synovium and surrounding soft tissues of the arthrotomy site prior to tourniquet inflation might reduce blood loss and pain after total knee arthroplasty (TKA). Materials and Methods: This randomized controlled trial included 60 patients undergoing unilateral TKA. Patients were randomly allocated into 1) the hemostasis group, bleeding vessels after arthrotomy and suprapatellar synovectomy were identified and cauterized before tourniquet inflation, and 2) the control group, the tourniquet was inflated before incision without identifying bleeding vessels. For both groups, the tourniquet was released after wound closure. Outcomes included intraoperative estimated blood loss (EBL), drain output, total blood loss (TBL), blood transfusion rate, numerical rating scales (NRSs) for pain and morphine consumption during the first 48 h (h) after TKA, and length of hospital stay (LHS). Results: The demographics of both groups were comparable. The hemostasis group had significantly shorter tourniquet time (84.5 vs. 99.5 min, p = 0.01), higher intraoperative EBL (55.3 vs. 32.7 mL, p < 0.01), lower drain output (279.3 vs. 384.7 mL, p < 0.01), and lower blood transfusion rates (13.3 vs. 43.3%, p = 0.02). Additionally, the hemostasis group had lower NRS pain scores at 24 h (4.1 vs. 5.8, p < 0.01) and 48 h (2.8 vs. 3.6, p < 0.01) and less morphine consumption in the first 24 h (4.0 vs. 5.5 mg, p < 0.01) and from 24 to 48 h (1.5 vs. 3.3 mg, p < 0.01), as well as shorter LHS. Conclusions: Hemostasis of the suprapatellar synovium and arthrotomy site prior to tourniquet inflation significantly reduced blood loss and transfusion requirements. Furthermore, this alternative approach leads to significantly lower VAS pain scores, reduced morphine consumption within the first 48 h post-TKA, and shorter lengths of hospital stay.
IntroductionCore outcome set (COS) is a consensus-based set of outcomes derived from a multimethod technique. The present study aimed to develop a COS for prognosis of hip osteonecrosis in response to treatment which was suitable for Iranian patients, and we performed stakeholder analysis.MethodsThis multimethod study was conducted in the following phases: (1) extraction of outcomes through an umbrella review of the previous meta-analyses, (2) expert panel survey, (3) qualitative interview with patients, and (4) compilation of the COS with the help of triangulation of study phases.ResultsThe umbrella review was performed on 34 documents. The outcomes were generally classified into several categories including clinical, radiological, and surgical outcomes. In the second phase, the expert panel proposed the outcomes as time to return to work, time to return to daily activity, joint range of motion, improvement in walking, bone swelling, weight bearing, extent of necrosis, conversion to total hip arthroplasty (THA), pain reduction, improvement in hygiene, and improvement in function. In the third phase, patients mainly complained of joint stiffness, and this was the first outcome that reached saturation in the interview. Finally, the COS was presented.ConclusionThe main focus was on the clinical outcomes, which were prioritized in the triangulation of the methods and the opinion of the stakeholders. Patients are looking for their movement problems and limitations to be corrected as soon as possible and to return to their daily activities. The final COS of this study for clinical use includes pain, joint range of motion and lack of stiffness, improvement in function, ability to walk, and return to daily activity.
BackgroundDespite recent advances in surgical treatment of dysplastic coxarthrosis, muscular dysfunction of the affected extremity and attempts to improve its functional capacity represent a significant problem.Materials and MethodsA prospective case-match study of 50 patients with severe dysplastic coxarthrosis was conducted. Initially, at 3 and 6 months, all patients were evaluated with handheld dynamometry (HHD), surface electromyography (sEMG), and Harris scoring. The study arm consisted of 25 patients with severe dysplastic coxarthrosis Crowe III-IV who underwent total hip arthroplasty. The control arm consisted of 25 consecutive patients who underwent conservative treatment due to the refusal of total hip arthroplasty.ResultsA progressive increase in muscle strength, amplitude, and electrical activity was observed in the study arm. Statistically significant differences were observed for the Harris index in patients in the study arm at 3 and 6 months -65.00 +/- 3.69 and 47.00 +/- 5.85 points at 3 months and 85.31 +/- 1.40 and 44.00 +/- 4, 92 points at 6 months, respectively. Total hip arthroplasty was found to be a significant prognostic factor for functional recovery of the muscles of the lower extremities (p = 0.034, RR - 2.287, CI: 0.023 - 9.301).ConclusionsThe results of our study suggest that total hip arthroplasty in patients with severe dysplastic coxarthrosis was associated with increased muscular strength, amplitude of the bioelectrical potential, and physical activity of the hip muscles. These findings could have a significant beneficial impact on the improvement of functional recovery in this category of patients.
Purpose:Geriatric hip fractures often require allogenic blood transfusions, which increases the risk of transfusion related complications. Tranexamic acid (TXA) has been shown to have a positive effect on hip fractures, with the American Academy of Orthopedic Surgeons (AAOS) recommending its use; however, optimal dosing and timing has not been delineated in the literature. This study evaluates the effectiveness of early TXA administration in reducing transfusion rates in extracapsular geriatric hip fracture patients. Methods:From 2021 to 2023, a retrospective chart review compared geriatric fragility hip fracture (AO/OTA 31A) patients who received TXA at admission (1-g IV at presentation and 1-g IV three hours later) with those who did not. The primary outcome evaluated was allogenic blood transfusion rates. Patient demographics, hemoglobin levels during admission, hidden blood loss, length of hospital stay, and 90-day perioperative complications were also recorded. Results:Among 168 patients, 102 received TXA and 66 did not. There was no statistically significant difference in allogenic transfusion rates between the groups (p = 0.27). Secondary outcomes, including hemoglobin/hematocrit levels, hidden blood loss, and length of hospital stay, were also similar. Thromboembolic event rates were comparable. Conclusion:Our findings align with recent literature that questions TXA's effectiveness in reducing transfusion rates in this population. Early TXA administration may not adequately address hidden blood loss in geriatric hip fractures, possibly due to high comorbidity burden, pre-existing anemia, and delayed surgery. Further research is necessary to explore alternative strategies for managing early blood loss and optimizing outcomes in this population.
Introduction:Distal radius fracture (DRF) is the most common fall-related fracture, with an incidence of up to 18% of the elderly population who are being examined in the emergency department. Conservative treatment in the geriatric population is the treatment of choice, and traditionally the wrist after reduction is placed in volar flexion and ulnar deviation position (Cotton position). The aim of this study is to compare two-cast position (Cotton and Functional position) for conservative treatment of geriatric DRFs, according to functional outcomes at twelve months. Patients and Methods:This randomized prospective study compared and evaluated the functional outcomes and cost of physiotherapy in the geriatric population with DRFs. Regarding functional outcomes, these were measured using the QuickDASH Score, Patient-Reported Wrist Evaluation, pain (VAS score), and health-related quality of life measurement (15D), while for the cost of physical therapy, the number of sessions performed by patients in both groups was measured. Results:Ninety-three patients (75 female and 18 men) with an average age 79.2 ± 6 (range 67-90 years) with a DRF were included in the study. Among these patients, 9 underwent surgical intervention due to loss of reduction and were consequently excluded from our study. The study ultimately encompassed a total of 84 patients. The mean age for Group A was 79 ± 2 years, and for Group B, it was 79 ± 1 years (p = 0.61). The mean follow up for all patients was 1 year. Functional cast-position group (Group B) showed better results in terms of functional recovery: PRWE (Mdiff = 1.52, 95% CI [-7.77, 3.81]), QuickDASH Score (Mdiff = 8.00, 95% CI [2.27, 13.72]), and posttraumatic pain (Mdiff = 1.27, 95% CI [0.86, 1.69]). Cost of physiotherapy (z = 128, p < 0.001) and HRQol-15(Mdiff = 1.81, 95% CI [1.02, 2.60]) was statistically significantly greater in the Cotton position group versus Functional position group. Conclusion:Our results indicate that functional cast-position produces better functional outcomes with a lower rate of complication than volar-flexion and ulnar-deviation cast (VFUDC) position. Despite the fact that the VFUDC group underwent a greater number of physical therapies, they presented less good functional results. In conclusion we recommend the use of functional cast in elderly low energy DRFs.
Introduction:Postoperative pain following total knee arthroplasty (TKA) can exacerbate sympathetic activity, elevate blood pressure, and potentially increase blood loss. However, the relationship between these factors remains unclear. This study evaluates the correlation between postoperative pain intensity and perioperative blood loss. Methods:A retrospective analysis was conducted on 405 unilateral TKAs, stratified by average visual analog scale (VAS) in the first 24 h postoperatively into mild (VAS 0-3), moderate (VAS > 3-6), and severe (VAS > 6-10) pain intensity groups. The primary outcomes were the effect of pain intensity on mean calculated blood loss (CBL) and risk of blood transfusion. Secondary outcomes included length of hospital stay (LHS) and complications. Multivariable regression analysis was employed. Results:Adjusted mean differences in CBL and LHS were not significantly different among the pain intensity groups. However, severe pain intensity was associated with a higher risk of blood transfusion (risk ratio: 1.92, p = 0.068). Preoperative hemoglobin (Hb) was the only protective factor against blood transfusion; each 1 g/dL increase in preoperative Hb reduced the blood transfusion risk by 61% (risk ratio: 0.39, p < 0.001). Additionally, the severe pain intensity group had the highest incidence of overall complications (13.3%) observed during 180 days post-TKA (p < 0.01). Conclusion:Patients experiencing severe pain intensity in the first 24 h after TKA tend to have a higher risk for blood transfusion and a significantly higher risk of overall complications. Thus, optimizing pain control is important to enhance recovery for current clinical pathways of TKA.
Purpose:Residual rotational instability following anterior cruciate ligament reconstruction (ACLR) remains a clinical challenge, leading to renewed interest in adjunctive lateral extra-articular procedures (LEAP). This study aimed to compare clinical decision-making between experienced orthopaedic surgeons and an artificial intelligence (AI) model regarding indications for LEAP in ACLR, to assess concordance, and to explore the potential role of AI in surgical planning. Methods:A cross-sectional comparative study was conducted using 40 hypothetical ACLR case profiles, reflecting a range of patient demographics, injury characteristics, and activity levels. An AI model trained on literature-based criteria and expert input generated binary recommendations ("perform LEAP" or "do not perform LEAP") for each case. Twenty-two high-volume knee surgeons independently reviewed all cases, blinded to AI recommendations, and indicated whether they would recommend a LEAP. Agreement between surgeon decisions and AI recommendations was calculated, and factors influencing concordance were analysed using chi-square tests, t-tests, and Pearson correlations (p < 0.05). Results:Overall, surgeon agreement with AI recommendations was high but varied by clinical factors. A positive pivot shift test was the strongest predictor of concordance (93.9% ± 4.8 vs. 71.8% ± 25.7; p = 0.0004, Cohen's d = 1.23). Surgeons agreed more often when the AI recommended LEAP (92.7% ± 6.5) than when it advised against it (70.9% ± 27.0; p = 0.0006). Male patient cases yielded higher agreement (91.1% ± 7.4) compared with female cases (75.7% ± 27.0; p = 0.018). Ligamentous laxity (Beighton score) showed a moderate positive correlation with agreement (r = 0.39; p = 0.013), while age, revision status, associated lesions, and time from injury to surgery were not significant predictors. Conclusion:Surgeons demonstrated strong alignment with AI recommendations in clear-cut scenarios, particularly when traditional clinical signs such as a positive pivot shift were present. Discordance emerged in borderline cases, notably when AI recommended against LEAP or in female patients. These findings suggest AI could support orthopaedic decision-making by standardising criteria for LEAP, enhancing consistency in ambiguous cases, and prompting the development of evidence-based scoring systems to refine indications. Trial Registration:IRB cleared, no need for trial registration as all cases hypothetical and no patient data included in the study.
