Aims. Arthroplasties of the elbow, including total elbow arthroplasty, radial head arthroplasty, distal humeral hemiarthroplasty, and radiocapitellar arthroplasty, are rarely undertaken. This scoping review aims to outline the current research in this area to inform the development of future research. Methods. A scoping review was undertaken adhering to the Joanna Briggs Institute guidelines using Medline, Embase, CENTRAL, and trial registries, limited to studies published between 1 January 1990 and 7 February 2021. Endnote software was used for screening and selection, and included randomized trials, non-randomized controlled trials, prospective and retrospective cohort studies, case-control studies, analytical cross-sectional studies, and case series of ten or more patients reporting the clinical outcomes of elbow arthroplasty. The results are presented as the number of types of studies, sample size, length of follow-up, clinical outcome domains and instruments used, sources of funding, and a narrative review. Results. A total of 362 studies met the inclusion criteria. Most were of total elbow arthroplasty (246; 68%), followed by radial head arthroplasty (100; 28%), distal humeral hemiarthroplasty (11; 3%), and radiocapitellar arthroplasty (5; 1%). Most were retrospective (326; 90%) and observational (315; 87%). The median sample size for all types of implant across all studies was 36 (interquartile range (IQR) 21 to 75). The median length of follow-up for all studies was 56 months (IQR 36 to 81). A total of 583 unique outcome descriptors were used and were categorized into 18 domains. A total of 105 instruments were used to measure 39 outcomes. Conclusion. We found that most of the literature dealing with elbow arthroplasty consists of retrospective observational studies with small sample sizes and short follow-up. Many outcomes have been used with many different instruments for their measurement, indicating a need to define a core set of outcomes and instruments for future research in this area. Cite this article: Bone Joint J 2022;104-B(10):1148–1155

Aim. Diagnosing low-grade periprosthetic joint infections (PJI) can be very challenging due to low-virulent microorganisms capable of forming biofilm. Clinical signs can be subtle and may be similar to those of aseptic failure. To minimize morbidity and mortality and to preserve quality of life, accurate diagnosis is essential. The aim of this study was to assess the performance of various diagnostic tests in diagnosing low-grade PJI. Methods. Patients undergoing revision surgery after total hip and knee arthroplasty were included in this retrospective cohort study. A standardized diagnostic workup was performed using the components of the 2021 European Bone and Joint Infection Society (EBJIS) definition of PJI. For statistical analyses, the respective test was excluded from the infection definition to eliminate incorporation bias. Receiver-operating-characteristic curves were used to calculate the diagnostic performance of each test, and their area-under-the-curves (AUC) were compared using the z-test. Results. 422 patients undergoing revision surgery after total hip and knee arthroplasty were included in this study. 208 cases (49.3%) were diagnosed as septic. Of those, 60 infections (28.8%) were defined as low-grade PJI (symptoms >4 weeks and caused by low-virulent microorganisms (e. g. coagulase-negative staphylococci, Cutibacterium spp., enterococci and Actinomyces)). Performances of the different test methods are listed in Table 1. Synovial fluid (SF) - WBC (white blood cell count) >3000G/L (0.902), SF - %PMN (percentage of polymorphonuclear neutrophils) > 65% (0.959), histology (0.948), and frozen section (0.925) showed the best AUCs. Conclusion. The confirmatory criteria according to the EBJIS definition showed almost ideal performances in ruling-in PJI (>99% specificity). Histology and synovial fluid cell count (SF-WBC and SF-%PMN) showed excellent accuracies for diagnosing low-grade PJI. However, a reduced immune reaction in these cases may necessitate lower cut-off values. Intraoperative frozen section may be valuable in cases with inconclusive preoperative diagnosis. For any tables or figures, please contact the authors directly

Introduction. The accuracy of hexapod circular external fixator deformity correction is contingent on the precision of radiographic analysis during the planning stage. The aim of this study was to compare the SMART TSF (Smith and Nephew, Memphis, Tennessee) in-suite radiographic analysis methods with the traditional manual deformity analysis methods in terms of accuracy of correction. Materials and Methods. Sawbones models were used to simulate two commonly encountered clinical scenarios. Traditional manual radiographic analysis and digital SMART TSF analysis methods were used to correct the simulated deformities. Results. The final outcomes of all six analysis methods across both simulated scenarios were satisfactory. Any differences in residual deformity between the analysis methods are unlikely to be clinically relevant. All three SMART TSF digital analyses were faster to complete than manual radiographic analyses. Conclusions. With experience and a good understanding of the software, manual radiographic analysis can be extremely accurate and remains the gold standard for deformity analysis. In-suite SMART TSF radiographic analysis is fast and accurate to within clinically relevant parameters. Surgeons can with confidence trust the SMART TSF software to provide analysis and corrections that are clinically acceptable

Imageless computer navigation systems have the potential to improve acetabular cup position in total hip arthroplasty (THA), thereby reducing the risk of revision surgery. This study aimed to evaluate the accuracy of three alternate registration planes in the supine surgical position generated using imageless navigation for patients undergoing THA via the direct anterior approach (DAA).

Fifty-one participants who underwent a primary THA for osteoarthritis were assessed in the supine position using both optical and inertial sensor imageless navigation systems. Three registration planes were recorded: the anterior pelvic plane (APP) method, the anterior superior iliac spines (ASIS) functional method, and the Table Tilt (TT) functional method. Post-operative acetabular cup position was assessed using CT scans and converted to radiographic inclination and anteversion. Two repeated measures analysis of variance (ANOVA) and Bland-Altman plots were used to assess errors and agreement of the final cup position.

For inclination, the mean absolute error was lower using the TT functional method (2.4°±1.7°) than the ASIS functional method (2.8°±1.7°, ρ = .17), and the ASIS anatomic method (3.7°±2.1, ρ < .001). For anteversion, the mean absolute error was significantly lower for the TT functional method (2.4°±1.8°) than the ASIS functional method (3.9°±3.2°, ρ = .005), and the ASIS anatomic method (9.1°±6.2°, ρ < .001). All measurements were within ± 10° for the TT method, but not the ASIS functional or APP methods.

A functional registration plane is preferable to an anatomic reference plane to measure intra-operative acetabular cup inclination and anteversion accurately. Accuracy may be further improved by registering patient location using their position on the operating table rather than anatomic landmarks, particularly if a tighter target window of ± 5° is desired.

Abstract. Purpose. Clinical registries are an important aspect of orthopaedic research in assessing the outcomes of surgical intervention and track medical devices. This study aimed to explore the research methodology available to account for patients lost to follow-up (LTFU) specifically in studies related to arthroscopic intervention and whether the rates of patient LTFU are within the acceptable margins for survey studies. Methods. A scoping review, where a literature search for studies from nine arthroscopy registries, was performed on EMBASE, MEDLINE, and the annual reports of each registry. Inclusion criteria included studies with information on patient-reported outcome measures and being based on nine national registries identified. Exclusion criteria included review articles, conference abstracts, studies not based on registry data, and studies from regional, claims-based, or multi-centre registries. Studies were then divided into categories based on method of LTFU analysis used. Results. Thirty-six articles were identified for the final analysis. Categories for LTFU analysis included dropout analyses (n=10), referencing validation studies (n=12), contacting non-responders (n=4), and sensitivity analyses (n=1). Referencing validation studies was the most common method (n=12). Majority (n=35) of the studies exceeded the recommended maximum rates for LTFU. Conclusions. Most arthroscopy studies have rates of LTFU higher than traditionally acceptable. Therefore, any conclusions drawn from these research papers may not be sufficiently valid or free from non-response bias

Prosthetic joint infections represent complications connected to the implantation of biomedical devices, they have high incidence, interfere with osseointegration, and lead to a high societal burden. The microbial biofilm, which is a complex structure of microbial cells firmly attached to a surface, is one of the main issues causing infections. Biofilm- forming bacteria are acquiring more and more resistances to common clinical treatments due to the abuse of antibiotics administration. Therefore, there is increasing need to develop alternative methods exerting antibacterial activities against multidrug-resistant biofilm-forming bacteria. In this context, metal-based coatings with antimicrobial activities have been investigated and are currently used in the clinical practice. However, traditional coatings exhibit some drawbacks related to the insufficient adhesion to the substrate, scarce uniformity and scarce control over the toxic metal release reducing their efficacy. Here, we propose the use of antimicrobial silver-based nanostructured thin films to discourage bacterial infections. Coatings are obtained by Ionized Jet Deposition, a plasma-assisted technique that permits to manufacture films of submicrometric thickness having a nanostructured surface texture, allow tuning silver release, and avoid delamination. To mitigate interference with osseointegration, here silver composites with bone apatite and hydroxyapatite were explored. The antibacterial efficacy of silver films was tested in vitro against gram- positive and gram-negative species to determine the optimal coatings characteristics by assessing reduction of bacterial viability, adhesion to substrate, and biofilm formation. Efficacy was tested in an in vivo rabbit model, using a multidrug-resistant strain of Staphylococcus aureus showing significant reduction of the bacterial load on the silver prosthesis both when coated with the metal only (>99% reduction) and when in combination with bone apatite (>86% reduction). These studies indicate that IJD films are highly tunable and can be a promising route to overcome the main challenges in orthopedic prostheses.

Introduction and Objective. Osteoarthritis (OA) represents one of the leading cause of disability all over the world. Cell therapies, mainly based on mesenchymal stem cells (MSCs), have shown to modulate the pathogenesis of OA in basic, preclinical and clinical studies. Adipose tissue (AT) have emerged as a rich and promising source of MSCs called adipose derived stem cells (ASCs). Different systems are available for processing lipoaspirate to purify the samples from oily and haemorrhagic fractions, minimizing the risk of complications and maximizing the biological yield for subsequent grafting. However, few studies compared the efficacy of the different processing devices already used in clinical practice. This study aims to characterize the products obtained by the use of two different systems such as micro-fragmentation or nano-fragmentation comparing them with the starting material (AT) and the collagenase isolated ASCs. Materials and Methods. AT from 12 donors arrived without selection to the laboratories: 4 lipoaspirated (LA), 4 micro-fragmented (mF) and 4 nano-fragmented (nF). The samples were divided into three aliquots for paraffin embedding, RNA extraction and digestion with collagenase for ASCs isolation. Paraffin embedded tissue sections were stained with hematoxylin-eosin to analyze morphology. RNA was extracted, retro-transcribed and analyzed with real-time PCR to analyze the expression of pluripotency genes (SOX2, NANOG and POU5F1) and inflammatory genes (IL-1beta and iNOS). Data were analyzed using Graphpad Prism 8.0 and expressed as mean ± SD. One-way ANOVA followed by Tukey test was used to compare the different groups. Results. The LA comprised small lobules, with intact cell membranes and structurally integer adipocytes. mF samples showed the presence of integer adipocytes, small lobules and higher amount of cell clusters. nF samples showed the almost completely absence of adipocytes, a high amount of cells without lipid content and a high amount of stromal matrix. Real-time PCR results showed the lowest expression levels of pluripotency genes in LA samples that were assumed equal to 1.0 and used to calculate the expression levels of the other samples. mF showed expression levels of pluripotency genes similar to AT. nF showed expression levels of pluripotency genes higher than AT and mF, but without statistically significant differences. ASCs showed statistically significant higher expression levels of these genes compared to LA and mF (p ≤ 0.001). Likewise, the expression of inflammatory genes resulted to be lowest in LA samples (assumed equal to 1.0), higher in mF samples and in nF samples without statistical significance. As expected, the highest values were found in ASCs isolated cells compared to all the other samples (p ≤ 0.0001). Conclusions. These results confirmed that micro-fragmentation (mF) and nano-fragmentation (nF) permitted to separate a cell mixture enriched in ASCs from a lipoaspirate sample without activating the inflammatory pathways. Both processing methods gave a minimally manipulated product suitable for OA cell therapy application. Further studies are needed to elucidate possible different activities of the ASCs enriched AT-derivatives

Aim

Culture-based conventional methods are still the gold standard to identify microorganisms in hip and knee PJIs diagnosis. However, such approach presents some limitations due to prior antimicrobial treatment or the presence of unusual and fastidious organisms. Molecular techniques, in particular specific real-time and broad-range polymerase chain reaction (PCR), are available for diagnostic use in a suspected PJI. However, limited data is available on their sensitivity and specificity.

This study aimed to evaluate the performance of a rapid and simple Investigational Use Only (IUO) version of the BioFire® JI multiplex PCR panel when compared to traditional microbiological procedures.

Introduction. The association between CoCr joint replacements and adverse tissue reactions has led to increased interest in alternative materials that are both biocompatible and wear-resistant. One approach is to manufacture components from titanium alloys with a hardened articulating surface to increase resistance to scratching and surface damage caused by third-body particles. In this study we investigate methods for characterizing the performance of retrieved TiAlV components with nitrogen-hardened bearing surfaces. Methods. Surface-hardened titanium knee implants (TiNidium) were retrieved from 18 patients (7.7 ±6.8 years) at revision surgery. After processing, the bearing surface of each component was characterized by stereomicroscopy, SEM, optical profilometry, and incremental nano-indentation hardness testing. A case-matched set of 18 CoCr components (6.7 ±5.6 years) were characterized for comparison. Results. Each bearing surface was graded for microscopic damage classified as pitting, abrasion, scratching, and burnishing using an Injury Severity Score. The components were divided into slight, average, and severe damage groups based on the resulting ISS scores. Representative specimens from each group were then subjected to SEM imaging, 12 roughness measurements, and 3 incremental nano-indentation hardness tests. Conclusion. There was no difference between the severity of surface damage of the hardened and CoCr components ((p=0.67); Table 1). The rate of surface damage was greatest in the first 2 years then decreased exponentially (Figure 1). Surface roughness (Ra) values were similar for both groups (TiAlV: 0.771um; CoCr: 0.884um) but decreased with the severity of visual damage in the TiNidium implants due to secondary burnishing of scratches. The hardness of the TiNidium implants varied with depth below the bearing surface in contrast to the CoCr controls in which hardness did not vary with depth (Figure 2). Our findings show that multiple complementary methods of are needed to adequately characterize the performance of surface hardened implants. For figures, tables, or references, please contact authors directly

Abstract

Decellularised porcine superflexor tendon (pSFT) provides an off-the-shelf, cost-efficient option for ACL reconstruction (ACLR). During decellularisation, phosphate buffered saline (PBS) is used for washing out cytotoxic solutes and reagents, maintaining tissue hydration. It has been shown to increase water content in tendon, swelling the tissue reducing mechanical properties. End stage PBS washes in the standard protocol were substituted with alternative solutions to study tissue swelling and its impact on the mechanical behaviour and matrix composition of pSFTs. 25%, 100% Ringers and physiological saline test groups were used (n=6 for all groups). pSFTs were subject to tensile and confined compression testing. Relative hydroxyproline (HYP), glycosaminoglycan (GAG) and denatured collagen content (DNC) were quantified. Modified decellularised tendon groups were compared to tendons decellularised using the standard protocol and native tendons. Specimen dimensions reduced (p=0.004) post-decellularisation only in 25% Ringers group. In all other modified groups, less swelling was apparent but not statistically different from standard group. Only 25% Ringers group had higher linear modulus (p=0.0035) and UTS (p=0.013) compared to standard group. All decellularised groups properties were reduced compared to native pSFTs. Stress relaxation properties showed a significant reduction in decellularised groups compared to native. Compression testing showed no significant differences in peak stress for modified decellularised groups compared to native. A reduction (p=0.036) was observed in standard group. Quantification of GAGs and DNC showed no significant differences between groups. HYP content was higher (p<0.0001) for saline group. A significant reduction in tissue swelling could be related to improved mechanical properties of decellularised pSFTs. Alternative solutions in end stage washes had no significant effect on quantities of matrix components, but altered structure/function could explain the differences in tensile and compressive behaviour, and should be further studied. In all decellularised groups, pSFTs retained suitable mechanical properties for ACLR.

Background

In fixation of the fibula in ankle fractures, AO advocate using a lag screw and one-third tubular neutralisation plate for simple patterns. Where a lag screw cannot be placed, bridging fixation is required. A local pilot service evaluation previously identified variance in use of locking plates in all patterns with significant cost implications. The FAIR study aimed to evaluate current practice and implant use across the United Kingdom (UK) and review outcomes and complication rates between different fibula fixation methods.

The ideal treatment method regarding various defect sizes after local aggressive tumor resection is unknown. We investigated the biomechanical properties of metaphyseal defect filling regarding different defect sizes and fixation methods.

Ninety-one sheep tibias were divided into five groups as 21 tibias per four study groups and 7 tibias in the control group. Study groups were further divided into three subgroups according to 25%, 50% and 75% metaphyseal defect size. Control group tibias were left intact. In study group 1, a metaphyseal defect was created and no further process was applied. Metaphyseal defects were filled with cement without fixation in group 2. Cement filling and fixation with 2 screws were performed in group 3. In addition to cement filling, plate-screw fixation was performed in group 4. Axial loading test was applied to all tibias and the results were compared between study subgroups and control group.

Plate-screw fixation was found to have the best biomechanical properties in all defect sizes. Load to failure for screw fixation was found to be significantly decreased between 25% and 50% defect size (P<0.05). However, load to failure for isolated cement filling was not affected from defect size (p>0.05).

In conclusion, size of the defect predicts the fixation method in addition to filling with cement. Filling with cement in metaphyseal defects was found to be biomechanically insufficient. In addition to filling with cement, additional screw fixation in less than 25% defects and plate-screw fixation in more than 25% defects may decrease tibial plateau fracture or metaphyseal fracture risk after local aggressive tumor resection.

Metal instrumentation (rods and screws) is used to stabilise the spine after trauma, malignancy or deformity. Approx 3% become infected often necessitating removal of metal. At surgery tissue samples and metal are removed for culture, but many clinical laboratories are not equipped to process metal or use simple culture methods. The causative bacteria exist as biofilms on the metal and they are often anaerobic and slow-growing, so conventional culture methods often fail to detect them. Also, they are common contaminants leading to diagnostic uncertainty. We have established a laboratory protocol to overcome these problems.

Removed metalwork was sonicated and the sonicate centrifuged and the supernatant discarded. Quantitative aerobic and anaerobic culture of the resuspended pellet for 14 days and microscopy were carried out.

Metalwork from 11 suspected infected cases was culture-positive (median 2857, 60–5000cfu/mL). Microscopy revealed an infection due to Candida albicans that would not have been detected otherwise. Bacteria were isolated from 8 of 10 non-infected cases (median 15, 0–35 cfu/mL). Conventionally processed samples failed to grow in 4 infected cases. (cfu/mL infected vs noninfected cases p=0.0093)

Micro-organisms on spinal metalwork grow as biofilms and they require sonication to dislodge them. The causative bacteria are slow-growing and P acnes is anaerobic and requires prolonged incubation. S epidermidis and P acnes are common contaminants and quantitative culture helps to distinguish pathogens from contaminants, removing the diagnostic uncertainty that conventional methods give. Microscopy of the sonicate can reveal micro-organisms that fail to grow on culture. We recommend that sonication of metalwork, prolonged anaerobic incubation and quantitative culture be adopted to improve diagnostic clarity for spinal instrumentation infections.

We need to shift our focus to integrating sex and gender into research proposals, so we can answer some of the most basic unanswered questions in the field of fracture management. Current evidence in guidelines indicate a near-to-linear increase from the 1990s for inclusion of sex and gender. However, these recommendations remain expressed in absolute terms, with little explanatory power, affecting uptake and implementation in clinical practice. This co-branded session, with members of the Orthopaedic Research Society – International section of fracture repair (ORS-ISFR), will provide participants with guiding principles and tools to assist researchers and grant reviewers understand what it means to include sex and gender in meaningful ways: from formulating research questions, recruitment strategies, to conducting sex-stratified analyses. In this presentation, we will consider diverse approaches, methods and, analyses to elevate sex and gender within trauma. A strong emphasis on the ways and means of including marginalized and vulnerable populations in research will be addressed.

Background

Currently, the gold standard for the microbiological diagnosis remains the culturing of preoperative aspirated joint fluid and intraoperative periprosthetic tissue samples, which give false negative results in about 7 % of cases. Lytic bacteriophages are viruses that specifically infect and lyse bacteria within their replication cycle.

To describe clinical situations for use of modified VAC in POC based on: diagnosis, comorbidities, BMI, wound size in cm, days following trauma when VAC was first applied, total duration of uninterrupted use, frequency of change, settings, bacterial growth, outcomes

To report the outcomes of mVAC use in POC within 6 months to help improve and standardize its application in the institution

This study involves data gathering from inpatients handled by orthopedic surgeons in training and subspecialty rotations in POC. The data collected are highly dependent on the doctors-in-charge's complete charting, thorough reporting and accurate documentation. Modified Vacuum Assisted Closure (mVAC) is used frequently in this study and is defined as a form of revised, adapted and reformed use of VAC based on available materials in the involved institution. The materials that are included are, but not limited to the following: sterile Uratex™ blue foam, nasogastric or suction tubing, phlegm suction machine, Bactigras™ and Opsite™ or Ioban™.

A total of 58 patients were included in the study. The average age of the population was 35 and are predominantly male. The most common mechanism of injury was motorcycle accident and 37 of the patients were diagnosed with an open fracture of the lower extremity with open tibia fractures (22) being the most common. Average wound area measured was 24.12 cm³. All patients yield a bacteria growth with e. coli being the most frequent. Average during of uninterrupted use was 39 days. Of the 58 included in the study, 8 patients underwent STSG, 2 had a flap coverage surgery, 4 patients eventually underwent amputation and 33 with complete resolution of soft tissue defect after conversion to biologic dressing post-mVAC. The rest of the population were still ongoing mVAC at the end of the study.

mVAC is an alternative temporary medium for soft tissue coverage for cases with or without concomitant fractures. mVAC promotes removal of exudate from the wound, supports wound apposition and granulation bed proliferation. Usage mVAC helps prepare for skin coverage procedure and on some cases leads to full resolution of defect.

Balloon kyphoplasty (BKP) is a minimally invasive surgical technique used to correct kyphosis and vertebral compression fractures. BKP uses cement to fill a void created by the inflation of a balloon in a vertebra, it can be used as an alternative to vertebroplasty to reduce cement extravasation. Issues such as poor inter digitisation of the cement and the trabecular bone can arise with the BKP method. This can be due to a compacted layer created during the procedure which can cause complications post-surgery. The primary aim of this study was to investigate alternative cement application methods which could improve the mechanical strength of the bone-cement interface. Three alternative methods were investigated, and cylindrical bone-cement specimens were created for all methods (BKP and three alternatives). An important part of this study was to replicate the compacted layer created by the inflation of the balloon tamp in BKP. Synthetic trabecular bone specimens (Sawbones®, Pacific Research Laboratories, Vashon Island, Washington, USA) were pre-loaded in compression and the resultant compacted layers were found to replicate the compacted layers found in surgery. Mechanical testing was carried out with an MTS Model 858 Bionix^® Servohydraulic load frame using static tensile and torsion loads. Static tests revealed that two of the three alternative methods were an improvement on BKP, with a high statistical significance in relation to the mechanical performance of the bone-cement interface (P < 0.001). This data illustrates the potential to improve the standard BKP technique, in terms of bone-cement interface performance.

Protocols for processing of tissue from arthroplasty infections vary and might affect the recovery of bacteria. We compared homogenization, bead beating and enzymatic disruption for recovery of live bacteria from tissue samples.

Suspensions of Staphylococcus aureus and Escherichia coli were prepared as controls. Three samples were taken from each and the first was bead beaten, the second homogenized, and Proteinase K was added for 10 and 30 minutes to the third sample before culturing. In addition, artificially inoculated pork tissue and known infected human tissue samples were processed by either homogenization or bead beating prior to cultures and results were compared.

Number of cycles of bead beating and homogenization and duration of Proteinase K treatment had significant effects. Bead beating for 2 and 4 cycles reduced the yield of S.aureus to 52% and 20% of control, and E.coli to 33% and 8%. Homogenization for 2 and 4 cycles reduced S.aureus to 86% and 65% of control, and E.coli to 90% and 87%. Proteinase K for 10 minutes and 30 minutes reduced the yield of S.aureus to 75% and 33% of control, and E.coli to 91% and 49% respectively. Inoculated Pork tissue showed a reduction in S.aureus recovery of 90% for bead beating compared to homogenization, and 80% in the case of E.coli. Bead beating of infected human tissue samples reduced the yield by 58% compared to homogenization.

Bead-beating is a common recommended method of processing tissue from arthroplasty cases. However, even though it produces a homogeneous sample, it does so at the cost of significant loss of viable bacteria. Homogenization and 10 minutes of Proteinase K incubation are almost equivalent, but the homogenizer is preferred being more controllable and cheaper. This should help to define guidelines for diagnosing infections using tissue samples.

Objectives. Our objective was to perform a systematic review of the literature and conduct a meta-analysis to investigate the outcomes of open versus arthroscopic methods of ankle fusion. Methods. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies comparing outcomes of arthroscopic and open ankle arthrodesis. The Newcastle-Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data. Results. We identified one prospective cohort study and 5 retrospective cohort studies, enrolling a total of 286 patients with ankle arthritis. Our analysis showed that open ankle fusion was associated with a lower fusion rate (OR 0.26, 95% CI 0.13–0.52, P = 0.0002), longer tourniquet time (MD 16.49, 95% CI 9.46–23.41, P<0.00001), and longer length of stay (MD 1.60,95% CI 1.10–2.10, P<0.00001) compared to arthroscopic ankle fusion; however, there was no significant difference between two groups in terms of infection rate (OR 2.41, 95% CI 0.76–7.64, P = 0.14), overall complication rate (OR: 1.54, 95% CI 0.80–2.96, P = 0.20), and operation time (MD 4.09, 95% CI −2.49–10.66, P = 0.22). The between-study heterogeneity was high for tourniquet time but low or moderate for other outcomes. The direction of the effect sizes remains unchanged throughout sensitivity analyses. Conclusions. The best available evidence demonstrates that arthroscopic ankle fusion may be associated with a higher fusion rate, shorter tourniquet time, and shorter length of stay compared to open ankle fusion. We found no significant difference between two groups in terms of infection rate, overall complication rate, and operation time. The best available evidence is not adequately robust to make definitive conclusions. Long-term results of the comparative efficacy of arthroscopic ankle fusion over open ankle fusion are not currently available. Further high quality randomised controlled trials that are adequately powered are required

Objective. The efficacy and safety of tranexamic acid (TXA) on reducing blood loss and transfusion has been confirmed in primary total hip arthroplasty (THA). The main methods of administration includes intravenous, topical alone or combined use, and the most appropriated methods remains undecided. This study was aimed to compare the efficacy and safety of different methods of TXA following primary THA. Methods. We prospectively collected patients' data through National Health Database from January 2013 to December 2016. The patients were divided into control group, intravenous group, topical group and combined group according to the different methods of TXA. The primary outcome was the incidence of transfusion and venous thromboembolism. Secondary outcomes were total blood loss, hemoglobin level on postoperative day 3 and decrease in hemoglobin, incidence of wound complications and other adverse events. Results. A total of 7537 primary THA procedures were collected, 4102 with TXA, 3435 without TXA. 2847 (37.8%) patients received intravenous TXA alone, 235 (3.1%) patients received topical TXA alone and 1020 (13.5%) patients received combined use. The transfusion rate decreased from 33.07% to 12.7% with the use of TXA (p< 0.001). The transfusion rate was 30.21% in topical group, 10.68% in intravenous group, and 14.31% in combined group, with a significant difference between treatment groups (p< 0.01 for all). The hemoglobin on postoperative day 3 in control group was 91.24±17.09 g/L, which was significantly lower than that in topical group (101.38±16.71 g/L), intravenous group (102.79±32.37 g/L) and combined group (104.34±16.67 g/L, p<0.05 for all). The hemoglobin drop on POD 3 in control group was 38.07±18.10 g/L, which was significantly higher than that in topical group (30.02±17.11 g/L), intravenous group (29.35±16.05 g/L) and combined group (29.22±16.37 g/L, p<0.05 for all). The total blood loss in control group was (1377.74 ± 851.97 ml), which was significantly higher than that in topical group (1123.15±628.59 ml), intravenous group (971.08±671.39 ml) and combined group (946.4±724.82 ml, p<0.05 for all). A total of 14 DVT (0.41%) in control group, 4 patients (0.1%) in TXA group occurred DVT, and the difference was significant (0.10%, p= 0.006). Cardiac infarction occurred in 3 patients (0.04%), stroke occurred in 2 patients (0.03%), and 3 patients (0.04%) developed wound infection. No episode of PE or death occurred. Conclusion. TXA was effective and safe to decrease blood loss and transfusion following primary THA no matter of intravenous, topical use alone or combined use. In order to achieve better hemostatic effect, intravenous or combined application was recommended if no contradictions were found