Reported wound complication in below knee surgery can be quite high. Recent study demonstrated that increased blood loss and hematoma formation increase wound complications especially in foot and ankle surgeries. Despite the evidence on the benefit of TXA on blood loss in TKA and THA it is not routinely used by surgeon in below knee surgery.

To assess the efficacy and safety of this medication in reducing wound complication and blood loss and the risk of thromboembolic complications in patients undergoing below knee surgery. A systematic literature search of PubMed, Embase, Ovid, the Cochrane Library and AAOS and AOFAS conference proceedings was conducted. The primary outcome was the rate of wound complications. Data were analyzed using the Review Manager 5.3 software.

Nine studies involving 861 patients met the inclusion criteria. The meta-analysis indicated that TXA, when compared to a control group, reduced wound complications (OR, 0.54; 95% IC, 0.31 to 0.95, p = 0,03), blood loss (MD = −149,4 ml; 95% CI, −205,3ml to −93,6ml), post-operative drainage (MD = −169,8 ml; 95% CI, −176,7 to −162,9 ml) and hemoglobin drop (MD = −8,75 g/dL; 95% IC, −9,6 g/dL to −7,8 g/dL). There was no significant difference in thromboembolic events (RR 0,53; 95% CI, 0,15 - 1,90; p = 0,33).

This study demonstrated that TXA could be use in below knee surgery to reduce wound complication and blood loss without increased thromboembolic complications. The small number of studies limit the findings interpretation. Further studies are needed to sustain those resutls.

There is no clear consensus regarding the indications for surgical treatment of middle third clavicle fractures. An initial shortening of 2 cm or more of the clavicle was associated with poor clinical outcomes and higher rate of non-union. The number needed to treat (NNT) clavicle fractures in order to prevent non-union ranges in the recent literature from 4.5 to 9.2. A direct relationship between shortening of the clavicle and a poor clinical outcome has not yet been demonstrated.

Prospective cohort study performed in a Level one trauma centre including 148 clavicle fractures treated conservatively. Eighty-five patients met the inclusion criteria (healed fracture in the middle third, no other upper limb lesions) and 63 were enrolled. A single assessment was realised at a minimum one year follow-up by an independent examiner and consisted in Constant and DASH scores, range of motion, strength in abduction (Isobex) and a specific radiographic evaluation using a calibrated AP radiographs of both clavicles. Two groups were constituted and analysed according to a radiologic shortening > 2 cm (patients and assessor blinded). Sub-analyses were performed to find any relevant clinical threshold.

The rate of shortening > 2cm in this cohort is 16.1% (10 patients). No clinical differences between the two groups for Constant scores (shortened > 2 cm = 96.0 ± 6.0 vs 95.2 ± 6.6, p=0,73) and DASH scores (8.4 ± 11.9 vs 5.4 ± 8.1, p=0,32). A slight loss in flexion was observed with a shortening > 2cm (175 deg ± 8.5 vs 179.3 ± 3.4, p=0,007). No clinical threshold (in absolute or relative length) was associated with lower functional scores. No relationship between clinical results and patient characteristics. Interestingly, cosmesis was not an issue for patients.

This study could not demonstrate any clinical impact of the shortening of the clavicle in patients treated conservatively for a fracture in the middle third. Functional scores are excellent and the slight difference in flexion is not clinically significant. We were not able to found patients unsatisfied with their treatment. The poor functional outcomes described in previous studies are mainly related to non-unions. Just after the trauma, protraction of the scapula and single AP views centered on the clavicle can overestimate the real shortening. An initial shortening of the clavicle > 2 cm is not a surgical indication for fractures in the middle third; patient selection for surgery should focus on risk factors for non-unions.