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To analyze the efficacy of intraoperative topical antibiotics in reducing the incidence of postoperative surgical site infections in pelvic and lower-limb trauma orthopaedic surgery.A search of Ovid MEDLINE, PubMed, and Embase was conducted for English language studies published from 1946 through September 3, 2021, using relevant keywords.Included studies were randomized controlled trials, cohort studies, or case-control studies reporting on the rate of surgical site infections in adult patients (age 16 and older) who underwent surgical fixation of lower-limb or pelvic traumatic fractures, including both open and closed fractures, with topical intraoperative antibiotics applied to the surgical site before wound closure.Studies were evaluated using the Joanna Briggs Institute Critical Appraisal Checklist for analytical cross-sectional studies. The risk of bias was assessed using the ROBINS-I and Cochrane risk-of-bias tools.A meta-analysis was conducted using the inverse variance method and random-effects model to assess effect significance and study heterogeneity.Seven studies were included in the systematic review. Results of the meta-analysis suggested a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intraoperative antibiotic powder compared with those managed with intravenous antibiotics alone (odds ratio 0.77, 95% confidence interval 0.52-1.13), although the results did not reach statistical significance. Further powered studies including randomized controlled trials would be of great value to validate the results suggested in this study and inform best practice intraoperative antibiotic prophylaxis in pelvic and lower-limb trauma surgery.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Adenomatous polyposis coli (APC) truncations occur in many colorectal cancers and are often associated with immune infiltration. The aim of this study was to determine whether a combination of Wnt inhibition with anti-inflammatory (sulindac) and/or proapototic (ABT263) drugs can reduce colon adenomas. Apcmin/+ and doublecortin-like kinase 1 (Dclk1)Cre/+;Apcfl/fl mice were exposed to dextran sulphate sodium (DSS) in their drinking water to promote the formation of colon adenomas. Mice were then treated with either a Wnt-signaling antagonist pyrvinium pamoate (PP), an anti-inflammatory agent sulindac or proapoptotic compound ABT263 or a combination of PP+ABT263, or PP+sulindac. Colon adenoma frequency, size, and T-cell abundance were measured. DSS treatment resulted in significant increases in colon adenoma number (P < 0.001, n > 5) and burden in Apcmin/+ (P < 0.01, n > 5) and Dclk1Cre/+;Apcfl/fl (P < 0.02, n > 5) mice. There was no effect on adenomas following treatment with PP in combination with ABT263. Adenoma number and burden were reduced with PP+sulindac treatment in Dclk1Cre/+;Apcfl/fl mice (P < 0.01, n > 17) and in Apcmin/+ mice (P < 0.001, n > 7) treated with sulindac or PP+sulindac with no detectable toxicity. PP treatment of Apcmin/+ mice increased the frequency of CD3+ cells in the adenomas. The combination of Wnt pathway inhibition with sulindac was more effective in Dclk1Cre/+;Apcfl/fl mice and provides an opportunity for killing Apc-mutant colon adenoma cells, indicating a strategy for both colorectal cancer prevention and potential new treatments for patients with advanced colorectal cancer. Outcomes from the results of this study may be translatable to the clinic for management of FAP and other patients with a high risk of developing colorectal cancer.Significance:Colorectal cancer is one of the most common cancers worldwide with limited therapeutic options. APC and other Wnt signaling mutations occur in the majority of colorectal cancers but there are currently no Wnt inhibitors in the clinic. The combination of Wnt pathway inhibition with sulindac provides an opportunity for killing Apc-mutant colon adenoma cells and suggests a strategy for colorectal cancer prevention and new treatments for patients with advanced colorectal cancer.

Adenoma tumour development in Apcmin/+ and Dclk1Cre/+;Apcfl/fl mice

Adenomatous polyposis coli (APC) truncations occur in many colorectal cancers and are often associated with immune infiltration. The aim of this study was to determine whether a combination of Wnt inhibition with anti-inflammatory (sulindac) and/or proapototic (ABT263) drugs can reduce colon adenomas. Apcmin/+ and doublecortin-like kinase 1 (Dclk1)Cre/+;Apcfl/fl mice were exposed to dextran sulphate sodium (DSS) in their drinking water to promote the formation of colon adenomas. Mice were then treated with either a Wnt-signaling antagonist pyrvinium pamoate (PP), an anti-inflammatory agent sulindac or proapoptotic compound ABT263 or a combination of PP+ABT263, or PP+sulindac. Colon adenoma frequency, size, and T-cell abundance were measured. DSS treatment resulted in significant increases in colon adenoma number (P < 0.001, n > 5) and burden in Apcmin/+ (P < 0.01, n > 5) and Dclk1Cre/+;Apcfl/fl (P < 0.02, n > 5) mice. There was no effect on adenomas following treatment with PP in combination with ABT263. Adenoma number and burden were reduced with PP+sulindac treatment in Dclk1Cre/+;Apcfl/fl mice (P < 0.01, n > 17) and in Apcmin/+ mice (P < 0.001, n > 7) treated with sulindac or PP+sulindac with no detectable toxicity. PP treatment of Apcmin/+ mice increased the frequency of CD3+ cells in the adenomas. The combination of Wnt pathway inhibition with sulindac was more effective in Dclk1Cre/+;Apcfl/fl mice and provides an opportunity for killing Apc-mutant colon adenoma cells, indicating a strategy for both colorectal cancer prevention and potential new treatments for patients with advanced colorectal cancer. Outcomes from the results of this study may be translatable to the clinic for management of FAP and other patients with a high risk of developing colorectal cancer. Significance: Colorectal cancer is one of the most common cancers worldwide with limited therapeutic options. APC and other Wnt signaling mutations occur in the majority of colorectal cancers but there are currently no Wnt inhibitors in the clinic. The combination of Wnt pathway inhibition with sulindac provides an opportunity for killing Apc-mutant colon adenoma cells and suggests a strategy for colorectal cancer prevention and new treatments for patients with advanced colorectal cancer.

AimThe aim of this study is to report the safety and efficacy of the Woodpecker pneumatic broaching system in direct anterior hip arthroplasty.Methods649 primary elective anterior bikini total hip arthroplasties (THA) using Woodpecker broaching over a 5-year period were included. Patients undergoing a THA through a different surgical approach, revision THA or arthroplasties for hip fractures were excluded (n=219). Preoperative and postoperative Harris Hip Scores (HHS) and postoperative radiographs were analysed to identify femoral fractures and femoral component positioning. Complications and component survivorship until most recent follow-up were analysed.ResultsThe average time taken for femoral preparation using Woodpecker broaching system was 2.8 min (1.4–7.5 min) in both cemented and uncemented THAs. Radiographic analysis revealed 67.3% of the stems were placed in 0°–1.82° of varus and 32.7% placed in 0°–1.4° of valgus. Average HHS were 24.4 preoperatively, with significant improvements at 6 weeks (80.95), 6 months (91.91) and 12 months (94.18) of follow-up. Complications not directly attributed to Woodpecker broaching included three intraoperative femoral fractures (0.4%), three periprosthetic postoperative fractures (0.3%), two cases of stem subsidence (0.3%) and two wound infections (0.3%). At the most recent follow-up, the survivorship of the acetabular component was 99.7% and the femoral component was 99.1%, with mean follow-up of 2.9 years (0.5–5 years).ConclusionThe pneumatic Woodpecker device is a safe and effective alternative tool in minimally invasive direct anterior hip replacement surgery for femoral broaching performed on a standard table.

Objectives Most patients want to resume normal activities as soon as possible after total knee arthroplasty (TKA), with driving an integral aspect to re-establish social and recreational independence. This study aimed to determine when patients resumed driving after TKA. Methods All patients undergoing patient-specific instrumented (PSI) medial pivot TKA between January 2017 and April 2018 were included. Patients who did not drive were excluded. A detailed questionnaire was sent to patients 2 weeks after surgery to record their driving status. 50 patients were randomly selected to assess flexion at the hip, knee and ankle joints while seated in the driver's seat of their own vehicle. Results 160 patients (female=94 and male=66) with a mean age of 68 years (45–90 years) underwent a PSI TKA (left side [L]=75, right side [R]=85). 73% patients returned to driving within the first 3 weeks after surgery, of which 15 (10%) resumed driving within the first postoperative week, 52 (35%) in the second week and 41 (28%) in the third week. The median time to resume driving following surgery was 3 weeks for both operative sides, with IQR of 2.0 (L) and 1.0 (R). Conclusion A majority of patients resume driving within 3 weeks after undergoing a PSI TKA, regardless of operative side or transmission of vehicle. Level of evidence IV

BACKGROUND: The widespread adoption of minimally invasive surgery and increased use of intra-operative fluoroscopy places surgeons and trainees at risk of cumulative occupational radiation exposure. Unfortunately, there is limited published data specific to surgeons on the potential health implications. This study aims to review current literature regarding the hazards of cumulative radiation exposure among operating theatre staff. METHODS: A systematic review was conducted of four databases for studies reporting on cumulative intra-operative radiation exposure for operating theatre staff and the hazards associated with prolonged and frequent use. References from relevant studies were screened for additional texts. English language studies, controlled trials and cross-sectional studies were included. Abstracts and full-text studies were assessed for relevance and eligibility independently by two authors using Covidence. RESULTS: Six studies were included, with cancer being the most commonly reported long-term health hazard possibly associated with cumulative radiation exposure. A 1.85 fold greater prevalence of all cancers and 2.9 fold greater prevalence of breast cancer was reported amongst female orthopaedic surgeons compared to a sex- and age-adjusted population, but the results were not replicated amongst other surgical specialties. Multiple limitations of quantifying health risks of intra-operative radiation exposure were identified, including identifying a dose-effect relationship and confounders such as nulliparity and maternal age. CONCLUSION: This article highlights the lack of robust evidence regarding the potential hazards of cumulative occupational intra-operative radiation exposure. This study demonstrates the importance of developing standardised national radiation safety protocols for surgical colleges and subspecialties to minimise risks to operating theatre staff.

PurposeThe purpose of this study was to report all complications during the first consecutive 865 cases of bikini incision direct anterior approach (DAA) total hip arthroplasty (THA) performed by a single surgeon. The secondary aims of the study are to report our clinical outcomes and implant survivorship. We discuss our surgical technique to minimize complication rates during the procedure.MethodsWe undertook a retrospective analysis of our complications, clinical outcomes and implant survivorship of 865 DAA THA’s over a period of 6 years (mean = 3.9yrs from 0.9 to 6.8 years).ResultsThe complication rates identified in this study were low. Medium term survival at minimum 2-year survival and revision as the end point, was 99.53% and 99.84% for the stem and acetabular components respectively. Womac score improved from 49 (range 40–58) preoperatively to 3.5(range 0–8.8) and similarly, HHS scores improved from 53(range 40–56) to 92.5(range 63–100) at final follow-up (mean = 3.9 yrs) when compared to preoperative scores.ConclusionsThese results suggest that bikini incision DAA technique can be safely utilised to perform THA.

Introduction: There has been an increased interest in minimally invasive direct anterior approach total hip arthroplasty (THA) to provide greater patient satisfaction, improve pain relief, and reduce the duration of hospitalisation. A direct anterior approach hybrid cemented THA, utilising a bikini line incision, can be technically challenging. We aimed to undertake radiological analysis of femoral stem cementation, clinical outcomes, and component survivorship. Methods: Over a 5-year period, 215 primary elective bikini anterior THA conducted by a single surgeon were included. All procedures were performed using a cemented collarless polished stem. The operation was performed on a standard operating table. Patients undergoing posterior approach, revision procedures, and fractured neck of femurs were excluded. Post-operative radiographs were analysed for femoral cementation quality using the Barrack grading system. Harris hip scores (HHS) were determined at 6 weeks, 12 weeks, annually thereafter and the difference in HHS was noted. Results: In total, 215 anterior bikini THA (R = 101, L = 114) were performed in 199 patients (M = 89, F = 110) with a mean age of 77 and mean follow up of 2.9 years (range = 0.5–5). Radiographic analysis of femoral cementation showed 189 femoral stems (88%) were either Barrack A or B cementation grade, suggesting optimal cementation. Lucency in the cement-bone interface occurred mainly in Gruen Zone 1 (43%) and Zone 13(46.9%). At the most recent follow-up (mean 2.9 years), component survivorship was at 99.54% (stem). Significant improvement was noted in Harris hip scores at final follow-up (from 54 preoperatively to 92.7 at 2.9 years postoperatively). Conclusion: Our results suggest that a bikini incision direct anterior approach for total hip arthroplasty can be safely employed to perform cemented femoral stems on a standard operating table.

Introduction: Patients desire to return to normal activities soon after hip arthroplasty, with driving often being an integral component. We aimed to determine when patients resumed driving following a minimally invasive anterior bikini hip replacement and when they returned to work. Methodology: All consecutive patients undergoing elective primary bikini hip replacements between January 2017 and April 2018 were included in the study. Patients who did not drive were excluded. A detailed questionnaire was sent to patients 3–6 weeks after surgery to record their driving status. Fifty patients were randomly selected to assess flexion at the hip, knee and ankle joints while seated in the driver's seat of their own vehicle. Results: Altogether 212 anterior bikini total hip replacements (L = 102, R = 108 and 1 bilateral one stage) were performed in 198 patients (F = 129 and M = 69) with a mean age of 69 years. A total of 76% patients returned to driving within the first 3 weeks after surgery, of which 25 (14%) resumed driving within the first post-operative week, 71 (39%) in the second week and 42 (23%) in the third week. Among them, 98.4% stated they were confident when they first started driving and 90.66% stated they were more comfortable driving after surgery than before. Employed patients returned to work within 1–79 days (mean = 24 days). Conclusion: Surgeons may allow patients to resume driving within 1 week after anterior hip replacement and return to work within 3 weeks if they are medically fit and deemed safe.