Advancements in de Quervain Tenosynovitis Management: A Comprehensive Network Meta-Analysis.

PURPOSE: This study presents a network meta-analysis aimed at evaluating nonsurgical treatment modalities for de Quervain tenosynovitis. The primary objective was to assess the comparative effectiveness of nonsurgical treatment options. METHODS: The systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Searches were performed in multiple databases, and studies meeting predefined criteria were included. Data extraction, risk of bias assessment, and statistical analysis were carried out to compare treatment modalities. The analysis was categorized into short-term (within six weeks), medium-term (six weeks up to six months), and long-term (one year) follow-up. RESULTS: The analysis included 14 randomized controlled trials encompassing various treatment modalities for de Quervain tenosynovitis. In the short-term, extracorporeal shockwave therapy demonstrated statistically significant improvement in visual analog scale pain scores compared with placebo. Extracorporeal shockwave therapy also ranked highest in the treatment options based on its treatment effects. Corticosteroid injections (CSIs) combined with casting and laser therapy with orthosis showed favorable outcomes. Corticosteroid injection alone, platelet-rich plasma injections alone, acupuncture, and orthosis alone did not significantly differ from placebo in visual analog scale pain score. In the medium-term, extracorporeal shockwave therapy remained the top-ranking option for visual analog scale pain score, followed by CSI with casting. In the long-term (one year), CSI alone and platelet-rich plasma injections demonstrated sustained pain relief. Combining CSI with orthosis also appeared promising when compared with CSI alone. CONCLUSIONS: Corticosteroid injection with a short duration of immobilization remains the primary and effective treatment for de Quervain tenosynovitis. Extracorporeal shockwave therapy can be considered a secondary option. Alternative treatment modalities, such as isolated therapeutic injection, should be approached with caution because they did not show substantial benefits over placebo. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Comparison of Interventions for Lateral Elbow Tendinopathy: A Systematic Review and Network Meta-Analysis for Patient-Rated Tennis Elbow Evaluation Pain Outcome.

PURPOSE: There is controversy regarding the optimal treatment for lateral elbow tendinopathy (LET), and not all available treatment options have been compared directly with placebo/control. A network meta-analysis was conducted to compare the effectiveness of different LET treatments directly and indirectly against control/placebo based on a validated outcome, the Patient-Rated Tennis Elbow Evaluation (PRTEE) pain score. METHODS: Randomized, controlled trials comparing different treatment methods for LET were included, provided they reported outcome data using the PRTEE pain score. A network meta-analysis with random effect was used to combine direct and indirect evidence between treatments compared with placebo in the short term (up to six weeks) and midterm (more than six weeks and up to six months) after intervention. RESULTS: Thirteen studies with 12 comparators including control/placebo were eligible. The results indicated no significant improvement in PRTEE pain score in the short term across all treatments compared with control/placebo. In the midterm, physiotherapy/exercise showed benefit against placebo (mean difference: -4.32, 95% confidence interval: -7.58 and -1.07). Although steroid injections, dry needling, and autologous blood also exhibited potential treatment effects, it is crucial for the clinician to consider certain pitfalls when considering these treatments. The limited number of small studies and paucity of data call for caution in interpreting the results and need for further evidence. CONCLUSIONS: Patients should be informed that there is currently no strong evidence that any treatment produces more rapid improvement in pain symptoms when compared with control/placebo in the short and medium terms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Leiomyosarcoma in the extremities and trunk wall: systematic review and meta-analysis of the oncological outcomes.

BACKGROUND: Leiomyosarcomas are aggressive malignancies which can occur on the trunk and extremities whose pathogenesis is poorly understood. We aim to quantify the prognostic impact of various clinical and pathological markers on survival and recurrence of leiomyosarcomas. METHODS: We conducted a systematic review as per PRISMA protocol. Survival, local recurrence, and metastasis were the outcome measures. Data were extracted from the studies for the outcome variables; the resultant odds ratios (OR) and 95% confidence interval (CI) were used for the synthesis of a forest plot. RESULTS: Our search revealed thirteen studies comprising 1380 patients. Seven of these 13 publications were since 2012. Our analysis showed that tumor size larger than 5 cm adversely affected the outcome with an OR 3.39 (2.26-5.10, p < 0.01). Other factors which reduced the overall survival were positive margins of excision OR 2.12 (1.36-3.32, p < 0.01). A reduced risk of metastasis has strongly associated the use of radiotherapy with OR 10.84 (4.41-26.61, p < 0.01). Only a few studies analyzed the impact of factors on local recurrence. CONCLUSIONS: Size larger than 5 cm and positive margins of excision are associated with poor overall survival. In comparison, the use of adjuvant radiotherapy was associated with a lower metastatic rate. There is a need for methodically high-quality studies with more uniform study design and reporting to evaluate the impact of various risk factors on local recurrence and metastases. LEVEL OF EVIDENCE: Level 1 Prognostic.

Total shoulder arthroplasty vs. hemiarthroplasty in patients with primary glenohumeral arthritis with intact rotator cuff: meta-analysis using the ratio of means.

BACKGROUND: Glenohumeral arthritis is a degenerative disease of the shoulder joint. There is limited evidence in the literature in superiority of outcomes between total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) for patients when the rotator cuff is intact. The purpose of this systematic review was to compare patient-reported outcome measures (PROMs) and rate of complication between these 2 interventions in patients with primary glenohumeral arthritis and an intact rotator cuff. Previous systematic reviews have focused only on results from randomized controlled trials, demonstrating mixed outcomes in PROMs and no difference in postoperative complications or rate of revision. Our study is the first, to our knowledge, to assess all comparative studies including prospective and retrospective observational studies, assessing a combined 1317 patients. Using the ratio of means, data from different PROMs were pooled to analyze and compare the total combined relative effect change following intervention. METHODS: We undertook literature review of the reference databases until March 2021. We included randomized controlled trials in addition to comparative observational studies and case series (more than 10 patients). Study participants were adults who had primary glenohumeral arthritis with an intact rotator cuff. Meta-analysis was performed by the ratio of means for PROMs and risk ratio for revision and complication data. RESULTS: Comparing clinical outcome of TSA against HA from 10 studies, meta-analyses using ratio of means demonstrated an 8% significantly improved relative increase in the postoperative PROMs in the TSA cohort (ratio of means 1.08, 95% confidence interval [CI] 0.04-1.12, P < .01). The TSA cohort additionally demonstrated a significantly lower revision rate (relative risk 1.84, 95% CI 1.05-3.24, P = .03). Although the risk of complication was nonsignificant, pooling revision and complications data revealed a 2-fold increased risk in the HA group compared with TSA (relative risk 2.09, 95% CI 1.17-3.74, P = .01). CONCLUSIONS: In patients with primary glenohumeral osteoarthritis with an intact rotator cuff, TSA is favored to HA in terms of clinical outcome, risk of revision surgery, and postoperative complications.

Pediatric distal humeral supracondylar fracture - achievement of optimal pinning configuration.

Pediatric supracondylar humeral fracture is com- monly managed using closed reduction and per- cutaneous Kirschner wires pinning. However, there is no consensus on optimal pinning configuration in the literature. Our study aims to review the pinning configuration in our department, correlate our results with the available literature, and suggest the optimal configuration using basic biomechanics principles. We performed a retrospective review on children that were treated with K-wire pinning for supracondylar fracture at our institution between August 2017 and August 2019. Intra-operative antero-posterior view fluoroscopic images were used to measure the pin separation ratio (PSR), pin crossing angle (PCA), medial inclination angle (MIA) and lateral inclination angle (LIA). Pearson Correlation was used to identify the relationship between the variables. Ninety-one patients were included for analysis (39 male: 52 female), with a mean age of 6. Average PCA in the crossed pin and lateral-entry only technique CA was 75° and 12°, respectively. Mean crossed pin and lateral-entry only technique PSR is 0.54 and 0.17, respectively. There was a significant difference in both mean PSR and PCA between the configurations (p <0.01). In subgroup analysis, optimal PSR > 0.33 and PCA >90° were best achieved in crossed pinning using 1 medial and 2 lateral pins. Assessing the biomechanical characteristics of the different fixation techniques, we have found that 2 lateral divergent pins and 1 medial pin using the crossed pin technique optimized both the PSR and PCA. We would recommend this configuration to optimize the stability of the fixation construct.

A Multicenter Retrospective Cohort Study of First Metatarsophalangeal Joint Arthrodesis.

In this multicenter study, we evaluated commonly used methods of fixation and 2 methods of joint preparation for first metatarsophalangeal joint fusion, in terms of radiological union and revision rates. Included were 409 consecutive fusions in 385 patients. The overall union rate was 91.4% (34/409). About 29.4% (10/34) of our nonunions were symptomatic. Preoperative hallux valgus showed a statistically significant relation to nonunion (odds ratio [OR] = 9.33, p = .017). Other potential contributing factors like gender (OR 1.9, p = .44), diabetes (OR = 0, p = .99), steroid use (OR = 2.07, p = .44), inflammatory arthritis (OR = 0, p = .99), and smoking (OR = 2.69, p = .34) did not attain statistical significance. Further, the methods of fixation like solid screws (OR = 0, p = .99), plate (OR = 3.6, p = .187), or cannulated screws (OR = 0.09, p = .06) showed no correlation with incidence of nonunion. We compared 2 techniques of joint preparation and found no significant difference in union rates (chi-square = 1.0426, p = .30). Our crude comparison of costs showed the average saving to the trust per year could be 33,442.50£ by choosing screws over plates. To conclude, only hallux valgus had a statistically significant relation to nonunion. All other variables had no significant impact on the union. Solid screw seems to be economically the most viable option and a valid alternative.

The Role of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis for Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Comparative Clinical Studies.

BACKGROUND: After its success in restoring rotational stability and reducing failure rates in primary anterior cruciate ligament reconstruction (ACLR), lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR) has been endorsed for use in revision ACLR surgery, where failure rates are historically higher. PURPOSE: To perform a systematic review and meta-analysis on whether the addition of a LET or ALLR results in superior clinical outcomes and stability compared with isolated revision ACLR (iACLR). STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis of comparative studies using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("extra-articular" OR "tenodesis" OR "anterolateral ligament" OR "iliotibial") AND ("anterior cruciate ligament") AND ("revision" OR "re-operation"). Data pertaining to all patient-reported outcome measures (PROMs), rotational stability, and postoperative complications were extracted from each study. RESULTS: After abstract and full-text screening, 10 clinical comparative studies were included. There were 793 patients, of whom 390 had an iACLR while 403 had an ACLR augmented with a LET or an ALLR (augmented ACLR [aACLR]). The mean time for assessment of PROMs was 35 months. The aACLR group had superior International Knee Documentation Committee (IKDC) scores (standardized mean difference [SMD], 0.27; 95% CI, 0.01 to 0.54; P = .04), rotational stability (odds ratio [OR], 2.77; 95% CI, 1.91 to 4.01; P < .00001), and lower side-to-side difference (OR, -0.53; 95% CI, -0.81 to -0.24; P = .0003) than those without the augmentation. Furthermore, they were less likely to fail (OR, 0.44; 95% CI, 0.24 to 0.80; P = .007). Subgroup analysis in the higher-grade laxity cohort (grade ≥2) revealed an even greater IKDC score (SMD, 0.51; 95% CI, 0.16 to 0.86; P = .005) and an improved Lysholm score (SMD, 0.45; 95% CI, 0.24 to 0.67; P < .0001) in the aACLR group. CONCLUSION: Revision aACLR with a LET or an ALLR can improve subjective IKDC scores, restore rotational stability, and reduce failure rates compared with iACLR. Although controversy remains on the necessity of augmenting all revision ACLRs, the present meta-analysis advocates adding a lateral procedure, particularly in those with a higher-grade pivot shift.

A systematic review and network meta-analysis of outcomes after total wrist arthroplasty in inflammatory and non-inflammatory arthritis.

This systematic review analysed the available evidence on the clinical outcomes of total wrist arthroplasty (TWA) in patients with inflammatory and non-inflammatory arthritis. After screening, 12 studies met the inclusion criteria. They involved 359 patients with 378 TWA implants. The results showed that TWA significantly improved Disabilities of the Arm, Shoulder and Hand (DASH)/Quick-DASH scores and pain visual analogue scale scores in both arthritis groups compared with preoperative values. However, there was no statistically significant difference in the outcome scores between the two groups. Three studies reported Patient-Rated Wrist Evaluation (PRWE) scores, and TWA significantly improved PRWE scores in non-inflammatory arthritis but not in inflammatory arthritis, with no significant difference in postoperative outcome scores between the two groups. Although the included studies have limitations, the review suggests that TWA may be a successful treatment for wrist pain in individuals with either inflammatory or non-inflammatory arthritis. However, further high-quality trials are needed to confirm these findings.

Surgical management of cubital tunnel syndrome: A systematic review and meta-analysis of randomised trials.

Background: Cubital tunnel syndrome (CUTS) is a common upper limb compression neuropathy with significant consequences when left untreated. Surgical decompression remains gold-standard treatment for moderate to severe disease, however the optimal operative technique remains unclear. This network meta-analysis (NMA) of Level I and II randomised prospective studies aims to discern superiority between open in-situ, endoscopic and anterior transposition (subcutaneous or submuscular techniques) with respect to the primary outcome of response-to-treatment and secondary outcomes which include complications, post-operative chronic pain VAS scale, return to work and re-operation. Methods: This NMA adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, Web of Science, Cochrane Central, Science direct and Embase were searched. The MESH database was further searched with the terms 'cubital tunnel' to improve sensitivity of the search. Data pertaining to the primary and secondary outcomes were pooled for NMA. Results: Following abstract and full-text screening, 10 randomised prospective trials were included. There was no statistical difference in the response-to-treatment between the four studied techniques. Endoscopic decompression conferred a significantly higher complication rate compared to open decompression (Odds Ratio [OR], 4.21; 95% CI, 1.22-14.59). Endoscopic decompression had a statistically significant lower risk of post-operative chronic pain compared to open in-situ decompression (OR, 0.03, 95% CI, 0.00-0.32). There were no differences between techniques with respect to return to work or re-operation rates. Conclusion: Response-to-treatment was similar between the four operative techniques for CUTS. Endoscopic decompression was found to be more hazardous when compared to open-in situ decompression but conferred significantly less post-operative chronic pain. There was significant heterogeneity in reported outcomes between the included articles. The authors suggest conducting more high-quality research with standardised outcome reporting to facilitate comparison. Level of evidence ii: Systematic Review and Meta-analysis of Randomised Prospective Trials- Therapeutic study.

Patients can accurately self-report their elbow range of motion following surgery for trauma.

INTRODUCTION: There is an increased demand of telemedicine in the recent century, especially with the outbreak of Covid-19. The aim of this study was to investigate patients' reliability in self-assessing own elbow range of motion following surgery for trauma. METHODS: All patients of age ≥16 years who underwent surgery for elbow trauma at the local trauma unit between March 2015 to Aug 2018 were reviewed retrospectively. Identified cohort was invited to self-assess their elbow range of motion (ROM) using questionnaire with image instruction. They were then followed up with a clinical review for objective measurements by the lead clinician. Independent T-test was used to compare the measurements between patients and clinician. The power of the study was calculated using G∗Power software. RESULTS: Thirty-five patients were enrolled in the study with mean age of 41 years. 11 of 35 patients had an associated elbow fracture dislocation associated. Mean patient reported total ROM was 105.7° ± 32.8°, with mean extension of 24.6° ± 18.9° to mean flexion of 130.3° ± 18.2°. Mean objective ROM measured by lead clinician was 112.6° ± 18.3°, with mean extension 22.4° ± 10.9° to mean flexion 135.0° ± 10.8°. No statistical significance was found between self-reported and clinician-based extension (p = 0.36), flexion (p = 0.076), and overall range of motion (p = 0.12). CONCLUSION: Patients can self-assess their elbow range of motion following surgery for trauma accurately. In the midst of increasing demands for telemedicine, we suggest the application of patients' self-reporting outcome in clinical settings.

A meta-analysis of union rate after proximal scaphoid fractures: terminology matters.

Heterogeneity in the anatomical definition of 'proximal' affects the comparison of outcomes of these scaphoid fractures. This study aims to review published outcomes of all variants to determine both, differences in terminology, and union rate based upon definition. A literature search was conducted to identify articles that reported descriptions and union rate of all acute (<8 weeks of injury) proximal scaphoid fractures in adult patients (>16 years old). Proximal fractures were grouped as reported ('third', 'pole', 'fifth' or 'undefined'). The data were pooled using a fixed-effects method, and a meta-analysis was conducted to compare relative risk (RR) of non-union against non-proximal fractures. Qualitative analysis of 12 articles included three main definitions: 'proximal' (1 article), 'proximal third' (3 articles), and 'proximal pole' (8 articles). Only 6 articles adopted a specific anatomical or ratio description. In a pooled meta-analysis of union rates (15 articles), 'proximal third' and 'proximal pole' fractures demonstrated a relative risk (RR) of non-union of 2.3 and 3.4 in comparison to non-proximal fractures, respectively. Operative management yielded lower non-union rates than non-operative for all fracture types (6% vs. 18%). In conclusion, non-union risk varies depending on definition, with non-standardised classifications adding heterogeneity to reported outcomes. We recommend an approach utilizing fixed anatomical landmarks on plain radiographs (referencing scaphoid length and scapho-capitate joint) to standardise reporting of proximal fracture union in future studies. Abbreviations: CI: confidence intervals; CT: computer tomography; Df: degrees of freedom; DL: dersimonian and laird estimator; MRI: magnetic resonance imaging; NICE: national institute for health and care excellence; OTA: orthopaedic trauma association; PA: posterior-anterior; PRISMA: preferred reporting items for systematic reviews and meta analyses; RCT: randomised controlled trial; RR: relative risk; SNAC: scaphoid non-union advanced collapse; UK: United Kingdom.

A Systematic Review and Single Center Experience With Percutaneous Needle Tenotomy in Congenital Talipes Equinovarus (CTEV).

Percutaneous scalpel tenotomy is frequently performed as part of congenital talipes equinovarus (CTEV) to correct the equinus deformity. The use of a scalpel is associated with complications such as neurovascular bundle damage and pseudoaneurysms. In the literature, a percutaneous large-bore needle has been found to be a safer alternative to a scalpel for performing tenotomies. The goal of this study was to conduct a systematic review and report a single-center case series on the use of percutaneous needle tenotomy in the treatment of CTEV. A Preferred Reporting Items of Systematic Review and Meta-analysis (PRISMA)-compliant literature search was conducted to identify studies describing the use of a percutaneous needle tenotomy in the treatment of idiopathic CTEV. A retrospective case series of patients with idiopathic CTEV treated with percutaneous needle tenotomy over a seven-year period from a single center were also conducted. The patients' demographics, the location of the clubfoot, and the Pirani score were all recorded. An analysis of descriptive statistics was carried out. Continuous data were expressed as mean and SD, whereas categorical variables were expressed as absolute numbers and percentages (%). The systematic review included eight papers with a total of 1026 feet and a mean age of 10.4 weeks (SD 5.9). There were 47 (0.04%) complications across all studies, with a pooled success rate of 95%. Eleven patients (16 feet) were included in the single-center case study. The patients' initial Pirani score was 4.8 (SD 1.5), with a final score of 0. (SD 0). Four complications occurred in the patient's cohort - one minor bleeding and three recurrences as a result of poor compliance with the post-tenotomy foot abduction brace. In conclusion, the percutaneous Achilles tenotomy of a CTEV foot with a large bore needle is a safe and effective alternative.

A prediction model for treatment decisions in distal radial physeal injuries: A multicenter retrospective study.

Background: There are no clearly defined guidelines for the management of distal radial physeal injuries. We aimed to identify the risk factors for patients with distal radial physeal trauma for the risk of deformity, physeal closure, and revision procedure and develop a predictive model. Methods: The retrospective study included patients less than 16 years old with displaced distal radial physeal injuries treated between 2011 and 2018 across five centers in the United Kingdom. Deformity was defined as a volar angulation of >11°, dorsal angulation of >15°, a radial inclination of <15° or >23°, or positive ulnar variance. Presence of a bony bar spanning the physis was considered physeal closure. Results: This study comprised of 479 patients. In that, 32 (6.6%) patients had a second procedure. Also, 49 (10.2%) patients had closure of physis, and 28 (6%) patients had deformity at the end of follow-up. The occurrence of deformity had a strong correlation with age (p = 0.04) and immobilization duration (p = 0.003). Receiver operating characteristic analysis showed that age >12.5 years (p = 0.006) and sagittal angulation of >21.7° (p = 0.002) had a higher odd of deformity. Immobilization for <4.5 weeks (p = 0.01) had a higher revision rate. The nomograms showed good calibration, with a sensitivity of 70% and specificity of 75%. Interpretation: The nomograms provide accurate, pragmatic multivariate predictive models. Anatomical reduction is recommended in patients >12.5 years of age with >22° of dorsal angulation with cast immobilization for no less than 4.5 weeks. Any revision procedure should be performed within 11 days from the date of injury to reduce the risk of physeal damage.

Intra-articular steroid injections in large joint arthritis: A survey of current practice.

INTRODUCTION: Intra-articular corticosteroid injections are widely used as a management modality for mild large joint osteoarthritis (OA). In contrast, there is little guidance or consensus on the use of steroids in moderate to severe disease. The aim of this study is to explore the current practice of surgeons in relation to the use of therapeutic intra-articular steroid injections in patients awaiting large joint arthroplasty for OA. METHODS: An anonymous questionnaire was distributed to consultants performing large joint arthroplasty in four National Health Service Trusts. Participants were questioned on their use of intra-articular therapeutic steroid injections in patients listed for elbow, shoulder, hip or knee arthroplasty. Data was collected over 6 months and analysed using Microsoft Excel. RESULTS: A total of 42 surgeons were included in the study with the majority performing lower limb arthroplasty (73%). About 21 (50%) surgeons indicated they would perform injections in the patient group of interest. Two would perform an unlimited number of injections, whilst the remainder would perform between one and three injections. Respondents most commonly indicated they would tell patients that an injection would provide between 6 and 12 weeks of benefit (14 of 39 surgeons, 36%). Most injecting surgeons (88%) leave 4 months between an injection and subsequent arthroplasty due to increased risk of infection if surgery is performed sooner. CONCLUSION: This study demonstrates variation in practice in the use of intra-articular steroids in the analysed patient group, and the way surgeons council their patients. National or specialist society guidelines may help to reduce this variation in practice.

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

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

Patient Outcomes Following Ankle Fracture Fixation.

BACKGROUND: Several studies have reported on potential negative predictive factors of functional outcomes after ankle fracture fixation. However, there is minimal patient-reported data on long-term outcomes. This study aimed to evaluate potential risk factors leading to a poor patient-reported functional outcome at 2 and 5 years following ankle fracture fixation. METHODS: We conducted a prospective cohort study over a 5-year period on patients undergoing open reduction and internal fixation for unstable ankle fractures. Patient demographics, medical comorbidities, fracture pattern, and fixation quality were recorded and analyzed. Patients were followed up at 2 and 5 years. Data collected include the Olerud-Molander Ankle Score (OMAS), Lower Extremity Functional Scale (LEFS), ongoing issues, and the need for further intervention. A P value <.05 was considered statistically significant. RESULTS: Out of 180 patients, follow-up data were available for 82 (46%) patients at 2 years and 94 (52%) patients at 5 years. At 2 years, age ≥60 years was a predictor of worse LEFS, while a body mass index ≥30 was a predictor of worse OMAS. Severely deformed ankle at presentation showed worse OMAS and LEFS score. However, these predictive factors were not significant at 5 years. An anatomically reduced ankle fracture fixation was more likely to have a better functional outcome at the 2- and 5-year follow-ups. A reduction in OMAS at 2 years was predictive of possible ongoing issues following surgery, which in turn increased the odds of worsening OMAS at 5 years. CONCLUSION: Achieving adequate fracture reduction during fixation is crucial for better ankle functional recovery postinjury. In this cohort, we found that patients who undergo ankle fracture fixation will have an ongoing negative impact on their functional and physical capacity at both 2 and 5 years postoperatively. Appropriate patient counseling is necessary to prepare them for the expected functional outcomes. LEVEL OF EVIDENCE: Level II, prognostic.

Management of Little Finger Metacarpal Fractures: A Meta-Analysis of the Current Evidence.

Background: The little finger metacarpal neck fracture, also known as boxer's fracture, is a commonly encountered upper limb fracture in orthopaedics. There are multiple ways of managing this fracture, ranging from immediate mobilization to rigid internal fixation. However, there is still a lack of consensus on the best management option. The aim of this study is to review all comparative studies, either randomized trial or cohort studies, on little finger metacarpal neck fracture management, meta-analyze the radiological and functional outcome between conservative and operative management. Methods: A systematic search of the literature was conducted between year 1987 to 2018 on MEDLINE and EMBASE. To be included, studies needed to have shown comparison between conservative against operative management, assessing the radiological (palmar angulation) and the patient reported functional outcomes. The data were pooled using fixed-effect method. The methodology was adapted from the Cochrane Handbook for Systematic Review of Interventions and compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO CRD42018099168). Results: 5 full papers were included in our study. Our meta-analysis showed that compared to operative management, conservative management report worse radiological palmar angulation at follow-up; but equivalent functional outcome in terms of Quick-DASH and grip strength. Conservative studies also showed fewer mean days off in comparison to operative management. Conservative management also showed equivalent Total Active Motion (TAM) and Visual Analogue Score for Pain (VAS), but some studies had insufficient data to be pooled. Conclusions: Regardless of palmar angulation, conservative treatment of little finger metacarpal neck fracture provides an equivalent functional outcome to surgical intervention with an earlier return to work and no risk of surgical complications. Larger, randomised controlled trials are required.

Bilateral knee septic arthritis: Was it from sternal wound?

Polyarticular septic arthritis is a rare but life-threatening condition and should not be underestimated. Clinicians should look for potential source of infection, either local spread or hematogenous distribution. However, this should not delay the main treatment for septic arthritis.