The Influence of a Booster Seat on the Motion of the Reclined Small Female Anthropomorphic Test Device in Low-Acceleration Far-Side Lateral Oblique Impacts.

Belt-positioning booster (BPB) seats may prevent submarining in reclined child occupants in frontal impacts. BPB-seated child volunteers showed reduced lateral displacement in reclined seating in low-acceleration lateral-oblique impacts. As submarining was particularly evident in reclined small adult female occupants, we examined if a booster seat could provide similar effects on the kinematics of the small female occupant to the ones found on the reclined child volunteers in low-acceleration far-side lateral oblique impacts. The THOR-AV-5F was seated on a vehicle seat on a sled simulating a far-side lateral-oblique impact (80 deg from frontal, maximum acceleration ∼2 g, duration ∼170 ms). Lateral and forward head and trunk displacements, trunk rotation, knee-head distance, seatbelt loads, and head acceleration were recorded. Three seatback angles (25 deg, 45 deg, 60 deg) and two booster conditions were examined. Lateral peak head and trunk displacements decreased in more severe reclined seatback angles (25-36 mm decrease compared to nominal). Forward peak head, trunk displacements, and knee-head distance were greater with the seatback reclined and no BPB. Knee-head distance increased in the severe reclined angle also with the booster seat (>40 mm compared to nominal). Seat belt peak loads increased with increased recline angle with the booster, but not without the booster seat. Booster-like solutions may be beneficial for reclined small female adult occupants to reduce head and trunk displacements in far-side lateral-oblique impacts, and knee-head distance and motion variability in severe reclined seatback angles.

Adhesions After Hip Arthroscopy Are Associated With Revision But Show Poorly Defined Criteria for Diagnosis and Operative Management: A Systematic Review.

PURPOSE: To evaluate the current body of evidence surrounding the diagnosis, management, and clinical outcomes of adhesions that developed after hip arthroscopy (HA). METHODS: A systematic search of the MEDLINE, Embase, Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) databases was designed and conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Eligible studies included patients with confirmed adhesions after HA that reported one or more of the following: (1) diagnostic procedures and criteria used; (2) indications for and details surrounding surgical management; and (3) clinical outcomes after the operative management of adhesions (e.g., patient-reported outcome measures). RESULTS: Nineteen studies involving a total of 4,145 patients (4,211 hips; 38% female sex) were included in this review. The quality of evidence was found to be fair for both comparative studies (mean, 17; range, 13-21) and noncomparative studies (mean, 10; range, 5-12) according to the Methodological Index for Non-randomized Studies (MINORS) instrument, with the level of evidence ranging from IIB to IV. Adhesions were often diagnosed intraoperatively at the time of revision surgery (10 of 19 studies, 53%), with only 3 studies specifying the criteria used to adjudicate adhesions. The most common indication for operative management (i.e., release or lysis of adhesions) was persistent pain (9 of 19, 47%), but this was often grossly stated for revision HA rather than being specific to adhesions. Patient-reported outcome measures were the most reported postoperative outcomes (9 of 19, 47%) and generally showed significant improvement from preoperative assessment across the short-term follow-up period (range, 24.5-38.1 months). There was a paucity of objective measures of clinical improvement (3 of 19, 16%) and of mid- and long-term follow-up (i.e., 5-7 years and ≥10 years, respectively). CONCLUSIONS: Despite the growing body of evidence suggesting that adhesions are highly contributory to revision HA, there is ambiguity in the diagnostic approach and indications for operative management of adhesions. Additionally, although the operative management of adhesions after HA has shown satisfactory clinical outcomes in the short term, there is a paucity of research elucidating the mid- to long-term outcomes, as well as minimal use of objective assessment of clinical improvement (e.g., biomechanics). LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Total shoulder arthroplasty in patients aged 80 years and older: a systematic review.

BACKGROUND: Elderly patients and their surgeons may eschew shoulder arthroplasty due to concerns over patient safety and longevity. The purpose of this study was to review the current literature evaluating the clinical and radiographic outcomes of shoulder arthroplasty performed in patients 80 years and older. METHODS: A literature search of the Embase, PubMed, Medline, and Cochrane databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating the outcomes of primary and revision anatomic (aTSA) and reverse (RSA) total shoulder arthroplasty in patients 80 years and older were included for analysis. RESULTS: A total of 15 studies evaluating 1685 primary aTSAs, 1170 primary RSAs, 69 RSAs performed for fracture, and 45 revision RSAs were included for review. The postoperative active forward flexion and external rotation ranged from 138° to 150° and 45° to 48° after aTSA and from 83° to 139° and 16° to 47° after RSA, respectively. Postoperative visual analog scale pain scores ranged from 0 to 1.8 after aTSA and from 0 to 1.4 after RSA. Ninety-day mortality ranged from 0% to 3%, and perioperative complications ranged from 0% to 32%. Late complications ranged from 5.6% to 24% for aTSA patients and 3.5% to 29% for patients undergoing RSA for all indications. Common complications included glenoid loosening (0%-18%) and rotator cuff tear (5.6%-10%) after aTSA and scapular notching (0%-40%) and scapular fracture (4%-9.4%) after RSA. Reoperation rates ranged from 0% to 6% after aTSA and from 0% to 13% after RSA. CONCLUSIONS: aTSA and RSA in this population are safe and effective, demonstrating low rates of perioperative mortality and reoperation, durability that exceeds patient longevity, satisfactory postoperative range of motion, and excellent pain relief. Late complication rates appear to be similar for aTSA and RSA.

Subchondral rafting wires reduce tibial plateau fracture subsidence.

PURPOSE: To determine if subchondral rafting wires retained as adjunctive tibial plateau fracture fixation affect postoperative articular subsidence. METHODS: A retrospective cohort study was conducted at one Level 1 trauma center and one academic university hospital. Consecutive adults with closed, displaced OTA/AO 41B/C tibial plateau fractures treated between 2018 and 2023 with open reduction internal fixation were included. Patients who were not ambulatory, with contralateral injuries limiting weight bearing, and without follow-up radiographs of the injured extremity were excluded. The intervention was retention of subchondral rafting wires as definitive fixation. The primary outcome was linear articular surface subsidence between postoperative and follow-up AP knee radiographs. Linear subsidence was compared between groups using Welch's two sample t test. Associations of linear subsidence with patient, injury, and treatment characteristics were assessed by multivariable linear regression. RESULTS: We identified 179 patients of a mean age of 44 ± 14 years, of whom 15 (8.4%) received subchondral rafting wires. Median follow-up was 121 days. No patients who received rafting wires as definitive implants experienced linear subsidence ≥ 2 mm, while 22 patients (13.4%) who did not receive rafting wires experienced linear subsidence ≥ 2 mm (p = 0.130). Subchondral rafting wires were associated with less linear subsidence (0.3 mm [95% confidence interval - 0.3-0.9 mm] vsersus 1.0 mm [- 0.9-2.9 mm], p < 0.001). The depth of linear subsidence was significantly associated on multivariable regression with male sex, depressed plateau area, active smoking, and retained rafting wires. CONCLUSION: Subchondral rafting wires were associated with a small reduction in articular subsidence after internal fixation of tibial plateau fractures. Routine rafting wires may be useful for patients and fractures at high risk of articular subsidence.

Anterior internal versus external fixation of unstable pelvis fractures was not associated with discharge destination, critical care, length of stay, or hospital charges.

PURPOSE: Determine if anterior internal versus supra-acetabular external fixation of unstable pelvic fractures is associated with care needs or discharge. METHODS: A retrospective cohort study was performed at two tertiary trauma referral centers. Adults with unstable pelvis fractures (AO/OTA 61B/61C) who received operative fixation of the anterior and posterior pelvic ring by two orthopedic trauma surgeons from October 2020 to November 2022 were included. The primary outcome was discharge destination. Secondary outcomes included intensive care unit (ICU) or ventilator days, length of stay, and hospital charges. RESULTS: Eighty-three eligible patients were 38.6% female, with a mean age of 47.2 ± 20.3 years and BMI 28.1 ± 6.4 kg/m2. Fifty-nine patients (71.1%) received anterior pelvis internal fixation and 24 (28.9%) received external fixation. External fixation was associated with weight-bearing restrictions (91.7% versus 49.2%, p = 0.01). No differences in demographic, functional status, insurance type, fracture classification, or injury severity measures were observed by treatment. Internal versus external anterior pelvic fixation was not associated with discharge to home (49.2% versus 29.2%, p = 0.10), median ICU days (3.0 [interquartile range (IQR) 7.8 versus 5.5 [IQR 4.3], p = 0.14, ventilator days (0 [IQR 6.0] versus 0 [IQR 2.8], p = 0.51), length of stay (13.0 [IQR 13.0] versus 17.5 (IQR 20.5), p = 0.38), or total hospital charges (US dollars 180,311 [IQR 219,061.75] versus 243,622 [IQR 187,111], p = 0.14). CONCLUSIONS: Anterior internal versus supra-acetabular external fixation of unstable pelvis fractures was not significantly associated with discharge destination, critical care, hospital length of stay, or hospital charges. This sample may be underpowered to detect differences between groups. LEVEL OF EVIDENCE: Therapeutic Level IV.

Labral Tears and Chondral Lesions Are Common Comorbidities Identified During Endoscopic Repair of Gluteal Tendon Tears for Greater Trochanteric Pain Syndrome: A Systematic Review.

PURPOSE: The primary purpose of this study was to systematically review the literature on intraoperative findings during endoscopic treatment for greater trochanteric pain syndrome (GTPS). Secondary outcomes were preoperative imaging findings and postoperative functional outcome measures. METHODS: Medline, PubMED, and Embase databases were searched from inception (1946, 1966, and 1974, respectively), to July 15, 2021, for records reporting intraoperative findings during endoscopic surgery for GTPS. Studies of Level I-IV evidence were eligible. All studies were assessed for quality using the Methodological Index for Non-Randomized Studies (MINORS) score. RESULTS: Sixteen studies met the inclusion criteria. Most patients underwent endoscopic greater trochanteric bursectomy with repair of the gluteal tendons. Intraoperative conditions reported were gluteal tendon tears usually involving the gluteus medius tendon, labral tears, and chondral lesions. Three studies reported an average of 9% of patients who subsequently underwent conversion to total hip arthroplasty. Pain was assessed using the visual analog scale, and functional outcome measures were measured using the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score Sport-Specific subscale, Hip Outcome Score Activities of Daily Living subscale, and iHOT-12. Pain and functional outcomes demonstrated significant improvement in nearly all the studies where they were reported. CONCLUSIONS: Patients who underwent endoscopic management of GTPS commonly underwent repair of gluteal tendon tears, and in many cases had concomitant labral tears and chondral lesions identified intraoperatively. There were low rates of adverse events, repair failure, and revision surgery. Patient-reported functional outcomes were improved at follow-up at least 1 year postoperatively. LEVEL OF EVIDENCE: IV, systematic review of level IV or better investigations.

From Protocol to Definitive Study-The State of Randomized Controlled Trial Evidence in Sports Medicine Research: A Systematic Review and Survey Study.

OBJECTIVE: To evaluate the progression, quality, and challenges associated with conducting and publishing randomized controlled trials (RCTs) in sports medicine. DESIGN: Systematic review and survey. SETTING: MEDLINE and Embase were searched for all publications before September 17, 2021. A targeted search of clinicaltrials.gov , BMC Musculoskeletal Disorders, PubMed, and Google Scholar were also conducted. The survey was administered to authors using REDCap. PARTICIPANTS: Where the systematic search revealed no corresponding published definitive trial, authors of the published pilots were surveyed. INTERVENTIONS: Survey assessing limitations to definitive trials. MAIN OUTCOME MEASURES: Protocol/method articles, pilot articles, and relevant clinical trial registry records with corresponding definitive trials were pooled. RESULTS: Our literature search yielded 27 006 studies; of which, we included 208 studies (60 (28.8%) pilot RCTs, 84 (40.4%) protocol/method articles, and 64 (30.8%) trial registry records). From these, 44 corresponding definitive RCTs were identified. Pilot study and definitive RCT methodological quality increased on average most significantly during the duration of this review (30.6% and 8.2%). Of the 176 authors surveyed, 59 (33.5%) responded; 24.6% (14/57) stated that they completed an unpublished definitive trial, while 52.6% (30/57) reported having one underway. CONCLUSIONS: The quality and number of RCT publications within the field of sports medicine has been increasing since 1999. The number of sports medicine-related protocol and pilot articles preceding a definitive trial publication showed a sharp increase over the past 10 years, although only 5 pilot studies have progressed to a definitive RCT.

Hip microinstability diagnosis and management: a systematic review.

PURPOSE: The purpose of this systematic review is to present the most common causes, diagnostic features, treatment options and outcomes of patients with hip micro-instability. METHODS: Three online databases (MEDLINE, Embase, and PubMed) were searched from database inception March 2022, for literature addressing the diagnosis and management of patients with hip micro-instability. Given the lack of consistent reporting of patient outcomes across studies, the results are presented in a descriptive summary fashion. RESULTS: Overall, there were a total of 9 studies including 189 patients (193 hips) included in this review of which 89% were female. All studies were level IV evidence with a mean MINORS score of 12 (range: 10-13). The most commonly used features for diagnosis of micro-instability on history were anterior pain in 146 (78%) patients and a subjective feeling of instability with gait in 143 (81%) patients, while the most common feature on physical examination was the presence of anterior apprehension with combined hip extension and external rotation in 123 (65%) patients. The most common causes of micro-instability were iatrogenic instability secondary to either capsular insufficiency or cam over-resection in 76 (62%) patients and soft tissue laxity in 38 (31%) patients. CONCLUSION: The most common symptom of micro-instability on history was anterior hip pain and on physical exam was pain with hip extension and external rotation. There are many treatment options and when managed appropriately based on the precise cause of micro-instability, patients may demonstrate improved outcomes. LEVEL OF EVIDENCE: IV.

Underweight patients experience higher inpatient complication and mortality rates following acetabular fracture.

PURPOSE: Underweight patients experience poor outcomes after elective orthopaedic procedures. The effect of underweight body mass index (BMI) on complications after acetabular fracture is not well-described. We evaluate if underweight status is associated with inpatient complications after acetabular fractures. METHODS: Adult patients (≥ 18 years) presenting with acetabular fracture between 2015 and 2019 were identified from Trauma Quality Program data. Adjusted odds (aOR) of any inpatient complication or mortality were compared between patients with underweight BMI (< 18.5 kg/m2) and normal BMI (18.5-25 kg/m2) using multivariable logistic regression and stratifying by age ≥ 65 years. RESULTS: The 1299 underweight patients aged ≥ 65 years compared to 11,629 normal weight patients experienced a 1.2-times and 2.7-times greater aOR of any complication (38.6% vs. 36.6%, p = 0.010) and inpatient mortality (7.9% vs. 4.2%, p < 0.001), respectively. The 1688 underweight patients aged 18-64 years compared to 24,762 normal weight patients experienced a 1.2-times and 1.5-times greater aOR of any inpatient complication (38.9% vs. 34.8%, aOR p = 0.006) and inpatient mortality (4.1% vs. 2.5%, p < 0.001), respectively. CONCLUSION: Underweight adult patients with acetabular fracture are at increased risk for inpatient complications and mortality, particularly those ≥ 65 years old. LEVEL OF EVIDENCE: Prognostic Level III.

Glaucoma Prevalence and Glaucoma Surgical Considerations in Prosthetic Replacement of the Ocular Surface Ecosystem Device Use.

OBJECTIVES: The purpose of this study was to identify patients with glaucoma and corneal/ocular surface disease who have been fit with Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE; BostonSight, Needham, MA) devices and to understand the PROSE device fit experience in patients with glaucoma at Weill Cornell Medicine (WCM). METHODS: This is a retrospective chart review of patients older than 18 years who underwent PROSE device fitting at WCM. Records were reviewed for demographic information and ophthalmic variables. Descriptive statistics were performed. RESULTS: Between 2011 and 2017, 281 patients underwent PROSE device fitting at WCM, of whom 24 patients (8.5%) had a glaucoma diagnosis and 17 patients (6.0%) were identified as glaucoma suspect. Ocular surface disease was the most common indication for PROSE device wear (58.3%). Five patients had a history of incisional glaucoma surgery in the eye undergoing PROSE device fitting: three valved glaucoma drainage implants and two trabeculectomies. Three of these eyes were successfully fit with PROSE devices. CONCLUSIONS: Patients fitted with Prosthetic Replacement of the Ocular Surface Ecosystem devices at WCM had a higher prevalence of glaucoma than in the general population. Among patients with incisional glaucoma surgery, PROSE device fitting was challenging, with a 40% failure rate.

Low rate of adverse events in a randomized controlled trial addressing the surgical treatment of femoroacetabular impingement (FAI) syndrome.

PURPOSE: The femoroacetabular impingement randomised controlled trial (FIRST) is a multi-center randomized controlled trial (RCT), comparing arthroscopic osteochondroplasty with arthroscopic lavage in adults aged 18-50 years diagnosed with non-arthritic femoroacetabular impingement (FAI) syndrome. The purpose of the present study is to report the prevalence, distribution and severity of adverse events during and within 24-month follow-up period. METHODS: Of the 220 patients included, 6 were adjudicated as ineligible, for a total of 214 patients included in the final analysis. An independent Adjudication Committee evaluated operatively treated and non-operatively treated adverse events that were related to the hip. Adverse events were also reported directly by each participating clinical site. Continuous variables were reported as mean and standard deviation, categorical variables were reported as counts and percentages. RESULTS: There were a total of 52 (24.2%, 52/214) adverse events in 46 (21.5%) patients (mean age 34.2 ± 7.9 years, 58.7% male) during the 24-month follow-up. There were 12.6% (27/214) operatively treated adverse events for: hip pain, re-injury of labrum and heterotopic ossification. There were 11.7% (25/214) non-operatively treated adverse events for predominantly: hip pain, hip tendinopathy and hip popping/snapping. Approximately, 87% of adverse events resolved within the 24-month follow-up time. CONCLUSION: Given the inherent challenges with conducting RCTs, the results of this adverse event study from the FIRST trial demonstrate that it is safe to perform an RCT addressing FAI syndrome. LEVEL OF EVIDENCE: Level III.

There is no definite consensus on the adequate radiographic correction in arthroscopic osteochondroplasty for femoroacetabular impingement: a systematic review and meta-analysis.

PURPOSE: The purpose of this study is to evaluate and define what is considered an adequate radiographic correction in arthroscopic osteochondroplasty for FAI and to secondarily assess how radiographic outcomes relate to patient reported outcomes and complications. METHODS: The databases EMBASE, PubMed, and MEDLINE were searched for relevant literature from database inception until January 2021. Studies were screened by two reviewers independently and in duplicate for studies reporting on post-operative radiographic outcomes in arthroscopic osteochondroplasty for FAI. Data on radiographic outcomes as well as data reporting functional outcomes and complications were recorded. A meta-analysis was used to combine the mean pre- and post-operative radiographic outcomes using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS score. RESULTS: The most commonly reported radiographic outcome was the alpha angle with a pooled mean post-operative angle of 44° (95% CI 41°-46°), and mean pre- to post-surgical difference of - 19° (- 22 to - 16, I2 = 96%), followed by the LCEA with a pooled mean post-operative angle of 30° (95% CI 29-31) and mean difference after surgery of - 4° (- 6 to - 1, I2 = 97%,). Eleven studies reported on the correlation between radiographic and clinical outcomes with no consistent consensus correlation found amongst the included studies. Similarly, six studies correlated radiographic outcomes with conversion to THA with no consistent consensus correlation found amongst the included studies. CONCLUSION: Based on this review, the main conclusion is that there is no consensus definition on the optimal radiographic correction for FAI and there was no consistent correlation between radiographic correction and functional outcomes. However, based on the uniform improvement in functional outcomes, this review suggests a post-operative alpha angle target of 44° with a correction target of 19° and LCEA target of 30° with a correction target of 3°. LEVEL OF EVIDENCE: IV.

Protocol for a multicenter prospective cohort study evaluating sport activity and development of femoroacetabular impingement in the adolescent hip.

BACKGROUND: Femoroacetabular impingement (FAI) is an important cause of hip pain in young and active individuals and occurs as a result of size and shape mismatch between the femoral head and acetabulum. Open physes in children can make hips more susceptible to injury, and high impact forces have been suggested to affect the developing femur. The diagnosis of FAI has recently risen, especially within adolescent populations, and there is an increasing trend towards year-round participation in sports with early specialization. The PREVIEW study is an international longitudinal study designed to determine the association between sport specialization in adolescence and the development of hip impingement. METHODS: This is a multicentre prospective cohort study evaluating 200 participants between the ages of 12-14 that include sport specialists at the moderate to vigorous physical activity (MVPA) level and non-sport specialists at any activity level. We will monitor physical activity levels of all participants using an activity log and a wrist-mounted activity tracker, with synced data collected every 3 months during the study period. In addition, participants will be evaluated clinically at 6, 12, and 18 months and radiographically at the time of enrolment and 24 months. The primary outcome is the incidence of FAI between groups at 2 years, determined via MRI. Secondary outcomes include hip function and health-related quality of life between subjects diagnosed with FAI versus no FAI at 2 years, as determined by the Hip Outcome Score (HOS) and Pediatric Quality of Life (PedsQL) questionnaires. DISCUSSION: It is important to mitigate the risk of developing hip deformities at a young age. Our proposed prospective evaluation of the impact of sport activity and hip development is relevant in this era of early sport specialization in youth. Improving the understanding between sport specialization and the development of pre-arthritic hip disease such as FAI can lead to the development of training protocols that protect the millions of adolescents involved in sports annually. TRIAL REGISTRATION: PREVIEW is registered with clinicaltrials.gov (NCT03891563).

How Useful Is the Flexion-Adduction-Internal Rotation Test for Diagnosing Femoroacetabular Impingement: A Systematic Review.

OBJECTIVE: Clinicians use the flexion, adduction, and internal rotation (FADIR) test in the diagnosis of femoroacetabular impingement (FAI). However, the diagnostic utility of this test remains unclear. The purpose of this review was to determine the utility of the FADIR test in diagnosing FAI. DATA SOURCES: MEDLINE, EMBASE, and PubMed were searched using relevant key terms and study screening was performed in duplicate. Patient demographics, diagnostic imaging, and summary measures (eg sensitivity, specificity, etc.) of the FADIR test in patients with FAI were recorded. MAIN RESULTS: Eight studies of levels III (87.5%) and IV (12.5%) evidence were included. Four hundred fifty-two patients (622 hips) with a mean age of 27.0 ± 9.0 were examined. Alpha (75.1%) and/or center-edge (26.8%) angles were used to diagnose hips with FAI. X-ray (78.9%), magnetic resonance imaging (MRI) (16.2%), and computed tomography (CT) (4.8%) were used to confirm the diagnosis of FAI. The sensitivity when confirmed by x-ray, MRI, or CT was 0.08 to 1, 0.33 to 1 and 0.90, respectively. The specificity when confirmed by x-ray and MRI was 0.11 and 1, respectively. CONCLUSIONS: Although the overall utility of the FADIR test in diagnosing FAI remains unclear given its moderate sensitivity and specificity, it may be a useful screening tool for FAI because of its low risk. Clinicians should consider the variability in sensitivity and specificity values reported and the low quality of literature available. Future studies should use large sample sizes and consistent radiographic measurements to better understand the usefulness of this physical examination maneuver in diagnosing FAI. LEVEL OF EVIDENCE: Level IV, Systematic Review of Level III and IV studies.

Deep gluteal syndrome is defined as a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space: a systematic review.

PURPOSE: Clinicians are not confident in diagnosing deep gluteal syndrome (DGS) because of the ambiguity of the DGS disease definition and DGS diagnostic pathway. The purpose of this systematic review was to identify the DGS disease definition, and also to define a general DGS diagnostic pathway. METHODS: A systematic search was performed using four electronic databases: PubMed, MEDLINE, EMBASE, and Google Scholar. In eligibility criteria, studies in which cases were explicitly diagnosed with DGS were included, whereas review articles and commentary papers were excluded. Data are presented descriptively. RESULTS: The initial literature search yielded 359 articles, of which 14 studies met the eligibility criteria, pooling 853 patients with clinically diagnosed with DGS. In this review, it was discovered that the DGS disease definition was composed of three parts: (1) non-discogenic, (2) sciatic nerve disorder, and (3) nerve entrapment in the deep gluteal space. In the diagnosis of DGS, we found five diagnostic procedures: (1) history taking, (2) physical examination, (3) imaging tests, (4) response-to-injection, and (5) nerve-specific tests (electromyography). History taking (e.g. posterior hip pain, radicular pain, and difficulty sitting for 30 min), physical examination (e.g. tenderness in deep gluteal space, pertinent positive results with seated piriformis test, and positive Pace sign), and imaging tests (e.g. pelvic radiographs, spine and pelvic magnetic resonance imaging (MRI)) were generally performed in cases clinically diagnosed with DGS. CONCLUSION: Existing literature suggests the DGS disease definition as being a non-discogenic sciatic nerve disorder with entrapment in the deep gluteal space. Also, the general diagnostic pathway for DGS was composed of history taking (posterior hip pain, radicular pain, and difficulty sitting for 30 min), physical examination (tenderness in deep gluteal space, positive seated piriformis test, and positive Pace sign), and imaging tests (pelvic radiographs, pelvic MRI, and spine MRI). This review helps clinicians diagnose DGS with more confidence. LEVEL OF EVIDENCE: IV.

Life-course BMI and biomarkers in persons aged 60 years or older: a comparison of the USA and Costa Rica.

OBJECTIVE: There is a large literature linking current BMI to levels of cardiovascular risk biomarkers, but it is unknown whether measures of BMI earlier in the life course and maximum BMI are predictive of current levels of biomarkers. The objective of the current study was to determine how current, maximum and age-25 BMI among individuals over the age of 60 years are associated with their current levels of cardiovascular risk biomarkers. DESIGN: Cross-sectional study with retrospective recall. SETTING: Costa Rica (n 821) and the USA (n 4110). SUBJECTS: Nationally representative samples of adults aged 60 years or over. RESULTS: We used regression models to examine the relationship between multiple meaures of BMI with four established cardiovascular risk biomarkers. The most consistent predictor of current levels of systolic blood pressure, TAG and HDL-cholesterol was current BMI. However, maximum BMI was the strongest predictor of glycosylated Hb (HbA1c) and was also related to HDL-cholesterol and TAG. HbA1c was independent of current BMI. We found that these relationships are consistent between Costa Rica and the USA for HbA1c and for HDL-cholesterol. CONCLUSIONS: Current levels of cardiovascular risk biomarkers are not only the product of current levels of BMI, but also of maximum lifetime BMI, particularly for levels of HbA1c and for HDL-cholesterol. Managing maximum obtained BMI over the life course may be most critical for maintaining the healthiest levels of cardiovascular risk.

Total knee arthroplasty using patient-specific instrumentation for osteoarthritis of the knee: a meta-analysis.

BACKGROUND: Total knee arthroplasty using patient-specific instrumentation (TKA-PSI), which are disposable cutting block guides generated to fit each patient's 3-dimensional knee anatomy, has been developed to treat patients with end-stage osteoarthritis of the knee. Surrogate markers such as radiographic malalignment have been well investigated, however, patient-important outcomes are not well examined to elucidate the efficacy of TKA-PSI. The aim of this review is to determine if TKA-PSI improves patient-reported outcome measures (PROM), surgery time, blood loss, transfusion and complications (e.g. surgical site infection, deep venous thrombosis, and revision TKA). METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and ongoing clinical trials. For PROMs, surgery time, blood loss, and transfusion rate, we included randomized controlled trials (RCT) comparing TKA-PSI and standard TKA to treat osteoarthritis of the knee. For complications, we also included non-randomized comparative studies (non-RCT). RESULTS: This review includes 38 studies, 24 of which were RCT and 14 of which were non-RCT. These included a total of 3487 patients. The predominant population in the included studies highly reflected the general population, with 62% being female, aged over 60 and having end-stage osteoarthritis of the knee. TKA-PSI did not improve PROMs as compared to standard TKA for less than 1-year (mean difference 0.48, 95% confidence interval (CI) -1.92-0.97 in the Oxford knee score, mean 3-month follow-up) and for 1-year or more (mean difference 0.25, 95%CI - 4.39-4.89 in the WOMAC score, mean 29-month follow-up). TKA-PSI did not reduce surgery time (mean difference - 3.09 min, 95%CI -6.73-0.55). TKA-PSI decreased blood loss with a small effect size corresponding to a 0.4 g/dl hemoglobin decrease (95%CI 0.18-0.88), but did not decrease transfusion rate (risk difference - 0.04, 95%CI -0.09-0.01). TKA-PSI did not reduce complication rates (risk difference 0.00, 95%CI - 0.01-0.01 in the composite outcome). CONCLUSIONS: TKA-PSI does not improve patient-reported outcome measures, surgery time, and complication rates as compared to standard TKA. TKA-PSI decreases blood loss with a small effect, which is not enough to reduce transfusion rate.

Tunnel osteolysis post-ACL reconstruction: a systematic review examining select diagnostic modalities, treatment options and rehabilitation protocols.

PURPOSE: The purpose of this systematic review was to (1) identify the optimal diagnostic modality for tunnel widening in skeletally mature patients; (2) identify potentially modifiable risk factors for tunnel widening, such as graft type, and (3) determine what elements of a post-operative rehabilitation program exert the most influence on TW. METHODS: The electronic databases MEDLINE, EMBASE, PubMed, and Cochrane Library were searched from database inception to January 2018. Studies that discussed tunnel widening following anterior cruciate ligament reconstruction (ACLR) of skeletally mature patients and written in English were included. Descriptive statistics, such as means, ranges, and measures of variance (e.g. standard deviations, 95% confidence intervals (CI)) are presented where applicable. RESULTS: 103 studies (6,383 patients) were included. Plain radiographs were the most commonly used diagnostic modality, but radiographs on average required 10 months longer than CT and 2 months longer on average than MRI to diagnose tunnel widening after ACLR. Although CT was the least commonly used modality, it was the shortest time to diagnose tunnel widening at 9.5 months after ACLR. Bone-patellar tendon-bone (BPTB) allograft had the largest average tunnel widening overall. BPTB autograft had the lowest average tunnel widening overall. Double-bundle hamstring graft configuration had a lower average tunnel widening than single-bundle configuration. Rehabilitation protocols after ACLR that used a full weight-bearing prescription in rehabilitation showed a greater average femoral tunnel widening than partial weight-bearing, and partial weight-bearing showed a greater average tibial tunnel widening than full weight-bearing. CONCLUSIONS: Based on this systematic review and the descriptive data evaluated, CT demonstrated a time of 9.5 months on average from ACLR to diagnosing tunnel osteolysis post-ACLR. With respect to graft types, double-bundle hamstring autografts reported lower average femoral and tibial TW than single-bundle hamstring autografts. BPTB autografts reported the lowest average TW and BPTB allograft the largest average TW of all the grafts. Furthermore, extension-locked bracing had the lowest TW of all the brace protocols. Lastly, several other surgical technical parameters influencing tunnel osteolysis remain to be determined. No definitive recommendations can be made at this time due to the high heterogeneity of data and the lack of comparative studies analysed in this systematic review. LEVEL OF EVIDENCE: IV.

Pilot randomized controlled trials in the orthopaedic surgery literature: a systematic review.

BACKGROUND: The primary objective of this systematic review is to examine the characteristics of pilot randomized controlled trials (RCTs) in the orthopaedic surgery literature, including the proportion framed as feasibility trials and those that lead to definitive RCTs. This review aim to answer the question of whether pilot RCTs lead to definitive RCTs, whilst investigating the quality, feasibility and overall publication trends of orthopaedic pilot trials. METHODS: Pilot RCTs in the orthopaedic literature were identified from three electronic databases (EMBASE, MEDLINE, and Pubmed) searched from database inception to January 2018. Search criteria included the evaluation of at least one orthopaedic surgical intervention, research on humans, and publication in English. Two reviewers independently screened the pool of pilot trials, and conducted a search for corresponding definitive trials. Screened pilot RCTs were assessed for feasibility outcomes related to efficiency, cost, and/or timeliness of a large-scale clinical trial involving a surgical intervention. The quality of the pilot and definitive trials were assessed using the Checklist to Evaluate a Report of a Non-Pharmacological Trial (CLEAR NPT). RESULTS: The initial search for pilot RCTs yielded 3857 titles, of which 49 articles were relevant for this review. 73.5% (36/49) of the orthopaedic pilot RCTs were framed as feasibility trials. Of these, 5 corresponding definitive trials (10.2%) were found, of which four were published and one ongoing. Based on author responses, the lack of a definitive RCT following the pilot trial was attributed to a lack of funding, inadequacies in recruitment, and belief that the pilot RCT sufficiently answered the research question. CONCLUSIONS: Based on this systematic review, most pilot RCTs were characterized as feasibility trials. However, the majority of published pilot RCTs did not lead to definitive trials. This discrepancy was mainly attributed to poor feasibility (e.g. poor recruitment) and lack of funding for an orthopaedic surgical definitive trial. In recent years this discrepancy may be due to researchers saving on time and cost by rolling their pilot patients into the definitive RCT rather than publish a separate pilot trial.

Venous Thromboembolism Events After Hip Arthroscopy: A Systematic Review.

PURPOSE: The purpose of this systematic literature review focused on hip arthroscopy was to (1) report the venous thromboembolism (VTE) event incidence in patients who receive VTE prophylaxis and those who do not, (2) report how VTE prophylaxis is currently being administered, and (3) report operative and patient-related risk factors for VTE identified in the literature. METHODS: The electronic databases MEDLINE, Embase, and PubMed were searched from database inception to October 10, 2016, and screened in duplicate for relevant studies. Data were collected regarding VTE prophylaxis, traction use, surgical time, VTE incidence, patient and operative factors, and postoperative weight bearing and rehabilitation. Study quality was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria. RESULTS: Outcome analyses included 14 studies that involved 2,850 patients (2,985 hips). The weighted mean follow-up period was 19 ± 8 months, ranging from 7 days to 103 months. The weighted mean age was 40.7 ± 7 years, ranging from 6 to 82 years, and 39.6% of patients were male patients. The overall weighted proportion of VTE events after hip arthroscopy found in 14 included studies was 2.0% (95% confidence interval, 0.01%-4.1%), with 25 VTE events. Several studies reported patient risk factors, which included increased age, increased body mass index, prolonged traction time, and use of oral contraceptives. CONCLUSIONS: The use and efficacy of VTE prophylaxis are highly under-reported within hip arthroscopy. The low incidence of VTE events found in this review (2.0%) suggests that prophylaxis may not be necessary in low-risk patients undergoing hip arthroscopy; however, the true rate may be under-reported. Current literature suggests that prophylaxis is typically not prescribed. Early mobility and postoperative rehabilitation may also help to further mitigate the risk of VTE events, but use of these strategies needs further prospective evaluation. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.