Does robotic-assisted surgery improve outcomes of total hip arthroplasty compared to manual technique? A systematic review and meta-analysis.

BACKGROUND: Robot-assisted total hip arthroplasty (THA) is an emerging technology that claims to position implants with very high accuracy. However, there is currently limited data in literature on whether this improved accuracy leads to better long-term clinical outcomes. This systematic review compares the outcomes of THA done with the help of robotic assistance (RA) to those done with conventional manual techniques (MTs). METHODS: Four electronic databases were searched for eligible articles that directly compared robot-assisted THA to manual THA and had data on the radiological or clinical outcomes of both. Data on various outcome parameters were collected. Meta-analysis was conducted using a random-effects model with 95% CIs. RESULTS: A total of 17 articles were found eligible for inclusion, and 3600 cases were analysed. Mean operating time in the RA group was significantly longer than in the MT group. RA resulted in significantly more acetabular cups being placed inside Lewinnek's and Callanan's safe zones (p<0.001) and had significantly reduced limb length discrepancy compared with MT. There were no statistically significant differences in the two groups in terms of incidence of perioperative complications, need for revision surgery and long-term functional outcome. CONCLUSION: RA leads to highly accurate implant placement and leads to significantly reduced limb length discrepancies. However, the authors do not recommend robot-assisted techniques for routine THAs due to lack of adequate long-term follow-up data, prolonged surgical times and no significant differences in the rate of complications and implant survivorship compared with conventional MTs.

Core decompression combined with intralesional autologous bone marrow derived cell therapies for osteonecrosis of the femoral head in adults: A systematic review and meta-analysis.

BACKGROUND: Core decompression (CD) is beneficial in the early stage of osteonecrosis of the femoral head (ONFH). Adjunctive bone marrow derived cell therapies (BMDCT) have been advocated which potentially aid the regenerative process. QUESTION/PURPOSE: This study was conducted to determine potential benefit of CD + BMDCT in ONFH, in terms of disease progression, conversion to arthroplasty (primary outcomes), and functional outcomes and complication rates (secondary outcomes). METHODS: A systematic review of literature was performed on 3 databases. Studies reporting CD + BMDCT (intralesional instillation) in ONFH, with a minimum follow up of 1 year and reporting the pre-defined outcome measures were included in the review. Meta-analysis consisted of two different arms: a comparative arm, to compare CD + BMDCT to CD alone, and a non-comparative meta-analysis arm, to determine pooled rates of disease progression, conversion to arthroplasty and complication rates. RESULTS: A total of 18 studies were included in the systematic review. CD + BMDCT had lower rates of disease progression (OR 0.19 [95% CI, 0.09, 0.40]) and conversion to arthroplasty (OR 0.20 [95% CI, 0.11, 0.40]) as compared to CD alone. Functional score (MD = -7.07 [95% CI, -12.28, -1.86]) and visual analog scale also showed better improvement with the use of CD + BMAC (MD = -10.39 [95% CI, -12.87, -7.90]). Increasing age and post-collapse stage at presentation were noted to have an adverse effect on the outcomes. CONCLUSION: CD + BMDCT was found to decrease disease progression and conversion to arthroplasty, and was noted to have better functional outcome scores as compared to CD alone.

Complications and mid to long term outcomes for hip resurfacing versus total hip replacement: a systematic review and meta-analysis.

INTRODUCTION: The long-term results of total hip replacement (THR) are excellent; however, it has higher failure rates in young and active patients. Hip resurfacing arthroplasty (HRA) is an alternative in such patients and gaining popularity. This review was done to compare complications and outcomes between HRA and THA by assessing the latest level 1 studies comparing the two from the past 10 years. METHOD: A systematic review and meta-analysis was conducted using three databases (PubMed, EMBASE and SCOPUS) to compare the complications between THR and HRA in medium to long term follow up. The primary outcome of interest included the complication and revision rate between the two techniques. Functional outcomes and ionic levels at follow up were also compared as secondary outcomes. Risk of bias assessment was done using the Cochrane risk of bias tool. RESULT: The present review included 6 level 1 studies. These included 308 THR and 304 HRA. On meta-analysis, overall complications rates were significantly lower in HRA compared to the THA group with an Odds ratio (OR) of 2.17 (95% CI 1.21, 3.88; p = 0.009). No difference was seen between the two groups in terms of revision rate (OR 1.06 95% CI 0.57, 1.99; p = 0.85). Functional outcomes in both the groups were satisfactory but the Harris Hip Score was found to be significantly better in the resurfacing group (MD 2.99 95% CI - 4.01, - 1.96, p < 0.00001). There were increased cobalt and chromium ions in the resurfacing group but no detrimental effect was seen in terms of reported poisoning. CONCLUSION: Despite similar function and revision rates, HRA was seen to have lesser associated complications and ionic levels may not be a detrimental issue. Hip resurfacing provides relative ease during revisions, especially in younger patients and it may be an alternative to THR in the younger population.

Outcomes and complications of the INFIX technique for unstable pelvic ring injuries with high-velocity trauma: a systematic review and meta-analysis.

BACKGROUND: The pelvic INFIX technique has been proposed as a useful alternative to symphyseal plating for management of unstable pelvic ring injuries. The minimally invasive nature of the procedure, shorter operative time and less perioperative blood loss have been purported as potential advantages. QUESTIONS/PURPOSES: This systematic review and meta-analysis were conducted to determine the outcomes and complications of the INFIX technique for unstable pelvic ring injuries. METHODS: A systematic review of literature was performed on the PubMed, EMBASE and Scopus databases. Prospective and retrospective studies in all languages, whether comparative or non-comparative, pertaining to the use of INFIX in pelvic fractures were included. Studies which did not evaluate INFIX, case reports, conference abstracts and those with less than 10 cases were excluded. Cadaveric studies, technique papers and studies that did not describe the prespecified outcome measures were also excluded. Meta-analysis consisted of two different arms: a comparative arm, to compare INFIX to symphyseal plating, and a non-comparative meta-analysis arm, to determine pooled rates of outcomes and complications. Risk of bias was determined by the Methodological Index for Non-Randomised Studies (MINORS) tool. RESULTS: A total of 22 studies were included in the systematic review, of which 7 were comparative and 15 were non-comparative. 746 patients were included for qualitative analysis and pooled analysis done for 589 patients. The average follow-up of these studies ranged from a minimum of 5.4 months to a maximum of 54 months. Comparative meta-analysis (n = 3 studies) of plating and INFIX showed significantly lesser blood loss (mean difference = 176.46 mL; 95% CI - 207.54 to - 145.38) and shorter operative time (mean difference = 26.43 min, 95% CI - 31.79 to - 21.07) with INFIX, but no significant difference in the overall complication rates (OR 1.59, 95% CI 0.83-3.05) and functional outcome scores (mean difference = - 2.51, 95% CI - 5.73 to 0.71). Pooled analysis showed overall good radiological (mean percentage of excellent to good reduction = 91.4%, 95% CI 0.860-0.969) and functional outcomes (mean Majeed score = 86.48, 95% CI 83.34-89.61) with INFIX. The most common complications were lateral femoral cutaneous nerve (LFCN) injury (overall rate 28%, 95% CI 15.1-41%) and heterotopic ossification (HO) (overall rate 9.4%, 95% CI 5.5-13.3%); rates of other complications were low. Significant heterogeneity was noted in the pooled analysis of blood loss, operative time, functional outcome, HO and LFCN injury. The overall strength of evidence was found to be weak. CONCLUSION: The INFIX technique can be considered as a viable alternative to symphyseal plating for unstable pelvic ring injuries. It has the advantages of shorter operative times and less blood loss, along with comparable functional outcomes, when compared to plating. Overall, good functional outcomes can be expected. However, well-designed, multi-center randomized controlled trials are needed to conclusively prove the benefit of this technique.

Does robotic-assisted surgery improve outcomes of total hip arthroplasty compared to manual technique? A systematic review and meta-analysis.

BACKGROUND: Robot-assisted total hip arthroplasty (THA) is an emerging technology that claims to position implants with very high accuracy. However, there is currently limited data in literature on whether this improved accuracy leads to better long-term clinical outcomes. This systematic review compares the outcomes of THA done with the help of robotic assistance (RA) to those done with conventional manual techniques (MTs). METHODS: Four electronic databases were searched for eligible articles that directly compared robot-assisted THA to manual THA and had data on the radiological or clinical outcomes of both. Data on various outcome parameters were collected. Meta-analysis was conducted using a random-effects model with 95% CIs. RESULTS: A total of 17 articles were found eligible for inclusion, and 3600 cases were analysed. Mean operating time in the RA group was significantly longer than in the MT group. RA resulted in significantly more acetabular cups being placed inside Lewinnek's and Callanan's safe zones (p<0.001) and had significantly reduced limb length discrepancy compared with MT. There were no statistically significant differences in the two groups in terms of incidence of perioperative complications, need for revision surgery and long-term functional outcome. CONCLUSION: RA leads to highly accurate implant placement and leads to significantly reduced limb length discrepancies. However, the authors do not recommend robot-assisted techniques for routine THAs due to lack of adequate long-term follow-up data, prolonged surgical times and no significant differences in the rate of complications and implant survivorship compared with conventional MTs.

Vitamin D and diabetes.

Vitamin D insufficiency and diabetes mellitus are two important aspects of endocrine care. Both these conditions are prevalent across the world, and pose a significant challenge to public health. In this article, we explore the various interactions between vitamin D and glucose metabolism.

Person-friendly insulin delivery devices.

This communication reviews various insulin delivery devices, their characteristics and advantages. The discussion helps diabetes care professionals understand the need to prescribe an appropriate insulin delivery device, and assists in rational decision-making. The importance of precision dosing, through modern delivery devices, is highlighted in this paper.

Mimicking high strength lightweight novel structures inspired from the trabecular bone microarchitecture.

Nature's evolution of a billion years has advanced flawless functionality in limitless optimized structures like bone structural adaptation in various physiological behaviours. In this study, porous structures are designed and fabricated from the nature-inspired trabecular bone microarchitecture. A three-dimensional (3D) model of the porous trabecular architecture from the compressive proximal zone of the femoral head was constructed using the micro-computed tomography scanning tool. The model was modified to get porous structures of different volume fractions varying from 20 to 40% with an increment of 10%. The obtained porous structures were 3D printed and analysed for deformation-resistant behaviour. Quasi-static compressive loading was performed at different strain rates (0.001-1 s-1) to get an insight into lightweight, high strength structural behaviour. Mechanical parameters, such as specific modulus, specific strength and specific energy absorption, were analysed for the optimal volume fraction. The original volume fraction (30%) of the trabecular bone shows the highest value of mechanical parameters. This study can help engineers to select and design lightweight porous structures with high energy-absorbing capacity, mimicking the desired architecture and porosity available in nature. This article is part of the theme issue 'Bioinspired materials and surfaces for green science and technology (part 3)'.

A Comparison of Reproductive Hormones and Biochemical Parameters in Hypothyroid and Euthyroid Postmenopausal Women.

BACKGROUND: Menopause and hypothyroidism, both individually, affect the reproductive hormone profile as well as body metabolism which is reflected in the form of a deranged biochemical profile. It will be interesting to observe the effects on both these profiles, when menopause is associated with hypothyroidism. METHODS: This study was conducted on 30 postmenopausal women with newly diagnosed primary hypothyroidism and 30 euthyroid menopausal females as controls. Serum samples of all the subjects were analyzed for complete thyroid profile including total T3 (TT3), total T4 (TT4), free T3 (FT3), free T4 (FT4), thyroid stimulating hormone (TSH), estradiol, progesterone, fasting glucose, renal function tests, liver function tests, and lipid profile. Data of both the groups was compared using Student's t-test. RESULTS: There was no statistically significant difference observed between the fasting glucose levels and renal and liver function tests in both the groups (p > 0.05). Serum triglycerides, total cholesterol, low density lipoprotein cholesterol (LDL-C) and very low density lipoprotein cholesterol (VLDL-C) were found to be significantly increased (p < 0.05) while high density lipoprotein cholesterol (HDL-C), estradiol, and progesterone were found to be significantly decreased (p < 0.05) in menopausal hypothyroid women as compared to their euthyroid counterparts. CONCLUSIONS: Thus, an association of both menopause and hypothyroidism may lead to accentuation of effect of each on biochemical and reproductive hormone profile.

Gross trunnion failure in metal on polyethylene total hip arthroplasty-a systematic review of literature.

BACKGROUND: Multiple cases of dissociation of the head from the neck termed as gross trunnion failure (GTF) in total hip replacement have been described. Very little quantitative data is available for patient and implant factors associated and predisposing to this complication. STUDY PURPOSE: To systematically review and analyze all studies which have gross trunnion failure in case of metal on polyethylene (MoP) total hip replacement. METHODS: PubMed database was searched. We also performed a secondary search by pearling bibliography of all full text articles obtained. Predefined inclusion and exclusion criteria were used for abstract screening by two independent observers. A total 46 cases met our inclusion criteria. These were included in the final analysis and data was pooled. RESULTS: Till date, 46 cases of GTF in MoP THR have been reported. The mean age at time of revision was 70.13 years (range 50 to 89 years). The mean time to revision surgery was 8.24 years (range 4.7 to 14 years). 91.4% cases were male. BMI was ≥ 25 in 38/41 cases and ≥ 30 in 21/41 cases. Pain (95.5%) and difficulty or inability to walk (97.7%) were the most common symptoms. A total of 19/44 cases described varying sounds like click, clunk, and pop before dislocation. Accolade TMZF/TMZF plus was the most common stem used in 34/46 cases. The stem neck angle was 127 degrees in 97% cases (32/33 cases). A positive neck offset of 4 mm or more was used in 91.1% cases (40/44 cases). The head size ≥ 36 mm in approximately 90% cases. The head material was cobalt chromium in all 45 cases, where data was available. Among the intra-operative findings, the most common findings were metallosis (41/44), black or brow coloured synovial fluid (21/44), pseudotumour (19/44), synovial hypertrophy (18/44), damage to the abductor musculature (17/44), proximal femoral osteolysis (5/44 cases), and heterotrophic ossification (2/44 cases). Histopathological analysis was available in 11 cases and was suggestive of fibrous tissue with chronic cellular infiltrate in all cases. The serum cobalt and chromium concentrations were raised above normal in 86.4% (19/22) and 21.7% cases (5/23) respectively. CONCLUSIONS: Gross trunnion failure may not be as uncommon as was previously thought. A number potential associations and predisposing factors of this complication have been highlighted in this review. But due to small sample size and weak level of evidence, further studies are needed in this field.

Colesevelam in the management of type 2 diabetes.

Colesevelam is a bile acid sequestrant, approved for the management of both dyslipidaemia and type 2 diabetes. This review discusses the potential for the use of colesevelam in the management of type 2 diabetes. Expert opinion suggests possible indications where colesevelam may add value as a glucose lowering agent. It also highlights the limitations of the drug, and precautions that must be observed while using it.

The Islet De-stress Hypothesis: A potential explanation for the gluco metabolic effects of ketogenic diet.

Ketogenic diet (KD) is an established therapy with indications which span multiple disciplines. Initial skepticism about the role of KD in diabetes and obesity has been replaced by interest in its mechanism of action. We propose that KD works by de-stressing the islet of Langerhans, and reducing its workload. This de-stress occurs at both beta and alpha cell, and suggests that the islet should be considered a single anatomic-functional unit. The Islet De-stress Hypothesis, as we term it, is based upon the Law of Endocrine Parsimony. Simply put, this states that minimal burden should be placed on any gland, including the islet of Langerhans, while managing endocrine disease.

Social insulin resistance: The forgotten frontier.

This opinion piece discusses the concept of social insulin resistance, and helps create a comprehensive biopsychosocial model of insulin resistance. Social insulin resistance is defined as a negative attitude, present in some social groups, directed towards avoidance or rejection of insulin therapy. The various aspects of social insulin resistance are described in detail. This important construct has both clinical and public health relevance, and will help plan strategies to improve the acceptance and usage of insulin in diabetes care.

Epidemiology of pelvic fractures in adults: Our experience at a tertiary hospital.

PURPOSE: Pelvic fractures are severe injuries and are often associated with multiple system injuries, exacerbating the overall outcome. In India, the incidence of pelvic fractures is on a rise due to suboptimal roads and traffics but related literature regarding the overall epidemiology of these injuries is scarce and scanty. Our aim was to study the epidemiology of patients admitted with pelvic fractures at a level 1 trauma centre in India. METHODS: A 16-month (between September 2015 and December 2016) prospective observational study was carried out on trauma patients with pelvic fractures at a level 1 trauma centre of a tertiary care hospital. Demography of patients, mechanism of injuries and complications were recorded prospectively. RESULTS: We observed 75 patients who presented with pelvic fractures, where 56 were males and 19 were females. Mean age of the study population was 37.57 years. Road traffic accidents were the most common mode of injuries. Lateral compression injuries were the most common pattern. Associated injuries frequently encountered were lower extremities and acetabulum fractures, blunt abdominal trauma, urogenital injuries and head injuries. Out of the 75 patients, 52 were treated surgically and 23 were managed by conservative methods. Associated injuries of the extremities, head, abdomen and urogenital system indicated a longer hospital stay. CONCLUSION: Pelvic fractures, although belong to a relatively rare trauma subset, cause a high morbidity and mortality with considerable burden on the economy. Proper road safety training and driving etiquettes along with its strict implementation in true sense and spirit are the need of the hour.

Atrial fibillation in diabetes: Need for cardiovigilance.

Atrial fibrillation (AF), the commonest arrhythmia in clinical practice, is also the commonest arrhythmia for which hospitalization is required. AF is associated with a 5 fold increase in stroke, a 2 fold increase in all-cause mortality, and a higher risk of heart failure. Hence, it is imperative to focus on the risk factors and clinical features of this condition, so that it can be prevented and managed in a timely manner. AF is linked with multiple metabolic and endocrine morbidities. This implies that the endocrinologist has an important role to play in AF detection and referral. This review, the first of a two part series, encourages preventive cardiovigilance, and especially electro-cardiovigilance, in diabetes practice.

Kuntscher's nail removal techniques: an illustrative walk-through its journey.

The use of Kuntscher nail for femur fracture dates back to World War 2. Since then, the technique of intramedullary nailing has evolved and the use of Kuntscher nail has become almost obsolete. The orthopaedic surgeons across the globe are facing a new challenge of removal of these Kuntscher nails due to different indications. Different but scattered English literature has been published describing the experiences and techniques of surgeon with K nail removal. Up till now, no systematic analysis has been performed evaluating the available literature. We have planned a systematic review to evaluate and explore the various indications and techniques of K nail removal.

Correction to: Hemiarthroplasty for neck of femur fractures: to cement or not? A systematic review of literature and meta-analysis.

The original version of this article unfortunately contained a mistake. The correct information is given below. In abstract, the last sentence of the "Primary outcomes" section should read as: Mortality at 1 year was the same in both the groups.

Hemiarthroplasty for neck of femur fractures: to cement or not? A systematic review of literature and meta-analysis.

BACKGROUND: Management of fractures of neck of femur in the elderly is largely joint sacrificing, with hemiarthroplasties being the most common entity used. Cemented and uncemented, both the techniques, are universally accepted; however, the former has been more time tested, despite its theoretical disadvantage in the form of cement embolism leading to intra-operative complications. Uncemented stems have been ever evolving with newer designs to increase incorporation, stability and durability. They have their own reported sets of disadvantages like subsidence and fractures. However, overall there is no established gold standard out of the two. OBJECTIVE: The present systematic review and meta-analysis of current literature was conducted, so as to determine the superiority of one technique over the other by comparing the primary outcomes like hip function, residual pain, local and general complications and mortality. Additionally secondary outcomes like duration of surgery, blood loss and re-operations were analysed as well. METHODOLOGY: Three databases of PubMed, EMBASE and SCOPUS were searched for relevant articles of last 10 years that directly compare uncemented and cemented hemiarthroplasties, and based on our inclusion and exclusion criteria, article selection was done. RESULTS: We analysed a total of six randomised controlled studies dated from 2008 to 2017. PRIMARY OUTCOMES: There was a significant difference in post-operative ability to ambulate at 1 year, between 2 groups with odds ratio 0.45 (95% CI 0.29-0.67, p = 0.0001) favouring cemented hemiarthroplasty. Prosthesis-related complications like fractures and subsidence and general complications like lung complications were more in uncemented group. Mortality at 1 year was more in cemented group. SECONDARY OUTCOMES: Mean surgical time was lesser in uncemented cases. There was no difference in blood loss and re-operation rates. CONCLUSION: Cementing techniques are here to stay, until a better, durable and more stable uncemented stem evolves, that could lessen the complications related to uncemented surgeries and match the cemented implants in pain relief and ambulation.

Long-term outcome of cataract surgery in patients with idiopathic hypoparathyroidism and its relationship with their calcemic status.

Cataract is a cardinal manifestation of hypoparathyroidism. Although patients with hypoparathyroidism require cataract surgery at a younger age than individuals without hypoparathyroidism, there is limited information on the outcome of this surgery. We assessed long-term complications of cataract surgery in patients with idiopathic hypoparathyroidism (IH) and its relationship with their clinical and biochemical parameters. Twenty-seven patients with IH and 25 nonhypoparathyroid controls with a minimum follow-up of 2 years after cataract surgery were assessed for visual acuity, intraocular pressure, lens centricity, Nd:YAG laser capsulotomy, and the severity of posterior capsular opacification (PCO) and anterior capsular opacification. High-resolution optical slit-lamp images were analyzed by an ophthalmologist. Patients with IH had cataract surgery at a younger age than controls (34.0 ± 16.4 years vs 58.0 ± 11.2 years, P < 0.001). A higher proportion of IH patients had dense white PCO (75.0 % vs 39.4 %, P = 0.004), Nd:YAG laser capsulotomy (44.2 % vs 10.0 %, P = 0.001), anterior capsular opacification (97.7 % vs 84.2 %, P = 0.03), and a decentric lens (28.3% vs 2.6 %, P = 0.001) at a comparable time after surgery (8.6 ± 6.1 years vs 8.7 ± 6.8 years, P = 0.85). On regression analysis, the severity of PCO in IH correlated only with male sex and not with other factors, including serum total calcium and inorganic phosphorus levels at the baseline and during follow-up. To conclude, patients with IH are likelier than individuals without IH to develop PCO and to require Nd:YAG laser capsulotomy after cataract surgery. Proper precautions should be taken during surgery to minimize this complication in IH.