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.

Long-term survival of CLS Spotorno femoral stem: a systematic review of literature.

BACKGROUND: CLS Spotorno is a time-tested femoral stem design with excellent early results; the present review was designed to assess the published evidence on CLS Spotorno stem in the literature to evaluate its long-term outcomes and compare it to two other popular stem designs the uncemented Corail™ and the cemented Exeter™ stems. RESEARCH QUESTION: Do CLS Spotorno stems provide adequate long-term rates of survival in terms of revisions and functional outcomes? METHODOLOGY: Medline, EMBASE and SCOPUS databases were searched for relevant articles and a total number of 670 hits were obtained, out of which 14 relevant studies were included in this review. Pooled analysis of revisions rates, subsidence and Harris Hip scores (HHS) were done. RESULTS: All the 14 studies were retrospective in design but had sufficiently large follow-up periods (12.3-27 years, mean 17.1 years). Of the 2459 hips reviewed, the documented revision rate was only 6.2%, with aseptic loosening reported in 3.1% and subsidence > 2 mm in 2.6% cases. The overall survival was similar to reported smaller cohorts of Corail (95% at 12 years) and Exeter stems (100% at 17 years). Varus malposition was seen in 10.6% cases, but it did not show any influence on implant survival or revision rates. Distal pedestal formation was seen in 172 of 805 hips across seven studies, while distal cortical hypertrophy was seen in 70 cases out of 398 hips; these were not related with stem malposition. The overall functional outcome was good, with mean HHS of 88.65 (95% CI = 86.08-91.23, p < 0.01). The improvement in scores from preoperative values (of 43.9 points) were comparable to Corail (43.8) and Exeter (45) stems. Thigh pain was seen in only 41 cases out of 1097 hips. CONCLUSION: Despite the limitations due to high heterogeneity of the cumulative data, the review suggests that CLS Spotorno femoral stems provides excellent long-term survival and good hip function. These outcomes are comparable to other commonly utilized femoral stems like the Corail and Exeter. LEVEL OF EVIDENCE: IV.

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.

Parameters That Can Be Used to Quantify Reduction Accuracy in Talar Neck Fractures and Malunions: A PRISMA-Compliant Scoping Review and Meta-Analysis.

Understanding the three-dimensional anatomy of the talar neck is essential in assessing the accuracy of reduction in talar neck fractures as well as for planning surgical correction for talar malunions. However, the geometrical parameters that describe this anatomy are sparsely reported in the orthopedics literature. We aimed to identify from the existing literature, geometrical parameters that describe the anatomy of the talar neck, determine how these are measured, and their normative values. A scoping literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guidelines. The primary searches were conducted on the PubMed, Embase, and Scopus databases. Any original research study looking at the human talus neck geometry was included. Parameters that described the anatomy of the talar neck were identified, and pooled estimates were determined by the random-effects meta-analysis model. Heterogeneity was assessed by the I2 test and leave-one-out meta-analysis. Subgroup analysis was done to compare the values of parameters between the Asian and Non-Asian populations. The risk of bias was assessed by the National Institutes of Health (NIH) Case Series Tool. The combined searches yielded 6326 results, of which 21 studies were included in the review and 15 in six different sets of metanalysis. The majority of the studies (n=19, 90.5%) evaluated adult tali, and only two (9.5%) evaluated pediatric tali. In most of the studies (n=13, 61.9%), talus neck geometry was evaluated on dry bones or anatomical specimens; evaluation by imaging techniques (radiographs, CT, MRI, and radiostereometric analysis) was used in eight studies, (39.1%). A total of eight different geometrical parameters (neck length, height, width, declination angle, inclination angle, torsion angle, circumference, and cross-sectional area) were identified. Except for talar torsion, variability was noted in methods of measurement of all other parameters. Subgroup analysis revealed that Asians had a higher neck height as compared to non-Asians; other parameters were not significantly different. Although the literature reports geometrical parameters to assess the talar geometry, the methods of measurement of these parameters are variable. Most of the available literature describes measurement techniques on cadaveric tali, and there is no literature on how these parameters should be measured on conventional CT or MRI slices. Further research needs to focus on the standardization of measurement techniques for these parameters on conventional CT and/or MRI scans.

Does the residual displacement of pelvic ring affect the functional outcome in pelvic ring injures?

PURPOSE: The effects of residual displacement on the functional outcome of the patient are not distinctly known and the acceptability criteria of residual displacement of the pelvic ring remain disputed. The purpose of this study is to evaluate the effect of residual displacement on functional outcome in pelvic ring injuries. MATERIALS AND METHODS: A total of 49 patients with pelvic ring injuries (both operative and non-operative) were followed up for six months. Anteroposterior (AP), Vertical and rotational displacements were measured at admission, after surgery and at six months. Resultant displacement (vector addition of AP and vertical displacement) was taken for comparison. Displacement was graded as excellent, good, fair and poor according to Matta's criteria. Functional outcome assessment was done at six months using Majeed score. Work adjusted Majeed score was calculated for non-working patients by taking the percentage score. RESULTS: We compared the means of residual displacement with functional outcome (Excellent/Good/Fair) and found that there was no significant difference between the groups in operative (P=0.33) or non-operative patients (P=0.09). This showed that patients with relatively higher residual displacement also had satisfactory functional outcomes. The functional outcomes were compared after dividing the residual displacement into 2 groups: <10 mm and >10 mm and no significant difference was found in outcomes for either operative or non-operative patients. CONCLUSION: Up to 10 mm of residual displacement is acceptable in pelvic ring injuries. More prospective studies with a longer follow up are needed for determination of correlation between reduction and functional outcome.

Spinopelvic fixation for vertically unstable AO type C pelvic fractures and sacral fractures with spinopelvic dissociation- A systematic review and pooled analysis involving 479 patients.

BACKGROUND: Posterior pelvic ring injuries can be fixed using iliosacral screws, plates or bars. Another promising modality is spinopelvic fixation or triangular osteosynthesis, indicated in vertical instability and sacral fractures associated with spinopelvic dissociation. QUESTION/PURPOSE: This systematic review and pooled analysis was conducted to analyze the outcomes (functional and radiological) of the use of spinopelvic fixation, as well as assess the associated complications and neurological recovery. METHODS: A systematic review of literature was performed from the PubMed/Medline, EMBASE and the SCOPUS databases. All studies reporting on spinopelvic fixations, with a minimum follow up of 1 year were included in the review. Pooled analysis was done for the outcome and complication rates. The MINORS Tool was used for assessing the risk of bias. RESULTS: A total of 22 studies were included with average follow-up between 12 and 86.4 months. There were 7 prospective and 15 retrospective case series. The functional outcomes were excellent/good in 90% cases, across 8 studies (95% CI 84-95%); radiological outcomes were excellent/good in 97% cases (95% CI 94-100%) across 5 studies. The most commonly reported complications were hardware prominence in 21.3% (95% CI 11.6,30.9%) and infections in 7.2% cases (95% CI 4.8,9.5%). 73% of the patients reported partial or complete improvement in their neurological condition. CONCLUSION: Spinopelvic fixation is an effective method in vertical instability of the pelvis and sacral fractures with spinopelvic dissociations, with good to excellent radiological and functional outcomes. However, adequate precautions are needed to avoid infections and wound complications.

Association of Specific Genetic Polymorphisms with Atraumatic Osteonecrosis of the Femoral Head: A Narrative Review.

Introduction: Atraumatic ONFH is one of the leading cause of hip morbidity in the working-age group. It is a multi-factorial disease whose root cause can be attributed to single-nucleotide polymorphism. Identifying such polymorphisms could pave the way for new modalities of treatment for ONFH. Methodology: Two databases were electronically searched for relevant articles. The articles were screened through titles, abstract and full texts to include the relevant studies. A secondary search was done through the reference list of selected articles. Results: A total of 52 studies were included among the 181 hits. All 181 were case-control studies. Summary of these studies identifies multiple SNPs which can cause ONFH. There were 117 SNPs in all 181 studies, of which 92 were associated with the causation of ONFH and 25 were protective against ONFH. Conclusion: SNPs play an essential role in causing atraumatic ONFH. Identification of SNP that contribute to causing ONFH may help reduce the disease burden by early identification, diagnosis and treatment, including targeted gene therapy.

Antegrade vs retrograde intramedullary nailing in humerus shaft fractures: A systematic review and meta-analysis.

Introduction: Plate osteosynthesis, external fixators and intramedullary nails are the commonly used devices for fixation of humerus shaft fractures. Humerus nails are gradually coming into popular use. Both antegrade and retrograde nails are used for this, however no evidence clearly states the benefits of one over the other. Thus, the purpose of this study was to evaluate the available evidence comparing the complications and outcomes of antegrade versus retrograde nails. Patients and methods: We followed the Preferred Reporting Items for Meta-analyses Statement (PRISMA) guidelines. All studies in any language comparing the use of antegrade and retrograde nailing for humerus fractures, with a minimum follow up of 12 months were included. The primary outcome measures were complications and time to union. Results: Seven studies including 384 patients (200 antegrade, 184 retrograde) were analyzed. A significantly lower complication rate was observed with retrograde nails (OR 1.77, p = 0.04, 95% CI 1.02,3.06; p = 0.04). Antegrade nails were associated with shorter operative time (MD -13.69, p > 0.00001). There was no significant difference in time to union and intra-operative blood loss between the two techniques. Conclusion: Retrograde nails have a significantly lower complication rate. However, the surgeon's experience with these devices and the location of the fracture are the primary considerations when choosing either implant. Loe: Level IV.

Early versus delayed thromboprophylaxis with LMWH in pelvic-acetabular trauma- a prospective study.

BACKGROUND: Delayed presentation of pelvic-acetabular fractures is a common scenario in developing countries and there is usually a delay of more than 24 h in their presentation. OBJECTIVES: We aim to comparatively analyse early(<24 h) versus delayed (>24 h) thromboprophylaxis with low molecular weight heparin (LMWH) in prevention of deep venous thrombosis (DVT) in Pelvic Acetabular fractures. METHODS: Patients of pelvic-acetabular fractures who presented during 1 year of study period were divided into 2 groups after exclusion of patients with contraindications for thromboprophylaxis. Group A included patients who received LMWH prophylaxis within 24 h of injury. Group B included patients who received LMWH prophylaxis after 24 h of injury. All patients underwent CT venography at day 14 and were followed up with doppler ultrasound on 4th and 8th week. RESULTS: 110 patients with pelvic-acetabular fractures were included after exclusion of 61 patients. 4 out of 29 patients in group A (13.8%) and 12 out of 81 patients (14.8%) in group B developed DVT. There was no significant difference in incidence of DVT between Group A and B (P value-0.893). CONCLUSION: There was no difference between early and delayed thromboprophylaxis with LMWH in pelvic-acetabular trauma.

Outcomes of Primary Total Knee Arthroplasty in Fractures Around the Knee in the Elderly: A Systematic Review and Pooled Analysis of 212 Patients Across 11 Studies.

Background: Treatment of fractures around the knee in the elderly is somewhat controversial with primary total knee arthroplasty (TKA) gaining prominence over the past decade or so, as an alternative for open reduction and internal fixation. The present review was conceptualized to review the published literature and evaluate outcomes of TKA in these patients, and to understand whether this is a viable treatment option for these fractures. We have further tried to identify complications and the challenges faced while performing this surgery. Methods: PRISMA guidelines were followed and search was conducted on three databases-PubMed, EMBASE and SCOPUS. Studies evaluating multiple factors related to outcomes and complications in primary TKA performed for fractures around the knee in the elderly were included. Cadaveric studies, conference abstracts, case reports, and any studies that included non-traumatic cases or revision after failed internal fixation, were all excluded. Results: Eleven studies, published between 2011 and 2021 were included in our review. There was significant female preponderance in the study population (M:F = 1:3). Implants with higher constraint (high post, hinged prosthesis) were frequently required to compensate for ligamentous laxity due to the fractures. On pooled analysis the mean Knee Society Score (KSS) knee score was 84.62 (excellent), and mean knee range of motion was 107.25°. However, the mean KSS function score was 56.71 (poor), which could have been due to co-morbid conditions and pre-operative status. Overall complication rate was 14.6%; surgical site infection was the most commonly reported. Conclusion: There remains limited evidence for the use of TKA as a primary treatment option for these injuries. In the presence of specific conditions, and in expert hands-it may be a viable alternative to osteosynthesis with comparable outcomes. More focused studies are needed to compare the two treatment options and to formulate guidelines.

Excision Versus Replacement in Unrepairable Comminuted Fractures of the Radial Head: A Systematic Review of Outcomes and Complications.

Background: The radial head fractures comprise approximately 4% of all fractures around the elbow. The outcomes of open reduction and internal fixation are poor in fractures with more than three fragments, and the excision of radial head is considered a viable surgical treatment option. However, it is associated with its own set of complications. The radial head prosthetic replacement has emerged as an alternative in management of these fractures with constraints of cost and related complications. Hence, the treatment for the unrepairable comminuted radial head fractures still remains controversial. Aims and Objectives: This systematic review and meta-analysis was conducted to compare the post-operative outcomes of the radial head excision versus prosthetic replacement in comminuted Mason type-III fractures of radial head. Methodology: Three databases of Medline (PubMed), Scopus, and Embase were searched for comparative studies on the study question and relevant studies which mentioned at least one of the outcomes of interest (functional outcome scores and number of complications) were included. Results: Six studies were part of this review with 82 excisions and 99 prosthetic replacements. There was no significant difference between the two groups in terms of number of complications (OR 0.65; 0.08-5.07); and measures of functional outcomes; Mayo elbow performance score or MEPS (mean difference - 6.56; - 23.45 to 10.33). The incidence of elbow osteoarthritis, heterotrophic ossification, stiffness, and instability were similar in both groups. The flexion extension arc in degrees was better in excision group (mean difference 9.93; 1.31-18.55; p = .02). Conclusion: Excision is a reasonable surgical option for isolated comminuted radial head fractures with similar results of function and associated rates of complications as prosthetic replacements. The arc of motion is also better with excisions. There have been reports of more osteoarthritis with excision and arthroplasty has been advised in younger patients; however, we had no quantitative proof of that in this review.

Locked Plating Versus Retrograde Intramedullary Nailing for Distal Femur Fractures: a Systematic Review and Meta-Analysis.

Modern advances in techniques and implants have allowed for a better operative fixation for distal femoral fractures. Both locked plating and retromedullary nail have allowed surgeons to stabilize these fractures with minimal soft tissue dissection and preserve blood supply. Although both the implants have been used extensively for such types of fractures, the superiority of one implant over the other is still doubtful. Therefore, we conducted this meta-analysis to compare locked plating and retrograde intramedullary nailing in distal femoral fractures. Based on prisma guidelines, electronic databases, including PubMed, Embase, Scopus, and Ovid Medline were searched using a well-defined search strategy. Outcome measures which were studied included blood loss, implant failure, infection, knee range of motion, malunion, non-union, pain, surgical duration and union time Surgical duration (95% CI 2.90 to 17.13, p <0.01) and blood loss (95% CI 69.60 to123.18, p <0.01) favoured plating group and the difference is significant. But while analysing parameters like implant failure, knee range of motion, non-union and union time, our analysis favoured nailing group, but the difference is not significant. Overall, both locked plating and retrograde intramedullary nailing are comparable with respect to union and complications in distal femur fractures, but we need further larger and high quality randomized studies to evaluate the difference.

Core decompression with bone marrow aspirate concentrate in post collapse avascular necrosis of hip: A systematic review and meta-analysis.

BACKGROUND: Avascular necrosis (AVN) of femoral head is commonly seen in middle age groups and in its advanced stages, it is a common indication for total hip replacements (THRs). These patients invariably require revision surgeries in their lifetime and modalities to delay the first arthroplasty are necessary. Core decompression (CD) with bone marrow aspirate concentrate (BMAC) have proved successful in early stages of AVN, but their role in advanced stages remains unclear. The present review was done to assess the same. RESEARCH QUESTION: Is CD and BMAC combination effective in delaying radiographic progression and THRs in post collapse stages of AVN hip? METHODOLOGY: A systematic review and meta-analysis was conducted to determine the overall efficacy of CD and BMAC in post collapse stages of AVN hip and to specifically compare primary outcomes like radiographic progression along with need of THR, with CD alone.Three data bases (PubMed, EMBASE and SCOPUS) were searched to identify relevant articles. RESULTS: The present review included 12 studies with 3 studies included in the meta-analysis. There were 270 hips across the 12 studies out of which 196 hips were treated with CD + BMAC. PRIMARY OUTCOMES: 39.8% cases worsened from stage 3 to stage 4, while the overall incidence of THR in stages 3 and 4 was 38.3%. On comparison with CD alone the combination of CD + BMAC did not show any enhanced efficacy in either delaying progression (Odds ratio of 1.41 (95% CI = 0.55-3.62) or in conversion to THR (Odds Ratio: 0. 92; 95% CI = 0.41-2.06). CONCLUSION: CD can be considered in stage 3 of AVN in younger population to delay the need of arthroplasty, before severe head distortion and arthritis sets in, and can be supplemented with bone strut grafts or tantalum rods, for supporting the articular cartilage. BMAC that has shown better results in early AVN, has not shown any additional benefits when compared to CD alone in advanced cases.

Bilateral crescent fracture-dislocation of the sacroiliac joint: a case-based discussion and review of literature.

BACKGROUND: Crescent fractures are a subset of lateral compression injuries associated with high energy trauma and are rotationally unstable. These fractures are rare bilaterally, and we present one such rare case of a bilateral crescent fracture. CASE DESCRIPTION: A 56-year-old male presented with run-over injury and was diagnosed with bilateral crescent fracture-dislocation of the Sacroiliac joint. He was stabilized hemodynamically and then operated with iliosacral screws and reconstruction plates. The fracture united, and the patient is doing his daily activities without discomfort at follow up of 1 year after fracture fixation. CONCLUSION: Bilateral pelvic crescent fractures are rare and need optimization and fixation for improved functional outcomes. It is necessary to evaluate associated injuries.

30-Day Mortality Rate in Hip Fractures Among the Elderly with Coexistent COVID-19 Infection: A Systematic Review.

PURPOSE: Hip fractures in the elderly require a multi-disciplinary approach and are associated with increased morbidity and mortality. The current COVID-19 pandemic has affected substantially this high-risk population group. This present review was done to ascertain whether or not the pandemic has affected the 30-day mortality and outcomes of hip fracture in the elderly. RESEARCH QUESTION: Does the coexistence of COVID-19 infection and hip fractures in the elderly increase the mortality rates? METHODOLOGY: A systematic review and meta-analysis were conducted using three databases (PubMed, EMBASE and SCOPUS) to compare the mortality rates between COVID-19 positive/suspect and COVID-19 negative patients. The secondary outcomes included comparison of in-hospital mortality, complication rate and length of hospital stay. Risk of bias assessment was done using the MINORS tool. RESULTS: The present review included 20 studies. Primary outcome: A significantly higher 30 day mortality rate was seen in COVID-19 positive/suspect patients with an Odds ratio of 6.09 (95% CI 4.75-8.59, p < 0.00001). Secondary outcome: We observed significantly higher rates of inpatient mortality [OR 18.22, (95% CI 7.10-46.75], complication rate (OR 9.28, 95% CI 4.46-19.30), and length of hospital stay (MD: 4.96, 95% CI 2.86-7.05) in COVID-19 positive/suspect patients as compared to COVID-19 negative patients. CONCLUSION: COVID-19 has deteriorated the outcomes in elderly patients with hip fractures and associated with higher rates of mortality in the short term. A multidisciplinary approach is needed to contain this "pandemic within a pandemic" and improve the overall outcome to survival.

INFIX-safe and effective surgical option for complex fracture patterns of the anterior pelvic ring: A prospective single center study.

BACKGROUND: Complex fracture patterns of anterior pelvic ring are a challenge and usually needs extensive surgeries. The purpose of this study was to evaluate INFIX as a minimally invasive procedure for such injuries in terms of feasibility, outcomes and complications in the Indian population. METHODS: Patients with complex fracture patterns of anterior pelvic ring were selected for anterior INFIX application along with standard posterior stabilization. Outcomes were assessed radiographically by Matta's criteria and amount of displacement. Post-operative CT scan for relation of implant to vital structures and Doppler at varying hip flexion for possible vascular occlusion was used. Functional outcomes included both disease specific scores (Majeed score, IOWA pelvic score) and quality of life scores (SMFA, SF-12). Complications were also noted. RESULTS: 12 cases out of 112 patients had complex fracture pattern of the anterior ring. Most common injury pattern were LC-3 and VS (n = 6 and 3) Young and Burgess type. The average follow up was 6 months. Fracture reduction as per Matta's criteria was excellent in 10 (83.3%) cases and good in 2 (16.6%) cases with functional outcomes excellent in 11 cases, and a mean Majeed score of 92.67 ± 5.8. The average SMFA score was 51 ± 4.39 and mean SF-12 scores for physical and mental health were 48.493 ± 6.74 and 56.370 ± 4.04 respectively. Complications noted were lateral femoral cutaneous nerve palsy (1/24 nerves), skin dehiscence (n = 2), infection (n = 2) and sacral nonunion (n = 1). CONCLUSION: INFIX is a safe and effective minimally invasive technique for addressing complexfracture patterns involving the anterior half of pelvic ring with excellent fracture reduction, radiological and functional outcomes and predictable fracture healing.

Role of supplemental teriparatide therapy in management of osteoporotic intertrochanteric femur fractures.

BACKGROUND: Despite the surgical advances, obtaining the desired outcome in osteoporotic intertrochanteric femur fractures is still a tough row to hoe for the surgeons. Consequently, the interest of the researchers has shifted towards establishing a holistic approach for managing such injuries. Teriparatide, a recombinant form of human parathyroid hormone, is a novel drug that has been proved to hasten fracture healing and in both animals and humans. We attempted to evaluate the influence of Teriparatide therapy in surgically fixed osteoporotic intertrochanteric femur fractures and provide the groundwork for further research in this area. METHODS: The results of osteoporotic patients who underwent only Proximal Femur Nailing [PFN] for intertrochanteric femur fractures were prospectively compared to the patients who received an additional Teriparatide therapy. We aimed to identify the effect of Teriparatide on the time to fracture union, bone mineral density [BMD], and other fracture related post-operative complications. The functional outcome was assessed using the Lower extremity functional scale [LEFS]. RESULTS: All patients were followed up for 6 months by which time all the fractures united. However, in the Teriparatide group, time to fracture union was shortened by about 2 weeks and improvement in BMD and functional outcome were significantly better. The rate of migration of the helical, varus collapse, and femoral shortening did not show any relevant difference. CONCLUSION: Our preliminary attempt shows that early union coupled with better functional improvement and a substantial increase in BMD tips the balance in favour of the Teriparatide therapy in osteoporotic patients with intertrochanteric femur fractures. Well-designed clinical trials conducted in a similar vein are further required to support our claim.

Autonomic Denervation Dermatitis: A Relatively Undocumented 'ADD'itional Complication of Total Knee Replacements and Other Surgeries Around the Knee.

BACKGROUND: Infrapatellar branch of the saphenous nerve lies subcutaneously and supplies the anterolateral aspect of knee below the patella. It is extremely susceptible to iatrogenic injuries during the surgeries around the knee, mainly total knee replacements (TKRs). Post operatively the patients present with localised area of numbness and in some instances a traumatic eczematous reaction termed autonomous denervation dermatitis (ADD) is witnessed, leading to skin manifestations that range from a simple rash to extensive lesions. METHODOLOGY: A review of literature was conducted with search of relevant articles from Medline (PubMed), Embase, and Scopus which discussed eczematous skin lesions secondary to total knee replacements. Additionally, we noted studies which described these lesions in other surgeries around the knee like arthroscopies and fracture fixations. RESULTS: Eight studies including atleast one case after TKR were reviewed. There was only one cohort study while the remaining included case reports and small case series. There were 69 cases of ADD appearing after TKR. The appearance of the skin lesions was lateral to the incision in 30/34 operated knees and on both sides of the incision in four knees after TKRs. Bilateral lesions were seen in only six patients of TKRs. There was no functional limitation caused by these lesions and they resolved either spontaneously or after using topical steroids. CONCLUSION: ADD is a relatively uncommonly reported complication of TKRs, which can reduce patient satisfaction and increase surgeon apprehension. Although all cases of nerve damage do not manifest as cutaneous lesions, steps to minimise the damage to the nerve intra operatively should be taken. The diagnosis requires a high index of suspicion, and should not be dispelled as a simple allergic reaction without adequate investigations. Patients should be counselled to alleviate unnecessary fear and apprehensions.