Tranexamic Acid Use in Anterior Cruciate Ligament Reconstruction Decreases Bleeding Complications: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: To systematically review all available randomized controlled trials (RCTs) in the literature that examine outcomes following tranexamic acid (TXA) use in anterior cruciate ligament reconstruction (ACLR) to determine its effectiveness. METHODS: PubMed/MEDLINE, Embase, Science Direct, Web of Science, CINAHL, and The Cochrane Library databases were systematically searched for RCTs comparing TXA versus no TXA in ACLR with a 4-week minimum follow-up. Quality was assessed using Risk of Bias 2. Pooled analyses were conducted using inverse variance for continuous variables and Mantel-Haenszel for dichotomous variables. The Grading of Recommendations, Assessment, Development and Evaluation guidelines were used to evaluate primary outcomes. RESULTS: A total of 807 patients (632 male, 175 female) from 7 RCTs were included. Mean age was 28.4 years. Bias was graded "low" in 4 RCTs, "some concerns" in 2 RCTs, and "high" in 1 RCT. Visual analog scale was found to be not significantly different with TXA use at day 1-3 (mean difference [MD] -0.92, I2 = 96%, P = .14) and 12 weeks (MD -0.03, I2 = 0%, P = .73). Visual analog scale was significantly decreased at week 2 (MD -1.18, I2 = 56%, P < .00001) and weeks 3-6 (MD -0.38, I2 = 73%, P < .010). Lysholm scores were greater with TXA use at week 2 (MD 9.04, I2 = 74%, P = .002) and weeks 4-6 (MD 6.17, I2 = 73%, P = .0004) but not significantly different at 12 weeks (MD 6.13, I2 = 98%, P = .28). Need for aspiration was less with TXA use (odds ratio 0.40, I2 = 49%, P = 0.0009). Considerable heterogeneity was seen in many results. Certainty was low for 2 primary outcomes, moderate for 2, and high for 5. CONCLUSIONS: Pooled data suggest that the use of TXA in ACLR reduces the need for aspiration, hemarthrosis, drain output, and knee swelling in the postoperative period. While early improvements in pain and function were observed, the clinical relevance is questionable. The risk of complications does not increase with TXA use, and the use of intravenous TXA over intra-articular TXA may improve and prolong hemarthrosis reduction, although the evidence is weak. LEVEL OF EVIDENCE: Level II, systematic review of therapeutic Level I-II studies.

Short- and long-term outcomes in Bankart repair vs. conservative treatment for first-time anterior shoulder dislocation: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: First-time anterior shoulder dislocations are associated with a high rate of residual instability. Therefore, many surgeons support initial Bankart repair surgery over conservative management to address this issue. However, the optimal treatment remains controversial because of uncertainty regarding long-term surgical outcomes. The primary objective of this systematic review and meta-analysis was to compare the short- and long-term rates of residual instability following Bankart repair or conservative management after a first-time anterior shoulder dislocation. METHODS: PubMed/MEDLINE, Embase, The Cochrane Library, Web of Science, CINAHL, and ScienceDirect databases were accessed for randomized controlled trials (RCTs) comparing Bankart repair to conservative management. RoB (Risk of Bias) 2 was used to check study quality. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines were followed in assessing primary outcomes. The inverse-variance method for continuous variables and the Mantel-Haenszel method for dichotomous variables was used. RESULTS: A total of 348 patients from 6 RCTs published across 8 articles, with a mean age of 23.7 years, were included. Bias was graded low in 3 studies, some concerns in 3 studies, and high in 2 studies. In the short term (2-3 years), surgery lowered recurrent instability (risk ratio [RR] 0.15, 95% confidence interval [CI] 0.08, 0.27; I2 = 0%; P < .0001). Similar findings were seen in the long term (5-12 years) (RR 0.23, 95% CI 0.14, 0.39; I2 = 0%; P < .0001). No difference was observed in return to sport (RR 1.18, 95% CI 0.91, 1.52; I2 = 78%; P = .21). Initial surgery lowered subsequent stabilization surgery in the short (RR 0.19, 95% CI 0.09, 0.43; I2 = 0%; P < .0001) and long term (RR 0.17, 95% CI 0.07, 0.39; I2 = 25%; P < .0001). Western Ontario Shoulder Instability Index (WOSI) scores did not differ in the short term (MD, 2.54, 95% CI -0.51, 5.59; I2 = 48%; P = .1) but were higher in the surgical group at long-term follow-up. Patient satisfaction was also higher with surgery (RR 1.75, 95% CI 1.4, 2.2; I2 = 88%; P < .0001). Certainty of evidence was low for only 1 long-term outcome measure. CONCLUSION: Bankart repair surgery for first-time anterior shoulder dislocation results in a large reduction in the risk of recurrent shoulder instability and subsequent stabilization surgery in both short- (2-3 years) and long-term (5-12 years) follow-up intervals. Additionally, slight improvements in overall patient satisfaction and WOSI score can be seen at long-term follow-up. However, surgical intervention failed to significantly improve the rate of return to sport when compared with conservative management.

Outcome of primary deltoid ligament repair in acute ankle fractures: a meta-analysis of comparative studies.

PURPOSE: The indications of deltoid ligament repair in ankle injuries with widened medial clear space in the absence of medial malleolus fracture remain controversial. Many authors reported no difference in long-term functional outcomes, while others stated that persistent medial clear space widening and malreduction are higher when deltoid ligaments went without repair. This meta-analysis aims to report the current published evidence about the outcomes of deltoid ligament repair in ankle fractures. METHODS: Several databases were searched through May 2018 for comparative studies. The primary outcome was the medial clear space correction, while secondary outcomes included maintenance of medial clear space reduction, pain scores, functional outcome, and total complications if any. Three comparative studies met the inclusion criteria for the meta-analysis. The analysis included a total of 192 patients, 81 in the deltoid ligament repair group and 111 in the non-repair group. RESULTS: The medial clear space correction and maintenance of the said correction on final follow-up radiographs were superior in the deltoid ligament repair group. Although the pain scores were better in the repair group at the final follow-up, this did not result in a better functional outcome, with similar total complication rates. CONCLUSION: In conclusion, those who had their deltoid ligament repaired had superior early and late radiological correction of the medial clear space, an indicator of the quality of ankle reduction with better pain scores. However, no differences in the functional outcome and complications rate were reported.

Platelet-Rich Plasma Versus Corticosteroids in the Treatment of Chronic Plantar Fasciitis: A Systematic Review and Meta-analysis of Prospective Comparative Studies.

Plantar fasciitis is a common cause of heel pain, which often results in a significant limitation of daily activity. The objective of this review was to compare platelet-rich plasma injection (PRP) and corticosteroids injection in the treatment of chronic plantar fasciitis. MEDLINE, PubMed, Web of Science, EMBASE, and the Cochrane library of clinical trials were searched in March 2019. Inclusion criteria were prospective comparative studies reporting functional scores or pain score with a minimum follow-up of 1 month. We excluded studies with patients younger than 18 years and patients with a history of surgical intervention, infection, or rheumatological disease. First author, publication year, sample size, type of intervention, outcome measures, and follow-up period were recorded. The American Orthopaedic Foot & Ankle Society score was significantly better in the PRP group at 6 months' follow-up, with a lower visual analogue scale at 6- and 12-month intervals. The Foot and Ankle Disability Index and Roles-Maudsley score were similar in the 2 treatments at 3 and 6 months. PRP injection in the treatment of chronic plantar fasciitis is considered safe, with a favorable functional outcome and pain control at intermediate and long-term follow-up in comparison to corticosteroid injection.

Early versus late treatment of paediatric femoral neck fractures: a systematic review and meta-analysis.

PURPOSE: Femoral neck fractures in children represent less than 1% of all paediatric fractures. Osteonecrosis of the femoral head is one of the devastating complications of this fracture. Time to treatment is one of the most important predictors of this outcome with no clear consensus in the literature. The aim of this study was to determine whether early treatment (< 24 hours) of pediatric femoral neck fractures is associated with a lower rate of osteonecrosis of the femoral head compared to late treatment (> 24 hours). METHODS: We searched several databases (PubMed, Embase, and Cochrane library), from January 1966 to November 2017 for any comparative studies that evaluated early (< 24 hours) versus late (> 24 hours) treatment of paediatric femoral neck fractures. We pooled the effect sizes using fixed effects model that compared the rate of osteonecrosis of the femoral head between children undergoing early versus late treatment, open versus closed reduction, displaced versus non-displaced and different Delbet type femoral neck fractures. Descriptive and qualitative data was also extracted. RESULTS: Of the 391 articles identified, six studies (prospective and retrospective cohort studies) were eligible for the meta-analysis, with a total of 231 paediatric femoral neck fractures. The pooled odds ratio (OR) for osteonecrosis of the femoral head did not show any statistically significant difference between early (< 24 hours) versus late (> 24 hours) treatment (OR = 1.19, 95% CI 0.56, 2.51, I2 = 23.6%), nor between open versus closed reduction of paediatric femoral neck fractures (OR = 1.62, 95% CI 0.82, 3.22, I2 = 19.57%). Displaced and Delbet type I/II femoral neck fractures were 3.8 (OR = 3.81, 95% CI 1.49, 9.78, I2 = 0.00%) and 2.4 (OR = 2.43, 95% CI 1.28, 4.61, I2 = 0.57%) times more associated with osteonecrosis of the femoral head compared to non-displaced and Delbet type III/IV fractures respectively. CONCLUSIONS: The cumulative evidence at present does not indicate an association between the time to treatment or method of reduction of femoral neck fractures in children and the risk of osteonecrosis of the femoral head. However, initial expedient treatment of femoral neck fractures in children should always remain the rule especially for displaced and Delbet type I/II femoral neck fractures. LEVEL OF EVIDENCE: II/III.

Isolated medial column stabilization surgery does not benefit adult acquired flatfoot stage IIa nor IIb by three-dimensional finite element biomechanical analysis.

The surgical treatment for stage II adult acquired flat foot deformity (AAFD) remains controversial. Biomechanical effects of medial column stabilization remain unclear. No study has biomechanically assessed the effect of medial column arthrodesis on the whole foot. Our study aimed to mechanically analyze the advantages and disadvantages of this. Stage IIa and IIb AAFD three-dimensional finite element models were established. The application of Geomagic software, Solidwork software, and Abaqus software was used to simulate a medial column stabilization operation (navicular-cuneiform joint fusion, metatarsal-cuneiform joint fusion, or both). The maximum pressure on plantar soft tissue, medial column bone, and medial ligaments was compared before and after simulated single-foot weight loading. Several data were measured to carry out a comprehensive comparison. The maximum plantar stress was located under the first metatarsal head after the simulated medial column stabilization operation. It increased significantly after medial column stabilization in a stage IIa flatfoot model, but did not change significantly after medial column stabilization in stage IIb model. Therefore, after medial column fusion, the stress of the corresponding joint was reduced, but it was increased in the adjacent joints of the medial column. The stresses on medial ligaments and plantar fascia were also not alleviated after medial column fusion. Our results showed isolated medial column stabilization surgery cannot help patients with stage IIa nor IIb flatfoot from the biomechanical point of view, and such stabilization increases stress on the sole, the joints around the fusion sites, medial soft tissue, and ligaments. It can only be used as a combined surgery to stabilize joints with excessive motion and correct the deformity of supination of the forefoot.

Vitamin D and tibiofemoral joint orientation angles in children.

Vitamin D is an important component in musculoskeletal development and function in children. The aim of our study was to investigate serum vitamin D levels and tibiofemoral joint orientation angles in children. We performed a retrospective review on a consecutive series of children presenting with lower limb complaints. The children underwent an assessment of serum vitamin D level and full-length standing lower limb anteroposterior radiographs, and were divided into normal and deficient vitamin D groups. Tibiofemoral angles (TFAs) [lateral distal femoral angle (LDFA); medial proximal tibial angle (MPTA)] were measured by three independent observers and compared between the groups. Correlation tests between serum vitamin D level and TFAs were also performed. Sixty (39 boys, 21 girls) children were reviewed. The mean serum vitamin D level for the entire group was 26.8 ng/ml and 75% of the children were deficient. The mean serum vitamin D levels in the normal (11 boys, four girls) and deficient (28 boys, 17 girls) groups were 46.7 ng/ml (range: 32-100) and 20.2 ng/ml (range: 4-29), respectively. The mean right and left LDFAs were significantly higher in the normal compared to the deficient vitamin D group (right LDFA: 98.7° vs. 92.2°, P=0.031; left LDFA: 99.1° vs. 92.6°, P=0.018). We also found a correlation between serum vitamin D level and LDFAs (right ρ=0.29, P=0.03; left ρ=0.30, P=0.02). We found no difference in the right and left MPTAs in the normal and deficient vitamin D groups. In addition, we could not find a correlation between serum vitamin D level and MPTAs. The majority of children were vitamin D deficient. Serum vitamin D level was associated with a change and correlation to the LDFAs compared to MPTAs. Further work is required to investigate the effect of vitamin D supplementation on TFAs in children.

Open Reduction and Internal Fixation Versus Nonsurgical Treatment in Displaced Midshaft Clavicle Fractures: A Meta-Analysis.

OBJECTIVES: To compare open reduction and internal fixation (ORIF) and nonsurgical treatment outcomes in displaced midshaft clavicle fractures. DATA SOURCES: PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library, and ClinicalTrials.gov were searched in September 2017. STUDY SELECTION: Inclusion criteria were randomized controlled trials reporting nonunion, shoulder functional outcomes, and subsequent surgery rates or pain scores. We excluded studies with patients younger than 16 years, maximum follow-up less than 9 months, and inaccessible full text. DATA EXTRACTION: Extracted data included the first author, publication year, number of patients, number of nonunions, Constant scores, disabilities of the arm, shoulder, and hand (DASH) scores, number of subsequent surgeries, and pain measured using the visual analog scale. DATA SYNTHESIS: The risk ratio of nonunion was 0.15 [95% confidence interval (CI), 0.08-0.31] in ORIF compared with that of nonsurgical treatment. Constant and DASH scores were significantly better in ORIF up to 6 months. The mean difference (MD) in DASH scores at 12 months was statistically insignificant in both treatments (MD, -4.19; 95% CI, -9.34 to 0.96). Constant scores remained significant in ORIF (MD, 4.39; 95% CI, 1.03-7.75). Subsequent surgeries and pain scores were similar in both treatments. CONCLUSIONS: Significant reduction in nonunions and favorable early functional outcomes are associated with ORIF. Nevertheless, late functional outcomes, subsequent surgeries, and pain scores are similar to those of nonsurgical treatment. Although patients treated with ORIF mainly had subsequent elective plate removals, nonsurgically treated patients had more surgical fixations for nonunions. As a result, there remains inconsistent evidence regarding the best treatment for displaced midshaft clavicle fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.