The safety and efficacy of hybrid surgery for multilevel cervical degenerative disc disease versus anterior cervical discectomy and fusion or cervical disc arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Multilevel cervical degenerative disc disease (CDDD) can be treated surgically with anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (CDA), or a hybrid surgery (HS) of the two in which both procedures are used at different vertebral levels. A systematic review and meta-analysis was performed to compare the clinical and radiographical outcomes of HS against ACDF or CDA alone. METHODS: Three electronic databases were searched for articles published before December 2018. The literature was searched and assessed by independent reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. RESULTS: Eight papers were identified as eligible with a total of 424 patients. Post-operative C2-C7 range of motion (ROM) was significantly greater after HS than ACDF (p = 0.004; mean difference (MD) 6.14°). The ROM of the superior adjacent segment was significantly lower after HS than ACDF (p < 0.0001; MD - 2.87°) as was the ROM of the inferior adjacent segment (p = 0.0005; MD - 3.11°). HS patients' return to work was shorter than those who underwent ACDF (p < 0.00001; MD - 32.01 days) and CDA (p < 0.00001; MD - 32.92 days). There were no statistically significant differences in functional outcomes following CDA compared with HS. There was no significant difference in operation time, intra-operative blood loss, or post-operative complications between any of the procedures. CONCLUSION: The number of included studies was small, the heterogeneity between them was substantial, and the quality of evidence was very low. Large randomised controlled trials are required to provide strong evidence that would enable recommendation of one intervention over another.

Selective fixation of the medial malleolus in unstable ankle fractures.

BACKGROUND: Whilst the lateral malleolus appears to be crucial in controlling anatomical reduction of the talus, the role of the medial malleolus is less clear. Medial sided complications including infection, damage to local structures and symptomatic hardware are not without morbidity. This study compares the outcomes of patients with bimalleolar or trimalleolar ankle fractures who underwent fibular nail stabilisation with or without medial malleolar fixation. METHODS: From a prospective single-centre trauma database, we identified 342 patients over a nine-year period who underwent fibular nail insertion to stabilise a bimalleolar or trimalleolar ankle fracture. Isolated lateral malleolar fractures were excluded. Demographic data, clinical outcomes, radiographic evaluation, return to work and sport, and patient reported outcomes, including Olerud-Molander Ankle Score (OMAS), EuroQol-5D (EQ-5D) and Manchester-Oxford Foot Questionnaire (MOXFQ) were collected. RESULTS: This study included 247 patients with a mean age of 66.7 years (range, 25-96 years), of whom 200 were female (81%). Medial malleolar fixation was not performed in 54 cases (22%). There was no significant difference between groups with respect to failure of fixation (p = 0.634) or loss of talar reduction (p = 0.157). No patient required surgery for a symptomatic medial malleolar non-union. Medial sided complications occurred in 32 (16%) of the fixation group, of whom 20 (10%) required further surgery. At a mean mid-term follow-up of 4.8 years (range, 8 months - 9 years) there was no significant difference between the non-fixation and fixation groups with respect to the median OMAS (85 vs 80; p = 0.885) or median EQ-5D (0.80 vs 0.81; p = 0.846). Patient satisfaction was not significantly different between the two groups (85/100 vs 87/100; p = 0.410). CONCLUSION: Non-operative management of the medial malleolar component of an unstable ankle fracture treated with a fibular nail may reduce the rate of post-operative complications without compromising the patient reported outcome.

Acquisition versus consolidation of auditory perceptual learning using mixed-training regimens.

Learning is considered to consist of two distinct phases-acquisition and consolidation. Acquisition can be disrupted when short periods of training on more than one task are interleaved, whereas consolidation can be disrupted when a second task is trained after the first has been initiated. Here we investigated the conditions governing the disruption to acquisition and consolidation during mixed-training regimens in which primary and secondary amplitude modulation tasks were either interleaved or presented consecutively. The secondary task differed from the primary task in either task-irrelevant (carrier frequency) or task-relevant (modulation rate) stimulus features while requiring the same perceptual judgment (amplitude modulation depth discrimination), or shared both irrelevant and relevant features but required a different judgment (amplitude modulation rate discrimination). Based on previous literature we predicted that acquisition would be disrupted by varying the task-relevant stimulus feature during training (stimulus interference), and that consolidation would be disrupted by varying the perceptual judgment required (task interference). We found that varying the task-relevant or -irrelevant stimulus features failed to disrupt acquisition but did disrupt consolidation, whereas mixing two tasks requiring a different perceptual judgment but sharing the same stimulus features disrupted both acquisition and consolidation. Thus, a distinction between acquisition and consolidation phases of perceptual learning cannot simply be attributed to (task-relevant) stimulus versus task interference. We propose instead that disruption occurs during acquisition when mixing two tasks requiring a perceptual judgment based on different cues, whereas consolidation is always disrupted regardless of whether different stimulus features or tasks are mixed. The current study not only provides a novel insight into the underlying mechanisms of perceptual learning, but also has practical implications for the optimal design and delivery of training programs that aim to remediate perceptual difficulties.