Intra-articular corticosteroid injections provide a clinically relevant benefit compared to placebo only at short-term follow-up in patients with knee osteoarthritis: A systematic review and meta-analysis.

PURPOSE: To quantify the clinical relevance of intra-articular corticosteroid effects compared to placebo for the injective treatment of knee osteoarthritis (OA). METHODS: The PubMed, Cochrane Library and Web of Science databases were searched on May 3, 2023. This study was conducted in accordance with the PRISMA guidelines. The inclusion criteria were randomized controlled trials (RCTs), published in English, with no time limitation regarding publication date, comparing intra-articular corticosteroids and placebo injections for knee OA. The effects were quantified at short- (≤6 weeks), mid- (>6 weeks and ≤3 months), and long-term (≥6 months) follow-ups. The minimal clinically important difference (MCID) for the outcomes (visual analogue scale for pain - VAS: 1.4, Western Ontario and McMaster University Osteoarthritis Index - WOMAC: 9) was used to interpret the clinical improvement provided by intra-articular corticosteroid injections compared to placebo. The quality of each article was assessed using the Cochrane RoB 2 tool and the GRADE guidelines. RESULTS: Among the 1030 articles retrieved, 11 RCTs (842 patients) were included. A comparison of the two groups revealed statistically significant differences in the improvement of VAS and WOMAC scores in terms of the mean difference (MD); this difference was in favour of corticosteroids at short-term (p < 0.001, MD = -1.6 and p < 0.001, MD = -9.9, respectively) and mid-term follow-ups (p = 0.001, mean MD = -1.3 and p = 0.005, MD = -4.9, respectively). No difference was observed at the long-term follow-up. The MDs between the improvements in the two groups reached the MCID values for the VAS and WOMAC only at the short-term follow-up. The RoB 2 tool and the GRADE evaluations showed the presence of risk of bias and limited quality of evidence. CONCLUSION: This systematic review and meta-analysis demonstrated that intra-articular corticosteroid injections offer clinically perceivable pain relief and functional improvement higher than the placebo effect only at short-term follow-up in patients affected by knee OA, with benefits losing clinical relevance already after 6 weeks. These results, together with the low number and the limited quality of the RCTs comparing this treatment with placebo, question the indication for the use of corticosteroid injections in clinical practice for the treatment of knee OA. LEVEL OF EVIDENCE: Level I.

No differences in clinical outcome between CMI and Actifit meniscal scaffolds: a systematic review and meta-analysis.

PURPOSE: To compare the results of two meniscal scaffolds, CMI and Actifit, for the treatment of partial meniscal lesions. METHODS: A systematic review was performed on the PubMed, Web of Science, Scopus, Embase, and Cochrane databases in January 2021, including randomized controlled trails (RCTs) and prospective and retrospective observational studies on the clinical results of meniscal scaffolds. A meta-analysis of the clinical results was performed; the rate of failures was recorded, as well as radiological results. The quality of the included studies was assessed with a modified Coleman Methodology Score (CMS). RESULTS: The search identified 37 studies (31 in the last 10 years): 2 RCTs, 5 comparative studies, 26 prospective and 4 retrospective series on a total of 1276 patients (472 CMI, 804 Actifit). The quality of evidence was generally low. An overall significant improvement in all clinical scores was documented for both scaffolds. The meta-analysis showed no differences between the two scaffolds in terms of patient reported outcome measures and activity level. The meta-analysis on the risk of failures documented a risk of failures of 7% in the CMI and of 9% in the Actifit group. CONCLUSIONS: There is a growing interest on the results of meniscal scaffolds, with most studies published recently. However, long-term data on the Actifit scaffold and high-level comparative studies are missing. Both CMI and Actifit offered good clinical results with a significant and comparable improvement in symptoms and function, and with a low number of failures over time. Accordingly, with the proper indication, their use may be encouraged in the clinical practice. LEVEL OF EVIDENCE: Level IV.

Peri-operative steroids reduce pain, inflammatory response and hospitalisation length following knee arthroplasty without increased risk of acute complications: a meta-analysis.

PURPOSE: There is no consensus regarding the risks and benefits of peri-operative steroid supplementation in total knee arthroplasty (TKA). The aim of this meta-analysis is to compare TKA protocols implemented with or without steroids in terms of pain, inflammatory response, hospitalisation length, and complications. METHODS: A systematic literature search was performed on July 2019 in PubMed, Medline, Embase, Web of Science, Cochrane library, and the grey literature for a meta-analysis of RCTs comparing peri-operative analgesia protocols implemented with or without steroids. Sub-analyses considering the administration route, steroid type, and dosage were performed. The inverse variance method and the Mantel-Haenszel test were used for pooling continuous variables and for dichotomous variables, respectively. Risk of bias and quality of evidence were defined according to the Cochrane guidelines. RESULTS: Twenty articles were included. Steroid supplementation provides significantly lower post-operative pain from day 1 to day 4 (p < 0.05), with less opioid consumption (p = 0.05), less nausea and vomiting (p < 0.05), and greater knee range of motion (p < 0.001), thus resulting in a shorter hospitalisation length (p = 0.01). Moreover, lower C-reactive protein (p < 0.05), and IL-6 (p < 0.05) levels, but a higher blood glucose level at day 1 (p = 0.004), were documented. No significant differences were documented in all the outcomes after 4 days of follow-up. These results were achieved without an increased incidence of complications. According to the results of the sub-analyses, the intravenous administration of 200 steroid equivalents of a long-acting steroid was associated with better results. CONCLUSION: Steroid supplementation of peri-operative drug protocols is effective in decreasing post-operative pain, opioid consumption, nausea and vomiting, range of motion limitation, and inflammatory markers without increasing short- and mid-term complications. Although these benefits last only the peri-operative period, steroid supplementation can reduce the length of hospitalisation after TKA. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level II.

Comparison of the survivorship between arthroplasty and ORIF for basi-cervical femoral neck fractures in the overall population and in polymorbid patients.

BACKGROUND: Femoral neck fractures (FNFs) are associated with high mortality and can be treated with arthroplasty or open reduction and internal fixation (ORIF). For basi-cervical FNFs, there is no agreement on which procedure is better. Do arthroplasty and open reduction with internal fixation (ORIF) have different rates of survival? Do age and comorbidities influence survivorship? HYPOTHESIS: Patients who underwent arthroplasty and patients who underwent ORIF have different rates of survival. PATIENTS AND METHODS: Survivorship curves, complications, and hospitalisation length were analysed in 154 patients who received hip arthroplasty, and in 72 patients who received ORIF. Age and ASA score were used to divide the patients into sub-groups and perform secondary analyses. RESULTS: At 4.9±2.4 years after surgery, 74 patients in the arthroplasty group (48%) and 33 in the ORIF group (45%) had died. The survivorship curves of the two groups showed a non-significant difference. The hospitalisation length was 13.5±8.9 days, with a non-significant difference between groups. There were 130 complications in total: 97 in the arthroplasty patients (19 patients had multiple complications, 52 had only one), 33 in the ORIF patients (4 patients had multiple complications, 29 had only one); the odds ratio was therefore 2.1 (p=0.02). Age, ASA score, Sernbo score, Charlson comorbidity index, and sex (male) were the best predictors of mortality. In the ASA 3-4 sub-group, the survivorship curves showed a lower mortality in the arthroplasty group (p=0.02). DISCUSSION: Arthroplasty and ORIF are both valid procedures for the treatment of basi-cervical FNFs, but a high mortality rate is associated with either procedures. There is no difference in terms of survivorship between arthroplasty and ORIF in the overall population, but the presence of comorbidities may favour arthroplasty, which should be considered when managing patients with basi-cervical FNFs. LEVEL OF EVIDENCE: III; retrospective, observational study.

Outpatient total knee arthroplasty leads to a higher number of complications: a meta-analysis.

BACKGROUND: Careful pre- and post-operative management can allow surgeons to perform outpatient TKA, making this a more affordable procedure. The aim of the present meta-analysis is to compare outpatient and inpatient TKA. METHODS: A systematic search of the literature was performed in July 2020 on PubMed, Web of Science, Cochrane library, and on the grey literature databases. The papers collected were used for a meta-analysis comparing outpatient and inpatient TKA in terms of complication and readmission rates. Risk of bias and quality of evidence were defined according to Cochrane guidelines. RESULTS: The literature search resulted in 4107 articles; of these, 8 articles were used for the meta-analysis. A total of 212,632 patients were included, 6607 of whom were TKA outpatients. The overall complication rate for outpatient TKAs was 16.1%, while inpatient TKAs had an overall lower complication rate of 10.5% (p = 0.003). The readmission rate was 4.9% in outpatient TKAs and 5.9% in inpatient TKAs. Only 3 studies reported the number of deaths, which accounted for 0%. The included studies presented a moderate risk of bias, and according to GRADE guidelines, the level of evidence for complications and readmissions was very low. CONCLUSIONS: This meta-analysis documented that outpatient TKA led to an increased number of complications although there were no differences in the number of readmissions. However, future high-level studies are needed to confirm results and indications for the outpatient approach, since the studies currently available have a moderate risk of bias and a very low quality of evidence.

Pain Trajectories in Knee Osteoarthritis-A Systematic Review and Best Evidence Synthesis on Pain Predictors.

Different profiles of pain progression have been reported in patients with knee osteoarthritis (OA), but the determinants of this heterogeneity are still to be sought. The aim of this systematic review was to analyze all studies providing information about knee OA pain trajectories to delineate, according to patients' characteristics, an evidence-based evolution pattern of this disabling disease, which is key for a more personalized and effective management of knee OA. A literature search was performed on PubMed, Web of Science, Cochrane Library, and grey literature databases. The Cochrane Collaboration's tool for assessing risk of bias was used, and a best-evidence synthesis was performed to define the predictors of pain evolution. Seven articles on 7747 patients affected by knee OA (mainly early/moderate) were included. Daily knee OA pain trajectories were unstable in almost half of the patients. In the mid-term, knee OA had a steady pain trajectory in 85% of the patients, 8% experienced pain reduction, while 7% experienced pain worsening. Low education, comorbidities, and depression were patient-related predictors of severe/worsening knee OA pain. Conversely, age, alcohol, smoking, pain coping strategies, and medications were unrelated to pain evolution. Conflicting/no evidence was found for all joint-related factors, such as baseline radiographic severity.

Arthroscopically assisted and three-dimensionally modeled minimally invasive rim plate osteosynthesis via modified anterolateral approach for posterolateral tibial plateau fractures.

AIM: The aim of this study was to describe a new, closed, arthroscopically-assisted reduction of posterolateral tibial plateau fractures with minimally invasive plate osteosynthesis using a plate pre-contoured over a 3D-model based on a CT-scan of the injured tibial plateau and positioned by using a minimal anterolateral approach. METHODS: A five to six centimeter long curvilinear incision was made over the Gerdy's tubercle. After subcutaneous dissection, the fascia was incised, the ileo-tibial band was split, and the dissection was extended posteriorly. The knee was flexed to 90° and the space between the fibular collateral ligament and the posterolateral plateau rim (para-FCL space) was created. A variable-angle locking compression plate contoured on a 3D-model was inserted flush to the tibial plateau rim. Two cortical screws were placed to ensure support under the area of depression as far posteriorly as possible. Two additional screws were implanted, and a cortical screw was used for the most anterior screw hole. The custom pre-contoured plate based on a person-specific 3D-model, associated with arthroscopy reduction, provides a supporting and containing effect to the posterolateral periarticular fragments and allows a minimally invasive plate osteosynthesis fixation to be performed. This guarantees a proper reduction and fixation without the described limitations and risks associated with the classic approaches. CONCLUSIONS: This approach should be considered to treat fractures of the posterolateral plateau, isolated or associated with medial tibial plateau fractures, as it could improve the outcome in terms of lower associated risks, better reduction and fixation, and faster and improved patient recovery.

Recurrent Patellar Dislocations Without Untreated Predisposing Factors: Medial Patellofemoral Ligament Reconstruction Versus Other Medial Soft-Tissue Surgical Techniques-A Meta-analysis.

PURPOSE: To provide a direct comparison between medial patellofemoral ligament (MPFL) reconstruction and the other medial patellofemoral soft-tissue surgeries in the restoration of the medial patellar restraint after lateral patellar dislocations in the absence of untreated predisposing factors such as high grade trochlear dysplasia, knee malalignment, patella alta or high tibial tubercle-trochlear groove distance. METHODS: PubMed, Cochrane-library, Web of Science, and gray literature databases were searched to find all the relevant records. Study selection, data extraction, and risk of bias assessment were performed following the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Different techniques to treat lateral patellar dislocation in the absence of untreated predisposing factors were compared in terms of redislocation and complication rates, Kujala, Lysholm, International Knee Documentation Committee, and Tegner scores at the short-term (3 years) and long-term (>3 years) follow-up through meta-analyses. RESULTS: Six studies involving 319 knees were included in the meta-analysis. The analyses of redislocation (0.7% vs 2.9%) and minor complication rates (12% vs 9%) showed no significant differences between MPFL reconstruction and other medial soft-tissue surgeries. Significant differences favoring MPFL reconstruction were documented in Kujala and Lysholm scores at short-term (8.6, P< .001; 10.9, P < .001) and long-term follow-ups (6.3, P = .02; 13.5, P < .001). No significant differences were found in the analyses of International Knee Documentation Committee (P = .10) and Tegner scores (P = .19). Level of evidence was low or very low. CONCLUSIONS: MPFL reconstruction and medial patellofemoral soft-tissue surgery procedures were both effective in restoring the medial restraining forces preventing redislocation, but MPFL reconstruction provided better functional outcomes both at short-term and long-term follow-up. Thus, besides the treatment of predisposing factors, MPFL reconstruction seems to be, based on the results of this meta-analysis, a suitable strategy to restore the medial restraining function in the treatment of recurrent LPD. LEVEL OF EVIDENCE: Level III (meta-analysis of randomized and nonrandomized comparative trials).

Anterior Cruciate Ligament Reconstruction Within 3 Weeks Does Not Increase Stiffness and Complications Compared With Delayed Reconstruction: A Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Injury-to-surgery time has been identified as a key point in anterior cruciate ligament (ACL) reconstruction, with early versus delayed treatment remaining a debated and controversial topic in the management of ACL tears. PURPOSE/HYPOTHESIS: The aim was to quantitatively synthesize the best literature evidence by including only randomized controlled trials (RCTs) comparing early versus delayed ACL reconstruction, with a clear and univocal definition of cutoffs of early or delayed surgery. The hypothesis was that early treatment would lead to similar final clinical results compared with the delayed approach while providing a faster recovery without an increase in complications after ACL reconstruction. STUDY DESIGN: Meta-analysis. METHODS: A systematic literature search was performed on February 12, 2019, using PubMed, Web of Science, Cochrane Library, and gray literature databases. According to previous literature, 2 analyses with different cutoffs for injury-to-surgery time (3 weeks and 10 weeks) were performed to distinguish early and delayed reconstruction. The influence of timing was analyzed through meta-analyses in terms of patient-reported outcome measures (PROMs), risk of complications, range of motion (ROM) limitation, risk of retears, and residual laxity. Risk of bias and quality of evidence were assessed following the Cochrane guidelines. RESULTS: Eight studies (5 in 3-week cutoff analysis and 3 in 10-week cutoff analysis) were included. No differences were found in terms of PROMs, risk of complications, ROM limitation, risk of retears, and residual laxity either in the 3-week cutoff analysis or in the 10-week cutoff analysis (P > .05). The level of evidence was moderate to low for the outcomes of the 3-week cutoff analysis and low to very low for the outcomes of the 10-week cutoff analysis. CONCLUSION: This meta-analysis did not confirm the previously advocated benefits of delaying ACL surgery to avoid the acute posttraumatic phase. In fact, RCTs demonstrated that timing of surgery after ACL tears has no influence on the final functional outcome, risk of retears, or residual instability. While no data were available about the recovery time, literature results showed that early ACL reconstruction could be performed without increasing the risk of complications. STUDY REGISTRATION: CRD42019119319 (PROSPERO).

Bone Bruise and Anterior Cruciate Ligament Tears: Presence, Distribution Pattern, and Associated Lesions in the Pediatric Population.

BACKGROUND: Bone bruise characteristics after anterior cruciate ligament (ACL) injury have been correlated with the level of joint derangement in adults. However, the literature lacks information about younger patients, whose higher ligamentous laxity may lead to different lesion patterns. PURPOSE: To investigate the prevalence, size, location, and role of bone bruise associated with ACL rupture in the pediatric population. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Knee magnetic resonance imaging scans (MRIs) of patients aged 8 to 16 years with ACL tears from 2010 to 2018 were selected from the institution database. Inclusion criteria were open or partially open physes, less than 90 days between trauma and MRI, and no history of injury or surgery. Presence, localization, and size of bone bruise were analyzed by 2 blinded researchers and scored with the Whole-Organ Magnetic Resonance Imaging Score (WORMS) bone bruise subscale. Ligamentous, cartilaginous, meniscal, and other lesions were documented. RESULTS: Of the 78 pediatric patients selected from the database, 54 (69%) had bone bruise. The mean area of bone bruise was larger in males than in females (femur, 3.8 ± 2.8 vs 2.2 ± 1.4 cm2, respectively, P = .006; tibia, 2.6 ± 1.6 vs 1.5 ± 0.8 cm2, respectively, P = .007). The subregions most affected by bone bruise were the lateral posterior tibia and the lateral central femur (in 83% and 80% of the knees affected, respectively). A low correlation was found between age and bone bruise area (biggest areas r = 0.30, P = .03, and sum of areas r = 0.27, P = .04), but no correlation was found between age and WORMS (femur, r = -0.03, P = .85; tibia, r = -0.04, P = .76). The injuries most associated with bone bruise were 23 meniscal lesions (43%), 10 lesions of other ligaments (19.0%), 2 cartilage lesions (3.7%), and 2 patellar fractures (3.7%). CONCLUSION: The prevalence of bone bruises in pediatric patients with ACL tears is high, although it seems slightly lower than the prevalence documented in adults but with similar localization. The area and the distribution pattern of bone bruises are similar among different ages. The pediatric patients had a lower presence of cartilage and meniscal lesions compared with that reported in adults, which suggests a different effect of this trauma on the knee of pediatric patients.

A Meta-analysis of Surgical Versus Nonsurgical Treatment of Primary Patella Dislocation.

PURPOSE: To compare outcomes after surgery versus nonsurgical treatment in the management of primary lateral patellar dislocation (LPD) through a meta-analysis of randomized controlled trials (RCTs) in terms of redislocation rate and clinical outcome, investigating both short-term (<6 years) functional recovery and overall benefit over time (>6 years). METHODS: A systematic search of the literature was performed in November 2018. Risk of bias and quality of evidence were evaluated according to the Cochrane guidelines. RCTs investigating differences between surgery and nonsurgical treatment in primary LPD were included. The outcomes evaluated were redislocation rate, reinterventions, and Kujala score at short-, mid-, and long-term follow-up, with subanalyses for the pediatric population. RESULTS: We included 510 patients from 10 RCTs in the meta-analysis. Redislocation rate was 0.40 (0.25 to 0.66; P < .001) and 0.58 (0.29 to 1.15; P = .12) at the short- and mid-term follow-ups, respectively, and the risk ratio for the need for further operations at 6 to 9 months' follow-up was 0.14 (0.02 to 1.03; P = .05), all favoring surgery. Concerning the Kujala score, an advantage of the surgical approach of 10.2 points (1.6 to 18.7; P = .02) at short-term follow-up was seen, whereas long-term follow-up results were similar between the groups. The subanalysis of the pediatric population at heterogeneous follow-up confirmed a lower risk of recurrence in surgery, with a risk ratio of 0.60 (0.26 to 1.37; P = .22), although not significant. CONCLUSION: The literature documents a low number of high-level trials. The meta-analysis of RCTs underlined that the redislocation rate is higher with the nonsurgical approach compared with the surgical one. Moreover, when looking at the clinical outcome, more favorable findings were found with the surgical approach up to 6 years, whereas results seems to be similar at a longer follow-up after either surgical or nonsurgical treatment of primary LPD. LEVEL OF EVIDENCE: II, meta-analysis of level I and level II randomized clinical trials.

Recurrent patellar dislocations: trochleoplasty improves the results of medial patellofemoral ligament surgery only in severe trochlear dysplasia.

PURPOSE: Medial patellofemoral ligament (MPFL) surgery combined with trochleoplasty (TP), is often performed to restore the normal patellofemoral biomechanics avoiding recurrent lateral patellar dislocation (LPD) in patients with trochlear dysplasia (TD). However, it is still unclear whether combining TP and MPFL surgery would be more beneficial than performing MPFL surgery on its own. This meta-analysis quantitatively synthesizes and compares published data on the outcomes of recurrent LPD treatment using MPFL surgery without or with TP in patients affected by TD. METHODS: A systematic literature search about the treatment of recurrent LPD in the presence of TD was conducted. The primary outcome was redislocation rate, analyzed for different types of TD. Kujala, and IKDC scores, as well as complication rate, were also analyzed through a separate meta-analysis. RESULTS: No statistically significant difference was found in the overall redislocation rate of MPFL surgery without and with TP. There was, however, a statistically significant difference (p < 0.001) in redislocation rate after MPFL surgery without TP between patients with type A or B TD (2.7%) and in patients with type C or D TD (18.6%). In the analysis for every single type of TD, the following results were obtained: redislocation rate of 1.8% in type A, 3.2% in type B, 11.9% in type C, and 7.4% in type D. A statistically significant difference in the complication rate, favouring MPFL surgery without TP, was documented. Both surgical approaches provided a significant improvement with no difference in Kujala and IKDC scores. These results were confirmed when data were analyzed including only patients with type B, C, or D TD, or without additional bone remodelling procedures. CONCLUSION: Isolated MPFL is as effective as combined TP and MPFL surgery in preventing redislocation and improving clinical and functional outcomes in patients with recurrent LPD and knees affected by moderate TD. However, in case of severe TD, the redislocation rate is lower when TP is performed in combination with MPFL surgery, although with comparable clinical outcomes and a higher risk of post-operative range of motion (ROM) limitation. LEVEL OF EVIDENCE: Systematic review and meta-analysis, Level IV.

Midshaft Clavicle Fractures: Surgery Provides Better Results as Compared With Nonoperative Treatment: A Meta-analysis.

BACKGROUND: There is no agreement on the best treatment for displaced midshaft clavicle fractures (MCFs), which are currently addressed by nonoperative or surgical approaches. PURPOSE: To compare fracture healing and functional outcome after surgical versus nonsurgical treatment of MCFs, to help specialists in deciding between these different strategies by providing a synthesis of the best literature evidence. STUDY DESIGN: Meta-analysis. METHODS: A systematic research of the literature was performed in different online databases: PubMed, Web of Science, Cochrane library, and grey literature. PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were used. The risk of bias was evaluated with the Cochrane Collaboration's "risk of bias" tool, and the quality of evidence was graded according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Randomized controlled trials investigating differences between surgery and nonoperative treatment for displaced MCFs were included. The primary outcome was the nonunion rate. Other outcomes analyzed were time to union and to return to activities, Constant score, and Disabilities of the Arm, Shoulder and Hand (DASH) index. Patients' satisfaction, secondary operations, and complications were also recorded. RESULTS: Out of 832 records found, 14 randomized controlled trials with 1546 patients were included. A significantly lower risk ratio was found for nonunion (10%; 95% CI, 6%-18%, P < .001) favoring surgery. Time to union was 5.1 weeks shorter with surgery (P = .007). The complication rate (including the number of reinterventions) was higher in the surgical group (31.3% vs 20.5%, P < .001). Shoulder function at short-term follow-up was significantly better in the surgical group (DASH index mean difference = 4.0 points), while no statistical difference was found in the Constant score and in the DASH index at midterm follow-up (P = .41 and .80, respectively). At long-term follow-up, both shoulder functional scores were significantly better in the surgery group: the overall Constant score mean difference was 5.3 points (95% CI, 2.3-8.4 points; P < .001), and the DASH index mean difference was 4.3 points (95% CI, 0.2-8.4 points; P = .04). CONCLUSION: Surgical treatment of MCFs significantly reduces the nonunion rate and shortens the time to union as compared with the nonoperative approach and, despite a slightly higher incidence of complications, leads to better shoulder functional scores at short- and long-term follow-up. Further studies should address the clinical significance of the documented improvement.