Bone-patellar tendon-bone versus two- and four-strand hamstring tendon autografts for ACL reconstruction in young adults: a Bayesian network meta-analysis.

Bone-patellar tendon-bone (BPTB), two- and four-strand hamstring tendon (4SHT and 2SHT, respectively) are the most common autografts used for anterior cruciate ligament (ACL) reconstruction. The present study compared BPTB, 2SHT, and 4SHT for ACL reconstruction in terms of joint laxity, patient reported outcome measures (PROMs), rate of failure and anterior knee pain (AKP). The time to return to sport and the peak torque between the autografts were also compared. Finally, prognostic factors leading to worse outcomes were also investigated. It was hypothesized that all grafts yield similar proprieties in terms of joint laxity, patient reported outcome measures (PROMs) and rate of failure, but that the BPTB autograft causes a greater rate of anterior knee pain (AKP). The literature search was conducted. All clinical trials comparing BTPB and/or 2SHT, and/or 4SHT were accessed. Grafts other than BTPB and/or 4SHT and/or 2SHT were not considered. Articles reporting outcomes of allografts or synthetic grafts were not eligible, nor were those concerning revision settings. Articles reporting ACL reconstruction in patients with multi-ligament damage were also not eligible. Data from 95,575 procedures were retrieved. The median length of follow-up was 36 months. The median age of the patients was 27.5 years. With regard to joint laxity, similarity was found in terms of Lachman and Pivot shift tests between all three autografts. The BPTB demonstrated the greatest stability in terms of instrumental laxity. BPTB demonstrated the greatest PROMs. BPTB demonstrated the greatest rate of AKP, while AKP in 2SHT and 4SHT was similar. Concerning failure, statistically significant inconsistency was found (P = 0.008). The 4SHT demonstrated the quickest return to sport, followed by BPTB, and 2SHT. There was evidence of a negative association between the time span between injury to surgery, Lysholm score (P = 0.04), and Tegner scale (P = 0.04). Furthermore, there was evidence of a weak positive association between the time span between injury to surgery and return to sport (P = 0.01). BPTB may result in lower joint laxity, greater PROMs, and greater peak flexion torque compared to 2SHT and 4SHT autografts. On the other hand, BPTB reported the lowest peak extension torque and the greatest rate of AKP. Finally, a longer time span between injury and surgery negatively influences outcome.

Comparable outcome for autografts and allografts in primary medial patellofemoral ligament reconstruction for patellofemoral instability: systematic review and meta-analysis.

PURPOSE: This study updates the current evidence on the role of allografts versus autografts for medial patellofemoral ligament (MPFL) reconstruction in patients with patellofemoral instability. METHODS: The study was performed according to the PRISMA guidelines. In March 2021, a literature search in the main online databases was performed. Studies reporting quantitative data concerning primary MPFL reconstruction using an allograft were considered for inclusion. The Coleman Methodology Score was used to assess the methodological quality of the selected articles. RESULTS: Data from 12 studies (474 procedures) were retrieved. The mean follow-up was 42.2 (15-78.5) months. The mean age was 21.1 ± 6.2 years. 64.9% (285 of 439) of patients were female. At the last follow-up, the Tegner (p < 0.0001), Kujala (p = 0.002) and the Lysholm (p < 0.0001) scores were minimally greater in the autografts. The similarity was found in the rate of persistent instability sensation and revision. The allograft group evidenced a lower rate of re-dislocations (p = 0.003). CONCLUSION: Allografts may represent a feasible alternative to traditional autograft for MPFL reconstruction in selected patients with patellofemoral instability. Allograft tendons yielded similar PROMs, rates of persistent instability, and revision. Allograft reconstructions tended to have modestly lower re-dislocation rates. LEVEL OF EVIDENCE: IV.

Better pain control with 8-gray single fraction palliative radiotherapy for skeletal metastases: a Bayesian network meta-analysis.

External Beam Radiotherapy (EBRT) allows remarkable pain control in patients with skeletal metastases. We performed a Bayesian network meta-analysis comparing the most commonly used radiotherapy regimens for palliative management in patients with skeletal metastases. The main online databases were accessed in October 2020. All randomized clinical trials evaluating the irradiation of painful bone metastases were considered. The following irradiation patterns were analysed and included in the present network meta-analysis: 8 Gy- and 10 Gy/single fraction, 20 Gy/5 fractions, 30 Gy/10 fractions. The Bayesian hierarchical random-effect model analysis was adopted in all comparisons. The Log Odds-Ratio (LOR) statistical method for dichotomic data was adopted for analysis. Data from 3595 patients were analysed. The mean follow-up was 9.5 (1 to 28) months. The cumulative mean age was 63.3 ± 2.9. 40.61% (1461 of 3595 patients) were female. The 8Gy/single fraction protocol detected reduced rate of "no pain response" (LOR 3.39), greater rate of "pain response" (LOR-5.88) and complete pain remission (LOR-7.05) compared to the other dose patterns. The 8Gy group detected a lower rate of pathological fractures (LOR 1.16), spinal cord compression (LOR 1.31) and re-irradiation (LOR 2.97) compared to the other dose patterns. Palliative 8Gy/single fraction radiotherapy for skeletal metastases shows outstanding results in terms of pain control, re-irradiations, pathological fractures and spinal cord compression, with no differences in terms of survivorship compared to the other multiple dose patterns.Level of evidence: I, Bayesian network meta-analysis of RCTs.

Pedicled Strip of Quadriceps Tendon Graft for Primary Medial Patellofemoral Ligament Reconstruction in Recurrent Patellofemoral Instability: A Systematic Review.

PURPOSE: A systematic review of the literature was conducted to ascertain advantages and limitations, update current evidences, and investigate the role of a pedicled quadriceps tendon autograft for primary medio-patellofemoral ligament (MPFL) reconstruction in patients with recurrent patellofemoral instability. METHODS: The present systematic review was performed according to the PRISMA guidelines. The literature search was conducted in September 2020. All the clinical studies investigating the role of a pedicled strip of quadriceps tendon autograft for primary MPFL reconstruction in patients with recurrent patellofemoral instability were considered for inclusion. Studies investigating the role of MPFL reconstruction combined with additional surgical procedures except for lateral retinacular release were excluded. The methodological quality assessment was performed through the modified Coleman Methodology score. RESULTS: Data from 9 articles (191 procedures) were retrieved. The mean follow-up was 12 to 38 months. The mean age of the patients was 11.5 to 25.2 years. One hundred twenty of 191 patients were female. All clinical scores showed significant improvement following the procedures. The Kujala score improved of 32.52% points (P < 0.0001), the Lysholm score of 23.74% (P = 0.006), the Tegner scale improved of 8.6% (P = 0.02). Concerning complications, after surgery the apprehension test was positive in 5 of 166 patients, and persistent joint instability was found in 5 of 149 patients. No patient experienced any re-dislocations or underwent reoperations. CONCLUSIONS: The use of pedicled strip of quadriceps tendon as graft for MPFL reconstruction is a suitable choice in patients with recurrent patellar instability. Although frequently associated with a lateral release, it is unclear whether the latter is necessary for the success of the technique. Appropriately powered randomized controlled trials comparing this graft source to the others commonly used are necessary to at least ascertain the noninferiority of this graft to the others. LEVEL OF EVIDENCE: IV, Systematic review of Level III-IV studies.

Impact of tourniquet during knee arthroplasty: a bayesian network meta-analysis of peri-operative outcomes.

INTRODUCTION: The role of tourniquet during knee arthroplasty is controversial. The present study compares various tourniquet protocols using a Bayesian network meta-analysis of peri-operative data. MATERIAL AND METHODS: The present study was conducted in accordance with the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health interventions. The literature search was conducted in September 2020. All clinical trials investigating the role of tourniquet in knee arthroplasty were considered for inclusion. Methodological quality was assessed using Review Manager 5.3. A Bayesian hierarchical random-effects model analysis was used in all comparisons. RESULTS: Ultimately, pooled data from 68 studies (7413 procedures) were analysed. Significant inconsistency was found in the data relating to total estimated blood lost; no assumption could be made on this outcome. Full-time tourniquet resulted in the shortest surgical duration and lowest intra-operative blood lost, in both cases followed by incision-to-suture. The incision-to-suture protocol achieved the smallest drop in haemoglobin during the first 72 h post-operatively and the lowest rate of blood transfusion, both followed by full-time tourniquet. Hospitalisation was shortest in the absence (no-tourniquet) group, followed by the cementation-to-end group. CONCLUSION: For knee arthroplasty, longer tourniquet use is associated with the shorter duration of surgery, lower intra-operative blood lost, lower drops in haemoglobin and fewer transfusion units. The shortest average hospitalisation was associated with no tourniquet use.

Medium-term results of arthroscopic treatment for femoroacetabular impingement.

INTRODUCTION: Femoroacetabular impingement (FAI) is a dynamic pathomechanical process of the femoral head-neck junction. Arthroscopic surgery for FAI has increased exponentially in the last decade, and this trend is expected to increase. SOURCE OF DATA: Recent published literatures. AREAS OF AGREEMENT: FAI promotes quick rehabilitation and low complication rates in the short-term follow-up. AREAS OF CONTROVERSY: Despite the growing interest on arthroscopic surgery for FAI, current evidence regarding the medium- and long-term role of arthroscopy are unsatisfactory. GROWING POINTS: Systematically summarize current evidences, analyse the quantitative available data and investigate the medium- and long-term outcomes of arthroscopic surgery for FAI. AREAS TIMELY FOR DEVELOPING RESEARCH: Arthroscopic surgery achieves very satisfactory outcomes for patients with FAI at a mean follow-up of 4 years.

The utility of echocardiography in paediatric patients with musculoskeletal infections and bacteremia.

PURPOSE: The clinical utility of echocardiography in the setting of a positive blood culture in paediatric patients presenting with osteomyelitis (OM) and/or septic arthritis (SA). METHODS: Retrospective review between 2013 and 2019: Patients < 18 years with OM, SA or combined infection (OM+SA) were included. Patients were excluded for immunodeficiency, loss of follow-up or penetrating infection. Charts with positive blood cultures were reviewed for echocardiography on that admission. Demographic variables were compared utilizing the Student's t-test and Fisher's exact test. A multivariable linear regression model was constructed to examine the association between echocardiography and length of stay, controlling for age, sex, fever, white blood cell (WBC) on admission, antibiotic administration and surgery performed. RESULTS: Of 157 patients with OM, SA or combined infection, 44 had a positive blood culture. In all, 26 had an echocardiogram, and none showed endocarditis. Echocardiography was independently associated with a 6.2-day length of stay increase. WBC count and surgical intervention demonstrated a trend toward significance in length of stay, with each WBC unit increase associated with a 0.53-day increase. Surgical intervention was associated with an average 6.3-day length of stay decrease. CONCLUSION: No patient had a positive echocardiogram, and no changes in management were initiated. However, an echocardiogram increased stay by 6.2 days. In addition to costs associated with increased stay, patients were billed between $1460 and $1700 per echocardiogram. The utility of echocardiograms in the setting of bacteremia associated with musculoskeletal infections in the paediatric population should be re-examined, and guidelines should be updated to reflect the cost-benefit analysis. LEVEL OF EVIDENCE: III.

Bone metastases: a comprehensive review of the literature.

The last report of the World Health Organization (WHO) stated that approximately four million people experience bone pain due to malignant diseases. Among them, metastatic bone pain is one of the most important sources of complaint. The estimated median survival in the presence of bone metastases ranks from 10 to 12 weeks. Bone represents a potential target of distant metastases for the majority of malignant tumours. However, the exact incidence of bone metastases is unknown. Bone metastases have an important socio-economic impact, and due to the enhancement of the overall survivorship, their incidence is increasing. Malignant neoplasms such as lung, thyroid, renal cancer, multiple myeloma, and melanoma often metastasize to the bone. Bone metastases commonly localize to the spinal column, pelvis, shoulder, and distal femur. The proper treatment for painful skeletal metastases is still unknown. Hence, the purpose of this review of the literature was to update current evidence concerning the aetiogenesis, biological behaviour, and treatment algorithms for painful skeletal metastases.

Implant positioning among the surgical approaches for total hip arthroplasty: a Bayesian network meta-analysis.

INTRODUCTION: Although there is anatomical individuality among patients, some standardized requirements for component orientation for total hip arthroplasty (THA) exist. To date, no study has compared implant positioning using a network meta-analysis (NMA). Hence, the purpose of this study was to perform a NMA comparing implant positioning among the various approaches for THA. METHODS: This study was conducted according to the PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions. All randomized (RCT) and non-randomized (nRCT) clinical trials comparing two or more different approaches for THA were considered for inclusion. For the statistical analysis, the STATA Software/ MP, Version 14.1 (Stata Corporation, College Station, Texas, USA) was used. The NMA was performed through a Stata routine for Bayesian hierarchical random-effects model analysis. RESULTS: We enrolled in the present study, a total of 4060 patients, with a mean of 17.84 ± 16.41 months follow-up. The patient baseline data were very homogeneous across the groups concerning age (P = 0.91), sex (P = 0.52), and BMI (P = 0.83). Concerning the cup anteversion, the anterolateral approach reported the value closest to the reference value. The test for overall inconsistency, however, was not statistically significant (P = 0.30). Concerning cup inclination, the lateral approach reported the value closest to the reference value. The test for overall inconsistency was statistically significant (P = 0.01). CONCLUSION: The anterolateral approach for total hip arthroplasty detected the best femoral stem alignment and cup anteversion. Data concerning cup inclination detected no sufficient transitivity to draw consistent conclusions.

Hemiarthroplasty versus total arthroplasty for displaced femoral neck fractures in the elderly: meta-analysis of randomized clinical trials.

INTRODUCTION: Displaced femoral neck fractures (FNF) are complicated by high mortality rates and continue to represent an important cause of disability, having a negative impact on patient mobility and physical independence. The purpose of this study was to update and analyse current outcomes and evidence concerning hip hemiarthroplasty (HHA) versus total hip arthroplasty (THA) for displaced femoral neck fractures in the elderly. Thus, a meta-analysis of randomized clinical trials was conducted. MATERIALS AND METHODS: This meta-analysis was conducted according to the PRISMA guidelines. In October 2019, the following databases were accessed: Embase, Google Scholar, Pubmed, Scopus. All randomized clinical trials (RCTs) comparing total hip arthroplasty versus hip hemiarthroplasty for displaced femoral neck fractures were included in the present study. For the statistical analysis and the methodological quality assessment, the Review Manager Software 5.3 (The Nordic Cochrane Collaboration, Copenhagen) and STATA/MP Software 14.1 (StataCorp, College Station, TX) were used. RESULTS: Data from 2325 (1171 HHA vs 1154 THA) patients were collected. The mean follow-up was 58.12 months. The HHA group reported lower values of the mean Harris hip score (EE 3.22; p = 0.2), surgical duration (EE 21.75; p < 0.0001), length of the hospitalization stay (EE 0.8; p = 0.4). The HHA group evidenced lower dislocations rate (OR 1.78; p = 0.01, Fig. 4), but higher rate of acetabular erosion (OR 0.08; p = 0.0006). At a mean of 58.12 ± 52.8 months follow-up, revisions rate scored reduced in the THA group (OR 0.76; p = 0.2). Subgroup analysis of RCTs < 5 years follow-up revealed reduced revision in favour of the HHA group (OR 2.19; p = 0.03), while subgroup analysis of RCTs > 5 years follow-up revealed reduced revision in favour of the THA group (OR 0.25; p = 0.0003). The Kaplan-Meier curve detected similarity of patients survivorship between the two groups (HR 1.06; p = 0.3). CONCLUSION: For the elderly population, both HHA and THA are valid solutions to treat displaced femoral neck fractures, with comparable survivorship. HHA detected reduced dislocations, while for THA a lower risk of acetabular erosion and further revision surgeries were reported. LEVEL OF EVIDENCE: Level I, meta-analysis of randomized clinical trials.

Single- versus double-bundle patellar graft insertion for isolated MPFL reconstruction in patients with patellofemoral instability: a systematic review of the literature.

INTRODUCTION: The MPFL reconstruction is performed either via a single-bundle (SB) or double-bundle (DB) procedure. The purpose of this study is to perform a systematic review comparing SB versus DB graft for recurrent patellofemoral instability, to summarize current evidence, and to clarify the role of both techniques. We focused on clinical scores, physical examination, complications, revision surgeries, and failures. MATERIAL AND METHODS: In May of 2019 the main online databases were accessed. All the clinical studies treating isolated MPFL reconstruction for patellofemoral instability through a single and/or double-bundle graft were enrolled in the present systematic review. Only articles reporting primary isolated MPFL reconstruction, reporting a minimum of 12-months follow-up were considered for inclusion. RESULTS: The scores of interest were in favour of the DB cohort: Kujala (+ 3.2, P = 0.03), Lysholm (+ 5.1, P = 0.001), Tegner (+ 0.3, P = 0.2), IKDC (+ 5.4, P = 0.01), VAS (+ 0.8, P = 0.3), ROM (+ 9.96, P = 0.04). In the DB graft, a reduction of overall complications (OR 0.59; P = 0.1), further surgeries (OR 0.64; P = 0.12) and re-dislocations (OR 0.61; P = 0.16) was observed. The SB group reported a reduction in the post-operative apprehension test (OR 2.42; P = 0.24). CONCLUSION: Current study support the use of double-bundle tendon graft for isolated MPFL reconstruction in selected patients with recurrent patellofemoral instability.

Graft choice for isolated MPFL reconstruction: gracilis versus semitendinosus.

INTRODUCTION: After the first patellar dislocation, most patients report damage of the medio-patellofemoral ligament (MPFL) and surgical reconstruction is required. The purpose of this study is to systematically review current evidence and to clarify the role of the gracilis and semitendinosus tendons as graft for isolated MPFL reconstruction. MATERIALS AND METHODS: The present systematic review was conducted according to the PRISMA guidelines. The literature search was conducted in October 2019. All clinical trials using the semitendinosus and/or gracilis tendon grafts for isolated MPFL reconstruction in patients with patellofemoral instability were considered for inclusion. Only articles reporting a minimum of 12-month follow-up were considered. The PEDro score was used for the methodological quality assessment. RESULTS: Data from 1491 procedures were collected. The mean follow-up was 36.12 months. There was comparability among the patient baseline. All the scores of interests (Kujala, Tegner, Lysholm) and range of motion scored better in the semitendinosus group. Moreover, in favour of the semitendinosus group, a statistically significant reduction of the revision surgeries and re-dislocations were evidenced. Apprehension test and persistent instability sensation found any statistical correlations. CONCLUSION: Isolated MPFL reconstruction through semitendinosus tendon graft performed better than the gracilis in selected patients suffering from recurrent patellofemoral instability.

Genetic variants in the TGFß-signaling pathway influence expression of miRNAs in colon and rectal normal mucosa and tumor tissue.

The TGF-ß signaling pathway is involved in regulation of cell growth, angiogenesis, and metastasis. We test the hypothesis that genetic variation in the TGF-ß signaling pathway alters miRNA expression.We use data from 1188 colorectal cancer cases to evaluate associations between 80 SNPs in 21 genes.Seven variants eIF4E rs12498533, NFκB1 rs230510, TGFB1 rs4803455, TGFBR1 rs1571590 and rs6478974, SMAD3 rs3743343, and RUNX1 rs8134179 were associated with expression level of miRNAs in normal colorectal mucosa. RUNX2 rs12333172 and BMPR1B rs13134042 were associated with miRNAs in normal colon mucosa; eIF4EBP3 rs250425, SMAD3 rs12904944, SMAD7 rs3736242, and PTEN rs532678 were associated with miRNA expression in normal rectal mucosa. Evaluation of the differential expression between carcinoma and normal mucosa showed that SMAD3 rs12708491 and rs2414937, NFκB1 rs230510 and rs3821958, and RUNX3 rs6672420 were associated with several miRNAs for colorectal carcinoma. Evaluation of site-specific differential miRNA expression showed that BMPR1B rs2120834, BMPR2 rs2228545, and eIF4EBP3 rs250425 were associated with differential miRNA expression in colon tissue and SMAD3 rs12901071, rs1498506, and rs2414937, BMPR2 rs2228545, and RUNX2 rs2819854, altered differential miRNA expression in rectal tissue.These data support the importance of the TGF-ß signaling pathway to the carcinogenic process, possibly through their influence on miRNA expression levels.

Clinical, Radiographic, and Surgical Presentation of Subscapularis Tendon Tears: A Retrospective Analysis of 139 Patients.

PURPOSE: To analyze and correlate the clinical, radiographic, and surgical presentation of subscapularis (SSc) tears treated with arthroscopic repair. METHODS: We retrospectively identified 455 patients who underwent rotator cuff tear repairs at our institution from 2010 to 2014. Of these patients, 139 underwent an SSc repair either in isolation or concurrently with other rotator cuff procedures. Tear size was classified arthroscopically by whether tears involved the superior one-third of the SSc tendon, superior two-thirds of the SSc tendon, or complete SSc tendon. Patient demographic characteristics, assessments of belly-press weakness and the lift-off test, magnetic resonance imaging (MRI) findings, and data on concurrent supraspinatus and biceps tendon pathology were collected and analyzed according to tear size. RESULTS: Our cohort had a mean age of 61.8 ± 12.5 years, with a male-female gender ratio of 1.7:1. There were 22 tears of the superior one-third of the SSc (16%), 96 tears of the superior two-thirds of the SSc (69%), and 21 complete SSc tears (15%). Overall, MRI diagnosis of SSc tears had a sensitivity of 83% and specificity of 70%. MRI sensitivity was associated with tear severity (P = .02), with complete tears having an MRI sensitivity of 100%; superior two-thirds, 82%; and superior one-third, 67%. Physical examination sensitivity for belly-press weakness and the lift-off test was 61% and 63%, respectively, and did not correspond with tear size. Increased SSc tear size corresponded with a history of trauma (P = .04) and the presence of concurrent supraspinatus tears (P = .03) and biceps pathology (P = .003). CONCLUSIONS: The diagnosis of SSc tears remains challenging because of the limited sensitivity of MRI and physical examination. The diagnostic sensitivity of MRI is associated with SSc tear size, whereas physical examination is independent of tear size. Additional associations identified in this study include increased SSc tear size corresponding with a history of trauma, presence of concurrent supraspinatus tears, and presence of concurrent biceps tendon pathology. LEVEL OF EVIDENCE: Level III, retrospective comparative study.