Does the Nonunion Rate of Atypical Femoral Fractures Differ According to Fracture Site?: A Meta-Analysis.

Background: The nonunion rate for atypical femoral fractures (AFF) is known to be higher than that for typical fractures of the femur. We performed a meta-analysis to determine the incidence of nonunion necessitating reoperation following fixation for AFF and compare the rates according to the fracture site (subtrochanter or midshaft). Methods: A total of 742 AFFs from 29 studies were included. A proportion meta-analysis utilizing a random-effects model was conducted to estimate the prevalence of nonunion. The outcomes were the incidence of reoperations that included osteosynthesis. To determine the association of nonunion with patient mean age or average duration of bisphosphonate use, meta-regression analysis was done. Results: In proportion meta-analysis, the estimated pooled prevalence of nonunion was 7% (95% confidence interval [CI], 5%-10%) from all studies. There was a significant difference in nonunion rate between the 2 groups (I2 = 34.4%, p = 0.02); the estimated prevalence of nonunion was 15% (95% CI, 10%-20%) in subtrochanteric AFFs and 4% (95% CI, 2%-6%) in midshaft AFFs. From meta-regression analysis, significant correlations were identified between nonunion rate and patient mean age (coefficient: -0.0071, p = 0.010), but not in the average duration of bisphosphonate use (coefficient: -0.0024, p = 0.744). Conclusions: A notable disparity existed in the nonunion rate among subtrochanteric AFFs and midshaft AFFs group. Therefore, it is critical for orthopedic surgeons to consider the complexity and challenges associated with AFF and to estimate the proper possibility of nonunion according to the fracture site.

Open Reduction and Internal Fixation for Vancouver B1 and B2 Periprosthetic Femoral Fractures: A Proportional Meta-Analysis.

Purpose: Periprosthetic femoral fracture (PFF) is a common complication after total hip arthroplasty, and open reduction and internal fixation (ORIF) is a common surgical treatment. We conducted a meta-analysis to compare the outcomes of ORIF in patients with different fracture patterns (Vancouver B1 and B2). Materials and Methods: We conducted a systematic search of PubMed, Embase, Cochrane Library and KoreaMed from inception to August 2022. We conducted a pair-wise meta-analysis (with a fixed-effects model) on the 10 comparative studies and a proportional meta-analysis on the data from the 39 articles to determine a consensus. The outcomes were the incidence of reoperations that included osteosynthesis, irrigation/debridement and revision arthroplasty. Results: The pair-wise meta-analysis showed similar outcomes between two groups; the risk of reoperation (odds ratio [OR]=0.82, confidence interval [CI] 0.43-1.55, P=0.542), nonunion (OR=0.49; CI 0.22-1.10, P=0.085) and deep infection (OR=1.89, CI 0.48-7.46, P=0.361). In proportion meta-analysis, pooled prevalence of reoperation was 9% (95% CI, 6-12) in B1 and 8% (95% CI, 2-15) in B2 (heterogeneity between two groups (Q), P=0.772). The pooled prevalence of nonunion was same as of 4% in B1 and B2 (Q, P=0.678), and deep infection was 2% (95% CI, 1-3) in B1 and 4% (95% CI, 2-7) in B2 (Q, P=0.130). Conclusion: ORIF is a feasible treatment for B1 and B2 periprosthetic femoral fractures, with acceptable outcomes in terms of, nonunion and infection. The results of this study would help clinicians and provide baseline data for further studies validating PFF.

Regional versus General Anesthesia in Postoperative Pain Management after Distal Radius Fracture Surgery: Meta-Analysis of Randomized Controlled Trials.

Distal radius fractures are the most prevalent upper extremity fractures, posing a significant public health concern. Recent studies comparing regional and general anesthesia for postoperative pain management after these fractures have yielded conflicting results. This meta-analysis aimed to compare the effectiveness of regional and general anesthesia concerning postoperative pain management and opioid consumption following distal radius fracture surgery. A comprehensive search was conducted in PubMed, Cochrane Library, and EMBASE databases to identify relevant randomized controlled trials. Four randomized trials involving 248 participants were included in the analysis. A pooled analysis revealed that regional anesthesia led to significantly reduced postoperative pain scores at 2 h compared to general anesthesia (SMD -2.03; 95% CI -2.88--1.17). However, no significant differences in pain scores were observed between the two anesthesia types after 12 h post-surgery. Regional anesthesia was associated with lower total opioid consumption (SMD -0.76; 95% CI -1.25--0.26) and fewer occurrences of nausea and vomiting compared to the general anesthesia. Nonetheless, opioid consumption on the first day post-discharge was significantly higher in the regional anesthesia group (SMD 0.83; 95% CI 0.47-1.20). The analgesic superiority of regional anesthesia is confined to the early postoperative hours with overall lower opioid use but a notable increase in opioid consumption on the first day post-discharge, potentially attributable to rebound pain.

Medial patellofemoral ligament reconstruction appears to be a better treatment than repair, proximal realignment, or conservative management for primary patellar dislocation: A network meta-analysis.

BACKGROUND: The purpose of this study was to compare the functional outcomes and re-dislocation rates of medial patellofemoral ligament (MPFL) reconstruction, MPFL repair, combined proximal realignment (CPR), and conservative management for primary patellar dislocation by conducting a systematic literature search of the available studies. The hypothesis was that MPFL repair and MPFL reconstruction would be better options for treating primary patellar dislocation. METHODS: Randomized controlled trials or prospective studies of primary patellar dislocation treated with MPFL reconstruction, MPFL repair, CPR, or conservative management were identified from the MEDLINE, EMBASE, and the Cochrane Library databases through December 31, 2021. A total of 626 patients met the prespecified inclusion criteria. The methodological quality of each study was assessed using a risk of bias table, Detsky quality index, and Newcastle-Ottawa Scale. The end-point data collected included comparisons of the mean in functional scores on knee outcomes scales and the number of patients who experienced re-dislocation. A network meta-analysis of the relevant literature was performed to investigate which treatment showed better outcomes. RESULTS: In total, 10 trials were included in this study. There was no statistically significant difference in the subgroup analysis in terms of the functional outcomes among MPFL reconstruction, MPFL repair, CPR, and conservative management. However, MPFL reconstruction showed statistically significantly better outcomes than MPFL repair, CPR, or conservative management in terms of the re-dislocation rate. Additionally, surface under the cumulative ranking curve percentage showed that MPFL reconstruction had a lower probability of re-dislocation than MPFL repair even though there was no significant difference (0.24, 95% confidence interval: 0.02-2.91). CONCLUSION: Using a network meta-analysis, this meta-analysis showed that there was no significant difference in functional outcomes in a subgroup analysis. In re-dislocation subgroup analysis, MPFL repair and MPFL reconstruction produced significantly better results than other treatments. Also, surface under the cumulative ranking curve percentage showed that MPFL reconstruction had a lower probability of re-dislocation than MPFL repair.

Idiopathic Avascular Necrosis of Trapezoid in Adolescence: 3-Year Follow-Up.

Avascular necrosis (AVN) is relatively uncommon in the carpal bones, although it most frequently involves the lunate and scaphoid. The trapezoid has abundant vascular channels from a rich network of dorsal and palmar vessels, and only a few cases of AVN have been reported in adults who sustained a traumatic insult. We present a rare case of idiopathic AVN of the trapezoid in an adolescent presenting with refractory pain at the second metacarpal base. Over a period of 36 months, follow-up symptom evaluations and serial magnetic resonance images showed prominent gradual improvement, consistent with spontaneous resolution.

Editorial Commentary: Outcomes of Arthroscopic Triangular Fibrocartilage Complex Repair: Can We Predict Who Will Benefit or Not?

The arthroscopic repair of avulsed triangular fibrocartilage complex generally demonstrates a satisfactory outcome after ruling out additional combined pathologies for ulnar-sided wrist pain. Previous studies have reported that 10% to 20% of patients complain of dissatisfaction with this surgical treatment, suggesting that it is not effective for all patients. Several prognostic factors for poor outcomes such as female gender, chronicity, baseline functional state, and reduced pronator quadratus muscle mass have been proposed. Transosseus foveal repair may be particularly beneficial in chronic cases compared with capsular repair, enhancing the healing rate between the scarred end of the triangular fibrocartilage complex and the bone with greater mechanical strength. However, unaccounted patient variables in uncontrolled small cases series could significantly complicate and confound the point of care application of the findings, and thus larger comprehensive studies are required to confirm these results.

Comparison of Ultrasound-Guided Versus Landmark-Based Corticosteroid Injection for Carpal Tunnel Syndrome: A Prospective Randomized Trial.

PURPOSE: Although a local corticosteroid injection for carpal tunnel syndrome (CTS) is frequently performed by palpation using anatomical landmarks, ultrasound (US) allows physicians to visualize and confirm placement of the injectate close to the median nerve, possibly improving the efficacy of the injection. The aim of this study was to compare the effectiveness and complications of US-guided steroid injections with landmark-based injections for CTS. METHODS: A total of 102 patients with CTS were randomized into 2 groups: landmark-based injection and US-guided injection. The response to treatment, including grip strength and the Boston Carpal Tunnel Questionnaires (BCTQ) was assessed at baseline and at 4, 12, and 24 weeks after the injection. RESULTS: The BCTQ symptom and function scores were similar in the 2 groups throughout the 24-week follow-up period, with the exception of significantly lower (better) symptom scores at 4-week follow-up in the US-guided injection group. The grip strength was similar in the 2 groups throughout the 24-week follow-up period. After 24 weeks, 12 patients (24%) in the landmark-based injection group and 9 patients (18%) in the US-guided injection group had undergone carpal tunnel surgery. Symptoms of median nerve irritation were more likely to occur in patients with landmark-based injections (14%) than in those with US-guided injection (2%). CONCLUSIONS: A US-guided steroid injection for CTS produces pain and functional results similar to those of landmark-based injection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Altered gene and protein expressions of vitamin D receptor in skeletal muscle in sarcopenic patients who sustained distal radius fractures.

Despite the presence of vitamin D receptor (VDR) in skeletal muscle cells, the relationship between VDR expressions and muscle mass or function has not been well studied. The purpose of this study was to compare VDR gene and protein expression in the forearm muscle between sarcopenic and non-sarcopenic individuals who have sustained distal radius fractures. Twenty samples of muscle tissue from sarcopenic patients (mean age 63.4 ± 8.1 years) and 20 age- and sex-matched control tissues (62.1 ± 7.9 years) were acquired from the edge of dissected pronator quadratus muscle during surgery for distal radius fractures. The mRNA expression levels of VDR as well as the myokines of interest that may be associated with muscle mass change (myogenin and myostatin) were analyzed with real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR). In addition, Western blot assay and immunohistochemistry for VDR were performed. Sarcopenic patients showed a significantly lower level of gene expression for VDR and myogenin, but a greater level of gene expression for myostatin than the controls according to qRT-PCR analysis. The density of VDR protein expressions was 2.1 times greater, while that of myostatin was 2.6 times lower, in the control group than in the sarcopenic group according to Western blot analysis. On immunohistochemical analysis, the density of the cells expressing VDR was significantly decreased in the sarcopenic patients. Sarcopenic patients who sustained distal radius fractures presented lower vitamin D receptor gene and protein expression in skeletal muscles compared to non-sarcopenic individuals.

Prognostic Factors for Nonsurgically Treated Sagittal Band Injuries of the Metacarpophalangeal Joint.

PURPOSE: The aim of this study was to evaluate the factors that influence the prognosis for patients with sagittal band injuries who were treated nonsurgically. METHODS: A total of 94 patients who had been diagnosed with traumatic sagittal band injury and initially treated with 7 weeks of metacarpophalangeal (MCP) joint extension orthosis wear (5 weeks of full-time followed by 2 weeks of part-time use) were studied. The response to treatment, including finger range of motion (ROM), extensor tendon instability, grip strength, and functional outcome measured as Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score were assessed at 24-week follow-up. The factors that were assessed for their influence on the outcomes were age, sex, occupation, hand dominance, type of injury, injury severity, time to treatment, and the duration of orthosis wear. Potential predictor variables in bivariate analyses were entered into multivariable analyses to determine prognostic indicators of the outcomes. RESULTS: After 24 weeks' follow-up, 67 patients (71%) achieved resolution of symptomatic tendon translocation with 83% of grip strength and 90% of ROM compared with the unaffected hand. The final mean QuickDASH scores was 15. Twenty-seven patients (29%) had persistently symptomatic tendon subluxation, and of those, 18 (19%) underwent surgical repair. There were significantly more manual laborers in the failure group than in the success group. Subjects in the treatment failure group were older, had longer symptom durations, and were more likely to have grade III injuries than were those in the success group. Multivariable analysis revealed that manual labor, longer symptom duration, and grade III injury were associated with a higher likelihood of treatment failure. CONCLUSIONS: An MCP extension orthosis for sagittal band injury (5 weeks of full-time followed by 2 weeks of part-time use) led to mostly satisfactory results with 71% of patients achieving resolution of symptomatic tendon translocation, but manual labor, longer symptom duration, and grade III injury were associated with a higher likelihood of treatment failure. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Osteonecrosis of bipartite patella following total knee arthroplasty without lateral release.

We present a case of osteonecrosis of bipartite patella occurring after total knee arthroplasty using medial parapatellar approach without lateral retinacular release in osteoarthritic knee of a 66 year-old-male. The surgery was performed using traditional technique with medial parapatellar approach and patella was resurfaced. Patella was everted during surgery. There was no event during follow-up period after surgery. Range of motion of the knee was 135° without flexion contracture. Eight months after the surgery, patella was fragmented and resorbed on the radiographs which was consistent with osteonecrosis. The patient showed extension limitation of 30° with no pain. Patellar osteonecrosis has been rarely reported after total knee arthroplasty with lateral retinacular release. However, there was no report of patellar osteonecrosis after total knee arthroplasty without lateral retinacular release. Caution should be taken about patellar osteonecrosis in case of bipartite patella even though lateral retinaculum is preserved during total knee arthroplasty.

The Prognostic Value of Pain Sensitization in Patients With Lateral Epicondylitis.

PURPOSE: Pain sensitization is a contributing factor to conditions of chronic pain. The aim of this study was to evaluate the influence of pain sensitization on the prognosis of lateral epicondylitis (LE) treated by self-stretching exercises and the use of a counterforce brace. METHODS: We enrolled 131 patients who presented with isolated LE symptoms for less than 6 months. We initially measured pain sensitization by assessing patients' pressure pain thresholds (PPTs) in the contralateral middorsal forearm and administering a pain sensitization questionnaire (PSQ). For outcome assessments, we assessed the self-administered, patient-reported Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire at 6 and 12 months' follow-up. RESULTS: Initial PSQ scores correlated moderately with baseline DASH scores and slightly with symptom duration; PPTs correlated slightly with baseline DASH scores. After we accounted for confounding variables, patient-reported disability was associated with lower PPTs, higher PSQ scores, and manual labor at 6 months. These 3 factors accounted for 36% of variance in the DASH scores; however, at 12 months only the PSQ score was associated with higher DASH scores, accounting for 14% of variance. CONCLUSIONS: Pain sensitization during the early stages of LE correlated with initial symptom severity and duration and was associated with persistently increasing disability after 1 year of nonsurgical treatment. More research is needed to show whether early identification and treatment of pain sensitization will enhance LE treatment outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Prognostic effect of pain sensitization in patients with de Quervain's tenovaginosis receiving corticosteroid injection.

We investigated the influence of pain sensitization on the prognosis of de Quervain's tenovaginosis after a local corticosteroid injection. One hundred and fifteen patients with de Quervain's tenovaginosis who were treated with corticosteroid injection were recruited. We initially measured pain sensitization by assessing the patients' pressure pain thresholds in the mid-dorsal forearm and by administering a Pain Sensitivity Questionnaire. The pain score using a visual analogue scale, the result of Eichhoff's test, and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire were assessed at baseline and at 6 and 24 weeks after the injection. The DASH scores at 6 weeks correlated slightly with higher Pain Sensitization Questionnaire scores, and the DASH scores at 24 weeks correlated moderately with higher Pain Sensitization Questionnaire scores and lower pressure pain thresholds. Lower pressure pain thresholds, higher Pain Sensitization Questionnaire scores, and heavy manual work were independently associated with a higher likelihood of persistent symptoms and signs after a local corticosteroid injection for de Quervain's tenovaginosis. Level of evidence: III.

Comparison of clinical outcomes after ulnar shortening osteotomy for ulnar impaction syndrome with or without arthroscopic debridement.

Forty-four patients who had been diagnosed with ulnar impaction syndrome and who were scheduled to undergo ulnar shortening osteotomy were randomized into two groups, one treated by ulnar shortening osteotomy alone and the other treated by ulnar shortening osteotomy combined with arthroscopic debridement. The response to treatment, including the pain numeric rating scale in an ulnar provocation test and the Disability of the Arm, Shoulder and Hand score was assessed at 3 and 12 months after surgery. The mean pain and disability scores showed significant clinical improvement at the 12-month follow-up in both groups. The pain scores at 3 months of follow-up were significantly better in the ulnar shortening osteotomy with arthroscopic debridement group. However, no significant differences were observed between the two groups in the disability scores at 3 and 12 months, or in the pain scores at 12-month follow-up. We conclude that similar improvements in symptom severity and hand function occurred in the long term in patients both with and without concomitant arthroscopic debridement. This information regarding concomitant arthroscopy could be used in the informed consent discussion with patients scheduled for ulnar shortening osteotomy. Level of evidence: II.