Complications after volar plate synthesis for distal radius fractures.

Purpose: Distal radius fractures (DRFs) represent up to 18% of all fractures in the elderly population, yet studies on the rate of complications following surgery are lacking in the literature. This systematic review aimed to quantify the rate of complications and reinterventions in patients treated with volar plate for distal radius fractures, and analyze if there was any predisposing factor. Methods: A comprehensive literature search was performed on three databases up to January 2023, following PRISMA guidelines. Studies describing volar plate complications and hardware removal were included. A systematic review was performed on complications and rate of reintervention. Assessment of risk of bias and quality of evidence was performed with the 'Down and Black's Checklist for measuring quality'. Results: About112 studies including 17 288 patients were included. The number of complications was 2434 in 2335 patients; the most frequent was carpal tunnel syndrome (CTS), representing 14.3% of all complications. About 104 studies reported the number of reinterventions, being 1880 with a reintervention rate of 8.5%. About 84 studies reported the reason of reintervention; the most common were patient's will (3.0%), pain (1.1%), CTS (1.2%), and device failure (1.1%). Conclusion: The complication rate after DRFs is 13.5%, with the main complication being CTS (14.3%), followed by pain and tendinopathy. The reintervention rate is 8.5%, mainly due to the patient's willingness, and all these patients had plate removal. Correct positioning of the plate and correct information to the patient before surgery can reduce the number of hardware removal, thereby reducing costs and the risk of complications associated with VLP for distal radius fractures.

Patients with rotator cuff tears present a psychological impairment, not only a functional deficit: a systematic review.

INTRODUCTION: Psychological factors impact patients with rotator cuff tears (RCT) in terms of pain level, shoulder function, sleep disturbance, and quality of life (QoL). The aim of this study was to quantify the prevalence of psychological factors in those patients, evaluate their influence on patient-reported outcomes (PROMs), and assess the possible improvement with surgical treatment. METHODS: The literature search was performed on PubMed, Web of Science, Wiley Cochrane Library up to January, 2023. INCLUSION CRITERIA: RCT treated with arthroscopic rotator cuff reconstruction (ARCR), description of psychological variables evaluated with validated questionnaires, descriptions of PROMs. RESULTS: Thirty-nine studies included 7021 patients. Depression was found in eight studies (19.2%), anxiety in 6 (13.0%), sleep disturbance in seven (71.3%), and distress in three studies (26.4%). Studies evaluating the relationship between psychological impairment and pain documented more pain and impaired shoulder function before and after ARCR in patients with altered psychological status. DISCUSSION: An impaired psychological status has an important impact on patients' perception of their disease. RCT patients with psychological alterations often experience more pain and reduced shoulder function, thus having worse QoL. CONCLUSION: This study underlines that psychological impairment largely affects RCT patient condition and treatment outcome, which underlines the importance of a multidisciplinary biopsychosocial intervention to achieve better results.

Proximal humerus fractures: deltopectoral open reduction and internal fixation vs deltosplit minimally invasive plate osteosynthesis: which surgical approach provides superior results?

Purpose: To compare the two main surgical approaches to address proximal humerus fractures (PHFs) stratified for Neer fracture types, to demonstrate which approach gives the best result for each fracture type. Methods: A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in PubMed, Web of Science, and Cochrane databases up to 4 January 2022. Inclusion criteria were studies comparing open reduction and internal fixation (ORIF) with deltopectoral (DP) approach and minimally invasive plate osteosynthesis (MIPO) with deltosplit (DS) approach of PHFs. Patient's demographic data, fracture type, Constant-Murley Score (CMS), operation time, blood loss, length of hospital stay, complications, fluoroscopy time, and radiological outcomes were extracted. Results were stratified for each type of Neer fracture. Results: Eleven studies (798 patients) were included in the meta-analysis. No functional difference was found in the CMS between the two groups for each type of Neer (P = n.s.): for PHFs Neer II, the mean CMS was 72.5 (s.e. 5.9) points in the ORIF group and 79.6 (s.e. 2.5) points in the MIPO group; for Neer III, 77.8 (s.e. 2.0) in the ORIF and 76.4 (se 3.0) in the MIPO; and for Neer IV, 70.6 (s.e. 2.7) in the ORIF and 60.9 (s.e. 6.3) in the MIPO. The operation time in the MIPO group was significantly lower than in the ORIF group for both Neer II (P = 0.0461) and Neer III (P = 0.0037) fractures. Conclusion: The MIPO with DS approach demonstrated no significant differences in the results to the ORIF with DP approach for the different Neer fractures in terms of functional results, with a similar outcome, especially for the Neer II and III fracture types. The MIPO technique proved to be as safe and effective as the ORIF approach.

Quality of Life from Return to Work and Sport Activities to Sexual Dysfunction after Surgical Treatment of Pelvic Ring Fractures.

BACKGROUND: Pelvic ring fractures are life-threatening injuries that have a severe impact on patients' lives. The aim of this clinical study was to evaluate the outcome of surgical treatment in terms of Quality of Life (QoL), return to work, functional results and sport activities, and post-operative sexual dysfunction. METHODS: A retrospective study with patients retrieved from a Level 1 Trauma Center was performed. Minimum patient follow-up was 12 months: QoL was evaluated with the SF-12 (Short Form Survey) questionnaire, return to work with the Workplace Activity Limitation Survey (WALS), functional outcomes and sport activities with the Harris Hip Score and Tegner activity score, respectively, and sexual function damage with a 0-10 NRS. RESULTS: Seventy-six patients (41 males and 35 females) were enrolled, with a mean age at surgery of 56.4 years (18-89 years). Overall, their quality of life remained significantly affected, with male patients reporting worse WALS outcomes (p = 0.036), sexual damage (p = 0.001), and SF-12 Bodily Pain (p = 0.046) than females. In particular, 70.7% of men and 45.7% of women reported sexual limitations, and only 53.7% returned to their job, with 35.2% losing their job as a consequence of the pelvic ring disruption. CONCLUSIONS: An important deterioration in general health state, return to work, and sexual function was documented in patients treated surgically for pelvic trauma, especially in male patients. There are disabling secondary sequels at all levels beyond the mere functional scores, and both patients and clinicians should be aware and have the correct expectations.

Biological intra-articular augmentation for osteotomy in knee osteoarthritis: strategies and results : A systematic review of the literature from the ESSKA Orthobiologics Initiative.

PURPOSE: To assess whether there is evidence supporting the use of augmentation strategies, either cartilage surgical procedures or injective orthobiologic options, to improve the results of osteotomies in knees with osteoarthritis (OA). METHODS: A systematic review of the literature was performed on the PubMed, Web of Science and the Cochrane databases in January 2023 on osteotomies around the knee associated with augmentation strategies (either cartilage surgical procedures or injective orthobiologic options), reporting clinical, radiological, or second-look/histological outcomes at any follow-up. The methodological quality of the included studies was assessed with the Coleman Methodology Score (CMS). RESULTS: Out of the 7650 records identified from the databases, 42 articles were included for a total of 3580 patients and 3609 knees treated; 33 articles focused on surgical treatments and 9 on injective treatments performed in association with knee osteotomy. Out of the 17 comparative studies with surgical augmentation, only 1 showed a significant clinical benefit of an augmentation procedure with a regenerative approach. Overall, other studies showed no differences with reparative techniques and even detrimental outcomes with microfractures. Regarding injective procedures, viscosupplementation showed no improvement, while the use of platelet-rich plasma or cell-based products derived from both bone marrow and adipose tissue showed overall positive tissue changes which translated into a clinical benefit. The mean modified CMS score was 60.0 ± 12.1. CONCLUSION: There is no evidence to support the effectiveness of cartilage surgical treatments combined with osteotomies in terms of pain relief and functional recovery of patients affected by OA in misaligned joints. Orthobiologic injective treatments targeting the whole joint environment showed promising findings. However, overall the available literature presents a limited quality with only few heterogeneous studies investigating each treatment option. This ORBIT systematic analysis will help surgeons to choose their therapeutic strategy according to the available evidence, and to plan further and better studies to optimize biologic intra-articular osteotomy augmentation. LEVEL OF EVIDENCE: Level IV.

Infection Risk Increases After Total Hip Arthroplasty Within 3 Months Following Intra-Articular Corticosteroid Injection. A Meta-Analysis on Knee and Hip Arthroplasty.

BACKGROUND: Much debate continues regarding the risk of postoperative infection after intra-articular corticosteroid injection prior to total joint arthroplasty. The aim of this study was to evaluate the risk of periprosthetic joint infection (PJI) or other complications after joint arthroplasty in patients who received preoperative corticosteroids injections. METHODS: A literature search was performed on PubMed, Web of Science, and Cochrane Library through January 4, 2022. Of 4,596 studies, 28 studies on 480,532 patients were selected for qualitative analysis. Studies describing patients receiving corticosteroids injections before joint arthroplasty (hip, knee) were included in the systematic review. A meta-analysis was performed of studies focusing on corticosteroids injections and PJI. Assessment of risk of bias and quality of evidence was based on the "Downs and Black's Checklist for Measuring Quality". RESULTS: A significant association (odds ratio: 1.55, P = .001, 95% confidence interval: 1.357-1.772) between PJI and corticosteroids injections was found for total hip arthroplasty (THA). No association was found for knee arthroplasty procedures. The risk of PJI is statistically higher (odds ratio: 1.20, P = .045, 95% confidence interval: 1.058-1.347) if the injections are performed within 3 months preoperatively in THA patients. CONCLUSION: Patients undergoing THA who previously received intra-articular injections of corticosteroids may expect a statistically higher risk of developing PJI. On the contrary, no association between corticosteroids injections and PJI could be seen in total knee arthroplasty patients. In addition, injection timing plays an important role: surgeons should refrain from administering corticosteroids injections within 3 months before hip arthroplasty, as it appears to be less safe than waiting a 3-month interval.

Effects of negative pressure wound therapy with instillation and dwell time (NPWTi-d) versus NPWT or standard of care in orthoplastic surgery: A systematic review and meta-analysis.

Negative pressure wound therapy (NPWT) is a wound-dressing system that applies sub-atmospheric pressure on the surface of a wound to promote healing. An evolution of this technology, NPWT with solution instillation and dwell time (NPWTi-d), is increasingly being used to maximise wound closure and reduce failure rates. However, there is still a lack of evidence concerning its use in orthoplastic surgery. Therefore, the aim of this study is to compare NPWTi-d with NPWT and standard of care for wound management in orthoplastic surgery. A comprehensive literature search using PubMed, Web of Science, and Cochrane databases up to 15 March 2022 was performed, including studies describing the outcomes of NPWTi-d for traumatic/orthopaedic injuries. A meta-analysis on the number of surgical debridements, as well as the rate of complete wound closure and complications was carried out, although for other outcomes, a descriptive statistic was applied. Risk of bias and quality of evidence were assessed using the Downs& Black's Checklist for Measuring Quality. Thirteen studies with a total number of 871 patients were included, in which NPWTi-d demonstrated significantly higher primary wound closure and lower complication rates (P < .05). No difference in the number of surgical procedures required for final wound healing was observed. Moreover, five out of six studies showed better results for NPWTi-d when the change of the bioburden and bacterial count of the wound were analysed. A singular study investigating the length of the hospital stay of patients treated with NPWTi-d showed a reduction in the latter. The present meta-analysis proves that NPWTi-d is superior to NPTW or conventional dressings in orthoplastic wound care management, in terms of complete wound closure rate and the reduced number of complications. Still, the limited quality of the studies analysed shows that future randomised studies are needed to confirm the benefits and to identify the most appropriate recommendations for using NPWTi-d in orthoplastic surgery, as well as to investigate the cost-effectiveness of this wound-dressing system.

Vascularized fibular grafts for the treatment of long bone defects: pros and cons. A systematic review and meta-analysis.

PURPOSE: To quantify union rate, complication rate, reintervention rate, as well as functional outcome after vascularized fibular bone grafts (VFGs) for the treatment of long-bone defects. METHODS: A comprehensive search was performed in the PubMed, Web of Science, and Cochrane databases up to August 18, 2020. Randomized controlled trials, comparative studies, and case series describing the various techniques available involving VFGs for the reconstruction of segmental long-bone defects were included. A meta-analysis was performed on union results, complications, and reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black's "Checklist for Measuring Quality". RESULTS: After full-text assessment, 110 articles on 2226 patients were included. Among the retrieved studies, 4 were classified as poor, 83 as fair, and 23 as good. Overall, good functional results were documented and a union rate of 80.1% (CI 74.1-86.2%) was found, with a 39.4% (CI 34.4-44.4%) complication rate, the most common being fractures, non-unions and delayed unions, infections, and thrombosis. Donor site morbidity represented 10.7% of the total complications. A 24.6% reintervention rate was documented (CI 21.0-28.1%), and 2.8% of the patients underwent amputation. CONCLUSIONS: This systematic review and meta-analysis documented good long-term outcomes both in the upper and lower limb. However, VFG is a complex and demanding technique; this complexity means an average high number of complications, especially fractures, non-unions, and vascular problems. Both potential and limitations of VFG should be considered when choosing the most suitable approach for the treatment of long-bone defects.

Quality of life from return to work and sports activities to sexual dysfunction after surgical treatment of acetabular fractures.

INTRODUCTION: To evaluate the outcomes of patients treated for acetabular fractures in terms of Quality of Life (QoL), return to work, functional outcome, sports activities, and post-operative sexual dysfunction. MATERIALS AND METHODS: The database of a level 1 trauma center was used to investigate the results of patients treated for acetabular fractures from 2010 to 2020. The minimum patient follow-up was 12 months. QoL was evaluated with the SF-12 questionnaire, return to work with the Workplace Activity Limitation Survey (WALS), functional outcomes and sports activities with Harris Hip Score (HHS) and Tegner activity scores, respectively, and the sexual function damage with a 0-10 NRS. RESULTS: Sixty-five patients (44 men, 21 women) were enrolled, mean age at surgery of 53.4 years (20-85 years). The HHS and Tegner scores were 79.0 ± 19.4 and 2.6 ± 1.5, respectively, and 18.5% of patients underwent THA after 21.3 ± 28.6 months. QoL evaluated with the SF-12 showed the worst results in terms of Bodily Pain and Role Physical; 35.4% of the patients who were working before the trauma lost their job, and one third was affected at sex functional level. Sex was found to influence significantly both Harris Hip Score (p < 0.05) and Tegner activity score (p < 0.05), with men reporting better scores. On the other hand, men presented a higher impact in terms of job loss and sexual dysfunction. CONCLUSION: Acetabular fractures affect patients' life as a whole, beyond the mere functional outcomes, often leading to a high rate of job loss and a significant probability of sexual functional worsening, especially for men. A significant number of patients also underwent THA at an early follow-up. Further efforts should aim at optimizing the surgical management, to improve functionality and the entire QoL sphere of patients affected by acetabular fractures.

Impact of tuberosity treatment in reverse shoulder arthroplasty after proximal humeral fractures: A multicentre study.

BACKGROUND: To assess how tuberosity treatment affects the short-term clinical outcome of patients with complex proximal humeral fractures (PHFs) treated with reverse shoulder arthroplasty (RSA). METHODS: This is a multicentre study on 90 patients affected by acute PHFs (Neer type-4/11C3.2 in 80% of patients, and a Neer type 3/11B3.2 in 20%) treated with RSA and followed at an average of 34 months. Patients were divided into two groups (reconstructed and non-reconstructed tuberosity) according to the surgical fixation of the tuberosities. Then, the "reconstructed tuberosity" was divided into "healed" and "non-healed" groups. All patients were clinically evaluated in terms of ROM and strength in elevation, as well as with 0-10 numerical rating scale (NRS), Constant and Murley Score (CMS), DASH Score, and EQ-VAS. X-rays in anteroposterior and Neer views were performed. RESULTS: Based on the status of the tuberosities, 18.9% were non-reconstructed (17 patients) and 81.1% were reconstructed (73 patients): out of these, 11 were correctly healed, 42 healed with malposition, and 20 were reabsorbed. Instability was found in 2/73 patients in the reconstructed group, and in 4/17 patients in the non-reconstructed group. NRS (1.4 vs 0.5), DASH (23.1 vs 13.9), and EQ-VAS (78.1 vs 83.7) scores had better final values in the non-reconstructed group (p < 0.05). However, the non-correctly healed tuberosity group (excision + resorption + malposition/migration) showed worse strength, as well as clinical scores when compared to the correctly healed tuberosity group. CONCLUSION: RSA ensures satisfactory functional results for PHFs. Patients with a successfully reconstructed tuberosity have an overall better outcome. However, in this series most of the reconstructed cases presented tuberosity reabsorption, malposition, or migration, which led to lower results. Thus, tuberosity reconstruction must be carefully considered and tuberosity reabsorption or migration factors should be investigated, to optimize tuberosity reconstruction and provide to a higher number of patients a better outcome of RSA for the treatment of PHFs.

Platelet-rich plasma does not improve clinical results in patients with rotator cuff disorders but reduces the retear rate. A systematic review and meta-analysis.

PURPOSE: To assess whether the use of Platelet-rich plasma (PRP) produces a clinical benefit in patients with rotator cuff disorders, treated either conservatively or surgically. METHODS: A systematic review was performed according to PRISMA guidelines on three databases (PubMed, Cochrane Library, Web of Science) to identify randomised controlled trials (RCTs) on the use of PRP in patients with rotator cuff disorders, treated either conservatively or surgically. A meta-analysis was performed on articles reporting results for Constant, UCLA, VAS, SST scores and retear rate. The RoB 2.0 and the modified Coleman Methodology Score were used to assess methodological quality. RESULTS: A total of 36 RCTs (20 surgical, 16 conservative) were included, for a total of 2,443 patients. Conservative treatment showed high heterogeneity and no clear consensus in favour of PRP. The meta-analysis of the studies with surgical treatment showed no benefit in using PRP in any of the clinical outcomes, either at the short or medium/long-term follow-up. However, the retear rate was lower with PRP augmentation (p < 0.001). The overall quality of the studies was moderate to high, with the surgical studies presenting a lower risk of bias than the conservative studies. CONCLUSION: The use of PRP as augmentation in rotator cuff surgical repair significantly reduces the retear rate. However, no benefits were documented in terms of clinical outcomes. PRP application through injection in patients treated conservatively also failed to present any clear advantage. While there are many studies in the literature with several RCTs of moderate to high quality, the high heterogeneity of products and studies remains a significant limitation to fully understanding PRP potential in this field. LEVEL OF EVIDENCE: Level I.

Arthroscopic rotator cuff repair: patients with physically demanding work have significantly worse time to return to work, level of employment, and job loss.

PURPOSE: The purpose of this study was to determine the results of arthroscopic rotator cuff repair (ARCR) in terms of return to work (RTW). METHODS: Inclusion criteria were working patients who underwent ARCR for rotator cuff rupture at the study site between 2008 and 2020 and minimum 12 months of follow-up. Patients were stratified based on the physical demand of their work according to the Canadian Classification and Dictionary of Occupations. The primary outcomes were time to RTW, level of employment (LoE), change of tasks, and work loss. Secondary outcomes included the return to sports activities, EQ-VAS, EQ-5D-5L, DASH, and Oxford Shoulder Score. RESULTS: Three-hundred and eighty-three patients were enrolled; at the follow-up evaluation, fifty-three patients (13.8%) lost their job, with a percentage of 34.4% (eleven patients) in the heavy-work category, and five patients (1.3%) chose early retirement. Other twenty-six patients (6.8%) had to lower their level of employment, and twenty patients (5.2%) changing their tasks, with 279 patients (72.9%) returning to their previous work activity. RTW was obtained at a mean time of 4.7 ± 4.6 months, ranging from 3.8 ± 3.1 months in the sedentary work vs 5.8 ± 2.8 months in the very heavy-work category (p = 0.015). The mean EQ-VAS score was 77.3 ± 18 points, the mean Oxford Shoulder Score was 43.4 ± 7.2 points, and the mean DASH score was 9.9 ± 14.5 points; 75.3% returned to their previous level of sport activity. CONCLUSIONS: The success of ARCR in terms of RTW is not always complete and varies significantly based on the physical demand of the patient's job. Patients with physically demanding work have a significantly higher time to RTW, reduction of the LoE, and job loss rate, thus affecting the possibility to have a satisfactory return to their previous life. The findings are of clinical relevance since they can help the surgeons to give their patients reliable expectations and to correctly plan the post-operative management. LEVEL OF EVIDENCE: IV.

Volar locking plate vs cast immobilization for distal radius fractures: a systematic review and meta-analysis.

Introduction: The aim of this systematic review and meta-analysis was to evaluate whether volar locking plate (VLP) fixation leads to better clinical and radiological outcomes than those of closed reduction and cast immobilization for the treatment of distal radius fractures (DRFs). Materials and methods: A comprehensive literature search was performed in PubMed, Web of Science, and Cochrane databases up to January 2022. Inclusion criteria included randomized controlled trial (RCT) studies comparing VLP fixation with cast immobilization for DRFs. Investigated parameters were Patient-Rated Wrist Evaluation questionnaire, Disabilities of the Harm, Shoulder, and Hand score (DASH), range of motion (ROM), grip strength, quality of life (QoL), radiological outcome, and complication and reoperation rate, both at short- and mid-/long-term follow-up. Assessment of risk of bias and quality of evidence was performed with Downs and Black's 'Checklist for Measuring Quality'. Results: A total of 12 RCTs (1368 patients) were included. No difference was found for ROM, grip strength, QoL, and reoperation, while the DASH at 3 months was statistically better in the VLP group (P < 0.05). No clinical differences were confirmed at longer follow-up. From a radiological perspective, only radial inclination (4°) and ulnar variance (mean difference 1.1 mm) at >3 months reached statistical significance in favor of the VLP group (both P < 0.05). Fewer complications were found in the VLP group (P < 0.05), but they did not result in different reintervention rates. Conclusions: This meta-analysis showed that the surgical approach leads to a better clinical outcome in the first months, better fracture alignment, and lower complication rate. However, no differences in the clinical outcomes have been confirmed after 3 months. Overall, these findings suggest operative treatment for people with higher functional demand requiring a faster recovery, while they support the benefit of a more conservative approach in less demanding patients.

Reply to Sidiropoulos, K.; Tsikopoulos, K. Comment on "Oldrini et al. PHILOS Synthesis for Proximal Humerus Fractures Has High Complications and Reintervention Rates: A Systematic Review and Meta-Analysis. Life 2022, 12, 311".

Thank you for the opportunity to respond to the commentary [...].

Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis.

To understand the potential and limitations of the different available surgical techniques used to treat large, long-bone diaphyseal defects by focusing on union, complication, re-intervention, and failure rates, summarizing the pros and cons of each technique. A literature search was performed on PubMed, Web of Science, and Cochrane databases up to March 16th, 2022; Inclusion criteria were clinical studies written in English, of any level of evidence, with more than five patients, describing the treatment of diaphyseal bone defects. The primary outcome was the analysis of results in terms of primary union, complication, reintervention, and failure rate of the four major groups of techniques: bone allograft and autograft, bone transport, vascularized and non-vascularized fibular graft, and endoprosthesis. The statistical analysis was carried out according to Neyeloff et al., and the Mantel-Haenszel method was used to provide pooled rates across the studies. The influence of the various techniques on union rates, complication rates, and reintervention rates was assessed by a z test on the pooled rates with their corresponding 95% CIs. Assessment of risk of bias and quality of evidence was based on Downs and Black's "Checklist for Measuring Quality" and Rob 2.0 tool. Certainty of yielded evidence was evaluated with the GRADE system. Seventy-four articles were included on 1781 patients treated for the reconstruction of diaphyseal bone defects, 1496 cases in the inferior limb, and 285 in the upper limb, with trauma being the main cause of bone defect. The meta-analysis identified different outcomes in terms of results and risks. Primary union, complications, and reinterventions were 75%, 26% and 23% for bone allografts and autografts, 91%, 62% and 19% for the bone transport group, and 78%, 38% and 23% for fibular grafts; mean time to union was between 7.8 and 8.9 months in all these groups. Results varied according to the different aetiologies, endoprosthesis was the best solution for tumour, although with a 22% failure rate, while trauma presented a more composite outcome, with fibular grafts providing a faster time to union (6.9 months), while cancellous and cortical-cancellous grafts caused less complications, reinterventions, and failures. The literature about this topic has overall limited quality. However, important conclusions can be made: Many options are available to treat critical-size defects of the diaphysis, but no one appears to be an optimal solution in terms of a safe, satisfactory, and long-lasting outcome. Regardless of the bone defect cause, bone transport techniques showed a better primary union rate, but bone allograft and autograft had fewer complication, reintervention, and failure rates than the other techniques. The specific lesion aetiology represents a critical aspect influencing potential and limitations and therefore the choice of the most suitable technique to address the challenging large diaphyseal defects.

Balance Remains Impaired after Hip Arthroplasty: A Systematic Review and Best Evidence Synthesis.

BACKGROUND: Hip arthroplasty (HA) is the most common intervention for joint replacement, but there is no consensus in the literature on the real influence of this procedure on balance, or on what factors in the pre-operative, surgical, and post-operative stages may affect it. PURPOSE: To synthesize the evidence on how Hip Arthroplasty (HA) affects balance, identifying pre-operative, surgical, and postoperative risk factors that may impair balance in HA patients, with the aim to improve patients' management strategies. METHODS: A literature search was performed on PubMed, PeDRO, and Cochrane Collaboration on 25 May 2021. INCLUSION CRITERIA: clinical report of any level of evidence; written in English; with no time limitation; about balance changes in hip osteoarthritis (OA) patients undergoing HA and related factors. RESULTS: 27 papers (391 patients) were included. Overall, the evidence suggested that balance is impaired immediately after surgery and, 4-12 months after surgery, it becomes better than preoperatively, although without reaching the level of healthy subjects. A strong level of evidence was found for hip resurfacing resulting in better balance restoration than total HA (THA), and for strength and ROM exercises after surgery positively influencing balance. CONCLUSION: Both the surgical technique and the post-operative protocols are key factors influencing balance; thus, they should be carefully evaluated when managing hip OA in patients undergoing HA. Moreover, balance at 4-12 months after surgery is better than preoperatively, although without reaching the level of the healthy population. Attention should be paid in the early post-operative phase, when balance may be impaired in patients undergoing HA.

PHILOS Synthesis for Proximal Humerus Fractures Has High Complications and Reintervention Rates: A Systematic Review and Meta-Analysis.

PURPOSE: The aim of this study was to quantify the rate of complications and reinterventions in patients treated with PHILOS plate for proximal humerus fractures (PHFs) synthesis. METHODS: A comprehensive literature search was performed on the PubMed, Web of Science, Embase, and Cochrane databases up to 7 October 2021. Studies describing medium and long-term complications in PHF synthesis using the PHILOS plate were included. A systematic review and meta-analysis were performed on complications and causes of reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black's "Checklist for Measuring Quality". RESULTS: Seventy-six studies including 4200 patients met the inclusion criteria. The complication rate was 23.8%, and the main cause was screw cut-out (4.1%), followed by avascular necrosis (AVN) (3.1%) and subacromial impingement (1.5%). In patients over 55 years, the complication rate was 29.5%. In the deltopectoral (DP) approach the complication rate was 23.8%, and in the delto-split (DS) it was 17.5%, but no difference between the two approaches was seen when considering the type of fracture. The overall reintervention rate was 10.5% in the overall population and 19.0% in older patients. CONCLUSIONS: Proximal humerus synthesis with a PHILOS plate has high complications and reintervention rates. The most frequent complication was screw cut-out, followed by humeral head AVN and subacromial impingement. These results need to be further investigated to better understand both the type of patient and fracture that is more at risk of complications and reintervention and to compare pros and cons of the PHILOS plate with respect to the other solutions to manage PHFs.

One-stage bilateral unicompartmental knee arthroplasty is a suitable option vs. the two-stage approach: a meta-analysis.

To compare one-stage vs. two-stage bilateral unicondylar knee arthroplasty (UKA) in terms of complications, mortality, reinterventions, transfusion rate, days to discharge, and outcomes for the treatment of bilateral mono-compartmental knee osteoarthritis.A systematic review was performed in the PubMed, Web of Science, and Cochrane databases up to February 2021. Randomized controlled trials, case-control studies, and case series describing the use of bilateral UKA were retrieved. A meta-analysis was performed on complications, mortality, reinterventions, transfusion rate, and days to discharge comparing one-stage vs. two-stage replacement, and outcomes were also reported. Assessment of risk of bias and quality of evidence was performed with the Newcastle-Ottawa Scale.Fifteen articles were included on 1451 patients who underwent bilateral UKA (44.9% men, 55.1% women, mean age 66 years). The systematic review documented, for bilateral one-stage UKA: 2.6% major and 5.4% minor complication rates, 0.5% mortality, 1.9% reintervention, 4.1% transfusion rates, and 4.5 mean days to discharge. No studies reported functional differences. The meta-analysis did not find differences for major complications, minor complications, mortality, reintervention, transfusion rates, or days to discharge versus two-stage bilateral procedures. The operative time was 112.3 vs. 125.4 minutes for one-stage and two-stage surgeries, respectively. The overall quality of the retrieved studies was high.Bilateral single-stage UKA is a safe procedure, with a few complications, and overall positive clinical results. No differences were found in terms of complications, mortality, reinterventions, transfusion rate, and days to discharge in comparison with the two-stage approach. Cite this article: EFORT Open Rev 2021;6:1063-1072. DOI: 10.1302/2058-5241.6.210047.

A taper-fit junction to improve long bone reconstruction: A parametric In Silico model.

PURPOSE: Critical size long bone defects represent a clinical challenge in orthopaedic surgery. Various grafting techniques have been developed through the years, but they all present several downsides. A key requirement of all grafting techniques is the achievement of a continuous interface between host bone and graft to enhance both biological processes and mechanical stability. This study used a parametric in silico model to quantify the biomechanical effect of the inaccuracies inherent to current osteotomy techniques, and to test a new concept of accurate taper-fit junction that may improve the biomechanical parameters of the reconstruction under load. METHODS: A population-based in-silico 3D model of the reconstruction of a long bone defect was built to represent a defect of the femoral mid-diaphysis. To fix the reconstruction a titanium plate was placed on the lateral aspect of the reconstruction. The model was modified to (i) quantify the biomechanical consequences of actual inaccuracies in the realization of a flat host-graft interface, (ii) compare the contact behaviour and bone strains among different taper angles of the new design and the current host-graft flat interface, (iii) evaluate the robustness of the taper-fit design to inter-subject variability in bone geometry and defect length. RESULTS: The influence of 2° single-plane misalignments of the host-graft interface is highly dependent on the misalignment orientation with respect to the metal plate. For some misalignment orientations, tangential micromotions of contact interfaces exceeded alert thresholds. When the angle of the taper-fit host-graft junction is changed from 10° to 30° and the results obtained are compared with the planar case, the overall stiffness is almost preserved, the bone strains are almost unchanged with safety factors higher than five, and full contact closure around the host-graft junction is achieved at 20°. Similarly, contact pressures decrease almost linearly with a 20% decrease at 30°. The host-graft micro motions are almost unchanged in both value and distribution up to 20° and never exceed the warning threshold of 50 µm. CONCLUSIONS: The present in silico study developed quantitative biomechanical evidence that an osteotomy performed with attention to the perpendicularity of the cut planes is needed to reduce the risk of mismatch and possible complications of long bone reconstructions, and that a new concept of a taper-fit junction may improve the biomechanical environment of the interface between the graft and the host bone. The optimal taper-fit configuration is suggested to be around a 20° taper angle. These results will serve as an input to conduct exvivo experiments to further corroborate the proposed taper-fit junction concept and to refine its surgical implementation.