Perioperative and Radiographic Outcomes Between Single-Position Surgery (Lateral Decubitus) and Dual-Position Surgery for Lateral Lumbar Interbody Fusion and Percutaneous Pedicle Screw Fixation: Meta-Analysis.

OBJECTIVE: Lateral lumbar interbody fusion (LLIF) and percutaneous posterior screw fixation (PPSF) techniques is used to treat degenerative lumbar pathologies. Dual-position (DP) lumbar surgery involves repositioning the patient from the supine or lateral decubitus position to prone for posterior fixation. Single-position (SP) lumbar surgery is commonly performed nowadays, a minimally invasive alternative performed entirely from the lateral decubitus position. However, controversy still exists. This meta-analysis aimed to compare perioperative outcomes between SP lumbar surgery and DP lumbar surgery for LLIF and PPSF. METHODS: We conducted this meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched Medline and Scopus from inception to November 11, 2021, for relevant studies. RESULTS: Six studies were identified, which contained totals of 502 and 447 patients in the SP and DP groups, respectively. The unstandardized mean difference in operative time, length of hospital stay, intraoperative blood loss, radiation doses, lumbar lordosis, and pelvic incidence-lumbar lordosis mismatch were -86.1 (95% confidence interval [CI] -149.2 to -23.1) minutes, -1.6 (95% CI -2.4 to -0.9) days, -55.6 (95% CI -127.5 to 16.2) mL, -30.3 (95% CI -80.5 to 19.8) mGy, 1.34 (95% CI -1.17 to 3.86) degrees, and -4.06 (95% CI -5.65 to -2.47) lower in SP when compared with DP. The chances of having complications and reoperations in SP were 0.75 (95% CI 0.49-1.14) and 0.77 (95% CI 0.44-1.36) times, respectively, compared with the DP group. No significant differences were found for intraoperative blood loss, radiation dose, lumbar lordosis, complications, and reoperations between the 2 groups. CONCLUSIONS: This meta-analysis found that SP have lower operative time and length of hospital stay compared with DP LLIF and PPSF. However, no differences in intraoperative blood loss, radiation dose, radiographic change, complications, and reoperation rates were found.

Risk factors for polyetheretherketone cage subsidence following minimally invasive transforaminal lumbar interbody fusion.

BACKGROUND: Interbody cage subsidence is a postoperative complication leading to poor outcomes after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). This study aimed to identify risk factors of cage subsidence in lumbar spinal diseases after MIS-TLIF using polyetheretherketone (PEEK) cage. METHODS: In this retrospective cohort study, plain radiographs and three-dimensional computed tomography (3D-CT) performed 12 months after MIS-TLIF were evaluated, and the risk of cage subsidence was calculated with odds ratio (OR), confidence interval (CI), and logistic regression analysis. RESULTS: A total of 114 patients (mean age, 65 years) and 135 levels were included in this study: 80 (59.3%) with and 55 (40.7%) without cage subsidence. Multifidus atrophy showed the strongest association with PEEK cage subsidence (p < 0.001). Compared to those with normal mass, the odds of PEEK cage subsidence were 76.0 (95% CI: 3.9-1472.9) for severe atrophy. The factors significantly associated with cage subsistence were posterior cage position (OR = 4.2; p = 0.005), cage height ≥ 12 mm (OR = 7.6; p = 0.008), use of an autograft mixed with demineralized bone matrix (DBM) (OR = 5.8; p = 0.002), body mass index (BMI) > 27.5 kg/m2 (OR = 4.2; p = 0.03), and titanium-coated PEEK (Ti-PEEK) cage-type (OR = 38.4, p = 0.02). CONCLUSIONS: In MIS-TLIF with a PEEK cage, the factors associated with an increased risk of cage subsidence were higher BMI, increased severity of multifidus muscle atrophy, Ti-coated PEEK cage-type, cage height ≥ 12 mm, use of DBM mixed autograft, and posterior cage position.

Comparative surgical risk between type of trampoline (size and place) and type of patients (age and sex) in trampoline related injury: a systematic review and indirect meta-analysis.

BACKGROUND: Despite its high risk of injury, many people are still favor trampolining. However, currently there is no consensus as to which type of trampoline and which type of participant is more likely to have a trampoline related injury that will require surgical management. METHODS: This systematic review and meta-analysis aims to assess and compare the factors that cause trampoline injuries requiring surgical treatment. These include the place of the trampoline (park versus home), size of the trampoline (full versus mini), the age of the participant (child versus adult) and the sex of the participant (male versus female). The clinical outcomes measured are surgical management after trampoline injury. This systematic review was conducted according to the PRISMA guidelines. RESULTS: Relevant studies that reported surgery after trampoline injury of either group were identified from Medline and Scopus from inception to May 14, 2019. Sixteen studies were included for the analysis of surgery after trampoline injury; a total of 4491 and 1121 patients were treated conservatively and surgically. The total surgery rate per patient was 31% (95% CI: 16, 46%) in all patients. The surgery rate was 0.3 (95% CI: 0.03, 0.58) and 0.06 (95% CI: 0.04, 0.09) in the full and mini size trampoline groups. There were 0.36 (95% CI: 0.06, 0.67) and 0.11 (95% CI: 0.0, 0.22) in the park and home trampoline groups. The surgery rates were 0.33 (95% CI: 0.14, 0.53), 0.24 (95% CI: 0.07, 0.11), 0.49 (95% CI: 0.47, 0.51) and 0.38 (95% CI: 0.22, 0.53) in children, adults, females and males respectively. Indirect meta-analysis shows that full size trampolines provided a 6.0 times higher risk of surgery (95% CI: 3.7, 9.7) when compared to mini size trampolines. Park trampolines had a higher risk of surgery of 2.17 (95% CI: 1.70, 2.78) when compared to home trampolines. In terms of age and sex of participants, there value was significantly higher at 1.65 (95% CI: 1.35, 2.01) and 1.54 (95% CI: 1.36, 1.74) in children compared to adults and females compared to males. From all the statistical data we summarized that the full size trampoline injuries have a 6 times higher risk of requiring surgery when compared to mini size trampoline injuries. Park trampoline use carries a 2 times higher risk of requiring surgery when compared to home trampoline use. In terms of age and sex of the participant, there is a 1.5 times significantly higher risk of injury in children compared to adults, and females when compared to males. CONCLUSION: In trampoline related injuries, full size, park trampoline, children and females had higher surgery rates when compared to mini size, home trampoline, adult and male majority in indirect meta-analysis methods.

Comparison of 1-year outcomes between MAKO versus NAVIO robot-assisted medial UKA: nonrandomized, prospective, comparative study.

BACKGROUND: We have conducted a prospective cohort study with the aim of comparing operative time, intraoperative blood loss, and radiologic and clinical outcomes between imageless (NAVIO) and image-based (MAKO) robot-assisted unicompartmental knee arthroplasty (UKA) for medial compartment osteoarthritis (OA) of the knee. METHODS: A total of 33 patients with medial compartment OA of the knee were prospectively allocated on alternate operative days of their surgery to MAKO (16 patients) or NAVIO (17 patients) robot-assisted UKA. The primary outcome (Knee Society Score [KSS] and Knee Functional Score [KFS]) and the secondary outcomes (intraoperative time of seven steps [registration of hip and ankle, femur and tibia, ligament tension, implant planning, preparation femur, tibia and trial implant], component alignment [coronal and sagittal of femur, tibia implant], blood loss, complications, and revision at 1 year after surgery) were compared between two groups. Statistical significance was set at P < 0.05. RESULTS: Mean KSS measured at baseline and 1 year were, respectively, 70.3 (5.6) and 96.9 (5.7) in the NAVIO group and 72.3 (4.5) and 94.7 (10.01) in the MAKO group. Mean KFS measured at baseline and 1 year were, respectively, 95.5 (7.9) and 99.9 (0.25) in the NAVIO group and 67.3 (7.8) and 99.5 (1.2) in the MAKO group. There were no significant differences for KFS and KSS outcomes (P = 0.203 and P = 0.457, respectively) between the NAVIO and MAKO groups. Mean operative time and blood loss in the NAVIO versus MAKO robot-assisted UKA groups were 98 min versus 82.5 min and 136.3 ml versus 80 ml, respectively, and these differences were statistically significant. In the MAKO group, the intraoperative time was statistically significantly shorter in registration of hip and ankle center, femur and tibia, femur preparation, and trial implantation compared with the NAVIO group. There were no significant differences of component alignment and radiologic alignment at 1 year between the two groups. No perioperative or delayed complications (infection, periprosthetic fracture, thromboembolism, and compromised wound healing) and revisions were reported in either group. CONCLUSIONS: This study demonstrated that two robotic systems showed no difference in clinical outcomes at 1 year and radiologic alignment of implants, whereas operative time and intraoperative blood loss were found to be less in MAKO robot-assisted UKA. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03954912. Registered on 17 May 2019. LEVEL OF EVIDENCE: II.

Comparison of surgical outcomes between rotator cuff repair with and without rotator interval capsular release for rotator cuff tears to prevent and improve postoperative stiffness: a meta-analysis.

BACKGROUND: A common complication of rotator cuff (RC) repair is a postoperative stiffness. Postoperative stiffness may develop and lead to inferior functional outcomes. Rotator cuff repair with additional rotator interval (RI) capsular release can be done to prevent postoperative stiffness in rotator cuff tears. However, routine rotator interval capsular release in rotator cuff repair is controversial. Therefore, we conducted a systematic review and meta-analysis to compare the postoperative outcomes between RC repair with and without RI capsular release for RC tears with and without concomitant stiffness. METHOD: We searched all comparative studies that compared postoperative outcomes (VAS, CS, ASES, complications and ROM at 3, 6 and 12 months) of RC repair with and without RI capsular release for RC tears with and without concomitant stiffness from PubMed and Scopus databases from inception to the February 1, 2020. RESULTS: Seven of 255 studies (six comparative studies and one RCT) (N = 803 patients) were eligible; 2 and 5 studies were included in the pooling of RC repair and RI release without concomitant stiffness and stiffness, respectively; 2, 6, 3, 6, 3, 5, 7, 7, and 7 studies were included in pooling of VAS, CS, ASES at 6 and 12 months and range of motion (internal, external rotation and forward flexion) at 3, 6 and 12 months, respectively. The UMD of VAS, CS and ASES scores at 6- and 12-month follow-up for the RC repair and RI release group was 0.48 (95% CI: 0.05, 0.90), 0.93 (-1.70, 3.56), -2.27 (-5.30, 0.76), -0.04 (-0.24, 0.15), 1.66 (0.77, 2.55) and 1.58 (0.21, 2.96) scores when compared to RC repair alone with and without concomitant stiffness. In terms of ROM, forward flexion for the RC repair and RI release group was -4.60 (-10.61, 1.41), -7.11 (-15.47, 1.25) and -0.70 (-2.51, -1.11) degrees at 3, 6 and 12 months, respectively, when compared to RC repair alone. For external rotation, RC repair and RI release were -0.12 (-8.27, 8.03), -3.98 (-12.09, 4.14) and -2.65 (-5.35, 0.04) degrees at 3, 6 and 12 months, respectively, when compared to RC repair alone. For internal rotation in RC repair and RI release, the values were -1.22 (-1.97, - 0.48), -1.01 (-1.79, -0.23) and -0.19 (-1.13, 0.74) degrees at 3, 6 and 12 months, respectively, when compared to RC repair alone. There were no differences with a RR of 0.92 (0.46, 1.84) between the two groups in terms of complications. After subgroup analysis, RC repair with RI release had no clinically significant differences for pain, function and ROM when compared to RC repair alone in RC tear patients with and without preoperative stiffness. CONCLUSIONS: RC repair with RI release in patients with and without preoperative stiffness had no statistically significant differences for pain, function (CS and ASES) and range of motion (FF, ER and IR) when compared to RC repair alone in RC injury patients. LEVEL OF EVIDENCE: II.

Clinical outcomes of chronic Achilles tendon rupture treated with flexor hallucis longus grafting and flexor hallucis longus grafting plus additional augmentation: A meta-analysis.

BACKGROUND: The treatment of chronic Achilles tendon rupture is still controversial. Many surgical procedures have been proposed and claim to have good post-operative clinical outcomes. These techniques include direct repair, V-Y flap, turndown flap, peroneus brevis tendon graft, flexor digitorum longus graft, FHL graft, semitendinosus graft, gracilis tendon graft or synthetic material. The two surgical techniques that are widely used include FHL grafting and the combination of FHL grafting plus additional augmentation. This meta-analysis was conducted with the purpose of comparing clinical outcomes of flexor hallucis longus (FHL) grafting and the combination of FHL grafting with additional augmentation techniques in the treatment of chronic Achilles tendon rupture. METHODS: Systematic literature searches were conducted on Medline, Embase and Scopus from their inception to April 4, 2019, and proceedings of reference list and scientific meetings were also searched. Relevant clinical studies (e.g., observational, cross-sectional, cohort or randomized controlled trial (RCT)) that reported AOFAS (American Orthopedic Foot Ankle Score) and postoperative complications of either technique were identified. RESULTS: Six studies (N = 68) were included for the analysis of FHL, and six studies (N = 124) were included for analysis of FHL with augmentation. A pooling of mean and standard deviation of preoperative and postoperative AOFAS were 57.09 (3.63), 92.97 (22.67) in FHL group and 66.92 (3.16), 95.25 (4.71) in FHL with additional augmentation group respectively. The pooled UMD of AOFAS in FHL with additional augmentation were 2.28 (-1.86, 6.42) scores higher when compared to the FHL group. The prevalence of complications in FHL and FHL with additional augmentation were 14 (N = 120) and 10 (N = 63) patients. The chance of having complications of FHL with additional augmentation group was 0.74 (95% CI: 0.35, 1.56) lower than FHL group. However, there is no statistically significant difference. CONCLUSIONS: FHL with additional augmentation group has higher foot function scores (AOFAS) and lower complications when compared to the FHL group. However this did not reach to statistically significant. Further research that assesses a larger sample size of RCTs is necessary to further evaluate FHL with additional augmentation and FHL in the treatment of chronic Achilles tendon rupture.

Efficacy of platelet-rich plasma in posterior lumbar interbody fusion: systematic review and meta-analysis.

INTRODUCTION: We have conducted a systematic review and meta-analysis that aims to compare outcomes (pain VAS, fusion and adverse event) of PRP and placebo after posterolateral lumbar fusion (PLF) surgery. MATERIALS AND METHODS: This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies were identified from Medline and Scopus from inception to September 16, 2019 that reported visual analog scale back pain, postoperative complications and fusions of either group. RESULTS: In a total of seven studies, two, two, three studies were RCT, prospective and retrospective studies, respectively. Overall, there were 270 patients (150 in the PRP group and 149 in the placebo group). Three, three, four, three, two, seven and four studies were reported for pain VAS back in 3 months, 6 months, 12 months, 24 months, period of fusion, postoperative fusion and adverse events, respectively. The unstandardized mean difference (UMD) VAS back in 3, 6, 6 and 24 months was - 0.41 (95% CI - 0.87, 0.05) score, - 0.97 (95% CI - 1.68, - 0.27) score, - 0.33 (95% CI - 0.61, - 0.59) score, - 0.19 (95% CI - 1.00, 0.62) scores lower than placebo after posterolateral lumbar fusion (PLF) patients. The UMD period of bone union were - 1.62 (95% CI - 1.85, - 1.39) months faster than placebo after PLF patients. A total of seven and four studies were reported fusion and adverse events between PRP and placebo group. No significant differences were noted for fusion and adverse events with the pooled RR of 1.03 (95% CI 0.48, 1.80) and 0.95 (95% CI 0.14, 6.56). CONCLUSIONS: PRP with autologous bone graft had lower back pain and faster bone union time than bone graft alone. While, there have no difference in fusion rate and adverse events in both groups. Larger, prospective randomized controlled studies are needed to confirm these findings as the current literature is still insufficient. Further research including cost of operation, postoperative function and satisfaction, quality of life and cost-efficacy analysis is required to determine whether the PRP with autologous bone graft is superior to bone graft alone or not. LEVEL OF EVIDENCE: Level II.

Full-endoscopic (bi-portal or uni-portal) versus microscopic lumbar decompression laminectomy in patients with spinal stenosis: systematic review and meta-analysis.

BACKGROUND: Lumbar stenosis causes pain in the lower lumbar spine and lower extremities and reduces the patient's quality of life and walking ability. Thus, these conditions are common surgical indications for spinal stenosis. Previous reports have shown satisfactory clinical outcomes of the full-endoscopic (FE) and MI technique decompressive laminectomy for lumbar stenosis. However, they still remain controversial. OBJECTIVE: We conducted a systematic review and meta-analysis to compare the postoperative outcomes between FE (bi-portal or uni-portal) and MI technique decompressive laminectomy for lumbar stenosis. METHOD: We searched all comparative studies that compared postoperative outcomes (operative time, VAS for back and leg pain, ODI in 3 months and last follow-up) of full-endoscopic (bi-portal or uni-portal) and microscopic technique decompressive laminectomy for lumbar stenosis from the PubMed and Scopus databases up to October 16, 2019. RESULTS: Nine of 1107 studies (five comparative studies and four RCT) (N = 994 patients) were eligible; all studies were included in pooling of FE and MI decompression. Five and three studies were included in pooling of bi-portal endoscopic, uni-portal endoscopic and MI decompression. All three techniques were compared in one study. Eight, nine, seven, eight, five, seven, eight and nine studies were included in pooling of VAS for back, leg, ODI in 3 months and last follow-up and operative time, respectively. The UMD of VAS for back, leg, ODI in 3 months and last follow-up of FE group was - 0.63 (95% CI - 1.15, - 0.12), - 0.15 (- 0.42, 0.11), - 2.06 (- 3.76, - 0.39), - 0.07 (- 0.22, 0.08), - 0.16 (- 0.29, - 0.03), - 0.20 (- 1.20, 0.81) scores and - 3.00 (- 12.25, 6.25) minutes when compared to MI in lumbar stenosis. In terms of complication, FE was lower risk of 0.62 (0.40, 0.96) times when compared to MI. After subgroup analysis, BESS had significant lower back and leg pain within 3 months when compared to MI group, while uni-portal FE had significant lower leg pain in the last follow-up and complication when compared to MI group. There had no difference in ODI and operative time between two groups. CONCLUSION: FE had statistically significant lower back pain, lower leg pain and lower risk of having complications when compared to MI decompression in lumbar stenosis, while there is no difference in ODI and operative time between both groups. Comparing to MI, BESS had better early postoperative back pain while uni-portal FE had better leg pain and risk of having complications. Larger, prospective randomized controlled studies are needed to confirm these findings as the current literature is still insufficient. LEVEL OF EVIDENCE: III.

Comparative outcomes of foot cast and short leg cast in pseudo-Jones avulsion fracture: a single blinded randomized controlled trial.

BACKGROUND: Fractures of the metatarsal bones account for 35% of all foot fractures. Conservative management of fractures proximal to the metaphyseal-diaphyseal junction of the fifth metatarsal bone (pseudo-Jones) is by protected weight bearing. The methods of protected weight bearing include short-leg casting and splinting (boot cast, Jones's bandage and elastic bandage). However, currently there is no consensus as to which method is the most suitable. METHOD: We have conducted a randomized controlled trial to compare outcomes of foot casting (FC) and short leg casting (SLC) to assess pain, function and complication outcomes for the treatment of pseudo-jones metatarsal fractures. This single-center, single blind,randomized controlled trial was conducted between 1 June 2016-1 July 2018 at Police General Hospital, Bangkok, Thailand. RESULT: A total of 72 pseudo-jones metatarsal fracture participants were randomly allocated to treatment by foot cast or short leg cast. The primary outcomes were pain VAS, AOFAS and complications measured at 2, 4, 6 and 8 weeks after receiving the treatment. Seventy-two patients (36 paticipants per group) were enrolled to receive either FC or SLC. The mean VAS measured at baseline, 2 weeks, 4 weeks, 6 weeks and 8 weeks were 7.36, 1.97, 0.58, 0.17 and 0.08 respectively in the FC group; and 6.09, 2.91, 1.23, 0.37 and 0.11 respectively in the SLC group. The mean AOFAS at baseline, 2, 4, 6 and 8 weeks were 33.60, 68.22, 82.72, 91.75 and 98.11 respectively in the FC group; and 32.60, 60.20, 70.20, 92.24 and 99.13 in the SLC group. The estimated mean difference of pain VAS and AOFAS at 2 weeks and 4 weeks were - 0.94 (95% CI: - 1.53, - 0.34), - 0.65 (95%CI: - 1.24, - 0.05), 8.02 (95%CI: 3.74, 12.10) and 12.52 (95%CI: 8.27, 16.78), which were statistically significantly better in the FC groups when compared to the SLC groups. However, there were no statistically significant difference between the two groups at 6 and 8 weeks. CONCLUSION: This study demonstrated that the application of foot casting can improve pain VAS and AOFAS function at 2 and 4 weeks in the treatment of pseudo-jones metatarsal fractures when compared to short leg casting. However, at 6 and 8 weeks, there were no statistically significantly different between the two groups.

Comparison of Complications and Revisions After Sacral 2 Alar Iliac Screw and Iliac Screw Fixation for Sacropelvic Fixation in Pediatric and Adult Populations: Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review and meta-analysis aims to assess and compare the postoperative outcomes of iliac screw (IS) fixation versus sacral 2 alar iliac (S2AI) screw fixation in the adult and pediatric populations. METHODS: We searched all comparative studies that compared postoperative outcomes of IS and S2AI fixation techniques for pelvic fixation from the PubMed and Scopus databases up to June 23, 2019. RESULTS: Eleven of 951 studies (N = 632 patients) were eligible; 8, 10, 5, 6, 3, 7, 2, and 2 studies were included in pooling of postoperative complications, revisions, implant failure, screw breakage, screw prominence, wound dehiscence, wound infection, visual analog scale (VAS), and ambulatory status (AS), respectively. The IS technique had a statistically significant higher chance of postoperative complications, revisions, implant failure, screw breakage, screw prominent, wound dehiscence, and wound infection by 1.89 (95% confidence interval [CI], 1.48-2.40), 1.91 (95% CI, 1.29-2.82), 2.28 (95% CI, 1.55-3.35), 3.96 (95% CI, 1.46-10.75), 6.83 (95% CI, 2.54-18.37), 4.62 (95% CI, 1.32-16.25), and 3.03 (95% CI, 1.62-5.66), respectively compared with the S2AI fixation technique. In subgroup analysis, the IS technique had a statistically significant higher chance of postoperative complications and revisions of 1.65 (95% CI, 1.25-2.16) and 1.71 (95% CI, 1.03-2.84) in pediatric populations and 2.32 (95% CI, 1.60-3.38) and 1.94 (95% CI, 1.00-3.73) in the adult populations compared with the S2AI fixation technique. IS screw fixation had a lower AS of -0.40 (95% CI, -0.76 to -0.15) than did S2AI fixation in the adult and pediatric populations. However, there was no difference in pain VAS between both groups. CONCLUSIONS: Sacropelvic fixation with IS screw fixation had more postoperative complications and revisions and lower AS than did S2AI fixation.

Comparative outcomes between collared versus collarless and short versus long stem of direct anterior approach total hip arthroplasty: a systematic review and indirect meta-analysis.

INTRODUCTION: Early research shows several advantages of the direct anterior approach (DAA) in THA that claimed to be as effective but less invasive than the posterior approach. However, due to the difficult femoral exposure and possible complications related to femoral preparation, this approach may result in a higher rate of undersized stems when compared to other approaches. The present authors believe that the femoral implant design (collar or collarless stem, short or long stem) in a collared femoral stem may relate to lower rates of stem subsidence and limb length discrepancy (LLD) in mid-term to long-term follow-up when compared to collarless femoral stems. However, currently, there is no consensus as to which femoral implant design is the most suitable for DAA in THA. METHODS: This systematic review and meta-analysis aim to assess and compare postoperative complications (neurapraxia, wound infection, LFCN, hematoma, artery injury, cup malposition, embolism, fracture and implant loosening) and revision rates due to dislocation, periprosthetic fracture and implant migration after DAA using collared compared to collarless femoral stem and short femoral stem compared to long femoral stem in THA. These clinical outcomes consist of the postoperative complications and revision femoral stem due to neurapraxia, wound, LFCN and LLD. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Relevant studies that reported postoperative complications and revision of either implant were identified from Medline and Scopus from inception to June 6, 2018. Thirty-four studies were included for the analysis of DAA in THA; 23 studies were retrospective cohorts, four studies were prospective cohorts, and seven studies were RCTs. Thirty-one studies and three studies were included for analysis of collarless and collared femoral stems. Twenty-six studies were long femoral stems and eight studies were short femoral stems. Overall, there were 6825 patients (6457 in the collarless group and 368 in the collared group, 4280 in long stem and 2545 in short stem). A total of 469 and 66 patients had complications and revisions in the collarless group, and no patient had complications and revisions in the collared stem group. The total complication and revision rate per patient were 5% (95%CI 3.3%, 7%) and 0.9% (95%CI 0.6%, 1.2%) in all patients. The complication rate and revision rate were 5.7% (95%CI 3.8%, 7.7%) and 0.9% (95%CI 0.6, 1.2) in the collarless group. There was no prevalence of complications and revisions in the collared stem group. The complication rate and revision rate were 10.2% (95%CI 9%, 11.4%), 0.7% (95%CI 0.3%, 1%) and 5.2% (95%CI 3.1, 7.2), 1.5% (95%CI 1%, 2%) in short and long femoral stems, respectively. Indirect meta-analysis shows that collared femoral stem provided a lower risk of complications of 0.02 (95%CI 0.001, 0.30) when compared to collarless femoral stem. Long femoral stems had a lower risk of having complications of 0.57 (95%CI 0.48, 0.68) when compared to short femoral stems. In terms of revision, there is no statistically significant difference in collared femoral stem compared to collarless femoral stem and long femoral stem compared to short femoral stem. CONCLUSION: In DAA THA, collared femoral stem and long femoral stem had decreased complication rates when compared to collarless femoral stem and short femoral stem by both direct and indirect meta-analysis methods. However, in terms of revision rates, there were no differences between all femoral stems (short versus long and collared versus collarless). Prospective randomized controlled studies are needed to confirm these findings as the current literature is still insufficient.

A new method for measurement of the size of subacromial spurs of the shoulder by cassette tilt view.

OBJECTIVE: Subacromial impingement syndrome is one of the most common causes of pain in the shoulder. To this date, there is no specific radiographic view that can be used to evaluate the size of a subacromial spur. This study aims to examine a cassette tilt view can be used to evaluate the size of a subacromial spur. METHODS: A cross-sectional study was conducted between the time period of January 1, 2016, and December 31, 2016. Forty-three consecutive patients that had planned treatment of arthroscopic subacromial decompression (SAD) participated in this study. Rockwood view and cassette tilt view (caudal tilt 30  with beam and cassette) X-rays were done in all these patients. The measurements of the spur sizes were calculated from both views and were compared to the spur sizes measured intraoperatively. RESULT: The size of the spurs from intraoperative measurement was not significantly different from the spur size measured using the cassette tilt view with a mean difference of 0.54 (95% confidence interval (CI): - 0.58, 1.65), but the intraoperative measurement was significantly different from the Rockwood view spur measurement, with a mean difference of 2.84 (95% CI: 1.56, 4.11). Average proportions of the size of the spur from the cassette tilt and Rockwood view compared to that from intraoperative measurements were 1.09 and 1.55, respectively. CONCLUSION: The cassette tilt view is a simple method of measurement of the size of subacromial spurs, with good inter- and intra-observer reliabilities and good validity. This can be useful clinically when setting the patient position and portals to evaluate the size of the spur when planning SAD. LEVEL OF EVIDENCE: This is level III.

Comparative Outcomes of Cast and Removable Support in Fracture Fifth Metatarsal Bone: Systematic Review and Meta-Analysis.

Fractures of the metatarsals account for 35% of all foot fractures. Conservative management of fractures proximal to the metaphyseal-diaphyseal junction of the fifth metatarsal bone (pseudo-Jones) is protected weightbearing. The methods of protected weightbearing include a short-leg cast and splint (boot cast, Jones bandage, and elastic bandage). However, no consensus has yet been reached regarding which method is most suitable. We conducted a systematic review and meta-analysis to compare the outcomes of a short-leg cast and splint for pseudo-Jones metatarsal fractures. We searched the PubMed and Scopus databases up to October 29, 2016. Five of 104 studies (3 comparative studies and 2 randomized controlled trials; n = 246 patients) were eligible. Of the studies, 3, 5, and 4 were included in pooling of early (within 1 month) and last follow-up foot function scale scores and fracture nonunion, respectively. The unstandardized mean difference of early (within 1 month) and last follow-up foot scores for the short leg cast were -14.58 (95% confidence interval [CI] -24.12 to -5.04) and -3.89 (95% CI -6.30 to -1.49), significantly lower than the scores for the splint (bandage or boot support) for pseudo-Jones fracture of the fifth metatarsal bone. The risk of nonunion of the fifth metatarsal bone fracture of the patients who were treated with short leg cast method was insignificantly greater at 1.57 times (95% CI 0.29 to 8.49) that compared with the splint. The treatment of fracture of the pseudo-Jones fifth metatarsal bone with a splint (boot or bandage) resulted in foot function scale scores better than those with short leg cast treatment and a lower nonunion rate.

Comparative Outcomes of Perioperative Epidural Steroids After Percutaneous Endoscopic Lumbar Discectomy for Lumbar Disc Herniation: A Randomized Placebo-Controlled Trial.

OBJECTIVE: To assess postoperative outcomes and complications after percutaneous endoscopic lumbar discectomy (PELD) with or without epidural steroids (ES) administration in lumbar disc herniation. METHODS: In a double-blind randomized, placebo-controlled trial at Ramathibodi Hospital, Mahidol University, from May 2014 to May 2015, 30 patients were randomly allocated to receive ES or placebo (saline) after PELD. The primary outcome was 24-hour morphine consumption. Secondary outcomes were visual analog scale (VAS) scores for leg and back pain, Oswestry Disability Index score, Roland-Morris Disability Questionnaire score, and complications at 6-month follow-up. RESULTS: Mean patient age was 60.0 years, and 0.57% of patients were male. Mean VAS back pain, VAS leg pain, Oswestry Disability Index, and Roland-Morris Disability Questionnaire scores at baseline were 4.7, 6.1, 24.9, 17.5 in the ES group and 5.1, 5.5, 24.7, 16.7 in the placebo group, respectively. Mean morphine requirements measured at 8, 16, and 24 hours were 3.47, 2.67, and <0.001 in the ES group and 3.13, 1.67, and 0.40 in the placebo group. The mean VAS scores measured at 4, 8, 12, 16, 20, and 24 hours were 2.99, 2.70, 2.56, 3.30, 3.05, and 2.05 the ES group and 3.13, 1.13, 1.26, 1.65, 1.22, and 1.08 in placebo group. The difference was not statistically significant (P > 0.05 for all). CONCLUSIONS: Administration of ES with PELD for lumbar disc herniation does not improve postoperative pain, morphine requirements, or disability scores in the short-term and midterm periods.

Comparative outcomes of epidural steroids versus placebo after lumbar discectomy in lumbar disc herniation: a systematic review and meta-analysis of randomized controlled trials.

Treatment for lumbar disc herniation after failed conservative treatment is discectomy. Discectomy can significantly relieve back pain as well as radicular symptoms. However, many patients with lumbar discectomy experience moderate-to-severe back pain and radicular leg pain. The results of application of epidural steroids (ES) for pain management after lumbar discectomy have previously been inconclusive. We have conducted a systematic review and meta-analysis aims to compare outcomes (efficacy and complications) of epidural steroid application and placebo after discectomy in lumbar disc herniation. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies that reported visual analog scale of back and leg pain, morphine consumption, hospital stay and post-operative complications of either group were identified from Medline and Scopus from the date of inception to 28 October 2017. A total of 12 studies were pooled and analysed, with nine studies having undergone conventional discectomy and three studies having undergone minimally invasive surgery (MIS) discectomy. Overall, there were 1006 patients (502 in the ES group and 504 in the placebo group) included. The unstandardized mean difference of VAS of back pain at 1 week and 1 month, leg pain at 1 week and 1 month, morphine consumption and hospital stay was - 0.53 (95% CI - 1.42, 0.36) score, - 0.89 (95% CI - 1.36, - 0.42) score, - 0.63 (95% CI - 0.75, - 0.50) score, - 0.47 (95% CI - 0.78, - 0.15) score, - 8.47 (95% CI - 16.16, - 0.78) mg and - 0.89 (95% CI - 1.49, - 0.30) days lower when compared to placebo after lumbar discectomy in patients with lumbar disc herniation. A total of ten studies compared the ratio of complication between the ES and placebo groups. No significant differences were noted for complications within the two groups (0.92; 95% CI 0.47, 1.83). This meta-analysis analysed lower back and leg pain, morphine consumption and hospital stay, with no significant difference in complications for ES application after lumbar discectomy in lumbar disc herniation. In terms of surgical approaches with MIS compared to conventional approach, this review demonstrates that ES can reduce post-operative morphine consumption when the surgical approach is conventional, but not for MIS.Level of evidence I.

Fixation method for treatment of unstable distal clavicle fracture: systematic review and network meta-analysis.

Surgical management is recommended for unstable distal clavicle fractures. A variety of methods have been previously reported, but there is no current consensus regarding which method is most suitable. Therefore, we have conducted a systematic review and network meta-analysis to compare postoperative shoulder function and complications between different fixation methods to identify which class of fixation is best for unstable distal clavicle fractures. We searched the literature systematically using eligibility criteria of all comparative studies that compared postoperative outcomes of coracoclavicular fixation (tight rope, screw or endobutton), hook plating, plate and screws, tension band wiring and transacromial pinning fixation for unstable distal clavicle fractures from PubMed, EMBASE, and Scopus databases up to February 10, 2018. Two reviewers independently extracted data. A network meta-analysis was applied to combine direct and indirect evidence and to estimate the relative effects of the treatment options. The probability of being the best treatment was estimated using surface under the cumulative ranking curves (SUCRA). Ten comparative studies (n = 505 patients) with one RCT study (n = 42) met the inclusion criteria. Intervention included coracoclavicular fixation (n = 111 patients), hook plating (n = 300 patients), plate and screws (n = 41 patients), tension band wiring (n = 81 patients) and transacromial pinning (n = 14 patients). A network meta-analysis showed that CM scores of coracoclavicular fixation were significantly higher when compared to hook plate and tension band wiring, with pooled mean of 2.98 (95% CI 0.05-5.91) and 7.11 (95% CI 3.04-11.18). For UCLA, CC fixation and plate and screw fixation had significantly higher scores compared to hook plating fixation with a mean score 2.22 (95% CI 0.44-3.99) and 3.20 (95% CI 0.28-6.12), respectively. In terms of complications, plate and screw fixation had lower risk with RRs of 0.63 (95% CI 0.20-1.98), 0.37 (95% CI 0.19-0.72), 0.11 (95% CI 0.04-0.30) and 0.02 (95% CI 0.002-0.16) when compared to coracoclavicular fixation, hook plating, tension band wiring and transacromial pinning. The SUCRA probabilities of CC fixation were in the first rank with 96.8% for CMS, while plate and screw fixation were in the first rank with 67.7 and 93.8% for UCLA score and complications. We recommend using plate and screw and CC fixation as the first- and second-line treatment of unstable distal clavicle fractures. As the quality of studies for this meta-analysis was not high, larger and higher-quality randomized controlled trials are required to confirm these conclusions for informed clinical decision making.

Short-term outcomes of subacromial injection of combined corticosteroid with low-volume compared to high-volume local anesthetic for rotator cuff impingement syndrome: a randomized controlled non-inferiority trial.

BACKGROUND: In symptomatic tendinosis, a corticosteroid injection into the subacromial space is a palliative treatment option. This study compares high volumes (10 cc) of local anesthetic (LA) combined with triamcinolone acetate (TA) with low volumes (4 cc) of LA combined with TA to see whether the latter would provide similar pain, function and complication outcomes for subacromial injections in patients with impingement syndrome. MATERIALS AND METHODS: This single-center, randomized, single-blind, non-inferiority trial included patients with shoulder pain and positive multiple clinical tests supporting the diagnosis of impingement syndrome. All 52 patients received subacromial injections, with either high-volume corticosteroid injections (HCI) (10 mL total volume of 1% lidocaine plus 40 mg TA) in 26 patients or low-volume corticosteroid injections (LCI) (4 mL total volume of 1% lidocaine plus 40 mg TA) in 26 patients. The demographic data were reported with the primary outcomes being VAS and WORC scores measured at 30 min, then 2 and 8 weeks after receiving the injections. A non-inferiority margin of 13% was assumed. RESULTS: Fifty-two patients (26 patients per group) were enrolled in the HCI and LCI. Mean VAS and WORC scores of HCI and LCI at baseline were 6.96, 33.85, 6.81 and 36.54, respectively. The mean VAS measured at 30 min, 2 and 8 weeks was 4.04, 2.08 and 1.20, respectively, in HCI group and 2.65, 1.95 and 1.26, respectively, in LCI group. The mean WORC at 2 and 8 weeks was 67.46 and 81.74, respectively, in HCI group and 65.42 and 80.12 in LCI group. These were not statistically significantly different (P > 0.05 in all). CONCLUSION: Corticosteroid injections can be used in the treatment of subacromial impingement syndrome. Low-volume (4 cc) corticosteroid injections have non-inferior pain results for VAS score when compared with high-volume (10 cc) corticosteroid injections. CLINICALTRIALS.GOV: NCT03120923. LEVEL OF EVIDENCE: Level I.

Clinical outcomes after minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion for treatment of degenerative lumbar disease: a systematic review and meta-analysis.

The surgical procedures used for arthrodesis in the lumbar spine for degenerative lumbar diseases remain controversial. This systematic review aims to assess and compare clinical outcomes along with the complications and fusion of each technique (minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) or minimally invasive lateral lumbar interbody fusion (MIS LLIF)) for treatment of degenerative lumbar diseases. Relevant studies were identified from Medline and Scopus from inception to July 19, 2016 that reported Oswestry Disability Index (ODI), back and leg pain visual analog score (VAS), postoperative complications, and fusion of either technique. Fifty-eight studies were included for the analysis of MIS-TLIF; 40 studies were included for analysis of LLIF, and 1 randomized controlled trial (RCT) study was included for comparison of MIS-TLIF to LLIF. Overall, there were 9506 patients (5728 in the MIS-TLIF group and 3778 in the LLIF group). Indirect meta-analysis, MIS-TLIF provided better postoperative back and leg pain (VAS), disabilities (ODI), and risk of having complications when compared to LLIF technique, but the fusion rate was not significantly different between the two techniques. However, direct meta-analysis between RCT study and pooled indirect meta-analysis of MIS-TLIF have better pain, disabilities, and complication but no statistically significant difference when compared to LLIF. In LLIF, the pooled mean ODI and VAS back pain were 2.91 (95% CI 2.49, 3.33) and 23.24 (95% CI 18.96, 27.51) in MIS approach whereas 3.14 (95% CI 2.29, 4.04) and 28.29 (95% CI 21.92, 34.67) in traditional approach. In terms of complications and fusion rate, there was no difference in both groups. In lumbar interbody fusion, MIS-TLIF had better ODI, VAS pain, and complication rate when compared to LLIF with direct and indirect meta-analysis methods. However, in terms of fusion rates, there were no differences between the two techniques.

Comparison of direct anterior, lateral, posterior and posterior-2 approaches in total hip arthroplasty: network meta-analysis.

Total hip arthroplasty (THA) is generally considered to be one of the most successful orthopedic surgical procedures. THA patients continue to experience symptoms, most commonly pain, which prevent their return to full function and activity. Possible causes include failure of fixation, instability and damage to soft tissues, associated with the trauma of the surgical procedure. Choosing the optimal surgical approach can minimize these risks and therefore improve the outcome of THA. Surgical approaches in THA include anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson-Jones)], posterior (posterolateral and posterior) and posterior-2 techniques. However, there is no current consensus regarding which approach is the most suitable. Therefore, we conducted a systematic review and network meta-analysis to compare the postoperative outcomes and complications among THA approach and identify which approach is the best for THA. We searched all RCT studies that compared intra-operative and postoperative outcomes of anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson-Jones)], posterior (posterolateral and posterior) and posterior-2 approaches for THA from the PubMed and Scopus databases up to February 1, 2017. Data were independently extracted by two reviewers. A network meta-analysis was applied to assess treatment outcomes. Probability of being the best treatment was estimated using surface under the cumulative ranking curves (SUCRA). Fourteen RCTs (N = 1017 patients) met inclusion criteria. Interventions were anterior (N = 233 patients), lateral (N = 334 patients), posterior (N = 405 patients) and posterior-2 (N = 45 patients) approaches. A network meta-analysis showed that effects of anterior approach were higher to lateral, posterior and posterior-2 approaches with the pooled mean postoperative within 1 month and last follow-up of HHS of 2.56 (95% CI - 0.79, 5.91), 4.80 (95% CI 1.33, 8.26), 10.80 (95% CI 2.10, 19.49) and 6.40 (95% CI 0.72, 12.09), 2.22 (95% CI - 3.21, 7.66), 4.22 (95% CI - 6.81, 15.25), respectively. For VAS, lateral approach was lower to anterior, posterior and posterior-2 approaches. In terms of complication, posterior approach was the lowest risk with RR of 0.39 (95% CI 0.19, 0.81), 0.57 (95% CI 0.21, 1.57) and 1.74 (95% CI 0.36, 8.33) when compared to anterior, followed by lateral and posterior-2 approaches. Results of SUCRA indicated anterior and lateral approaches were the first and second ranks for postoperative HHS and VAS score, while posterior and lateral approaches were the first and second ranks for postoperative complications. We recommended using lateral approach that has an acceptable postoperative pain, function and complications (second rank for all outcomes) as a surgical technique for THA.

The short and midterm outcomes of lumbar transforaminal epidural injection with preganglionic and postganglionic approach in lumbosacral radiculopathy: a systematic review and meta-analysis.

The purpose of this study was to compare clinical outcomes after preganglionic versus ganglionic epidural steroid injection (ESI) using a systematic review and network meta-analysis. A systematic review and meta-regression was performed to compare postoperative outcomes between the two difference injection techniques. Relevant randomized controlled trials were identified from Medline and Scopus up to September 24, 2016. Sixteen out of 598 studies were eligible; 3, 2, and 3 studies were included in the pooling of outcomes including effectiveness, visual analog score (VAS), and complications (nerve root, injury, dural puncture, and intraneural injection). Preganglionic ESI has a 2.38 (95% CI 1.12, 5.04) times statistically significantly higher chance of effectiveness when compared to ganglionic ESI. There were differences in pain VAS and complications in lumbar radiculopathy, but these displayed no statistical significance. This meta-analysis indicated that preganglionic ESI has a statistically significantly higher chance of effectiveness when compared to ganglionic ESI. In terms of pain score and complications, there were no statistically significant differences between the two groups. These results were generally homogeneous and with little publication bias, thus should be generalizable.