Do Osteobiologics Augment Fusion in Anterior Cervical Discectomy and Fusion Surgery Performed With Mechanical Interbody Devices (Polyether ether ketone, Carbon Fiber, Metal Cages) and is the Fusion Rate Comparable to that With Autograft? A Systematic Review.

STUDY DESIGN: Systematic Review of the Literature. OBJECTIVE: The purpose of this study was to perform a systematic review describing fusion rates for anterior cervical discectomy and fusion (ACDF) using autograft vs various interbody devices augmented with different osteobiologic materials. METHODS: A systematic review limited to the English language was performed in Medline, Embase and Cochrane library using Medical Subject Heading (MeSH) terms. Studies that evaluated fusion after ACDF using autografts and osteobiologics combined with PEEK, carbon fibre, or metal cages were searched for. Articles in full text that met the criteria were included in the review. The main outcomes evaluated were the time taken to merge, the definition of the fusion assessment, and the modality of the fusion assessment. The risk of bias of each article was assessed by the MINORS score or ROB 2.0 depending on the randomisation process. RESULTS: The total number of references reviewed was six hundred and eighty-two. After applying the inclusion criteria, 54 were selected for the retrieval of the full text. Eight studies were selected and included for final analysis in this study. Fusion rates were reported between 83.3% and 100% for autograft groups compared to 46.5% and 100% for various interbody device/osteobiological combinations. The overall quality of the evidence in all radiographic fusion studies was considered insufficient due to a serious risk of bias. CONCLUSION: Mechanical interbody devices augmented with osteobiologics performed similarly to autografts in terms of reliability and efficacy. Their time to fusion and fusion rate were comparable to autografts at the end of the final follow-up.

Nonoperative management of lisfranc injuries - A systematic review of outcomes.

BACKGROUND: Historically, most Lisfranc injuries have been considered to be unstable and treated with surgical intervention. However, with better access to cross-sectional imaging, stable injury patterns are starting to be recognised. The aims of the current study were to perform a systematic review of outcomes of Lisfranc injuries treated non-operatively. METHODS: A literature review was performed of studies reporting nonoperative management of Lisfranc injuries (PROSPERO registered and following PRISMA guidelines). Following exclusions, 8 papers were identified: 1 prospective and 7 retrospective studies. A total of 220 patients were studied with a mean age of 39.8 years and a mean follow-up of 4.3 years. Outcomes included function, displacement, and rates of surgery. RESULTS: High heterogeneity was observed with variable outcomes. Four papers reported good outcomes, with adjusted functional scores ranging from 82.6 to 100 (out of 100). However, one study reported late displacement in 54 % of patients. Rates of secondary osteoarthritis ranged from 5 % to 38 %. Rates of surgical intervention were as high as 56 %. Several studies compared operative to non-operative treatment, reporting superior outcomes with surgery. Those injuries with no displacement on CT, measured at the medial cuneiform-second metatarsal had the best outcomes. CONCLUSION: Reported outcomes following nonoperative treatment of Lisfranc injuries vary widely, including high rates of conversion to surgery. In contrast, some studies have reported excellent functional outcomes. CT seems to be an important diagnostic tool in defining a stable injury. Due to limited data and lack of a clear definition of a stable injury or treatment protocol, prospective research is needed to determine which Lisfranc injuries can be safely treated nonoperatively.

A comparison of distal femoral replacement versus fixation in treating periprosthetic supracondylar femur fractures: a systematic review and meta-analysis.

BACKGROUND: The treatment of periprosthetic femur fractures around a total knee replacement remains a technical challenge for the orthopedic surgeon. Management options include non-operative treatment, plate fixation, intramedullary nailing and distal femur replacement (DFR), with few studies comparing fixation with DFR. This is an up-to-date meta-analysis in the literature to directly compare clinical outcomes between fixation and distal femoral replacement in the treatment of supracondylar periprosthetic femur fractures. METHODS: A stratified literature search of the Medline, EMBASE and Cochrane databases was performed. All studies in English language were searched from inception to July 2022. The search was performed with the following MeSH terms: Periprosthetic fracture AND ORIF OR Internal Fixation AND Distal Femur Replacement. The search was conducted using a predesigned search strategy where all eligible literature was critically appraised for methodological quality using the Cochrane collaboration tool. We included Level I, II and III studies comparing fixation with DFR in the treatment of periprosthetic supracondylar femur fractures. Data from eligible studies were extracted by two authors (NP and AR) and a table created which included author, year, sample size, mean age, measured parameters, follow-up period, fracture classification, length of stay (days), mortality rate, revision rate and complication rate. RESULTS: The extracted data were pooled for meta-analysis using RevMan® v5.3.5 software (Nordic Cochrane Centre, Copenhagen, Denmark) and forest plots constructed. A p value < 0.05 was considered statistically significant and confidence intervals (CI) set to 95%. A total of six studies were included in the meta-analysis (n = 406). 153 patients underwent distal femur replacement and 253 patients underwent fixation with a mean follow-up time of 71.4 months. The results of this analysis suggest no statistically significant difference in measured outcomes. CONCLUSION: The results of this meta-analysis suggest no proven statistically significant difference between DFR and fixation in terms of length of hospital stay, mortality rate, revision rate and complication rate for the treatment of periprosthetic supracondylar femur fractures. Further prospective randomized research may help to define the specific indications for each treatment option which must include fracture configuration. Early functional outcome and cost-effectiveness have yet to be evaluated in the available literature.

Functional outcomes in patient specific instrumentation vs. conventional instrumentation for total knee arthroplasty; a systematic review and meta-analysis of prospective studies.

BACKGROUND: Total Knee Arthroplasty (TKA) is an established surgical option for knee osteoarthritis (OA). There are varying perceptions of the most suitable surgical technique for making bone cuts in TKA. Conventional Instrumentation (CI) uses generic cutting guides (extra- and intra-medullary) for TKA; however, patient specific instrumentation (PSI) has become a popular alternative amongst surgeons. METHODS: A literature search of electronic databases Embase, Medline and registry platform portals was conducted on the 16th May 2021. The search was performed using a predesigned search strategy. Eligible studies were critically appraised for methodological quality. The primary outcome measure was Knee Society Function Score. Functional scores were also collected for the secondary outcome measures: Oxford Knee Score (OKS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Visual Analog Scale (VAS) for pain. Review Manager 5.3 was used for all data synthesis and analysis. RESULTS: There is no conclusive evidence in the literature to suggest that PSI or CI instrumentation is better for functional outcomes. 23 studies were identified for inclusion in this study. Twenty-two studies (18 randomised controlled trials and 4 prospective studies) were included in the meta analysis, with a total of 2277 total knee arthroplasties. There were 1154 PSI TKA and 1123 CI TKA. The majority of outcomes at 3-months, 6-months and 12 show no statistical difference. There was statistical significance at 24 months in favour of PSI group for KSS function (mean difference 4.36, 95% confidence interval 1.83-6.89). The mean difference did not exceed the MCID of 6.4. KSS knee scores demonstrated statistical significance at 24 months (mean difference 2.37, 95% confidence interval (CI) 0.42-4.31), with a MCID of 5.9. WOMAC scores were found to be statistically significant favouring PSI group at 12 months (mean difference -3.47, 95% confidence interval (CI) -6.57- -0.36) and 24 months (mean difference -0.65, 95% confidence interval (CI) -1.28--0.03), with high level of bias noted in the studies and a MCID of 10. CONCLUSIONS: This meta-analysis of level 1 and level 2 evidence shows there is no clinical difference when comparing PSI and CI KSS function scores for TKA at definitive post operative time points (3 months, 6 months, 12 months and 24 months). Within the secondary outcomes for this study, there was no clinical difference between PSI and CI for TKA. Although there was no clinical difference between PSI and CI for TKA, there was statistical significance noted at 24 months in favour of PSI compared to CI for TKA when considering KSS function, KSS knee scores and WOMAC scores. Studies included in this meta-analysis were of limited cohort size and prospective studies were prone to methodological bias. The current literature is limited and insufficiently robust to make explicit conclusions and therefore further high-powered robust RCTs are required at specific time points.

Systematic Review of Operative vs Nonoperative Treatment of Displaced Intraarticular Calcaneal Fractures.

Background: Management of displaced intraarticular calcaneus fractures can be operative or nonoperative. Several randomized and case-controlled trials have been recently conducted in order to reach a consensus. The purpose of this analysis is to provide recommendations for the management of these injuries based on the best available clinical evidence. Methods: An up-to-date search was conducted using predefined eligibility criteria. The Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) was followed. Randomized and prospective clinical trials were only included after agreement among all authors. Relevant literature was appraised for methodologic quality using the Cochrane collaboration tool for the randomized controlled trials (RCTs) and Newcastle Ottawa Score for the prospective trials. Outcome measures included American Orthopaedic Foot & Ankle Society ankle-hindfoot score, visual analog scale score, return to activity, complications, residual pain, and development of arthritis. RevMan, version 5.3.5 software, was used for data analysis. A P value of <.05 was considered statistically significant, and CIs were set at 95%. Results: A total of 13 studies and 1251 patients were included in our analysis. This involved 10 RCTs and 3 prospective clinical trials. Shoe fitting problems and failure to return to activity favored the operative group. No other studied variables showed clear superiority of a specific treatment approach. Conclusion: The best evidence available at this time favors an advantage to operative treatment. Patients should be informed that the clear differences are centered on comfort of shoe wear and return to desired activity level.Level of Evidence: Level II, meta-analysis of RCT and Prospective Cohort studies.

A comparison of simple and complex single-row versus transosseous-equivalent double-row repair techniques for full-thickness rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: Rotator cuff injuries have traditionally been managed by either single-row or double-row arthroscopic repair techniques. Complex single-row techniques have recently been proposed as a biomechanically stronger alternative treatment option. However, no rigorous meta-analysis has evaluated the effectiveness of complex single-row against double-row repair. This meta-analysis aims to evaluate clinical outcomes in patients with full-thickness rotator cuff injuries treated with both simple and complex single-row, as well as transosseous-equivalent (TOE) double-row procedures. METHODS: An up-to-date literature search was performed using the predefined search strategy. All studies that met the inclusion criteria were assessed for methodological quality and included in the meta-analysis. Pain, functional scores, range of motion, and retear rate were all considered in the study. CONCLUSION: The results of our meta-analysis suggest that there is no significant difference between complex single-row and TOE double-row procedures in any of the observed outcomes. At this point in time, the available comparative data between simple single-row and TOE double-row repair techniques are limited. Further high-quality studies are required to assess the clinical outcomes and cost-effectiveness of these different techniques.

Cephalo-medullary nailing versus dynamic hip screw with trochanteric stabilisation plate for the treatment of unstable per-trochanteric hip fractures: a meta-analysis.

BACKGROUND: The use of cephalo-medullary nails (CMN) is a widely accepted management option for the treatment of unstable per-trochanteric hip fractures. A growing body of literature has reported good functional and radiological outcomes in patients managed with a dynamic hip screw supplemented with a trochanteric stabilisation plate (DHS w/ TSP). However, a robust meta-analysis does not exist in the current literature comparing the two fixation methods. PURPOSES: Management of these kinds of injuries is very challenging in orthopaedic practice, yet no strong evidence is in place to delineate which implant gives the best results. This meta-analysis is the first to determine the efficacy of CMN versus DHS w/ TSP. METHODS: An up-to-date literature search was performed using a predetermined search strategy and eligibility criteria. All suitable literature was appraised for methodological quality using the Cochrane's collaboration tool. Hospital stay, operative time, intra-operative complication rate, mechanical failure rate, infection rates, revision rates and functional outcomes were all considered. RESULTS: A total of five studies were included in the meta-analysis. The results of this analysis suggest that CMN is only associated with lower revision rates when compared to DHS w/ TSP; however, no significant difference was found in terms of hospital stay, operative time, blood transfusion, complications rate and functional outcome. CONCLUSION: Both CMN and DHS w/TSP proved to be reliable in the management of unstable per-trochanteric fractures; however, more extensive datasets are required to draw robust conclusions.

Infrapatellar versus suprapatellar approach for intramedullary nailing of the tibia: a systematic review and meta-analysis.

BACKGROUND: Intramedullary nailing (IMN) is a conventional technique for the treatment of tibial shaft fractures. It has been suggested that the suprapatellar (SP) approach holds advantages over the traditional infrapatellar (IP) approach. Current literature lacks adequate data to provide robust clinical recommendations. This meta-analysis aims to determine the efficacy of infrapatellar versus suprapatellar techniques for IMN. METHODS: An up-to-date literature search of the Embase, Medline, and registry platform databases was performed. The search was conducted using a predesigned search strategy and all eligible literature was critically appraised for methodological quality via the Cochrane's collaboration tool. Fluoroscopy time, operative time, pain score, knee function, deep infection, non-union and secondary operation rates were all considered. CONCLUSION: A total of twelve studies were included in the meta-analysis. The results of this analysis show that suprapatellar nailing is associated with reduced post-operative pain scores and improved functional outcomes. The data suggest no significant difference in terms of operative times, fluoroscopy times, rates of deep infection, non-union or secondary procedures when compared to infra-patellar techniques. Further studies are required to confirm these findings and assess long-term results.

Locked compression plating versus retrograde intramedullary nailing in the treatment of periprosthetic supracondylar knee fractures: a systematic review and meta-analysis.

BACKGROUND: Periprosthetic fractures of the distal femur above a total knee arthroplasty (TKA) have traditionally been managed by locking compression plating (LCP). This technique is technically demanding and is associated with high rates of non-union and revision. More recently, retrograde intramedullary nailing (RIMN) has been proposed as an acceptable alternative. This meta-analysis aims to evaluate clinical outcomes in patients with periprosthetic supracondylar femoral fractures who were treated with LCP and RIMN. METHODS: An up-to-date literature search was carried out using the pre-defined search strategy. All studies that met the inclusion criteria were assessed for methodological quality with the Cochrane's collaboration tool. Operative time, functional score, time-to-union, non-union rates and revision rates were all considered. CONCLUSION: Ten studies with a total of 531 periprosthetic fractures were included. This meta-analysis has suggested that there is no significant difference in any of the outcome measures assessed. Further, more extensive literature is required on the subject to draw more robust conclusions.