Short- and long-term outcomes in Bankart repair vs. conservative treatment for first-time anterior shoulder dislocation: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: First-time anterior shoulder dislocations are associated with a high rate of residual instability. Therefore, many surgeons support initial Bankart repair surgery over conservative management to address this issue. However, the optimal treatment remains controversial because of uncertainty regarding long-term surgical outcomes. The primary objective of this systematic review and meta-analysis was to compare the short- and long-term rates of residual instability following Bankart repair or conservative management after a first-time anterior shoulder dislocation. METHODS: PubMed/MEDLINE, Embase, The Cochrane Library, Web of Science, CINAHL, and ScienceDirect databases were accessed for randomized controlled trials (RCTs) comparing Bankart repair to conservative management. RoB (Risk of Bias) 2 was used to check study quality. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines were followed in assessing primary outcomes. The inverse-variance method for continuous variables and the Mantel-Haenszel method for dichotomous variables was used. RESULTS: A total of 348 patients from 6 RCTs published across 8 articles, with a mean age of 23.7 years, were included. Bias was graded low in 3 studies, some concerns in 3 studies, and high in 2 studies. In the short term (2-3 years), surgery lowered recurrent instability (risk ratio [RR] 0.15, 95% confidence interval [CI] 0.08, 0.27; I2 = 0%; P < .0001). Similar findings were seen in the long term (5-12 years) (RR 0.23, 95% CI 0.14, 0.39; I2 = 0%; P < .0001). No difference was observed in return to sport (RR 1.18, 95% CI 0.91, 1.52; I2 = 78%; P = .21). Initial surgery lowered subsequent stabilization surgery in the short (RR 0.19, 95% CI 0.09, 0.43; I2 = 0%; P < .0001) and long term (RR 0.17, 95% CI 0.07, 0.39; I2 = 25%; P < .0001). Western Ontario Shoulder Instability Index (WOSI) scores did not differ in the short term (MD, 2.54, 95% CI -0.51, 5.59; I2 = 48%; P = .1) but were higher in the surgical group at long-term follow-up. Patient satisfaction was also higher with surgery (RR 1.75, 95% CI 1.4, 2.2; I2 = 88%; P < .0001). Certainty of evidence was low for only 1 long-term outcome measure. CONCLUSION: Bankart repair surgery for first-time anterior shoulder dislocation results in a large reduction in the risk of recurrent shoulder instability and subsequent stabilization surgery in both short- (2-3 years) and long-term (5-12 years) follow-up intervals. Additionally, slight improvements in overall patient satisfaction and WOSI score can be seen at long-term follow-up. However, surgical intervention failed to significantly improve the rate of return to sport when compared with conservative management.

Tranexamic Acid Use in Anterior Cruciate Ligament Reconstruction Decreases Bleeding Complications: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: To systematically review all available randomized controlled trials (RCTs) in the literature that examine outcomes following tranexamic acid (TXA) use in anterior cruciate ligament reconstruction (ACLR) to determine its effectiveness. METHODS: PubMed/MEDLINE, Embase, Science Direct, Web of Science, CINAHL, and The Cochrane Library databases were systematically searched for RCTs comparing TXA versus no TXA in ACLR with a 4-week minimum follow-up. Quality was assessed using Risk of Bias 2. Pooled analyses were conducted using inverse variance for continuous variables and Mantel-Haenszel for dichotomous variables. The Grading of Recommendations, Assessment, Development and Evaluation guidelines were used to evaluate primary outcomes. RESULTS: A total of 807 patients (632 male, 175 female) from 7 RCTs were included. Mean age was 28.4 years. Bias was graded "low" in 4 RCTs, "some concerns" in 2 RCTs, and "high" in 1 RCT. Visual analog scale was found to be not significantly different with TXA use at day 1-3 (mean difference [MD] -0.92, I2 = 96%, P = .14) and 12 weeks (MD -0.03, I2 = 0%, P = .73). Visual analog scale was significantly decreased at week 2 (MD -1.18, I2 = 56%, P < .00001) and weeks 3-6 (MD -0.38, I2 = 73%, P < .010). Lysholm scores were greater with TXA use at week 2 (MD 9.04, I2 = 74%, P = .002) and weeks 4-6 (MD 6.17, I2 = 73%, P = .0004) but not significantly different at 12 weeks (MD 6.13, I2 = 98%, P = .28). Need for aspiration was less with TXA use (odds ratio 0.40, I2 = 49%, P = 0.0009). Considerable heterogeneity was seen in many results. Certainty was low for 2 primary outcomes, moderate for 2, and high for 5. CONCLUSIONS: Pooled data suggest that the use of TXA in ACLR reduces the need for aspiration, hemarthrosis, drain output, and knee swelling in the postoperative period. While early improvements in pain and function were observed, the clinical relevance is questionable. The risk of complications does not increase with TXA use, and the use of intravenous TXA over intra-articular TXA may improve and prolong hemarthrosis reduction, although the evidence is weak. LEVEL OF EVIDENCE: Level II, systematic review of therapeutic Level I-II studies.

Appropriateness of the post-operative rehabilitation of low energy hip fractures in elderly in comparison with the AAOS appropriate use criteria at a level one trauma center.

PURPOSE: This study aimed to assess the appropriateness of the post-operative rehabilitation of low energy hip fractures in the elderly by comparing between the rehabilitations actually provided at level one trauma center and the AAOS Appropriate Use Criteria (AUC) recommendations. METHODS: A retrospective review of the medical charts of all patients who underwent surgery for hip fractures followed by post-operative rehabilitation between October 2016 and May 2018. The age, gender, fracture types, four AUC variables including; the surgical approach, pre-operative mobility/functional status, cognitive impairment, and post-operative delirium, and types of post-operative rehabilitation received were collected. The four patient variables were entered into the AUC application to generate the recommended rehabilitation procedures. Afterward, the rate of appropriateness of the treatments and the agreement between the rehabilitations actually provided and the AUC recommendation were measured. RESULTS: Over the study period, a consecutive series of 101 patients were included. The mean age was 75 years. Most of the patients were males (51.5%). Seventeen scenarios were observed in our patients. The most common scenario were patients with low functional/physical demands (48%), intact cognitive function (91%), non-arthroplasty approach (76%), and no post-operative delirium(97%). The overall appropriateness rate of the provided rehabilitation treatments for our patients in comparison with AUC recommendation was appropriate in 356 (48.7%) (P = .001), maybe appropriate in 19 (3%) (P < .001), rarely appropriate in 61 (8.3%) (P = .59), and 40% of rehabilitation procedures were not provided (P < .001). The actual treatment was appropriate and in agreement with the AUC recommendations in (100%) of three procedures (Deep venous thrombosis prophylaxis, pain management, and Inpatient Rehabilitation Facility or Skilled Nursing Facility), in (72.2%) of osteoporosis assessment/management, in (63.8%) of outpatient occupational/physical therapy, in (10.2%) of delirium prevention, in (33.3%) of delirium management and in (25%) of home care therapy. CONCLUSIONS: This study demonstrated that there is a remarkable variation in the appropriateness of the various post-operative rehabilitation procedures for elderly hip fracture. Additionally, the AUC application was easy to use and simple for identifying post-operative rehabilitation protocols for elderly hip fractures, hence, we recommend to use it in the trauma clinical practice. LEVEL OF EVIDENCE: IV.

Appropriateness of hip osteoarthritis management in clinical practice compared with the American Academy of Orthopaedic Surgeons (AAOS) criteria.

PURPOSE: The American Academy of Orthopaedic Surgeons (AAOS) developed the appropriate use criteria (AUC) for the management of hip osteoarthritis (OA) to guide surgeons in making decisions based on the best available evidence. This study aimed to assess the applicability of the AUC by comparing the actual treatment provided at our institution with the AUC recommendations. METHODS: A retrospective review of 115 patients who were diagnosed and treated for hip OA at our institution between December 2017 and December 2019 was performed. Data were collected and entered into the AUC application to determine the rate of appropriateness of the provided treatment according to the AUC recommendations. Then, the actual provided treatments were compared with the AUC recommendations to determine the agreement between the two. RESULTS: There were 115 patients, with a mean age of 50.08 years (range, 30-80 years). The most frequent patient characteristics were middle age (40-65 years) with function-limiting pain at moderate to long distances, minimal hip OA on X-ray examination, mild range of motion limitation, and presence of modifiable risk factors for negative outcomes. The overall rate of appropriateness and in agreement with the AUC recommendations was 100% for conservative treatments and 80.1% for surgical treatments. CONCLUSIONS: This study shows that the majority of the hip OA treatments provided at our institution were appropriate and in agreement with the AUC recommendations. Furthermore, the AUC can be easily accessed through a free web application using a computer or smartphone to obtain the recommended treatment for any patient with hip OA.

Platelet-Rich Plasma Versus Corticosteroids in the Treatment of Chronic Plantar Fasciitis: A Systematic Review and Meta-analysis of Prospective Comparative Studies.

Plantar fasciitis is a common cause of heel pain, which often results in a significant limitation of daily activity. The objective of this review was to compare platelet-rich plasma injection (PRP) and corticosteroids injection in the treatment of chronic plantar fasciitis. MEDLINE, PubMed, Web of Science, EMBASE, and the Cochrane library of clinical trials were searched in March 2019. Inclusion criteria were prospective comparative studies reporting functional scores or pain score with a minimum follow-up of 1 month. We excluded studies with patients younger than 18 years and patients with a history of surgical intervention, infection, or rheumatological disease. First author, publication year, sample size, type of intervention, outcome measures, and follow-up period were recorded. The American Orthopaedic Foot & Ankle Society score was significantly better in the PRP group at 6 months' follow-up, with a lower visual analogue scale at 6- and 12-month intervals. The Foot and Ankle Disability Index and Roles-Maudsley score were similar in the 2 treatments at 3 and 6 months. PRP injection in the treatment of chronic plantar fasciitis is considered safe, with a favorable functional outcome and pain control at intermediate and long-term follow-up in comparison to corticosteroid injection.