Partial Scapholunate Interosseous Ligament Injuries: A Systematic Review of Treatment Options.

Purpose This systematic review summarizes the existing evidence on treatment options and outcomes for partial scapholunate interosseous ligament (pSLIL) injuries. Methods A systematic electronic search of Medline, Embase, and CINAHL was performed from inception through to February 13, 2022. All primary research articles addressing the treatment of pSLIL tears were eligible for inclusion regardless of timing of surgery, surgical technique, or rehabilitation. The PRISMA Checklist guided the reporting and data abstraction. Descriptive statistics and forest plots are presented. Results A total of 14 studies with 342 patients were included for analysis. Treatments were categorized into four groups: electrothermal shrinkage (ES), arthroscopic capsuloplasty (AC), open capsulodesis (OC), and no treatment (NT). There were five studies in the ES group ( N = 69, mean age = 34.3 ± 3.3 years), three studies in the AC group ( N = 138, mean age = 32.2 ± 3.8 years), five studies in the OC group ( N = 123, mean age of 30.7 ± 7.8 years), and one study in the NT group ( N = 12, mean age = 43 years, range = 28-67 years). The average postintervention visual analog scale pain score for the ES group was 1.4 ± 0.5 (from 5.7 ± 1.8), for the AC group was 3.2 ± 1.3 (from 6.6 ± 0), for the OC group was 2.3 ± 2.1 (from 5.6 ± 1.6), and for the NT group was 3.2 (from 7.6). The wrist extension range of motion improved postoperatively for all intervention groups (ES = 66.3°-70.7°; AC = 67°-74.5°; and OC = 48.9°-63.5°), whereas it remained unchanged for the NT group (46°-45°). Grip strength also improved in all intervention groups (ES = 17.9-29.9 kg; AC = 24.0-32.2 kg; and OC = 15.8-26.6 kg), while the NT group remained unchanged (25-24 kg). The radiographic scapholunate gap improved postoperatively in all groups that reported pre- and postintervention (ES = 2.2-1.9 mm; OC = 2.5-1.8 mm) and slightly worsened in the NT group (2.5-2.7 mm). In the ES group, there were three complications (11.5%, no major complications), in the AC group there was one major complication (0.9%, complex regional pain syndrome [CRPS]), and in the OC group there were six complications (15.4%, four major complications-CRPS). Conclusion All interventional treatment options (ES, AC, and OC) provided significant improvements in patient-reported pain, range of motion, grip strength, and radiographic parameters, with low complication rates. In comparison, no improvement in range of motion or grip strength was noted in the NT group. Therefore, surgical management of pSLIL injuries is an effective and relatively safe treatment option. Further studies comparing the outcomes of specific surgical treatments are warranted to further elucidate the optimal management option for pSLIL tears. Level of Evidence Level III, systematic review of Level III-IV studies.

Local vancomycin administration in Orthopaedic Surgery - A systematic review of comparative studies.

Background: There is still controversy surrounding the routine use of vancomycin locally in primary orthopaedic surgery procedures. Therefore, the aim of this review is to assess how local vancomycin impacts the rates and microbiology of surgical site infections. Methods: A systematic electronic search of MEDLINE, EMBASE, and Web of Science was carried out for all comparative studies comparing locally applied vancomycin to control for primary orthopaedic surgery procedures published before August 14, 2022. Results: A total of 61 studies with 65,671 patients were included for analysis. Forty-six studies used vancomycin powder, 12 studies with grafts soaked in vancomycin, two studies used vancomycin irrigation, and one study administered vancomycin interosseously. There were 15 studies (of 26) in spine surgery, five (of 14) in arthroplasty, ten (of 11) in sports medicine, and two (of five) in trauma surgery that found statistically significant decreases in overall infection rates when applying local vancomycin. Only one study (in spine surgery) found significant increases in infection rates with local vancomycin application. For spine surgery, local vancomycin application had the greatest proportion of gram-negative bacteria (40.7%) isolated compared to S. aureus (42.4%) in controls. In arthroplasty and trauma surgery, there were increases in the proportions of gram-negative bacteria when vancomycin was added. There were no reported systemic adverse reactions associated with local vancomycin use in any of the studies. Conclusion: Applying local vancomycin during primary orthopaedic surgery procedures may reduce the rates of infections in multiple different orthopaedic specialties, particularly in spine surgery and sports medicine. However, careful consideration should be applied when administering local vancomycin during specific orthopaedic procedures given the heterogeneity of included studies and breadth of surgeries included in this review. Level of evidence: Level III. A systematic review of level I - III studies.

Arthroscopic stabilization surgery for first-time anterior shoulder dislocations: a systematic review and meta-analysis.

BACKGROUND: The optimal management of first-time anterior shoulder dislocations (FTASDs) remains controversial. Therefore, the purpose of this study was to assess the efficacy of arthroscopic stabilization surgery for FTASDs through a systematic review and meta-analysis of existing literature. METHODS: MEDLINE, Embase, and Web of Science were searched from inception to December 18, 2022, for single-arm or comparative studies assessing FTASDs managed with arthroscopic stabilization surgery following first-time dislocation. Eligible comparative studies included studies assessing outcomes following immobilization for an FTASD, or arthroscopic stabilization following recurrent dislocations. Eligible levels of evidence were I to IV. Primary outcomes included rates of shoulder redislocations, cumulative shoulder instability, and subsequent shoulder stabilization surgery. RESULTS: Thirty-four studies with 2222 shoulder dislocations were included. Of these, 5 studies (n = 408 shoulders) were randomized trials comparing immobilization to arthroscopic Bankart repair (ABR) after a first dislocation. Another 16 studies were nonrandomized comparative studies assessing arthroscopic Bankart repair following first-time dislocation (ABR-F) to either immobilization (studies = 8, n = 399 shoulders) or arthroscopic Bankart repair following recurrent dislocations (ABR-R) (studies = 8, n = 943 shoulder). Mean follow-up was 59.4 ± 39.2 months across all studies. Cumulative loss to follow-up was 4.7% (range, 0%-32.7%). A composite rate of pooled redislocation, cumulative instability, and reoperations across ABR-F studies was 6.8%, 11.2%, and 6.1%, respectively. Meta-analysis found statistically significant reductions in rates of redislocation (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.04-0.3, P < .001), cumulative instability (OR 0.05, 95% CI 0.03-0.08, P < .001), and subsequent surgery (OR 0.08, 95% CI 0.04-0.15, P < .001) when comparing ABR-F to immobilization. Rates of cumulative instability (OR 0.32, 95% CI 0.22-0.47, P < .001) and subsequent surgery rates (OR 0.27, 95% CI 0.09-0.76, P = .01) were significantly reduced with ABR-F relative to ABR-R, with point estimate of effect favoring ABR-F for shoulder redislocation rates (OR 0.59, 95% CI 0.19-1.83, P = .36). Return to sport rates to preoperative levels or higher were 3.87 times higher following ABR-F compared to immobilization (95% CI 1.57-9.52, P < .001), with limited ABR-R studies reporting this outcome. The median fragility index of the 5 included randomized controlled trials (RCTs) was 2, meaning reversing only 2 outcome events rendered the trials' findings no longer statistically significant. CONCLUSION: Arthroscopic stabilization surgery for FTASDs leads to lower rates of redislocations, cumulative instability, and subsequent stabilization surgery relative to immobilization or arthroscopic stabilization surgery following recurrence. Although a limited number of RCTs have been published on the subject matter to date, the strength of their conclusions is limited by a small sample size and statistically fragile results.

The impact of surgical randomised controlled trials on the management of FAI syndrome: a citation analysis.

PURPOSE: To identify and assess the clinical impact of randomised controlled trials (RCTs) assessing the surgical management of femoroacetabular impingement syndrome (FAIS) through a citation analysis. METHODS: MEDLINE, EMBASE and CENTRAL were searched from inception to April 22, 2023 for RCTs assessing the surgical management of FAIS. Study characteristics were directly abstracted from included trials and citation metrics were obtained from the Clarivate Web of Knowledge database on May 19, 2023. The continuous fragility index (CFI) was calculated for eligible outcomes. Univariate regression models were used to explore correlations between total citations per year and various study characteristics. RESULTS: Ten studies comprising one thousand two hundred ninetypatients were eligible for analysis. Studies were published from 2013 to 2023. Eight countries were represented across various trials with 91% being either North American or European. The mean journal impact factor of published studies was 39.684 (median 2.982; range 1.31-202.73). The mean citation density was 14.17 (range 0.33-48.67). The median CFI was 4.8 (range 1-32.2). Correlation analysis demonstrated strong and statistically significant correlations to study sample size (R = 0.75, p = 0.012), journal impact factor (R = 0.80, p = 0.006) and continuous fragility index (R = 0.95, p = 0.015). CONCLUSION: Trials assessing the surgical management of FAIS present with a wide range of clinical uptake based on citation density and are published in journals of broadly variable impact factor. Despite promising citation metrics, high-quality evidence on arthroscopy for FAIS is limited to the United States and Europe with an unclear international impact. Future knowledge translation efforts are warranted to maximise the international uptake of evidence regarding arthroscopic management of FAIS. LEVEL OF EVIDENCE: I.

Transportal Tibiotalocalcaneal Nail Ankle Arthrodesis: A Systematic Review of Initial Series.

Background: There is currently a scarcity of information and consensus for transportal (arthroscopic or fluoroscopic) joint preparation during tibiotalocalcaneal (TTC) fusion, and therefore this review aims to summarize the available techniques and to evaluate the outcomes after this procedure. Methods: A systematic electronic search of MEDLINE, EMBASE, and Web of Science was performed for all English-language studies published from their inception to April 4, 2022. All articles addressing arthroscopy in TTC nailing were eligible for inclusion. The PRISMA Checklist guided the reporting and data abstraction. Descriptive statistics are presented. Result: A total of 5 studies with 65 patients were included for analysis. All studies used arthroscopic portals for tibiotalar and subtalar joint preparation (in 4 studies) prior to TTC nailing, with 4 studies using an arthroscope and 1 study using fluoroscopy. The overall major complication rate was 13.8%; however, there was only 1 instance of deep wound infection (1.5%) and 4 instances of surgical site infections (6.2%). Full fusion was achieved in 86% of patients with an average time to fusion of 12.9 weeks. The mean American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score preoperatively was 34.0 and postoperatively was 70.5. Conclusion: Although limited by the number of studies, transportal joint preparation during TTC nail ankle fusion is associated with good rates of complications and successful fusion. Level of Evidence: Level III, systematic review of Level III-IV studies.

Management of Very Distal Ulna Fractures: A Systematic Review.

OBJECTIVES: To synthesize all-cause complications and reoperations data, and secondary clinical, functional, and radiographic outcomes after the management of very distal ulna fractures (VDUFs) either nonoperatively or operatively. DATA SOURCES: MEDLINE, Embase, and Web of Science were searched for English-language articles from inception to February 17, 2022. STUDY SELECTION: Studies reporting the nonoperative or operative management of VDUFs were eligible for inclusion. VDUFs were defined as either being Q2-Q5 distal ulna fractures using the OTA/AO Comprehensive Classification of Fractures for distal ulna fractures associated with distal radius fractures or being amenable to characterization by the classification system for ulnar head, neck and metaphyseal fractures by Biyani et al. DATA EXTRACTION: Two reviewers independently extracted data from included studies. Study validity was assessed using the methodological index for nonrandomized studies. DATA SYNTHESIS: Seventeen studies (512 VDUFs) were included for analysis. There were 209, 237, and 66 fractures in the nonoperative, open reduction internal fixation (ORIF), and distal ulna resection groups, respectively. Descriptive statistics including weighted mean values, standard deviations, and 95% confidence intervals were calculated. CONCLUSIONS: The treatment of VDUFs with nonoperative management, ORIF, or distal ulna resection may all be acceptable treatment options in specific patient populations. Nonoperative management of VDUFs is a promising treatment strategy even for complex fracture patterns in patients 65 years of age or older. Despite higher reoperation rates, ORIF may be considered for the younger, high-demand patient. Distal ulna resection presents with very favorable functional outcomes in patients 65 years of age or older presenting with a complex VDUF with the lowest reoperation rate across all groups. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Both low and high knee flexion angles during tibial graft fixation yield comparable outcomes following ACL reconstruction with quadriceps tendon autograft: A systematic review.

IMPORTANCE: A paucity of clinical evidence surrounds the effect of the knee flexion angle during tibial fixation of the graft during anterior cruciate ligament (ACL) reconstruction. While biomechanical studies have recently sought to revive this area of study in both single- and double-bundle graft populations, they have done so using variants of the hamstring graft. This does not shed light on the optimal fixation of other autograft options, namely, the quadriceps tendon (QT) autograft. OBJECTIVES: To determine the effect of the knee flexion angle during tibial graft fixation on functional and clinical outcomes following ACL reconstruction using single-bundle QT autograft, inclusive of both soft-tissue and bone-plug graft types. EVIDENCE REVIEW: An electronic search of MEDLINE, EMBASE, Web of Science, and the Cochrane Library was carried out from database inception to June 2020. Following study screening, patient demographics and fixation technique as well as both subjective and objective clinical outcomes were abstracted. Studies were divided based on the knee flexion angle during tibial fixation of the graft. The low knee flexion angle (L-KFA) group included patients with a tibial fixation angle of < 30° of flexion, and the high knee flexion (H-KFA) group included those with a tibial fixation of exactly 30° of flexion. The data were qualitatively synthesized due to significant heterogeneity across the included studies. FINDINGS: Sixteen studies (1,169 patients) were included for analysis. There were 675 patients in the L-KFA group (mean age range, 18.7-34.5 years) and 494 patients in the H-KFA group (mean age range, of 23.2-32.1 years). Both groups yielded statistically significant improvements from preoperative to postoperative scores across several functional and clinical outcomes. Return to pre-injury activity levels ranged from 64% to 81% in L-KFA studies and from 73.3% to 86.7% in H-KFA studies. All-cause graft failure rates ranged from 1.4% to 4.3% in L-FKA studies and from 0%-10.7% in H-KFA studies. CONCLUSION: Both low- and high-knee flexion angles during tibial graft fixation produce improved postoperative clinical and functional outcomes with comparable outcomes across groups. There is inconclusive evidence to recommend the ideal knee flexion angle for graft fixation in primary ACLR. LEVEL OF EVIDENCE: Level IV.

Return to Sport and Work Following Distal Femoral Varus Osteotomy: A Systematic Review.

Background: Distal femoral varus osteotomy (DFVO) is an effective surgical intervention for the management of symptomatic valgus malalignment of the knee. Because it preserves the native knee joint and its ligamentous stability, DFVO is preferred to total knee arthroplasty (TKA) in the young, active population. Purpose: We sought to assess return to work (RTW) and return to sport (RTS) rates following DFVO for valgus malalignment of the knee. Methods: For this systematic review, we searched EMBASE, MEDLINE, and Web of Science from inception through December 31, 2020. English language studies of all levels of evidence explicitly reporting on RTS and RTW rates following DFVO for valgus malalignment of the knee were eligible for inclusion. Results: Seven studies and 127 patients were included in our analysis. Mean age was 32.4 ± 8.8 years with men comprising 46.7% ± 22.3% of study populations. The mean RTS rate was 87.2% ± 10.7%, with a return to preoperative activity levels rate of 65.4% ± 26.8%. The mean RTW rate was 81.8% ± 23.3%, with a return to preoperative activity levels of 72.8% ± 18.1%. The mean reoperation rate was 35.6% ± 18.8% within a mean follow-up period of 5.5 ± 1.9 years. Conclusions: This systematic review of low-level studies found DFVO to be a safe and effective procedure for the management of genu valgum in young, active populations, with most patients returning to sport and/or work, although not all at their preoperative activity levels. A paucity of data surrounds RTS and RTW rates following DFVO. Future studies should explicitly report both return to activity rates and whether patients returned to their preoperative activity levels.

Quadriceps tendon autograft for pediatric anterior cruciate ligament reconstruction results in promising postoperative function and rates of return to sports: A systematic review.

PURPOSE: To assess the performance of the quadriceps tendon (QT) autograft in pediatric anterior cruciate ligament reconstruction (ACLR). METHODS: A systematic search of MEDLINE, PubMed, and EMBASE was conducted on March 1, 2021. Studies of all levels of evidence reporting outcomes and/or complications after QT autograft ACLR in pediatric patients (≤ 18 years old) were eligible for inclusion. Study demographics, patient demographics, reported outcomes, and complications were abstracted. Screening and data abstraction were designed in accordance with PRISMA and R-AMSTAR guidelines. Descriptive statistics were presented when applicable, with data for heterogeneous outcomes presented in narrative summary fashion. RESULTS: A total of 14 studies examining 596 patients (46.3% female), mean age 15.4 years, were included in this systematic review. Mean postoperative Lysholm scores ranged from 94.0 to 99.5. Mean postoperative IKDC subjective scores ranged from 75.9 to 94.0. Limb symmetry index ranged from 96.8 ± 10.4 to 100.4 ± 7.6% across multiple hop tests. Return to sports (RTS) rates ranged from 88.9 to 91.7%. Eleven studies reported postoperative complications, whereby 16 patients (4.8%) experienced contralateral complications and injuries. Forty-six patients (9.4%) experienced ipsilateral complications, including ten graft failures (2.5%) and two growth disturbances (0.6%). CONCLUSIONS: QT autograft ACLR in the pediatric population retains the potential of regaining a preinjury level of knee stability, and yields promising postoperative function and rates of RTS, yielding comparable outcomes relative to HT autograft and the reference-standard BPTB ACLR that have previously been described in the literature. Moreover, use of the QT autograft is associated with low rates of postoperative complications, including graft failure and growth disturbances in this active and high-risk patient population in observational studies to date. Therefore, clinical equipoise exists to further appraise the influence of QT autograft on postoperative outcomes compared to aforementioned autograft options in a randomized control trial fashion. LEVEL OF EVIDENCE: IV.

Thromboprophylaxis after knee arthroscopy does not decrease the risk of deep vein thrombosis: a network meta-analysis.

PURPOSE: The primary aim of this network meta-analysis (NMA) is to compare the incidence of venous thromboembolisms (VTE) and bleeding risk following the use of pharmacological and non-pharmacological thromboprophylaxis for arthroscopic knee surgery (AKS). This study assumed the null hypothesis which was that there will be no difference in the incidence of VTE and bleeding risk when comparing no treatment, pharmacological treatment, and non-pharmacological treatment for preventing VTE events following AKS. METHODS: A systematic electronic search of CENTRAL, Medline, Embase, and ClinicalTrials.gov was carried out. All English language prospective randomized clinical trials published from date of database inception to November 21, 2021 were eligible for inclusion. All papers addressing arthroscopic knee surgery were eligible for inclusion regardless of timing of surgery, operation, surgical technique, or rehabilitation. Multiple random effects NMAs were conducted to compare all treatments for each outcome. The primary outcome was the incidence of pulmonary embolism (PE) and secondary outcomes consisted of overall deep vein thrombosis (DVT), symptomatic DVT, asymptomatic DVT, and all-cause mortality. Adverse outcomes consisted of major and minor bleeding, as well as adverse events. RESULTS: A total of nine studies with 4526 patients were included for analysis. There were 1054 patients in the no treatment/placebo group (NT/Placebo), 1646 patients in the graduated compression stockings, 810 patients in the extended-duration (> 10 days) low molecular weight heparin (Ext-LMWH) group, 650 patients in the short-duration (< 10 days) LMWH group (Short-LMWH), and 356 patients in the rivaroxaban group. GCS, Ext-LMWH, Short-LMWH and rivaroxaban all demonstrated low risks of PE, symptomatic DVT, asymptomatic DVT, combined DVT and all-cause mortality. Similarly, all interventions demonstrated a low risk of major bleeding. CONCLUSION: There is no significant difference in the risk reduction of PEs, symptomatic DVTs, major/minor bleeding, and/or all-cause mortality when using LWMH (including short or extended regimens), rivaroxaban, graduated compression stockings or no treatment following arthroscopic knee surgery. Future primary research on the efficacy of thromboprophylaxis following arthroscopic knee surgery should stratify outcomes based on key patient (i.e., age, sex, comorbidities) and surgical (i.e., major vs. minor surgery) characteristics and should include acetylsalicylic acid as an intervention. LEVEL OF EVIDENCE: I, network meta-analysis of Level I studies.

Bone Grafting the Patellar Defect After Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction Decreases Anterior Knee Morbidity: A Systematic Review.

PURPOSE: The aim of this systematic review was to evaluate the impact of bone grafting of patellar defects on reported anterior knee morbidity and subjective outcomes after bone-patellar tendon-bone autograft reconstruction of the anterior cruciate ligament. METHODS: A systematic electronic search of MEDLINE, Embase, Web of Science, and the Cochrane Library was carried out. All English-language prospective randomized clinical trials published from January 1, 2000, to July 24, 2020, were eligible for inclusion. All studies addressing patellar defect grafting were eligible for inclusion regardless of the timing of surgery, graft type, surgical technique, or rehabilitation protocol. RESULTS: A total of 39 studies with 1,955 patients were included for analysis. There were 796 patients in the no patellar grafting (NPG) group, with a mean age range of 22.7 to 33.0 years, and 1,159 patients in the patellar grafting (PG) group, with a mean age range of 17.8 to 34.7 years. The visual analog scale pain score ranged from 1.2 to 5.1 in the NPG group compared with 0.3 to 3.7 in the PG group. The proportion of patients with anterior knee pain ranged from 19% to 81% in the NPG group and from 15% to 32% in the PG group. Moderate to severe kneeling pain was reported in 22% to 57% of patients in the NPG group and 10% of those in the PG group. The percentage of patients with at least 3° of extension loss ranged from 4% to 43% in the NPG group and from 2% to 11% in the PG group. CONCLUSIONS: PG favors decreased anterior knee pain, kneeling pain, and extension loss compared with non-grafted defects; however, the functional outcomes are comparable. Owing to the heterogeneity in reporting, statistical conclusions could not be drawn. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Membrane curvature allosterically regulates the phosphatidylinositol cycle, controlling its rate and acyl-chain composition of its lipid intermediates.

Signaling events at membranes are often mediated by membrane lipid composition or membrane physical properties. These membrane properties could act either by favoring the membrane binding of downstream effectors or by modulating their activity. Several proteins can sense/generate membrane physical curvature (i.e. shape). However, the modulation of the activity of enzymes by a membrane's shape has not yet been reported. Here, using a cell-free assay with purified diacylglycerol kinase ϵ (DGKϵ) and liposomes, we studied the activity and acyl-chain specificity of an enzyme of the phosphatidylinositol (PI) cycle, DGKϵ. By systematically varying the model membrane lipid composition and physical properties, we found that DGKϵ has low activity and lacks acyl-chain specificity in locally flat membranes, regardless of the lipid composition. On the other hand, these enzyme properties were greatly enhanced in membrane structures with a negative Gaussian curvature. We also found that this is not a consequence of preferential binding of the enzyme to those structures, but rather is due to a curvature-mediated allosteric regulation of DGKϵ activity and acyl-chain specificity. Moreover, in a fine-tuned interplay between the enzyme and the membrane, DGKϵ favored the formation of structures with greater Gaussian curvature. DGKϵ does not bear a regulatory domain, and these findings reveal the importance of membrane curvature in regulating DGKϵ activity and acyl-chain specificity. Hence, this study highlights that a hierarchic coupling of membrane physical property and lipid composition synergistically regulates membrane signaling events. We propose that this regulatory mechanism of membrane-associated enzyme activity is likely more common than is currently appreciated.