High rate of radiolucent lines following the cemented original design of the ATTUNE total knee arthroplasty.

Aims: Loosening of components after total knee arthroplasty (TKA) can be associated with the development of radiolucent lines (RLLs). The aim of this study was to assess the rate of formation of RLLs in the cemented original design of the ATTUNE TKA and their relationship to loosening. Methods: A systematic search was undertaken using the Cochrane methodology in three online databases: MEDLINE, Embase, and CINAHL. Studies were screened against predetermined criteria, and data were extracted. Available National Joint Registries in the Network of Orthopaedic Registries of Europe were also screened. A random effects model meta-analysis was undertaken. Results: Of 263 studies, 12 were included with a total of 3,861 TKAs. Meta-analysis of ten studies showed high rates of overall tibial or femoral RLLs for the cemented original design of the ATTUNE TKA. The overall rate was 21.4% (95% confidence interval (CI) 12.7% to 33.7%) for all types of design but was higher for certain subgroups: 27.4% (95% CI 13.4% to 47.9%) for the cruciate-retaining type, and 29.9% (95% CI 15.6% to 49.6%) for the fixed-bearing type. Meta-analysis of five studies comparing the ATTUNE TKA with other implants showed a significantly higher risk of overall tibial or femoral RLLs (odds ratio (OR) 2.841 (95% CI 1.219 to 6.623); p = 0.016) for the ATTUNE. The rates of loosening or revision for loosening were lower, at 1.2% and 0.9% respectively, but the rates varied from 0% to 16.3%. The registry data did not report specifically on the original ATTUNE TKA or on revision due to loosening, but 'all-cause' five-year revision rates for the cemented ATTUNE varied from 2.6% to 5.9%. Conclusion: The original cemented ATTUNE TKA has high rates of RLLs, but their clinical significance is uncertain given the overall low associated rates of loosening and revision. However, in view of the high rates of RLLs and the variation in the rates of loosening and revision between studies and registries, close surveillance of patients who have undergone TKA with the original ATTUNE system is recommended.

Has anything changed in Evidence-Based Medicine?

The Evidence-Based Medicine (EBM) movement, undoubtably one of the most successful movements in medicine, questions dogma and "clinical authority" and combines the "best available evidence" with clinical expertise and patient values in order to provide the best care for the individual patient. Although since its inception in the 1990s its strong theoretical foundations remain unaltered, a lot has changed in its practical implementation due to the electronic explosion of information and the unprecedented COVID-19 crisis. The purpose of this article is to succinctly provide the reader with an update on the major changes in EBM, including the important most recent ones that were "fast-tracked" due to the COVID-19 challenge.

The role of Platelet-Rich Plasma (PRP) intraarticular injections in restoring articular cartilage of osteoarthritic knees. A systematic review and meta-analysis.

Objective: To assess the effect of PRP on knee articular cartilage content (thickness/volume) and examine the correlation between cartilage changes and clinical outcomes in patients with knee OA. Method: A systematic literature search was performed using the Cochrane methodology in four online databases. Studies were included if they reported on cartilage content with cross-sectional imaging pre- and post-injection. A random-effects model meta-analysis was performed. Correlation with clinical outcomes was evaluated. Results: 14 studies (n â€‹= â€‹1099 patients) from 1452 records met the inclusion criteria: seven RCTs (n â€‹= â€‹688), one prospective (n â€‹= â€‹50), one retrospective (n â€‹= â€‹68), and four case-series (n â€‹= â€‹224). The PRP preparation process and treatment protocol varied widely (follow-up 6-12 months). In meta-analysis, PRP treatment was not associated with a significant increase in cartilage thickness (4 studies, n â€‹= â€‹187, standardized mean difference: Hedges g: 0.079; 95%CI: 0.358 - 0.516; p â€‹= â€‹0.723). Meta-analysis of 3 RCTs (n â€‹= â€‹112) showed no significant difference in the change of overall knee cartilage content with PRP injections compared with no PRP (Hedges' g: 0.217; 95%CI: 0.177 - 0.611; P â€‹= â€‹0.281). Conclusion: The current literature does not support the PRP as chondrogenic in treatment of knee OA. However, there is substantial heterogeneity in the evaluated studies which limits the robustness of any conclusion. An adequately powered RCT, with a standardized PRP regime and standardized high-resolution MRI is needed to definitely define any effect of PRP on knee cartilage content and its relation to clinical outcomes. Until such high-quality evidence becomes available, we recommend that PRP is not administered with the intention of promoting chondrogenesis.

Relationship Between Timing of Anterior Cruciate Ligament Reconstruction and Chondral Injuries: A Systematic Review and Meta-analysis.

BACKGROUND: After anterior cruciate ligament (ACL) injury, the optimal timing of ACL reconstruction and the influence of this timing on chondral damage remain unclear. PURPOSE: To assess the effect of timing of ACL reconstruction on the presence of chondral injuries via a systematic review and meta-analysis. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: Two reviewers independently performed systematic literature searches of 5 online databases using the Cochrane methodology for systematic reviews. Eligibility criteria were any comparative study of patients aged >16 years that assessed the relationship between timing of primary ACL reconstruction surgery and rates of chondral injuries. Meta-analysis was conducted using a random-effects model. RESULTS: After screening, 14 studies (n = 3559 patients) out of 2363 titles met the inclusion criteria: 3 randomized controlled trials (n = 272), 3 prospective cohort studies (n = 398), and 8 retrospective cohort studies (n = 2889). In analysis of the studies, chondral injury rates were compared between ACL reconstructions performed before and after 3 time points: 3, 6, and 12 months after injury (eg, ≤3 vs >3 months). The rates of chondral injury increased with each time point. The increase was mostly due to low-grade injuries at 3 months (estimated odds ratio, 1.914; 95% CI, 1.242-2.949; P = .003), with the increase in high-grade injuries becoming predominant after 12 months (estimated odds ratio, 3.057; 95% CI, 1.460-6.40; P = .003). CONCLUSION: Our findings suggest that delaying ACL reconstruction surgery results in a higher rate of chondral injuries and the severity of these lesions worsens with time. These findings are comparable with those of our previously published study, which demonstrated a higher risk of meniscal tears associated with delayed ACL surgery. When ACL reconstruction is indicated, surgery ≤3 months after injury is associated with a lower risk of intra-articular damage. REGISTRATION: CRD42016032846 (PROSPERO).

Fracture fixation in extremity trauma with carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates: evidence today.

PURPOSE: To compare the CFR-PEEK plates with conventional plates in fracture fixation with regards to clinical and radiological outcomes and complications. METHODS: A systematic literature search was conducted in four online databases independently by two reviewers using the Cochrane methodology for systematic reviews. The identified relevant studies were assessed against predetermined inclusion/exclusion criteria. Independent data extraction and assessment of risk of bias and study quality was carried out. RESULTS: Nine studies (patient n = 361) out of 6594 records were included for analysis: 2 RCTs (n = 63), 3 prospective cohort studies (n = 151), and 4 retrospective cohort studies (n = 147). Studies were grouped per anatomic area of fixation. Four studies (n = 200) examined fixation of proximal humerus fractures. Two studies (n = 74) examined fixation of distal radius fractures. Two studies (n = 53) assessed outcomes of fixation of distal femur fractures. One study (n = 87) assessed the outcomes of fixation of ankle fractures. All nine studies reported very high union rates (from 91% in distal femur to 100% in upper limb) for the CFR-PEEK plate groups and low complication rates. There was no significant difference in clinical outcomes, and rate of complications as compared to the conventional plate groups. CONCLUSION: CFR-PEEK plates have high union rates in extremity fracture fixation similar to conventional plates with comparable good clinical outcomes and a very low and comparable rate of complications. Considering their advantages, CFR-PEEK plates seem to be valid alternative to conventional plating.

Perioperative Hypothermia Is Associated With Increased 30-Day Mortality in Hip Fracture Patients in the United Kingdom: Α Systematic Review and Meta-analysis.

OBJECTIVES: To undertake a systematic review and meta-analysis to determine the relationship between perioperative hypothermia and mortality after surgery for hip fracture. DATA SOURCES: A systematic literature search of Medline, EMBASE, CINAHL, and Cochrane CENTRAL databases was performed using the Cochrane methodology for systematic reviews with no publication year limit. Only studies available in the English language were included. STUDY SELECTION: Predetermined inclusion criteria were patients of any age with a hip fracture, exposure was their body temperature and outcome was mortality rate. Any comparative study design was eligible. DATA EXTRACTION: The quality of selected studies was assessed according to each study design with the Methodological Index for Non-Randomised Studies (MINORS) used for all the retrospective comparative studies. The GRADE approach was used to assess the quality of evidence. DATA SYNTHESIS: A meta-analysis was conducted using a random-effects model. RESULTS: The literature search identified 1016 records. After removing duplicates and those not meeting inclusion criteria, 3 studies measuring 30-day mortality were included. All included studies were carried out in the United Kingdom. The mortality rate was higher in the hypothermic groups as compared with the normothermic group in all the studies, with the difference being significant in 2 of the studies (P < 0.0001). The meta-analysis showed that low body temperature was associated with an increased mortality risk (estimated odds ratio: 2.660; 95% confidence interval: 1.948-3.632; P < 0.001) in patients undergoing surgery for hip fracture. CONCLUSIONS: This study shows that low body temperature in hip fracture patients is associated with an increased 30-day mortality risk in the United Kingdom. Randomized control trials are required to determine whether the association between perioperative hypothermia in hip fracture patients and mortality is causal. Nevertheless, based on this analysis, we urge the maintenance of normal body temperature in the perioperative period to be included in national hip fracture guidelines. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Timing of Anterior Cruciate Ligament Reconstruction and Relationship With Meniscal Tears: A Systematic Review and Meta-analysis.

BACKGROUND: Anterior cruciate ligament (ACL) ruptures are common, but the ideal timing for ACL reconstruction after injury is unclear with regard to meniscal insult. PURPOSE: To determine whether there is a relationship between timing from ACL rupture to ACL reconstruction and development of meniscal tears within this period. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic literature search was undertaken independently by 2 reviewers using the Cochrane method for systematic reviews in 5 online databases. The reviewers performed independent data extraction and assessment of risk of bias and study quality. The search included any comparative study, including randomized controlled trials (RCTs), prospective and retrospective cohort studies, and case-control studies of an adult population, that assessed the relationship between timing of ACL reconstruction surgery and rates of meniscal tears. RESULTS: After screening, 12 studies (No. of participants = 3042) out of 3390 records were included for analysis: 3 RCTs (n = 272), 2 prospective cohort studies (n = 307), and 7 retrospective cohort studies (n = 2463). In analysis of these studies, rates of reported meniscal tears were compared for ACL procedures performed at 3 and 6 months after injury. Meta-analysis of 5 studies (n = 2012) showed that ACL reconstruction performed >3 months after injury was associated with a higher rate of medial meniscal tears compared with ACL reconstruction performed within 3 months of injury (estimated OR, 2.235; 95% CI, 1.183-4.223; P = .013) but not with a higher rate of lateral meniscal tears. Similarly, meta-analysis of 4 studies (n = 990) showed that ACL reconstruction performed >6 months after injury was associated with a higher rate of medial meniscal tears compared with ACL reconstruction performed within 6 months of injury (estimated OR, 2.487; 95% CI, 1.241-4.984; P = .01) but not with a higher rate of lateral meniscal tears. CONCLUSION: Our results suggest that delay of ACL reconstruction surgery >3 months after injury is associated with a higher rate of medial meniscal tears within this prereconstruction time frame. Further high-quality prospective studies may help determine whether this is a causal effect. However, based on current evidence, in those patients for whom ACL reconstruction is indicated, ACL reconstruction within 3 months of injury may be recommended. REGISTRATION: CRD42016032846 (PROSPERO).

Is There a Genetic Predisposition to Frozen Shoulder?: A Systematic Review and Meta-Analysis.

BACKGROUND: Frozen shoulder is a common disorder that leads to substantial functional loss for patients by impairing activities of daily living. It also adversely affects patients and society by impairing the ability to work. Its pathogenesis is not fully understood. The aim of the present study was to perform a systematic review and meta-analysis to assess the evidence suggesting a genetic link to frozen shoulder. METHODS: A literature search of MEDLINE, EMBASE, and CINAHL databases using relevant keywords revealed 5506 studies. After appropriate screening of titles, abstracts, and full studies, seven studies were analyzed. RESULTS: Three studies investigated rates of frozen shoulder among relatives. One study (n = 1828 twin pairs) showed an 11.6% prevalence in twin pairs and demonstrated a heritability of 42% for frozen shoulder after adjusting for age. A second study (n = 273) showed that 20% of patients with frozen shoulder had a positive family history involving a first-degree relative. The relative risk of frozen shoulder was 4:1 when all patients with frozen shoulder were compared with a control population. A third study (n = 87) showed that 29% of patients with frozen shoulder had a first-degree relative with frozen shoulder. Two studies evaluated racial predilection for frozen shoulder. One study (n = 50) reported a substantially higher number of white patients (76%) with frozen shoulder than black patients (24%). A second study (n = 87) showed that being born or having parents or grandparents born in the British Isles were risk factors for frozen shoulder. Four immunological studies investigated human leukocyte antigen (HLA)-B27 as a risk factor for frozen shoulder. Meta-analysis of two of these studies with clearly defined controls showed significantly higher rates of HLA-B27 positivity in patients with frozen shoulder as compared with controls (p < 0.001). CONCLUSION: The limited evidence points toward a genetic link to frozen shoulder. We used family history and racial predilection as markers for genetic association, both of which indicated the presence of a genetic predisposition to frozen shoulder. However, as there is a lack of unbiased genetic approaches, there is an opportunity for genome-wide association studies to address definitively the molecular genetics of frozen shoulder. Such studies may eventually lead to a better understanding of the pathogenesis of frozen shoulder and the development of novel therapeutic interventions. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The 6-Hour Rule for Surgical Debridement of Open Tibial Fractures: A Systematic Review and Meta-Analysis of Infection and Nonunion Rates.

OBJECTIVES: The aim of this study was a systematic review and meta-analysis of studies comparing early (<6 hours) versus late (>6 hours) surgical debridement of open tibial fractures, with regards to infection and nonunion rates. METHODS: A systematic literature search of MEDLINE, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature (1961 to present), Allied and Complementary Medicine, and COCHRANE databases was conducted using any combination of the key words: "open," "tibial," and "fractures." After appropriate screening, 7 studies were included for analysis. Inclusion criteria were studies assessing the relation between time to debridement from injury and infection and/or nonunion rates. RESULTS: Three studies (n = 365) evaluated overall infection rates that varied from 7.7% to 8.9% in the early group versus 1%-18.5% in the late group. Three studies (n = 197) evaluated deep infection rates that varied from 13% to 18.5% in the early group versus 7.1%-18.6% in the late group. Four studies (n = 245) evaluated nonunion rates that varied from 13.2% to 26.1% in the early group versus 0%-32.6% in the late group. Meta-analysis showed no statistical difference between groups with regards to overall infection rates (risk ratio = 1.32; 95% CI, 0.54-3.23; P = 0.55), deep infection rates (risk ratio = 0.99; 95% CI, 0.48-2.07; P = 0.98), and nonunion rates (risk ratio = 1.49; 95% CI, 0.64-3.49; P = 0.36). CONCLUSIONS: The available literature suggests that there is no obvious difference in the overall/deep infection and nonunion rates between open tibial fractures debrided within 6 hours and those debrided at more than 6 hours. The findings presented here would appear to indicate that judicious delays of greater than 6 hours may not result in a significantly increased risk of adverse events or peri-operative morbidity. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluating a Ward-based Foundation Year 1 (FY1) System in an Orthopaedic Setting.

BACKGROUND: Various models of hospital in-patient cover arrangements for junior doctors have been utilised in the United Kingdom. Some settings follow a team-based system for junior doctors and some a ward-based system. The aim of this study was to determine staff's satisfaction rates with regard to a ward-based system for Foundation Year 1 (FY1) doctors in relation to continuity of patient care and doctors' training. MATERIAL AND METHODS: The Orthopaedic department of a District Teaching Hospital in the United Kingdom moved to a ward-based system for the FY1s from a previous team-based system. A questionnaire was administered to FY1s, nursing staff and senior doctors asking their satisfaction rates. RESULTS: 42 practitioners were questioned. They included 15 FY1s, 15 ward nurses and 12 senior doctors. 73.3% of FY1s were satisfied with the ward-based system with regard to continuity of patient care and 40% of them were very satisfied/satisfied with it with regard to achieving training objectives. All nurses, 66.7% of FY1s and 66.7% of senior doctors were very satisfied/satisfied with the ward-based system for achieving service provision (p=0.053). All nurses and 60% of FY1s preferred the ward-based system (p=0.017). All nurses and 66.7% of senior doctors rated the ward-based system as being much better/better than team-based at achieving service provision (p-0.028). CONCLUSIONS: 1. Our results suggest that a ward-based system for FY1s can be successfully implemented in an orthopaedic setting. 2. Ward-based system confers high satisfaction rates with regard to care provision and continuity of care. 3. Taking into account training needs and substitutes for structured team work would be an area for improvement.

Do intra-articular steroid injections increase infection rates in subsequent arthroplasty? A systematic review and meta-analysis of comparative studies.

Intra-articular steroid injections are widely used in joint arthritis. The safety of such injections has been questioned as they may increase infection rates in subsequent arthroplasty. We carried out a meta-analysis of studies examining the relation between intra-articular steroid injections and infection rates in subsequent joint arthroplasty. A literature search was undertaken. Eight studies looking at hip and knee arthroplasties were analyzed. Meta-analysis showed that steroid injection had no significant effect on either deep (risk ratio = 1.87; 95% CI 0.80-4.35; P = 0.15) or superficial infection rates (risk ratio = 1.75; 95% CI 0.76-4.04; P = 0.19) of subsequent arthroplasty. Further large cohort studies would be of value in further examining whether steroid injections close to the time of arthroplasty are safe.