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F T Spindler, V Herterich, B M Holzapfel, W Böcker, H Polzer, and S F Baumbach

Purpose

  • The aim was to conduct a systematic literature review and meta-anaylsis to analyze the diagnostic accuracy of the external rotation stress test (ERST) for syndesmotic injuries.

Methods

  • The systematic review was conducted according to the PRISMA-P guidelines (Prospero ID: CRD42021282457). Four common databases were searched from inception to September 29, 2021. Eligible were any studies facilitating the ERST under fluoroscopy in a defined state of syndesmotic instability. Syndesmotic ligament-specific rupture must have been proven by MRI, arthroscopy, or controlled dissection (cadaver study). Two reviewers independently conducted each step of the systematic literature review. The risk of bias was assessed by the Quality Appraisal for Cadaveric Studies Score scale. The data analysis was performed qualitatively and quantitatively.

Results

  • Eight studies were eligible for a qualitative analysis, and six studies were eligible for a quantitative analysis. All studies included were cadaver studies. The qualitative analysis comprised 94 specimens and revealed considerable heterogeneity. Six studies allowed for a quantitative analysis of the tibiofibular clear space (TFCS) and five studies for the medial clear space (MCS) during the ERST. The quantitative analysis of the TFCS revealed no significant differences between intact and any stage of syndesmotic injury. The MCS was able to differentiate between intact and 2-ligament- (Z = 2.04, P = 0.02), 3-ligament- (Z = 3.2, P = 0.001), and 3-ligament + deltoid ruptures (Z = 3.35, P < 0.001).

Conclusion

  • The ERST is the only noninvasive test to assess syndesmotic instability and can be conducted bilaterally. The uninjured contralateral side can serve as a baseline reference. Based on the conducted quantitative analysis, the MCS seems to be able to differentiate between stable (intact/1-ligament) and unstable (2-ligament/3-ligament) lesions.

Xue Ling Chong, Lisca Drittenbass, Victor Dubois-Ferriere, and Mathieu Assal

  • Current literature has described many of the complications following hallux valgus surgery and their treatment options.

  • Iatrogenic transfer metatarsalgia is a distinctive and challenging complication that has not been addressed in a comprehensive fashion yet.

  • Iatrogenic transfer metatarsalgia may result from poor preoperative assessment, planning and/or surgical technique.

  • We have classified the causes of iatrogenic transfer metatarsalgia based on a multiplanar assessment of the malalignment(s) and are recommending a comprehensive treatment algorithm to guide surgeons in addressing this complication.

  • With this knowledge, surgeons may avoid potential pitfalls in the primary surgery that can result in iatrogenic transfer metatarsalgia and find the appropriate treatment option to correct them.

Wen-xi Sun, Hao-nan Liu, Meng-tong Chen, Yong-peng Lin, Hong-shen Wang, and Bo-lai Chen

Objective

  • The aim of this study was to comprehensively evaluate the efficacy of oblique lateral interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of degenerative lumbar spondylolisthesis by meta-analysis.

Methods

  • A computer-based search of PubMed, Cochrane Library, Embase, Web of Science Core Collection databases, the China National Knowledge Infrastructure, China Biology Medicine, and Wanfang Digital Periodicals was conducted from the time of inception of each database to December 2021. The review process was conducted according to the PRISMA guidelines and registered in the PROSPERO database. Meta-analysis was performed using RevMan 5.4 software provided by the Cochrane Library.

Results

  • Thirteen studies were included in the statistical analysis. One randomized controlled study and 12 cohort studies with 954 patients were included. In terms of operation time, intraoperative blood loss, Oswestry disability index score, intervertebral height, and complications, the OLIF group was better than the TLIF group, and the difference was statistically significant (P < 0.05). There was no significant difference between the two groups in terms of visual analogue scale score, lumbar lordosis or fused segment lordosis (P > 0.05).

Conclusion

  • Both OLIF and TLIF are effective surgical modalities in the treatment of degenerative lumbar spondylolisthesis. They achieve similar therapeutic effects, but OLIF is superior to TLIF in restoring intervertebral height. At the same time, OLIF has the advantages of short operation time and less intraoperative blood loss.

Victor Lu, Maria Tennyson, Andrew Zhou, Ravi Patel, Mary D Fortune, Azeem Thahir, and Matija Krkovic

Introduction

  • Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation. Tibiotalocalcaneal (TTC) nailing is an alternative option for the geriatric patient. This meta-analysis provides the most detailed analysis of TTC nailing for fragility ankle fractures.

Methods

  • A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, and Web of Science, identifying 14 studies for inclusion. Studies including patients with a fragility ankle fracture, defined according to NICE guidelines as a low-energy fracture obtained following a fall from standing height or less, that were treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded. This review was registered in PROSPERO (ID: CRD42021258893).

Results

  • A total of 312 ankle fractures were included. The mean age was 77.3 years old. In this study, 26.9% were male, and 41.9% were diabetics. The pooled proportion of superficial infection was 10% (95% CI: 0.06–0.16), deep infection 8% (95% CI: 0.06–0.11), implant failure 11% (95% CI: 0.07–0.15), malunion 11% (95% CI: 0.06–0.18), and all-cause mortality 27% (95% CI: 0.20–0.34). The pooled mean post-operative Olerud–Molander ankle score was 54.07 (95% CI: 48.98–59.16). Egger’s test (P = 0.56) showed no significant publication bias.

Conclusion

  • TTC nailing is an adequate alternative option for fragility ankle fractures. However, current evidence includes mainly case series with inconsistent post-operative rehabilitation protocols. Prospective randomised control trials with long follow-up times and large cohort sizes are needed to guide the use of TTC nailing for ankle fractures.

Andrew J Curley, Ethan R Ruh, Amisha Shah, Ashley E Disantis, April Krivoniak, Craig S Mauro, and Michael P McClincy

  • Bone morphology has been increasingly recognized as a significant variable in the evaluation of non-arthritic hip pain in young adults.

  • Increased availability and use of multidetector CT in this patient population has contributed to better characterization of the osseous structures compared to traditional radiographs.

  • Femoral and acetabular version, sites of impingement, acetabular coverage, femoral head–neck morphology, and other structural abnormalities are increasingly identified with the use of CT scan.

  • In this review, a standard CT imaging technique and protocol is discussed, along with a systematic approach for evaluating pelvic CT imaging in patients with non-arthritic hip pain.

Lorenzo Massimo Oldrini, Pietro Feltri, Jacopo Albanese, Stefano Lucchina, Giuseppe Filardo, and Christian Candrian

Introduction

  • The aim of this systematic review and meta-analysis was to evaluate whether volar locking plate (VLP) fixation leads to better clinical and radiological outcomes than those of closed reduction and cast immobilization for the treatment of distal radius fractures (DRFs).

Materials and methods

  • A comprehensive literature search was performed in PubMed, Web of Science, and Cochrane databases up to January 2022. Inclusion criteria included randomized controlled trial (RCT) studies comparing VLP fixation with cast immobilization for DRFs. Investigated parameters were Patient-Rated Wrist Evaluation questionnaire, Disabilities of the Harm, Shoulder, and Hand score (DASH), range of motion (ROM), grip strength, quality of life (QoL), radiological outcome, and complication and reoperation rate, both at short- and mid-/long-term follow-up. Assessment of risk of bias and quality of evidence was performed with Downs and Black’s ‘Checklist for Measuring Quality’.

Results

  • A total of 12 RCTs (1368 patients) were included. No difference was found for ROM, grip strength, QoL, and reoperation, while the DASH at 3 months was statistically better in the VLP group (P <  0.05). No clinical differences were confirmed at longer follow-up. From a radiological perspective, only radial inclination (4°) and ulnar variance (mean difference 1.1 mm) at >3 months reached statistical significance in favor of the VLP group (both P < 0.05). Fewer complications were found in the VLP group (P < 0.05), but they did not result in different reintervention rates.

Conclusions

  • This meta-analysis showed that the surgical approach leads to a better clinical outcome in the first months, better fracture alignment, and lower complication rate. However, no differences in the clinical outcomes have been confirmed after 3 months. Overall, these findings suggest operative treatment for people with higher functional demand requiring a faster recovery, while they support the benefit of a more conservative approach in less demanding patients.

Elena Gálvez-Sirvent, Aitor Ibarzábal-Gil, and E Carlos Rodríguez-Merchán

  • Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis.

  • The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA.

  • Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection.

  • In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage).

  • Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.

Abdul-ilah Hachem, Andres Molina-Creixell, Xavier Rius, Karla Rodriguez-Bascones, Francisco Javier Cabo Cabo, Jose Luis Agulló, and Miguel Angel Ruiz-Iban

  • Recurrent posterior glenohumeral instability is an entity that demands a high clinical suspicion and a detailed study for a correct approach and treatment. Its classification must consider its biomechanics, whether it is due to functional muscular imbalance or to structural changes, volition, and intentionality.

  • Due to its varied clinical presentations and different structural alterations, ranging from capsule-labral lesions and bone defects to glenoid dysplasia and retroversion, the different treatment alternatives available have historically had a high incidence of failure.

  • A detailed radiographic assessment, with both CT and MRI, with a precise assessment of glenoid and humeral bone defects and of glenoid morphology, is mandatory.

  • Physiotherapy focused on periscapular muscle reeducation and external rotator strengthening is always the first line of treatment. When conservative treatment fails, surgical treatment must be guided by the structural lesions present, ranging from soft tissue repair to posterior bone block techniques to restore or increase the articular surface.

  • Bone block procedures are indicated in cases of recurrent posterior instability after the failure of conservative treatment or soft tissue techniques, as well as symptomatic demonstrable nonintentional instability, presence of a posterior glenoid defect >10%, increased glenoid retroversion between 10 and 25°, and posterior rim dysplasia. Bone block fixation techniques that avoid screws and metal allow for satisfactory initial clinical results in a safe and reproducible way.

  • An algorithm for the approach and treatment of recurrent posterior glenohumeral instability is presented, as well as the author’s preferred surgical technique for arthroscopic posterior bone block.

Qiushi Bai, Yuanyi Wang, Jiliang Zhai, Jigong Wu, Yan Zhang, and Yu Zhao

  • Tandem spinal stenosis (TSS) is defined as the concomitant occurrence of stenosis in at least two or more distinct regions (cervical, thoracic, or lumbar) of the spine and may present with a constellation of signs and symptoms. It has four subtypes, including cervico-lumbar, cervico-thoracic, thoraco-lumbar, and cervico-thoraco-lumbar TSS. The prevalence of TSS varies depending on the different subtypes and cohorts.

  • The main aetiologies of TSS are spinal degenerative changes and heterotopic ossification, and patients with developmental spinal stenosis, ligament ossification, and spinal stenosis at any region are at an increased risk of developing TSS.

  • The diagnosis of TSS is challenging. The clinical presentation of TSS could be complex, concealed, or severe, and these features may be confusing to clinicians, resulting in an incomplete or delayed diagnosis. Additionally, a consolidated diagnostic criterion for TSS is urgently required to improve consistency across studies and form a basis for establishing treatment guidelines.

  • The optimal treatment option for TSS is still under debate; areas of controversies include choice of the decompression range, choice between simultaneous or staged surgical patterns, and the order of the surgeries.

  • The present study reviews publications on TSS, consolidates current awareness on prevalence, aetiologies, potential risk factors, diagnostic dilemmas and criteria, and surgical strategies based on TSS subtypes. This is the first review to include thoracic spinal stenosis as a candidate disorder in TSS and aims at providing the readers with a comprehensive overview of TSS.

Geovanny Ruiz, Norberto J Torres-Lugo, Pablo Marrero-Ortiz, Humberto Guzmán, Gerardo Olivella, and Norman Ramírez

  • Early-onset scoliosis (EOS) is defined as any spinal deformity that is present before 10 years old, regardless of etiology.

  • Deformity must be evaluated based on the intercorrelation between the lungs, spine, and thorax.

  • Curvatures of early-onset have increased risk of progression, cardiorespiratory problems, and increased morbidity and mortality.

  • Progression of the deformity may produce thoracic insufficiency syndrome, where a distorted thorax is unable to support normal respiratory function or lung growth.

  • Management and treatment of EOS should pursue a holistic approach in which the psychological impact and quality of life of the patient are also taken into consideration.

  • Growth-friendly surgical techniques have not met the initial expectations of correcting scoliotic deformity, promoting thoracic growth, and improving pulmonary function.