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National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Use the PICO framework to formulate a specific clinical question.
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Formulate a search strategy.
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Prospectively register the review protocol.
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Execute the literature search.
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Apply eligibility criteria to exclude irrelevant studies.
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Extract data and appraise each study for risk of bias and external validity.
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Provide a narrative review.
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If appropriate data are available, perform a meta-analysis.
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Report the review findings in the context of the risk of bias assessment, any sensitivity analyses and the analysis of risk of publication bias.
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Useful resources include the Cochrane Handbook, PROSPERO, GRADE and PRISMA.
Cite this article: EFORT Open Rev 2019;4:213-220. DOI: 10.1302/2058-5241.4.180049
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Twenty randomized controlled trials comprising 1893 primary total knee replacements were included in this review.
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The subvastus approach conferred superior results for mean difference (MD) in time to regain an active straight leg raise (1.7 days, 95% confidence interval [CI] 1.0 to 2.3), visual analogue score for pain on day one (0.8 points on a scale out of 10, 95% CI 0.2 to 1.4) and total range of knee movement at one week (7°, 95% CI 3.2 to 10.7). The subvastus approach also resulted in fewer lateral releases (odds ratio 0.4, 95% CI 0.2 to 0.7) and less peri-operative blood loss (MD 57 mL, 95% CI 10.5 to 106.4) but prolonged surgical times (MD 9.7 min, 95% CI 3.9 to 15.6).
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There was no difference in Knee Society Score at six weeks or one year, or the rate of adverse events including superficial or deep infection, deep vein thrombosis or knee stiffness requiring manipulation under anaesthesia.
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This review demonstrates evidence of early post-operative benefits following the subvastus approach with equivalence between approaches thereafter.
Cite this article: EFORT Open Rev 2018;3:78-84. DOI: 10.1302/2058-5241.3.170030.
AO Research Institute Davos, Switzerland
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Department of Trauma Surgery, Trauma Center Murnau, Germany
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National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
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Billions of screws are inserted by surgeons each year, making them the most commonly inserted implant. When using non-locking screws, insertion technique is decided by the surgeon, including how much to tighten each screw. The aims of this study were to assess, through a systematic review, the screw tightness and rate of material stripping produced by surgeons and the effect of different variables related to screw insertion.
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Twelve studies were included, with 260 surgeons inserting a total of 2793 screws; an average of 11 screws each, although only 1510 screws have been inserted by 145 surgeons where tightness was measured – average tightness was 78±10% for cortical (n = 1079) and 80±6% for cancellous screw insertions (n = 431).
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An average of 26% of all inserted screws irreparably damaged and stripped screw holes, reducing the construct pullout strength. Furthermore, awareness of bone stripping is very poor, meaning that screws must be considerably overtightened before a surgeon will typically detect it.
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Variation between individual surgeons’ ability to optimally insert screws was seen, with some surgeons stripping more than 90% of samples and others hardly any. Contradictory findings were seen for the relationship between the tightness achieved and bone density.
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The optimum tightness for screws remains unknown, thus subjectively chosen screw tightness, which varies greatly, remains without an established target to generate the best possible construct for any given situation. Work is needed to establish these targets, and to develop methods to accurately and repeatably achieve them.
Cite this article: EFORT Open Rev 2020;5:26-36. DOI: 10.1302/2058-5241.5.180066
