Index For Non-randomized Studies Score Research Articles

Development of a unified and comprehensive definition of successful spinal fusion: a systematic review.

Spinal fusion is a commonly performed surgical procedure used to relieve pain, deformity, and instability of various spinal pathologies. Although there have been attempts to standardize spinal fusion assessment radiologically, there is currently no unified definition that also considers clinical symptomology. This review attempts to create a more holistic and standardized definition of spinal fusion. A systematic review of the current literature on cervical, thoracic, and lumbar spinal fusion was conducted using the PubMed, Google Scholar, and EBSCO databases adhering to PRISMA guidelines. Data were collected and analyzed from more than 20 publications that contained pertinent information on the efficacy of different imaging modalities, classification systems, clinical presentations, and the normal course of healing in relation to spinal fusion. The mean methodological index for nonrandomized studies score was 18 ± 2.5. Furthermore, industry experts and board-certified spinal surgeons were consulted in the development of a proposed definition of successful spinal fusion. A total of 20 studies evaluating 1324 spinal fusion procedures were included in the final analysis. Based on the available literature, a clinical algorithm that physicians can implement in their practice to determine whether a spinal fusion procedure may be deemed successful was created. The algorithm begins broadly by stratifying patients as either symptomatic or asymptomatic. Asymptomatic patients can be considered as having successful fusions after 12 months. If patients are symptomatic, the imaging modality and healing characteristics are based on the quality of pain experienced. For radicular pain, fusion evaluation includes a flexion/extension (F/E) radiograph to assess for foraminal compression, trabecular bridging, minimal angular rotation, minimal translational movement, and minimal halo sign. For axial pain, a helical CT scan is recommended, with characteristics of success that include trabecular bridging, lack of radiolucent shadowing, lack of visible bone or hardware fracture, lack of cystic or sclerotic changes, low subsidence level near the graft, and minimal screw-rod construct migration. Spinal fusion is considered "unsuccessful" if symptoms persist beyond a year postoperatively, regardless of radiographic findings. The authors have constructed a systematic, standardized method for evaluating spinal fusion success that incorporates clinical symptoms, various imaging modalities, and the natural course of bone healing. A potential limitation of this algorithm is its reliance on radiographic imaging and heterogeneous data. However, the authors believe that implementation of this algorithm and a widespread unified fusion definition will lead to better postoperative evaluation, better surgical outcomes, and a standardized metric to assess developments in spinal fusion procedures and technology.

Epilepsy Surgery for Drug-Resistant Epilepsy in Africa: A Systematic Review.

Nearly one-third of individuals with epilepsy have drug-resistant epilepsy, treated most effectively with surgery. This study aims to discuss the demographic profile, surgical access, and strategies used in drug-resistant epilepsy in Africa. A systematic review was performed using PubMed, Google Scholar, Embase, and Web of Science in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Nine studies encompassing 498 patients from 6 African countries (Egypt, Kenya, Morocco, South Africa, Tunisia, and Uganda) were included. The mean Methodological Index for Non-Randomized Studies score for these articles was 9.6 ± 1.6. The average patient age was 24.9 years (95% CI: 18.9-30.8 years), with a male predominance of 53.4%. The average age of seizure onset was 10.4 years (95% CI: 6.1-14.7 years). Most patients experienced focal onset seizures (73.1%), with head trauma (33.1%) being the most reported risk factor. The predominant etiologies were hippocampal sclerosis (66.8%, 95% CI: 42.7-91), microdysgenesis (26.7%, 95% CI: 20.7-32.7), and brain tumors (22.3%, 95% CI: 6.4-38.2). Lesions were primarily located in the left hemisphere (61.9%, 95% CI: 26.7-97.1), with temporal lobe involvement in 54.8% of cases (95% CI: 28.7-80.8). Temporal lobectomy was the most frequently performed surgery (59.6%), followed by lesionectomy (9.6%). Postoperatively, 80.6% of patients achieved Engel class I outcomes, indicating seizure freedom, and long-term follow-up (1 to 5 years) showed that 70.3% maintained Engel class I outcomes. Surgical complications were reported in 8.8% of cases. These findings demonstrate the efficacy and long-term benefits of epilepsy surgery in Africa, where epilepsy is a significant public health challenge. The high rates of seizure freedom and reduced seizure frequency from surgery highlight its potential to improve the quality of life for individuals with drug-resistant epilepsy in Africa.

The Safety and Feasibility of Ambulatory Minimally Invasive Partial Nephrectomy: A Systematic Review and Meta-Analysis.

Purpose: Emerging evidence supports the use of minimally invasive partial nephrectomy (MIPN) in ambulatory settings. We conducted a systematic review and meta-analysis to evaluate differences in perioperative characteristics, complication/readmission rates and satisfaction/cost data between ambulatory and standard-length discharge (SLD) MIPN. Methods: This study was prospectively registered in PROSPERO (CRD42023429854). A systematic literature search of PubMed, Embase, and Web of Science databases was conducted, including studies comparing ambulatory MIPN vs SLD MIPN for patients with renal masses. Studies were assessed for quality using the Methodological Index for Non-Randomized Studies score. Meta-analysis was performed for comparative studies, and non-comparative studies were included narratively. Results: Eleven studies were included with a pooled population of 20,548 patients, of which 1,419 (7%) had a length of stay less than 1 day and were considered the ambulatory group. There were no significant differences in the total complication rates (RR: 0.50, 95% CI: 0.24, 1.04; p = 0.06) or 30-day readmission rates (RR: 0.87, 95% CI: 0.56, 1.35; p = 0.53) between the ambulatory and SLD groups. There were fewer >3 Clavien-Dindo complications in the ambulatory group (RR: 0.34, 95% CI: 0.19, 0.59; p = 0.0002). Few studies reported average health care cost and patient satisfaction. Conclusions: In appropriately selected patients, ambulatory MIPN is safe and feasible. Future studies are needed to quantify cost and patient satisfaction differences and further identify appropriate patient selection criteria for ambulatory MIPN.

The Impact of Sedative Choice in the Management of Aneurysmal Subarachnoid Hemorrhage: A Scoping Review.

Aneurysmal subarachnoid hemorrhage (aSAH) is characterized by high mortality and morbidity. This scoping review assesses the current evidence regarding the use of sedatives and analgesics in the acute intensive care unit management of aSAH. We conducted a systematic search of Ovid MEDLINE, Ovid Embase, Ovid EmCare, APA PsycInfo, CINAHL, and the Cochrane Database of Systematic Reviews from inception to June 2023. Studies were included if they enrolled intensive care unit patients aged 18 or older with a significant proportion (> 20%) who had aSAH and evaluated the impact of one or more commonly used analgosedatives on physiological parameters in the management of aSAH. The methodological quality of the studies was assessed using the Methodological Index for Nonrandomized Studies score. Of 2,583 articles, 11 met the inclusion criteria. The median sample size was 47 (interquartile range 10-127), and the median Methodological Index for Nonrandomized Studies score was 9.5 (interquartile range 8-11). The studies' publication years ranged from 1980 to 2023. Dexmedetomidine and ketamine showed potential benefits in reducing the incidence of cortical spreading depolarization and delayed cerebral ischemia. Propofol and opioids appeared safe but lacked robust evidence for efficacy. Benzodiazepines were associated with increased delayed cerebral ischemia-related cerebral infarctions and cortical spreading depolarization events. The evidence available to guide the use of analgosedative medications in aSAH is critically inadequate. Dexmedetomidine and ketamine warrant further exploration in large-scale prospective studies because of their potential benefits. Improved study designs with consistent definitions and a focus on patient-centered outcomes are necessary to inform clinical practice.

Horizontal ridge augmentation through ridge expansion via osseodensification, guided bone regeneration and ridge‑split: Systematic review and meta‑analysis of clinical trials.

The aim of the present systematic review was to compare three ridge augmentation procedures in order to assist clinicians in finding the ideal surgical method relative to the horizontal bone gain needed and the width of the alveolar ridge available. An electronic and hand literature search was performed in the online databases PubMed-Medline, Cochrane Central Register of Controlled Trials, EMBASE, Cochrane Oral Health Group Trials Register and Web of Science, and various specialized journals, between January 2017 and December 2022. The included studies were evaluated using the Methodological Index for Non-randomized Studies score and Cochrane's RoB tool. The primary variable studied in the meta-analysis was the final bone gain. The implant survival rate and initial ridge width were the secondary variables. Then four studies on ridge expansion via osseodensification (OD), seven on guided bone regeneration (GBR) and seven on the ridge-split technique (RS) were included in the review; 17 out of 18 were selected for meta-analysis. The mean horizontal bone gain for OD was 2.151 mm [1.327-2.975 mm; 95% confidence interval (CI)], for GBR was 4.036 mm (3.351-4.772 mm 95%CI) and for RS was 3.661 mm (2.991-4.399 mm 95%CI). The results were statistically significant (P=0.002). GBR reported the most bone gain horizontally, followed closely by RS and then OD. OD is a recent technique that should be taken into account when discussing the protocols of horizontally atrophied ridge rehabilitation.

Comparison of Clinical Outcomes After Different Surgical Approaches for Lateral Epicondylitis: A Systematic Review and Meta-analysis.

Lateral epicondylitis (LE) is one of the most common causes of lateral elbow pain. When nonoperative treatment fails, 1 of the 3 surgical approaches-open, percutaneous, or arthroscopic-is used. However, determining which approach has the superior clinical outcome remains controversial. To review the outcomes of different operative modalities for LE qualitatively and quantitatively. Systematic review; Level of evidence, 4. This review was performed and reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies published in PubMed, Medline (via EBSCO), and ScienceDirect databases that treated LE with open, percutaneous, or arthroscopic approaches with at least 12 months of follow-up were included. Study quality was assessed using the Cochrane Risk of Bias 2 tool and the Methodological Index for Non-Randomized Studies score. The primary outcome was the success rate of each operative treatment approach-open, percutaneous, and arthroscopic. From an initial search result of 603 studies, 43 studies (n = 1941 elbows) were ultimately included. The arthroscopic approach had the highest success rate (91.9% [95% CI, 89.2%-94.7%]) compared with the percutaneous (91% [95% CI, 87.3%-94.6%]) and open (82.7% [95% CI, 75.6%-89.8%]) approaches for LE surgery with changes in the mean visual analog scale pain score of 5.54, 4.90, and 3.63, respectively. According to the Disabilities of the Arm, Shoulder and Hand score, the functional outcome improved in the arthroscopic group (from 54.11 to 15.47), the percutaneous group (from 44.90 to 10.47), and the open group (from 53.55 to 16.13). The overall improvement was also found in the Mayo Elbow Performance Score, the arthroscopic group (from 55.12 to 90.97), the percutaneous group (from 56.31 to 87.65), and the open group (from 64 to 93.37). Arthroscopic surgery had the highest rate of success and the best improvement in functional outcomes among the 3 approaches of LE surgery.

Methodological Assessment of the 100 Most-Cited Articles in Total Knee Arthroplasty in the Last Decade Compared to the All-Time List

BackgroundRecent advances in total knee arthroplasty (TKA) have been driven by a growing focus on evidence-based medicine. This transition is reflected in the critical appraisal of both, the quality of work and the potential impact on the orthopedic community. The purpose of our study was to (1) identify the top 100 most-cited articles in TKA in the last decade and from all-time, and (2) compare methodological rigor of the most-cited articles in TKA in the last decade to articles all-time by level of evidence. MethodsThe top 100 cited articles were recorded for manuscripts from the last decade, January 1, 2012 to December 31, 2022, and manuscripts from all-time for TKA. We collected authors, year of publication, journal of the article, country of origin of authors, article type (basic science article, clinical research article), level of evidence, methodological index for non-randomized studies score, physiotherapy evidence database scale, and citation density (total citations/years published). ResultsThe largest number of studies for all-time TKA (53.0%) and decade TKA (42.0%) were Level III. The average methodological index for non-randomized studies score for comparative studies was 18.7 for all-time TKA and 20.7 for decade TKA (P < .001). The average physiotherapy evidence database score was 6.1 for all-time TKA and 8.1 for decade TKA (P > .05). The highest citation density for all-time TKA was 111 and for past decade was 63. The number of level II studies in TKA increased from 19.0% from all time to 38.0% from the last decade (P < .05). ConclusionsOur findings of improved methodologies over time reflect positive steps toward evidence-based practice in TKA. A continued focus on producing methodologically sound studies may guide evidence-based clinical decision-making.

Management of proximal tibial stress fracture associated with advanced knee osteoarthritis: A systematic review

PurposeTibial stress fracture associated with knee osteoarthritis is an unusual and difficult clinical scenario. There is no clear existing treatment guideline for this uncommon clinical disease. The aim of this study is to review the impact of various treatment options for patients with advanced knee osteoarthritis associated with proximal tibial stress fracture. MethodsThe study was performed using the databases of PubMed and Scopus. Methodological index for non-randomized studies score was used to evaluate the included studies’ bias. The concluded data included the treatment approach, reported outcome measure, and time to fracture union. The literature search was started in December 2021 and accomplished in January 2022. A narrative description of the different methods and comparison of their results were done. ResultsOut of total assessed 69 studies, 9 studies were included in our review. The commonest treatment approach used was total knee arthroplasty by long tibial stem extension. The mean preoperative knee society score and knee functional score were 30.62 and 23.17, respectively. The mean postoperative knee society knee score was 86.87, while the functional score was 83.52. The average reported time to achieve fracture union was 4 months (a range of 2.07 – 5.50 months). ConclusionThe optimal clinical outcome for treating either acute or mobile tibial stress fracture in patients with advanced knee osteoarthritis can be achieved with long stem total knee arthroplasty. However, due to heterogeneity of data, comparison of different treatment options for chronic proximal tibial stress fracture mal-union/non-union coexisting with knee osteoarthritic and such inferences need to be judged cautiously.

Proximal humerus fracture management and outcomes are distinctly different for individuals 60 years of age or younger: a systematic review

Proximal humerus fractures (PHFs) occur most commonly in an elderly and osteoporotic population, but a considerable proportion of these injuries occur in relatively younger individuals. Differences in treatment principles and outcomes in this younger population remain poorly understood. The purpose of this review was to characterize the treatment algorithms and outcomes for patients less than or equal to 60 years of age with PHFs. A comprehensive search of the Medline, Pubmed, Embase, and Cochrane databases for articles published between January 2005 and December 2020 was performed in January 2021. Levels of evidence I-IV analyzing outcomes (patient reported outcomes and/or complications) following PHFs in adult patients less than or equal to 60 years of age were included. The search was carried out in accordance with the preferred reported items for systematic reviews and meta-analyses guidelines. The risk of bias 2 tool and methodological index for nonrandomized studies score were utilized to evaluate included studies. Fourteen studies met the inclusion criteria (open reduction internal fixation: 5, intramedullary nail: 4, hemiarthroplasty: 2, nonoperative: 1, and reverse total shoulder arthroplasty (RTSA): 1). Seven studies reported differences in outcomes between younger and older patient populations, with three studies noting separate management algorithms for those 60 years of age or younger. There were no studies comparing different treatments modalities in those less than 60 years of age, and the lone study on RTSA did not include patient-reported outcomes. Treatment algorithms and outcomes following PHFs in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. However, evidence-based treatment recommendations for this younger population are limited by the lack of studies comparing treatment modalities and the absence of patient-reported outcomes for individuals undergoing RTSA.

Nerve alerts and peripheral nerve injury in patients undergoing shoulder arthroplasty with intraoperative neuromonitoring: a systematic review

BackgroundIntraoperative neuromonitoring (IONM) during shoulder arthroplasty can be useful for detecting and preventing nerve deficits. The purpose of this investigation was to systematically review the literature for studies that used IONM to investigate the incidence of potential nerve injury during and after shoulder arthroplasty. MethodsA systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, and Cochrane Central Register of Controlled Trials were searched for level I-IV studies that reported on the incidence of nerve alerts and peripheral nerve injuries following shoulder arthroplasty with IONM. Data recorded included study demographics, IONM parameters, nerve alerts, and postoperative nerve injuries. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies score. Forest plots of proportions were generated for nerve alerts and nerve injury. A P value of 0.05 was set as significant. ResultsThe initial search yielded 1556 articles (414 duplicates, 1142 screened, and 31 full-text review). Nine articles (699 patients, three somatosensory evoked potential (SSEP) and six transcranial electric motor evoked potential (MEP) studies; 53.6% females; mean age range, 58-74.8 years; mean Methodological Index for Non-Randomized Studies score, 15.4 ± 4.6) were included and analyzed. Five studies set the threshold for a nerve alert to be a ≥50% reduction in amplitude, whereas four studies set this threshold to be a ≥80% reduction in amplitude. Of the procedures performed, 44.9% were anatomic total shoulder arthroplasties (aTSAs), 42.1% were reverse total shoulder arthroplasties (rTSAs), 3.7% were hemiarthroplasties, and 14% were revision arthroplasties. In all but one study that utilized MEP for IONM, axillary nerve alerts were the most common (39%). The humeral and glenoid preparation/implant stages accounted for the highest percentage of nerve alerts in all studies. Overall, 47% of patients had at least one intraoperative nerve alert. A significantly higher percentage of patients monitored with MEP had a nerve alert compared to those monitored with SSEP only (56% vs. 39%; P < .001). The overall pooled percentage of patients who had evidence of a clinical nerve injury postoperatively was 5% [2%-13%]. All but two clinical neurological deficits resolved within six months, and one resolved within one year. ConclusionIONM during shoulder arthroplasty identifies and may help prevent nerve injury. IONM with MEPs detected significantly more nerve alerts than that with SSEPs. The axillary nerve was the most common peripheral nerve affected. Humeral and glenoid preparation/implant stages were responsible for most alerts. The advantages of IONM must be balanced with the time, cost, and intraoperative clinical ambiguity of responding to nerve alerts.

Outcomes after resection arthroplasty versus permanent antibiotic spacer for salvage treatment of shoulder periprosthetic joint infections: a systematic review and meta-analysis.

Although revision to new components is favored after shoulder periprosthetic joint infections (PJIs), implant exchange is not always feasible. In certain cases, definitive treatment may be retainment of an antibiotic spacer or resection arthroplasty. The purpose of this investigation was to systematically review the literature for studies reporting on outcomes after resection arthroplasty or permanent antibiotic spacer for salvage treatment of shoulder PJIs. A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV studies that reported on the final treatment of periprosthetic shoulder infections using resection arthroplasty or a permanent antibiotic spacer. Data recorded included study demographics, causative infectious organism, shoulder-specific range of motion and outcome measures, and infection eradication rate. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies score. Forest plots of proportions and meta-analyses of single means were generated for infection eradication rates and outcomes, respectively. Heterogeneity was quantified using the I2 statistic. A P value of .05 was set as significant. The initial search yielded 635 articles (211 duplicates, 424 screened, 57 full-text review). Twenty-three articles (126 resection arthroplasty and 177 retained antibiotic spacer patients, 51% females, mean age range 37-78.5 years, mean Methodological Index for Non-Randomized Studies score 9.6 ± 0.7) were included and analyzed. The pooled infection eradication rate was 82% (72%-89%) after resection arthroplasty and 85% (79%-90%) after permanent antibiotic spacer. The pooled mean forward flexion (71.5° vs. 48.7°; P < .001) and mean American Shoulder and Elbow Surgeons score (53.5 vs. 31.0; P < .001) were significantly higher for patients treated with a permanent antibiotic spacer compared with resection arthroplasty. No significant differences were found for mean external rotation (13.5° vs. 20.5°; P = .07), abduction (58.2° vs. 50.3°; P = .27), or visual analog scale pain (3.7 vs. 3.4; P = .24) between groups. There was a statistically significant, but not clinically significant, difference in mean Constant score between permanent antibiotic spacer and resection arthroplasty patients (33.6 vs. 30.0; P < .001). When implant exchange after shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures that provide similar rates of infection eradication. Although both can decrease pain levels, the permanent antibiotic spacer may result in better functional outcomes compared with resection arthroplasty.

326 The Incidence and Prevalece of Unruptured Intracranial Aneurysms in Sickle Cell Disease Patients: A Systematic Review

Abstract Aim To estimate the prevalence, incidence, and characteristics of Unruptured Intracranial Aneurysms (UIAs) in (sickle cell disease) SCD patients and compare same with the metrics and features in the general population. Method The Data repositories, Medline (PubMed), Embase and Web of science were systematically searched from January 1st, 1990, to July 31st, 2021. Publications that passed an inclusion test were reviewed for data on the incidence and prevalence of UIAs, aneurysm characteristics and outcomes in SCD patients extracted. Findings from the included studies were appraised, using the Methodological Index for Non-randomized studies score (MINORS). The results were descriptively analysed. Given the marked heterogeneity of retrieved data, results were reported as standardized values, including the mean weighted annual incidence rate. Results 105 SCD patients with 186 UIAs were identified in 10 retrospective studies. Mean age ranged from 10.5 to 40.18 across studies with adult (&amp;gt;18 years) predominance. Prevalence of UIAs in SCD was 4.1% (95%CI 3.6 and 4.6) incidence rate was 1290.3/100,000 patient-years (95% CI 1018.0 to 1562.6). Aneurysms tended to be small (60%), anterior (76.1%), multiple (45.7%), managed conservatively (62%) with mostly good outcomes (95%). Average MINORS score was 9.4 ±3.1 for non-comparative studies (n = 8) and 19.5 ±0.7 for comparative studies (n = 2). Conclusions UIAs have a definite relationship with SCD, with higher incidence figures relative to the general population. Aneurysmal characteristics although largely similar, tend to be smaller in SCD patients. The low methodological quality of reviewed studies informs the need for well-designed prospective randomized controlled studies to better understand the mechanics of this relationship.

Swashbuckler approach for distal femur fractures: A systematic review

PurposeThe review aims to reach a common consensus regarding the swashbuckler approach for distal femur fractures by a systematic review of the available literature and to evaluate the complications, union, and outcomes. MethodsElectronic database search engines like Cochrane Library, PubMed, Google Scholar, and Scopus were searched until May 2021. Studies comparing the clinical complications, and functional outcome scores of Swashbuckler approach for distal femur were considered. The quality of the articles were evaluated using Methodological Index for Non-Randomized Studies score. ResultsEleven studies were included for the final analysis. An anterior midline incision was used in the majority of studies. Superficial infection was the most common complication seen followed by knee stiffness and deep infections. 66.45% of the patients had excellent/good outcomes. 1.08% had a painful implant and 1.89% had deep infection. ConclusionSwashbuckler approach offers itself as a viable option in cases of distal femur fractures, especially in AO type C. The quadriceps sparing approach provides excellent/good outcomes in approximately 66.45% of the patients.

Is the modified Ponseti method effective in treating atypical and complex clubfoot? A systematic review.

In 2006, Ponseti modified the standard technique to treat cases of "atypical" and "complex" clubfoot. To determine the outcomes of Ponseti's modified method to treat complex idiopathic clubfoot patients, we asked the following: (1) What is the deformity correction success rate? (2) What is the relapse rate after the correction? (3) What is the incidence of complications? We performed a systematic review by searching the EMBASE, MEDLINE, Cochrane Library, and Web of Science databases from inception to March 1, 2021. All studies on idiopathic, complex, and atypical clubfoot that assessed Ponseti's modified technique were included. Of 699 identified articles, ten met the inclusion criteria. The mean index for non-randomized studies score for the included studies was 11.8 ± 1.7. Early detection of the deformity and modifying the standard protocol, as described by Ponseti, resulted in a high rate of success. Initial correction occurred in all children, with a mean ankle dorsiflexion of 15°. Relapse occurred often ranging between 10.5 and 55%. The incidence of complications associated with the modified Ponseti method ranged from 6 to 30%. Studies using the modified Ponseti technique have shown high initial correction rates and a smaller number of relapses. However, studies with prospective designs and long-term follow-up are required to conclude whether these observations are due to properly performing the modified method or if higher rates of relapse increase with further follow-up.

Adverse Reactions and Clinical Outcomes for Leukocyte-Poor Versus Leukocyte-Rich Platelet-Rich Plasma in Knee Osteoarthritis: A Systematic Review and Meta-analysis.

Background:Platelet-rich plasma (PRP) has gained attention as a therapeutic option for knee osteoarthritis; however, its efficacy varies widely. Leukocytes in PRP raise the concern of aggravating proinflammatory activity. To date, PRP has rarely been investigated with regard to leukocyte concentration.Purpose:To provide clinical evidence of the intra-articular injection of PRPs containing different leukocyte concentrations.Study Design:Systematic review; Level of evidence, 4.Methods:We systematically searched the MEDLINE, Embase, Cochrane Library, CINAHL, and Scopus databases. PRP was classified into leukocyte-poor (LP-PRP) and leukocyte-rich (LR-PRP). Clinical outcomes including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain score, International Knee Documentation Committee (IKDC) subjective score, and adverse reactions were evaluated. The Methodological Index for Non-Randomized Studies criteria were used for quality assessment.Results:Included were 32 studies with an evidence level between 1 and 4. Both LP-PRP and LR-PRP showed improvements above the minimal clinically important difference (MCID) in VAS pain score. No significant intergroup difference was seen at 3, 6, or 12 months of follow-up. Regarding function, both LP-PRP and LR-PRP showed improvements above the MCID in the WOMAC and IKDC scores, with no significant difference between the groups. Adverse reactions for pain were significantly higher in LR-PRP than in LP-PRP (odds ratio, 1.64; 95% confidence interval, 1.29-2.10; P = .01). After intra-articular PRP injection, LR-PRP showed a significantly higher rate of swelling than LP-PRP (odds ratio, 1.56; 95% confidence interval, 1.22-1.99; P = .02). The mean Methodological Index for Non-Randomized Studies score of the included studies was 18.6 (range, 10-24).Conclusion:Intra-articular PRP injection resulted in improvements above the MCID in terms of pain and function in patients with knee osteoarthritis up to 12 months. The risk of local adverse reactions appeared to be increased after LR-PRP compared with LP-PRP injection. The findings of this review can support the potential use of intra-articular PRP injection for the treatment of knee osteoarthritis. In clinical application, clinicians need to consider selecting a specific type of PRP for knee osteoarthritis.

Objective measurements for upper airway obstruction in infants with Robin sequence: what are we measuring? A systematic review.

Identifying optimal treatment for infants with Robin sequence (RS) is challenging due to substantial variability in the presentation of upper airway obstruction (UAO) in this population. Objective assessments of UAO and treatments are not standardized. A systematic review of objective measures of UAO was conducted as a step toward evidence-based clinical decision-making for RS. A literature search was performed in the PubMed and Embase databases (1990-2020) following PRISMA guidelines. Articles reporting on RS and UAO treatment were included if the following objective measures were studied: oximetry, polysomnography, and blood gas. Quality was appraised by the methodological index for nonrandomized studies (range: 0-24). A total of 91 articles met the inclusion criteria. The mean methodological index for nonrandomized studies score was 7.1 (range: 3-14). Polysomnography was most frequently used (76%) followed by oximetry (20%) and blood gas (11%). Sleep position of the infant was reported in 35% of studies, with supine position most frequently, and monitoring time in 42%, including overnight recordings, in more than half. Of 71 studies that evaluated UAO interventions, the majority used polysomnography (90%), of which 61% did not specify the polysomnography technique. Reported polysomnography metrics included oxygen saturation (61%), apnea-hypopnea index (52%), carbon dioxide levels (31%), obstructive apnea-hypopnea index (27%), and oxygen desaturation index (16%). Only 42 studies reported indications for UAO intervention, with oximetry and polysomnography thresholds used equally (both 40%). In total, 34 distinct indications for treatment were identified. This systematic review demonstrates a lack of standardization, interpretation, and reporting of assessment and treatment indications for UAO in RS. An international, multidisciplinary consensus protocol is needed to guide clinicians on optimal UAO assessment in RS. Logjes RJH, MacLean JE, de Cort NW, et al. Objective measurements for upper airway obstruction in infants with Robin sequence: what are we measuring? A systematic review. J Clin Sleep Med. 2021;17(8):1717-1729.

Osteochondral Lesions of the Distal Tibial Plafond: A Systematic Review of Lesion Locations and Treatment Outcomes.

Background:Osteochondral lesions of the tibial plafond (OLTPs) remain less common than osteochondral lesions of the talus (OLTs), but recognition of the condition has increased.Purpose:To systematically evaluate the literature on lesion locations and treatment outcomes of OLTPs, whether in isolation or in combination with OLTs.Study Design:Systematic review; Level of evidence, 4.Methods:A search was performed using the PubMed, Embase, and CINAHL databases for studies on lesion locations or with imaging or treatment outcomes of OLTPs. Case reports and reports based on expert opinion were excluded. Lesion locations as well as outcome measure results were aggregated. The Methodological Index for Non-randomized Studies score was used to assess methodological quality when applicable.Results:Included in this review were 10 articles, all published in 2000 or later. Most studies were evidence level 4, and the mean Methodological Index for Non-randomized Studies score was 8.6 (range, 8-10). Overall, 174 confirmed OLTP cases were identified, and the mean patient age was 38.8 years. Of the 157 lesions with confirmed locations, the most common was central-medial (32/157; 20.4%). Of 6 studies on treatment outcomes, all but 1 evaluated bone marrow stimulation techniques. Microfracture of small lesions (<150 mm2) was the most common treatment utilized. Imaging and functional outcomes appeared favorable after treatment. The data did not support differences in outcomes between isolated OLTPs and OLTPs with coexisting OLTs.Conclusion:Osteochondral lesions of the distal tibia most commonly occurred at the central-medial tibial plafond. Microfracture of small lesions was the most common treatment utilized, and clinical and magnetic resonance imaging results were favorable, although data were heterogeneous. Areas for future research include the following: the effect of patient factors and additional pathologies on outcomes; larger or deeper lesion treatment; more direct comparisons of outcomes between kissing or coexisting lesions and isolated lesions; and head-to-head comparison of treatments, such as microfracture, bone marrow–derived cell transplantation, and osteochondral autografts/allografts.

Low Reinfection Rates But a High Rate of Complications in THA for Infection Sequelae in Childhood: A Systematic Review.

Childhood hip infections can result in serious sequelae during adulthood, including persistent pain, functional limitations, and premature THA. When THA is performed in patients who had hip joint infections during childhood, surgeons surmise these arthroplasties are at an increased risk of complications and incomplete recovery. However, the degree to which this is true is not well characterized and has varied across a large number of small, retrospective studies. (1) What proportion of THAs performed in patients who had pediatric septic arthritis result in periprosthetic joint infection? (2) What are the Harris hip scores associated with these reconstructions? (3) What proportion of these patients develop complications after THA? (4) What proportion of patients undergo revision after these THAs? For this systematic review, we searched the MEDLINE (PubMed), Scopus, and CINAHL (EbscoHost) electronic databases. We evaluated studies published in English between 1980 and 2020 that had a minimum of 10 patients (with a minimum of 2 years of follow-up) in whom sequelae of septic arthritis of the hip were treated with single-stage THA. We also evaluated studies reporting clinical outcomes by means of the Harris hip score, along with a radiographic assessment of the prosthesis. Updates of previous studies using the same database, case reports, surgical technique reports, systematic reviews, and expert opinions were excluded. No restrictions were applied regarding study design and loss to follow-up. A total of 430 studies were identified through the initial search, and 11 studies were included after applying the inclusion and exclusion criteria. All but two studies, which included a historical control group, were retrospective case series. A total of 691 patients with a mean age of 45 years were involved. A total of 599 patients underwent cementless THAs, 84 patients underwent hybrid THA (cemented stems), and the remaining eight patients received a cemented THA. A total of 287 additional procedures were performed on the acetabulum, including autografting, allografting, and medial wall osteotomies; in three hips, tantalum augments were used. Three hundred thirty-five additional procedures were performed on the femora, including 223 shortening osteotomies and 112 greater trochanter osteotomies. The mean follow-up duration ranged from 5.5 to 15.2 years (minimum follow-up range 2-13 years). To assess the quality of the studies, we used the Methodological Index for Non-randomized Studies and the Assessment of Quality in Lower-limb Arthroplasty, for which a higher score represents a better study quality. The mean Methodological Index for Non-randomized Studies score for case series was 9 of 16 (range 6-12), and 19 and 18 of 24 for the two comparative studies. The mean reporting quality of the Assessment of Quality in Lower Limb Arthroplasty score was 6 of 8 (range 3-8). Because of loss to follow-up, which was not consistently reported in the source studies, we caution the reader that the estimates provided here likely underestimate the risks of adverse events and overestimate the mean hip scores. The pooled proportion of patients in whom infections developed was 1% (seven of 691 THAs). Considering only studies published in the past 10 years, the proportion was 0.7% (two of 276 THAs). The Harris hip score increased from a mean of 52 ± 6 points before THA to a mean of 88 ± 2 points after THA. The pooled proportion of complications, including sciatic nerve palsy, femoral nerve palsy, intraoperative periprosthetic fracture, deep venous thrombosis, and dislocation, was 11% (76 complications among 691 THAs). The pooled proportion of patients who underwent revision was 8% (53 revisions of any components for any reason among 691 THAs) at a mean follow-up interval of 9.1 ± 3 years. In THAs for sequelae of childhood septic arthritis, reinfections were uncommon, whereas generally, infection rates were slightly higher than those reported for conventional primary THAs. However, the duration of follow-up might have been insufficient to identify all patients in whom infections later developed, and the available data were not adequate to precisely detect the minimum quiescent period to avoid reinfections. Moreover, the studies in this systematic review were retrospective, and selection bias, transfer bias, and assessment bias likely influenced our findings. The general effect of these biases is to cause an underestimation of the harms of the intervention. Complications, especially intraoperative fracture and nerve palsy, were common in patients with the most-severe infections. Further data on this topic are needed, ideally from multicenter or registry studies with even longer follow-up durations. Level IV, therapeutic study.

A systematic review and meta-analysis of bioresorbable vascular scaffolds for below-the-knee arterial disease.

Different types of bioresorbable vascular scaffolds (BVSs) have been developed and used in below-the-knee (BTK) arterial diseases. This is the first study reviewing and analyzing the literature on BVS treatment for BTK arterial disease. MEDLINE, Embase, and Cochrane were searched for studies published until October 21, 2019. The search, study selection, quality assessment, and data extraction were performed by 2 authors independently. Articles that studied the treatment of BTK arterial disease by using BVSs were eligible. Exclusion criteria were studies with a variant design (e.g. case reports <5 patients), non-BTK indications for BVS use, and nonhuman studies. Primary endpoint was 12-month primary patency. Secondary endpoints were 12-month freedom from clinically driven target lesion revascularization (CD-TLR), limb salvage, survival, and amputation-free survival (AFS). Study quality was assessed by the Methodological Index for Non-randomized Studies score. Five studies representing 155 patients with 160 treated limbs met the inclusion criteria. Pooled 12-month primary patency per limb was 90% (143/160; 95% confidence interval [CI]: 0.84-0.95), freedom from CD-TLR 96% (124/130; 95% CI: 0.91-0.99), limb salvage rate 97% (156/160; 95% CI: 0.94-1.00), survival rate 90% (112/125; 95% CI: 0.82-0.96), and AFS rate 89% (110/125; 95% CI: 0.81-0.94). Subgroup analyses of included Absorb BVS studies showed similar results. All studies were assessed as moderate quality. This meta-analysis of case series showed good 12-month patency and clinical results with BVSs for BTK arterial disease, even in patients with multimorbidity and short but complex lesions. These results encourage a revival of this scaffold.

Cutting, Impingement, Contact, Endurance, Flexibility, and Asymmetric/Overhead Sports: Is There a Difference in Return-to-Sport Rate After Arthroscopic Femoroacetabular Impingement Surgery? A Systematic Review and Meta-analysis

Background: Previous studies have established a classification of sports based on hip mechanics: cutting, impingement, contact, endurance, flexibility, and asymmetric/overhead. No previous review has compared the outcomes of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) using this classification. Purpose: To determine whether the rate of return to sport differs among cutting, impingement, contact, endurance, flexibility, and asymmetric/overhead athletes who undergo hip arthroscopy for FAIS. We also aimed to identify differences in patient characteristics, intraoperative procedures performed, and time to return to play among the 6 sport categories. Study Design: Systematic review and meta-analysis. Methods: Three electronic databases were searched for eligible articles. Two reviewers independently screened the titles, abstract, and full-text articles using prespecified criteria. Eligible articles were those that reported the rate of return to sport (defined by the number of hips) after hip arthroscopy for FAIS in athletes of all levels. Data collected were patient age, sex, body mass index, type of sport, rate and time to return to sport, and intraoperative procedures performed. A mixed effects model was used for meta-analysis. Results: A total of 29 articles and 1426 hip arthroscopy cases were analyzed with 185 cutting, 258 impingement, 304 contact, 207 endurance, 116 flexibility, and 356 asymmetric/overhead athletes. The mean age was similar among the 6 subgroups (P = .532), but the proportion of female athletes was significantly higher in flexibility, endurance, and asymmetric/overhead sports as compared with impingement and contact athletes. Flexibility athletes had the highest rate of return to sport after hip arthroscopy for FAIS (94.8%), whereas contact athletes had the lowest rate (88%). The longest mean ± SD time (8.5 ± 1.9 months) to return to sport was reported in cutting sports, while endurance athletes returned faster than the rest (5.4 ± 2.6 months). The difference in rate and time to return to sport, as well as the intraoperative procedure performed, did not reach statistical significance among the 6 subgroups. There was evidence of publication bias and study heterogeneity, and the mean Methodological Index for Non-randomized Studies score was 13 ± 2.6. Conclusion: Flexibility athletes had the highest rate of return to sport after hip arthroscopy for FAIS, while endurance athletes returned the fastest. The difference in rate and time to return to sport and intraoperative procedures performed did not reach statistical significance among the 6 subgroups. These results are limited by the evidence of publication bias and should be interpreted with caution. Laboratory-based studies are necessary to validate the classification of sports based on hip mechanics.