Modified Coleman Methodology Score Research Articles

Intra-articular Injection of Autologous Adipose-Derived Stem Cells or Stromal Vascular Fractions: Are They Effective for Patients With Knee Osteoarthritis? A Systematic Review With Meta-analysis of Randomized Controlled Trials

Background: Intra-articular injection of adipose-derived stem cells, which are divided into adipose-derived mesenchymal stem cells (ASCs) and adipose-derived stromal vascular fractions (ADSVFs), has been reported to be a viable treatment modality for knee osteoarthritis (OA); however, its efficacy remains limited. Purpose: This study aimed to provide comprehensive information about the efficacy and safety of intra-articular injections of autologous ASCs and ADSVFs without adjuvant treatment in patients with knee OA. Study Design: Meta-analysis; Level of evidence, 1. Methods: A systematic search of the MEDLINE, Embase, Web of Science, and Cochrane Library databases was performed to identify randomized controlled trials (RCTs) that evaluated the efficacy and safety of intra-articular injections of autologous ASCs or ADSVFs without adjuvant treatments compared with placebo or hyaluronic acid in patients with knee OA. Clinically, the 100-mm visual analog scale for pain relief and the Western Ontario and McMaster Universities Osteoarthritis Index for functional improvement were implemented. Radiologically, cartilage status was assessed using magnetic resonance imaging (MRI). Procedure-related knee pain, swelling, and adverse events (AEs) were evaluated for safety. Additionally, we performed subgroup analyses comparing ASCs versus ADSVFs. Methodological quality was assessed using the modified Coleman Methodology Score (mCMS). Results: A total of 5 RCTs were included in this study. Based on the meta-analysis, ASCs or ADSVFs showed significantly better pain relief at 6 months (Z = 7.62; P < .0001) and 12 months (Z = 7.21; P < .0001) and functional improvement at 6 months (Z = 4.13; P < .0001) and 12 months (Z = 3.79; P = .0002), without a difference in procedure-related knee pain or swelling compared with controls. Although a meta-analysis with regard to cartilage improvements was not performed owing to heterogeneous MRI assessment, 3 studies reported significantly improved cartilage status after the injection. No serious AEs associated with ASCs or ADSVFs were reported. Subgroup analyses showed similar efficacy between ASC and ADSVF treatments. The median mCMS was 70 (range, 55-75). Conclusion: For patients with knee OA, intra-articular injection of autologous ASCs or ADSVFs without adjuvant treatment showed remarkable clinical efficacy and safety at short-term follow-up. Some degree of efficacy has been shown for cartilage regeneration in knee OA, although the evidence remains limited. Further RCTs that directly compare ASCs and ADSVFs are needed.

Syndesmosis Injury Imparts A Large Negative Effect on Patient Reported Outcomes: A Systematic Review

Category:Trauma; Ankle; SportsIntroduction/Purpose:Syndesmosis injuries are common, comprising up to 25% of all ankle sprains and being present in 35% or more of ankle fractures. Within the narrative of the syndesmosis literature, the substantial negative impact of syndesmosis injury is commonly described in intuitive yet qualitative terms. Therefore, a constructive criticism of the literature is to question how often and how well these reports have characterized the magnitude of the impact of the syndesmosis injury itself compared to confounding factors like concomitant injury. Indeed, such information particularly in aggregate, has the potential to influence clinical practice. Within this context, the objective of this systematic review was to assess how often and how well the literature has characterized the magnitude of syndesmosis injury.Methods:Included reports were grouped based on the setting in which syndesmosis injury was studied: (1) isolated syndesmosis disruption compared to lateral ankle sprain, (2) isolated syndesmosis disruption, (3) ankle fracture with concomitant syndesmosis disruption compared to ankle fracture with no syndesmosis disruption, and (4) ankle fracture with concomitant syndesmosis disruption without a comparison group with no syndesmosis disruption. Literature quality was assessed via the Modified Coleman Methodology Score (MCMS). Patients with and without syndesmosis injury were compared by independent sample t-tests using pooled values for specific patient reported outcome measures. Additionally, for these datasets, effect sizes were computed using Cohen's d.Results:Mean MCMS across all four groups was 59.9, indicating a moderate level of evidence. MCMS did not differ significantly between groups (p = 0.07). Analysis of reported outcomes indicated that syndesmosis injury has a significant (p = 0.007) effect and a large negative effect (effect size = 1.77) (Figure 1) on time to return to play when comparing athletes with isolated syndesmosis sprain to those with lateral ankle sprain. Additionally, analysis of ankle fracture patients indicated that syndesmosis injury has a large negative effect on functional outcomes (effect sizes > 0.80 for Olerud Molander and AOFAS scores), but little effect on pain (effect size = 0.14 for VAS pain). Studies which reported long term outcomes (mean 87 months) showed a very large negative effect (effect size 9.24) for Olerud Molander scores across 95 patients.Conclusion:In athletic populations, days missed due to syndesmosis disruption was statistically significant with a large effect size compared to lateral ankle sprain. Further, among ankle fracture patients, Olerud Molander and AOFAS scores indicate a large negative impact of syndesmosis disruption on functional outcomes despite a small negative impact on short term pain. These results indicate that the continued impact of this injury extends beyond the initial painful period and requires more attention.These patient-reported outcomes support the qualitative assertions that syndesmosis injury potentially imparts a large negative effect on clinical outcomes.

The Generation Game: Has Modern Contemporary Total Ankle Replacement (TAR) Improved Survivorship?

Category:AnkleIntroduction/Purpose:Total ankle replacements (TARs) provide pain relief with preservation of movement and function. The most successful TARs are either 2nd or current 3rd generation in design, whilst 4th generation implants are steadily being introduced. This meta-analysis evaluates the survivorship of 2nd, 3rd and 4th generation ankle replacements used today to determine whether any difference between generations and bearing types exist.Methods:A systematic review and meta-analysis of published data from January 2000 to January 2020 was conducted following PRISMA guidelines. Inclusion criteria: English language papers, adult population, >= 20 ankles with a minimum follow up >= 24 months, pre- and post-operative functional scores available. Clinical outcomes of primary TARs were evaluated as well as their associated survivorship. Statistical analyses were undertaken to determine survivorship and complications associated with the second, third and fourth generation implants and the bearing design. Ankle generations were determined from the original studies and confirmed based on literature set definitions. The modified Coleman Methodology Score was used to evaluate the quality of studies.Results:A total of 4642 TARs in 4487patients from 51-studies were included. The mean age was 61.9years and mean follow up of 57.8months. The most common indications were post-traumatic-OA (54.5%), primary-OA (25.5%) and inflammatory-arthropathy (15.2%). Relative-risk calculations showed significant reductions in nerve-injury (p < 0.01), post-operative fracture ( p < 0.01), wound complications (p < 0.01), radiolucencies ( p < 0.01), or heterotopic bone formation (p < 0.01), aseptic loosening (p < 0.01) for later generations. Sensitivity analysis performed for the withdrawal of 2 prostheses showed 2yr survivorship for 2nd, 3rd and 4th generation TARs was 95.3%, 97.9% and 98.9% (p < 0.05). Third-generation TARs had better 10-yr survivorship compared to 2nd generation (83.50% vs. 70.76%) (p < 0.01). Bearing design had little influence on survivorship.Conclusion:In the real world subsequent generations of modern contemporary TAR demonstrate lower rates of complications and improved survivorship independent of bearing design, without reaching designer series levels. Population changes have meant a reduction in mean age at implementation and the commonest pathology for a TAR has become post traumatic OA without a observed detrimental affect in outcomes. Even so, superior short-term survivorship of fourth generation implants is promising for the future of modern TAR surgery.

The Prognostic Value of Syndesmosis Malreduction for Revision Surgery: A Systematic Review

Category:Ankle; TraumaIntroduction/Purpose:Reported rates of syndesmosis malreduction are highly variable due to applied criteria that differ in imaging modality, threshold for malreduction and use of the contralateral ankle for comparison. Studies have emphasized the importance of anatomic reduction while providing inconclusive evidence for the need for revision surgery in malreduced ankles. With no industry standard for determining malreduction, it is unclear whether the most commonly used criteria is a valuable discriminator for clinical decision making. Our objective was to describe the rates of syndesmosis revision that are reported in the literature and to determine if malreduction diagnoses are reliable in predicting the need for syndesmosis revision surgery.Methods:Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analyses) guidelines, a systematic review of the literature was performed in order to describe revision syndesmosis surgery. Included studies were grouped based on criteria for determining malreduction - group 1 (N = 954) used unilateral radiograph, group 2 (N = 41) used unilateral CT scan, group 3 (N =531) used bilateral CT scan and group 4 (N = 119) used bilateral radiograph. Evidentiary quality was graded with the Modified Coleman Methodology Score (MCMS). Student t tests were used to calculate the differences between groups for rates of malreduction and revision. For the screening criteria most commonly used to determine malreduction, the test characteristics sensitivity, specificity and positive predictive value (PPV) were calculated.Results:Pooled rates of malreduction and revision for the groups using CT scan (groups 2 and 3, N = 572, mean follow up 16 months) were 23.5% and 0.25% respectively. Pooled rates of malreduction and revision for the groups using bilateral imaging (groups 3 and 4, N = 650, mean follow up 20 months) were 18.5% and 0.8% respectively. Significant differences were found between CT scan and radiograph for malreduction (p<0.001) and for revision (p=0.02). Significant differences were also found between bilateral and unilateral imaging for malreduction (p=0.01). The malreduction criteria of a 2mm difference in tibiofibular space on CT scan between the injured and uninjured side was used in 6 studies (N = 531, mean follow up 19 months). The sensitivity of this criteria for detecting cases which required revision was 100%, specificity 78%, and PPV 6%.Conclusion:It is unclear whether high rates of malreduction are due to suboptimal surgical repair which lead to clinical detriment or are they solely an imaging finding which depend heavily on the criteria for diagnosis. The most commonly used criteria for malreduction - a 2mm side-to-side difference in tibiofibular space on CT scan - is highly sensitive for reoperations. The specificity and PPV indicate that a threshold of more than 2mm is needed to better evaluate those ankles which may require revision surgery. Based on the current findings, malreduction diagnoses do not adequately translate from disease-oriented information to patient-oriented information.

Timing of postoperative weightbearing in the treatment of traumatic chondral injuries of the knee in athletes - A systematic review of current concepts in clinicalpractice

BackgroundSurgery aims to stimulate healing and enable a safe return to sport in athletes with symptomatic cartilage lesions of the knee. Timing of postoperative weightbearing is crucial, balancing a stimulation of the healing and avoiding reinjury.To explore current concepts of timing to partial and full weightbearing and rate of return to sport in athletes after articular cartilage surgery of the knee.Systematic Review of studies with level of evidence I-III MethodsFour databases (Pubmed, Web of Science, Scopus and Embase) were searched using a predetermined keyword strategy. Two independent reviewers screened results according to inclusion and exclusion criteria. Modified Coleman Methodology Score (mCMS) was used for the quality assessment. Results5294 records were found. Data from ten studies was extracted after duplicate removal, title and abstract screening and full-text evaluation. Eight of the ten studies included a detailed rehabilitation protocol, including 336 out of a total athletic population of 401. 62% began partial weightbearing (PWB) 1–2 weeks postoperatively, while 38% began within 3–4 weeks. The studies that had a later PWB all returned to full weightbearing (FWB) within 6–8 weeks. One study with early PWB returned to early FWB, while the other two returned 10–12 weeks postoperatively. “Return to Sport” (RTS) was the most common reported outcome measure, with most studies reporting RTS at 80% or higher. ConclusionThere is no clear evidence that the timing of weightbearing (WB) affects the outcome and return to sport in athletes after surgery for focal full-thickness cartilage lesions of the knee. On the other hand, there seems to be no adverse effects in adopting an early WB strategy, currently defined differently by different authors. Further studies directly comparing the timing of WB for specific surgical procedures in athletes and with relevant control groups is recommended. There is a need for a consensus in regard to more exactly defining “early” vs “late” weightbearing in relation to a universal and precisely defined state of healing.

Efficacy of Bone Graft on Fusion Rates in Primary Open Ankle Arthrodesis: A Systematic Review

Category:Ankle Arthritis; Basic Sciences/Biologics; TraumaIntroduction/Purpose:Success in ankle arthrodesis has been reported between 74% and 100%. Despite many recent reports with success rates >95%, the modern literature details a precipitous increase in the use of biological adjuvants for primary ankle arthrodesis. These additions raise the cost of the procedure and potentially incur morbidity related to the donor site or adverse graft response. For these reasons the routine use of bone graft has come under scrutiny with no consensus regarding its use. The cost - both direct and indirect - of biological adjuvant should be weighed against its added value to clinical outcomes. This systematic review aimed to assess the efficacy of bone autograft versus no graft on achieving a clinically successful primary open ankle arthrodesis fixated using cannulated screws.Methods:Included studies were divided into 3 groups based on the use of bone graft: no bone graft (NBG), fibular onlay with local autograft (FOBG), and the use of autograft without fibular onlay (BG). Pooled data analysis was performed, and fusion rates were frequency weighted in order to appropriately judge the impact of each study. Cohen's d was used to evaluate effect size for the use of bone graft. Modified Coleman Methodology Score (MCMS) was calculated to analyze reporting quality.Results:These selected studies described outcomes for a total of 884 patients with mean follow up of 46 months. The reviewed literature was of moderate quality, with an MCMS of 60.6. The weighted mean rate of fusion for the 3 groups was 96% in the NBG group (n=182), 96% in the FOBG group (n = 257), and 95% in the BG group (n = 445), with no significant difference between the groups (p=0.98). Use of bone graft resulted in a Cohen's d effect size of 0.10 (95% confidence interval 0.07- 0.26). Time to fusion for the 3 groups was 13.60 weeks for the NBG group, 14.51 weeks for the FOBG group, and 15.10 weeks for the BG group, with no significant difference between the groups (p=0.87). Number needed to treat was 7 with the event of interest defined as a fusion rate less than 95%.Conclusion:Bone graft use in primary open ankle arthrodesis fixated with cannulated screws did not have a significant effect (p=0.98) on union rates and yielded a small effect size. Further data demonstrated that 7 ankle arthrodesis patients need to be treated with bone graft in order to prevent 1 clinically significant nonunion. The current findings are both clinically and economically relevant, as commercial bone graft carries additional cost and autologous graft harvest is not consistently a benign endeavor. With increased cost and potential for complication, bone graft use should demonstrably improve clinical outcomes in order to validate these additional burdens.

Chronic Achilles Tendon Ruptures: A Systematic Review

Category:Ankle; TraumaIntroduction/Purpose:Chronic Achilles tendon ruptures (CATR) are an uncommon injury compared to acute ruptures. Currently, no evidence-based guidelines exist for treating CATR. The purpose of this systematic review was to present the outcomes of the current treatment options for CATR and to analyze the level of evidence (LOE) and quality of evidence (QoE) of the included studies.Methods:In July 2020, MEDLINE, EMBASE and Cochrane Library databases were systematically reviewed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The LOE and QOE of the included studies was evaluated using the Modified Coleman Methodology Score. Studies reporting outcomes following repair of CATR were included.Results:Thirty-one studies with 653 CATRs were included. Three studies were LOE III and 28 studies were LOE IV. Six studies reported dual technique procedures and 23 studies reported single technique procedures. Semitendinosus graft was the most frequently utilized single technique procedure amongst the included studies. Most studies reported good postoperative subjective outcomes, strength outcomes, and return to sports data at mid-term follow-up. In total, 14.6% of patients experienced postoperative complications. The most common complication was surgical wound complications (10.8%).Conclusion:This systematic review found that no evidence-based treatment guidelines exists for CATR. Surgical management of CATR produces good clinical outcomes at mid-term follow up, but a high complication rate (14.6%) was noted. Future studies of higher QOE and LOE with improved data reporting are warranted to determine the optimal treatment strategy for CATR.

Glenohumeral osteoarthritis with intact rotator cuff treated with reverse shoulder arthroplasty: a systematic review.

Although reverse shoulder arthroplasty (RSA) has shown satisfactory outcomes in rotator cuff-deficient shoulders, its performance in shoulders with an intact rotator cuff has not been fully elucidated. Shoulder osteoarthritis can present with alterations in glenoid morphology, which have contributed to inconsistent outcomes in anatomic shoulder replacement. The glenoid component is responsible for a predominance of these arthroplasty complications. Given these glenoid-related difficulties, RSA may provide a more favorable option. We aimed to summarize the current literature on rotator cuff intact osteoarthritis treated with primary RSA and to determine whether morphologic changes in the glenoid led to inferior outcomes. A literature search was performed using an inclusion criterion of primary RSA for osteoarthritis with an intact rotator cuff. The Modified Coleman Methodology Score was calculated to analyze reporting quality. Following appropriate exclusions, of the 1002 studies identified by the databases, 13 were selected. Postoperative improvement in weighted means for Constant scores reached statistical significance (P = .02). The mean rate of major complications was 3.8%. A subset of 8 studies was created that detailed the following descriptions of altered glenoid morphology: "static posterior instability," "severe posterior subluxation," "posterior glenoid wear >20°," "significant posterior glenoid bone loss," "biconcave glenoid," "B2 glenoid," and "B/C glenoid." Within this subset, the mean complication rate was 4.7%, with 4 of the 7 studies having a rate ≤ 3%, and improvements in the Constant score (P = .002) and external rotation (P = .02) reached statistical significance. RSA as treatment for osteoarthritis with an intact rotator cuff provides optimal outcomes with low complication rates across a short term of follow up. Preoperative considerations for using reverse arthroplasty in the treatment of osteoarthritis with an intact rotator cuff include glenoid retroversion, posterior humeral subluxation, and glenoid bone loss. The attributes of reverse arthroplasty that contribute to favorable outcomes in arthritic shoulders include its semiconstrained design and robust glenoid fixation. Soft-tissue imbalances as a consequence of pathologic glenoid morphology and chronic humeral subluxation can be mitigated with the RSA semiconstrained design. Glenoid bone loss can be effectively managed with RSA's robust glenoid fixation, with and without the use of bone graft. The capability to lateralize the joint center of rotation may be valuable when faced with a medialized glenoid wear pattern. The current findings suggest that reverse arthroplasty can achieve highly favorable outcomes for glenohumeral osteoarthritis with an intact rotator cuff.

Return-to-Sport Outcomes After Primary Ulnar Collateral Ligament Reconstruction With Palmaris Versus Hamstring Tendon Grafts: A Systematic Review.

Background:Ulnar collateral ligament (UCL) reconstruction is the current gold standard of treatment for overhead athletes with a symptomatic, deficient UCL of the elbow who have failed nonoperative treatment and wish to return to sport (RTS) at a high level. The palmaris longus and hamstring tendons are common graft choices, but no study has analyzed the existing literature to assess whether one graft is superior to the other.Purpose:To systematically report on the outcomes of UCL reconstruction using palmaris and hamstring autografts.Study Design:Systematic review; Level of evidence, 4.Methods:A combination of the terms “ulnar collateral ligament,” “valgus instability,” “Tommy John surgery,” “hamstring,” and “palmaris longus” were searched in PubMed, Embase, and the Cochrane Library. RTS and return-to-same-level (RSL) rates, patient-reported outcomes, and complications were included for analysis. We used the modified Coleman Methodology Score and risk-of-bias tool for nonrandomized studies to assess the quality of the included studies.Results:This review included 6 studies (combined total of 2154 elbows) that directly compared palmaris and hamstring graft use in UCL reconstruction. Follow-up ranged from 24 to 80.4 months, and the mean patient age across all studies was 21.8 years. The mean RSL across all studies and grafts was 79.0%, and the mean RTS was 84.1%, consistent with results previously reported in the literature. The mean RTS and RSL rates for the palmaris graft group were 84.6% and 82%, respectively; the hamstring graft group showed mean RTS and RSL rates of 80.8% and 80.8%. Meta-analysis revealed no significant difference in RSL between the 2 graft groups (odds ratio, 1.06; 95% CI, 0.77-1.46). The combined complication rate of the included studies was 18.2%, with failure rates ranging from 0% to 7.1%.Conclusion:Results of this review indicated that both palmaris and hamstring tendon grafts are viable options for primary UCL reconstruction. Graft choice should be determined by a combination of patient and surgeon preference.

Outcomes of Acute Operative Repair of Complete Digital Proximal Interphalangeal Joint Collateral Ligament Ruptures: A Systematic Review.

Background: No consensus exists regarding the management of complete collateral ligament injuries of the proximal interphalangeal joint (PIPJ) of fingers. Methods: We aimed to systematically review the outcomes of Acute (< 1 month) surgical repairs of these injuries. Outcomes assessed included Stability, Pain, Range-of-Motion and Return to Function. The Modified Coleman Methodology Score (MCMS) was utilised in critical appraisal. Results: 70 patients with complete collateral ligament injuries of the PIPJ were identified in 5 studies. 49 were managed operatively and 21 non-operatively. All trials were methodologically flawed with a mean MCMS of 50.4, corresponding to a "Poor" Level of evidence. Conclusions: Whilst acute surgical repair of complete collateral ligament injuries of finger PIPJs are a described viable management option with promising results, there is insufficient high-quality evidence to inform current practice. Based on the current literature, no evidence-based conclusions can be made regarding superiority of acute surgical repair over conservative management or one method of surgical repair over another. Further high level studies are required.

Osteochondral Lesions of the Tibial Plafond: A Systematic Review.

Background:There is a paucity of data regarding osteochondral lesions of the tibial plafond (OLTPs), in part because they are far less common than osteochondral lesions of the talus.Purpose:To evaluate the topographical characteristics of OLTPs and outcomes after surgical intervention, while analyzing the level of evidence (LOE) and quality of evidence (QOE) of the included studies.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies reporting clinical data for OLTPs were included. The LOE and QOE of the included studies were evaluated using a 5-level grading system and the modified Coleman Methodology Score, respectively.Results:Included were 20 studies with 426 OLTPs; 4 studies were LOE 2 and 16 studies were LOE 4. Overall, 86.7% of OLTPs were associated with a traumatic history and/or previous ankle sprain. OLTPs were most commonly located in the centromedial region of the tibial plafond (30.4%), with the fewest number of OLTPs found in the anteromedial region of the tibial plafond (3.9%). In 17 of the studies, a total of 46.9% of OLTPs were associated with coexisting osteochondral lesions of the talus. The most frequently used surgical technique to treat OLTPs was microfracture, which resulted in good clinical outcomes at midterm follow-up.Conclusion:The results of this systematic review indicated that OLTPs are frequently preceded by ankle trauma and are often associated with coexisting osteochondral lesions of the talus. Clinical outcomes after arthroscopic intervention appear to produce good results in the midterm, but the low LOE, poor QOE, marked heterogeneity, and underreporting of the data confound any recommendation based on this systematic review.

Autograft Versus Allograft for Medial Patellofemoral Ligament Reconstruction: A Systematic Review.

Background:Patients with recurrent lateral patellar dislocations are often treated with reconstruction of the medial patellofemoral ligament (MPFL).Purpose:To perform a systematic review to evaluate clinical outcomes and the risk of recurrent patellar dislocation after MPFL reconstruction (MPFLR) with autograft versus allograft.Study Design:Systematic review; Level of evidence, 4.Methods:The authors conducted a search of PubMed, the Cochrane Library, and Embase to identify studies comparing outcomes of MPFLR with autograft versus allograft. The inclusion criteria were full-text studies that directly compared clinical outcomes and/or risk of recurrent patellar instability between patients undergoing MPFLR with autograft versus allograft. A quality assessment was performed using the modified Coleman Methodology Score, and risk-of-bias assessment was performed using the Risk Of Bias In Non-randomized Studies–of Interventions and the Cochrane Collaboration tools.Results:Seven studies (1 evidence level 2, 3 level 3, 3 level 4) that met inclusion criteria were identified and included a total of 150 patients who underwent MPFLR with autograft and 193 with MPFLR with allograft. One study found a significantly higher failure rate among patients with autograft, and another study found a trend toward a significantly higher failure rate among patients with autograft. One study demonstrated no significant difference between postoperative tibial tubercle–trochlear groove distance (measured on magnetic resonance imaging scans) in failed versus successful grafts. One study found that patellar tilt angle improved significantly from preoperatively to postoperatively (P < .001) but there was no difference between the groups. Kujala scores significantly improved for both autograft and allograft groups across studies. Two studies found significant differences in postoperative Kujala scores between the 2 groups, 1 of which found better scores in the allograft group (P = .0032) and another in which scores were better in the autograft group (P = .02).Conclusion:Patients undergoing MPFLR with either autograft or allograft can expect to experience improvement in clinical outcomes. Subjective outcomes improved to a similar degree in both groups. Graft failure was more frequently observed in patients with autograft. Allograft may be a better option for MPFLR owing to lower failure rate.

A Historical Analysis of Randomized Controlled Trials in the Management of Pain in Rotator Cuff Tears.

The aim of this analysis was to assess the quality of reporting of randomized controlled trials (RCTs) relating to pain management in rotator cuff (RC) tears. This review evaluated the quality of the studies in the literature regarding this topic through the use of some factors and trends. The online databases used to search all RCTs on the topic of RC surgery were Medline, Scopus, CINAHL, EMBASE, and CENTRAL. This research was completed in September 2020. To assess the quality of reports, the Consolidated Standards of Reporting Trials (CONSORT) and the modified Coleman methodology score (MCMS) were used. From the research, 262 articles emerged. Finally, 79 studies were included in this historical analysis. There were no statistically significant changes in MCMS across trials that included or did not include a CONSORT diagram (p = 0.10). A statistically significant difference in MCMS was discovered between papers produced prior to 2009 and publications produced after 2015 (p = 0.03). There was no association between the number of checklist items for each article and the Coleman score. During the years there has been a significant increase in both quantity and quality of RCTs relating to pain in RC tears.

Osteosynthesis or non-operative treatment of the fibula for distal lower-leg fractures with tibial nailing: a systematic review and meta-analysis.

Fibular fixation to treat distal lower-leg fractures is a controversial intervention. To ensure better stability itself, better rotational stability, and to prevent secondary valgus dislocation – all these are justifications for addressing the fibula via osteosynthesis. High surgical costs followed by increased risks are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of malunion and malrotation, as well as infections and nonunions.We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were modified Coleman Methodology Score (mCMS) > 60, a distal lower-leg fracture treated by nailing, and adult patients. Biomechanical and cadaver studies were excluded. Relevant articles were reviewed independently by referring to title and abstract. In a meta-analysis, we compared five studies and 741 patients.A significantly lower rate of valgus/varus deviation is associated with fixation of the fibula (OR = 0.49; 95% CI: 0.29–0.82; p = .006). A higher risk for pseudarthrosis was revealed when the fibula underwent surgical therapy, but not significantly (OR = 1.46; 95% CI: 0.76–2.79; p = .26). Nevertheless, we noted an increased risk of postoperative wound infection following fibular plating (OR = 1.90; 95% CI: 1.21–2.99; p = .005). There was no statistically significant difference in the rate of nonunions between the two groups.Overall, the stabilization of the fibula may reduce secondary valgus/varus dislocation in distal lower-leg fractures but is associated with an increased risk of postoperative wound infections. The indication for fibula plating should be made individually. Cite this article: EFORT Open Rev 2021;6:816-822. DOI: 10.1302/2058-5241.6.210003

Analysis of the Quality of Prospective Randomized Controlled Trials for Treatment of Boxer's Fractures.

This study aimed to review level I and II therapeutic studies on boxer's fractures to measure variation in quality among the highest level study designs. We used quantitative measures of study quality to evaluate prospective randomized controlled trials (RCTs) of treatments of boxer's fractures. A search of PubMed, using terms "boxer's fracture" and "fifth metacarpal neck fracture" identified 164 articles from 1961 to 2019. From this list, we identified 6 RCTs. Two observers classified each trial according to 3 systems: the Oxford Levels of Evidence, the modified Coleman Methodology Score, and the revised Consolidated Standards of Reporting Trials (CONSORT) score. The 2 reviewers were consistent in their use of the Oxford Levels of Evidence (100% agreement). The differences between the average modified Coleman Methodology scores and the average CONSORT scores assigned by the 2 observers were not significant (46.2 vs 45.3 points, κ = 0) and (13.7 vs 14.3 points, κ = 0.33), respectively. Both observers rated all the studies as level I and as unsatisfactory according to the Coleman Methodology Score (100% and 100%), and less than half as unsatisfactory according to the CONSORT score (50% and 17%). Areas of deficiency included randomization, blinding, group comparability, clinical effect measurements, and allocation into treatment arms. Classifying orthopedic scientific reports according to the levels of evidence implies a degree of respect for level I and II studies that may not always be merited. Our data suggest that the quality of higher level studies, namely those involving boxer's fractures, varies and may often be unsatisfactory when critically evaluated.

Influential Articles on Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Bibliometric Analysis.

Background:The understanding of pediatric anterior cruciate ligament (ACL) injuries and optimal treatment has evolved significantly. Influential articles have been previously evaluated using article citations to determine impact.Purpose:To identify and characterize the 50 most cited and recent influential articles relating to pediatric and adolescent ACL injuries, to examine trends in publication characteristics, and to evaluate correlations of study citations with quality of evidence.Study Design:Cross-sectional study.Methods:The top 50 most cited articles on pediatric and adolescent ACL injuries were gathered using the Web of Science and Scopus online databases by averaging the number of citations from each database. Articles from recent years were also aggregated and sorted by citation density (citations/year). Publication and study characteristics were recorded. Level of evidence and methodologic quality were assessed where applicable using the modified Coleman Methodology Score (mCMS), modified Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS). Spearman correlation was used to evaluate the association between citation data and level of evidence or methodologic quality scorings.Results:The top 50 cited papers had a mean of 117.5 ± 58.8 citations (range, 58.5-288.5 citations), with a mean citation density of 9.4 ± 5.4 citations per year (range, 2.9-25.8 citations/year); 80% were published in 2000 or later, and 6% were considered basic science. Articles were mainly level 4 evidence (27/42; 64.3%), and none was level 1. There were moderate, significant associations between publication year and level of evidence (r S = −0.45; P = .0030) and citation density and publication year (r S = 0.59; P < .001). Mean methodologic quality scores were as follows: mCMS, 53 ± 7.2 (range, 39-68); modified Jadad scale, 3.2 ± 1.1 (range, 2-6); and MINORS, 11.2 ± 3.2 (range, 6-20). There was a significant, strong correlation between rank of mean citations and modified Jadad scale (r S = 0.76; P < .0001), suggesting poorer score associated with more mean citations.Conclusion:Influential articles on pediatric and adolescent ACL injuries were relatively recent, with a low proportion of basic science–type articles. Most of the studies had a lower evidence level and poor methodologic quality scores. Higher methodologic quality did not correlate positively with citation data.

Arthroscopic Treatment Results of Triangular Fibrocartilage Complex Tears in Adolescents: A Systematic Review.

Introduction: Injury to the triangular fibrocartilage complex (TFCC) may cause chronic wrist pain and instability if left untreated. The current literature of adult cases suggests that arthroscopic treatment offers favorable outcomes and is associated with a low complication rate. This systematic review evaluated the outcomes of arthroscopic TFCC surgery in adolescents. Materials and Methods: A PRISMA-guided literature search of PubMed, Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Cochrane Clinical Answers was conducted in May 2020. All studies reporting on (1) arthroscopic TFCC repair or debridement in (2) patients under the age of 19 years with (3) a minimum case number of four patients were extracted by two independent observers. The level of evidence of each study was assessed according to the Oxford Centre for Evidence-Based Medicine, and study quality was graded according to the Modified Coleman Methodology Score and the MINORS criteria. Clinical outcome scores, functional parameters, and any complications were reviewed. Results: The selected search terms initially resulted in a total of 986 possible articles. The authors eventually identified eight papers (all LoE IV) for inclusion in this systematic review. A total of 254 patients with verified TFCC tears and a mean age of 16 years (range, 7–19) received arthroscopic repair (162 patients, 67.1% of total) or debridement (77 patients, 29.7% of total). Arthroscopic treatment resulted in low pain levels, high patient satisfaction, and a fast return to sport. Complications overall were sparse and consisted mainly of persistent wrist pain (n = 31) and temporary paresthesia (n = 6) of the dorsal sensory branch of the ulnar nerve. Recurrent tears were sparse, with only four reported cases due to sports participation. Conclusion: Wrist arthroscopy is a reliable surgical option for treating TFCC tears in adolescents. The results obtained are comparable to those published in the literature. However, the variety of repair techniques and the low level of evidence across all included articles demand further prospective studies.

Use of intramedullary locking nail for displaced intraarticular fractures of the calcaneus: what is the evidence?

Intramedullary locking devices (ILDs) have recently been advocated as a minimally invasive approach to manage displaced intraarticular calcaneal fractures (DIACFs), to minimise complications and improve outcomes. We reviewed clinical and biomechanical studies dealing with commercially available devices to identify their characteristics, efficacy and safety. Following a PRISMA checklist, Medline, Scopus and EMBASE databases were searched to identify studies reporting the use of ILDs for treating DIACFs. Biomechanical studies were first evaluated. Cohort studies were then reviewed for demographics, surgical technique, postoperative protocol, clinical and radiographic scores, complications and reoperations. The modified Coleman Methodology Score (CMS) was used to assess the quality of studies. Eleven studies were identified which investigated two devices (Calcanail®, C-Nail®). Three biomechanical studies proved they offered adequate primary stability, stiffness, interfragmentary motion and load to failure. Eight clinical studies (321 feet, 308 patients) demonstrated a positive clinical and radiographic outcome at 16-months average follow-up. Metalware irritation (up to 20%) and temporary nerve entrapment symptoms (up to 30%) were the most common complications, while soft tissue issues (wound necrosis, delayed healing, infection) were reported in 3-5% of cases. Conversion to subtalar fusion was necessary in up to 6% of cases. Four (50%) out of 8 studies were authored by implant designers and in 5 (62%) relevant conflicts of interest were disclosed. Mean (± standard deviation) CMS was 59 ± 9.8, indicating moderate quality. Treating DIAFCs with ILDs leads to satisfactory clinical outcomes at short-term follow-up, enabling restoration of calcaneal height and improved subtalar joint congruency. Metalware irritation and temporary nerve entrapment symptoms are common complications although wound complications are less frequent than after open lateral approaches. The quality of evidence provided so far is moderate and potentially biased by the conflict of interest, raising concerns about the generalisability of results. Level V - Review of Level III to V studies.

No differences in clinical outcome between CMI and Actifit meniscal scaffolds: a systematic review and meta-analysis.

To compare the results of two meniscal scaffolds, CMI and Actifit, for the treatment of partial meniscal lesions. A systematic review was performed on the PubMed, Web of Science, Scopus, Embase, and Cochrane databases in January 2021, including randomized controlled trails (RCTs) and prospective and retrospective observational studies on the clinical results of meniscal scaffolds. A meta-analysis of the clinical results was performed; the rate of failures was recorded, as well as radiological results. The quality of the included studies was assessed with a modified Coleman Methodology Score (CMS). The search identified 37 studies (31 in the last 10 years): 2 RCTs, 5 comparative studies, 26 prospective and 4 retrospective series on a total of 1276 patients (472 CMI, 804 Actifit). The quality of evidence was generally low. An overall significant improvement in all clinical scores was documented for both scaffolds. The meta-analysis showed no differences between the two scaffolds in terms of patient reported outcome measures and activity level. The meta-analysis on the risk of failures documented a risk of failures of 7% in the CMI and of 9% in the Actifit group. There is a growing interest on the results of meniscal scaffolds, with most studies published recently. However, long-term data on the Actifit scaffold and high-level comparative studies are missing. Both CMI and Actifit offered good clinical results with a significant and comparable improvement in symptoms and function, and with a low number of failures over time. Accordingly, with the proper indication, their use may be encouraged in the clinical practice. Level IV.

Treating Knee Osteoarthritis With Platelet-Rich Plasma and Hyaluronic Acid Combination Therapy: A Systematic Review

Background: Platelet-rich plasma (PRP) and hyaluronic acid (HA) are injectable treatments for knee osteoarthritis. The focus of previous studies has compared their efficacy against each other as monotherapy. However, a new trend of combining these 2 injections has emerged in an attempt to have a synergistic effect. Purpose: To systematically review the clinical literature examining the combined use of PRP + HA. Design: Systematic review. Methods: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using PubMed and Embase. The following search terms were used: knee osteoarthritis AND platelet rich plasma AND hyaluronic acid. The review was performed by 2 independent reviewers who applied the inclusion/exclusion criteria and independently extracted data, including methodologic scoring, PRP preparation technique, HA composition, and patient-reported outcomes (PROs). Results: A total of 431 articles were screened, 12 reviewed in full, and 8 included in the final analysis: 2 case series, 3 comparative, and 3 randomized studies. Average follow-up was 9 months. The modified Coleman Methodology Score was 38.13 ± 13.1 (mean ± SD). Combination therapy resulted in improved PROs in all studies. Of the comparative and randomized studies, 2 demonstrated that combination therapy was superior to HA alone. However, when PRP alone was used as the control arm (4 studies), combination therapy was not superior to PRP alone. Conclusion: Combination therapy with PRP + HA improves PROs and is superior to HA alone but is not superior to PRP alone.