Tourniquet Use During Open Reduction and Internal Fixation of Ankle Fractures – A Systematic Review and Meta-Analysis

The intra-operative use of tourniquet in open reduction and internal fixation (ORIF) of ankle fractures remains a topic of debate. The purpose of this study was to perform a systematic review and meta-analysis of randomized control trials (RCTs) comparing clinical outcomes of patients undergoing ankle ORIF with tourniquet use versus a control group where no tourniquet was used. A systematic review was performed with reference to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of the Pubmed, Scopus, Embase, and Cochrane Library databases. Studies were included if they were an RCT comparing tourniquet and no-tourniquet in ankle ORIF. Meta-analysis was performed using RevMan, and p-value <.05 was considered to be statistically significant. On completion of the literature search, a total of 4 RCTs including 350 ankles (52.6% males), with a mean age of 47.1 ± 5.7 years were included. There were 173 patients in the tourniquet group (T), versus 177 patients in the no tourniquet control group (NT), with nonsignificant differences between the groups for age, gender and body mass index demographics (all p > .05). There were significantly shorter duration of surgery, with significantly higher patient-reported rates of pain levels at day 2 postoperatively (both p < .001) in the T group. Additionally, there were significantly greater ranges of ankle motion at 6 weeks postoperatively (p = .03), with nonsignificant differences reported incidence of wound infections and deep vein thrombosis (p = .056 and p = .130 respectively) between the groups. In conclusion, current evidence suggests that although intraoperative tourniquet usage in cases of ankle ORIF results in significant reductions in duration of surgery, this may be at the expense of higher patient-reported pain scores and reduced range of motion postoperatively.     

Surgical Treatment Versus Conservative Management for Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Acute Achilles tendon ruptures can be treated with surgical and nonsurgical treatment. However, the optimal intervention for acute Achilles tendon rupture remains controversial. The aim of the present study was to compare the clinical outcomes of surgical treatment versus conservative management for acute Achilles tendon rupture. Eight randomized controlled studies involving 762 patients were included in the meta-analysis. In general, re-rupture occurred in 14 of 381 surgically treated patients (3.7%) and 37 of 377 nonsurgically treated patients (9.8%). Pooled results showed that the total re-rupture rate was significantly lower in surgical group than that in the nonsurgical group (risk ratio 0.38, 95% confidence interval 0.21 to 0.68; p = .001). No significant differences were found between the 2 treatment groups in the incidence of deep venous thrombosis, the number who returned to sport, ankle range of motion (dorsiflexion, plantarflexion), Achilles tendon total rupture score, or physical activity scale. Surgical treatment can effectively reduce the re-rupture rate and might be a better choice for the treatment of acute Achilles tendon rupture. Multicenter, double-blind randomized controlled trials with stratification and long-term follow-up are needed to obtain a higher level of evidence and to guide clinical practice, especially in the comparison and selection of different treatments.     

Is There any Difference in Clinical Outcome between Open and Arthroscopic Treatment for Tennis Elbow? A Systematic Review and Meta-Analysis

There is considerable controversy regarding the optimal approach (open vs arthroscopic) of releasing and/or debridement for the treatment of tennis elbow (TE). The aim of this study was to determine the clinical outcomes of the two techniques by quantitatively synthesizing outcome data. The study was performed by searching the PubMed, EMBASE, Ovid, and Elsevier databases between January 1995 and April 2022 for a minimum follow-up of 6 months. The searching strategy was “(tennis elbow [Title/Abstract] OR lateral epicondylitis [Title/Abstract]) AND (open [Title/Abstract] OR arthroscopic [Title/Abstract] OR release [Title/Abstract] OR debridement [Title/Abstract] OR surgery [Title/Abstract])”. The quality of each study was investigated using the Coleman Methodology Score. In total, 1411 (693 open, 718 arthroscopic) elbows in 1392 patients who underwent releasing and debridement for tennis elbow were identified. The mean Coleman Methodology Score for the included studies was 55.2 ± 8.6 (open: 55.0 ± 9.4, arthroscopic: 55.8 ± 8.2). Improved clinical results were achieved after treatment with either open or arthroscopic treatment. The surgical success rate was 95.6% in open surgery and 92.4% in arthroscopic management. The complication rates were 2.2% and 1.5% for open and arthroscopic procedures, respectively. Similar subjective and objective outcomes, and surgical success rate were observed in patients with both techniques. Patients who had undergone arthroscopic release seemed to return to work earlier (5.3 weeks vs 7.1 weeks). To draw more definite conclusions, high-quality long-term follow-up randomized controlled trials are needed.     

Is Gum Chewing Useful for Ileus After Elective Colorectal Surgery? A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Background  The evaluation of the usefulness of gum chewing for postoperative ileus has given inconclusive results. We evaluated the efficacy of gum chewing in the treatment of ileus after elective colorectal surgery. Materials and Methods  We performed a meta-analysis of randomized clinical trials comparing the effect of gum chewing+standard treatment vs. standard treatment on ileus after colorectal surgery. MEDLINE, EMBASE, the Cochrane Controlled Trial Register, and the Cochrane Database of Systematic Reviews were searched until August 2008. Primary outcomes were time to first flatus, time to first passage of feces, and length of hospital stay. The mean difference (MD) in hours was calculated with the random effects model to assess the effect of gum chewing on the outcomes. Results  Six trials including 244 patients were analyzed. Time to first flatus was significantly reduced with gum chewing+standard treatment compared to standard treatment alone (MD −14 h, 95% confidence interval [95%CI] −23.5 to −4.6). Time to first passage of feces was significantly reduced (MD −25 h, 95%CI −42.3 to −7.7), but the length of hospital stay was only marginally reduced (MD −26.2 h, 95%CI −57.5 to 5.2) with gum chewing. Conclusion  In patients with ileus after colonic surgery, gum chewing in addition to standard treatment significantly reduces the time to first flatus and the time to first passage of feces when compared to standard treatment alone. There is also a trend to reduce the length of hospital stay. Gum chewing should be added to the standard treatment of these patients.     

The Effectiveness of Bariatric Surgery for Chinese Obesity in 2 Years: A Meta-Analysis and Systematic Review

Aim: Bariatric surgery is becoming an acceptable option for treatment of obesity worldwide, but there is no systemic review and meta-analysis focusing on obese patients in China. This study is to quantify the overall effects of bariatric surgery for Chinese obesity using up-to-date, comprehensive data. Methods: We systematically searched MEDLINE, EMBASE, Cochrane Library, ISI Web of Science, and CNKI databases in English and Chinese. The weighted mean difference (MD) and 95% confidence interval (CI) were calculated from the original literature. Obese Chinese adults (body mass index [BMI] ≥ 30 kg/m²) with a minimum six-month follow-up were included. Results: The meta-analysis included 23 literature reviews with 1,316 morbidly Chinese obese adults. Bariatric surgery could significantly decrease the levels of BMI (MD = 10.75 kg/m², 95% CI: 8.65–12.85, p <.01) and hemoglobin A1c (MD = 2.15%, 95% CI: 1.55–2.75, p <.00001), and improve lipid profile dramatically. In the subgroup analysis by BMI values, subjects lost more weight in BMI ≥ 40 kg/m² group (MD = 14.01 kg/m², 95% CI: 11.20–16.82) than BMI < 40 kg/m² group (MD = 8.09 kg/m², 95% CI: 6.49–9.68, p <.00001) after surgery. When we stratified analysis by surgical procedures, fasting blood glucose decreased more in gastric bypass group (MD = 3.08 mmol/L, 95% CI: 2.18–3.98) than restrictive procedures (MD = 1.27 mmol/L, 95% CI: 0.45–2.09, p =.008) and postprandial blood glucose levels (gastric bypass procedures: 8.44 mmol/L, 95% CI: 6.83–10.04; restrictive procedures: MD = 2.80 mmol/L, 95% CI: 1.86–3.74, p <.00001). Conclusions: Bariatric surgery provides substantial metabolic effects for Chinese morbid obese adults at least in a relative short term. Further high-quality randomized controlled trials with long follow-up periods are needed to provide more reliable evidence.     

Fixation Methods for Calcaneus Fractures: A Systematic Review of Biomechanical Studies Using Cadaver Specimens

Calcaneal fractures are notoriously difficult to treat and wound complications occur often. However, owing to the rare nature of these fractures, clinical trials on this subject are lacking. Thus, biomechanical studies form a viable source of information on this subject. With our systematic review of biomechanical studies, we aimed to provide an overview of all the techniques available and guide clinicians in their choice of method of fracture fixation. A literature search was conducted using 3 online databases to find biomechanical studies investigating methods of fixation for calcaneal fractures. A total of 14 studies investigating 237 specimens were identified. Large diversity was found in the tested fixation methods and in the test setups used. None of the studies found a significant difference in favor of any of the fixation methods. All tested methods provided a biomechanically stable fixation. All the investigated methods of fixation for calcaneal fractures seem to be biomechanically sufficient. No clear benefit was found for locking plates in the fixation of calcaneal fractures; however, a subtle mechanical superiority might exist compared with nonlocking plates in the case of fractures in osteoporotic bone. Several of the techniques tested would be suitable for a minimal invasive approach. These should be investigated further in clinical trials.     

The Acute Surgical Unit Model Verses the Traditional “On Call” Model: A Systematic Review and Meta-Analysis

Background

The acute surgical unit (ASU) is a novel model for the provision of emergency general surgery care. The ASU model was initially developed in New South Wales hospitals during 2005 and 2006. Several studies have analysed the effects on patient outcomes and timeliness of care for nontrauma patients presenting with acute general surgical conditions. The purpose of this study was to perform a meta-analysis to determine the efficacy of the ASU model compared with the traditional on-call model for specific conditions.

Methods

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Original data were extracted from each study and used to calculate a pooled odd ratio (OR) and 95 % confidence interval (CI).

Results

The search identified 18 studies; appendectomy (n = 9), acute cholecystitis (n = 7), and small-bowel obstruction (SBO) (n = 2). In the appendectomy cohort, the proportion of appendicular perforation were similar in pre-ASU and ASU period (OR 1.02, 95 % CI 0.77–1.37, p = 0.13). The incidence of complications in the appendectomy cohort was significantly lower in the ASU group; 14.5 % pre-ASU and 10.9 % post-ASU (OR 1.649, 95 % CI 0.732–3.714, p = 0.009). The negative appendectomy rate was similar for the pre- and post-ASU groups (OR 1.07, 95 % CI 0.88–1.31, p = 0.83). Likewise the conversion rate to open surgery and total hospital stay were similar between the two groups. The proportion of night time operations reduced significantly in the ASU period (OR 1.9, 95 % CI 1.32–2.74, p = 0.001). In the acute cholecystitis cohort, the conversion rate to open surgery was significantly higher in the pre-ASU group (15.1 %) compared with the post-ASU group (7.5 %) (OR 1.879, 95 % CI 1.072–3.293, p = 0.04) The incidence of complications was higher in the pre-ASU (14 %) compared with the post-ASU (6.8 %) group (OR 2.231, 95 % CI 1.372–3.236, p = 0.03). The mean hospital stay was significantly lower in the ASU period (5.3 vs. 3.7 days, p = 0.0063). There was insufficient data available to analyse outcomes for SBO.

Conclusions

The ASU model provides a safe surgical environment for patients and is associated with a reduced complication rate for appendectomy and laparoscopic cholecystectomy for acute cholecystitis. There is a reduced conversion rate and a shorter length of stay for patients with acute cholecystitis. Overall, the ASU model has translated to better outcomes for patients presenting with acute general surgical conditions.     

Labral Resection or Preservation During FAI Treatment? A Systematic Review

Background

Open and arthroscopic treatment of femoroacetabular impingement and resultant labral pathology has increased significantly over the past decade. Although the functional importance of the labrum and the labral seal has been established in biomechanical studies, good clinical results have been reported for both labral debridement and labral refixation.

Questions/Purposes

The purpose of this paper is to summarize existing literature on the surgical treatment of labral pathology to provide treatment recommendations and direct future research. A systematic review was performed with the following research question in mind: Does preservation of the hip labrum improve outcomes as compared to labral debridement for the treatment of labral pathology?

Methods

The MEDLINE database was searched for level I, II, or III articles in English or German comparing labral debridement to labral refixation. Five studies were included in the analysis.

Results

Good short-term results were reported for both groups. Three out of five papers report improved outcomes after labral refixation as compared to labral debridement.

Conclusions

In short-term follow-up, labral refixation appears to have slightly better outcomes than labral debridement. Studies with prospectively defined cohorts and longer follow-up are, however, necessary to provide definitive recommendations for labral treatment.     

AMIC Procedure for Treatment of Osteochondral Lesions of Talus—A Systematic Review of the Current Literature

Osteochondral lesions of talus are a common injury where surgery is indicated in case of failed non-operative treatment or displaced lesions. Many studies have been conducted on the effectiveness of the AMIC procedure. The goal of our study is to create an overview of the current literature. A systematic search adhering to the PRISMA guidelines was conducted in PubMed (MEDLINE) and EMBASE on May 27, 2020. All included studies were evaluated according to the modified Coleman Methodology Score and information on study type, patient numbers, age, follow-up period, grade, location and size of the lesion, study in- and exclusion criteria, associated surgery, surgical technique, scaffold- and fixation technique, postoperative restrictions, reoperation rates, study outcome score, rehabilitation program, and surgical complications was extracted. Ninety-six studies were identified with 18 studies being included in our analysis. The overall quality of the literature was fair with no studies being graded as excellent. Data on preoperative evaluation and surgical technique, complication and reoperation rates, postoperative management and study outcome was extracted in order to create an overview of the current literature. The literature supports the use of the AMIC procedure as an effective treatment for osteochondral lesions of talus. Great heterogeneity exists and comparative studies are missing. While the number of studies on the topic is increasing further are needed and especially with optimized design.     

Do Intra-Articular Steroid Injections Increase Infection Rates in Subsequent Arthroplasty? A Systematic Review and Meta-Analysis of Comparative Studies

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

What Is the Best Definitive Treatment for Graves’ Disease? A Systematic Review of the Existing Literature

Background

The management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists for Graves’ disease (GD) include any of the following modalities: ¹³¹I therapy, antithyroid medication, or thyroidectomy. No in-depth analysis has been performed comparing the treatment options, even though a single treatment option seems to be universally accepted.

Methods

A systematic review of the literature was performed to examine contemporary literature between 2001 and 2011 evaluating the management options of GD. We compiled retrospective and prospective studies analyzing surgery and radioactive iodine. Outcomes of interest included postoperative hypothyroidism, euthyroidism, and persistent or recurrent hyperthyroidism without supplementation. Success was defined as postoperative euthyroidism or hypothyroidism. Failure was defined as persistent or recurrent hyperthyroidism.

Results

Of the 14,245 patients, 4,546 underwent surgery [3,158 patients had subtotal thyroidectomy (STT) and 1,388 had total thyroidectomy (TT)] and 9,699 had radioactive iodine. The radioactive iodine group consisted of 2,383 patients receiving 1–10 mCi, 1,558 patients receiving 11–15 mCi, 516 patients receiving >15 mCi, and 5,242 patients receiving an unspecified amount. Surgery was found to be 3.44 times more likely to be successful than radioactive iodine (p < 0.001). STT and TT were found to be 2.33 and 94.45 times more likely to be successful than radioactive iodine (p < 0.001), respectively.

Conclusions

On the basis of the outcomes analyzed, surgery appears to be the most successful in the management of GD, with TT being the preferred surgical option.     

Total Knee Arthroplasty in Hemophilia: Survivorship and Outcomes—A Systematic Review and Meta-Analysis

BackgroundPatients with hemophilia (PWHs) may experience spontaneous or traumatic bleeding episodes. Recurrent bleeding can lead to end-stage hemophilic arthropathy and total knee replacement (TKR) provides an effective treatment. The aim of this study is to investigate outcomes in PWHs who undergo TKR.MethodsA systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study outcomes included patient-reported functional outcomes, implant survivorship, and complications. Subgroup analysis was performed assessing the effect of recombinant prophylaxis medication by comparing studies that included only TKRs performed after the year 2000 (period A), to those that included TKRs before 2000 (period B).ResultsTwenty-eight studies were included, with a total of 1210 TKRs performed in 917 PWHs. The mean age of patients was 38.5 years (standard deviation 5.1) with a mean length of follow-up of 7.1 years (standard deviation 2.9). The total complication rate was 28.7%, with 19.3% requiring a further procedure. Hospital for Special Surgery Knee Score improved by 44.6 points (confidence interval 38.9-50.4) and Knee Society Score function improved by 35.9 points (confidence interval 30.1-41.8). Total range of motion improved by 22.3°. The most common complication was post-operative hemarthrosis (7.6%, 92 TKRs). Deep infection (6.2% vs 3.9%) and aseptic loosening (3.8% vs 2.1%) rates fell between period B and period A.ConclusionTKR in PWHs is a successful procedure improving function, reducing pain, and improving range of motion. PWHs undergo TKR at a younger age and have a higher risk of complications, though contemporary treatment has reduced these risks. PWHs can expect similar survivorship to the general population.