Operative versus non-operative management of primary patellar dislocation: A systematic review and network meta-analysis

BackgroundAcute patellar dislocation is a common knee injury in adolescents and adults that is associated with a high incidence of medial patellofemoral ligament (MPFL) injuries. The aim of this network meta‐analysis was to compare the different operative and non-operative protocols for the management of primary patellar dislocation (PPD).MethodsWe searched Medline, Embase, and CENTRAL databases. We included randomized controlled trials (RCTs) that compared operative and non-operative protocols for adolescent or adult patients with acute traumatic PPD. We sought to evaluate the clinical and functional outcomes of each management protocol by considering the results of Kujala score, Tegner activity score, redislocation rate, and subluxation rate. The effectiveness of the different management protocols was measured through frequentist network meta-analysis, using the Netmeta statistical package in R software. All treatment protocols were ranked using the netrank function, yielding P scores.ResultsA total of 10 RCTs were deemed eligible. As per P-scores, open MPFL repair yielded the highest effectiveness with respect to Kujala score (P=0.81) and lowest odds for redislocation (P=0.14) whereas arthroscopic MPFL repair yielded the highest effectiveness with respect to Tegner activity score (P=0.85) and lowest odds for subluxation (P=0.21). Arthroscopic MPFL repair showed a significant reduction in redislocation and subluxation rate.ConclusionThis network meta-analysis demonstrated arthroscopic MPFL repair is the most effective treatment protocol for the management of acute primary patellar dislocation.     

Surgical versus conservative management of ankle fractures in adults: A systematic review and meta-analysis

AimsThis study compared outcomes of surgical versus conservative management of ankle fractures in adults through a systematic review and meta-analysis.MethodsWe searched CINAHL, EMBASE, MEDLINE and CENTRAL databases (1946–June 2019) for randomised and quasi-randomised controlled trials comparing surgical versus conservative management of closed adult ankle fractures of any type. Estimates of effect were pooled using random effects meta-analysis.Results1153 patients from 7 trials were included. Our primary outcome, ankle function score, was not statistically significantly different at 6-months (pooled mean difference (surgical minus conservative) = 1.0; 95% CI: −2.3 to 4.3; p = 0.55) or 12-months or more (pooled mean difference = 4.6; 95% CI: −1.0 to 10.2; p = 0.11) between surgical and conservative groups in three trials assessing displaced or unstable fractures, and two trials using non-validated questionnaires. One trial assessing AO-type-B1 fractures without talar shift had a statistically significant difference favouring conservative management, which was not clinically meaningful. Surgery had lower rates of early treatment failure and malunion/non-union, but higher rates of further surgery and infection.ConclusionsSurgical and conservative management of displaced or unstable ankle fractures produce similar short-term functional outcomes. The higher risk of early treatment failure and malunion/non-union in the conservative group versus higher rates of further surgery and infection in the surgical group should be considered. Trials are needed to assess longer-term results and inform management of select patient groups.     

Surgical versus conservative management of traumatic proximal adductor longus avulsion injuries: A systematic review

BackgroundProximal avulsion injuries of the adductor longus have been managed both conservatively and operatively with good clinical outcomes, but there is no consensus on which option yields the best results. Thus, the present study aimed to review the available literature, comparing the outcomes and the time to return to sports with different management options.Material and methodsThis study was conducted according to the PRISMA statement. The literature search was conducted in September 2020. All the clinical trials investigating the management of traumatic proximal adductor longus avulsion injuries were considered for inclusion. Only studies reporting data from athletes were considered. The outcomes of interest were the time to return to sport and return to preinjury activity level.ResultsData from 46 patients were retrieved. The mean follow-up was 24.6 ± 23.8 months. The study population was represented by male athletes with a mean age of 30.0 ± 4.8. Mean stump retraction was 3.3 ± 0.6 cm in the surgical and 1.7 ± 0.6 in the conservative cohort (P = 0.07). The rate of patients returning to prior activity level was similar in the two groups, but surgically treated patients required a longer time to return to sport (3.9 ± 1.5 months vs. 2.2 ± 1.0 months, P = 0.0001).ConclusionConservative management for traumatic avulsion of the proximal adductor longus insertion may produce shorter time to return to sport. Both conservative and operative strategies allowed to achieve similar pre-injury activity level.Level of evidenceIV, systematic review.     

小直径腹主动脉瘤手术治疗和保守治疗疗效的Meta分析

目的:系统评价手术治疗与保守治疗对小直径腹主动脉瘤(AAA)的疗效。方法:检索国内外文献数据库,选择手术治疗(血管腔内修补术和开放手术)与保守治疗小直径AAA的随机对照实验,按照Cochrance系统评价员手册对纳入文献的方法学质量进行评价后,采用Rev Man5.1软件进行Meta分析。结果:共纳入4个随机试验,4篇文献,共计3 314例患者,其中行血管腔内修补术和开放手术1 680例,保守治疗1 634例。Meta分析结果显示,两组之间总原因病死率(SMD=0.97,95%CI=0.68~1.38)、动脉瘤相关病死率(SMD=0.81,95%CI=0.56~1.17)、动脉瘤破裂率(SMD=0.49,95%CI=0.09~2.54,P=0.39)、术后30 d或者住院期间病死率(SMD=0.88,95%CI=0.60~1.291)差异均无统计学意义(均P0.05)。结论:小直径AAA手术治疗与保守治疗疗效相似,但不能确定该结论是否有临床意义,笔者经综合分析认为小直径AAA仍应积极手术治疗。     

Surgical versus conservative treatment for acute first-time anterior shoulder dislocation: the evidence

Acute anterior dislocation of the shoulder is a common injury associated with a high rate of recurrence in young active men. Management of traumatic anterior shoulder dislocation aims to restore range of motion, to reduce the risk of recurrence and to assure an improved quality of life with a stable and painless shoulder. It includes conservative and surgical-open or arthroscopic treatment, followed by rehabilitation. No clear consensus has been reached on the best management, surgical or conservative, to adopt in first-time anterior shoulder dislocation. The aim of this review was to collect and evaluate the scientific evidence supporting the effectiveness of immediate surgical treatment versus immobilization and rehabilitation for first-time traumatic anterior shoulder dislocation. There is some evidence to support primary surgery in young active patients with an acute first traumatic shoulder dislocation, in order to reduce the risk of recurrence, but there is no evidence for the best surgical technique or best conservative approach, nor is there information regarding the best treatment in other categories of patients.     

初次髌骨脱位早期治疗研究进展

髌骨脱位是青少年和年轻运动员中的常见运动损伤。近来研究表明初次髌骨脱位保守治疗往往显示出高复发率等诸多弊端，早期手术治疗的可行性成为当前讨论和研究的热点。尽管手术治疗方法多样，但基于不同手术治疗的临床结果在与传统保守治疗对比中的优越性报道不一，因此尚未形成统一术式。随着近年来初次髌骨脱位的复发机制得到进一步阐明，内侧髌股韧带修复或重建手术开始受到重视，尤其是重建手术在初次髌骨脱位早期治疗中显示出良好的发展前景。     

Surgical treatment of stomal prolapse: A systematic review and meta-analysis of the literature

Aim

This study aimed to assess success, recurrence, and overall complication rates among different surgical procedures for stomal prolapse.

Methods

This study was a PRISMA-compliant systematic review. PubMed, Scopus, and Google Scholar were searched until March 2022. Studies that assessed surgical treatments of stomal prolapse in adults were included. The primary outcome was recurrence of stomal prolapse and the secondary outcome was 30-day complications. A random-effect meta-analysis was used to estimate the weighted mean rates of recurrence.

Results

Six studies published (111 patients; 103 males) were included. 52 (46.8%) patients had end colostomies, 35 (31.5%) had loop colostomies. Seven procedures were assessed and included local stoma reconstruction (40%), stapled local repair (27%), modified Altemeier technique (10%), mesh strip repair (9%), stoma relocation (6%) redo laparotomy repair (5%), and colectomy and end ileostomy (3%). The weighted mean recurrence rate after local stoma reconstruction was 37.2% (95% CI: −1.8 to 76.3), higher than that after the stapled local repair technique (14.9%; 95% CI: 1.7–28.2). The crude recurrence rate of the modified Altemeier technique was 20%, and of stoma relocation was 66.6%. No recurrence was detected after the mesh strip technique (n = 10). The median follow-up ranged between 7 months and 2.5 years.

Conclusion

Several surgical techniques are available to treat stomal prolapse. Local stoma reconstruction may be associated with high rates of recurrence while the stapled local repair and modified Altemeier procedure has relatively low recurrence. Further larger studies are needed to compare the efficacy of these techniques.     

Surgical versus medical treatment for infective endocarditis in patients on dialysis: a systematic review and meta-analysis

Infective endocarditis (IE) is a serious infection and causes significant morbidity and mortality. However, the benefit of surgery for endocarditis besides antibiotic treatment in dialysis patients remains controversial. We performed a systematic review of studies published between 1960 and February 2022. Meta-analysis was conducted with a random-effects model to explore the in-hospital, 30, 60, 90, 180-d, and 1-year mortality rates in adult dialysis patients with IE. Sensitivity analysis, subgroup analysis, and meta-regression were performed to explore potential sources of heterogeneity. Confidence of evidence was evaluated by the GRADE system. Thirteen studies were included. The pooled odds ratio of in-hospital mortality was 0.62 (95% confidence interval [CI]: 0.30–1.28, p = .17), with moderate heterogeneity (I² = 62%, p < .01). Three studies reported 30-d mortality, and the pooled odds ratio for surgery compared with medical treatment was even lower (0.36; 95% CI: 0.22–0.61, p < .01), with low heterogeneity (I² = 0%, p = .86). With studies on fewer than 30 patients excluded, the sensitivity analysis revealed a low odds ratio of in-hospital mortality for surgery versus medical treatment (0.52; 95% CI: 0.27–0.99, p = .047), with moderate heterogeneity (I² = 63%, p < .01). Subgroup analysis revealed no significant differences between any two comparator subgroups. Based on a very low strength of evidence, compared with medical treatment, surgical treatment for IE in patients on dialysis is not associated with lower in-hospital mortality. When studies on fewer than 30 patients were excluded, surgical treatment was associated with better survival.     

Surgical versus conservative treatment for first patellofemoral dislocations: a meta-analysis of clinical trials

European Journal of Orthopaedic Surgery & Traumatology - The first approach for acute patellar dislocation is still a debated topic. The purpose of the present study was to perform a...     

Surgical anatomy of sigmoid arteries: A systematic review and meta-analysis

BackgroundThe purpose of this systematic review and meta-analysis was to determine the prevalence of the number of sigmoid arteries (SA) and variations in their origins.MethodsA thorough systematic search of literature through February 2020 was conducted on major electronic databases to identify eligible studies. Data were extracted and pooled into a meta-analysis using Metafor package in R. The primary outcome was the variations in the SA origin (according to modified Zebrowski classification), and the secondary outcome was the prevalence of the number of SA.ResultsA total of 22 studies (n = 2653 patients) were included. Type 1 modified Zebrowski (separated origins or common trunk of the SA originating from descending recto-sigmoid trunk (DRST)) was the most common origin type of the SA (pooled prevalence estimate (PPE) = 49.67% (95% CI 32. 67- 66.71)), while type 3 (separated origins or common trunk of 1 or 2 SA originating from DRST or superior rectal artery (SRA) and 1 or 2 SA originating from DRST or SRA) was the least common (PPE = 0.18%; 95% CI 0.00–2.82)). Of the Type 1 variants, the not specified (N.S) variant was by far the most prevalent. The number of SA ranged from one to five, with three being the mode (PPE = 42.3%).ConclusionThis is the most comprehensive analysis of arterial vascular anatomy of the sigmoid colon. In light of the highly variable anatomical pattern displayed by the SA, thorough pre-operative knowledge of their anatomy can be crucial in minimizing incidences of iatrogenic injury.     

Tape versus cast for non-operative treatment of primary patellar dislocation: a randomized controlled trial

Purpose

We hypothesized that taping results in better short-term functional outcome and comparable redislocation rates.

Methods

In a prospective randomised clinical trial, 18 patients with a primary patellar dislocation ≥18?years old without accompanying fractures or previous surgery to the knee were included. After 1?week of dorsal splinting, they were randomized into two groups: taping and cylinder cast immobilization. Physical examination and knee function according to the Lysholm Knee Scoring Scale were taken at 1-, 6- and 12-week and at 1- and 5-year follow-up. We also compared the redislocation rates.

Results

Taping resulted in a significantly better Lysholm score at 6 and 12?weeks post-dislocation (P?P?Conclusion Tape bandage immobilization seems superior to a cylinder cast even after 5?years.     

A systematic review and meta-analysis of the treatment of acute lisfranc injuries: Open reduction and internal fixation versus primary arthrodesis

BackgroundInjuries to the Lisfranc complex, although relatively rare carry a high morbidity and are often associated with other injuries. Despite a number published studies to determine the best operative management, there is an ongoing debate to whether open reduction and internal fixation (ORIF) or primary arthrodesis (PA) produces the best outcomes for patients. There have been further studies published in the last few years that have not been assessed as part of the wider literature and therefore we wished to perform an updated systematic review and meta-analysis with inclusion of outcomes not assessed in the previous studies.MethodsWe performed a structured search for retrospective and prospective comparative papers and identified 8 relevant articles (2 RCT studies and 6 non-RCT studies) that compared the outcomes of ORIF versus PA; these studies included a total of 547 patients. Each of the studies was assessed for suitability and quality before inclusion. We performed a statistical analysis of the aggregated results as part of the review.ResultsWe found no statistically significant difference between the outcomes of ORIF versus PA in terms of return to work or activity (Odds Ratio 0.80 (CI 95%, 0.32–2.02, P = 0.64)) and satisfaction rates (Odds Ratio 0.15 (CI 95%, 0.01–.00, P = 0.25)). Patients undergoing ORIF have a higher risk of undergoing further surgery to remove the metalwork (Odds Ration 13.13 (CI 95%, 7.65–22.54, P < 0.00001)) or to undergo secondary fusion, but, the overall complication rates appear to be equivalent in both groups (risk difference 0.03 (CI 95%, –0.15–0.21, P = 0.76)).ConclusionsAlthough there were no significant differences in the functional outcomes, the overall power of the studies is low. The rates of metalwork removal and secondary fusion were higher in the ORIF group and this risk should be presented to the patient when counselling them for any procedure. We noted that there is a high level of heterogeneity in the type of injuries and measured outcomes included in each study and, therefore, further trials are needed to determine the best treatment across the spectrum of Lisfranc complex injuries.     

Operative versus conservative treatment of proximal rectus femoris avulsions: A systematic review with meta-analysis of clinical outcomes,complications and return to sports

Prospero registration numberCRD42020198333.ObjectiveTo compare the surgical and conservative treatment of proximal rectus femoris avulsions regarding clinical outcomes, rate of return to sports and incidence of complications.DesignSystematic review and meta-analysis.Data sourcesCochrane, Medline, Scopus and SPORTDiscus.Eligibility criteria for selecting studiesStudies reporting on outcomes of PRFAs or return to sports were included.ResultsNine studies consisting of a total eighty-two patients met the inclusion criteria. The mean age was 22.2 years and 75.9% of patients were male. Mean follow-up was 28.9 months and 65% avulsions were managed surgically. The overall outcomes were similar in surgical and conservative treatment group (p = 0.72) with similar incidence of complications (14%). The rate of return to sports was 95% in surgical and 92.7% in the conservative management groups (p = 0.93). Overall, the quality of the methodology of included studies was low, with a mean CMS of 45.6.ConclusionBoth conservative and operative treatment provide excellent outcomes in proximal rectus femoris avulsions, with similar rates of return to sports and incidence of complications. More prospective and good quality studies are needed to compare surgical techniques and time to return to sports. Avulsions with retraction of more than 20 mm and high demand patients may benefit from surgical treatment. Patients should be counselled accordingly.     

Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis

OBJECTIVE: Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the commonly preferred methods of anastomosis after pancreaticoduodenectomy (PD). The ideal choice of anastomosis remains a matter of debate. DATA SOURCES: Articles published until end of March 2006 comparing PJ and PG after PD were searched. STUDY SELECTION: Two reviewers independently assessed quality and eligibility of the studies and extracted data for further analysis. Meta-analysis was performed with a random-effects model by using weighted odds ratios. DATA EXTRACTION AND SYNTHESIS: Sixteen articles were included; meta-analysis of 3 randomized controlled trials (RCT) revealed no significant difference between PJ and PG regarding overall postoperative complications, pancreatic fistula, intra-abdominal fluid collection, or mortality. On the contrary, analysis of 13 nonrandomized observational clinical studies (OCSs) showed significant results in favor of PG for the outcome parameters with a reduction of pancreatic fistula and mortality in favor of PG. CONCLUSIONS: All OCSs reported superiority of PG over PJ, most likely influenced by publication bias. In contrast, all RCTs failed to show advantage of a particular technique, suggesting that both PJ and PG provide equally good results. This meta-analysis yet again highlights the singular importance of performing well-designed RCTs and the role of evidence-based medicine in guiding modern surgical practice.     

Acute patellar dislocation in adolescents: operative versus nonoperative treatment

Purpose  

The purpose of this prospective non-randomised study was to compare the efficacy of two opposed methods, operative and conservative. Our hypothesis was that if the method was selected correctly, on an individual basis, the results should be approximately equal.