Transosseous tunnels versus suture anchors for the repair of acute quadriceps and patellar tendon ruptures: A systematic review and meta-analysis of biomechanical studies

BackgroundMultiple techniques have been developed for the repair of acute quadriceps and patellar tendon ruptures with the goal of optimizing clinical outcomes while minimizing complications and costs. The purpose of this study was to evaluate the biomechanical properties of transosseous tunnels and suture anchors for the repair of quadriceps and patellar tendon ruptures.MethodsA systematic review of the PubMed and Embase databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using specific search terms and eligibility criteria. Meta-analysis was performed by fixed-effects models for studies of low heterogeneity (I² <25%) and random-effects models for studies of moderate to high heterogeneity (I² ≥25%).ResultsA total of 392 studies were identified from the initial literature search with 7 studies meeting the eligibility criteria for quadriceps tendon repair and 8 studies meeting the eligibility criteria for patellar tendon repair. Based on the random-effects model for total gap formation and load to failure for quadriceps tendon repair, the mean difference was 8.88 mm (95% CI, −8.31 mm to 26.06 mm; p = 0.31) in favor of a larger gap with transosseous tunnels and −117.25N (95%CI, −242.73N to 8.23N; p = 0.07) in favor of a larger load to failure with suture anchors. A similar analysis for patellar tendon repair demonstrated a mean difference of 2.86 mm (95% CI, 1.08 mm to 4.64 mm; p = 0.002) in favor of a larger gap with transosseous tunnels and −56.34N (95% CI, −226.75 to 114.07N; p = 0.52) in favor of a larger load to failure with suture anchor repair.ConclusionsTransosseous tunnels are biomechanically similar to suture anchors for quadriceps tendon repair. Patellar tendon repair may benefit from reduced gap formation after cycling with suture anchor repair, but the load to failure for both techniques is biomechanically similar. Additional studies are necessary to evaluate these and alternative repair techniques.Level of evidenceSystematic review and meta-analysis of biomechanical studies, Level V.     

Clinical outcomes after ACL reconstruction with free quadriceps tendon autograft versus hamstring tendons autograft. A retrospective study with a minimal follow-up two years

ObjectiveThe aim of this retrospective study was to compare the clinical outcomes of anatomic single bundle ACL reconstruction using either a free quadriceps tendon autograft or a quadrupled hamstring autograft with a minimum follow-up of 24 months.MethodsConsecutive patients undergoing ACL reconstruction using either a free quadriceps tendon autograft or hamstring tendon autograft from January 2013 to December 2014 were included. ACL reconstruction was done in all patients due to isolated ACL tears. Patients with associated cartilage lesions > Outerbridge III, meniscal lesions in need of meniscectomy or repair as well as patients with prior knee surgery on the affected or contralateral knee were excluded. The primary outcome evaluation was the side-to-side difference in instrumented Lachman testing. Secondary outcome evaluation consisted in the Lysholm, modified Cincinnati and SF-36 scores. Side-to-side difference in range of motion and thigh diameter was also documented.ResultsAfter applying the inclusion/exclusion criteria, a total of 82 patients were identified and 72 (87.8%) presented to the hospital for follow-up. There were 39 patients with quadriceps graft (30.64 ± 8.71, range: 18–53 years) and 33 patients with hamstrings (28.60 ± 6.74, range: 18–46 years). No statistically significant difference between groups was detected with regard to KT-1000 measurements (p = 0.326). No significant difference was found between the mean postoperative Lysholm (p = 0.299), the modified Cincinnati (p = 0.665) and the general SF-36 scores between groups (p = 0.588). Less side-to-side thigh diameter difference was noted in the quadriceps graft group (p = 0.026).ConclusionIn conclusion, similar clinical results, in terms of stability and subjective measures, can be obtained after ACL reconstruction both with a free quadriceps and a 4-strand hamstring tendons autograft.Level of evidenceLevel III, Therapeutic Study.     

Quadriceps tendon rupture in maintenance haemodialysis patients: Results of surgical treatment and analysis of risk factors

BackgroundReports of spontaneous quadriceps ruptures in end-stage renal disease (ESRD) patients are scarce, and the assessment of risk factors for tendon rupture is poorly addressed in the majority of the studies. The purpose of the present study is to report a series of patients on haemodialysis with spontaneous quadriceps tendon ruptures operated at our institution. The results of the surgical treatment are described and the potential risk factors associated with the rupture are analyzed.MethodsOur study consisted of retrospective analysis of patient's charts. Clinical and laboratory findings of the operated group were compared to the ones of a control group of haemodialysis patients matched by age, gender, and time on haemodialysis, but without tendon rupture.ResultsBetween 1998 and 2010, six ESRD patients with 11 spontaneous ruptures of the quadriceps tendon were treated at our institution. On postoperative evaluation all patients were able to walk without crutches after six months of follow-up, and there were no new ruptures. Positive serology for Hepatitis C was present in two cases (33%) but in none of the controls (p = 0.034). Mean serum levels of intact parathormone (iPTH) and alkaline phosphatase were both higher in cases (p = 0.013 and p = 0.034, respectively). In contrast, mean serum levels of albumin, ferritin and haemoglobin were all lower in cases (p = 0.008, p = 0.043 and p = 0.016, respectively).ConclusionReconstructive surgery is a good way to restore knee function in ESRD patients with quadriceps tendon ruptures. Our cases exhibited higher levels of iPTH and alkaline phosphatase than control patients, reinforcing the role of secondary hyperparathyroidism in tendon weakening. They also had a higher frequency of hepatitis C and lower levels of albumin and haemoglobin compared to controls, possibly implicating chronic inflammation as a potential risk factor for tendon rupture.     

Amoxycillin/Clavulanic acid monotherapy in complicated paediatric appendicitis: Good enough?

BackgroundAntibiotic choice for complicated appendicitis should be based on both microbiological effectiveness as well as ease of administration and cost especially in lower resourced settings. Data is limited on comparative morbidity outcomes for antibiotics with similar microbiological spectrum of activity.Incidence and morbidity of surgical site infection after appendectomy for complicated appendicitis was assessed after protocol change from triple antibiotic (ampicillin, gentamycin, and metronidazole) regimen to single agent (amoxycillin/clavulanic acid).MethodsSurgical site infection (SSI) rate, relook surgery rate and length of hospital stay were retrospectively compared in patients treated for acute appendicitis preceding (2014, 2015; “triple-therapy, TT”) and following (2017, 2018; “single agent, SA”) antibiotic protocol change.ResultsThe rate of complicated appendicitis was similar between groups; 72.6% in TT and 66% in SA (p = 0.239). Significantly, SSI occurred in 22.7% of the SA group compared to 13.3% in TT group (OR 1.920, 95% CI 1.000–3.689, p = 0.048).Use of laparoscopy increased from 31% in TT to 89% in SA, but with subgroup analysis this was not associated with increased SSI (17.3% in open and 20.6% in laparoscopic; OR 0.841, 95% CI 0.409–1.728, p = 0.637). Relook rate (OR 1.444, 95% CI 0.595–3.507, p = 0.093) length of hospital stay (U = 6859, z = -1.163, p = 0.245), and ICU admission (U = 7683, z = 0.634 p = 0.522) were equivocal. Neither group had mortalities.ConclusionsDespite increased SSI with SA, overall morbidity relating to ICU admission, relook rate and length of hospital stay was similar in both groups. More prospective research is required to confirm equivalent overall morbidity and that single agent therapy is more cost-effective with acceptable clinical outcomes.     

The effect of subscapularis management technique on outcomes and complication rates following reverse total shoulder arthroplasty

BackgroundRepair of the subscapularis tendon following rTSA has been shown to decrease postoperative dislocations in some studies, but the effect of repair on other outcomes has not been defined. We proposed to assess differences in postoperative pain, function, range of motion, strength, complications, and reoperations after three types of management of the subscapularis tendon—primary repair (tendon-to-tendon), transosseous repair, and no repair—at a minimum of two years of follow-up after rTSA.MethodsReview of an institutional database identified patients with primary rTSA treated by a single surgeon using the same operative technique and implant (medial glenoid with lateral humeral implant) except for subscapularis repair (tendon-to-tendon repair, transosseous repair, no repair). Patients with revision rTSA, anatomic TSA, hemiarthroplasty, or surgery for proximal humeral fracture, nonunion, or malunion were excluded.ResultsOf 210 patients meeting inclusion criteria, 82 (39%) had primary tendon repair of the subscapularis (PTR), 88 (41.9%) had transosseous repair (TOR), and 40 (19%) did not have the subscapularis repaired (NR). Of all demographics and comorbidities measured, the only significant differences among treatments groups were in gender (54.9% female in PTR, 43.2% in TOR, and 72.5% in NR, p = 0.008) and subscapularis status before surgery (89% intact in PTR, 80.7% in TOR, and 38.5% in NR, p < 0.001). There were significantly more patients in the NR group whose operative indication was massive rotator cuff tear compared to the TO and PR groups. Similarly, there were significantly more patients whose operative indication was primary osteoarthritis in the TR group over the PR group, and the PR group over the NR group. There were no significant differences in complication rates (11% PTR, 13.6% TOR, 15% NR, p = 0.79) or reoperation rates (PTR 2.4%, TOR 2.3%, NR 5.0%, p = 0.66) or associations between subscapularis management technique and reoperation or complication rates.ConclusionSubscapularis management technique in rTSA did not affect complication or reoperation rates, and the procedure led to improvements in pain, function, range of motion, and strength in all three treatment groups. Repair of the subscapularis, regardless of technique, led to greater improvements in pain compared to no repair, although this may be partially attributable to better preoperative subscapularis status in the repair groups. Both repair techniques led to equal improvements in all measured outcomes, with the exception of primary tendon repair producing more improvement in ER strength compared to transosseous repair.Level of evidenceLevel III; Case Control Study     

Clinical outcome of primary medial collateral ligament-posteromedial corner repair with or without staged anterior cruciate ligament reconstruction

IntroductionMedial collateral ligament (MCL) is a prime valgus stabilizer of the knee, and MCL tears are currently managed conservatively. However, posteromedial corner (PMC) injury along with MCL tear is not same as isolated MCL tear and the former is more serious injury and requires operative attention. However, literature is scarce about the management and outcome of PMC-MCL tear alongside anterior cruciate ligament (ACL) tear. The purpose of this study is to report the clinical outcome of primary repair of MCL and PMC with or without staged ACL reconstruction.MethodsA retrospective evaluation was performed on patients with MCL-PMC complex injury with ACL tear who underwent primary repair of MCL-PMC tear followed by rehabilitation. Further, several of them chose to undergo ACL reconstruction whereas rest opted conservative treatment for the ACL tear. A total of 35 patients of two groups [Group 1 (n = 15): MCL-PMC repaired and ACL conserved; Group 2 (n = 20): MCL-PMC repaired and ACL reconstructed] met the inclusion criteria with a minimum follow-up of two years. Clinical outcome measures included grade of valgus medial opening (0° extension and 30° flexion), Lysholm and International knee documentation committee (IKDC) scores, KT-1000 measurement, subjective feeling of instability, range of motion (ROM) assessment and complications.ResultsWhile comparing group 2 versus group 1, mean Lysholm (94.6 vs. 91.06; p = 0.017) and IKDC scores (86.3 vs. 77.6; p = 0.011) of group 2 were significantly higher than group 1. 60% patients of group 1 complained of instability against none in the group 2 (p < 0.0001). All the knees of both the groups were valgus stable with none requiring late reconstruction. The mean loss of flexion ROM in group 1 and 2 was 12° and 9° respectively which was not statistically different (p = 0.41). However while considering the loss of motion, two groups did not show any significant difference in clinical scores.ConclusionsPrimary MCL-PMC repair renders the knee stable in coronal plane in both the groups and further ACL reconstruction adds on to the stability of the knee providing a superior clinical outcome. Minor knee stiffness remains a concern after primary MCL-PMC repair but without any unfavorable clinical effect.     

Meniscus repair with simultaneous anterior cruciate ligament reconstruction: Clinical outcomes,failure rates and subsequent processing

PurposeTo retrospectively analyze the clinical outcomes of meniscus repair with simultaneous anterior cruciate ligament (ACL) reconstruction and explore the causes of failure of meniscus repair.MethodsFrom May 2013 to July 2018, the clinical data of 165 patients who were treated with meniscus surgery and simultaneous ACL reconstruction, including 69 cases of meniscus repair (repair group) and 96 cases of partial meniscectomy (partial meniscectomy group) were retrospectively analyzed. The exclusion criteria were as follows: (1) ACL rupture associated with fracture, collateral ligament injury, or complex ligament injury; (2) a history of knee surgery; or (3) a significant degree of osteoarthritis. The 69 patients in the repair group were divided into the non-failure group (62 cases) and the failure group (7 cases) depending on the repair effect. Postoperative outcomes of the repair group and the partial meniscectomy group were compared. General conditions and postoperative outcomes of the failure group and the non-failure group were compared. During the median follow-up period of 28 months (range, 4 - 65 months) after the second arthroscopy, postoperative outcomes of seven patients in the failure group were summarized. SPSS 25.0 statistical software was used for statistical analysis. A p value less than 0.05 was considered statistically significant.ResultsSeven patients in the failure group who underwent the second arthroscopy were followed up for (30 ± 17.4) months and their postoperative outcomes were summarized. Compared with the partial meniscectomy group, the International Knee Documentation Committee scores of patients in the repair group improved significantly (p = 0.031). Compared with the non-failure group, more patients in the failure group were younger than 24 years (p = 0.030). The median follow-up period was 39.5 months. All patients recovered well after subsequent partial meniscectomy and relieved clinical symptoms. Visual analog scale scores decreased significantly (p = 0.026), and the International Knee Documentation Committee and Lysholm scores improved significantly (p = 0.046 for both).ConclusionThe failure rate of meniscus repair in this study was 10.1% (7/69), all of which were medial meniscus tears. However, the surgical outcomes of ACL reconstruction were not affected, and there might be a role for graft protection. Therefore, meniscus retears can be successful treated by performing subsequent partial meniscectomy in patients with repair failure.     

Thoracoscopic surgery for congenital lung malformations: Does previous infection really matter?

Background/ PurposeElective resection of congenital lung malformations (CLMs) is still debatable. The two main risks are malignant transformation and recurrent pulmonary infections. Our study aimed to assess the effect of previous pulmonary infection on the intraoperative and postoperative courses of thoracoscopic surgery for CLMs.MethodsThis is a retrospective study including all thoracoscopic lung resections for CLMs between 2010 and 2019. Ninety patients were included. There was a history of previous pulmonary infection in 28 patients (group A) and no such history in 62 patients (group B).ResultsThe median age at operation for group A was 20.4 months (IQR:14.9–41.4) versus 15.1 months (IQR:9.7–20.8) in group B (p = 0.006). There were 10 conversions (35.7%) in group A and 8 (12.9%) in group B (p = 0.02). The operative time was significantly shorter in group B (p<0.002). In group A, 32.1% of patients experienced postoperative fever versus 11.3% of group B (p = 0.03), with higher antibiotics requirement (28.6% versus 6.5% respectively, p = 0.007). However, no significant differences were found in terms of postoperative complications (p = 0.99).ConclusionEarlier intervention for CLMs before the development of pulmonary infection carries higher chances for the success of the thoracoscopic approach with shorter operative time and more uneventful postoperative courses.     

Risk factors for achilles tendon rupture: A matched case control study

PurposeThe purpose of this study was to elucidate whether body mass index (BMI), activity level, and other risk factors predispose patients to Achilles tendon ruptures.Materials and methodsA retrospective review of 279 subjects was performed (93 with Achilles tendon rupture, matched 1:2 with 186 age/sex matched controls with ankle sprains). Demographic variables and risk factors for rupture were tabulated and compared.ResultsThe rupture group mean BMI was 27.77 (95% CI, 26.94–28.49), and the control group mean BMI was 26.66 (95% CI, 26.06–27.27). These populations were found to be statistically equivalent (p = 0.047 and p < 0.001 by two one-sided t-test). A significantly higher proportion of those suffering ruptures reported regular athletic activity at baseline (74%) versus controls (59%, p = 0.013).ConclusionThere was no clinically significant difference found in BMI between patients with ruptures and controls. Furthermore, it was found that patients who sustained ruptures were also more likely to be active at baseline than their ankle sprain counterparts.     

Concomitant Patellar Tendon Tear (PTT) with Cruciate and/ Collateral ligament injury (Multi- Ligamentous Knee Injury –MLKI) and new pathoanatomical -Ganga PTT classification aids to strategize treatment options

IntroductionConcomitant patellar tendon (PT) tear with cruciate or multi-ligament knee injuries (MLKI) following high-velocity injury requires a systematic approach.MethodsThe study is a retrospective case series of patients (2008–2019) with concomitant PT ligament injury with cruciate or collateral ligament injury (MLKI), including bony avulsion injuries. Isolated cruciate and MLKI without patellar tendon tears are excluded. N = 32 patients (1 female and 31 male) are divided into two groups, Group 1 (11 patients) with PT tear and ACL tear and group 2 (21 patients) with PT tear and MLKIs. Patients were taken up for a single stage in types 1,2,3 and staged repair with reconstruction for types 4,5 of our new classification. All the patients are followed up regularly, and IKDC and Lyshom's score and objective radiological stress x-rays taken at each follow-upResultsIncidence of PTT combined injuries among all knee ligament injuries is 0.57%. The mean age was 35.09+/-11.96 SD(group1) and 36.55+/-11.89 SD(group2). The average follow-up was 34.45 months +/- 12.86SD (group 1) and 35.3 months +/- 15.75 SD (group2). Mean post-operative Lysholm score and IKDC score of group 1 and group 2 improvement was statistically significant p-value <=0.01. The mean post-operative ROM of the two groups were 132.73 (SD 6.46) (Group 1) and 111.75 (15.75) (Group 2) and was a statistically significant p-value <0.01. Residual lag of 30^° seen in all patients improved by 3rd month in group 1 and 6th month in group 2. Knee stiffness is seen in 2 patients and superficial infection in 2 patients.ConclusionPTT combined injuries are rare and occurs due to direct impact injuries. Single-stage PT repair with ACL reconstruction gives adequate stability, and extensor lag is eminent and needs supervised rehabilitation. PT with MLKI is a challenging scenario that can be performed in single-stage/multiple stages, depending on the injuries, surgical expertise, and institutional facilities. Newer simplified classification aids surgeons in planning a treatment strategy.     

Outcomes of isokinetic tests and functional assessment of anterior cruciate ligament reconstruction: Transtibial versus single anatomic femoral tunnel technique

ObjectiveThe aim of the study was to compare the outcomes of the transtibial and anatomical femoral single tunnel surgical techniques in ACL reconstruction.MethodsA total of 30 patients, with 16 patients (15 males and 1 female; mean age: 27.2 ± 7.04) with anatomical femoral single-tunnel technique (AFT) and 14 (12 males and 2 females; mean age: 29.4 ± 8.82) with transtibial technique (TT) were included into the study. All patients were evaluated with isokinetic tests at an angular velocity of 60°/s and 180°/s and the IKDC and Lysholm tests were performed preoperatively and in third, sixth, and 12th months postoperatively. The results were compared between the groups. The mean follow-up time was 17.1 ± 6.48 months.ResultsPostoperative third month changes in extension parameters of peak torque (AFT: ?93.286, TT: ?61.500), peak work (AFT: ?77.071, TT: ?47.500), peak torque ext/kg (AFT: ?1.182, TT: ?0.773), peak work ext/kg (AFT: ?0.982, TT: ?0.604), peak work (AFT: ?55.143 TT: ?33.063) at an angular velocity of 60°/s and postoperative third month change in extension parameter of peak power (AFT: ?86.786 TT: ?54.875) at an angular velocity of 180°/s were found to be better in the transtibial group (p < 0.05) and postoperative sixth month peak torque (AFT: 1.429, TT: ?5.688) value at an angular velocity of 60°/s was found to be less in the anatomical femoral single-tunnel group (p < 0.05). The IKDC (AFT: 94.671, TT: 90.025) (p < 0.05) and Lysholm (AFT: 96.714, TT: 92.375) (p < 0.05) scores of the anatomical femoral single-tunnel group were better than the transtibial group regarding to the postoperative final follow-up. There are positive intermediate correlations between preoperative IKDC and Lysholm scores with preoperative and postoperative some isokinetic test ratio (r = 0.539; p = 0.031), and preoperative peak power extension (r = 0.541; p = 0.030) at the both angular velocity of 60°/s and 180°/s in the transtibial group. There was no significant difference between the two groups with regards to the Lachman, anterior drawer and pivot shift tests (p < 0.05).ConclusionThere were differences in terms of isokinetic parameters in early outcomes but there was no statistical difference between isokinetic parameters at the end of 1st year between two groups. There were some correlations between IKDC and Lysholm scores with some isokinetic parameters.Level of EvidenceLevel III, Therapeutic Study.     

Early rehabilitation after open repair for patients with a rupture of the Achilles tendon

PurposeAs outdoor activities participation increase, Achilles tendon rupture incidence also tends to increase. There are a number of treatment and rehabilitation options for a ruptured Achilles tendon. However, the optimal rehabilitation protocols are still under debate. The purpose of this study is to determine whether early rehabilitation is more effective than conventional rehabilitation.MethodsMedical records of 56 patients who had been treated with open repair after a ruptured Achilles tendon were retrospectively reviewed. 24 patients were treated postoperatively with below knee cast immobilization for four weeks, and they started tolerable weight-bearing rehabilitation at four weeks’ follow-up. The remaining 32 patients were managed postoperatively with short leg splint immobilization for two weeks and started the tolerable weight-bearing at two weeks’ follow-up. We evaluated the patients several times to identify when the single heel raise was possible and measured the American Orthopedic Foot and Ankle Society (AOFAS) scores and Achilles tendon total rupture scores (ATRS) as a functional outcome.ResultsThe single heel raise test was positive in all patients at the last assessment. But there were no statistically significant differences between the groups (p = 0.137). The patients in the Cast group took significantly more time to return to work than did the patients in the Splint group (p = 0.032). And AOFAS scores and ATRS were slightly higher in the Splint group than in the Cast group. There were statistically significant differences (p = 0.042, p = 0.028) between the two groups.ConclusionThe early rehabilitation did not lead to greater endurance, but it showed better results in the return to work and the Achilles functional score. Early rehabilitation after open repair for patients with a ruptured Achilles tendon is helpful for functional recovery.Type of study / Level of evidence: Therapeutic, Level III.     

Surgical approaches to intramedullary nailing of the tibia: Comparative analysis of knee pain and functional outcomes

IntroductionPost-operative knee pain is common following intramedullary nailing of the tibia, regardless of surgical approach, though the exact source is controversial. Historically, the most common surgical approaches position the knee in hyperflexion, including patellar tendon splitting (PTS) and medial parapatellar (MPP). A novel technique, the semi-extended lateral parapatellar approach simplifies patient positioning, fracture reduction, fluoroscopic assessment, and implant insertion. It also avoids violation of the knee joint capsule. However, this approach has not yet been directly compared against the historical standards. We hypothesised that in a comparison of patient outcomes, the semi-extended approach would be associated with decreased knee pain and better function relative to knee hyperflexion approaches.MethodsA trauma patient database from a Level I centre was queried for patients who underwent intramedullary nailing of the tibia between 2009 and 2013. Patients were surveyed for knee pain severity (NRS scale 1 to 10) and location, and completion of the Lysholm Knee Scale (LKS). Data was compared between the semi-extended lateral parapatellar, medial parapatellar, and tendon splitting groups regarding knee pain severity, location, total LKS, and individual knee function scores from the Lysholm questionnaire. Pre-hoc power analysis determined the necessary sample size (n = 34). Post-hoc analysis utilised two-way ANOVA analysis with a significance threshold of p < 0.05.ResultsComparison of knee pain severity between the groups found no significant difference (p = 0.69), with average ratings of: semi-extended (3.26), PTS (3.59), and MPP (3.63). Analysis found no significant differences in total LKS score (p = 0.33), with average sums of: semi-extended (75.97), MPP (77.53), and PTS (81.68). Individual knee function scores from the LKS were similar between the groups, except for limping, with MPP being significantly worse (p = 0.04). There was no significant difference in knee pain location (p = 0.45).ConclusionIn this adequately-powered study, at minimum 1 year follow-up there were no significant differences between the 3 approaches in knee pain severity, location, or overall function. The three were significantly different in post-operative limping, with medial parapatellar having the lowest score. The semi-extended lateral parapatellar approach vastly simplifies many technical aspects of nailing compared to knee hyperflexion approaches, and does not violate the knee joint.     

Surgeon level variation in outcome of repair of congenital diaphragmatic hernia with particular reference to the management of recurrence

IntroductionThe aim of this study is to investigate firstly, the rate of recurrence following primary repair of a congenital diaphragmatic hernia (CDH) and secondly, the rate of recurrence following revisional surgical repair. The primary outcome is rate of recurrence. Secondary outcomes are to establish whether recurrence is related to surgeon, surgeon volume, side of defect, the use of a patch, or a thoracopscopic approachMethodsAll repairs performed in an English regional center over 22 years were recorded. Possible explanatory variables were whether the repair was itself of a recurrence, the surgeon's identity, the surgeon's volume of prior repairs, the side of the defect, the use of a patch.Results198 repairs were performed; 170 primary repairs and 28 of recurrences. Failure occurred significantly more commonly among recurrences (32%) than primary repairs (11%), p = 0.005. Failure of the primary repair was significantly more common where a patch was used 8/34 (23%) rather than a sutured repair 10/136 (7%), p = 0.006, or where a thoracoscopic technique was used 4/13 (31%) rather than laparotomy 14/157 (9%) p = 0.01. Failure of the primary repair was unrelated to the identity of the surgeon (Χ² = 5, p = 0.9) or the volume of prior repairs (t = 0.3, p = 0.6). However, failure of repair of a recurrence was significantly related to the surgeon's volume of prior repairs (t = 2.3, p = 0.01) and the identity of the surgeon (Χ² = 17, p = 0.014), but not the use of a patch (Χ² = 1.6, p = 0.2).ConclusionsRepair of a recurrence of a CDH has a higher probability of failure than the original repair and is related to both the identity of the surgeon and the prior volume of experience. There is a volume outcome relationship for the repair of recurrence, but not the primary repair of CDH. Our study suggests the repair of recurrence of CDH should be restricted to surgeons with proven outcomes for this procedure.     

Is early mobilization after volar locking plate fixation in distal radius fractures really beneficial? A meta-analysis of prospective randomized studies

Study designThis was a systematic review with a meta-analysis.IntroductionDespite rising trends toward surgical treatment of distal radius fractures (DRF) with volar locking plate (VLP) fixation, there is a lack of consensus on when to start vigorous wrist range of motion (ROM) exercises after surgery.PurposeWe performed a meta-analysis to compare early and late mobilization after VLP fixation in patients with DRF.MethodsFour prospective randomized controlled trials with a minimum of 6 months of follow-up were retrieved through MEDLINE (PubMed), EMBASE, Web of Science, the Cochrane Library, and the KoreaMed databases in March 2021. We divided patients into an early group (patients who started ROM exercises of the wrist within 2 weeks after surgery), and a late group (patients who started ROM exercises 5 or 6 weeks after surgery). The primary outcome was treatment efficacy which was measured through improvement in pain score, function score, ROM, and grip power. The secondary outcome was the incidence of postoperative complications.ResultsThis meta-analysis included 127 patients in the early group and 131 patients in the late group. The outcomes were compared at 6 weeks, 3 months, and 6 months postoperatively. There was no significant difference in pain score, though the early group had a lower average visual analog scale score. The early group had a lower arm, shoulder, and hand disability score than the late group (95 % CI, -16.25 to -8.35 points; P < .001) at 6 weeks postoperatively, suggesting significantly superior outcomes. A similar trend persisted at 3 (n = 74 in the early group and n = 77 in the late group; 95% CI, -5.45 to -0.30; P = .029) and 6 months (n = 102 in the early group and n = 100 in the late group; 95% CI, -4.81 to 0.21; P = .073), but the differences were smaller. The early group had a higher grip power at all follow-up periods, but the difference was only significant at 6 months postoperatively (n = 88 in the early group and n = 83 in the late group; 95% CI, 0.50 to 6.99; P = 0.024). The early group also had more favorable ROM in all directions at 6 weeks, but only in supination at 6 months. The complication rate was not significantly different between the 2 groups. There were no differences in the rates of secondary operation and reduction loss.ConclusionEarly ROM exercise after VLP in DRF resulted in superior functional scores and grip power until 6 months postoperatively. The dominance of the joint ROM, which was seen at 6 weeks after surgery in the early exercise group, decreased with time and ultimately showed little difference at 6 months. Early exercise is safe and did not increase complication rates.     

The Efficacy of Posterior Fasciotomy Versus Inserted Vacuum Drainage in Reducing Postoperative Surgical Site Infection in Open Achilles Tendon Repair: A Prospective Cohort Study With Inverse Probability Treatment Weight Propensity Score Analysis

Posterior crural fasciotomy (PF) may reduce postoperative surgical site infection (SSI) rate compared to inserted vacuum suction drainage (VD) in open Achilles tendon repair surgery. Thus, we aimed to compare the postoperative SSI rate between PF and VD in open Achilles's tendon repair surgery. A prospective, single-centered, nonrandomized controlled study of consecutive adult patients undergoing primary open Achilles tendon repair was performed at tertiary referral hospital between January 2017 and January 2020. Patients received either PF or VD from 2 experienced surgeons. Data were collected on demographic, clinical, and intraoperative characteristics along with postoperative SSI and other outcomes. The primary outcome was SSI rate. Secondary outcomes were Achilles tendon total rupture score, functional foot index, and visual analogue scale. A total of 60 patients were eligible and included in the final analysis (PF group n = 30 and VD group n = 30). Two (6.7%) patients in the PF group and 5 (16.7%) patients in the VD group experience postoperative SSI (crude risk ratio 0.40; 95% confidence interval 0.08, 1.90; p = .228). In inverse-probability-treatment-weighted propensity score analysis, the PF group had a significantly lower SSI rate than the VD group (adjusted risk ratio 0.30; 95% confidence interval 0.01, 0.91; p = .033). Inverse-probability-treatment-weighted propensity score analysis of Achilles tendon total rupture score along with crude analysis of total functional foot index and visual analogue scale were also significantly better in the PF group than the VD group (all p < .05). PF during open Achilles repair was associated with a significant reduction in postoperative SSI infection rate compared to VD.     

Metabolic syndrome reduces spinal range of motion: The Yakumo study

BackgroundExcess visceral fat can accumulate owing to lack of exercise. The relationship between metabolic syndrome (MetS) and spinal range of motion (ROM) is not clear. The purpose of this study was to investigate the relationship between MetS and spinal alignment and ROM.MethodsOrthopedic evaluation was prospectively performed in 544 participants. The participants were classified into two groups on the basis of the Japanese-specific MetS criteria proposed by the Japanese Committee of the Criteria for MetS (JCCMS). Lower back pain (LBP), knee joint pain with the visual analog scale (VAS), Kellgren–Lawrence (K–L) grade for knee osteoarthritis, body mass index (BMI), and spinal alignment and ROM were evaluated.ResultsForty-four (8.1%) were diagnosed as having MetS. The prevalence rate of K–L grade 4 in the MetS group was significantly higher than that in the non-MetS group (p < 0.05). When sex, age, and BMI were evaluated as covariates, there were significant differences in the VAS score for knee pain (non-MetS group vs MetS group: 13.7 vs 23.3, p < 0.05), L1–S1 flexion spinal ROM (44.1° vs 38.1°, p < 0.001), flexion spinal inclination angle (SIA) ROM (107.6° vs 99.3°, p < 0.01), and SIA ROM (135.4° vs 124.0°, p < 0.05).ConclusionsKnee pain increased and flexion spinal ROM decreased significantly in the MetS group as compared with non-MetS group. Systemic factors associated with MetS may have a specific impact on spinal ROM while promoting knee osteoarthrosis and increased knee pain.     

Incidence of post-traumatic seizures in children during combat operations in Afghanistan and Iraq

ObjectivesChildren represent a significant portion of the patient population treated at combat support hospitals. There is significant data regarding post injury seizures in adults but with children it is lacking. We seek to describe the incidence of post-traumatic seizures within this population.MethodsThis is a secondary analysis of previously described data from the Department of Defense Trauma Registry (DODTR). Within our dataset, we searched for documentation of seizures after admission.ResultsOf the 3439 encounters in our dataset, we identified 37 casualties that had a documented seizure after admission. Most were in the 1–4 year age group (37.8%), male (59.4%), injured by explosive (40.5%), with serious injuries to the head/neck (75.6%). The median ISS was higher in the seizure group (22 versus 10, p<0.001). Most survived to hospital discharge with no statistically significant increased mortality noted in the seizure group (seizure 90.2% versus 91.8%, p = 1.000). In the prehospital setting, the seizure group was more frequently intubated (16.2% versus 6.0%, p = 0.023), received ketamine (20.0% versus 3.2%, p<0.001), and administered an anti-seizure medication (5.4% versus 0.1%, p = 0.001). In the hospital setting, the seizure group was more frequently intubated (56.7% versus 17.7%, p<0.001), had intracranial pressure monitoring (24.3% versus 2.6%, p<0.001), craniectomy (10.8% versus 2.5%, p = 0.014), and craniotomy (21.6% versus 4.7%, p<0.001).ConclusionsWithin our dataset, we found an incidence of 1% of pediatric casualties experiencing a post-traumatic seizure. While this number appears infrequent, there is likely significant under detection of subclinical seizures.     

Gait analysis combined with the expression of TGF-β1, TGF-β3 and CREB during Achilles tendon healing in rat

PurposeTo observe the changes of gait behavior and the expression of wound healing factors of transforming growth factor-β1 (TGF-β1), TGF-β3 and cAMP response element binding protein-1 (CREB-1) during the healing of Achilles tendon in a rat model, and to investigate whether gait analysis can be used to evaluate the tendon healing.MethodsAchilles tendon of 40 healthy male Sprague-Dawley rats were transected and sutured to establish the Achilles tendon injury (ATI) model. They were randomly divided into 4 groups based on the observational time point at 1, 2, 4 and 6 weeks after injury (n = 10 for each group). Before modeling, 9 rats were randomly selected for CatWalk gait analysis, which contained step cycle, single stance time and average speed. Data were recorded as the normal controls. After then, ATI models were established in the left hind limbs of the all 40 rats (ATI group), while the right hind limbs were only cut and sutured without injury of the Achilles tendon (sham operation group). At 1, 2, 4 and 6 weeks after injury, the gait behavior of the corresponding group of rats (n = 9) as observed and recorded by CatWalk platform. After then, the rats were sacrificed and Achilles tendon of both limbs was harvested. The tendon healing was observed by gross anatomy and histological examination, and the protein and mRNA expression of TGF-β1, TGF-β3, CREB-1 were observed by immunohistochemistry and qPCR. The results of tendon gross grading were analyzed by Wilcoxon rank sum test, and other data were analyzed by one-way analysis of variance among multiple groups.ResultsCompared with normal controls, all gait indexes (step cycle, single stance time and average speed) were greatly affected following ATI, which however improved with time. The step cycle was significantly lower at 1, 2 and 4 weeks after ATI (compared with normal controls, all p < 0.05), but almost returned to the normal level at 6 weeks ((0.694 ± 0.102) vs. (0.503 ± 0.094) s, p > 0.05). The single stance time of the ATI group was significantly shorter at 1 and 2 weeks after operation ((0.078 ± 0.010) s at 1 week, (0.078 ± 0.020) s at 2 weeks, all p < 0.001) and revealed no significant difference at 4 weeks (p = 0.120). The average speed of ATI group at 1, 2, 4, 6 weeks was significantly lower than that in the normal control group (all p < 0.001).Gross observation showed that the grade of local scar adhesion in ATI group increased significantly at 2, 4 and 6 weeks, compared with the sham operation group (all p < 0.001). Extensive adhesion was formed at 6 weeks after ATI. The results of HE staining showed that the number of fibroblast increased gradually and arranged more orderly in ATI group at 1, 2 and 4 weeks (all p < 0.001), and decreased at 6 weeks, but it was still significantly higher than that of the sham operation group (p < 0.001). Immunohistochemistry showed that the positive expression of TGF-β1, TGF-β3, CREB-1 in ATI group was higher than that in the sham operation group at 4 time points (all p < 0.05), which reached the peak at 2 weeks after operation and decreased at 4 weeks (p = 0.002, p < 0.001, p = 0.041, respectively). The results of qPCR suggested that the mRNA expression of TGF-β1, TGF-β3, CREB-1 in ATI group was higher than that in the sham operation group at all-time points (all p < 0.05), which reached the peak at 2 weeks after operation, decreased at 4 weeks, and significantly decreased at 6 weeks (all p < 0.001).ConclusionGait behavior indexes are associated with Achilles tendon healing. The study gives an insight of TGF-β1, TGF-β3, CREB-1 changes in the coursing of Achilles tendon healing and these cytokines may be able to be used to regulate the Achilles tendon healing.     

Delayed versus early repair of inguinal hernia in preterm infants: A systematic review and meta-analysis

ObjectivesTo evaluate the clinical outcomes of herniotomy in preterm infants undergoing early versus delayed repair, the risk factors for complications, and to identify best timing of surgery.MethodsMedline, Embase and Central databases were searched from inception until 25 Jan 2021 to identify publications comparing the timing of neonatal inguinal hernia repair between early intervention (before discharge from first hospitalization) and delayed (after first hospitalisation discharge) intervention. Inclusion criteria was preterm infants diagnosed with inguinal hernia during neonatal intensive care unit admission. Results were analyzed using fixed and random effects meta-analysis (RevManv5.4).ResultsOut of 721 articles found, six studies were included in the meta-analysis. Patients in the early group had lower odds of developing incarceration [odds ratio (OR) 0.43, 95% confidence interval (CI) 0.34–0.55, I² = 0%, p < 0.001]; but higher risk of post-operative respiratory complications (OR 4.36, 95% CI 2.13–8.94, I² = 40%, p < 0.001). No significant differences were reported in recurrence rate (OR 3.10, 95% CI 0.90–10.64, I² = 0%, p = 0.07) and surgical complication rate (OR 0.94, 95% CI 0.18–4.83, I² = 0%, p = 0.94) between early and delayed groups.ConclusionWhile early inguinal hernia repair in preterm infants reduces the risk of incarceration, it increases the risk of post-operative respiratory complications compared to delayed repair. Surgeons should discuss the risks and benefits of delaying inguinal hernia repair with the caregivers to make an informed decision best suited to the patient physiology and circumstances.Level of evidenceTreatment study, level 3.