Complications of Unilateral Biportal Endoscopic Spinal Surgery for Lumbar Spinal Stenosis: A Systematic Review of the Literature and Meta‐analysis of Single‐arm Studies

PurposeThis article aims to summarize the incidence of these complications through a meta‐analysis, analyze the causes of complications and provide clinical promotion and recommendations.MethodsDatabases and retrieval platform including PubMed, Web of science, Springer link, Cochrane clinical trials, ProQuest, ScienceDirect, Europe PMC, Wiley online, OVID, Clinical trials, CNKI and WanFang, and supplement the literature through Google Scholar, collect all the unilateral biportal endoscopy (UBE) controlled trials and non‐controlled trials of UBE in the treatment of lumbar spinal stenosis (LSS). The search time limit is from January 1, 2000 to December 25, 2021. After two reviewers independently screened the literature, extracted data and evaluated the risk of bias in the included studies, meta‐analysis was performed using Stata 15.1 software.ResultsFinally, 24 studies were included, including 999 patients. The results of a single‐arm rate meta‐analysis showed that the overall complication rate of UBE treatment of LSS was 6.27% [95% CI (0.0412, 0.0876)], and the incidence of dural tear was 2.49% [95% CI (0.0133, 0.0390)], the incidence of transient paresthesia was 0.14% [95% CI (0.0000, 0.0072)], the incidence of postoperative spinal epidural hematoma was 0.27% [95% CI (0.0000, 0.0096)], the incidence of postop headache, inadequate decompression, root injury and infection was 0.00%.ConclusionCurrent evidence shows that the complication rate of UBE in the treatment of LSS is low, mainly due to dural tears. Limited by the number and quality of included studies, the above conclusions still need to be confirmed by more studies.     

Comparison of Single‐Radius with Multiple‐Radius Femur in Total Knee Arthroplasty: A Meta‐Analysis of Prospective Randomized Controlled Trials

BackgroundWhether there was clinical superiority for the single‐radius prosthesis over the multi‐radius prothesis in total knee arthroplasty (TKA) still remains to be clarified. We updated a meta‐analysis including prospective randomized controlled trials (RCTs) to compare the clinical prognosis of patients receiving single‐radius TKA (SR‐TKA) or multi‐radius TKA (MR‐TKA).MethodsWe searched the databases of PubMed, Web of Science, EMBASE, Cochrane Library, MEDLINE for eligible RCTs. Two reviewers evaluated the study quality according to the Risk of Bias tool of the Cochrane Library and extracted the data in studies individually. The extracted data included the baseline data and clinical outcome. The baseline data include the author''s name, country, and year of included studies, the name of knee prosthesis used in studies, sample size, follow‐up time, and BMI of patients. The clinical data comprised primary indicators including postoperative knee range of motion (ROM), sit‐to‐stand rest, severe postoperative scorings, such as visual analog scale (VAS), American Knee Society knee score (AKS), Oxford knee scoring (OKS), and SF‐36 Quality of Life Scale, as well as various secondary indicators of complications including anterior knee pain, postoperative infection, aseptic prosthesis loosening, and prosthesis revision. The data analysis was performed using Review Manager 5.3 software and STATA 12.0. The sensitivity analysis was performed using STATA 12.0.ResultsA total of 13 RCTs, along with 1720 patients and 1726 knees, were finally included in our present meta‐analysis. We found that patients in SR‐TKA group performed better in the sit‐to‐stand test (OR = 1.89, 95% CI: 1.05–3.41, p = 0.03) and satisfaction evaluation (OR = 3.27, 95% CI: 1.42–7.53, p = 0.005), which were only evaluated in two included RCTs. While no significant difference was found between SR‐TKA and MR‐TKA groups in terms of postoperative ROM, VAS scoring, AKS scoring, SF‐36 scoring, OKS scoring, and various complications including anterior knee pain, postoperative infection, aseptic prosthesis loosening, and prosthesis revision.ConclusionIn conclusion, our present meta‐analysis indicated that SR implants were noninferior to MR implants in TKA, and SR implants could be an alternative choice over MR implants, since patients after SR‐TKA felt more satisfied and performed better in the sit‐to‐stand test, with no significant difference in complications between SR‐TKA and MR‐TKA groups. While more relevant clinical trials with long‐term follow‐up time and specific tests evaluating the function of knee extension mechanism should be carried out to further investigate the clinical performance of SR implants.     

Comparisons of the Efficacy and Safety of Total Knee Arthroplasty by Different Surgical Approaches: A Systematic Review and Network Meta‐analysis

The purpose of this network meta‐analysis was to investigate the efficacy and safety of total knee arthroplasty (TKA) considering seven different surgical approaches. Four databases (PubMed, Cochrane Library, EMBASE, Web of Science) were searched for clinical randomized controlled trials (RCTs) involving TKA with different surgical approaches. STATA 14.0 was used to construct network maps and publication bias graphs and conduct inconsistency tests, network meta‐analyses, and surface under the cumulative ranking (SUCRA) calculations. A total of 51 RCTs involving 4061 patients and 4179 knees from 18 countries were included. Among the seven surgical approaches, the midvastus approach (MV) was the top choice to reduce tourniquet use time, the subvastus approach (SV) had the shortest operation time, the mini‐midvastus approach (Mini‐SV) was associated with the least amount of time to achieve straight leg raise (SLR) after surgery, the mini‐medial parapatellar approach (Mini‐MP) reduced postoperative pain effects, and the medial parapatellar approach (MP) was the best approach to improve range of motion (ROM). Excluding the quadriceps‐sparing approach (QS), which was not compared, the use of the mini‐midvastus (Mini‐MV) may shorten the hospital stay. There were no significant differences in blood loss, postoperative complications, American Knee Society Score (AKSS) objective, or AKSS functional between the seven surgical approaches (P > 0.05).     

Comparisons between Direct Anterior Approach and Lateral Approach for Primary Total Hip Arthroplasty in Postoperative Orthopaedic Complications: A Systematic Review and Meta‐Analysis

The direct anterior approach (DAA) are attracting increasing attention from orthopedic arthroplasty surgeons, due to the less blood loss, mild soft tissue invasion, rapid rehabilitation and shorter length of stay. However, the longer learning curve in DAA can give rise to several complications, such as intraoperative femoral fracture, lateral femoral cutaneous nerve injury, wound‐healing problem, premature revision and so on. This meta‐analysis was performed to compare the rate of postoperative orthopedic complications between the DAA and the lateral approach (LA). All studies involving the comparison of postoperative orthopedic complications after THA between the DAA and LA group were searched in 7 databases prior to October 2020. The odds ratio (OR) with the 95% confidence intervals (CI) for each outcome was calculated by using the RevMan 5.3. The methodological bias of included studies was evaluated and the potential heterogeneity sources were analyzed. Thirteen comparative studies including a total of 24853 hips (9575 hips in the DAA group and 15278 hips in the LA group) were eligible for this meta‐analysis. There was no significant difference in the rate of surgical site infection [2.59% vs 2.14% (OR = 0.98; 95% CI: 0.59‐1.61, P = 0.93)], heterotopic ossification [12.16% vs 26.47% (OR = 0.46; 95% CI: 0.20‐1.07, P = 0.07)] and reoperation [2.70% and 2.11% respectively (OR = 0.93; 95% CI: 0.68‐1.26, P = 0.64)] between the DAA and LA groups. Although a lower rate in prosthesis malposition [36.19% vs 54.86% (OR = 0.50; 95% CI: 0.35‐0.73, P = 0.0003)], leg length discrepancy [1.87% vs 2.37% (OR = 2.35; 95% CI: 1.30‐4.25, P = 0.005)] and Trendelenburg gait [1.68% vs 4.78% (OR = 0.29; 95% CI: 0.13‐0.65, P = 0.003)] was observed in the DAA group, a higher rate in dislocation [0.77% vs 0.18% (OR = 3.73; 95% CI: 2.35‐5.94, P< 0.00001)], periprosthetic fracture [1.05% vs 0.41% (OR = 2.38; 95% CI: 1.58‐3.58, P< 0.0001)], prosthesis loosening [0.61% vs 0.37% (OR = 1.66; 95% CI: 1.05‐2.62, P = 0.03)] and nerve injury [0.95% vs 0% (OR = 7.12; 95% CI: 1.66‐30.48, P = 0.008)] was found in the DAA group. This meta‐analysis demonstrated several evidences indicating that the DAA exhibited the advantages in the accurate prosthesis placement and less damage of surrounding hip musculature. However, a higher rate in dislocation, periprosthetic fracture, prosthesis loosening and nerve injury in the DAA group should be paid more attention, due to the limited exposure and a longer learning curve, compared to the LA.     

显微椎管减压术与传统椎管减压术治疗腰椎管狭窄症的比较性研究

目的比较显微镜下减压与传统开放手术减压治疗腰椎狭窄症的临床疗效。方法2008年12月～2010年12月手术治疗腰椎狭窄症患者90例,其中48例行显微镜下椎管减压术治疗(A组),42例采用传统开窗减压术(B组)。比较两组手术时间、术中出血量、平均下地时间、平均住院时间及术后症状缓解等方面的指标。采用日本骨科协会JOA评分、Oswestry功能障碍指数问卷表(ODI)和视觉模拟评分(VAS)对两组术前和术后1周、3个月、6个月、12个月、18个月治疗效果进行评定。结果两组均顺利完成手术,伤口一期愈合,无神经损伤、感染等并发症,B组2例硬膜破裂,术中修补。A组手术时间较B组长,但术中出血量、术后下地活动时间及住院时间均显著少于B组(P<0.01)。两组术后3月至18月腰腿痛VAS评分及ODI、JOA评分均较术前显著改善(P<0.01),但组间比较无统计学差异(P>0.05)。结论显微减压术治疗腰椎管狭窄症具有创伤小、出血少、恢复快的优点,是一种有效的微创治疗腰椎管狭窄症的方法,较传统椎管减压术有明显优势。     

Efficacy and Safety of Hyaluronic Acid Intra‐articular Injection after Arthroscopic Knee Surgery: A Systematic Review and Meta‐analysis

ObjectiveHyaluronic acid (HA) intra‐articular injection after arthroscopic knee surgery has been widely applied but its efficacy and safety remain controversial. The aim of this systematic review is to analyze the efficacy and safety of HA intra‐articular injection after arthroscopic knee surgery, and to compare the efficacy of HA with different molecular weights.MethodsWe conducted a systematic literature search in PubMed, Embase, Google scholar and the Cochrane library from inception to 16 September 2022 for English‐written articles, in order to identify randomized controlled trials that evaluated the clinical efficacy and/or safety of HA intra‐articular injection after arthroscopic knee surgery. Then we meta‐analyzed the outcomes of patients given intra‐articular HA injections postoperatively and control patients. We also evaluated the influence of HA with different molecular weights. In every calculation, sensitive analysis was performed. The visual analogue scale (VAS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and adverse events were selected as the primary outcome measurements, while Lysholm, International Knee Documentation Committee (IKDC) and Tegner score were selected as the secondary outcome measurements. Publication bias of every outcome was evaluated using egger test.ResultsFifteen studies involving 951 knees were included and 12 of them were used to performed the meta‐analysis. The results showed no significant difference between the HA group and control group according to VAS, whether assessed at less (P = 0.90) or more than 6 months (P = 0.55). Besides, there were no statistical differences between the HA group and control group according to subgroup analysis (Ps = 0.77, 0.91 and 0.81 in anterior cruciate ligament reconstruction, meniscectomy and overall groups, respectively). Compared to control group, the overall effect of WOMAC score showed no significant differences (P = 0.25), nor did in two subgroups (P = 0.37 and P = 0.22). Outcomes measured by Lysholm (P = 0.13), IKDC (P = 0.86) and Tegner (P = 0.42) scores showed no significant differences, either. The analysis of the risk of adverse events indicated no increase in HA groups (P = 0.06). We found no significant differences between high‐ and low‐molecular‐weight HA at 6 (P = 0.96) or 12 months (P = 0.93) postoperatively. Two studies failed to pass the sensitive analysis and the reasons were discussed detailly and acceptable publication bias was observed.ConclusionsAlthough HA injection after arthroscopic knee surgery is safe, the available evidence does not support its efficacy in pain relief and functional recovery. Therefore, the application of HA injection after arthroscopic knee surgery is not recommended.     

A Novel Method for the Quantitative Evaluation of Lumbar Spinal Stenosis

Study design A retrospective study of computed tomography (CT) myelographic images in patients with degenerative lumbar spinal stenosis (LSS).Objectives To introduce a new technique for the quantitative evaluation of LSS.Background Advances in hardware and software technology now permit inexpensive digitalization of radiological images, and enable methodologies for quantifying space available for neural elements in spinal canal. However, a valid method with quantitative evaluation of spinal stenosis in living patients has not been developed yet.Methods and materials Preoperative CT myelographic scans of 50 patients with degenerative LSS were collected for retrospective investigation. The patients subsequently underwent lumbar decompressive surgery. They included scans from thoracic vertebra 12 (T12) to sacrum (S1), in which each segment was scanned through both the vertebral body and disk. All CT scan films were digitized using a high-resolution digital camera. ImageTool™ software was used to measure three parameters: cross-sectional area of dural sac at disk level (A), cross-sectional area of spinal canal at midpedicular level (B), and cross-sectional area of vertebral body (C). The dural sac canal ratio (DSCR) was calculated as A/B×100%. Low DSCR implied severe dural sac compression with a high degree of stenosis. The spinal canal vertebral ratio (CVR) was also calculated as B/C×100%. Low CVR implied a low baseline of canal capacity for neural elements. They were calculated from T12 to S1.Results The study consisted of 26 male and 24 female patients, with an average age of 68.4 (35–97) years. A total of 295 segments were evaluated, of which 118 (40%) were surgically decompressed. There were wide ranges of canal cross-sectional areas (140–475 mm²) and dural sac cross-sectional area (54–435 mm²). Male patients had a slightly larger canal cross-sectional area than female patients at each level. The mean CVR was found decreased from T12 (26.1%) to L4 (18.3%). This was higher in female than in male patients, especially from T12 to L2 (P < 0.01). There were significant correlations between spinal canal and dural sac cross-sectional area (r = 0.55, P < 0.001), and also between CVR and DSCR (r = 0.31, P < 0.001). Of the levels decompressed, 82% was performed from the level L2 to L5, in which there was no significant difference in canal cross-sectional area and CVR between decompression and nondecompression (P > 0.05). There was a good correspondence between decreasing mean DSCR and increasing percentile of levels decompressed.Conclusion DSCR represents a useful method for the quantitative diagnosis of lumbar spinal canal stenosis. ImageTool™ software is a useful tool in measuring spinal morphometry.     

Effectiveness of moist dressings in wound healing after surgical suturing: A Bayesian network meta‐analysis of randomised controlled trials

The moist healing theory proves that a moderately moist and airtight environment is conducive to wound healing. However, different moist dressings have different functions. We aim to evaluate the effects of moist dressings on wound healing after surgical suturing and identify superior moist dressings. Randomised controlled trials investigating the application of moist dressings were retrieved from electronic databases, including PubMed, EMBASE, Web of Science, and the Cochrane Library. Wound healing, surgical site infection (SSI), and times of dressing change were assessed. The values of the surface under the cumulative ranking (SUCRA) curve were calculated based on the Bayesian network meta‐analysis. Inconsistency tests and funnel plots were applied to analyse the consistency and publication bias. All the analysis complies with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) 2020 Checklist and AMSTAR (Assessing the Methodological Quality of Systematic Reviews) Guidelines. Sixteen randomised controlled trials involving 4444 patients were pooled in the network meta‐analysis. The ionic silver dressing (SUCRA, 93%) ranked first in wound healing, the metallic silver dressing (SUCRA, 75.9%) ranked first in SSI, and the hydrocolloid dressing (SUCRA, 73.9%) ranked first in times of dressing change. Inconsistency was only observed in wound healing, and no publication bias was observed in this study. The effects of moist dressings are better than gauze dressings in the process of wound healing. The ionic silver dressing is effective in wound healing, whereas the metallic silver dressing is effective in SSI prevention. The hydrocolloid dressing requires the fewest times of dressing change. More high‐quality RCTs are required to support the network meta‐analysis.     

Role of D‐dimer and Fibrinogen in the Diagnosis of Periprosthetic Joint Infection: A Systematic Review and Meta‐Analysis

The diagnostic potential of D‐dimer and fibrinogen to detect periprosthetic joint infection (PJI) of the hip and knee is not well‐understood. The aim of this study was to determine whether D‐Dimer and fibrinogen can be used as effective biomarkers to screen PJI. A systematic review of the literature indexed in Web of Science, PubMed, Cochrane Library, Embase, and Google Scholar databases was performed. All studies using D‐dimer levels in serum or plasma, or fibrinogen levels in plasma, for the diagnosis of PJI were included. Meta‐analysis estimates, including sensitivity, specificity, diagnostic odds ratios (DOR), and the area under the summary receiver operating characteristic curve (AUSROC), were calculated using a random‐effects model, and used to assess the diagnostic accuracy of these biomarkers. A total of nine studies were analyzed, and their quality was considered to be acceptable. D‐dimer gave a limited diagnostic value if serum and plasma combined: sensitivity (0.77, 95% confidence interval [CI] [0.63 to 0.87]), specificity (0.67, 95% CI [0.54 to 0.78]), DOR (6.81, 95% CI [2.67 to 17.37]), and AUSROC (0.78, 95% CI [0.74 to 0.82]). Plasma D‐dimer levels were associated with less satisfactory sensitivity (0.65, 95% CI 0.57 to 0.71), specificity (0.58, 95% CI 0.50 to 0.66), DOR (2.52, 95% CI 1.64 to 3.90), and AUSROC (0.65, 95% CI 0.61 to 0.69). Serum D‐dimer levels showed higher corresponding values of 0.89 (95% CI 0.79 to 0.94), 0.76 (95% CI 0.55 to 0.89), 24.24 (95% CI 10.07 to 58.32), and 0.91 (95% CI 0.88 to 0.93). Plasma fibrinogen showed acceptable corresponding values of 0.79 (95% CI 0.70 to 0.85), 0.73 (95% CI 0.57 to 0.85), 10.14 (95% CI 6.16 to 16.70), and 0.83 (95% CI 0.79 to 0.86). Serum D‐dimer may be an effective marker for the diagnosis of PJI in hip and knee arthroplasty patients, and it may show higher diagnostic potential than plasma fibrinogen. Plasma D‐dimer may have limited diagnostic potential.     

Effectiveness and Feasibility of Injectable Escherichia coli‐Derived Recombinant Human Bone Morphogenetic Protein‐2 for Anterior Lumbar Interbody Fusion at the Lumbosacral Junction in Adult Spinal Deformity Surgery: A Clinical Pilot Study

ObjectiveTo explore the effectiveness and feasibility of injectable Escherichia coli‐derived recombinant human bone morphogenetic protein‐2 (injectable E‐rhBMP‐2, a combination of E. coli‐derived recombinant human bone morphogenic protein‐2 and a hydrogel type beta‐tricalcium phosphate carrier) as a bone substitute for anterior lumbar interbody fusion (ALIF) of the lumbosacral junction in adult spinal deformity (ASD) patients.MethodsA prospective single‐institution therapeutic exploratory trial was conducted. Twenty patients (average age: 69.1 years; 19 female and one male; average fusion level: 7.95) diagnosed with ASD with sagittal imbalance who underwent surgical treatment including ALIF at the lumbosacral junction from December 2017 to January 2019 were evaluated. Injectable E‐rhBMP‐2 was prepared by dissolving 3 mg of E. coli‐derived recombinant human bone morphogenetic protein‐2 in 1.5 ml H₂O and mixing in situ with 9 g hydrogel type beta‐tricalcium phosphate. This bone graft substitute was loaded onto a metal ALIF cage and L₅–S₁ ALIF was performed in routine manner. Then posterior column osteotomy with multilevel oblique lumbar interbody fusion or pedicle subtraction osteotomy with accessory rod technique was performed to restore sagittal balance. Patients were followed up for 12 months. CT‐based fusion rates were examined at 6 and 12 months after surgery. Also, clinical outcomes (Oswestry Disability Index [ODI], Visual Analog Scale [VAS] score of the back and leg) were evaluated at 6 and 12 months after surgery. All postoperative adverse events were evaluated for the association with injectable E.BMP‐2.ResultsOf the 20 patients, loss to follow‐up occurred with one patient at 6 months after surgery and one patient at 12 months after surgery, resulting in a total of 18 patients who were available for follow‐up. Six months after surgery, 68.4% patients achieved solid fusion. Twelve months after surgery, 100% fusion rate was achieved. Compared to baseline values, ODI scores improved to 45.8% and 63.7%, VAS (back) improved to 69.2% and 72.8%, and VAS (leg) improved to 49.2% and 64.8%, respectively, at 6 and 12 months after surgery (p < 0.001 for all). Ten cases of adverse events occurred. But no adverse events were associated with injectable E‐rhBMP‐2.ConclusionInjectable E‐rhBMP‐2 will be an effective bone graft substitute when achieving solid interbody fusion in the lumbosacral junction.     

Percutaneous Endoscopic Unilateral Laminotomy and Bilateral Decompression for Lumbar Spinal Stenosis

To introduce a new surgery, percutaneous endoscopic unilateral laminotomy and bilateral decompression (Endo‐ULBD) using visual trepan, and investigate its efficacy and safety in elderly patients with lumbar spinal stenosis. In our retrospective study, a total of 69 patients were enrolled between March 2018 and September 2018; 31 patients were treated with Endo‐ULBD and 38 patients were treated with posterior lumbar interbody fusion surgery (PLIF). The operation time, intraoperative blood loss, and hospitalization duration were compared between the two groups. A visual analog scale (VAS) was used to evaluate the degree of pain. The Oswestry Disability Index (ODI) and European Quality of Life‐5 Dimensions (EQ‐5D) were used to evaluate lumbar function and quality of life, respectively. Lumbar X‐ray, computed tomography (CT) and magnetic resonance imaging (MRI) were performed postoperatively at different time points. MacNab''s outcome assessment and perioperative complications were also documented. The surgeon completed all surgeries successfully, and all 69 patients were followed up. The operative time of the Endo‐ULBD group was 60.68 ± 0.47 min, while that of the PLIF group was 120.23 ± 10.24 min. The operative time of the Endo‐ULBD group was shorter than that of the PLIF group, and the difference was statistically significant (P < 0.001). The volume of intraoperative blood loss was 47.25 ± 0.43 mL in the Endo‐ULBD group and 256.90 ± 20.83 mL in the PILF group (P < 0.001). The length of hospital stay in the Endo‐ULBD group was 5.12 ± 1.60 days and that in the PILF group was 10.54 ± 1.82 days (P < 0.001). The VAS scores at postoperative 1 day, 3 months, 6 months, final follow‐up (Endo‐ULBD: 6.58 ± 0.65, 4.55 ± 0.54, 2.78 ± 0.24, 1.31 ± 0.78; PLIF: 7.19 ± 1.14, 4.80 ± 0.13, 2.71 ± 0.83, 1.29 ± 0.56) were significantly improved compared with those before surgery (Endo‐ULBD: 8.63 ± 0.37; PLIF: 8.31 ± 1.34). The ODI and EQ‐5D scores of lumbar function and quality of life at each time point after surgery (Endo‐ULBD ODI: 30.29% ± 0.47%, 23.35% ± 0.95%, 19.45% ± 0.81%, 10.84% ± 0.36%; EQ‐5D: 0.38 ± 0.15, 0.45 ± 0.17, 0.63 ± 0.14, 0.71 ± 0.20; PLIF ODI: 33.56% ± 1.58%, 25.69% ± 2.69%, 20.01% ± 1.49%, 10.72% ± 0.29%; EQ‐5D: 0.33 ± 0.03, 0.39 ± 0.05, 0.62 ± 0.07, 0.72 ± 0.10) were significantly improved compared with those before surgery (Endo‐ULBD: 44.56 ± 1.32, 0.33 ± 0.07; PLIF: 43.79 ± 1.91, 0.31 ± 0.09, respectively), with statistically significant differences (P < 0.05); however, there was no significant difference between the two groups at the last follow‐up (P > 0.05). At the last follow‐up, the excellent and good efficacy rate was 90.3% (28/31) in the Endo‐ULBD group and 89.4% (34/38) in the PILF group (χ² = 0.089, P = 0.993). No mortality, irreversible nerve injury, or even paralysis occurred in either group. Endo‐ULBD for lumbar spinal stenosis has the advantages of less trauma, a shortened operation time, and rapid recovery and is an effective alternative for the treatment of lumbar spinal stenosis. Strict surgical indications, reasonable surgical plans, and experienced surgeons are important factors to ensure safety and satisfactory postoperative efficacy.     

The effect of low‐level laser therapy on diabetic foot ulcers: A meta‐analysis of randomised controlled trials

Our purpose was to perform a meta‐analysis to evaluate the effect of Low‐level laser therapy (LLLT) on diabetic foot ulcers (DFUs). The PubMed, Cochrane, Embase, Web of Science, Chinese BioMedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), VIP and Wanfang databases were searched systematically up to August 27, 2020. Studies that met the inclusion criteria were included in the analysis. A total of 13 randomised controlled trials (RCTs) and 413 patients were analysed. Compared with the control group, LLLT significantly increased the complete healing rate (risk ratio [RR] = 2.10, 95% confidence interval [CI] 1.56‐2.83, P < .00001), reduced the ulcer area (standardised mean difference [SMD] = 3.52, 95% CI 1.65‐5.38, P = .0002), and shortened the mean healing time (SMD = −1.40, 95% CI −1.90 to −0.91, P < .00001) of patients with DFUs. The quality of the evidence was very low according to the GRADE system. LLLT is a promising and effective adjuvant treatment to accelerate the healing of DFUs. Further evidence from larger samples and higher quality RCTs is needed to prove the effect of LLLT and to determine the most appropriate parameters for the healing of DFUs.     

Full‐Endoscopic Foraminotomy with a Novel Large Endoscopic Trephine for Severe Degenerative Lumbar Foraminal Stenosis at L5S1 Level: An Advanced Surgical Technique

To (i) introduce the technical notes of a novel full‐endoscopic foraminotomy with a large endoscopic trephine for the treatment of severe degenerative lumbar foraminal stenosis at L₅S₁ level; (ii) assess the primary clinical outcomes of this technique; (iii) compare the effectiveness of this full‐endoscopic foraminotomy technique and other previous techniques for lumbar foraminal stenosis. From January 2019 to August 2019, a retrospective study of L₅S₁ severe degenerative lumbar foraminal stenosis was performed in our center. All patients who were diagnosed with severe foraminal stenosis at L₅S₁ level and failed conservative treatment for at least 6 weeks were identified. Patients with segmental instability or other coexisting contraindications were excluded. A total of 21 patients were enrolled in the study. All patients were treated by full‐endoscopic foraminotomy using large endoscopic trephine. The visual analogue scale (VAS) and Oswestry disability index (ODI) were evaluated preoperatively and at 1, 3, 6 months, and 1 year after the surgery, and the modified MacNab criteria were used to evaluate clinical outcomes at the last follow‐up. There were 10 males and 11 females with a mean age of 66.38 ± 9.51 years. Five patients had a history of lumbar surgery. The mean operative time was 63.57 ± 25.74 min. The mean follow‐up time was 13.29 ± 1.38 months. The mean postoperative hospital stay time was 1.29 ± 0.56 days. The mean preoperative VAS score significantly decreased from 7.38 ± 1.02 to 2.76 ± 1.09 (t = 19.759, P < 0.01), 2.25 ± 1.02 (t = 21.508, P < 0.01), 1.60 ± 1.05 (t = 31.812, P < 0.01), and 1.45 ± 1.10 (t = 25.156, P < 0.01) at 1 month, 3 months, 6 months, and 1 year after the operation. The mean preoperative ODI score significantly decreased from 64.66% ± 4.91% to 30.69% ± 4.59% (t = 33.724, P < 0.01), 29.44% ± 4.50% (t = 32.117, P < 0.01), 24.22% ± 4.14% (t = 33.951, P < 0.01), and 22.44% ± 4.94% (t = 30.241, P < 0.01) at 1 month, 3 months, 6 months, and 1 year after the operation. At the last follow‐up, 19 patients (90.48%) got excellent or good outcomes. One patient suffered postoperative dysesthesia, and the symptoms were controlled by conversion treatment. One patient took revision surgery due to the incomplete decompression. There were no other major complications. Percutaneous endoscopic decompression is minimally invasive spine surgery. However, the application of endoscopic decompression for L₅S₁ foraminal stenosis is relatively difficult due to the high iliac crest and narrow foramen. Full‐endoscopic foraminotomy with the large endoscopic trephine is an effective and safe technique for the treatment of degenerative lumbar foraminal stenosis.     

The likelihood of severe COVID‐19 outcomes among PLHIV with various comorbidities: a comparative frequentist and Bayesian meta‐analysis approach

IntroductionThe SARS‐CoV‐2 virus can currently pose a serious health threat and can lead to severe COVID‐19 outcomes, especially for populations suffering from comorbidities. Currently, the data available on the risk for severe COVID‐19 outcomes due to an HIV infection with or without comorbidities paint a heterogenous picture. In this meta‐analysis, we summarized the likelihood for severe COVID‐19 outcomes among people living with HIV (PLHIV) with or without comorbidities.MethodsFollowing PRISMA guidelines, we utilized PubMed, Web of Science and medRxiv to search for studies describing COVID‐19 outcomes in PLHIV with or without comorbidities up to 25 June 2021. Consequently, we conducted two meta‐analyses, based on a classic frequentist and Bayesian perspective of higher quality studies.Results and discussionWe identified 2580 studies (search period: January 2020–25 June 2021, data extraction period: 1 January 2021–25 June 2021) and included nine in the meta‐analysis. Based on the frequentist meta‐analytical model, PLHIV with diabetes had a seven times higher risk of severe COVID‐19 outcomes (odd ratio, OR = 6.69, 95% CI: 3.03–19.30), PLHIV with hypertension a four times higher risk (OR = 4.14, 95% CI: 2.12–8.17), PLHIV with cardiovascular disease an odds ratio of 4.75 (95% CI: 1.89–11.94), PLHIV with respiratory disease an odds ratio of 3.67 (95% CI: 1.79–7.54) and PLHIV with chronic kidney disease an OR of 9.02 (95% CI: 2.53–32.14) compared to PLHIV without comorbidities. Both meta‐analytic models converged, thereby providing robust summative evidence. The Bayesian meta‐analysis produced similar effects overall, with the exclusion of PLHIV with respiratory diseases who showed a non‐significant higher risk to develop severe COVID‐19 outcomes compared to PLHIV without comorbidities.ConclusionsOur meta‐analyses show that people with HIV, PLHIV with coexisting diabetes, hypertension, cardiovascular disease, respiratory disease and chronic kidney disease are at a higher likelihood of developing severe COVID‐19 outcomes. Bayesian analysis helped to estimate small sample biases and provided predictive likelihoods. Clinical practice should take these risks due to comorbidities into account and not only focus on the HIV status alone, vaccination priorities should be adjusted accordingly.     

Patellar Resurfacing in Primary Total Knee Arthroplasty: A Meta‐analysis and Trial Sequential Analysis of 50 Randomized Controlled Trials

ObjectiveDuring total knee arthroplasty, femur and tibia parts are regularly replaced, while resurfacing the patellar or not is an ongoing discussion. To compare revision rate, anterior knee pain rate, patient‐reported outcome measures, complication, radiographic, and clinical outcomes after patellar resurfacing versus non‐resurfacing in total knee arthroplasty.MethodsPubMed, Medline, EMBASE, CENTRAL, and CINAHL databases were searched on 25 April 2021 to enroll randomized controlled trials that compared patellar resurfacing versus non‐resurfacing. We used the grading of recommendations assessment, development and evaluation (GRADE) framework to assess the certainty of evidence. Our primary outcome was revision rate and secondary outcomes was anterior knee pain rate. Outcomes were pooled using the random‐effect model and presented as risk ratio (RR), or mean difference (MD), with 95% confidence interval (CI).ResultsFifty studies (5586 knees) were included. Significant reductions in patellar revision rate (RR 0.41, 95% CI [0.19, 0.88]; P = 0.02; I ² = 24.20%) and non‐patellar revision rate (RR 0.64, 95% CI [0.55, 0.75]; P < 0.001; I ² = 0%) were seen after patellar resurfacing. Patellar resurfacing significantly reduced the anterior knee pain rate than nonresurfacing (RR 0.72, 95% CI [0.57, 0.91]; P = 0.006; I ² = 69.5%). Significant differences in patient‐reported outcome measures were found. However, these differences were inconsistent and lacked clinical importance. Patellar resurfacing resulted in a significant lower rate of patellar clunk (RR 0.58, 95% CI [0.38, 0.88]; P = 0.01; I ² = 0%), a higher patellar score (MD 1.24, 95% CI [0.67, 0.81]; P < 0.001; I ² = 73.8%), but prolonged surgical time (MD 8.59, 95% CI [5.27, 11.91]; P < 0.001; I ² = 88.8%).ConclusionsThe clear relationship is that patellar resurfacing reduces revisions, anterior knee pain, and patellar clunk. It will be interesting to compare the initial cost with the revision cost when required and cost‐utility analysis with long‐term results in future studies.     

Arthroscopic Hip Surgery versus Conservative Therapy on Femoroacetabular Impingement Syndrome: A Meta‐Analysis of RCTs

To determine the outcome and differences between arthroscopic hip surgery and conservative therapy in patients suffering from femoroacetabular impingement syndrome, we searched articles from PubMed, Embase, Cochrane, Web of Science and Clinicaltrials.gov using a Boolean search algorithm. Only randomized controlled trials comparing arthroscopic hip surgery and conservative therapy were included in this meta‐analysis of femoroacetabular impingement syndrome management. Two authors determined eligibility, extracted the needed data and assessed the risk of bias of eligible studies independently. Then we meta‐analyzed three articles to assess pooled estimate size (ES) and 95% confidence interval for Hip Outcome Score of activities of daily living (HOS ADL subscale), Hip Outcome Score sport (HOS sports subscale) and International Hip Outcome Tool (iHOT‐33) analyses were performed by using STATA version 14.0 MP (STATA, College Station, TX, USA) with the principal summary measures are mean between group difference, sample size, and standard deviation. We collected 52 articles in total after removing duplicates and screened by titles and abstracts. A total of three RCTs were included finally. There was definite evidence of additional benefit of arthroscopic hip surgery against conservative therapy in the field of improving quality of life (three trials, 575 participants, ES = 2.109, 95% CI: 1.373 to 2.845, I ² = 42.8%, P = 0.000) and activity of daily living (two trials, 262 participants, ES = 9.220, 95% CI: 5.931 to 12.508, I ² = 16.5%, P = 0.000). However, no significant difference could be seen in sports function improvement (two trials, ES = 7.562, 95% CI: −2.957 to 18.082, I ² = 60.1%, P = 0.159). In conclusion, this meta‐analysis suggests that arthroscopic hip surgery provided essential benefit compared with conservative therapy in improving activity of daily living and quality of life.     

腰椎间盘突出症及腰椎管狭窄症手术的疗效分析（附580例远期随访报告）

本文报告对５８０例采用手术治疗的腰椎间盘突出症及腰椎管狭窄症的近期疗效和经过８年以上随访的远期疗效，满意率均达到９０％。术后早期无效的１０例，后诊断为臀肌筋膜无菌炎症性损害，经用软组织松解术治愈，早期属优后来复发的８例经再次手术治愈。１０例从早期属优降为好转的因术后腰椎发生失稳。作者提出对根性和干性坐骨神经痛的鉴别诊断；对于伴腰椎间盘膨出的腰椎管狭窄症，可只作椎管内软组织松解术而不切除膨出的椎间盘。     

The application of platelet‐rich plasma for skin graft enrichment: A meta‐analysis

Existing evidence demonstrated that the role of platelet‐rich plasma (PRP) in skin graft enrichment is uncertain. The aim of this study was to evaluate the efficacy and safety of PRP for skin graft. PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for randomised controlled trials that compared outcomes of skin graft treated with PRP versus those treated with blank controls. The outcomes mainly included the rate of skin graft take, number of skin graft loss and haematoma formation, and complications. There were 11 studies involving a total of 910 cases of skin grafts. Compared with the control group, PRP group had a significantly higher rate of skin graft take (mean difference = 5.47%; 95% confidence interval [CI], 2.80%‐8.14%; P < .0001), fewer number of skin graft loss (risk ratio [RR] = 0.26; 95% CI, 0.13‐0.55; P = .0004) and fewer cases of haematoma formation (RR = 0.24; 95% CI, 0.11‐0.54; P = .0006). There was no significant difference in the incidence of complications between two groups. This meta‐analysis summarises current evidence and indicates that PRP is a safe and effective adjuvant for skin graft enrichment.