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Foot & Ankle Orthopaedics Apr 2021This investigation's purpose was to perform a systematic review of the literature examining the biomechanics of the ligaments comprising the distal tibiofibular... (Review)
Review
BACKGROUND
This investigation's purpose was to perform a systematic review of the literature examining the biomechanics of the ligaments comprising the distal tibiofibular syndesmosis with specific attention to their resistance to translational and rotational forces. Although current syndesmosis repair techniques can achieve an anatomic reduction, they may not reapproximate native ankle biomechanics, resulting in loss of reduction, joint overconstraint, or lack of external rotation resistance. Armed with a contemporary understanding of individual ligament biomechanics, future operative strategies can target key stabilizing structure(s), translating to a repair better equipped to resist anatomic displacing forces.
STUDY DESIGN
Systematic review.
METHODS
A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using a PRISMA checklist. Biomechanical studies testing cadaveric lower limb specimens in the intact and injured state measuring the distal tibiofibular syndesmosis resistance to translational and rotational forces were included in this review. Only studies that included numerical data were included in this review; studies that only reported figures and graphs were excluded.
RESULTS
Twelve studies met the inclusion and exclusion criteria. Two studies determined the mechanical properties of syndesmotic ligaments, finding superior strength and stiffness of the interosseous ligament (IOL), as compared to the anterior (AITFL) or posteroinferior tibiofibular ligament (PITFL). Four studies examined native ankle biomechanics establishing physiologic range of motion of the fibula relative to the tibia. Fibular range of motion was found to be up to 2.53 mm of posterior translation (Markolf et al), 1.00 mm lateral translation (Xenos et al), 3.6 degrees of external rotation (Burssens et al), and 1.4 degrees of internal rotation (Clanton et al). Four studies evaluated syndesmotic biomechanics under physiological loading and found that the AITFL, IOL, and PITFL provide the majority of resistance to external rotation, diastasis, and internal rotation, respectively. Two studies investigated the biomechanics of clinically and intraoperatively used tests for syndesmotic injuries and found increased sensitivity of sagittal plane posterior fibular translation, as opposed to coronal plane lateral fibular translation for unstable injuries.
CONCLUSIONS
Study findings suggest that although the IOL is the strongest syndesmotic ligament, the AITFL has a dominant role stabilizing the distal tibiofibular syndesmosis to external rotation force. Because of these characteristics, operative repair of the AITFL along its native vector may provide a more biomechanically advantageous construct and should be investigated clinically. Additionally, evaluation of clinical stress tests revealed that the external rotation stress test is the most sensitive test to recognize an AITFL tear, and that a 3-ligament disruption is needed to cause diastasis greater than 2 mm.
PubMed: 35097448
DOI: 10.1177/24730114211012701 -
Journal of Foot and Ankle Research Apr 2021Diabetes mellitus is associated with changes in soft tissue structure and function. However, the directionality of this change and the extent to which either tissue...
BACKGROUND
Diabetes mellitus is associated with changes in soft tissue structure and function. However, the directionality of this change and the extent to which either tissue thickness or stiffness contributes to the pathogenesis of diabetes-related foot ulcerations is unclear. Hence, this systematic review aims to summarise the existing evidence for soft tissue structural differences in the feet of people with and without diabetes.
METHODS
In compliance with MOOSE and PRISMA guidelines, AMED, CINAHL, MEDLINE, ProQuest Health & Medical Collection, ProQuest Nursing & Allied Health Database, and Web of Science electronic databases were systematically searched for studies published from database inception until 1st October 2020 [Prospero CRD42020166614]. Reference lists of included studies were further screened. Methodological quality was appraised using a modified critical appraisal tool for quantitative studies developed by McMaster University.
RESULTS
A total of 35 non-randomised observational studies were suitable for inclusion. Within these, 20 studies evaluated plantar tissue thickness, 19 studies evaluated plantar tissue stiffness, 9 studies evaluated Achilles tendon thickness and 5 studies evaluated Achilles tendon stiffness outcomes. No significant differences in plantar tissue thickness were found between people with and without diabetes in 55% of studies (11/20), while significantly increased plantar tissue stiffness was found in people with diabetes in 47% of studies (9/19). Significantly increased Achilles tendon thickness was found in people with diabetes in 44% of studies (4/9), while no significant differences in Achilles tendon stiffness were found between people with and without diabetes in 60% of studies (3/5).
CONCLUSIONS
This systematic review found some evidence of soft tissue structural differences between people with and without diabetes. However, uncertainty remains whether these differences independently contribute to diabetes-related foot ulcerations. The heterogeneity of methodological approaches made it difficult to compare across studies and methodological quality was generally inadequate. High-quality studies using standardised and validated assessment techniques in well-defined populations are required to determine more fully the role of structural tissue properties in the pathogenesis of diabetes-related foot ulcerations.
Topics: Achilles Tendon; Diabetes Mellitus; Diabetic Foot; Female; Humans; Male; Middle Aged; Observational Studies as Topic; Plantar Plate
PubMed: 33910602
DOI: 10.1186/s13047-021-00475-7 -
Knee Surgery, Sports Traumatology,... Jun 2023The objective of this systematic literature review was to report the results and complications of recent remnant preservation techniques in posterior cruciate ligament... (Review)
Review
PURPOSE
The objective of this systematic literature review was to report the results and complications of recent remnant preservation techniques in posterior cruciate ligament (PCL) reconstruction.
METHODS
A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers searched the PubMed, Scopus, Embase, and Cochrane Library databases using the terms "posterior cruciate ligament" or "PCL" and "remnant preserving." The outcome measures extracted from the studies were the Lysholm score, the International Knee Documentation Committee's (IKDC) subjective and objective scores, Tegner scores, Orthopädische Arbeitsgruppe Knie (OAK) rate of return to sports, and rate of complications. Data were also extracted from studies that used stress radiographs to perform a quantitative assessment of the preoperative and postoperative anteroposterior stability.
RESULTS
The systematic review included 13 studies. The patient cohort of consisted of 643 participants (544 [84.6%] men and 99 [15.4%] women) with a mean age of 32.9 ± 4.0 years. The mean postoperative follow-up was 34.5 ± 10.9 months (range: 24-96 months), while the mean time from injury to surgery was 14.4 ± 9.9 months (range: 0-240 months). All studies reported clinically significant improvement at final follow-up, as evident from the measured subjective and objective IKDC scores, Lysholm score, Tegner score, and OAK rate. Only three studies reported return to sports activity, with a mean percentage of 90.8% (99/109). All studies showed a significant improvement in posterior translation, from 11.5 ± 1.2 mm to 3.3 ± 1.1 mm, using radiography (side-to-side difference). This systematic review revealed 13 (2.0%) failures and 33 (5.1%) minor complications: 10 (1.6%) cases of stiffness, 21 (4.9%) screws removal, 1 (0.2%) injury of the peroneal nerve, and 1 (0.2%) fibular fracture.
CONCLUSIONS
With the currently available data, all studies included in the review on posterior cruciate ligament reconstruction with remnant preservation demonstrated satisfactory outcomes at mid-term follow-up (> 24 months), despite varying surgical techniques and graft types, and intervals from injury to surgery. For clinical relevance, standard PCL reconstruction is a highly effective operation in terms of improvement in functional status, knee stability, quality of life, and cost effectiveness. The remnant preservation technique requires more comprehensive diagnostic assessments of the PCL remnant patterns and more complicated surgical procedures. Given the absence so far of high quality studies with long-term follow-up, the remnant-preserving techniques should be recommended only by experienced knee arthroscopic surgeons.
LEVEL OF EVIDENCE
Level IV.
STUDY REGISTRATION
reviewregistry1376- www.researchregistry.com .
Topics: Male; Humans; Female; Adult; Posterior Cruciate Ligament Reconstruction; Quality of Life; Treatment Outcome; Knee Joint; Arthroscopy; Radiography; Anterior Cruciate Ligament Injuries
PubMed: 36208342
DOI: 10.1007/s00167-022-07192-z -
Patient Related Outcome Measures 2020The aim of this study was to evaluate the effect of perioperative vitamin D levels in terms of functional results, patient-related outcome measures (PROMs) and infection... (Review)
Review
The Effect of Perioperative Vitamin D Levels on the Functional, Patient-Related Outcome Measures and the Risk of Infection Following Hip and Knee Arthroplasty: A Systematic Review.
INTRODUCTION
The aim of this study was to evaluate the effect of perioperative vitamin D levels in terms of functional results, patient-related outcome measures (PROMs) and infection risk after hip or knee replacement.
MATERIALS AND METHODS
A systematic search in PubMed, Cochrane library, ScienceDirect and ClinicalTrials.gov was conducted according to the PRISMA guidelines from inception to January 2020.
RESULTS
Eighteen studies with more than 8000 knee and 1500 hip joint arthroplasties were included. The mean follow-up ranged from 6 weeks to 1 year and mean patients' age from 59.4 to 76 years. Hypovitaminosis was diagnosed in 26.7% of cases. Most studies did not find significant differences in pre- and postoperative functional results, PROMs and length of hospital stay between hypovitaminosis and euvitaminosis groups. Deficient patients may be at higher risk of postoperative joint stiffness. Patients suffering from hip and knee periprosthetic joint infection seem to have lower vitamin D levels compared to those with aseptic loosening of implants.
CONCLUSION
The necessity of pre-operative correction of vitamin D levels to achieve better functional results and minimize the risk of infection following hip and knee arthroplasty remains inconclusive. Extend of exposure to low vitamin D levels and comparison between outliers needs further evaluation.
PubMed: 32982524
DOI: 10.2147/PROM.S261251 -
PloS One 2024Hand osteoarthritis poses a significant health challenge globally due to its increasing prevalence and the substantial burden on individuals and the society. In current... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Hand osteoarthritis poses a significant health challenge globally due to its increasing prevalence and the substantial burden on individuals and the society. In current clinical practice, treatment options for hand osteoarthritis encompass a range of approaches, including biological agents, antimetabolic drugs, neuromuscular blockers, anti-inflammatory drugs, hormone medications, pain relievers, new synergistic drugs, and other medications. Despite the diverse array of treatments, determining the optimal regimen remains elusive. This study seeks to conduct a network meta-analysis to assess the effectiveness and safety of various drug intervention measures in the treatment of hand osteoarthritis. The findings aim to provide evidence-based support for the clinical management of hand osteoarthritis.
METHODS
We performed a comprehensive search across PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials was conducted until September 15th, 2022, to identify relevant randomized controlled trials. After meticulous screening and data extraction, the Cochrane Handbook's risk of bias assessment tool was applied to evaluate study quality. Data synthesis was carried out using Stata 15.1 software.
RESULTS
21 studies with data for 3965 patients were meta-analyzed, involving 20 distinct Western medicine agents. GCSB-5, a specific herbal complex that mainly regulate pain in hand osteoarthritis, showed the greatest reduction in pain [WMD = -13.00, 95% CI (-26.69, 0.69)]. CRx-102, s specific medication characterized by its significant effect for relieving joint stiffness symptoms, remarkably mitigated stiffness [WMD = -7.50, 95% CI (-8.90, -6.10)]. Chondroitin sulfate displayed the highest incidence of adverse events [RR = 0.26, 95% CI (0.06, 1.22)]. No substantial variation in functional index for hand osteoarthritis score improvement was identified between distinct agents and placebo.
CONCLUSIONS
In summary, GCSB-5 and CRx-102 exhibit efficacy in alleviating pain and stiffness in HOA, respectively. However, cautious interpretation of the results is advised. Tailored treatment decisions based on individual contexts are imperative.
Topics: Humans; Osteoarthritis; Network Meta-Analysis; Treatment Outcome; Hand; Randomized Controlled Trials as Topic
PubMed: 38722915
DOI: 10.1371/journal.pone.0298774 -
The Cochrane Database of Systematic... Apr 2015No cure for rheumatoid arthritis (RA) is known at present, so treatment often focuses on management of symptoms such as pain, stiffness and mobility. Treatment options... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
No cure for rheumatoid arthritis (RA) is known at present, so treatment often focuses on management of symptoms such as pain, stiffness and mobility. Treatment options include pharmacological interventions, physical therapy treatments and balneotherapy. Balneotherapy is defined as bathing in natural mineral or thermal waters (e.g. mineral baths, sulphur baths, Dead Sea baths), using mudpacks or doing both. Despite its popularity, reported scientific evidence for the effectiveness or efficacy of balneotherapy is sparse. This review, which evaluates the effects of balneotherapy in patients with RA, is an update of a Cochrane review first published in 2003 and updated in 2008.
OBJECTIVES
To perform a systematic review on the benefits and harms of balneotherapy in patients with RA in terms of pain, improvement, disability, tender joints, swollen joints and adverse events.
SEARCH METHODS
We searched the Cochrane 'Rehabilitation and Related Therapies' Field Register (to December 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 1), MEDLIINE (1950 to December 2014), EMBASE (1988 to December 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to December 2014), the Allied and Complementary Medicine Database (AMED) (1985 to December 2014), PsycINFO (1806 to December 2014) and the Physiotherapy Evidence Database (PEDro). We applied no language restrictions; however, studies not reported in English, Dutch, Danish, Swedish, Norwegian, German or French are awaiting assessment. We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing and recently completed trials.
SELECTION CRITERIA
Studies were eligible if they were randomised controlled trials (RCTs) consisting of participants with definitive or classical RA as defined by the American Rheumatism Association (ARA) criteria of 1958, the ARA/American College of Rheumatology (ACR) criteria of 1988 or the ACR/European League Against Rheumatism (EULAR) criteria of 2010, or by studies using the criteria of Steinbrocker.Balneotherapy had to be the intervention under study, and had to be compared with another intervention or with no intervention.The World Health Organization (WHO) and the International League Against Rheumatism (ILAR) determined in 1992 a core set of eight endpoints in clinical trials concerning patients with RA. We considered pain, improvement, disability, tender joints, swollen joints and adverse events among the main outcome measures. We excluded studies when only laboratory variables were reported as outcome measures.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected trials, performed data extraction and assessed risk of bias. We resolved disagreements by consensus and, if necessary, by third party adjudication.
MAIN RESULTS
This review includes two new studies and a total of nine studies involving 579 participants. Unfortunately, most studies showed an unclear risk of bias in most domains. Four out of nine studies did not contribute to the analysis, as they presented no data.One study involving 45 participants with hand RA compared mudpacks versus placebo. We found no statistically significant differences in terms of pain on a 0 to 100-mm visual analogue scale (VAS) (mean difference (MD) 0.50, 95% confidence interval (CI) -0.84 to 1.84), improvement (risk ratio (RR) 0.96, 95% CI 0.54 to 1.70) or number of swollen joints on a scale from 0 to 28 (MD 0.60, 95% CI -0.90 to 2.10) (very low level of evidence). We found a very low level of evidence of reduction in the number of tender joints on a scale from 0 to 28 (MD -4.60, 95% CI -8.72 to -0.48; 16% absolute difference). We reported no physical disability and presented no data on withdrawals due to adverse events or on serious adverse events.Two studies involving 194 participants with RA evaluated the effectiveness of additional radon in carbon dioxide baths. We found no statistically significant differences between groups for all outcomes at three-month follow-up (low to moderate level of evidence). We noted some benefit of additional radon at six months in terms of pain frequency (RR 0.6, 95% CI 0.4 to 0.9; 31% reduction; improvement in one or more points (categories) on a 4-point scale; moderate level of evidence) and 9.6% reduction in pain intensity on a 0 to 100-mm VAS (MD 9.6 mm, 95% CI 1.6 to 17.6; moderate level of evidence). We also observed some benefit in one study including 60 participants in terms of improvement in one or more categories based on a 4-point scale (RR 2.3, 95% CI 1.1 to 4.7; 30% absolute difference; low level of evidence). Study authors did not report physical disability, tender joints, swollen joints, withdrawals due to adverse events or serious adverse events.One study involving 148 participants with RA compared balneotherapy (seated immersion) versus hydrotherapy (exercises in water), land exercises or relaxation therapy. We found no statistically significant differences in pain on the McGill Questionnaire or in physical disability (very low level of evidence) between balneotherapy and the other interventions. No data on improvement, tender joints, swollen joints, withdrawals due to adverse events or serious adverse events were presented.One study involving 57 participants with RA evaluated the effectiveness of mineral baths (balneotherapy) versus Cyclosporin A. We found no statistically significant differences in pain intensity on a 0 to 100-mm VAS (MD 9.64, 95% CI -1.66 to 20.94; low level of evidence) at 8 weeks (absolute difference 10%). We found some benefit of balneotherapy in overall improvement on a 5-point scale at eight weeks of 54% (RR 2.35, 95% CI 1.44 to 3.83). We found no statistically significant differences (low level of evidence) in the number of swollen joints, but some benefit of Cyclosporin A in the number of tender joints (MD 8.9, 95% CI 3.8 to 14; very low level of evidence). Physical disability, withdrawals due to adverse events and serious adverse events were not reported.
AUTHORS' CONCLUSIONS
Overall evidence is insufficient to show that balneotherapy is more effective than no treatment, that one type of bath is more effective than another or that one type of bath is more effective than mudpacks, exercise or relaxation therapy.
Topics: Antirheumatic Agents; Arthritis, Rheumatoid; Balneology; Cyclosporine; Humans; Hydrotherapy; Mud Therapy; Osteoarthritis; Pain Management; Publication Bias; Radon; Randomized Controlled Trials as Topic
PubMed: 25862243
DOI: 10.1002/14651858.CD000518.pub2 -
Orthopaedic Journal of Sports Medicine Jun 2024While the biomechanical properties of the native medial patellofemoral ligament (MPFL) have been well studied, there is no comprehensive summary of the biomechanics of... (Review)
Review
BACKGROUND
While the biomechanical properties of the native medial patellofemoral ligament (MPFL) have been well studied, there is no comprehensive summary of the biomechanics of MPFL reconstruction (MPFLR). An accurate understanding of the kinematic properties and functional behavior of current techniques used in MPFLR is imperative to restoring native biomechanics and improving outcomes.
PURPOSE
To provide a comprehensive review of the biomechanical effects of variations in MPFLR, specifically to determine the effect of graft choice and reconstruction technique.
STUDY DESIGN
Systematic review.
METHODS
A systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 32 studies met inclusion criteria: (1) using ≥8 human cadaveric specimens, (2) reporting on a component of MPFLR, and (3) having multiple comparison groups.
RESULTS
Gracilis, semitendinosus, and quadriceps grafts demonstrated an ultimate load to failure (N) of 206.2, 102.8, and 190.0 to 205.0 and stiffness (N/mm) of 20.4, 8.5, and 21.4 to 33.6, respectively. Single-bundle and double-bundle techniques produced an ultimate load to failure (N) of 171 and 213 and stiffness (N/mm) of 13.9 and 17.1, respectively. Anchors placed centrally and superomedially in the patella produced the smallest degree of length changes throughout range of motion in contrast to anchors placed more proximally. Sutures, suture anchors, and transosseous tunnels all produced similar ultimate load to failure, stiffness, and elongation data. Femoral tunnel malpositioning resulted in significant increases in contact pressures, patellar translation, tilt, and graft tightening or loosening. Low tension grafts (2 N) most closely restored the patellofemoral contact pressures, translation, and tilt. Graft fixation angles variably and inconsistently altered contact pressures, and patellar translation and tilt.
CONCLUSION
Data demonstrated that placement of the MPFLR femoral tunnel at the Schöttle point is critical to success. Femoral tunnel diameter should be ≥2 mm greater than graft diameter to limit graft advancement and overtensioning. Graft fixation, regardless of graft choice or fixation angle, is optimally performed under minimal tension with patellar fixation at the medial and superomedial patella. However, lower fixation angles may reduce graft strain, and higher fixation angles may exacerbate anisometry and length changes if femoral tunnel placement is nonanatomic.
PubMed: 38855071
DOI: 10.1177/23259671241241537 -
Computational and Mathematical Methods... 2022To compare the efficacy of warming needle moxibustion (WNM) with that of drug therapy for treating knee osteoarthritis (KOA), so as to provide evidence-based reference... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To compare the efficacy of warming needle moxibustion (WNM) with that of drug therapy for treating knee osteoarthritis (KOA), so as to provide evidence-based reference for the treatment of knee osteoarthritis.
METHODS
PubMed, Embase, Cochrane Library, VIP, WanFang, and CNKI were searched from inception to March 23, 2022. Literature selection was processed in strict accordance with inclusion and exclusion criteria. Cochrane Risk of Bias Assessment tool was applied for quality assessment of included studies. Data analysis and publication bias assessment were performed using Stata 15.0.
RESULTS
There were 30 RCTs included, with 1324 participants in the WNM group and 1293 in the control group. Meta-analysis showed that the WNM group yielded more excellent effect than the control group ( = 1.22, 95% CI (1.17, 1.27), = 0), improvement in WOMAC scores was greater in the WNM group than in the control group (WMD = -8.48, 95% CI (-13.13, -3.83), = 0.002), activity of daily living (ADL) score was higher in the WNM group than in the control group (WMD = -7.66, 95% CI (-10.22, -5.09), = 0.01), improvement in joint stiffness scores was greater in the WNM group than in the control group (WMD = -1.72, 95% CI (-2.50, -0.93), = 0.005), and improvement in pain scores was greater in the WNM group than in the control group (SMD = -1.09, 95% CI (-1.38, -0.79), = 0.001).
CONCLUSIONS
WNM would be more effective in improving quality of life, decreasing WOMAC score, promoting knee function recovery, and alleviating the joint pain and stiffness, compared with orally taken drug therapies. Therefore, WNM could be given prior consideration for the treatment of KOA.
Topics: Humans; Moxibustion; Needles; Osteoarthritis, Knee; Quality of Life
PubMed: 35936371
DOI: 10.1155/2022/3056109 -
Musculoskeletal Science & Practice Nov 2023Guidelines recommend exercise for the management of knee osteoarthritis (OA), however, recently it has been suggested that including additional lifestyle modifications... (Meta-Analysis)
Meta-Analysis Review
The addition of structured lifestyle modifications to a traditional exercise program for the management of patients with knee osteoarthritis: A systematic review and meta-analysis of randomised trials.
BACKGROUND
Guidelines recommend exercise for the management of knee osteoarthritis (OA), however, recently it has been suggested that including additional lifestyle modifications with a traditional exercise program may elicit greater benefits than exercise alone.
OBJECTIVES
To investigate the influence of the addition of lifestyle modifications to a traditional exercise program, with respect to functional outcomes and quality of life among individuals with knee OA.
DESIGN
Systematic review and meta-analysis.
METHODS
Four databases were searched to identify randomised controlled trials comparing an exercise program, which included the addition of lifestyle modifications, to an exercise program alone in individuals with knee OA. Methodological quality of included studies was assessed via the PEDro scale. Results synthesis through meta-analysis using a random effects model was conducted to determine the pooled effect on eligible outcomes and a GRADE approach was utilised to rate the certainty of evidence.
RESULTS
Meta-analysis of seven studies showed the inclusion of lifestyle modifications to an exercise program can further decrease pain intensity (SMD -0.68 [95% CI -1.26 to -0.10]), improve joint stiffness (MD -0.69 [95% CI -1.21, -0.17]) and increase physical function (MD -1.26 s ([95% CI -1.34, -1.17]) at six-months. Individual results showed improvements in quality of life with the addition of lifestyle modifications, however, this was not demonstrated through meta-analysis.
CONCLUSION
This systematic review supports the inclusion of additional lifestyle modifications to a traditional exercise program, for pain intensity, joint stiffness and physical function for individuals with knee OA.
TRIAL REGISTRATION
PROSPERO registration number: CRD42021279594.
Topics: Humans; Osteoarthritis, Knee; Exercise Therapy; Quality of Life; Arthralgia; Life Style; Randomized Controlled Trials as Topic
PubMed: 37793243
DOI: 10.1016/j.msksp.2023.102858 -
The Cochrane Database of Systematic... Sep 2015Fractures of the tibial plateau, which are intra-articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Fractures of the tibial plateau, which are intra-articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including early-onset osteoarthritis. Surgical fixation is usually used for more complex tibial plateau fractures. Additionally, bone void fillers are often used to address bone defects caused by the injury. Currently there is no consensus on either the best method of fixation or bone void filler.
OBJECTIVES
To assess the effects (benefits and harms) of different surgical interventions, and the use of bone void fillers, for treating tibial plateau fractures.
SEARCH METHODS
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (12 September 2014), the Cochrane Central Register of Controlled Trials (2014 Issue 8), MEDLINE (1946 to September Week 1 2014), EMBASE (1974 to 2014 Week 36), trial registries (4 July 2014), conference proceedings and grey literature (4 July 2014).
SELECTION CRITERIA
We included randomised and quasi-randomised controlled clinical trials comparing surgical interventions for treating tibial plateau fractures and the different types of filler for filling bone defects.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened search results, selected studies, extracted data and assessed risk of bias. We calculated risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). Only very limited pooling, using the fixed-effect model, was possible. Our primary outcomes were quality of life measures, patient-reported outcome measures of lower limb function and serious adverse events.
MAIN RESULTS
We included six trials in the review, with a total of 429 adult participants, the majority of whom were male (63%). Three trials evaluated different types of fixation and three analysed different types of bone graft substitutes. All six trials were small and at substantial risk of bias. We judged the quality of most of the available evidence to be very low, meaning that we are very uncertain about these results.One trial compared the use of a circular fixator combined with insertion of percutaneous screws (hybrid fixation) versus standard open reduction and internal fixation (ORIF) in people with open or closed Schatzker types V or VI tibial plateau fractures. Results (66 participants) for quality of life scores using the 36-item Short Form Health Survey (SF-36)), Hospital for Special Surgery (HSS) scores and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function scores tended to favour hybrid fixation, but a benefit of ORIF could not be ruled out. Participants in the hybrid fixation group had a lower risk for an unplanned reoperation (351 per 1000 people compared with 450 in the ORIF group; 95% CI 197 fewer to 144 more) and were more likely to have returned to their pre-injury activity level (303 per 1000 people, compared with 121 in the ORIF group; 95% CI 15 fewer to 748 more). Results of the two groups were comparable for the WOMAC pain subscale and stiffness scores, but mean knee range of motion values were higher in the hybrid group.Another trial compared the use of a minimally invasive plate (LISS system) versus double-plating ORIF in 84 people who had open or closed bicondylar tibial plateau fractures. Nearly twice as many participants (22 versus 12) in the ORIF group had a bone graft. Quality of life, pain, knee range of motion and return to pre-injury activity were not reported. The trial provided no evidence of differences in HSS knee scores, complications or reoperation entailing implant removal or revision fixation. A quasi-randomised trial comparing arthroscopically-assisted percutaneous reduction and internal fixation versus standard ORIF reported results at 14 months in 58 people with closed Schatzker types II or III tibial plateau fracture. Quality of life, pain and return to pre-injury activity were not reported. There was very low quality evidence of higher HSS knee scores and higher knee range of motion values in the arthroscopically assisted group. No reoperations were reported.Three trials compared different types of bone substitute versus autologous bone graft (autograft) for managing bone defects. Quality of life, pain and return to pre-injury activity were not reported. Only one trial (25 participants) reported on lower limb function, finding good or excellent results in both groups for walking, climbing stairs, squatting and jumping at 12 months. The incidences of individual complications were similar between groups in all three trials. One trial found no cases of inflammatory response in the 20 participants receiving bone substitute, and two found no complications associated with the donor site in the autograft group (58 participants). However, all 38 participants in the autologous iliac bone graft group of one trial reported prolonged pain from the harvest site. Two trials reported similar range of motion results in the two groups, whereas the third trial favoured the bone substitute group.
AUTHORS' CONCLUSIONS
Currently, there is insufficient evidence to ascertain the best method of fixation or the best method of addressing bone defects during surgery. However, the evidence does not contradict approaches aiming to limit soft-tissue dissection and damage or to avoid autograft donor site complications through using bone substitutes. Further well-designed, larger randomised trials are warranted.
Topics: Adult; Bone Substitutes; Bone Transplantation; Female; Fracture Fixation; Fracture Fixation, Internal; Humans; Male; Quality of Life; Randomized Controlled Trials as Topic; Tibial Fractures
PubMed: 26370268
DOI: 10.1002/14651858.CD009679.pub2