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Injury Aug 2017Neglected tibial eminence avulsion fractures of the anterior cruciate ligament (ACL) are uncommonly seen in modern times, but are fairly common due to a missed... (Review)
Review
INTRODUCTION
Neglected tibial eminence avulsion fractures of the anterior cruciate ligament (ACL) are uncommonly seen in modern times, but are fairly common due to a missed diagnosis/mismanagement in developing countries.
OBJECTIVES
To determine the outcomes after open reduction and internal fixation of late presenting ACL avulsion fractures, and to review the literature for similar cases, in an attempt to evaluate the ideal surgical management in this unique scenario.
STUDY DESIGN
Retrospective observational study and systematic review MATERIALS: The study included 10 male and 2 female cases (mean age 29.9 years). Patients were assessed for the pre-operative knee range-of-motion (ROM), flexion deformity and stability; functional assessment was conducted using the Lysholm scale, both pre and post-operatively. Open reduction and internal fixation with two partially threaded screws (via a mini anterior approach) was performed in all 12 cases. All patients were clinically followed up for a minimum duration of 12 months. We searched PubMed, Embase and Cochrane databases from the period of inception to January 15, 2017 for similar case series/reports involving management of chronic/neglected ACL avulsion fractures and systematically reviewed these studies following standard PRISMA guidelines.
RESULTS
The median duration of presentation after injury was 12 months (range 3 to 312 months; mean 45.3 months). The mean follow-up duration was 24.1 months (range 12-48 months). All patients achieved normal knee extension except one patient who had a residual 5° flexion contracture. On physical examination, Lachman and pivot-shift tests were negative in all but 1 patient. No case required ACL reconstruction, and the fractures united radiologically within 12 weeks; all patients regained former activity levels.
DISCUSSION
Eleven published studies, mainly case reports, reported on the management of chronic/neglected ACL avulsion fractures. Arthroscopic suture/wire fixation, arthroscopic debridement of avulsed fragment and open reduction, internal fixation (ORIF) with screws are the described techniques for this uncommon entity. However, anatomic reduction of ACL avulsion fractures is difficult arthroscopically as crater depth assessment and repositioning of the avulsed fragment become a problem; the avulsed fragment may also hypertrophy, and some contractures in ACL may develop. A mini-open procedure does not add to the morbidity, overcomes reduction obstacles and allows easy fixation with screws, and can be done even in centers that do not have arthroscopic experience. The key point is accurate reduction and rigid fixation, ensuring no impingement on full extension CONCLUSIONS: Mini-open fixation allows accurate, anatomic reduction and stable fixation with screws, and should be the preferred method of fixation for late presenting ACL avulsion fractures; embedding the fragment deep into the crater or size reduction are key to preventing extension deficits.
Topics: Adult; Anterior Cruciate Ligament Injuries; Arthroscopy; Female; Follow-Up Studies; Fracture Fixation, Internal; Humans; Knee Joint; Male; Observational Studies as Topic; Range of Motion, Articular; Retrospective Studies; Suture Techniques; Tibial Fractures; Treatment Outcome
PubMed: 28802422
DOI: 10.1016/S0020-1383(17)30495-3 -
The American Journal of Sports Medicine Mar 2018Tibial-sided avulsion injuries of the posterior cruciate ligament (PCL) generally require surgical intervention. No consensus exists concerning the optimal surgical...
BACKGROUND
Tibial-sided avulsion injuries of the posterior cruciate ligament (PCL) generally require surgical intervention. No consensus exists concerning the optimal surgical treatment approach for these injuries.
PURPOSE
To perform a systematic review investigating the open and arthroscopic surgical treatment modalities, outcomes, and complications of PCL tibial-sided bony avulsions.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
The authors performed a systematic review of the literature utilizing PubMed and EMBASE from 1975 to present outlining open versus arthroscopic surgical repair of PCL bony avulsion injuries and comparing subjective and objective postoperative patient-reported outcomes, including Tegner, IKDC (International Knee Documentation Committee), and Lysholm scoring systems, as well as rates of patient complications. The quest was performed in June 2016, and searched terms included posterior cruciate ligament, PCL, bony, avulsion(s), tibial-sided, open, and arthroscopic. Inclusion criteria included English-language studies involving surgical fixation strategies for PCL tibial-sided bony avulsions. Exclusion criteria included non-English language, case studies/case series, and subject matter not pertaining to PCL bony avulsions.
RESULTS
Twenty-eight articles comprising 637 patients met the criteria and were included in the final review. PCL injuries with a tibial-sided avulsion were the result of motor vehicle accidents in 68.4% of patients, with 59.0% of these injuries resulting from motorcycle accidents. The arthroscopic group had better IKDC grade A scores (78.9%), indicating a normal knee postoperatively, as compared with the open group (65.9%). The postoperative Lysholm scores were similar between the groups, with a mean of 95.0 in the arthroscopic group and 92.8 in the open group. The arthroscopic group also reported 100% return to preinjury level of activity, compared with 86.2% in the open group. The most common complication in both groups was arthrofibrosis, which was reported more often in the arthroscopic group (0%-35%) versus the open treatment group (0%-25%).
CONCLUSION
In patients with displaced tibial-sided PCL avulsion fractures treated operatively, surgical approaches render similar outcomes and risks. While the arthroscopic group had somewhat higher subjective and objective knee outcome scores, it demonstrated a slightly higher rate of arthrofibrosis. The clear advantage of the arthroscopic approach is that concomitant intra-articular injuries seen on preoperative magnetic resonance imaging, such as meniscal tears or osteochondral loose fragments, can be addressed at the time of the index operation.
Topics: Arthroscopy; Humans; Knee Injuries; Knee Joint; Posterior Cruciate Ligament; Tibia; Treatment Outcome
PubMed: 28437619
DOI: 10.1177/0363546517701911 -
BMC Musculoskeletal Disorders Apr 2017Avulsion fractures of the pelvic apophyses typically occur in adolescent athletes due to a sudden strong muscle contraction while growth plates are still open. The main... (Comparative Study)
Comparative Study Meta-Analysis Review
Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports.
BACKGROUND
Avulsion fractures of the pelvic apophyses typically occur in adolescent athletes due to a sudden strong muscle contraction while growth plates are still open. The main goals of this systematic review with meta-analysis were to summarize the evidence on clinical outcome and determine the rate of return to sports after conservative versus operative treatment of avulsion fractures of the pelvis.
METHODS
A systematic search of the Ovid database was performed in December 2016 to identify all published articles reporting outcome and return to preinjury sport-level after conservative or operative treatment of avulsion fractures of the pelvis in adolescent patients. Included studies were abstracted regarding study characteristics, patient demographics and outcome measures. The methodological quality of the studies was assessed with the Coleman Methodology Score (CMS).
RESULTS
Fourteen studies with a total of 596 patients met the inclusion criteria. The mean patient age was 14.3 ± 0.6 years and 75.5% of patients were male. Affected were the anterior inferior iliac spine (33.2%), ischial tuberosity (29.7%), anterior superior iliac spine (27.9%), iliac crest (6.7%) lesser trochanter (1.8%) and superior corner of the pubic symphysis (1.2%). Mean follow-up was 12.4 ± 11.7 months and most of the patients underwent a conservative treatment (89.6%). The overall success rate was higher in the patients receiving surgery (88%) compared to the patients receiving conservative treatment (79%) (p = 0,09). The rate of return to sports was 80% in conservative and 92% in operative treated patients (p = 0,03). Overall, the methodological quality of the included studies was low, with a mean CMS of 41.2.
CONCLUSION
On the basis of the present meta-analysis, the overall success and return to sports rate was higher in the patients receiving surgery. Especially in patients with fragment displacement greater 15 mm and high functional demands, surgical treatment should be considered.
Topics: Adolescent; Athletic Injuries; Clinical Decision-Making; Conservative Treatment; Female; Fractures, Avulsion; Humans; Male; Orthopedic Procedures; Pelvic Bones; Return to Sport; Treatment Outcome
PubMed: 28420360
DOI: 10.1186/s12891-017-1527-z -
Dental Traumatology : Official... Feb 2017The association between trauma and caries is still controversial in the literature. The aim of this study was to evaluate the possible association between caries and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND/AIM
The association between trauma and caries is still controversial in the literature. The aim of this study was to evaluate the possible association between caries and dental trauma through a systematic review with meta-analysis.
DESIGN
A systematic literature search was performed in PubMed, Lilacs, BBO, Scopus, Web of Science, Cochrane Library, and Open Grey databases. The MeSH terms used were 'Tooth injuries', 'Tooth fractures', 'Tooth avulsion', 'Tooth movement'; 'Dental caries'; 'DMF index'; and 'Tooth demineralization'. MeSH synonyms, related terms, and free terms were included. The inclusion criteria comprised clinical investigations of subjects with and without caries that had suffered dental trauma. Quality assessment and bias control were carried out. Meta-analysis was performed using the comprehensive meta-analysis software (version 3.2). Heterogeneity was assessed using the I index, and the odds ratio was also calculated (P < 0.05).
RESULTS
From 1290 abstracts, seven met the inclusion criteria. All studies had high methodological quality and five were included in the meta-analysis. The results demonstrated a positive association (P < 0.001) between dental trauma and dental caries in permanent teeth [OR: 1.490, 95%, CI: 1.209-1.835]. However, for children with primary teeth, the results showed a negative association (P = 0.006) between dental trauma and caries [OR: 0.706, 95%, CI: 0.550-0.906].
CONCLUSIONS
The results demonstrated positive and negative association between the presence of caries and dental trauma in permanent and primary teeth, respectively.
Topics: Dental Caries; Humans; Risk Factors; Tooth Injuries
PubMed: 27439566
DOI: 10.1111/edt.12295 -
British Medical Bulletin Jun 2016Arthroscopy procedures are the gold standard for the management of tibial spine avulsion. This review evaluates and compares different arthroscopic treatment options for... (Review)
Review
INTRODUCTION
Arthroscopy procedures are the gold standard for the management of tibial spine avulsion. This review evaluates and compares different arthroscopic treatment options for tibial spine fractures.
SOURCE OF DATA
PubMed, Medline, Ovid, Google Scholar and Embase databases were systematically searched with no limit regarding the year of publication.
AREAS OF AGREEMENT
An arthroscopic approach compared with arthrotomy reduces complications such as soft-tissue lesions, post-operative pain and length of hospitalization.
AREAS OF CONTROVERSY
The use of suture techniques, compared to cannulated screw technique, avoids a second surgery for removal of the screws, but requires longer immobilization and partial weight bearing.
GROWING POINTS
Clinical outcomes and radiographic results do not seem to differ in relation to the chosen method of fixation.
AREAS TIMELY FOR DEVELOPING RESEARCH
Further studies are needed to produce clear guidelines to define the best choice in terms of clinical outcomes, function and complications.
Topics: Arthroscopy; Bone Screws; Fracture Fixation, Internal; Fracture Healing; Humans; Length of Stay; Pain, Postoperative; Radiography; Reproducibility of Results; Soft Tissue Injuries; Suture Techniques; Tibial Fractures; Treatment Outcome; Weight-Bearing
PubMed: 27151952
DOI: 10.1093/bmb/ldw018 -
International Journal of Sports... Apr 2016Chronic ankle instability (CAI) is a condition that often develops after repeated ankle sprains, increasing the suceptability of the ankle to move into excessive...
BACKGROUND
Chronic ankle instability (CAI) is a condition that often develops after repeated ankle sprains, increasing the suceptability of the ankle to move into excessive inversion when walking on unstable surfaces. Treatment for CAI costs approximately three billion health care dollars annually. Currently, common diagnostic tools used to identify ankle instability are arthroscopy, imaging, manual laxity testing, and self-reported questionnaires.
PURPOSE
The purpose of this systematic review was to investigate the effectiveness of ultrasonography in diagnosing CAI, in comparison with other diagnostic tools.
METHODS
Search limits: articles published between the years 2000-2015, and articles that were peer reviewed and published in the English language. Databases searched: CINAHL, PubMed, Medline, Medline Plus, Science Direct, OVID, Cochrane, and EBSCO. Titles and abstracts of the 1,420 articles were screened for the inclusion criteria by two independent raters, with discrepancies solved by a third rater. The modified 14-point Quality Assessment of Diagnostic Accuracy Studies (QUADAS) scale was used to assess methodological quality of included articles.
RESULTS
Six high quality articles were included in this systematic review, as indicated by high scores on the QUADAS scale, ranging from 10 to 13. Sensitivity of US ranged from: 84.6 % -100%, specificity of US ranged from: 90.9% - 100% and accuracy ranged from: 87% - 90.9%.
DISCUSSION
The results of the included studies suggest that US is able to accurately differentiate between the grades of ankle sprains and between a lax ligament, torn ligament, thick ligament, absorbed ligament and a non-union avulsion fracture. These findings indicate that US is a reliable method for diagnosing CAI, and that US is able to classify the degree of instability.
CONCLUSION
Researchers found that US is effective, reliable, and accurate in the diagnosis of CAI.
CLINICAL IMPLICATIONS
US would allow for earlier diagnosis, which could increase the quality of care as well as decrease the number of outpatient visits. This could lead to improvement in treatment plans, goals and rehabilitation outcomes.
LEVEL OF EVIDENCE
1a.
PubMed: 27104050
DOI: No ID Found -
Arthroscopy : the Journal of... May 2016To develop evidence-based recommendations for the diagnosis and treatment of skeletally immature patients with subscapularis and lesser tuberosity avulsion injuries. (Review)
Review
PURPOSE
To develop evidence-based recommendations for the diagnosis and treatment of skeletally immature patients with subscapularis and lesser tuberosity avulsion injuries.
METHODS
We searched the online databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews (CDSR) for relevant publications on subscapularis and lesser tuberosity injuries in skeletally immature patients. All publication dates and languages were included. From studies identified, data were extracted to identify patient characteristics, history and physical examination findings, time to diagnosis, results from imaging studies, and treatment outcomes. These findings were combined and descriptively analyzed.
RESULTS
We identified 32 publications on 60 patients with a mean age of 13.5 ± 1.7 years. The most common physical examination finding at the time of diagnosis was anterior shoulder pain, followed by subscapularis muscle weakness. The sensitivity of imaging was 16% for radiographs and 95% for magnetic resonance imaging. The median time to diagnosis was 2 months (interquartile range, 1 to 7 months). Of 60 patients, 10 (17%) underwent successful nonoperative treatment. Fifty patients (83%) underwent surgical repair, without differences in clinical outcomes after open versus arthroscopic repair. Five cases (8%) were identified where delayed treatment was associated with suboptimal outcomes and ongoing shoulder pain.
CONCLUSIONS
Subscapularis and lesser tuberosity avulsion injuries in skeletally immature patients are most commonly seen in male patients during early adolescence. A high index of suspicion should be maintained in patients with anterior shoulder pain and subscapularis muscle weakness, especially after a fall on an outstretched arm or an eccentric external rotation injury. Magnetic resonance imaging should be considered early, even if radiographic findings are negative. Both open and arthroscopic repairs are effective in restoring function, if fixation respects the soft bone of the lesser tuberosity.
LEVEL OF EVIDENCE
Level IV, systematic review of low-quality studies.
Topics: Adolescent; Arthroplasty; Arthroscopy; Child; Fractures, Avulsion; Humans; Humeral Fractures; Magnetic Resonance Imaging; Physical Examination; Postoperative Complications; Radiography; Rotation; Rotator Cuff Injuries; Shoulder Pain; Treatment Outcome
PubMed: 26786826
DOI: 10.1016/j.arthro.2015.10.022 -
European Spine Journal : Official... May 2020Zero-profile (also called self-locking, anchored or stand-alone cages) have been recently proposed as an interesting alternative for anterior cervical discectomy and...
BACKGROUND CONTEXT
Zero-profile (also called self-locking, anchored or stand-alone cages) have been recently proposed as an interesting alternative for anterior cervical discectomy and fusion (ACDF), as they are supposed to reduce the rates of post-operative cage extrusion without necessarily incurring in the additional surgical time and increased rates of dysphagia associated with plating. Nevertheless, the exact indications of zero-profile anchored cages have not yet been established in the literature.
PURPOSE
To report the first case of a vertebral body fracture between the blades of zero-profile anchored cages after ACDFs in adjacent levels and to review the available literature on hardware-related complications after multi-level ACDFs with zero-profile anchored cages.
STUDY DESIGN
Case report and systematic literature review.
METHODS
The authors report the first case of a vertebral body fracture between the blades of zero-profile anchored cages after ACDFs in adjacent levels. The patient presented with refractory mechanical neck pain at the 1-month post-operative follow-up, ultimately requiring a posterior instrumented fusion. A comprehensive systematic literature review on the available data regarding the safety, complications as well as radiological and clinical outcomes of zero-profile anchored cages is also performed.
RESULTS
In the reported case, the use of zero-profile anchored cages in adjacent levels on the cervical spine led to a fracture of the vertebral body between the cages at the 1-month follow-up, with anterior avulsion of the part of the vertebral body where the blades from the two cages converged. According to the systematic literature review which included 409 patients from 10 different clinical series (with a total cumulative follow-up of approximately 535 patients-year), there were only two reported hardware-related complications after ACDF with zero-profile anchored cages, none of them involving fracture at the level of convergence of blades or screws.
CONCLUSIONS
Although hardware-related complications after the use of zero-profile anchored cages seem to be rare events, future biomechanical and clinical studies are warranted in order to evaluate the safety of employing such devices for the treatment of multilevel degenerative disc disease in the cervical spine.
Topics: Cervical Vertebrae; Deglutition Disorders; Diskectomy; Humans; Spinal Fusion; Vertebral Body
PubMed: 26733015
DOI: 10.1007/s00586-015-4358-3 -
Journal of Pediatric Orthopedics 2016Systematic review of the literature was done to determine (1) the frequency and type of associated injuries, (2) frequency of concomitant Osgood-Schlatter disease, (3)... (Review)
Review
BACKGROUND
Systematic review of the literature was done to determine (1) the frequency and type of associated injuries, (2) frequency of concomitant Osgood-Schlatter disease, (3) methods of treatment, (4) functional and radiologic outcomes according to fracture type, and (5) complications of tibial tubercle fractures in pediatric patients.
METHODS
A systematic review of the English literature from 1970 to 2013 included 23 eligible articles reporting 336 fractures with a mean follow-up of 33.56 months (range, 5.7 to 115 mo). Fractures were classified by a comprehensive system that included characteristics of previous systems. Clinical outcomes were assessed by a qualitative scale (excellent/fair/poor), the rate of return to preinjury activity, and knee range of motion. Rate of fracture healing, associated injuries (patellar/quadriceps tendon avulsion and meniscal tears), compartment syndrome, and complications were also recorded.
RESULTS
Mean age at surgery was 14.6 years and the most common fracture reported was type III (50.6%). The overall associated injury rate was 4.1%, most common in type III fractures (4.7%). Compartment syndrome was present in 3.57% of cases. Open reduction and internal fixation were done in 98% of surgical cases. Rates of return to preinjury activity and knee range of motion were 98%, regardless of the type of fracture. Fracture consolidation was achieved in 99.4% of cases. Overall complication rate was 28.3%; removal of an implant because of bursitis (55.8%) was most common. Tenderness/prominence (17.9%) and refracture (6.3%) were also common.
CONCLUSIONS
Treatment of tibial tubercle fractures in adolescents produced good clinical and radiologic results regardless of fracture type, which was more related to potential complications. Fractures with intra-articular involvement tended to present with more associated injuries and to have fair functional outcomes, suggesting that advanced imaging may be justified with these fractures. Complications could be more common than expected without a significant effect on final outcome. Finally, there is a need for longer follow-up to determine long-term outcomes.
LEVEL OF EVIDENCE
Level III-systematic review of level III/IV studies.
Topics: Adolescent; Anterior Compartment Syndrome; Child; Comorbidity; Female; Fracture Fixation, Internal; Fracture Healing; Humans; Intra-Articular Fractures; Knee Injuries; Knee Joint; Male; Open Fracture Reduction; Osteochondrosis; Patellar Ligament; Postoperative Complications; Range of Motion, Articular; Tendon Injuries; Tibial Fractures; Tibial Meniscus Injuries; Treatment Outcome
PubMed: 25887827
DOI: 10.1097/BPO.0000000000000488