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Injury Jun 2024Currently there is no consensus on the need for investigating knee ligamentous and meniscal injuries in a patient with a tibial plateau fracture. Consequently, many soft... (Review)
Review
INTRODUCTION
Currently there is no consensus on the need for investigating knee ligamentous and meniscal injuries in a patient with a tibial plateau fracture. Consequently, many soft tissue injuries are likely undiagnosed and therefore untreated. The impact this has on long term knee outcomes is not well defined. We aimed to identify the impacts of various diagnostic methods on the management of meniscal injuries associated with tibial plateau fractures and evaluate the clinical outcomes.
MATERIALS AND METHODS
We performed a systematic review using Pubmed, Medline, Embase, CINAHL and Cochrane following Cochrane guidelines. We included studies that operatively managed tibial plateau fractures and soft tissue injuries, which were diagnosed with either preoperative MRI, intra-operative arthroscopy or arthrotomy.
RESULTS
18 articles with 884 people, with a mean age of 46.4 years were included. Soft tissue injuries were detected on MRI (32-73%) and arthroscopy (12-70%), of which the most common were lateral meniscal injuries (7-64% of tibial plateau fractures). When identified by arthroscopy and arthrotomy, these injuries were almost always treated, either by repair or debridement. The clinical outcomes of these patients were poorly reported, with a heterogenous use of patient reported outcome measures, and follow up time points. There were no randomised trials or control groups for comparative analysis, however operative treatment yielded good to excellent outcomes.
CONCLUSION
There is a high incidence of concomitant soft tissue injuries with tibial plateau fractures, particularly lateral meniscal injuries. There are 2 main approaches to meniscal injuries: surgeons who don't investigate, don't treat, whilst surgeons who do investigate often do surgically treat. Although studies that treated these injuries achieved good to excellent results, the currently available evidence doesn't confirm treatment superiority. As there is plausibility for better outcomes, randomised studies are needed to further investigate this clinical question.
Topics: Humans; Tibial Fractures; Soft Tissue Injuries; Tibial Meniscus Injuries; Arthroscopy; Magnetic Resonance Imaging; Knee Injuries; Debridement; Tibial Plateau Fractures
PubMed: 38599010
DOI: 10.1016/j.injury.2024.111546 -
The American Journal of Sports Medicine Mar 2024Anterior cruciate ligament reconstruction (ACLR) is one of the most frequently performed procedures in sports medicine, and undesirable outcomes still may range from...
BACKGROUND
Anterior cruciate ligament reconstruction (ACLR) is one of the most frequently performed procedures in sports medicine, and undesirable outcomes still may range from 3-18%. One technique that has been explored to improve outcomes is preservation of the ACL remnant tibial stump, as opposed to stump debridement, at the time of reconstruction.
PURPOSE
To review current high-level evidence and compare remnant-preserving anterior cruciate ligament reconstruction (ACLR) versus standard ACLR in terms of clinical outcomes and measures of knee stability.
HYPOTHESIS
ACLR with remnant preservation would result in improved clinical outcomes and knee stability measures.
STUDY DESIGN
Systematic review; Level of evidence, 2.
METHODS
A systematic review of randomized controlled trials (RCTs) and cohort studies comparing remnant-preserving ACLR with standard ACLR with a minimum level of evidence of 2 was performed. Extracted data were summarized as general information, surgical characteristics, postoperative clinical outcomes, knee stability, graft evaluation, tunnel assessment, and postoperative complications. When feasible, a meta-analysis was performed.
RESULTS
Seven RCTs and 5 cohort studies met the inclusion criteria. In total, 518 patients underwent remnant-preserving ACLR and 604 patients underwent standard ACLR. Ten studies performed the reconstruction with hamstring tendon (HT) autografts, 1 study with HT and bone-patellar tendon-bone autografts, and 1 study with HT and tibialis anterior allografts. On meta-analysis, remnant-preserving ACLR provided comparable outcomes with respect to International Knee Documentation Committee grades or Tegner scores. Even though there was a significant improvement in Lysholm scores (mean difference, -1.9; 95% CI, -2.89 to -0.91; = .0002) with the remnant-preserving technique, this did not exceed previously reported minimal clinically important difference values. Remnant-preserving ACLR demonstrated superior knee stability in terms of patients achieving negative pivot shift when compared with the control group (88.89% vs 79.92%; = .006). Although there was a significant improvement in the side-to-side difference in anterior tibial translation favoring remnant preservation ( = .004), the mean difference was 0.51 mm.
CONCLUSION
Remnant-preserving ACLR, primarily with HT autografts, results in comparable clinical outcome scores and significantly improved knee stability relative to standard ACLR without remnant preservation without increasing the complication rate. Further studies will help clarify if remnant-preserving ACLR also has benefits in terms of enhancing graft integration and maturation, improving proprioception, limiting tunnel enlargement, and reducing complications.
PubMed: 38551115
DOI: 10.1177/03635465231225984 -
Pharmaceutics Feb 2024The treatment of peri-implantitis is challenging in the clinical practice of implant dentistry. With limited therapeutic options and drug resistance, there is a need for... (Review)
Review
The treatment of peri-implantitis is challenging in the clinical practice of implant dentistry. With limited therapeutic options and drug resistance, there is a need for alternative methods, such as photodynamic therapy (PDT), which is a minimally invasive procedure used to treat peri-implantitis. This study evaluated whether the type of photosensitizer used influences the results of inflammatory control, reduction in peri-implant pocket depth, bleeding during probing, and reduction in bone loss in the dental implant region. We registered the study in the PROSPERO (International Prospective Register of Systematic Review) database. We searched three main databases and gray literature in English without date restrictions. In vivo randomized clinical studies involving individuals with peri-implantitis, smokers, patients with diabetes, and healthy controls were included. PDT was used as the primary intervention. Comparators considered mechanical debridement with a reduction in pocket depth as the primary outcome and clinical attachment level, bleeding on probing, gingival index, plaque index, and microbiological analysis as secondary outcomes. After reviewing the eligibility criteria, we included seven articles out of 266. A great variety of photosensitizers were observed, and it was concluded that the selection of the most appropriate type of photosensitizer must consider the patient's characteristics and peri-implantitis conditions. The effectiveness of PDT, its effects on the oral microbiome, and the clinical patterns of peri-implantitis may vary depending on the photosensitizer chosen, which is a crucial factor in personalizing peri-implantitis treatment.
PubMed: 38543201
DOI: 10.3390/pharmaceutics16030307 -
Plastic and Reconstructive Surgery.... Mar 2024Diabetic foot ulcers (DFUs) are common complications of uncontrolled diabetes mellitus that can result in infection and amputation of the lower extremities. This study...
BACKGROUND
Diabetic foot ulcers (DFUs) are common complications of uncontrolled diabetes mellitus that can result in infection and amputation of the lower extremities. This study compared the benefits and risks of hyperbaric oxygen therapy with those of other DFU treatments, based on the Wagner grading system.
METHODS
Systematic searches for randomly controlled trials using hyperbaric oxygen therapy for DFUs were performed using PubMed, the Cochrane Library, and Embase. Data regarding demographics, wound healing, minor and major amputations, operative debridement, nonhealing wounds, and adverse effects were analyzed based on Wagner grades, using RevMan 5.4.1 and Microsoft Excel.
RESULTS
Hyperbaric oxygen therapy was significantly superior to other treatments for wound healing rates 8 or more weeks after the final treatment (RR = 2.39; 1.87-3.05; < 0.00001) minor/distal amputations (RR = 0.58; 0.43-0.80; < 0.007), and major/proximal amputations (RR = 0.31; 0.18-0.52; < 0.00001) for the 14 studies analyzed. In addition, this therapy increased the rate of complete wound healing for Wagner grades II (RR = 21.11; 3.05-146.03; = 0.002), III (RR = 19.58; 2.82-135.94, = 0.003), and IV (RR = 17.53; 2.45-125.44; = 0.004); decreased the minor/distal amputation rate for grade III (RR = 0.06; 0.01-0.29; = 0.0004) and the major/proximal amputation rate on for grade IV (RR = 0.08; 0.03-0.25; < 0.0001); and decreased the operative debridement rate for Wagner grade II (RR = 0.09; 0.01-0.60; = 0.01).
CONCLUSIONS
Moderate-quality evidence revealed that adjunctive hyperbaric oxygen therapy improved DFU wound healing for Wagner grades II, III, and IV; prevented minor and major amputations for grades III and IV, respectively; and prevented operative debridement in grade II wounds.
PubMed: 38528847
DOI: 10.1097/GOX.0000000000005692 -
Journal of Burn Care & Research :... Mar 2024There is no consensus for the optimal management of diabetic foot burn injuries. Here, we systematically identify studies reporting on diabetic foot burns and evaluate...
There is no consensus for the optimal management of diabetic foot burn injuries. Here, we systematically identify studies reporting on diabetic foot burns and evaluate outcomes among patients managed operatively versus non-operatively. PubMed, Embase, and Web of Science were searched. Screening was performed by independent reviewers. Primary research studies with English full texts published between 1980 to 2023 that discussed outcomes of foot burns in adults with diabetes were included and critically appraised using validated tools. Results are presented using descriptive statistics of aggregated data. The search yielded 2,402 non-duplicate papers, of which 35 met inclusion criteria. Nine papers were included for meta-analysis, including seven retrospective comparative analyses, one cross-sectional study, and one retrospective chart review. There were 1798 diabetic foot burn patients. Mean age was 58.2 years (SD 4.12) and 73.1% (n = 1,314) were male. A total of 15.7% (n = 283) of patients were surgically managed, including debridement (3.7%, n = 66), grafting (8.2%, n = 147), flap (0.2%, n = 3), and primary amputation (7.1%, n = 127). Secondary amputation rate, defined as amputation following initial surgery, was 4.9%, (n = 14). The overall amputation rate was 7.8% (n = 141). Other complications included infection (4.0%, n = 72), osteomyelitis (1.9%, n = 34), and graft failure (8.2%, n = 12). One study reported functional status at last visit. Diabetic foot burns are highly morbid. The surgical management of these complex injuries is high risk, as amputation results in poorer quality of life and functional outcomes.
PubMed: 38520367
DOI: 10.1093/jbcr/irae051 -
Photobiomodulation, Photomedicine, and... Mar 2024Peri-implantitis, an inflammatory condition in implant tissues, requires bacterial eradication and implant surface decontamination, with aPDT as a helpful surgical... (Meta-Analysis)
Meta-Analysis Review
Peri-implantitis, an inflammatory condition in implant tissues, requires bacterial eradication and implant surface decontamination, with aPDT as a helpful surgical adjunct. This project was designed to investigate the effect of antibiotic therapy versus aPDT, as adjuncts to conventional mechanical debridement (MD), on the peri-implant clinical and/or radiographic parameters among patients with peri-implant diseases. A comprehensive search was conducted across electronic databases, including PubMed, Scopus, and Web of Science, up to and including April 2023, without any restriction on the language and year of publication, focusing the following research question: "Does adjunctive aPDT improve the peri-implant clinical and/or radiographic parameters in treating peri-implant diseases compared to antibiotic therapy?" Statistical analysis was performed on peri-implant clinical [plaque index (PI), probing depth (PD), and bleeding on probing (BOP)] and radiographic parameters [marginal bone loss (MBL)]. The study included six randomized controlled trials and one clinical (nonrandomized) study. The systematic review findings indicate that the application of aPDT as an adjunct to MD is equally effective as adjunctive antibiotic therapy in improving peri-implant clinical parameters and radiographic parameters in patients with peri-implant diseases. Only two studies were classified as having a low risk of bias (RoB), two were assessed as having an unclear RoB, and the remaining three studies were determined to have a high RoB. However, the meta-analysis results revealed no statistically significant difference in peri-implant PI, PD, and MBL scores between patients treated with adjunct aPDT or adjunct antibiotic therapy. Notably, there was a statistically significant difference favoring adjunct aPDT in peri-implant BOP values compared to the control group. Despite the limited number of included studies and the significant heterogeneity among them, the findings suggest that aPDT yields comparable peri-implant clinical and radiographic outcomes to adjunctive antibiotic therapy, as adjuncts to MD, for the potential treatment of peri-implant diseases.
Topics: Humans; Peri-Implantitis; Phototherapy; Randomized Controlled Trials as Topic
PubMed: 38512322
DOI: 10.1089/photob.2023.0157 -
Advances in Wound Care Apr 2024As an essential procedure, wound care comes with acute pain, which is short but high in intensity, causing patients to fear and affecting subsequent treatment. Nitrous...
As an essential procedure, wound care comes with acute pain, which is short but high in intensity, causing patients to fear and affecting subsequent treatment. Nitrous oxide (NO) is used to relieve pain related to wound care; however, evidence regarding its application is conflicting. Thus, this systematic review and meta-analysis was performed to evaluate the efficacy of NO in wound care-related pain. Randomized controlled trials that investigated the effect of NO in adults undergoing wound care were systematically searched from PubMed, Embase, the Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov up to February 2023. The primary outcome was the pain score. Secondary outcomes included patients' satisfaction and side effects. Through screening the 265 identified articles, seven and six studies were finally included in the systematic review and meta-analysis, respectively. Pooled analysis suggested that there was no significant difference in reducing wound care-related pain between the NO group and the control group (mean difference [MD], -0.02, 95% confidence interval [CI], -1.46, 1.42; = 0.98, = 96%). Subgroup analyses indicated that there was a significant difference in favor of NO for burns, not for ulcers, and NO was superior to oxygen and similar to topical or intravenous anesthesia. There was no significant difference in patients' satisfaction or the incidence of side effects between groups. This review suggests that NO might be effective for pain management in patients undergoing wound care. Caution must be taken when interpreting these results due to the high risk of biased methods in the included studies.
PubMed: 38511513
DOI: 10.1089/wound.2023.0211 -
Arthroscopy : the Journal of... Mar 2024To report the clinical outcomes of arthroscopic debridement for the treatment of Kellgren-Lawrence (KL) grade I and II (mild) and III (moderate) knee osteoarthritis (OA)... (Review)
Review
PURPOSE
To report the clinical outcomes of arthroscopic debridement for the treatment of Kellgren-Lawrence (KL) grade I and II (mild) and III (moderate) knee osteoarthritis (OA) at a minimum 1-year follow-up.
METHODS
A systematic review of primary literature was performed in concordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines using the Medline, Embase, and Cochrane databases for studies regarding arthroscopic debridement/chondroplasty for management of knee OA at a minimum 1-year follow-up. Studies were included if they included KL grades I to III or dichotomized clinical outcomes by KL grade. The primary outcome was patient-reported outcome measures (PROMs) at the final follow-up. Bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS) score.
RESULTS
Eight studies including a total of 773 patients met inclusion criteria (range of patients in each study, 31-214). Mean age of patients ranged from 35.5 to 64 years, with most studies having a mean patient age of 55 to 65 years. Mean follow-up ranged from 1.5 to 10 years. Seven of the 8 (87.5%) studies reported good to excellent PROMs at a minimum 1- to 4-year follow-up after arthroscopic debridement. Improvements in PROMs were superior in patients with less severe knee OA (KL I-II) in comparison to KL III in most studies. Conversion to arthroplasty ranged from 7.6% to 50% in KL III patients compared with 0% to 4.5% in KL I-II patients after arthroscopic debridement. Two of the 3 studies with at least a 4-year clinical follow-up reported that clinical improvements diminished with time (improvements no longer significant in total Western Ontario and McMaster Universities Osteoarthritis Index score). The lone randomized controlled trial was the only investigation that did not find a benefit of arthroscopic debridement over quality nonoperative care. MINORS scores ranged from 6 to 10 (mean, 8.0) for the 5 nonrandomized studies without controls.
CONCLUSIONS
Arthroscopic debridement for the management of mild to moderate knee OA is effective at short-term follow-up in patients who have exhausted conservative care. There is limited evidence demonstrating the durability of improvement following arthroscopic debridement after 2 years.
LEVEL OF EVIDENCE
Level IV, systematic review of Level I to IV studies.
PubMed: 38508289
DOI: 10.1016/j.arthro.2024.03.016 -
Diving and Hyperbaric Medicine Mar 2024There are inconsistencies in outcome reporting for patients with necrotising soft tissue infections (NSTI). The aim of this study was to evaluate reported outcome... (Review)
Review
INTRODUCTION
There are inconsistencies in outcome reporting for patients with necrotising soft tissue infections (NSTI). The aim of this study was to evaluate reported outcome measures in NSTI literature that could inform a core outcome set (COS) such as could be used in a study of hyperbaric oxygen in this indication.
METHODS
A systematic review of all NSTI literature identified from Cochrane, Ovid MEDLINE and Scopus databases as well as grey literature sources OpenGrey and the New York Academy of Medicine databases which met inclusion criteria and were published between 2010 and 2020 was performed. Studies were included if they reported on > 5 cases and presented clinical endpoints, patient related outcomes, or resource utilisation in NSTI patients. Studies did not have to include intervention. Two independent researchers then extracted reported outcome measures. Similar outcomes were grouped and classified into domains to produce a structured inventory. An attempt was made to identify trends in outcome measures over time and by study design.
RESULTS
Three hundred and seventy-five studies were identified and included a total of 311 outcome measures. Forty eight percent (150/311) of outcome measures were reported by two or more studies. The four most frequently reported outcome measures were mortality without time specified, length of hospital stay, amputation performed, and number of debridements, reported in 298 (79.5%), 260 (69.3%), 156 (41.6%) and 151 (40.3%) studies respectively. Mortality outcomes were reported in 23 different ways. Randomised controlled trials (RCTs) were more likely to report 28-day mortality or 90-day mortality. The second most frequent amputation related outcome was level of amputation, reported in 7.5% (28/375) of studies. The most commonly reported patient-centred outcome was the SF-36 which was reported in 1.6% (6/375) of all studies and in 2/10 RCTs.
CONCLUSIONS
There was wide variance in outcome measures in NSTI studies, further highlighting the need for a COS.
Topics: Humans; Soft Tissue Infections; Outcome Assessment, Health Care; Oxygen; Patient Reported Outcome Measures
PubMed: 38507909
DOI: 10.28920/dhm54.1.47-56 -
Pain Physician Mar 2024Unilateral percutaneous endoscopic debridement and drainage (UPEDD) and bilateral PEDD (BPEDD) are commonly implemented, and have consistently yielded favorable clinical... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Unilateral percutaneous endoscopic debridement and drainage (UPEDD) and bilateral PEDD (BPEDD) are commonly implemented, and have consistently yielded favorable clinical outcomes. Nevertheless, there is a scarcity of literature contrasting the advantages and disadvantages between these 2 procedures.
OBJECTIVE
The goal of this research was to conduct a meta-analysis to compare the clinical effects of UPEDD and BPEDD.
STUDY DESIGN
A systematic review and meta-analysis.
METHODS
A systematic review of studies reporting outcomes following UPEDD and/or BPEDD procedures was performed. The extracted data were used for meta-analysis. Pooled event rates for positive bacteria culture, pain control satisfaction, reoperation, and complications were estimated. The pooled operation time and blood loss were also calculated.
RESULTS
Among 764 retrieved articles, 28 studies with 661 patients met the inclusion criteria and were used for our meta-analysis. A total of 21 studies (462 patients) investigated UPEDD outcomes and 7 studies (199 patients) investigated BPEDD outcomes. For the UPEDD group, the pooled event rates for positive bacteria culture, pain control satisfaction, reoperation, and complications were 72%, 91%, 9% and 4%, respectively; the pooled operation time and blood loss were 89.90 minutes and 59.77 mL. For the BPEDD group, these were 79%, 92%, 4%, 8%, 93.23 minutes and 64.93 mL, respectively.
LIMITATIONS
First, all included studies were retrospective series, limiting our study design to a single-arm meta-analysis. Second, there was a limited amount of studies that were determined to be fitting, particularly on BPEDD; the sample size was also small. Third, the clinical effects of UPEDD and BPEDD needed to be compared in greater detail, such as the time it took for inflammatory markers to return to normal, the incidence of local kyphosis, and whether the duration of antibiotic use could be shortened after adequate debridement with BPEDD. Lastly, further studies are necessary to compare the clinical outcome of PEDD and percutaneous endoscopic interbody debridement and fusion.
CONCLUSIONS
Both UPEDD and BPEDD can provide a relatively reliable causative-pathogen identification and satisfactory clinical outcome. The 2 techniques are not significantly different in terms of positive bacteria culture rate, pain control satisfaction rate, complication rate, and reoperation rate.
Topics: Humans; Debridement; Retrospective Studies; Endoscopy; Drainage; Pain
PubMed: 38506676
DOI: No ID Found