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Archives of Orthopaedic and Trauma... Nov 2020In adults, treatment of recalcitrant long bone non-union is extremely challenging, with poorly vascularised and atrophic defects unresponsive to standard...
INTRODUCTION
In adults, treatment of recalcitrant long bone non-union is extremely challenging, with poorly vascularised and atrophic defects unresponsive to standard non-vascularised bone graft treatment. Recent studies have documented the use of free vascularised periosteal flaps to achieve union in refractory long bone fracture non-union, yet its use is not well established. This systematic review aims to assess the evidence for free vascularised periosteal flaps in recalcitrant long bone non-union.
MATERIALS AND METHODS
The MEDLINE®/PubMed and Embase databases were searched for the Medical Subject Heading (MeSH) terms periosteal flap/vascularised flap/long bone/non-union/non united fracture in accordance with the PRISMA guidelines. Bibliographies were scrutinised for additional articles.
RESULTS
Pooled data from 14 studies met the inclusions criteria, comprising 137 cases of non-union, with 117 relating to long bone non-union. Pooled data indicated an overall 99% (116/117) successful union rate. All studies were of mid- to low-level evidence (Level III, IV and V). Only one study directly compared vascularised periosteal flaps to non-vascularised bone grafts, showing union rates of 100% versus 80% and faster time to union (2 versus 5.5 months).
CONCLUSIONS
Free vascularised periosteal flaps are promising with pooled data showing a 99% success rate in achieving union in refractory long bone non-union. This compares favourably with standard orthopaedic care consisting of revision fixation and non-vascularised bone graft union rates of approximately 80%. However, study design flaws should be addressed by validated outcome measures plus adequate blinding, and further comparative studies with greater patient numbers are required.
Topics: Bone Transplantation; Femur; Free Tissue Flaps; Humans
PubMed: 31974694
DOI: 10.1007/s00402-020-03354-1 -
International Journal of Oral and... Jul 2020The aim of this review was to determine the effect of cortical perforations in bone regeneration considering the surgical technique. An electronic search in the PubMed...
The aim of this review was to determine the effect of cortical perforations in bone regeneration considering the surgical technique. An electronic search in the PubMed (MEDLINE) and ScienceDirect databases and a hand search of the literature was conducted covering the period July 2008 to December 2018. Studies that specified the creation of perforations in the recipient area as a study variable associated with the regenerative technique were included. The quality of the randomized clinical trials included in this systematic review was also assessed. A total of 16 articles met both inclusion criteria and were eligible for analysis. Studies were grouped into three blocks according to the associated surgical technique. All studies were performed in an experimental model except for one. Qualitative assessment of the studies showed a moderate to high risk of bias of the overall studies. The evidence for creating perforations in guided bone regeneration and also in combination with autologous bone blocks in order to increase bone formation is limited according to the publications analysed. Although the number and size of perforations do not appear to interfere with the result, their effect in the upper maxilla and in the mandible should be evaluated separately due to the structural anatomical differences.
Topics: Bone Regeneration; Humans; Mandible; Maxilla
PubMed: 31718859
DOI: 10.1016/j.ijom.2019.10.011 -
BMC Public Health Nov 2019Pain is common in older adults. To maintain their quality of life and promote healthy ageing in the community, it is important to lower their pain levels....
BACKGROUND
Pain is common in older adults. To maintain their quality of life and promote healthy ageing in the community, it is important to lower their pain levels. Pharmacological pain management has been shown to be effective in older adults. However, as drugs can have various side effects, non-pharmacological pain management is preferred for community-dwelling older adults. This systematic review evaluates the effectiveness, suitability, and sustainability of non-pharmacological pain management interventions for community-dwelling older adults.
METHODS
Five databases, namely, CINHAL, Journals@Ovid, Medline, PsycInfo, and PubMed, were searched for articles. The criteria for inclusion were: full-text articles published in English from 2005 to February 2019 on randomized controlled trials, with chronic non-cancer pain as the primary outcome, in which pain was rated by intensity, using non-pharmacological interventions, and with participants over 65 years old, community-dwelling, and mentally competent. A quality appraisal using the Jadad Scale was conducted on the included articles.
RESULTS
Ten articles were included. The mean age of the older adults was from 66.75 to 76. The interventions covered were acupressure, acupuncture, guided imagery, qigong, periosteal stimulation, and Tai Chi. The pain intensities of the participants decreased after the implementation of the intervention. The net changes in pain intensity ranged from - 3.13 to - 0.65 on a zero to ten numeric rating scale, in which zero indicates no pain and ten represents the worst pain.
CONCLUSIONS
Non-pharmacological methods of managing pain were effective in lowering pain levels in community-dwelling older adults, and can be promoted widely in the community.
Topics: Aged; Analgesics, Opioid; Chronic Pain; Complementary Therapies; Female; Humans; Independent Living; Male; Pain Management; Quality of Life; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 31703654
DOI: 10.1186/s12889-019-7831-9 -
Revista Da Associacao Medica Brasileira... Jul 2019To evaluate the epidemiological data and available treatments for fractures secondary to radiotherapy treatment.
OBJECTIVE
To evaluate the epidemiological data and available treatments for fractures secondary to radiotherapy treatment.
METHODS
Identification of publications on pathological skeletal fractures previously exposed to ionizing radiation.
RESULTS
The incidence of fractures after irradiation varies from 1.2% to 25% with a consolidation rate of 33% to 75%, being more frequent in the ribs, pelvis, and femur. The time elapsed between irradiation and fracture occurs years after radiotherapy. Risk factors include age above 50 years, female gender, extensive periosteal detachment, circumferential irradiation, tumor size, and anterior thigh location. The etiology is still uncertain, but cellular disappearance, reduction of bone turnover and activity were observed hematopoietic as possible causes of failure of consolidation.
CONCLUSION
There is no consensus in the literature on the factors related to the development of fractures, with radiation dose, previous tumor size and periosteal detachment being suggested as potential factors.
Topics: Fractures, Bone; Humans; Radiation Injuries; Radiotherapy; Risk Factors
PubMed: 31340323
DOI: 10.1590/1806-9282.65.6.902 -
Journal of Oral and Maxillofacial... Oct 2019Controversy remains regarding the optimal degree of anatomic exposure, reduction, and fixation required during open reduction and internal fixation of... (Meta-Analysis)
Meta-Analysis
PURPOSE
Controversy remains regarding the optimal degree of anatomic exposure, reduction, and fixation required during open reduction and internal fixation of zygomaticomaxillary complex (ZMC) fractures. We critically examined the reported data to compare the patient outcomes after various degrees of ZMC reduction and internal fixation.
MATERIALS AND METHODS
A systematic review and meta-analysis were designed to test the null hypothesis of no difference in outcomes between different degrees of fixation of ZMC fractures. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation method.
RESULTS
Of 1213 screened studies, 13 met the inclusion criteria. Fracture instability at 3 months was greater with 2-point fixation (61.1%) than with 3-point fixation (10.6%; relative risk, 2.5, 95% confidence interval [CI], 1.4 to 3.3). Less vertical orbital dystopia was seen with 3-point fixation than with 2-point fixation (mean difference, 0.9 mm; 95% CI, 0.6 to 1.3 mm). The incidence of infection and malar asymmetry did not differ between the groups. The quality of evidence was very low to low.
CONCLUSIONS
The reported data were limited by low quality, retrospective studies. However, the meta-analysis of randomized control trial data suggested a superiority of 3 points of exposure and fixation regarding fracture stability. When 2 points appear to provide stable fixation, the potential benefits of a third point should be weighed against the cost, operative time, and exposure/periosteal stripping on a case-by-case basis.
Topics: Fracture Fixation; Fracture Fixation, Internal; Fractures, Bone; Humans; Open Fracture Reduction; Retrospective Studies; Zygomatic Fractures
PubMed: 31132344
DOI: 10.1016/j.joms.2019.04.025 -
The American Journal of Sports Medicine Jan 2020Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well...
BACKGROUND
Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well understood.
PURPOSE/HYPOTHESIS
The purpose was to determine cost-efficacy of cartilage therapies in the United States with available mid- or long-term outcomes data. The authors hypothesized that cartilage treatment strategies currently approved for commercial use in the United States will be cost-effective, as defined by a cost <$50,000 per quality-adjusted life-year over 10 years.
STUDY DESIGN
Systematic review.
METHODS
A systematic search was performed for prospective cartilage treatment outcome studies of therapies commercially available in the United States with minimum 5-year follow-up and report of pre- and posttreatment International Knee Documentation Committee subjective scores. Cost-efficacy over 10 years was determined with Markov modeling and consideration of early reoperation or revision surgery for treatment failure.
RESULTS
Twenty-two studies were included, with available outcomes data on microfracture, osteochondral autograft, osteochondral allograft (OCA), autologous chondrocyte implantation (ACI), and matrix-induced ACI. Mean improvement in International Knee Documentation Committee subjective scores at final follow-up ranged from 17.7 for microfracture of defects >3 cm to 36.0 for OCA of bipolar lesions. Failure rates ranged from <5% for osteochondral autograft for defects requiring 1 or 2 plugs to 46% for OCA of bipolar defects. All treatments were cost-effective over 10 years in the baseline model if costs were increased 50% or if failure rates were increased an additional 15%. However, if efficacy was decreased by a minimum clinically important amount, then ACI (periosteal cover) of femoral condylar lesions ($51,379 per quality-adjusted life-year), OCA of bipolar lesions ($66,255) or the patella ($66,975), and microfracture of defects >3 cm ($127,782) became cost-ineffective over 10 years.
CONCLUSION
Currently employed treatments for knee cartilage defects in the United States are cost-effective in most clinically acceptable applications. Microfracture is not a cost-effective initial treatment of defects >3 cm. OCA transplantation of the patella or bipolar lesions is potentially cost-ineffective and should be used judiciously.
Topics: Cartilage; Cartilage Diseases; Cost-Benefit Analysis; Humans; Knee Joint; Orthopedic Procedures; Patella; Reoperation; Treatment Outcome; United States
PubMed: 31038980
DOI: 10.1177/0363546519834557