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Journal of Patient-reported Outcomes Apr 2022The Patient-Reported Outcomes Information System (PROMIS®) is more and more extensively being used in medical literature in patients with an orthopedic fracture. Yet,... (Review)
Review
BACKGROUND
The Patient-Reported Outcomes Information System (PROMIS®) is more and more extensively being used in medical literature in patients with an orthopedic fracture. Yet, many articles studied heterogeneous groups with chronic orthopedic disorders in which fracture patients were included as well. At this moment, there is no systematic overview of the exact use of PROMIS measures in the orthopedic fracture population. Therefore this review aimed to provide an overview of the PROMIS health domains physical health, mental health and social health in patients suffering an orthopedic fracture.
METHODS
This systematic review was documented according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. We searched Embase, Medline, Web of Science Core Collection, and Cochrane Central Register of controlled Trials, CINAHL and Google Scholar in December 2020 using a combination of MeSH terms and specific index terms related to orthopedic fractures and PROMIS questionnaires. Inclusion criteria were available full text articles that were describing the use of any PROMIS questionnaires in both the adult and pediatric extremity fracture population.
RESULTS
We included 51 relevant articles of which most were observational studies (n = 47, 92.2%). A single fracture population was included in 47 studies of which 9 involved ankle fractures (9/51; 17.6%), followed by humeral fractures (8/51; 15.7%), tibia fractures (6/51; 11.8%) and radial -or ulnar fractures (5/51; 9.8%). PROMIS Physical Function (n = 32, 32/51 = 62.7%) and PROMIS Pain Interference (n = 21, 21/51 = 41.2%) were most frequently used questionnaires. PROMIS measures concerning social (n = 5/51 = 9.8%) and mental health (10/51 = 19.6%) were much less often used as outcome measures in the fracture population. A gradually increasing use of PROMIS questionnaires in the orthopedic fracture population was seen since 2017.
CONCLUSION
Many different PROMIS measures on multiple domains are available and used in previous articles with orthopedic fracture patients. With physical function and pain interference as most popular PROMIS measures, it is important to emphasize that other health-domains such as mental and social health can also be essential to fracture patients.
PubMed: 35384568
DOI: 10.1186/s41687-022-00440-3 -
BMC Musculoskeletal Disorders Apr 2022Osteochondral lesions of the talus (OLT) are common after ankle trauma. Studies have shown that bioactive substances, such as hyaluronic acid (HA), alone, or in... (Review)
Review
BACKGROUND
Osteochondral lesions of the talus (OLT) are common after ankle trauma. Studies have shown that bioactive substances, such as hyaluronic acid (HA), alone, or in combination, with surgical treatment could improve cartilage regeneration and repair, but the effect of HA on patient reported outcomes is unclear.
METHODS
Literature searches were performed across four databases (PubMed, SPORTDiscus, Scopus, and The Cochrane Library) for randomized controlled trials in which at least one treatment arm involved use of HA as an adjunct to microfracture to treat patients with OLT. Primary outcomes included the American Orthopaedic Foot and Ankle Society scores (AOFAS), and the Visual Analog Scale (VAS) for pain. The level of evidence and methodological quality were evaluated using the Modified Coleman Methodology Score (MCMS).
RESULTS
Three randomized studies were eligible for review with a total of 132 patients (35, 40, 57 patients, respectively) and follow-up ranged from 10.5 to 25 months. Utilization of HA at the time of microfracture resulted in greater improvement in AOFAS scores compared to microfracture alone. The pooled effect size was moderate (Standardized Mean Difference [SMD] 0.45, 95% Confidence Interval [CI] 0.06, 0.84; P = .02) and between-study heterogeneity was low (I-squared = 0%). Utilization of HA during microfracture also led to greater improvement in VAS-pain scores compared to microfracture alone. The pooled effect size was very large (SMD -3.86, 95% CI -4.75, - 2.97; P < .001) and heterogeneity was moderate (I-squared = 69%).
CONCLUSION
Hyaluronic acid injection as an adjunct to arthroscopic MF in OLT provides clinically important improvements in function and pain at short-term follow-up compared to MF alone. Future longer-term follow-up studies are warranted to investigate the durability of MF with HA for treatment of OLT.
Topics: Arthroscopy; Fractures, Stress; Humans; Hyaluronic Acid; Randomized Controlled Trials as Topic; Talus
PubMed: 35366851
DOI: 10.1186/s12891-022-05236-6 -
Clinical Orthopaedics and Related... Aug 2022Ankle injuries are common presentations to the emergency department and may lead to syndesmotic instability. These have a high socioeconomic burden due to prolonged... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Ankle injuries are common presentations to the emergency department and may lead to syndesmotic instability. These have a high socioeconomic burden due to prolonged rehabilitation, chronic pain, and posttraumatic arthritis. Early diagnosis is essential to minimize these complications, and the assessment of instability in the clinical setting is often limited by pain and clinician experience. Cross-sectional imaging of the distal syndesmosis accurately evaluates the syndesmosis through abnormal bony relationships, which in the presence of instability, worsens during physiological loading. Cone-beam CT (CBCT) has gained popularity in the diagnosis of these injuries because it enables syndesmotic assessment under weightbearing conditions, it mitigates the high radiation dose, and it is time-efficient.
QUESTIONS/PURPOSES
The purposes of this systematic review were: (1) to establish normal values for weightbearing CBCT of the syndesmosis in uninjured ankles and ascertain interobserver reliability and (2) to identify the impact of weightbearing on the syndesmosis in patients with occult ankle injuries and assess the effect of patient demographics on these metrics.
METHODS
This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in PROSPERO (ID CRD42021248623). MEDLINE, PubMed, Embase, and Emcare databases were searched for studies assessing for syndesmotic instability, of which 307 studies were screened and 11 studies with 559 ankles in 408 uninjured patients and 151 patients with syndesmotic instability were included. All patients 18 years of age or older presenting with unilateral ankle injuries who underwent weightbearing CBCT for the diagnosis of an occult fracture or syndesmotic instability compared with the uninjured contralateral side were included. A control group of uninjured ankles was identified during weightbearing CBCT performed for other indications such as forefoot or midfoot injuries. Methodological assessment of the studies was performed using the Risk of Bias In Non-randomized Studies (ROBINS-1) tool and most included studies had a low risk of bias. Thus, a random-effects restricted maximum likelihood ratio model was used.
RESULTS
In the uninjured ankle, the mean area of the tibiofibular syndesmosis was 112.5 ± 7.1 mm 2 , which increased to 157.5 ± 9.6 mm 2 after injury when compared with uninjured ankles with a standardized mean difference of 29.5 (95% confidence interval 19.5 to 39.5; p < 0.01), and an excellent interobserver agreement (κ = 1.0 [95% CI 0.9 to 1.0]). However, syndesmosis volume decreased with age (β = -0.76; p = 0.04), and therefore, has a negative association with increasing age.
CONCLUSION
Our study has shown that the syndesmotic area is the most reliable parameter in the assessment of syndesmotic injuries because it increases in the presence of instability during weightbearing status. It is a composite measurement that could potentially allow clinicians to use weightbearing CBCT as an adjunct when there is a clinical suspicion of syndesmotic instability. Thus, weightbearing CBCT has the potential of being diagnostic of syndesmotic instability and should be evaluated against current radiological modalities to evaluate its accuracy.
LEVEL OF EVIDENCE
Level IV, prognostic study.
Topics: Adolescent; Adult; Ankle; Ankle Injuries; Ankle Joint; Cone-Beam Computed Tomography; Humans; Joint Instability; Reproducibility of Results; Tomography, X-Ray Computed; Weight-Bearing
PubMed: 35275097
DOI: 10.1097/CORR.0000000000002171 -
Clinical Orthopaedics and Related... Jun 2022Osteochondral lesions of the talus are common, particularly after trauma. Arthroscopic bone marrow stimulation has emerged as the first-choice surgical treatment for...
BACKGROUND
Osteochondral lesions of the talus are common, particularly after trauma. Arthroscopic bone marrow stimulation has emerged as the first-choice surgical treatment for small primary lesions less than 100 mm2. Individual studies on the topic are small and heterogeneous, and they have differed in their main findings; for this reason, systematically reviewing the available evidence seems important.
QUESTIONS/PURPOSES
In this systematic review, we asked: (1) What patient-reported outcomes and pain scores have been observed after arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus? (2) What complications were reported? (3) What demographic and clinical factors were reported to be associated with better patient-reported outcome scores?
METHODS
We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using Embase, EmCare, PubMed, CINAHL, and Scopus (databases last searched June 23, 2021). A two-stage title/abstract and full-text screening process was performed independently by two reviewers. Randomized control trials, cohort studies, and observational studies published in English that evaluated the outcome of arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus were included. Case reports, review articles, commentaries, abstracts, and letters to the editor were excluded. A total of 12 articles (10 case series and two retrospective comparative studies) involving 446 patients were included. Of these, 111 patients with a mean age of 33 years (range 20 to 49) received arthroscopic bone marrow stimulation for a secondary osteochondral lesion of the talus. The Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess the methodologic quality of included studies. The MINORS is a numerical score ranging from 0 to 16 for studies with no comparison group and 0 to 24 for comparative studies, with higher quality studies receiving higher scores. Of the 10 noncomparative case series, the highest score was 10 of 16, with a median (range) score of 7.5 (4 to 10), while the two comparative studies scored 22 of 24 and 19 of 24, respectively.
RESULTS
Studies varied widely in terms of patient-reported outcome measures such as the American Orthopaedic Foot and Ankle Society score (AOFAS), with inconsistent reporting across studies regarding whether or how much patients improved; there was variation in some effect sizes with regard to improvement seeming close to or below the minimum clinically important difference (MCID). Although no perioperative complications were reported in any included studies, 34% (26 of 77, in seven studies that reported on this endpoint) of patients who underwent a revision procedure. One study found a negative association between lesion size and AOFAS and VAS score. No other studies reported on factors associated with patient-reported outcome scores, and most studies were far too small to explore relationships of this sort.
CONCLUSION
We found that arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus yielded inconsistent and often small improvements in patient-reported outcomes, with approximately one in three patients undergoing a revision procedure. Reported outcomes likely represent a best-case scenario, inflated by low-level study designs and major sources of bias that are known to make treatment effects seem larger than they are. Therefore, the use of arthroscopic bone marrow stimulation in such patients cannot be recommended, unless we are able to refine selection criteria to effectively identify patients who show a substantial clinical benefit.
LEVEL OF EVIDENCE
Level IV, therapeutic study.
Topics: Adult; Arthroscopy; Bone Marrow; Cartilage, Articular; Humans; Intra-Articular Fractures; Middle Aged; Retrospective Studies; Talus; Treatment Outcome; Young Adult
PubMed: 35130190
DOI: 10.1097/CORR.0000000000002134 -
Foot & Ankle Orthopaedics Jan 2021Patients undergoing fixation for foot and ankle fractures may experience poor outcomes despite achieving apparent anatomic reduction. Adjunct arthroscopy to identify... (Review)
Review
BACKGROUND
Patients undergoing fixation for foot and ankle fractures may experience poor outcomes despite achieving apparent anatomic reduction. Adjunct arthroscopy to identify missed concomitant injuries and subtle displacements has been proposed as a vehicle to enhance functional results for these patients. The purpose of this review is to provide an overview of the literature regarding arthroscopically assisted open reduction and internal fixation (AAORIF) methods for commonly encountered foot and ankle injuries including pilon, ankle, and calcaneus fractures published to date.
METHODS
A systematic review of the literature was performed using the PubMed database to access all studies reporting on arthroscopically assisted internal fixation methods for pilon, ankle, and calcaneus fractures. Relevant publications were analyzed for details on their respective study designs, the operative technique used, clinical outcomes, outcome instruments used, and reported complications.
RESULTS
A total of 32 studies were included in this review. Two studies on pilon fractures, a randomized controlled trial (RCT) and case series with a total of 243 patients, met inclusion criteria. Postoperative articular reductions, bone union, and Mazur scores were found to be significantly better for those using adjunct arthroscopy when compared to those with no arthroscopy use. Patient-reported outcomes were overall reported as excellent for most patients, with no difference in patient-reported outcomes reported in the RCT. For ankle fractures, a total of 17 studies comprising of 2 systematic reviews, 1 meta-analysis, 2 RCTs, 5 retrospective comparative studies, 6 case series, and 1 case-control study met inclusion criteria for this review. Results were mixed, though the overall consensus was that arthroscopy use may help to better visualize concomitant intra-articular injuries and is generally considered safe with at least comparable outcomes to conventional methods. For the calcaneus, 13 studies met the criteria. Two studies were review papers, 8 were case series, and 3 were retrospective comparative studies. A total of 308 patients with 316 fractures formed the basis of analysis. In general, the studies found comparable functional outcomes between with or without arthroscopy use, but found that anatomical reductions were significantly improved with the use of arthroscopy.
CONCLUSIONS
Arthroscopy shows promise as a valuable adjunct tool for internal fixation of foot and ankle fractures, though definitive conclusions as to its clinical significance have yet to be drawn because of limited evidence. Potential advantages related to the direct visualization of the fracture site and minimally invasive nature of arthroscopy were suggested throughout studies examined in this review. The presence of intra-articular pathology may lead to unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with an otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions with arthroscopy, therefore, has the potential to improve patient outcomes. To date, however, available literature has not shown that significant improvements in anatomical reductions and treatment of these intra-articular injuries provide any improvement in outcomes over standard fixation methods. Few prospective randomized controlled studies have been performed comparing these 2 operative techniques, rendering any suggestion that AAORIF improves clinical outcomes over traditional open fixation difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct prior to advocating for its routine use in patients.
PubMed: 35097419
DOI: 10.1177/2473011420950214 -
Diagnostics (Basel, Switzerland) Jan 2022(1) Background: Ankle fracture results in pain, swelling, stiffness and strength reduction, leading to an altered biomechanical behavior of the joint during the gait... (Review)
Review
(1) Background: Ankle fracture results in pain, swelling, stiffness and strength reduction, leading to an altered biomechanical behavior of the joint during the gait cycle. Nevertheless, a common pattern of kinematic alterations has still not been defined. To this end, we analyzed the literature on instrumental gait assessment after ankle fracture, and its correlation with evaluator-based and patient-reported outcome measures. (2) Methods: We conducted a systematic search, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, of articles published from January 2000 to June 2021 in PubMed, Embase and PEDro on instrumental gait assessment after ankle fracture. (3) Results: Several changes in gait occur after ankle fracture, including a reduction in step length, swing time, single support time, stride length, cadence, speed and an earlier foot-off time in the affected side. Additionally, trunk movement symmetry (especially vertical) is significantly reduced after ankle fracture. The instrumental assessments correlate with different clinical outcome measures. (4) Conclusions: Instrumental gait assessment can provide an objective characterization of the gait alterations after ankle fracture. Such assessment is important not only in clinical practice to assess patients' performance but also in clinical research as a reference point to evaluate existing or new rehabilitative interventions.
PubMed: 35054366
DOI: 10.3390/diagnostics12010199 -
Canadian Journal of Surgery. Journal... 2022Deltoid ligament repair (DLR) was historically a common adjunct to ankle fracture fixation; however, prevailing clinical practice is to explore the medial side of the...
BACKGROUND
Deltoid ligament repair (DLR) was historically a common adjunct to ankle fracture fixation; however, prevailing clinical practice is to explore the medial side of the ankle only if reduction is blocked. We performed a systematic review to determine the breadth and quality of the literature evaluating DLR in the context of ankle fractures.
METHODS
We searched the MEDLINE and Embase databases in May 2020 for English-language articles evaluating DLR versus no repair or syndesmotic fixation in patients with acute ankle fractures. We used descriptive statistics to compare studies and draw conclusions.
RESULTS
Of 362 articles identified, 8 (3 randomized controlled trials [RCTs] and 5 retrospective cohort studies) were included in our final analysis. Five studies compared DLR to conservative management, and 3 compared DLR to transsyndesmotic fixation. Functional outcomes were equivalent between groups. Five of the 6 studies that included radiographic outcomes showed a statistically significant decrease in the medial clear space and decreased malreduction rates postoperatively in the DLR groups.
CONCLUSION
High-quality evidence guiding treatment of deltoid ligament injury in acute ankle fractures is lacking; currently available evidence appears to support DLR. Given recent increased interest in DLR and syndesmotic fixation, a comprehensive multicentre RCT is warranted. Although radiographic evidence indicates the potential benefit of DLR, further research is required to establish the superiority of DLR versus clinical equipoise.
Topics: Ankle Fractures; Humans; Joint Diseases; Ligaments, Articular; Orthopedic Procedures; Outcome and Process Assessment, Health Care
PubMed: 35017184
DOI: 10.1503/cjs.020320 -
Journal of Clinical Medicine Dec 2021Charcot neuroarthropathy is a non-infective, destructive process occurring in patients rendered insensate by peripheral neuropathy, which is caused mainly by diabetes.... (Review)
Review
BACKGROUND
Charcot neuroarthropathy is a non-infective, destructive process occurring in patients rendered insensate by peripheral neuropathy, which is caused mainly by diabetes. Repetitive trauma from standing and walking provides a neuro-traumatic stimulus that leads to dislocation, or peri-articular fracture, or both, within the ankle. This review concentrates on the management protocols regarding the ankle only.
METHODS
A Pubmed search for clinical trials performed to manage ankle Charcot neuroarthropathy and a systematic review of these articles were undertaken.
RESULTS
Twenty papers met the inclusion criteria: four of them describe non-surgical management, while the rest show different surgical management options of ankle Charcot neuroarthropathy.
CONCLUSIONS
Surgical algorithms for the treatment of CN of the ankle are based almost entirely on level four. There is inconclusive evidence concerning the timing of treatment and the use of different fixation methods. Instability and ulceration are the main precursors for surgical interventions. Prospective series and randomized studies, albeit difficult to perform, are necessary to support and strengthen current practice.
PubMed: 34945220
DOI: 10.3390/jcm10245923 -
Deutsches Arzteblatt International Sep 2021Metatarsal fractures are among the most common foot and ankle injuries, with an annual incidence of 6.7 per 100 000 persons. Approximately 30% of metatarsal fractures...
BACKGROUND
Metatarsal fractures are among the most common foot and ankle injuries, with an annual incidence of 6.7 per 100 000 persons. Approximately 30% of metatarsal fractures affect the base of the fifth metatarsal bone. Nevertheless, no evidence-based treatment recommendations are available to date.
METHODS
The three fracture localizations according to Lawrence and Botte (zone I, proximal to the intermetatarsal joint between the fourth and fifth metatarsal bones; zone II, in the area of the joint; zone III, at the distal end of the joint) are analyzed on the basis of a systematic literature search. Studies were included that compared the treatment of two types of fracture in the same manner, or that compared two different treatments for a single type of fracture.
RESULTS
Nine studies compared different treatments of zone I fractures. Two of these were randomized controlled trials (RCTs); in one RCT, patients given functional therapy returned to work much sooner than those treated with immobilization (11 vs. 28 days; p = 0.001), with otherwise similar outcomes. The non-randomized studies revealed a faster return to full function (33 vs. 46 days; p<0.05) with early functional therapy, and similar outcomes for immobilization and surgery. One RCT that compared functional therapy with immobilization for zone II fractures revealed no statistically significant difference. Five studies compared fractures in zones I and II that were treated in the same manner, revealing similar outcomes. One RCT compared surgery and immobilization for zone III fractures: surgery led to statistically significant improvement of the outcome in all of the measured parameters.
CONCLUSION
Fractures in zones I and II should be treated with early functional therapy. There seems to be no reason to consider zone I and II fractures as two separate entities, as the outcomes in the two groups are similar. In contrast, fractures in zone III should primarily be treated surgically.
Topics: Ankle Injuries; Foot Injuries; Fracture Fixation, Internal; Fractures, Bone; Humans; Metatarsal Bones; Randomized Controlled Trials as Topic
PubMed: 34789369
DOI: 10.3238/arztebl.m2021.0231 -
PloS One 2021Rupture of the deltoid ligament (DL) in acute ankle fracture is very common. However, there is still insufficient evidence on whether to repair the DL in acute ankle... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Rupture of the deltoid ligament (DL) in acute ankle fracture is very common. However, there is still insufficient evidence on whether to repair the DL in acute ankle fracture. Therefore, a systematic review and meta-analysis of comparative studies was performed to report the outcome of DL repair in acute ankle fracture.
METHODS
The PubMed, Cochrane Library, EMBASE and Web of Science databases were searched from the inception dates to October 31, 2020, for comparative studies. The methodological quality was evaluated based on the risk-of-bias tool of the Cochrane Collaboration for Randomized Controlled Trials (RCTs) or the Risk-of-Bias Assessment Tool for Non-randomized Studies (RoBANS). The post-operative medial clear space (MCS), final MCS, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS) score and incidence of complications were analysed.
RESULTS
A total of 8 comparative studies involving 388 participants who suffered Weber type B or C ankle fractures were included in this meta-analysis. The results showed that the post-operative MCS, final MCS, AOFAS score and rate of complications were statistically superior in the DL repair group. For the VAS score, there was no significant difference between the DL repair group and the DL non-repair group.
CONCLUSIONS
In this meta-analysis of comparative studies, DL repair offered great advantages in terms of the post-operative MCS, final MCS, AOFAS score and rate of complications compared with non-repair. The repair of the DL in patients with acute ankle fractures might be beneficial to ankle joint stability and assist in improving the quality of ankle reduction. More high-quality and prospective studies with long follow-up durations are needed to further demonstrate the superiority of DL repair over non-repair.
Topics: Adult; Ankle Fractures; Ankle Joint; Bone Screws; Follow-Up Studies; Fracture Fixation, Internal; Humans; Ligaments, Articular; Middle Aged; Rupture; Suture Anchors; Treatment Outcome; Visual Analog Scale
PubMed: 34767584
DOI: 10.1371/journal.pone.0258785