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Annals of the Royal College of Surgeons... Jan 2015Total hip arthroplasty is one of the most commonly performed orthopaedic procedures. Despite this, medical evidence to inform the choice of surgical approach is lacking.... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Total hip arthroplasty is one of the most commonly performed orthopaedic procedures. Despite this, medical evidence to inform the choice of surgical approach is lacking. Currently in the UK, the two most frequently performed approaches to the hip are the posterior and the direct lateral.
METHODS
This systematic review was performed according to Cochrane guidelines following an extensive search for prospective controlled trials published in any language before January 2014. Of the 728 records identified from searches, 6 prospective studies (including 3 randomised controlled trials) involving 517 participants provided data towards this review.
FINDINGS
Compared with the lateral approach, the posterior approach conferred a significant reduction in the risk of Trendelenburg gait (odds ratio [OR]: 0.31, p=0.0002) and stem malposition (OR: 0.24, p=0.02), and a non-significant reduction in dislocation (OR: 0.37, p=0.16) and heterotopic ossification (OR: 0.41, p=0.13). Neither approach conferred a functional advantage. We draw attention to the paucity of evidence and the need for a further randomised trial.
Topics: Adult; Arthroplasty, Replacement, Hip; Hip Prosthesis; Humans; Postoperative Complications; Treatment Outcome
PubMed: 25519259
DOI: 10.1308/003588414X13946184904008 -
The Cochrane Database of Systematic... Sep 2014Anterior cruciate ligament (ACL) reconstruction is one of the most frequently performed orthopaedic procedures. The most common technical cause of reconstruction failure... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Anterior cruciate ligament (ACL) reconstruction is one of the most frequently performed orthopaedic procedures. The most common technical cause of reconstruction failure is graft malpositioning. Computer-assisted surgery (CAS) aims to improve the accuracy of graft placement. Although posterior cruciate ligament (PCL) injury and reconstruction are far less common, PCL reconstruction has comparable difficulties relating to graft placement. This is an update of a Cochrane review first published in 2011.
OBJECTIVES
To assess the effects of computer-assisted reconstruction surgery versus conventional operating techniques for ACL or PCL injuries in adults.
SEARCH METHODS
For this update, we searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (from 2010 to July 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2013), MEDLINE (from 2010 to July 2013), EMBASE (from 2010 to July 2013), CINAHL (from 2010 to July 2013), article references and prospective trial registers.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) and quasi-randomized controlled trials that compared CAS for ACL or PCL reconstruction versus conventional operating techniques not involving CAS.
DATA COLLECTION AND ANALYSIS
Two authors independently screened search results, assessed the risk of bias in the studies and extracted data. Where appropriate, we pooled data using risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI).
MAIN RESULTS
The updated search resulted in the inclusion of one new study. This review now includes five RCTs with 366 participants. There were more female than male participants (70% were female); their ages ranged from 14 to 53 years. All trials involved ACL reconstructions performed by experienced surgeons.Assessing the studies' risk of bias was hampered by poor reporting of trial methods, and consequently several studies were judged to be 'unclear' for several types of bias. One trial presenting primary outcome data was at high risk of detection bias from lack of clinician blinding and attrition bias from an unaccounted loss to follow-up at two years.We found moderate quality evidence (three trials, 193 participants) of no clinically relevant difference between CAS and conventional surgery in International Knee Documentation Committee (IKDC) subjective scores (self-reported measure of knee function; scale of 0 to 100 where 100 was best function). Pooled data from two of these trials (120 participants) showed a small, but clinically irrelevant difference favouring CAS (MD 2.05, 95% CI -2.16 to 6.25). A third trial (73 participants) also found minimal difference in IKDC subjective scores (reported MD 0.2).We found low quality evidence (two trials, 120 participants) showing no difference between the two groups in Lysholm scores, also measured on a scale 0 to 100 where 100 is best function (MD 0.25, 95% CI -3.75 to 4.25). We found very low quality evidence (one trial, 40 participants) showing no difference between the two groups in Tegner scores. We found low quality evidence (three trials, 173 participants) showing the majority of participants in both groups were assessed as having normal or nearly normal knee function (86/87 with CAS versus 84/86 with no CAS; RR 1.01, 95% CI 0.96 to 1.06).Similarly, no differences were found for our secondary outcome measures of knee stability, loss in range of motion and tunnel placement. None of the trials reported on re-operation.No adverse post-surgical events were reported in two trials (133 participants); this outcome was not reported by the other three trials.CAS use was associated with longer operating times compared with conventional operating techniques: the mean difference in operating times reported in the studies ranged between 9 and 27 minutes.
AUTHORS' CONCLUSIONS
From the available evidence, we are unable to demonstrate or refute a favourable effect of CAS for cruciate ligament reconstructions of the knee compared with conventional reconstructions. However, the currently available evidence does not indicate that CAS in knee ligament reconstruction improves outcome. There is a need for improved reporting of future studies of this technology.
Topics: Adolescent; Adult; Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Anterior Cruciate Ligament Reconstruction; Female; Humans; Male; Middle Aged; Orthopedic Procedures; Posterior Cruciate Ligament; Randomized Controlled Trials as Topic; Plastic Surgery Procedures; Surgery, Computer-Assisted; Treatment Outcome; Young Adult
PubMed: 25180899
DOI: 10.1002/14651858.CD007601.pub4 -
The Cochrane Database of Systematic... Jul 2014Securing the endotracheal tube is a common procedure in the neonatal intensive care unit. Adequate fixation of the tube is essential to ensure effective ventilation of... (Review)
Review
BACKGROUND
Securing the endotracheal tube is a common procedure in the neonatal intensive care unit. Adequate fixation of the tube is essential to ensure effective ventilation of the infant whilst minimising potential complications secondary to the intervention. Methods used to secure the endotracheal tube often vary between units and sometimes even between healthcare providers in the same nursery.
OBJECTIVES
To compare the different methods of securing the endotracheal tube in the ventilated neonate and their effects on the risk of accidental extubation and other potential complications that can result from an unstable endotracheal tube.
SEARCH METHODS
A literature search of MEDLINE (from 1966 to June 2013), CINAHL (from 1982 to June 2013) and CENTRAL in The Cochrane Library was conducted to identify relevant trials to be analysed.
SELECTION CRITERIA
All randomised and quasi-randomised controlled trials of infants who were intubated for mechanical ventilation in a neonatal intensive care nursery where methods of stabilising the endotracheal tube were being compared.
DATA COLLECTION AND ANALYSIS
Data were collected from individual studies to determine the methods being compared, the methodology of the trial, and whether there were areas of bias that could significantly affect the results of the studies. In particular, studies were assessed for blinding of randomisation and allocation, blinding of the intervention, completeness of follow up, blinding of outcome assessments and selective reporting.
MAIN RESULTS
Five randomised controlled trials were identified and included for review. Accidental extubation was the most common outcome measured (five studies). None of the studies reported on the need for re-intubation or the rate of tube malposition, however one study did report on endotracheal tube slippage. A variety of other adverse effects were reported including mortality, incidence of perioral skin trauma and tube re-taping. All five studies were of poor methodological quality, small size, contained significant risks of bias and compared methods of securing the endotracheal tube that were too dissimilar for the data to be collated or included in a meta-analysis. We have not reported these further.
AUTHORS' CONCLUSIONS
This review highlighted the need for further well designed and completed studies to be conducted for this common neonatal procedure. Evidence is lacking to determine the most effective and safe method to stabilise the endotracheal tube in the ventilated neonate.
Topics: Equipment Safety; Humans; Infant, Newborn; Infant, Premature; Intensive Care, Neonatal; Intubation, Intratracheal; Randomized Controlled Trials as Topic; Respiration, Artificial
PubMed: 25079665
DOI: 10.1002/14651858.CD007805.pub2 -
Clinical Orthopaedics and Related... Jun 2014There is an inherently difficult learning curve associated with minimally invasive surgical (MIS) approaches to spinal decompression and fusion. The association between... (Review)
Review
BACKGROUND
There is an inherently difficult learning curve associated with minimally invasive surgical (MIS) approaches to spinal decompression and fusion. The association between complication rate and the learning curve remains unclear.
QUESTIONS/PURPOSES
We performed a systematic review for articles that evaluated the learning curves of MIS procedures for the spine, defined as the change in frequency of complications and length of surgical time as case number increased, for five types of MIS for the spine.
METHODS
We conducted a systematic review in the PubMed database using the terms "minimally invasive spine surgery AND complications AND learning curve" followed by a manual citation review of included manuscripts. Clinical outcome and learning curve metrics were categorized for analysis by surgical procedure (MIS lumbar decompression procedures, MIS transforaminal lumbar interbody fusion, percutaneous pedicle screw insertion, laparoscopic anterior lumbar interbody fusion, and MIS cervical procedures). As the most consistent parameters used to evaluate the learning curve were procedure time and complication rate as a function of chronologic case number, our analysis focused on these. The search strategy identified 15 original studies that included 966 minimally invasive procedures. Learning curve parameters were correlated to chronologic procedure number in 14 of these studies.
RESULTS
The most common learning curve complication for decompressive procedures was durotomy. For fusion procedures, the most common complications were implant malposition, neural injury, and nonunion. The overall postoperative complication rate was 11% (109 of 966 cases). The learning curve was overcome for operative time and complications as a function of case numbers in 20 to 30 consecutive cases for most techniques discussed within this review.
CONCLUSIONS
The quantitative assessment of the procedural learning curve for MIS techniques for the spine remains challenging because the MIS techniques have different learning curves and because they have not been assessed in a consistent manner across studies. Complication rates may be underestimated by the studies we identified because surgeons tend to select patients carefully during the early learning curve period. The field of MIS would benefit from a standardization of study design and collected parameters in future learning curve investigations.
Topics: Bone Screws; Cervical Vertebrae; Clinical Competence; Decompression, Surgical; Humans; Laparoscopy; Learning Curve; Lumbar Vertebrae; Minimally Invasive Surgical Procedures; Operative Time; Orthopedic Procedures; Postoperative Complications; Spinal Fusion; Time Factors; Treatment Outcome
PubMed: 24510358
DOI: 10.1007/s11999-014-3495-z -
The Journal of Family Planning and... Apr 2014The intrauterine device (IUD) and intrauterine system (IUS) are widely used forms of long-acting reversible contraception. Occasionally, IUD/IUS users have an ultrasound... (Review)
Review
INTRODUCTION
The intrauterine device (IUD) and intrauterine system (IUS) are widely used forms of long-acting reversible contraception. Occasionally, IUD/IUS users have an ultrasound scan that shows a low-lying IUD/IUS or an IUD/IUS is found incidentally on scan to be low-lying within the uterus. No formal guidelines exist on the clinical implications of this scenario or the most appropriate management. We report here on a systematic review of the literature.
METHODS
A search of the online database PubMed was performed to identify articles relating to low-lying or malpositioned IUD/IUS.
RESULTS
A total of 1101 articles was identified, and 15 were determined to be relevant to the research question.
DISCUSSION
There is little published evidence to determine the nature and extent of the clinical relevance of a low-lying IUD. We recommend individualised management of these women, with particular caution in younger women and those with a history of previous IUD/IUS expulsion. Consideration may be given to attempting to readjust the IUD/IUS position, but if removal is performed, immediate replacement is essential if provision of alternative effective contraception has not been established.
Topics: Abdominal Pain; Hemorrhage; Intrauterine Device Migration; Intrauterine Devices; Risk Assessment; Women's Health
PubMed: 24395060
DOI: 10.1136/jfprhc-2013-100684 -
PloS One 2013It remains controversial whether mini-incision (MI) benefits patients in total hip arthroplasty (THA). We performed a meta-analysis of randomized controlled trials... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
It remains controversial whether mini-incision (MI) benefits patients in total hip arthroplasty (THA). We performed a meta-analysis of randomized controlled trials (RCTs) to assess the effects of MI on surgical and functional outcomes in THA patients.
METHODS
A systematic electronic literature search (up to May 2013) was conducted to identify RCTs comparing MI with standard incision (SI) THA. The primary outcome measures were surgical and functional outcomes. According to the surgical approach taken, MI THA patients were divided into four subgroups for sub-group meta-analysis. Standardized mean differences (SMDs) or risk differences (RDs) with accompanying 95% confidence intervals (CIs) were calculated and pooled using a fixed-effect or random-effect model according to the heterogeneity.
RESULTS
A total of 14 RCTs involving THA 1,174 patients met the inclusion criteria. The trials were medium risk of bias. The overall meta-analysis showed MI THA reduced total blood loss (95% CI, -201.83 to -21.18; p=.02) and length of hospital stay ( 95% CI, -0.67 to -0.08; p=.01) with significant heterogeneity. However, subgroup meta-analysis revealed posterior MI THA had perioperative advantages of reduced surgical duration ( 95% CI, -8.45 to -2.67; P<.001), less blood loss ( 95% CI, -107.20 to -1.73; P=.04) and shorter hospital stay ( 95% CI, -0.74 to -0.06; p=.002) with low heterogeneity. There were no significant differences between MI and SI THA groups in term of pain medication dose, functional outcome (HHS), radiological outcome or complications (P>.05, respectively).
CONCLUSIONS
Although no definite overall conclusion can be arrived at on whether MI THA is superior to SI THA, posterior MI THA clearly result in a significant decrease in surgical duration, blood loss and hospital stay. It seems to be a safe minimally invasive surgical procedure without increasing the risk of component malposition or complications.
Topics: Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Humans; Length of Stay; Pain; Postoperative Complications; Publication Bias; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 24265792
DOI: 10.1371/journal.pone.0080021 -
BioMed Research International 2013Ceramic bearing surfaces are increasingly used for total hip replacement, notwithstanding that concern is still related to ceramic brittleness and its possible... (Meta-Analysis)
Meta-Analysis Review
Ceramic bearing surfaces are increasingly used for total hip replacement, notwithstanding that concern is still related to ceramic brittleness and its possible mechanical failure. The aim of this systematic review is to answer three questions: (1) Are there risk factors for ceramic component fracture following total hip replacement? (2) Is it possible to perform an early diagnosis of ceramic component failure before catastrophic fracture occurs? (3) Is it possible to draw guidelines for revision surgery after ceramic components failure? A PubMed and Google Scholar search was performed and reference citations from publications identified in the literature search were reviewed. The use of 28 mm short-neck femoral head carries an increased risk of fracture. Acetabular component malposition might increase the risk of ceramic liner fractures. Synovial fluid microanalysis and CT scan are promising in early diagnosis of ceramic head and liner failure. Early revision is suggested in case of component failure; no consensus exists about the better coupling for revision surgery. Ceramic brittleness remains a major concern. Due to the increased number of ceramic on ceramic implants, more revision surgeries and reports on ceramic components failure are expected in the future. An algorithm of diagnosis and treatment for ceramic hip failure is proposed.
Topics: Arthroplasty, Replacement, Hip; Ceramics; Humans; Prosthesis Failure; Risk Factors; Stress, Mechanical; Surface Properties
PubMed: 23844356
DOI: 10.1155/2013/157247 -
European Spine Journal : Official... Feb 2014At present, most spinal surgeons undertake pedicle screw implantation using either anatomical landmarks or C-arm fluoroscopy. Reported rates of screw malposition using... (Review)
Review
PURPOSE
At present, most spinal surgeons undertake pedicle screw implantation using either anatomical landmarks or C-arm fluoroscopy. Reported rates of screw malposition using these techniques vary considerably, though the evidence generally favors the use of image-guidance systems. A miniature spine-mounted robot has recently been developed to further improve the accuracy of pedicle screw placement. In this systematic review, we critically appraise the perceived benefits of robot-assisted pedicle screw placement compared to conventional fluoroscopy-guided technique.
METHODS
The Cochrane Central Register of Controlled Trials, PubMed, and EMBASE databases were searched between January 2006 and January 2013 to identify relevant publications that (1) featured placement of pedicle screws, (2) compared robot-assisted and fluoroscopy-guided surgery, (3) assessed outcome in terms of pedicle screw position, and (4) present sufficient data in each arm to enable meaningful comparison (>10 pedicle screws in each study group).
RESULTS
A total of 246 articles were retrieved, of which 5 articles met inclusion criteria, collectively reporting placement of 1,308 pedicle screws (729 robot-assisted, 579 fluoroscopy-guided). The findings of these studies are mixed, with limited higher level of evidence data favoring fluoroscopy-guided procedures, and remaining comparative studies supporting robot-assisted pedicle screw placement.
CONCLUSIONS
There is insufficient evidence to unequivocally recommend one surgical technique over the other. Given the high cost of robotic systems, and the high risk of spinal surgery, further high quality studies are required to address unresolved clinical equipoise in this field.
Topics: Fluoroscopy; Humans; Pedicle Screws; Robotic Surgical Procedures; Spinal Fusion
PubMed: 23801017
DOI: 10.1007/s00586-013-2879-1 -
Anesthesia and Analgesia Mar 2013Near-infrared spectroscopy is used during cardiac surgery to monitor the adequacy of cerebral perfusion. In this systematic review, we evaluated available data for adult... (Review)
Review
BACKGROUND
Near-infrared spectroscopy is used during cardiac surgery to monitor the adequacy of cerebral perfusion. In this systematic review, we evaluated available data for adult patients to determine (1) whether decrements in cerebral oximetry during cardiac surgery are associated with stroke, postoperative cognitive dysfunction (POCD), or delirium; and (2) whether interventions aimed at correcting cerebral oximetry decrements improve neurologic outcomes.
METHODS
We searched PubMed, Cochrane, and Embase databases from inception until January 31, 2012, without restriction on languages. Each article was examined for additional references. A publication was excluded if it did not include original data (e.g., review, commentary) or if it was not published as a full-length article in a peer-reviewed journal (e.g., abstract only). The identified abstracts were screened first, and full texts of eligible articles were reviewed independently by 2 investigators. For eligible publications, we recorded the number of subjects, type of surgery, and criteria for diagnosis of neurologic end points.
RESULTS
We identified 13 case reports, 27 observational studies, and 2 prospectively randomized intervention trials that met our inclusion criteria. Case reports and 2 observational studies contained anecdotal evidence suggesting that regional cerebral O(2) saturation (rSco(2)) monitoring could be used to identify cardiopulmonary bypass cannula malposition. Six of 9 observational studies reported an association between acute rSco(2) desaturation and POCD based on the Mini-Mental State Examination (n = 3 studies) or more detailed cognitive testing (n = 6 studies). Two retrospective studies reported a relationship between rSco(2) desaturation and stroke or type I and II neurologic injury after surgery. The observational studies had many limitations, including small sample size, assessments only during the immediate postoperative period, and failure to perform risk adjustments. Two randomized studies evaluated the efficacy of interventions for treating rSco(2) desaturation during surgery, but adherence to the protocol was poor in one. In the other study, interventions for rSco(2) desaturation were associated with less major organ injury and shorter intensive care unit hospitalization compared with nonintervention.
CONCLUSIONS
Reductions in rSco(2) during cardiac surgery may identify cardiopulmonary bypass cannula malposition, particularly during aortic surgery. Only low-level evidence links low rSco(2) during cardiac surgery to postoperative neurologic complications, and data are insufficient to conclude that interventions to improve rSco(2) desaturation prevent stroke or POCD.
Topics: Adult; Brain; Cardiac Surgical Procedures; Humans; Monitoring, Intraoperative; Nervous System Diseases; Oximetry; Postoperative Complications; Randomized Controlled Trials as Topic; Spectroscopy, Near-Infrared; Treatment Outcome
PubMed: 23267000
DOI: 10.1213/ANE.0b013e318277a255 -
International Orthopaedics Feb 2011Over the past decade, minimally invasive surgery has gained popularity as a means of optimising early postoperative rehabilitation and increasing patient satisfaction... (Meta-Analysis)
Meta-Analysis Review
Over the past decade, minimally invasive surgery has gained popularity as a means of optimising early postoperative rehabilitation and increasing patient satisfaction and cosmesis following total hip arthroplasty (THA). However, this surgical exposure has also been associated with increased risk of iatrogenic nerve injury and implant mal-positioning due to limited visibility compared to conventionally larger surgical incisions. The purpose of this meta-analysis was to compare the outcomes of these two surgical exposures. A systematic review of the published and unpublished literature was conducted to include all randomised and non-randomised controlled trials comparing the clinical and radiological outcomes of minimally invasive and conventional THA procedures. In total, 28 studies met the eligibility criteria and included 2,849 hips, i.e. 1,428 minimally invasive compared to 1,421 conventional THAs. The meta-analysis of the current evidence base showed that minimally invasive THA is associated with a significantly increased risk of transient lateral femoral cutaneous nerve palsy (pā=ā0.006) with no significantly better outcome.
Topics: Arthroplasty, Replacement, Hip; Female; Hip Joint; Humans; Male; Middle Aged; Minimally Invasive Surgical Procedures; Paralysis; Postoperative Complications; Skin
PubMed: 20559827
DOI: 10.1007/s00264-010-1075-8