-
Academic Emergency Medicine : Official... Aug 2011Acutely swollen or painful joints are common complaints in the emergency department (ED). Septic arthritis in adults is a challenging diagnosis, but prompt... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Acutely swollen or painful joints are common complaints in the emergency department (ED). Septic arthritis in adults is a challenging diagnosis, but prompt differentiation of a bacterial etiology is crucial to minimize morbidity and mortality.
OBJECTIVES
The objective was to perform a systematic review describing the diagnostic characteristics of history, physical examination, and bedside laboratory tests for nongonococcal septic arthritis. A secondary objective was to quantify test and treatment thresholds using derived estimates of sensitivity and specificity, as well as best-evidence diagnostic and treatment risks and anticipated benefits from appropriate therapy.
METHODS
Two electronic search engines (PUBMED and EMBASE) were used in conjunction with a selected bibliography and scientific abstract hand search. Inclusion criteria included adult trials of patients presenting with monoarticular complaints if they reported sufficient detail to reconstruct partial or complete 2 × 2 contingency tables for experimental diagnostic test characteristics using an acceptable criterion standard. Evidence was rated by two investigators using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS). When more than one similarly designed trial existed for a diagnostic test, meta-analysis was conducted using a random effects model. Interval likelihood ratios (LRs) were computed when possible. To illustrate one method to quantify theoretical points in the probability of disease whereby clinicians might cease testing altogether and either withhold treatment (test threshold) or initiate definitive therapy in lieu of further diagnostics (treatment threshold), an interactive spreadsheet was designed and sample calculations were provided based on research estimates of diagnostic accuracy, diagnostic risk, and therapeutic risk/benefits.
RESULTS
The prevalence of nongonococcal septic arthritis in ED patients with a single acutely painful joint is approximately 27% (95% confidence interval [CI] = 17% to 38%). With the exception of joint surgery (positive likelihood ratio [+LR] = 6.9) or skin infection overlying a prosthetic joint (+LR = 15.0), history, physical examination, and serum tests do not significantly alter posttest probability. Serum inflammatory markers such as white blood cell (WBC) counts, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are not useful acutely. The interval LR for synovial white blood cell (sWBC) counts of 0 × 10(9)-25 × 10(9)/L was 0.33; for 25 × 10(9)-50 × 10(9)/L, 1.06; for 50 × 10(9)-100 × 10(9)/L, 3.59; and exceeding 100 × 10(9)/L, infinity. Synovial lactate may be useful to rule in or rule out the diagnosis of septic arthritis with a +LR ranging from 2.4 to infinity, and negative likelihood ratio (-LR) ranging from 0 to 0.46. Rapid polymerase chain reaction (PCR) of synovial fluid may identify the causative organism within 3 hours. Based on 56% sensitivity and 90% specificity for sWBC counts of >50 × 10(9)/L in conjunction with best-evidence estimates for diagnosis-related risk and treatment-related risk/benefit, the arthrocentesis test threshold is 5%, with a treatment threshold of 39%.
CONCLUSIONS
Recent joint surgery or cellulitis overlying a prosthetic hip or knee were the only findings on history or physical examination that significantly alter the probability of nongonococcal septic arthritis. Extreme values of sWBC (>50 × 10(9)/L) can increase, but not decrease, the probability of septic arthritis. Future ED-based diagnostic trials are needed to evaluate the role of clinical gestalt and the efficacy of nontraditional synovial markers such as lactate.
Topics: Adult; Arthritis, Infectious; Biomarkers; Evidence-Based Practice; Hip Prosthesis; Humans; Knee Prosthesis; Middle Aged; Risk Factors; Sensitivity and Specificity; Synovial Fluid
PubMed: 21843213
DOI: 10.1111/j.1553-2712.2011.01121.x -
Clinics in Sports Medicine Jan 2020Meniscus injuries are among the most common athletic injuries and result in functional impairment in the knee. Repair is crucial for pain relief and prevention of...
Meniscus injuries are among the most common athletic injuries and result in functional impairment in the knee. Repair is crucial for pain relief and prevention of degenerative joint diseases like osteoarthritis. Current treatments, however, do not produce long-term improvements. Thus, recent research has been investigating new therapeutic options for regenerating injured meniscal tissue. This review comprehensively details the current methodologies being explored in the basic sciences to stimulate better meniscus injury repair. Furthermore, it describes how these preclinical strategies may improve current paradigms of how meniscal injuries are clinically treated through a unique and alternative perspective to traditional clinical methodology.
Topics: Adipose Tissue; Biomechanical Phenomena; Bone Marrow Cells; Cartilage; Chondrocytes; Humans; Intercellular Signaling Peptides and Proteins; Menisci, Tibial; Platelet-Rich Fibrin; Platelet-Rich Plasma; Regeneration; Stem Cell Transplantation; Synovial Membrane; Tibial Meniscus Injuries; Tissue Engineering; Tissue Scaffolds
PubMed: 31767102
DOI: 10.1016/j.csm.2019.08.003 -
BMC Musculoskeletal Disorders Aug 2016Frozen shoulder is a common yet poorly understood musculoskeletal condition, which for many, is associated with substantial and protracted morbidity. Understanding the... (Review)
Review
BACKGROUND
Frozen shoulder is a common yet poorly understood musculoskeletal condition, which for many, is associated with substantial and protracted morbidity. Understanding the pathology associated with this condition may help to improve management. To date this has not been presented in a systematic fashion. As such, the aim of this review was to summarise the pathological changes associated with this primary frozen shoulder.
DATABASES
Medline, Embase, CINAHL, AMED, BNI and the Cochrane Library, were searched from inception to 2nd May, 2014. To be included participants must not have undergone any prior intervention. Two reviewers independently conducted the; searches, screening, data extraction and assessment of Risk of Bias using the Cochrane Risk of Bias Assessment Tool for non-Randomised Studies of Interventions (ACROBAT-NRSI). Only English language publications reporting findings in humans were included. The findings were summarised in narrative format.
RESULTS
Thirteen observational studies (involving 417 shoulders) were included in the review. Eight studies reported magnetic resonance imaging or arthrography findings and 5 recorded histological findings. When reported mean ages of the participants ranged from 40.0 to 59.8 years. Duration of symptoms ranged from 0 to 30 months. The majority of studies (n = 7) were assessed to be of moderate risk of bias, two studies at high risk and the remaining four were rated as low risk of bias. Study characteristics were poorly reported and there was widespread variety observed between studies in respect of data collection methods and inclusion criteria employed. Pathological changes in the anterior shoulder joint capsule and related structures were commonly reported. Imaging identified pathological changes occurring in the coracohumeral ligament, axillary fold and rotator interval. Obliteration of the subcoracoid fat triangle also appeared to be pathognomonic. Histological studies were inconclusive but suggested that immune, inflammatory and fibrotic changes where associated with primary frozen shoulder.
CONCLUSIONS
This systematic review presents a summary of what is currently known about the tissue pathophysiology of primary frozen shoulder. Further studies that use standardised inclusion and exclusion criteria and investigate changes in naïve tissue at different stages of the condition are required.
Topics: Adult; Arthrography; Bursitis; Humans; Ligaments, Articular; Magnetic Resonance Imaging; Middle Aged; Shoulder Joint; Shoulder Pain
PubMed: 27527912
DOI: 10.1186/s12891-016-1190-9 -
Arthritis & Rheumatology (Hoboken, N.J.) Oct 2015Existing criteria for the classification of gout have suboptimal sensitivity and/or specificity, and were developed at a time when advanced imaging was not available....
OBJECTIVE
Existing criteria for the classification of gout have suboptimal sensitivity and/or specificity, and were developed at a time when advanced imaging was not available. The current effort was undertaken to develop new classification criteria for gout.
METHODS
An international group of investigators, supported by the American College of Rheumatology and the European League Against Rheumatism, conducted a systematic review of the literature on advanced imaging of gout, a diagnostic study in which the presence of monosodium urate monohydrate (MSU) crystals in synovial fluid or tophus was the gold standard, a ranking exercise of paper patient cases, and a multicriterion decision analysis exercise. These data formed the basis for developing the classification criteria, which were tested in an independent data set.
RESULTS
The entry criterion for the new classification criteria requires the occurrence of at least 1 episode of peripheral joint or bursal swelling, pain, or tenderness. The presence of MSU crystals in a symptomatic joint/bursa (i.e., synovial fluid) or in a tophus is a sufficient criterion for classification of the subject as having gout, and does not require further scoring. The domains of the new classification criteria include clinical (pattern of joint/bursa involvement, characteristics and time course of symptomatic episodes), laboratory (serum urate, MSU-negative synovial fluid aspirate), and imaging (double-contour sign on ultrasound or urate on dual-energy computed tomography, radiographic gout-related erosion). The sensitivity and specificity of the criteria are high (92% and 89%, respectively).
CONCLUSION
The new classification criteria, developed using a data-driven and decision analytic approach, have excellent performance characteristics and incorporate current state-of-the-art evidence regarding gout.
Topics: Arthralgia; Europe; Gout; Humans; Synovial Fluid; United States; Uric Acid
PubMed: 26352873
DOI: 10.1002/art.39254 -
Scientific Reports Mar 2021Detailed understanding of the innervation of the hip capsule (HC) helps inform surgeons' and anaesthetists' clinical practice. Post-interventional pain following... (Meta-Analysis)
Meta-Analysis
Detailed understanding of the innervation of the hip capsule (HC) helps inform surgeons' and anaesthetists' clinical practice. Post-interventional pain following radiofrequency nerve ablation (RFA) and dislocation following total hip arthroplasty (THA) remain poorly understood, highlighting the need for more knowledge on the topic. This systematic review and meta-analysis focuses on gross anatomical studies investigating HC innervation. The main outcomes were defined as the prevalence, course, density and distribution of the nerves innervating the HC and changes according to demographic variables. HC innervation is highly variable; its primary nerve supply seems to be from the nerve to quadratus femoris and obturator nerve. Many articular branches originated from muscular branches of the lumbosacral plexus. It remains unclear whether demographic or anthropometric variables may help predict potential differences in HC innervation. Consequently, primary targets for RFA should be the anterior inferomedial aspect of the HC. For THA performed on non-risk patients, the posterior approach with capsular repair appears to be most appropriate with the lowest risk of articular nerve damage. Care should also be taken to avoid damaging vessels and muscles of the hip joint. Further investigation is required to form a coherent map of HC innervation, utilizing combined gross and histological investigation.
Topics: Arthroplasty, Replacement, Hip; Cadaver; Femoral Nerve; Hip Joint; Humans; Joint Capsule; Obturator Nerve; Pain, Postoperative; Radiofrequency Ablation; Sciatic Nerve
PubMed: 33674621
DOI: 10.1038/s41598-021-84345-z -
Arthroscopy, Sports Medicine, and... Aug 2022To summarize the quantitative and qualitative anatomy of the acromioclavicular (AC) and coracoclavicular (CC) ligaments of the AC joint. (Review)
Review
PURPOSE
To summarize the quantitative and qualitative anatomy of the acromioclavicular (AC) and coracoclavicular (CC) ligaments of the AC joint.
METHODS
A systematic review of the literature evaluating the quantitative and qualitative anatomy of the CC and AC ligaments of the AC joint was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.
RESULTS
The conoid ligament (CL) arises from the posterior coracoid precipice and courses with a tapered inferior apex to insert on the conoid tubercle of the posteroinferior clavicle. The trapezoid ligament originates from the anterior-superior coracoid with medially extending fibers anterior to the conoid's C-shaped footprint and runs with the CL to insert along the trapezoid line on the inferior aspect of the anterior clavicle, anterolateral to the conoid tubercle. The AC capsule's superoposterior bundle and the CL are robust stabilizing ligaments characterized by prominent attachment sites to the posteroinferior clavicle.
CONCLUSIONS
Clear and consistent quantitative and qualitative descriptions of the CC ligaments (CL and trapezoid ligament) have been well defined; however, quantitative data on the capsuloligamentous anatomy of AC ligaments (superoposterior and anteroinferior) ligaments) remain limited.
CLINICAL RELEVANCE
There are high complication and failure rates after AC joint stabilization. To improve patient outcomes, the anatomy of the CC and AC joints needs to be better understood.
PubMed: 36033198
DOI: 10.1016/j.asmr.2022.04.026 -
Bulletin of the NYU Hospital For Joint... 2011Dislocation of the sternoclavicular joint is a rare injury that has a low incidence of signifcant long-term symptoms. Surgical reconstruction of the joint is indicated... (Review)
Review
BACKGROUND
Dislocation of the sternoclavicular joint is a rare injury that has a low incidence of signifcant long-term symptoms. Surgical reconstruction of the joint is indicated in patients with symptomatic, chronic anterior instability or with irreducible or recurrent posterior instability. There have been many reported techniques for stabilization of the joint, but few investigators have reported more than several cases. The ideal reconstruction has not been identifed.
PURPOSE
The purpose of this investigation was to perform a systematic review of the available literature with the objective of identifying one technique of sternoclavicular reconstruction that could be recommended.
METHODS
A systematic review of literature pertaining to treatment of sternoclavicular joint injuries was performed, focusing on clinical reports with at least six patients and 1 year of follow-up. We also reviewed biomechanical reports pertaining to sternoclavicular reconstruction.
RESULTS
Six clinical reports and two biomechanical studies were identifed that met our inclusion criteria. Treatments described in the clinical reports included conservative treatment with a sling, repair of the joint capsule with provisional stabilization, and joint reconstruction with local tissue or graft tissue. One biomechanical study compared the strength of three reconstruction techniques.
CONCLUSION
Reconstruction with tendon tissue woven in a figure-of-eight pattern through drill holes in the manubrium and clavicle is stronger than reconstructions with local tissue. The review of clinical reports suggests excellent outcomes with this technique, and it is recommended in cases of chronic instability. In cases of acute instability requiring open reduction or inability to maintain a reduction in a posterior dislocation, there is evidence that repair of the joint capsule is suffcient surgical treatment.
Topics: Biomechanical Phenomena; Humans; Joint Dislocations; Joint Instability; Orthopedic Procedures; Plastic Surgery Procedures; Recovery of Function; Sternoclavicular Joint; Treatment Outcome
PubMed: 22035392
DOI: No ID Found -
Orthopaedics & Traumatology, Surgery &... Dec 2022Irreducible knee dislocations (IKD) are rare and can often be missed or misdiagnosed. The incidence of knee dislocation is quoted between 0.01% and 0.2% of all... (Review)
Review
BACKGROUND
Irreducible knee dislocations (IKD) are rare and can often be missed or misdiagnosed. The incidence of knee dislocation is quoted between 0.01% and 0.2% of all orthopaedic injuries, with up to 4% of these dislocations sub-classified as irreducible. The primary aim of this systematic review was to analyse cases of IKD described in the literature, with a secondary aim of producing a streamlined approach for managing these patients.
PATIENTS AND METHODS
A systematic review of the literature was conducted on 1st September 2021 in accordance with the PRISMA guidelines using the online databases Medline and EMBASE. The review was registered prospectively in the PROSPERO database. Case reports or clinical studies or reporting on IKD were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool and Newcastle-Ottawa quality assessment scale.
RESULTS
The search strategy identified 60 studies eligible for inclusion, giving a total of 114 cases of IKD. Posterolateral dislocation was most common, seen in 85% of cases. The dimple sign was present in 70%. All cases required surgical intervention to achieve joint reduction. The most commonly involved structure blocking reduction was the medial collateral ligament (MCL)±medial structures, seen in 52.4%. MCL reconstruction or repair was carried out in 32.3% cases. The overall incidence of neurovascular injury was 9% and the overall complication rate was 14.4%.
CONCLUSION
Based on the findings of this SR we conclude that: the most common type of IKDs are PL dislocations, and the MCL, medial retinaculum and capsule and vastus medialis oblique form the most common structures involved in block to reduction and often will require open reduction and repair in acute setting if arthroscopic reduction fails. The most common pattern of injury to ligament is likely to be ACL, PCL, MCL±other structures but the MCL will be the most commonly repaired ligament. The dimple sign is often present and is highly pathognomonic of IKD. The incidence of neurovascular injury is uncommon. The most common post-operative complications likely to be encountered is medial skin necrosis and postoperative knee stiffness. Therefore, patients should be mobilised as early as possible with ROM in hinge brace.
LEVEL OF EVIDENCE
IV.
Topics: Humans; Anterior Cruciate Ligament Injuries; Braces; Knee Dislocation; Knee Joint; Treatment Outcome; Arthroscopy
PubMed: 36126871
DOI: 10.1016/j.otsr.2022.103415 -
Rheumatology (Oxford, England) May 2023Prompt diagnosis of septic arthritis (SA) in acute native hot joints is essential for avoiding unnecessary antibiotics and hospital admissions. We evaluated the utility... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Prompt diagnosis of septic arthritis (SA) in acute native hot joints is essential for avoiding unnecessary antibiotics and hospital admissions. We evaluated the utility of synovial fluid (SF) and serum tests in differentiating causes of acute hot joints.
METHODS
We performed a systematic literature review of diagnostic testing for acute hot joints. Articles were included if studying ≥1 serum or SF test(s) for an acute hot joint, compared with clinical assessment and SF microscopy and culture. English-language articles only were included, without date restriction. The following were recorded for each test, threshold and diagnosis: sensitivity, specificity, positive/negative predictive values and likelihood ratios. For directly comparable tests (i.e. identical fluid, test and threshold), bivariate random-effects meta-analysis was used to pool sensitivity, specificity, and areas under the curves.
RESULTS
A total of 8443 articles were identified, and 49 were ultimately included. Information on 28 distinct markers in SF and serum, differentiating septic from non-septic joints, was extracted. Most had been tested at multiple diagnostic thresholds, yielding a total of 27 serum markers and 156 SF markers. Due to heterogeneity of study design, outcomes and thresholds, meta-analysis was possible for only eight SF tests, all differentiating septic from non-septic joints. Of these, leucocyte esterase had the highest pooled sensitivity [0.94 (0.70, 0.99)] with good pooled specificity [0.74 (0.67, 0.81)].
CONCLUSION
Our review demonstrates many single tests, individually with diagnostic utility but suboptimal accuracy for exclusion of native joint infection. A combination of several tests with or without a stratification score is required for optimizing rapid assessment of the hot joint.
Topics: Humans; Sensitivity and Specificity; Arthritis, Infectious; Biomarkers; Predictive Value of Tests; Leukocyte Count; Synovial Fluid
PubMed: 36264140
DOI: 10.1093/rheumatology/keac606 -
Evidence-based Complementary and... 2023To systematically evaluate the efficacy and safety of the Shuangdan Mingmu capsule in the treatment of diabetic retinopathy (DR). (Review)
Review
OBJECTIVE
To systematically evaluate the efficacy and safety of the Shuangdan Mingmu capsule in the treatment of diabetic retinopathy (DR).
METHODS
Common Chinese and English databases, including PubMed, Medline, Embase, VIP, Wanfang, and the Chinese National Knowledge Infrastructure (CNKI), were searched from their inception to May 31, 2022. According to the Cochrane Handbook, two reviewers independently evaluated and collected data on the included studies. Meta-analysis was performed by RevMan software 5.4.
RESULTS
Seven trials with a total of 835 patients were included. The clinical effectiveness rate was defined as the primary outcome, and the TCM symptom score, Chinese-Version Low Vision Quality of Life Questionnaire (CLVQOL) scores, macular thickness, hemorrhagic spot area, vascular endothelial growth factor levels, platelet-derived growth factor levels, and the incidence of adverse effects were the secondary outcome. The results of the meta-analysis showed that, compared with conventional medical treatment alone, the Shuangdan Mingmu capsule combined with conventional treatment could significantly improve the clinical effectiveness rate of treating DR (OR = 4.07, 95% CI (2.10, 7.89), < 0.0001), and reduce the incidence of adverse reactions in DR patients (OR = 0.47, 95% CI (0.26, 0.86), =0.01). In addition, other results showed that TCM symptom score(OR = -3.47, 95% CI (-3.84, -3.10), < 0.00001); CLVQOL scores (OR = 23.93, 95% CI (21.37, 26.49), < 0.00001); macular thickness (OR = -47.34, 95% CI (-50.67, 44.00), < 0.00001); hemorrhagic spot area (OR = -0.91, 95% CI (-1.01, -0.81), < 0.00001); vascular endothelial growth factor levels (OR = -45.76, 95% CI (-49.74, 41.79), < 0.00001); platelet-derived growth factor levels (OR = -1.73, 95% CI (-2.15, -1.31), < 0.00001).
CONCLUSION
Compared with conventional treatment alone, the Shuangdan Mingmu capsule combined with conventional treatment is more effective and safer in the treatment of diabetic retinopathy. However, due to the limitations of the included studies, more high-quality studies are still needed to further assess the efficacy and safety of the Shuangdan Mingmu capsule in the treatment of diabetic retinopathy.
PubMed: 36743463
DOI: 10.1155/2023/4655109