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The Cochrane Database of Systematic... Oct 2019Dislocation of the acromioclavicular joint is one of the most common shoulder injuries in a sport-active population. The question of whether surgery should be used... (Review)
Review
BACKGROUND
Dislocation of the acromioclavicular joint is one of the most common shoulder injuries in a sport-active population. The question of whether surgery should be used remains controversial. This is an update of a Cochrane Review first published in 2010.
OBJECTIVES
To assess the effects (benefits and harms) of surgical versus conservative (non-surgical) interventions for treating acromioclavicular dislocations in adults.
SEARCH METHODS
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to June 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 6), MEDLINE (1946 to June 2019), Embase (1980 to June 2019), and LILACS (1982 to June 2019), trial registries, and reference lists of articles. There were no restrictions based on language or publication status.
SELECTION CRITERIA
We included all randomised and quasi-randomised trials that compared surgical with conservative treatment of acromioclavicular dislocation in adults.
DATA COLLECTION AND ANALYSIS
At least two review authors independently performed study screening and selection, 'Risk of bias' assessment, and data extraction. We pooled data where appropriate and used GRADE to assess the quality of evidence for each outcome.
MAIN RESULTS
We included five randomised trials and one quasi-randomised trial. The included trials involved 357 mainly young adults, the majority of whom were male, with acute acromioclavicular dislocation. The strength of the findings in all studies was limited due to design features, invariably lack of blinding, that carry a high risk of bias. Fixation of the acromioclavicular joint using hook plates, tunnelled suspension devices, coracoclavicular screws, acromioclavicular pins, or (usually threaded) wires was compared with supporting the arm in a sling or similar device. After surgery, the arm was also supported in a sling or similar device in all trials. Where described in the trials, both groups had exercise-based rehabilitation. We downgraded the evidence for all outcomes at least two levels, invariably for serious risk of bias and serious imprecision.Low-quality evidence from two studies showed no evidence of a difference between groups in shoulder function at one year, assessed using the Disability of the Arm, Shoulder, and Hand questionnaire (DASH) (0 (best function) to 100 (worst function)): mean difference (MD) 0.73 points, 95% confidence interval (CI) -2.70 to 4.16; 112 participants. These results were consistent with other measures of function at one-year or longer follow-up, including non-validated outcome scores reported by three studies. There is low-quality evidence that function at six weeks may be better after conservative treatment, indicating an earlier recovery. Very low-quality evidence from one trial found no difference between groups in participants reporting pain at one year: risk ratio (RR) 1.32, 95% CI 0.54 to 3.19; 79 participants. There is very low-quality evidence that surgery may not reduce the risk of treatment failure, usually resulting in non-routine secondary surgery: 14/168 versus 15/174; RR 0.99, 95% CI 0.51 to 1.94; 342 participants, 6 studies. The main source of treatment failure was complications related to surgical implants in the surgery group and persistent symptoms, mainly discomfort, due to the acromioclavicular dislocation in the conservatively treated group.There is low-quality evidence from two studies that there may be little or no difference between groups in the return to former activities (sports or work) at one year: 57/67 versus 62/70; RR 0.96, 95% CI 0.85 to 1.10; 137 participants, 2 studies. Low-quality but consistent evidence from four studies indicated an earlier recovery in conservatively treated participants compared with those treated with surgery. There is low-quality evidence of no clinically important difference between groups at one year in quality of life scores, measured using the 36-item or 12-item Short Form Health Survey (SF-36 or SF-12) (0-to-100 scale, where 100 is best score), in either the physical component (MD -0.63, 95% CI -2.63 to 1.37; 122 participants, 2 studies) or mental component (MD 0.47 points, 95% CI -1.51 to 2.44; 122 participants). There is very low-quality and clinically heterogenous evidence of a greater risk of an adverse event after surgery: 45/168 versus 16/174; RR 2.82, 95% CI 1.65 to 4.82; 342 participants, 6 studies; I = 48%. Common adverse outcomes were hardware complications or discomfort (18.5%) and infection (8.7%) in the surgery group and persistent symptoms (7.1%), mainly discomfort, in the conservatively treated group. The majority of surgical complications occurred in older studies testing now-outdated devices known for their high risk of complications. The very low-quality evidence from one study (70 participants) means that we are uncertain whether there is a between-group difference in patient dissatisfaction with cosmetic results.It is notable that the evidence for function, return to former activities, and quality of life came from the two most recently conducted studies, which tested currently used devices and interventions in clearly defined participant populations that represented the commonly perceived population for which there is uncertainty over the use of surgery. There were insufficient data to conduct subgroup analysis relating to type of injury and whether surgery involved ligament reconstruction or not.
AUTHORS' CONCLUSIONS
There is low-quality evidence that surgical treatment has no additional benefits in terms of function, return to former activities, and quality of life at one year compared with conservative treatment. There is, however, low-quality evidence that people treated conservatively had improved function at six weeks compared with surgical management. There is very low-quality evidence of little difference between the two treatments in pain at one year, treatment failure usually resulting in secondary surgery, or patient satisfaction with cosmetic result. Although surgery may result in more people sustaining adverse events, this varied between the trials, being more common in techniques such as K-wire fixation that are rarely used today. There remains a need to consider the balance of risks between the individual outcomes: for example, surgical adverse events, including wound infection or dehiscence and hardware complication, against risk of adverse events that may be more commonly associated with conservative treatment such as persistent symptoms or discomfort, or both.There is a need for sufficiently powered, good-quality, well-reported randomised trials of currently used surgical interventions versus conservative treatment for well-defined injuries.
PubMed: 31604007
DOI: 10.1002/14651858.CD007429.pub3 -
The Angle Orthodontist Jul 2018To evaluate the quantitative effects of miniscrew supported appliances for maxillary molar distalization in Class II malocclusion.
OBJECTIVES
To evaluate the quantitative effects of miniscrew supported appliances for maxillary molar distalization in Class II malocclusion.
MATERIALS AND METHODS
The systematic search included MEDLINE, EMBASE, CINAHL, PsychINFO, Scopus, and key journals and review articles. The date of the last search was January 30, 2017. Methodological quality of the retrospective studies was graded by means of the Quality Assessment Tool for Quantitative Studies, developed for the Effective Public Health Practice Project (EPHPP) and prospective studies by means of Newcastle-Ottawa Scale.
RESULTS
In total, 298 studies were identified for screening, and 14 studies were eligible. The Quality Assessment Tool for Quantitative Studies rated all of the four included retrospective studies as moderate. The Newcastle-Ottawa Scale rated seven studies as high quality and three studies as low quality. The mean molar distalization values varied from 1.8 mm to 6.4 mm. Mean distal tipping of molars varied from 1.65° to 11.3°. The mean distal movement of premolars and incisors varied from 1.75 mm to 5.4 mm and 0.1 mm to 2.7 mm, respectively.
CONCLUSIONS
Miniscrew-supported appliances are effective in molar distalization with distal movement of premolars with minimal anchorage loss and distal tipping of the molar teeth.
Topics: Bone Screws; Humans; Malocclusion, Angle Class II; Maxilla; Molar; Orthodontic Anchorage Procedures; Tooth Movement Techniques
PubMed: 29664335
DOI: 10.2319/091717-624.1 -
The Angle Orthodontist Mar 2020To evaluate systematically the effectiveness of miniscrew-supported maxillary incisor intrusion compared with other nonsurgical intrusive mechanics for deep-bite... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To evaluate systematically the effectiveness of miniscrew-supported maxillary incisor intrusion compared with other nonsurgical intrusive mechanics for deep-bite correction.
MATERIALS AND METHODS
Unrestricted electronic searches in Embase, Web of Science, MEDLINE, LILACS, and Cochrane's CENTRAL as well as manual searches were conducted up to August 2019. Only randomized clinical trials (RCTs) were included. Study selection, data extraction, and bias assessment were done by two independent reviewers. The Cochrane risk-of-bias tool was used, and the quality of evidence was graded using the GRADE approach. A random-effects meta-analysis of continuous data, with its 95% confidence intervals (CIs), was used.
RESULTS
Seven RCTs were included in the quantitative synthesis, and the overall quality of evidence was very low to low. When compared with intrusion arches, miniscrews resulted in a more efficient deep-bite reduction with a standardized mean difference (SMD) of -0.48 (95% CI, -0.89 to -0.07). When miniscrews were used, a statistically significant difference was observed favoring less maxillary molar extrusion (SMD, -0.86; 95% CI, -1.46 to -0.27) and more incisor intrusion as measured from centroid to palatal plane (SMD, -0.95; 95% CI, -1.41 to -0.49). Results also showed a statistically nonsignificant difference regarding the amount of resultant root resorption between miniscrews and intrusion arches.
CONCLUSIONS
There is weak evidence indicating efficient deep-bite correction using miniscrews. Root resorption seems to be an associated adverse effect that occurs regardless of the intrusive mechanics used. These conclusions should be viewed with great caution as further well-designed long-term research is recommended.
Topics: Bone Screws; Humans; Incisor; Orthodontic Anchorage Procedures; Overbite; Tooth Movement Techniques
PubMed: 31816252
DOI: 10.2319/061119-400.1 -
The Cochrane Database of Systematic... Oct 2017Recognition of some of the limitations of titanium plates and screws used for the fixation of bones has led to the development of plates manufactured from bioresorbable... (Review)
Review
BACKGROUND
Recognition of some of the limitations of titanium plates and screws used for the fixation of bones has led to the development of plates manufactured from bioresorbable materials. Whilst resorbable plates appear to offer clinical advantages over metal plates in orthognathic surgery, concerns remain about the stability of fixation and the length of time required for their degradation and the possibility of foreign body reactions. This review compares the use of titanium versus bioresorbable plates in orthognathic surgery and is an update of the Cochrane Review first published in 2007.
OBJECTIVES
To compare the effects of bioresorbable fixation systems with titanium systems used during orthognathic surgery.
SEARCH METHODS
Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 20 January 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11) in the Cochrane Library (searched 20 January 2017); MEDLINE Ovid (1946 to 20 January 2017); and Embase Ovid (1980 to 20 January 2017). We searched the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (clinicaltrials.gov; searched 20 January 2017), and the World Health Organization International Clinical Trials Registry Platform (searched 20 January 2017) for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.
SELECTION CRITERIA
Randomised controlled trials comparing bioresorbable versus titanium fixation systems used for orthognathic surgery in adults.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We resolved disagreement by discussion. Clinical heterogeneity between the included trials precluded pooling of data, and only a descriptive summary is presented.
MAIN RESULTS
This review included two trials, involving 103 participants, one comparing titanium with resorbable plates and screws and the other titanium with resorbable screws. Both studies were at high risk of bias and provided very limited data for the primary outcomes of this review. All participants in one trial suffered mild to moderate postoperative discomfort with no statistically significant difference between the two plating groups at different follow-up times. Mean scores of patient satisfaction were 7.43 to 8.63 (range 0 to 10) with no statistically significant difference between the two groups throughout follow-up. Adverse effects reported in one study were two plate exposures in each group occurring between the third and ninth months. Plate exposures occurred mainly in the posterior maxillary region, except for one titanium plate exposure in the mandibular premolar region. Known causes of infection were associated with loosened screws and wound dehiscence with no statistically significant difference in the infection rate between titanium (3/196), and resorbable (3/165) plates.
AUTHORS' CONCLUSIONS
We do not have sufficient evidence to determine if titanium plates or resorbable plates are superior for fixation of bones after orthognathic surgery. This review provides insufficient evidence to show any difference in postoperative pain and discomfort, level of patient satisfaction, plate exposure or infection for plate and screw fixation using either titanium or resorbable materials.
Topics: Absorbable Implants; Bone Plates; Bone Screws; Device Removal; Humans; Internal Fixators; Mandible; Maxilla; Osteotomy; Randomized Controlled Trials as Topic; Titanium
PubMed: 28977689
DOI: 10.1002/14651858.CD006204.pub3 -
EFORT Open Reviews Jan 2020Billions of screws are inserted by surgeons each year, making them the most commonly inserted implant. When using non-locking screws, insertion technique is decided by... (Review)
Review
Billions of screws are inserted by surgeons each year, making them the most commonly inserted implant. When using non-locking screws, insertion technique is decided by the surgeon, including how much to tighten each screw. The aims of this study were to assess, through a systematic review, the screw tightness and rate of material stripping produced by surgeons and the effect of different variables related to screw insertion.Twelve studies were included, with 260 surgeons inserting a total of 2793 screws; an average of 11 screws each, although only 1510 screws have been inserted by 145 surgeons where tightness was measured - average tightness was 78±10% for cortical ( = 1079) and 80±6% for cancellous screw insertions ( = 431).An average of 26% of all inserted screws irreparably damaged and stripped screw holes, reducing the construct pullout strength. Furthermore, awareness of bone stripping is very poor, meaning that screws must be considerably overtightened before a surgeon will typically detect it.Variation between individual surgeons' ability to optimally insert screws was seen, with some surgeons stripping more than 90% of samples and others hardly any. Contradictory findings were seen for the relationship between the tightness achieved and bone density.The optimum tightness for screws remains unknown, thus subjectively chosen screw tightness, which varies greatly, remains without an established target to generate the best possible construct for any given situation. Work is needed to establish these targets, and to develop methods to accurately and repeatably achieve them. Cite this article: 2020;5:26-36. DOI: 10.1302/2058-5241.5.180066.
PubMed: 32071771
DOI: 10.1302/2058-5241.5.180066 -
Acta Ortopedica Mexicana 2023fractures involving the posterior malleolus (PM) of the ankle can have significant functional and clinical implications if not properly treated. The optimal treatment... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
fractures involving the posterior malleolus (PM) of the ankle can have significant functional and clinical implications if not properly treated. The optimal treatment approach for these fractures remains uncertain. This review aims to compare the use of cannulated screws versus plate with screw fixation in terms of their impact on the development of postoperative ankle osteoarthritis and functional outcomes in patients with PM fractures.
MATERIAL AND METHODS
a comprehensive search was conducted in PubMed, EMBASE, and Cochrane Library databases to identify studies directly comparing cannulated screws versus plate with screw fixation for PM fractures and their association with the development of postoperative osteoarthritis and functional outcomes. The quality of the included studies was assessed using appropriate assessment tools. The data on osteoarthritis development and functional outcomes were extracted and analyzed.
RESULTS
a total of 691 articles were screened, and several studies were included for analysis. The findings revealed no statistically significant difference in the development of postoperative ankle osteoarthritis between the cannulated screws and plate with screw fixation groups. Similarly, there was no significant difference in functional outcomes between the two treatment approaches.
CONCLUSION
based on the available evidence, there is no significant difference in the development of postoperative ankle osteoarthritis or functional outcomes between cannulated screws and plate with screw fixation for PM fractures. However, further research is needed to strengthen these findings and provide more conclusive evidence.
Topics: Humans; Fracture Fixation, Internal; Ankle Fractures; Bone Plates; Bone Screws; Osteoarthritis; Treatment Outcome; Retrospective Studies
PubMed: 38052441
DOI: No ID Found -
Journal of Orthopaedic Translation Jul 2020Osteosynthesis-associated infection is a challenging complication post fracture fixation, burdening the patients and the orthopaedic surgeons alike. A clinically... (Review)
Review
OBJECTIVE
Osteosynthesis-associated infection is a challenging complication post fracture fixation, burdening the patients and the orthopaedic surgeons alike. A clinically relevant animal model is critical in devising new therapeutic strategies. Our aim was to perform a systematic review to evaluate existing preclinical models and identify their applications in aspects of animal selection, bacterial induction, fracture fixation and complications.
METHODS
A systematic literature research was conducted in PubMed and Embase up to February 2020. A total of 31 studies were included. Information on the animal, bacterial induction, fracture fixation, healing result and complications were extracted.
RESULTS
Animals selected included murine (23), rabbit (6), ewe (1) and goat (1). Larger animals had enabled the use of human-sized implant, however small animals were more economical and easier in handling. was the most frequently chosen bacteria for induction. Bacterial inoculation dose ranged from 10 CFU. Consistent and replicable infections were observed from 10 CFU in general. Methods of inoculation included injections of bacterial suspension (20), placement of foreign objects (8) and pretreatment of implants with established biofilm (3). Intramedullary implants (13), plates and screws (18) were used in most models. Radiological (29) and histological evaluations (24) in osseous healing were performed. Complications such as instability of fracture fixation (7), unexpected surgical death (5), sepsis (1) and persistent lameness (1) were encountered.
CONCLUSION
The most common animal model is the infected open fracture internally fixated. Replicable infections were mainly from 10 CFU of bacteria. However, with the increase in antibiotic resistance, future directions should explore polymicrobial and antibiotic resistant strains, as these will no doubt play a major role in bone infection. Currently, there is also a lack of osteoporotic bone infection models and the pathophysiology is unexplored, which would be important with our aging population.
THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE
This systematic review provides an updated overview and compares the currently available animal models of osteosynthesis-associated infections. A discussion on future research directions and suggestion of animal model settings were made, which is expected to advance the research in this field.
PubMed: 32440511
DOI: 10.1016/j.jot.2020.03.002 -
The Cochrane Database of Systematic... May 2018Rigid internal fixation of the jaw bones is a routine procedure for the management of facial fractures. Titanium plates and screws are routinely used for this purpose.... (Comparative Study)
Comparative Study Review
BACKGROUND
Rigid internal fixation of the jaw bones is a routine procedure for the management of facial fractures. Titanium plates and screws are routinely used for this purpose. The limitations of this system has led to the development of plates manufactured from bioresorbable materials which, in some cases, omits the necessity for the second surgery. However, concerns remain about the stability of fixation and the length of time required for their degradation and the possibility of foreign body reactions.
OBJECTIVES
To compare the effectiveness of bioresorbable fixation systems with titanium systems for the management of facial fractures.
SEARCH METHODS
We searched the following databases: The Cochrane Oral Health Group's Trials Register (to 20th August 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to 20th August 2008), EMBASE (from 1980 to 20th August 2008), http://www.clinicaltrials.gov/ and http://www.controlled-trials.com (to 20th August 2008).
SELECTION CRITERIA
Randomised controlled trials comparing resorbable versus titanium fixation systems used for facial fractures.
DATA COLLECTION AND ANALYSIS
Retrieved studies were independently screened by two review authors. Results were to be expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals. Heterogeneity was to be investigated including both clinical and methodological factors.
MAIN RESULTS
The search strategy retrieved 53 potentially eligible studies. None of the retrieved studies met our inclusion criteria and all were excluded from this review. One study is awaiting classification as we failed to obtain the full text copy. Three ongoing trials were retrieved, two of which were stopped before recruiting the planned number of participants. In one study, the excess complications in the resorbable arm was declared as the reason for stopping the trial.
AUTHORS' CONCLUSIONS
This review illustrates that there are no published randomised controlled clinical trials relevant to this review question. There is currently insufficient evidence for the effectiveness of resorbable fixation systems compared with conventional titanium systems for facial fractures. The findings of this review, based on the results of the aborted trials, do not suggest that resorbable plates are as effective as titanium plates. In future, the results of ongoing clinical trials may provide high level reliable evidence for assisting clinicians and patients for decision making. Trialists should design their studies accurately and comprehensively to meet the aims and objectives defined for the study.
Topics: Absorbable Implants; Bone Plates; Facial Bones; Fracture Fixation, Internal; Humans; Skull Fractures; Titanium
PubMed: 29797347
DOI: 10.1002/14651858.CD007158.pub3 -
Orthopaedic Journal of Sports Medicine Oct 2023Glenohumeral dislocations often lead to glenoid bone loss and recurrent instability, warranting bony augmentation. While numerous biomechanical studies have investigated... (Review)
Review
BACKGROUND
Glenohumeral dislocations often lead to glenoid bone loss and recurrent instability, warranting bony augmentation. While numerous biomechanical studies have investigated fixation methods to secure a graft to the glenoid, a review of available constructs has yet to be performed.
PURPOSE
To synthesize the literature and compare the biomechanics of screw and suture button constructs for anterior glenoid bony augmentation.
STUDY DESIGN
Systematic review.
METHODS
A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. There were 2 independent reviewers who performed a literature search using the PubMed, Embase, and Google Scholar databases of studies published between 1950 and 2020. Studies were included that compared the biomechanical outcomes of fixation for the treatment of anterior shoulder instability with glenoid bone loss.
RESULTS
Overall, 13 of the 363 studies screened met the inclusion criteria. The included studies measured the biomechanical strength of screws or suture buttons on a cadaveric or synthetic Latarjet construct. Screws and suture buttons were biomechanically similar, as both constructs exhibited comparable loads at failure and final displacement. Screw type (diameter, threading, or composition) did not significantly affect construct strength, and double-screw fixation was superior to single-screw fixation. Additionally, 2 screws augmented with a small plate had a higher load at failure than screws that were not augmented. Unicortical double-screw fixation was inferior to bicortical double-screw fixation, although construct strength did not significantly decrease if 1 of these screws was unicortical. Further, 2 screws inserted at 15° off axis experienced significantly higher graft displacement and lower ultimate failure loads than those inserted at 0° parallel to the glenoid.
CONCLUSION
Suture buttons provided comparable strength to screws and offer an effective alternative to reduce screw-related complications. Augmentation with a small plate may clinically enhance construct strength and decrease complications through the dispersion of force loads over a greater surface area. Differences in screw type did not appear to alter construct strength, provided that screws were placed parallel to the articular surface and were bicortical.
PubMed: 37840899
DOI: 10.1177/23259671231186429 -
Journal of Orthopaedics and... Feb 2022Press-fit cementless acetabular cup is widely used in total hip arthroplasty (THA). However, the use of additional screws for the acetabular cup has been extensively... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Press-fit cementless acetabular cup is widely used in total hip arthroplasty (THA). However, the use of additional screws for the acetabular cup has been extensively debated. The purpose of this review is to compare the stability, revision rate, wear rate, and clinical scores of cementless acetabular cups with and without screws in THA.
MATERIALS AND METHODS
Comprehensive literature searches of the following databases were performed: Cochrane Library, Pubmed, Web of Science, OVID, Elsevier ClinicalKey, Clinicaltrials.gov, and EMBASE. We searched for trials that compared cementless acetabular cups with screws or without screws, and were published in the English language. We evaluated the stability of the prosthesis by osteolysis and migration. The clinical scores included Harris hip scores (HHS) and pain scores.
RESULTS
Nineteen articles involving 4046 THAs met the inclusion criteria. Our analysis revealed that additional screws did not increase the stability of acetabular cups, and there was no statistical significance between the groups with and without screws in osteolysis and clinically relevant migration. Revision rates showed no significant difference between the groups with and without screws. There was no difference in wear between the two groups. Our analysis showed no difference in pain scores and HHS between groups.
CONCLUSION
Press-fit without screws could achieve sufficient acetabular cup stability. Acetabular cups without screws showed no difference from acetabular cups with screws in many outcomes. Additional screws are not required for cementless acetabular cups.
LEVEL OF EVIDENCE
Level III.
Topics: Acetabulum; Arthroplasty, Replacement, Hip; Bone Screws; Hip Prosthesis; Humans; Osteolysis; Prosthesis Design; Prosthesis Failure
PubMed: 35142933
DOI: 10.1186/s10195-022-00629-8