Efort Open Reviews最新文献

Alkaptonuria is an extremely rare disorder of tyrosine metabolism caused by an autosomal recessive enzymatic deficiency of homogentisic acid (HGA) oxidase, causing its accumulation in collagenous structures, especially in hyaline cartilage. It is characterized by a triad of homogentisic aciduria, bluish-black discoloration of connective tissues (ochronosis) and arthropathy of the spine and large weight-bearing joints. Several clinical manifestations were described including coronary and valvular calcification, aortic stenosis, limited chest expansion, and renal, urethral and prostate calculi as well as ocular and cutaneous pigmentation. Skeletal affection usually presents as spondylotic changes of the spine. The knee is the most common peripheral joint to be involved. Enthesopathy or tendon ruptures may occur, and reduced bone density is not unusual. A low-protein diet and ascorbic acid may reduce HGA levels. Nitisinone can safely and effectively reduce HGA production and urinary excretion. In severe ochronotic arthropathy, joint arthroplasty can offer reliable pain relief and excellent functional outcomes. Cementless fixation is successful in young patients.

Purpose: The proximal femur is a frequent site of cancer dissemination in the extremities. Patients treated surgically for skeletal metastases have poorer overall health compared to other orthopedic patients, with only one-third expected to survive two years post-surgery. Choosing a treatment that minimizes revision risk and ensures the implant outlives the patient is therefore crucial. We conducted a systematic review to assess the revision rate following internal fixation (IF) or endoprosthetic reconstruction (EPR) of the proximal femur for metastatic bone disease (MBD).

Methods: This study adhered to the PRISMA guidelines. MEDLINE and Embase were searched, identifying 10,299 records. After removing duplicates, 7731 unique records were screened, 334 of which were retrieved for full-text screening. We included 34 studies in the qualitative synthesis. The MINORS instrument was used for quality assessment.

Results: The quality of the included studies was low to moderate, with median scores of 6/16 for non-comparative studies and 10/24 for comparative studies. We therefore refrained from a comparative analysis. Revision rates varied between 0 and 12.4% following EPR (25 studies) and between 0 and 26.7% following IF, while implant removal rates ranged between 0 and 8.3% and 0 and 26.7%, respectively.

Conclusions: Revision and implant removal rates for various methods of EPR and IF are satisfactory. However, a meta-analysis or comparison between IF and EPR is not feasible due to a lack of prospective studies, randomized trials and high-quality studies.

Wounds in orthopaedic surgery differ from wounds in other surgical fields in various ways. Tissues that are highly affected due to the trauma itself, the presence of an orthopaedic implant and the performance of prosthetic surgery in patients with many comorbidities make these wounds need special consideration. Complications of the surgical wound in orthopaedic surgery are not unusual, being the main cause of medical care and readmission in the first 90 days. There is no consensus on the best way to perform closure in orthopaedic surgery. The national 'Adequate Wound Management in Orthopaedic Surgery' survey has shown interindividual variability in wound closure and soft tissue management in orthopaedic surgery at the local level. This consensus document, generated by a group of experts in soft tissue management in orthopaedic surgery, proposes recommendations based on evidence (using the GRADE methodology) to promote best practices in this field. This document considers recommendations for surgical wound closure, dressing management and haemostasis. In addition, some of the 32 questions in the national survey, plus others relevant to the subject, were taken as a starting point for developing the contents.

Purpose: To evaluate the clinical and biomechanical evidence for the addition of acromioclavicular (AC) ligament repair and reconstruction in the surgical management of high-grade AC joint (ACJ) dislocation.

Methods: This is a systematic review of biomechanical and clinical studies that describe AC reconstructive or reparative techniques. The search ranged from 1946 to 2024 and included OVID, MEDLINE, PubMed, CINAHL, Embase, Google Scholar and the Cochrane Library databases. Clinical and biomechanical outcomes were evaluated.

Results: Thirty-two eligible studies were identified. Of these, four biomechanical studies focused on the ACJ exclusively. Twenty-eight other studies (15 clinical and 13 biomechanical) were identified involving reconstruction of the ACJ in addition to the treatment of the coracoclavicular (CC) ligaments. There was clinical evidence of improved outcomes with ACJ repair and reconstruction, although comparison was difficult. In comparative studies, ACJ-specific Taft and acromioclavicular joint instability scores were improved in patients with ACJ reconstruction. Constant score and subjective shoulder value also increased, although this was observed in studies lacking a control group. The biomechanical studies provide evidence of increased translational and rotational stability with ACJ repair and reconstruction, but the optimal technique has not been identified.

Conclusion: ACJ repair and reconstruction, in addition to CC repair, results in improved biomechanical and functional outcomes and should be considered when treating high-grade ACJ injuries. There is insufficient evidence in the literature to be able to recommend a specific technique to treat ACJ injuries.

Purpose: Total knee arthroplasty (TKA) in patients who underwent previous knee surgeries can be a challenging procedure both technically and for the complication rate. Conversion TKA is affected by a higher risk of infection compared to primary TKA. The aims of this meta-analysis are i) to compare the infectious risk among patients undergoing TKA after a prior hardware implantation, evaluating removal vs maintenance of the hardware, and ii) within the removal group, to compare staged vs concurrent procedure.

Methods: In accordance with the PRISMA guidelines, a systematic literature review was conducted up to January 2024. The review was registered in the PROSPERO database: CRD42024510444. The inclusion criteria comprised the following: i) patients aged 18 years or older, ii) individuals who had undergone total knee replacement and iii) those with a history of prior nonabsorbable hardware implantation. The pooled incidence of periprosthetic joint infections (PJI) was reported using odds ratios with corresponding 95% confidence intervals (CIs).

Results: The investigation of database and references identified 284 studies. PJI risks differed significantly among groups, with a higher risk in the removal group (z = 3.5630, P = 0.0004). Furthermore, within the removal group, the risk of PJI was lower in cases of staged removal compared to concurrent removal (z = 2.0931, P = 0.0363).

Conclusions: TKA following a previous knee hardware implantation indicates a higher PJI risk when the hardware is removed compared to leaving it in place. If hardware removal is necessary, staged removal is recommended. The presence of minor hardware is the only scenario where, if removal is necessary, one-stage approach is preferred.

Purpose: Evolving evidence demonstrates the role of epigenetics in the pathogenesis of osteoarthritis (OA), whereas in terms of mechanism, DNA methylation has received the highest attention thus far. This systematic review summarizes the current knowledge of DNA methylation and its influence on the pathogenesis of OA.

Methods: A protocol in alignment with the PRISMA guidelines was employed to systematically review eight bibliographic databases between 1 January 2015 and 31 January 2021, to identify associations between DNA methylation and articular chondrocytes in OA.

Results: We identified 23 gene-specific studies and 28 genome-wide methylation analyses. Gene-specific studies focused on pro-inflammatory markers in OA, demonstrating that DNA hypomethylation in the promoter region results in overexpression and hypermethylation is linked to gene silencing. Others reported on the association between OA risk genes and DNA methylation. Genome-wide methylation studies reported on differentially methylated regions (DMRs) comparing OA and non-OA chondrocytes. DMRs were seen in hip OA and knee OA chondrocytes.

Conclusion: The current body of literature demonstrates the potential and crucial role of DNA methylation in the pathogenesis and progression of OA. This knowledge contributes to the understanding of the pathomechanisms behind OA at gene-specific and genome-wide levels. The observed differences in DNA methylation between healthy and diseased tissues indicate the occurrence of changes in DNA methylation. Based on this, future research in this field that explores the characteristics of potentially reversible changes in DNA methylation may lead to opportunities for causative treatment options for OA.

Knee osteoarthritis (OA) is a common chronic condition that leads to joint pain and disability among older adults. An interprofessional collaborative approach has nowadays been widely advocated in knee OA management although little is known about the characteristics of care, roles and responsibilities of healthcare providers and how they collaborate as a team to optimise treatment outcomes. The Donabedian structure-process-outcome framework was used in the review. Six databases were searched from February 2013 to March 2023. A total of 26 articles that met our inclusion criteria were reported. All studies (n = 26) identified the physiotherapist as a critical member of the interprofessional team. Several studies (n = 5) have offered training to healthcare providers in the management of knee OA. The intervention components in most studies included disease-based education (n = 21) and exercise therapy (n = 16). A comprehensive understanding of the existing interprofessional knee OA care in this review could potentially assist the government and healthcare organisations in developing interprofessional practice guidelines and designing intervention programmes that maximise their benefits.

Purpose: Investigate intra- and post-operative complications and revisions following distal femoral and/or high tibial derotational osteotomies to correct rotational malalignments of the lower limb in patients with anterior knee pain (AKP) and/or patellofemoral instability (PFI).

Methods: A literature search was conducted on PubMed, EMBASE and Web of Science (until 30 September 2023), including studies reporting complications, reinterventions and revisions following knee derotational osteotomies. Incidence rates were collected for each level of derotational osteotomy (distal femur, high tibia or double-level). A meta-analysis using the Freeman-Tukey double arcsine transformation was conducted to estimate the pooled proportions with their 95% confidence intervals (CIs).

Results: Twenty-one studies involving 564 osteotomies (n = 484) were included, with a mean follow-up of 45.6 ± 15.7 months. The overall complication proportion was 7.5% (95% CI: 3.9-11.8%). Postoperative residual AKP was seen in a pooled proportion of 7.6% (95% CI: 0.7-18.8%), and persistent PFI was not common (0.1%; 95% CI: 0.0-1.7%). Intraoperative complications occurred in a pooled proportion of 3.8% (95% CI: 2.4-6.0%), with peroneal nerve injury being the most common (1.3%) after derotational high tibial osteotomy. Reintervention was needed in a pooled proportion of 13.0% (95% CI: 2.9-27.2%), primarily for hardware removal (n = 158; 28.3%). There was a pooled proportion of knees requiring revision procedures of 12.3% (95% CI: 2.6-26.1%).

Conclusions: Distal femur and high tibial derotational osteotomies exhibit a considerable incidence of intra- and post-operative complications. Peroneal nerve injury, although infrequent, is a significant complication, underscoring the importance of implementing intraoperative preventive measures during derotational high tibial osteotomy.

Purpose: A staged bilateral total knee arthroplasty (BTKA) procedure is considered when a patient is not deemed suitable for simultaneous BTKA due to concerns about the risk of mortality and complications. However, no network meta-analysis has been conducted to compare simultaneous vs staged BTKA procedures with different intervals in terms of postoperative mortality and overall complication rates.

Methods: Four databases - Medline, Embase, Cochrane Library and Web of Science - were searched from inception to December 19, 2023, for studies comparing patients who underwent staged BTKA with different intervals and simultaneous BTKA. The primary outcome domains were 1-year mortality and 90-day overall complications. Secondary outcomes included neurological, cardiovascular, pulmonary, infectious and venous thromboembolic complications within 90 days.

Results: Fifteen observational studies were included. Staged BTKA with intervals between 6 weeks and 3 months (odds ratio (OR): 0.69, 95% CI: 0.53-0.91), between 3 and 6 months (OR: 0.67, 95% CI: 0.53-0.84) and longer than 6 months (OR: 0.67, 95% CI: 0.55-0.83) exhibited a lower mortality risk compared to simultaneous BTKA. Staged BTKA with an interval shorter than 6 weeks and longer than 6 months exhibited a higher risk of pulmonary (OR: 1.24, 95% CI: 1.03-1.49; OR: 1.64, 95% CI: 1.10-2.44) and infectious complications (OR: 1.50, 95% CI: 1.15-1.96; OR: 1.52, 95% CI: 1.14-2.02) compared to simultaneous BTKA. An interval between 3 and 6 months ranked best in outcomes of 1-year mortality (P score = 0.7849) and 90-day complications (P score = 0.7077).

Conclusions: Staged BKTA with an interval of more than 6 weeks but less than 6 months is associated with a lower risk of postoperative mortality and complications. However, these results should be interpreted with caution due to potential biases inherent in the inclusion of nonrandomized studies.

Level of evidence: II.