Recent Submissions

  • The onset, progress and factors influencing degenerative arthritis of the wrist following scaphoid fracture non-union

    Dias, Joseph; Kheiran, Amin; Adeleye, Emmanuel; Wildin, Clare; Ullah, Aamer; Bhowal, Bhaskar
    Background/aims: Scaphoid non-union causes osteoarthritis but factors associated are poorly understood. We investigated the rate of osteoarthritis after scaphoid fracture non-union, and if duration and fracture location influenced arthritis and its severity. Methods: This retrospective cross-sectional observational study of 278 consecutive cases with scaphoid fracture non-union retrieved data on demographics, non-union duration, fracture location, dorsal intercalated segment instability (DISI), severity and distribution of wrist arthritis. Patient Evaluation Measure (PEM) and Quality of Life assessed impact on patients. Regression models investigated prediction of osteoarthritis by different variables. Time-to-event analysis investigated osteoarthritis evolution. Missing (MAR) data for the PEM and QoL was imputed and analysed. Results: 278 patients, 246 males, aged 27.9 years (range 11 to 78 years), with a scaphoid fracture non-union confirmed on computed tomography (CT) scans (243) and plain radiographs (35) were reviewed. The interval between injury and imaging was 3.3 years (SD 5.9 years; range 0.1-45). The fracture was proximal to the ridge in 162, distal to the ridge in 83 and in the proximal 20% in 33. DISI (RLA ≥ 10°) occurred in 93.5% (260/278). Osteoarthritis was identified in 62.2% (173/278), and we classified a SNAC pattern in 93.6% (162/173). Of these, 100 (61.7%) had SNAC 1, 22 (13.6%) SNAC 2, 17 (10.5%) SNAC 3, and 23 (14.2%) SNAC 4. The mean duration in years for SNAC 1, 2, 3 and 4 were 2.5, 6.0, 8.2, and 11.3 years respectively. In fractures proximal to the ridge, 50% had arthritis in 2.2 years. Whereas in proximal pole, and distal to the ridge, 50% developed in 3.8 and 6.6 years, respectively. The PEM score was 42.8% (SD 18.9%) in those without arthritis and 48.8% (SD 21.5%) in those with arthritis. The mean QoL was 0.838 in patients without SNAC and 0.792 with SNAC. Conclusion: Scaphoid fracture non-union caused early carpal collapse, majority had osteoarthritis usually observed within a year following injury and occurred earliest in proximal waist fractures. Distribution of osteoarthritis (SNAC stage) may not always follow a distinctive pattern, as previously described.
  • Desmoid fibromatosis associated with Endobutton use for anterior cruciate ligament reconstruction

    Onafowokan, Oluwatobi; Aujla, Randeep; Eastley, Nicholas; Ashford, Robert
    No abstract available
  • Intra-articular steroid injections in large joint arthritis: A survey of current practice

    Loumpardias, Georgios; Boksh, Khalis; Chong, Han Hong; Eastley, Nicholas
    Introduction: Intra-articular corticosteroid injections are widely used as a management modality for mild large joint osteoarthritis (OA). In contrast, there is little guidance or consensus on the use of steroids in moderate to severe disease. The aim of this study is to explore the current practice of surgeons in relation to the use of therapeutic intra-articular steroid injections in patients awaiting large joint arthroplasty for OA. Methods: An anonymous questionnaire was distributed to consultants performing large joint arthroplasty in four National Health Service Trusts. Participants were questioned on their use of intra-articular therapeutic steroid injections in patients listed for elbow, shoulder, hip or knee arthroplasty. Data was collected over 6 months and analysed using Microsoft Excel. Results: A total of 42 surgeons were included in the study with the majority performing lower limb arthroplasty (73%). About 21 (50%) surgeons indicated they would perform injections in the patient group of interest. Two would perform an unlimited number of injections, whilst the remainder would perform between one and three injections. Respondents most commonly indicated they would tell patients that an injection would provide between 6 and 12 weeks of benefit (14 of 39 surgeons, 36%). Most injecting surgeons (88%) leave 4 months between an injection and subsequent arthroplasty due to increased risk of infection if surgery is performed sooner. Conclusion: This study demonstrates variation in practice in the use of intra-articular steroids in the analysed patient group, and the way surgeons council their patients. National or specialist society guidelines may help to reduce this variation in practice.
  • Should Arthroscopic Bone Marrow Stimulation Be Used in the Management of Secondary Osteochondral Lesions of the Talus? A Systematic Review

    Bhatia, Maneesh
    Background: Osteochondral lesions of the talus are common, particularly after trauma. Arthroscopic bone marrow stimulation has emerged as the first-choice surgical treatment for small primary lesions less than 100 mm2. Individual studies on the topic are small and heterogeneous, and they have differed in their main findings; for this reason, systematically reviewing the available evidence seems important. Questions/purposes: In this systematic review, we asked: (1) What patient-reported outcomes and pain scores have been observed after arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus? (2) What complications were reported? (3) What demographic and clinical factors were reported to be associated with better patient-reported outcome scores? Methods: We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using Embase, EmCare, PubMed, CINAHL, and Scopus (databases last searched June 23, 2021). A two-stage title/abstract and full-text screening process was performed independently by two reviewers. Randomized control trials, cohort studies, and observational studies published in English that evaluated the outcome of arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus were included. Case reports, review articles, commentaries, abstracts, and letters to the editor were excluded. A total of 12 articles (10 case series and two retrospective comparative studies) involving 446 patients were included. Of these, 111 patients with a mean age of 33 years (range 20 to 49) received arthroscopic bone marrow stimulation for a secondary osteochondral lesion of the talus. The Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess the methodologic quality of included studies. The MINORS is a numerical score ranging from 0 to 16 for studies with no comparison group and 0 to 24 for comparative studies, with higher quality studies receiving higher scores. Of the 10 noncomparative case series, the highest score was 10 of 16, with a median (range) score of 7.5 (4 to 10), while the two comparative studies scored 22 of 24 and 19 of 24, respectively. Results: Studies varied widely in terms of patient-reported outcome measures such as the American Orthopaedic Foot and Ankle Society score (AOFAS), with inconsistent reporting across studies regarding whether or how much patients improved; there was variation in some effect sizes with regard to improvement seeming close to or below the minimum clinically important difference (MCID). Although no perioperative complications were reported in any included studies, 34% (26 of 77, in seven studies that reported on this endpoint) of patients who underwent a revision procedure. One study found a negative association between lesion size and AOFAS and VAS score. No other studies reported on factors associated with patient-reported outcome scores, and most studies were far too small to explore relationships of this sort. Conclusion: We found that arthroscopic bone marrow stimulation for secondary osteochondral lesions of the talus yielded inconsistent and often small improvements in patient-reported outcomes, with approximately one in three patients undergoing a revision procedure. Reported outcomes likely represent a best-case scenario, inflated by low-level study designs and major sources of bias that are known to make treatment effects seem larger than they are. Therefore, the use of arthroscopic bone marrow stimulation in such patients cannot be recommended, unless we are able to refine selection criteria to effectively identify patients who show a substantial clinical benefit.
  • Alteration of anterior cruciate ligament orientation in knees with trochlear dysplasia: description of a novel angle on MRI

    Esler, Colin; Rennie, Winston (2022)
    Aim: To assess changes in anterior cruciate ligament (ACL) geometry and inclination in trochlear dysplasia (TD) and analyse their significance. Materials and methods: Ninety-nine consecutive knees with TD and 23 normal knee magnetic resonance imaging (MRI) examinations were included as controls (n=122). Varying degrees of TD were classified into four distinct groups (A-D) according to the Dejour classification. MRI images were reviewed independently to measure four ACL angles. Interobserver and intra-observer agreements with statistical significance were determined for TD and various angles. Results: A significant association was found between TD and two measured angles compared with the control group (sagittal ACL and anteromedial ACL angles, p<0.001 for each). The results indicate that TD can predispose to more vertical ACL inclination as measured in the coronal plane on MRI. No association was found with the Blumenstat angle. Conclusion: The present study found significant associations with TD and steeper sagittal ACL, which have been implicated in ACL failure. A novel angle (anteromedial ACL angle) is described which has significant association with TD and is specific for the anteromedial bundle as measured in the coronal plane. Careful consideration of ACL fibre orientation in the coronal plane on MRI is suggested in knees with TD and the use of this newly described angle in assessing ACL reconstruction (ACLR) grafts.
  • Ulnar variance in distal radial fractures: assessment and interpretation

    Johnson, Nick; Dias, Joseph
    We explored patterns of shortening of the distal radius and investigated the effect of displacement on 'ulnar variance' in 250 patients with distal radial fractures. A small number of patients (5%) had a fracture that resulted in true shortening. Thirty-two per cent had fractures that appeared short, but lateral radiographs revealed that the articular surface was tilted, with either the anterior or dorsal rim of the articular surface being proximal to the distal ulna but the other rim was distal to it. We recommend initial assessment of variance on lateral radiographs. If the anterior and dorsal rims of the distal radial articular surface are proximal to the distal ulna, then true shortening is present and lengthening and stabilization, to hold the radius distracted, should be considered. If only one rim is proximal to the distal ulna, then correction of the tilt will lessen the apparent positive variance.
  • The importance of the early appropriate management of foot and ankle soft tissue sarcomas - experiences of a regional sarcoma service

    Kheiran, Amin; Eastley, Nicholas; Hanson, Josephine; McCulloch, Thomas; Allen, Patricia; Ashford, Robert (2022)
    Introduction: Soft tissue sarcomas (STS) are a group of rare malignant tumours that can occur at almost any anatomical location in patients of any age, which often present to health care professional working outside a recognised sarcoma service. A review of foot and ankle STSs was conducted, reporting on patient and tumour characteristics, and patient outcome following surgery performed within and outside our sarcoma service. Patients and methods: A retrospective review of all foot and ankle STSs managed by our sarcoma service over a 14 year period was performed. Patient demographics, tumour characteristics, management and patient outcomes including recurrence rates and survival were analysed. Results: Twenty-six patients were analysed (16F:10M) with a mean age of 57.7 years (range 17-87). The mean follow-up was 6.3 years (range 1-16). Sixteen tumours involved the foot, nine the ankle, and one spanned the foot and ankle. Mean tumour size was 4.3 cm (range 0.8-15), although 61% of cases were smaller than 4 cm, and almost one third of cases smaller than 1 cm. Seven of 26 (27%) cases were diagnosed after an unplanned excision performed by non sarcoma surgeons. These patients were more likely to undergo an incomplete tumour excision (p < 0.001), suffer local recurrence (p = 0.001), and eventually undergo a secondary amputation (p = 0.034) than those patients managed exclusively by a sarcoma service. Overall, 12 (46%) patients died of their disease during follow up, equating to a five-year survival rate of 69%. Conclusion: Our data shows that unplanned excisions continue to be performed on foot and ankle STSs, and that these have detrimental effects on patients. Despite this, our results also show that these complex patients can be managed successfully when referred appropriately to a sarcoma service, prior to any surgical treatment. This highlights the importance of vigilance amongst all health care professionals managing any foot or ankle lumps, regardless of their size.
  • The UK foot and ankle COVID-19 national (FAlCoN) audit - Regional variations in COVID-19 infection and national foot and ankle surgical activity

    Houchen-Wollof, Linzy; Mangwani, Jitendra
    Aims: This paper details the impact of COVID-19 on foot and ankle activity in the UK. It describes regional variations and COVID-19 infection rate in patients undergoing foot and ankle surgery before, during and after the first national lock-down. Patients & methods: This was a multicentre, retrospective, UK-based, national audit on foot and ankle patients who underwent surgery between 13th January and 31st July 2020. Data was examined pre- UK national lockdown, during lockdown (23rd March to 11th May 2020) and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Regional, demographic and COVID-19 related data were captured. Results: 6644 patients were included. In total 0.53% of operated patients contracted COVID-19 (n = 35). The rate of COVID-19 infection was highest during lockdown (2.11%, n = 16) and lowest after lockdown (0.16%, n = 3). Overall mean activity during lockdown was 24.44% of pre-lockdown activity with decreases in trauma, diabetic and elective foot and ankle surgery; the change in elective surgery was most marked with only 1.73% activity during lock down and 10.72% activity post lockdown as compared to pre-lockdown. There was marked regional variation in numbers of cases performed, but the proportion of decrease in cases during and after lockdown was comparable between all regions. There was also a significant difference between rates of COVID-19 and timing of peak, cumulative COVID-19 infections between regions with the highest rate noted in South East England (3.21%). The overall national peak infection rate was 1.37%, occurring during the final week of lockdown. General anaesthetic remained the most common method of anaesthesia for foot and ankle surgery, although a significant increase in regional anaesthesia was witnessed in the lock-down and post-lockdown periods. Conclusions: National surgical activity reduced significantly for all cases across the country during lockdown with only a slow subsequent increase in elective activity. The COVID-19 infection rate and peaks differed significantly across the country.
  • Throat and voice problems in Ehlers-Danlos syndromes and hypermobility spectrum disorders

    Lam, Chon Meng (2021)
    A small number of case reports and observational studies describe chronic nasal congestion, upper airway obstruction, dysphonia, vocal cord abnormalities, and swallowing abnormalities in the Ehlers-Danlos syndromes. Little is known of the causes and therefore treatments of these, yet they are not uncommon findings in persons with hypermobility-related conditions presenting in the healthcare setting. We have a specialist multidisciplinary ear, nose, and throat and speech therapy practice with accumulating observational and empirical experience of managing these conditions, which include altered voice, choking, high dysphagia and anterior and deep neck pains. Here, we present our experience, some illustrative cases, and suggestions for future work in this evolving field.
  • Inflammation and physical dysfunction: responses to moderate intensity exercise in chronic kidney disease

    Watson, Emma L; Wilkinson, Thomas; Graham-Brown, Matthew; Major, Rupert; Ashford, Robert; Smith, Alice (2021)
    Background: People with chronic kidney disease (CKD) experience skeletal muscle wasting, reduced levels of physical function and performance, and chronic systemic inflammation. While it is known that a relationship exists between inflammation and muscle wasting, the association between inflammation and physical function or performance in CKD has not been well studied. Exercise has anti-inflammatory effects, but little is known regarding the effect of moderate intensity exercise. This study aimed to (i) compare systemic and intramuscular inflammation between CKD stage G3b-5 and non-CKD controls; (ii) establish whether a relationship exists between physical performance, exercise capacity and inflammation in CKD; (iii) determine changes in systemic and intramuscular inflammation following 12 weeks of exercise; and (iv) investigate whether improving inflammatory status via training contributes to improvements in physical performance and muscle mass. Methods: This is a secondary analysis of previously collected data. CKD patients stages G3b-5 (n = 84, n = 43 males) and non-CKD controls (n = 26, n = 17 males) underwent tests of physical performance, exercise capacity, muscle strength and muscle size. In addition, a subgroup of CKD participants underwent 12 weeks of exercise training, randomized to aerobic (AE, n = 21) or combined (CE, n = 20) training. Plasma and intramuscular inflammation and myostatin were measured at rest and following exercise. Results: Tumour necrosis factor-α was negatively associated with lower $^{^{^{.}}}{\rm V}$O2Peak (P = 0.01), Rectus femoris-cross sectional area (P = 0.002) and incremental shuttle walk test performance (P < 0.001). Interleukin-6 was negatively associated with sit-to-stand 60 performances (P = 0.006) and hand grip strength (P = 0.001). Unaccustomed exercise created an intramuscular inflammatory response that was attenuated following 12 weeks of training. Exercise training did not reduce systemic inflammation, but AE training did significantly reduce mature myostatin levels (P = 0.02). Changes in inflammation were not associated with changes in physical performance. Conclusions: Systemic inflammation may contribute to reduced physical function in CKD. Twelve weeks of exercise training was unable to reduce the level of chronic systemic inflammation in these patients, but did reduce plasma myostatin concentrations. Further research is required to further investigate this.
  • Primary skeletal muscle cells from chronic kidney disease patients retain hallmarks of cachexia in vitro

    Graham-Brown, Matthew; Major, Rupert; Ashford, Robert; Smith, Alice; Watson, Emma L (2022)
    Background: Skeletal muscle wasting and dysfunction are common characteristics noted in people who suffer from chronic kidney disease (CKD). The mechanisms by which this occurs are complex, and although progress has been made, the key underpinning mechanisms are not yet fully elucidated. With work to date primarily conducted in nephrectomy-based animal models, translational capacity to our patient population has been challenging. This could be overcome if rationale developing work could be conducted in human based models with greater translational capacity. This could be achieved using cells derived from patient biopsies, if they retain phenotypic traits noted in vivo. Methods: Here, we performed a systematic characterization of CKD derived muscle cells (CKD; n = 10; age: 54.40 ± 15.53 years; eGFR: 22.25 ± 13.22 ml/min/1.73 m2 ) in comparison with matched controls (CON; n = 10; age: 58.66 ± 14.74 years; eGFR: 85.81 ± 8.09 ml/min/1.73 m2 ). Harvested human derived muscle cells (HDMCs) were taken through proliferative and differentiation phases and investigated in the context of myogenic progression, inflammation, protein synthesis, and protein breakdown. Follow up investigations exposed HDMC myotubes from each donor type to 0, 0.4, and 100 nM of IGF-1 in order to investigate any differences in anabolic resistance. Results: Harvested human derived muscle cells isolated from CKD patients displayed higher rates of protein degradation (P = 0.044) alongside elevated expression of both TRIM63 (2.28-fold higher, P = 0.054) and fbox32 (6.4-fold higher, P < 0.001) in comparison with CONs. No differences were noted in rates of protein synthesis under basal conditions (P > 0.05); however, CKD derived cells displayed a significant degree of anabolic resistance in response to IGF-1 stimulation (both doses) in comparison with matched CONs (0.4 nm: P < 0.001; 100 nM: P < 0.001). Conclusions: In summary, we report for the first time that HDMCs isolated from people suffering from CKD display key hallmarks of the well documented in vivo phenotype. Not only do these findings provide further mechanistic insight into CKD specific cachexia, but they also demonstrate this is a reliable and suitable model in which to perform targeted experiments to begin to develop novel therapeutic strategies targeting the CKD associated decline in skeletal muscle mass and function.
  • Non-surgical treatments for Morton's neuroma: A systematic review

    Thomson, Lauren; Divall, Pip; Bhatia, Maneesh (2020-10)
    Background: Morton's neuroma (MN) is an entrapment degenerative neuropathy with a strong predilection for the 3rd interdigital web space. The objective of our study was to identify the most significant evidence produced for the non-operative treatment of Morton's neuroma and assess outcomes of these interventions. Method: The electronic databases Medline, Ovid EMBASE, CINAHL and Cochrane CENTRAL from inception to October 2018 were searched. Two independent reviewers assessed the quality of the studies using the Modified Coleman Criteria. Statistics were combined across cohort studies to calculate pooled mean results, and improvements in outcomes. Results: Initial electronic and hand search identified 486 studies. After title and abstract review there were 38 that went on to full-text review. Finally, 22 studies were included in the final review. We identified 9 different non-operative treatment modalities; Corticosteroid injection, Alcohol injection, Extra-corporeal Shockwave therapy (ESWT), Radiofrequency Ablation (RFA), Cryoablation, Capsaicin injection, Botulinum toxin, Orthosis and YAG Laser Therapy. Corticosteroid showed a statistically significant reduction in mean VAS over all their studies (p < 0.01), with 50% success at 12 months. Alcohol showed promising short-term pain-relieving results only. Orthotics, Capsaicin injections, Cryoablation, Botulinum toxin, RFA and ESWT did show statistically significant improvements, but with limitation to their application. Conclusion: Following review, the authors would recommend the use of corticosteroid injections to treat Morton's neuromas. The authors feel that radio-frequency ablation and cryoablation would benefit from further well designed randomised controlled trials.
  • Risk of hip fracture following a wrist fracture-A meta-analysis

    Johnson, Nick; Stirling, Euan; Thompson, John R.; Ullah, Aamer; Divall, Pip; Dias, Joseph (2017-02)
    Aims: This purpose of this meta analysis was to investigate and quantify the relative risk of hip fracture in patients who have sustained a wrist fracture. Method: Studies were identified by searching Medline, Embase, Cochrane CENTRAL database and CINAHL from their inception to August 2015. Studies reporting confirmed hip fracture following wrist fracture were included. Data extraction was carried out using a modified Cochrane data collection form by two reviewers independently. Quality assessment was carried out using a modified Coleman score and the Newcastle Ottawa scale for cohort studies. An assessment of bias was performed for each study using a modified Cochrane Risk of Bias tool. A pooled relative risk(RR) was estimated with 95% CI from the RR/HRs and CIs reported in the studies. Results: 12 studies were included in the final meta-analysis (4 male, 8 female only). Relative risk of hip fracture following wrist fracture for women was 1.43 (CI 1.27 to 1.60). In men it was not significantly increased (RR 2.11, 95% CI: 0.93-4.85). Heterogeneity was low (I squared 0%) for both groups so a fixed effects model was used. Conclusion: Risk of a subsequent hip fracture is increased for women who suffer a wrist fracture (RR 1.43). Resources and preventative measures should be targeted towards these high risk patients to prevent the catastrophic event of a hip fracture. This meta analysis confirms and quantifies the increased relative risk of hip fracture after wrist fracture in women.
  • Origins of the threshold for surgical intervention in intra-articular distal radius fractures.

    Esworthy, George; Johnson, Nick; Divall, Pip; Dias, Joseph (2021-09)
    AIMS: The aim of this study was to identify the origin and development of the threshold for surgical intervention, highlight the consequences of residual displacement, and justify the importance of accurate measurement. METHODS: A systematic review of three databases was performed to establish the origin and adaptations of the threshold, with papers screened and relevant citations reviewed. This search identified papers investigating functional outcome, including presence of arthritis, following injury. Orthopaedic textbooks were reviewed to ensure no earlier mention of the threshold was present. RESULTS: Knirk and Jupiter (1986) were the first to quantify a threshold, with all their patients developing arthritis with > 2 mm displacement. Some papers have discussed using 1 mm, although 2 mm is most widely reported. Current guidance from the British Society for Surgery of the Hand and a Delphi panel support 2 mm as an appropriate value. Although this paper is still widely cited, the authors published a re-examination of the data showing methodological flaws which is not as widely reported. They claim their conclusions are still relevant today; however, radiological arthritis does not correlate with the clinical presentation. Function following injury has been shown to be equivalent to an uninjured population, with arthritis progressing slowly or not at all. Joint space narrowing has also been shown to often be benign. CONCLUSION: Knirk and Jupiter originated the threshold value of 2 mm. The lack of correlation between the radiological and clinical presentations warrants further modern investigation. Measurement often varies between observers, calling a threshold concept into question and showing the need for further development in this area. The principle of treatment remains restoration of normal anatomical position.
  • Dorsal bridge plating versus. Transarticular screw fixation for lisfranc injuries: A systematic review and meta-analysis

    Boksh, Khalis; Divall, Pip; Mangwani, Jitendra; Sharma, Ashwini (2020)
    Lisfranc injuries are relatively uncommon but carry devastating consequences if left untreated. Although many surgical techniques have been proposed for best operative management, there is an ongoing debate over which procedure is superior. We performed a systematic review and meta-analysis comparing the outcomes of transarticular screw fixation and dorsal bridge plating in management of Lisfranc injuries. Ovid MEDLINE, Ovid Embase and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised controlled trials (RCTs) and cohort studies comparing the outcomes between screw and dorsal plate fixation. The pooled outcome data were calculated by random and fixed effect models. One prospective cohort and three retrospective studies were identified with a total of 210 patients with mean follow up of 40.6 months. All papers were analysed for quality using the modified Newcastle Ottawa score. The results show that dorsal bridge plating is associated with better American Orthopaedic Foot and Ankle Society score (AOFAS) compared with transarticular screw fixation (OR - 0.71, 95% CI -1.31 to -0.10, p = 0.02). Dorsal plating may also be associated with fewer cases of arthritis, although this was not significant (OR 2.46, 95% CI 0.89 to 6.80, p = 0.08). We found no significant differences between the groups in terms of Foot Function Index (FFI), post traumatic arthritis and failure of hardware material. Although our results suggest dorsal bridge plating may provide superior functional outcomes, there is a scarcity of literature with little robustness to make definitive conclusions. High quality randomised trials are required.
  • Use of Suture Tapes Versus Conventional Sutures for Arthroscopic Rotator Cuff Repairs: A Systematic Review and Meta-analysis

    Boksh, Khalis; Haque, Aziz; Sharma, Ashwini; Divall, Pip; Singh, Harvinder (2021)
    Background: Various suture materials are available for arthroscopic rotator cuff repair. More recently, suture tapes have become popular as they are perceived to be easier to use with less soft tissue irritation. However, little is known about their biomechanical and clinical properties compared with conventional sutures in rotator cuff repairs. Purpose: To perform a systematic review and meta-analysis on whether suture tapes are biomechanically superior to conventional sutures in arthroscopic rotator cuff repairs and whether this translates to superior functional outcomes and a lower incidence of retears. Study design: Meta-analysis. Methods: The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: (rotator cuff repair OR arthroscopic rotator cuff repair) AND ("tape" OR "wire" OR "cord" OR "suture"). Data pertaining to certain biomechanical properties (contact area, contact pressure, gap formation, load to failure, and stiffness), retears, and patient-reported outcome measures (PROMs) were extracted. The pooled outcome data were analyzed by random- and fixed-effects models. Results: After abstract and full-text screening, 7 biomechanical and 6 clinical studies were included. All biomechanical studies were on animals, with 91 suture tapes and 91 conventional sutures compared. Suture tapes had higher contact pressure (mean difference [MD], 0.04 MPa; 95% CI, 0.01-0.08; P = .02), higher load to failure (MD, 52.62 N; 95% CI, 27.34-77.90; P < .0001), greater stiffness (MD, 4.47 N/mm; 95% CI, 0.57-8.38; P = .02), and smaller gap formation (MD, -0.30 mm; 95% CI, -0.45 to -0.15; P < .0001) compared with conventional sutures. From the clinical analysis of the 681 rotator cuff repairs treated with a suture tape (n = 380) or conventional suture (n = 301), there were no differences in retear rates between the groups (16% vs 20% suture tape and wire, respectively; P = .26) at a mean of 11.2 months. Qualitatively, there were no differences in PROMs between the groups at a mean of 36.8 months. Conclusion: Although biomechanically superior, suture tapes showed similar retear rates and postoperative function to conventional sutures. However, higher-quality clinical studies are required to investigate whether there are no true differences.
  • Unconstrained metacarpophalangeal joint arthroplasties: a systematic review

    Divall, Pip; Aujla, Randeep; Sheikh, Nomaan; Bhowal, Bhaskar; Dias, Joseph (2017)
    Aims: We performed a systematic review of the current literature regarding the outcomes of unconstrained metacarpophalangeal joint (MCPJ) arthroplasty. Materials and methods: We initially identified 1305 studies, and 406 were found to be duplicates. After exclusion criteria were applied, seven studies were included. Outcomes extracted included pre- and post-operative pain visual analogue scores, range of movement (ROM), strength of pinch and grip, satisfaction and patient reported outcome measures (PROMs). Clinical and radiological complications were recorded. The results are presented in three groups based on the design of the arthroplasty and the aetiology (pyrocarbon-osteoarthritis (pyro-OA), pyrocarbon-inflammatory arthritis (pyro-IA), metal-on-polyethylene (MoP)). Results: Results show that pyrocarbon implants provide an 85% reduction in pain, 144% increase of pinch grip and 13° improvements in ROM for both OA and IA combined. Patients receiving MoP arthroplasties had a reduction in pinch strength. Satisfaction rates were 91% and 92% for pyrocarbon-OA and pyrocarbon-IA groups, respectively. There were nine failures in 87 joints (10.3%) over a mean follow-up of 5.5 years (1.0 to 14.3) for pyro-OA. There were 18 failures in 149 joints (12.1%) over a mean period of 6.6 years (1.0 to 16.0) for pyro-IA. Meta-analysis was not possible due to the heterogeneity of the studies and the limited presentation of data. Conclusion: We would recommend prospective data collection for small joint arthroplasties of the hand consisting of PROMs that would allow clinicians to come to stronger conclusions about the impact on function of replacing the MCPJs. A national joint registry may be the best way to achieve this.