Costas Papakostidis

Topical tranexamic acid in total knee replacement: A systematic review and meta-analysis

BACKGROUND To examine the safety and efficacy of topical use of tranexamic acid (TA) in total knee arthroplasty (TKA). METHODS An electronic literature search of PubMed Medline; Ovid Medline; Embase; and the Cochrane Library was performed, identifying studies published in any language from 1966 to February 2013. The studies enrolled adults undergoing a primary TKA, where topical TA was used. Inverse variance statistical method and either a fixed or random effect model, depending on the absence or presence of statistical heterogeneity were used; subgroup analysis was performed when possible. RESULTS We identified a total of seven eligible reports for analysis. Our meta-analysis indicated that when compared with the control group, topical application of TA limited significantly postoperative drain output (mean difference: -268.36ml), total blood loss (mean difference=-220.08ml), Hb drop (mean difference=-0.94g/dL) and lowered the risk of transfusion requirements (risk ratio=0.47, 95CI=0.26-0.84), without increased risk of thromboembolic events. Sub-group analysis indicated that a higher dose of topical TA (>2g) significantly reduced transfusion requirements. CONCLUSIONS Although the present meta-analysis proved a statistically significant reduction of postoperative blood loss and transfusion requirements with topical use of TA in TKA, the clinical importance of the respective estimates of effect size should be interpreted with caution. LEVEL OF EVIDENCE I, II.

Prevalence of complications of open tibial shaft fractures stratified as per the Gustilo-Anderson classification.

The aim of the present study was to comparatively analyse certain outcome measures of open tibial fractures, stratified per grade of open injury and method of treatment. For this purpose, a systematic review of the English literature from 1990 until 2010 was undertaken, comprising 32 eligible articles reporting on 3060 open tibial fractures. Outcome measures included rates of union progress (early union, delayed union, late union and non-union rates) and certain complication rates (deep infection, compartment syndrome and amputation rates). Statistical heterogeneity across component studies was detected with the use of Cochran chi-square and I(2) tests. In the absence of significant statistical heterogeneity a pooled estimate of effect size for each outcome/complication of interest was produced. All component studies were assigned on average a moderate quality score. Reamed tibial nails (RTNs) were associated with significantly higher odds of early union compared with unreamed tibial nails (UTNs) in IIIB open fractures (odds ratio: 12, 95% CI: 2.4-61). Comparing RTN and UTN modes of treatment, no significant differences were documented per grade of open fractures with respect to both delayed and late union rates. Surprisingly, nonunion rates in IIIB open fractures treated with either RTNs or UTNs were lower than IIIA or II open fractures, although the differences were not statistically significant. Significantly increased deep infection rates of IIIB open fractures compared with all other grades were documented for both modes of treatment (RTN, UTN). However, lower deep infection rates for IIIA open fractures treated with RTNs were recorded compared with grades I and II. Interestingly, grade II open tibial fractures, treated with UTN, presented significantly greater odds for developing compartment syndrome than when treated with RTNs. Our cumulative analysis, providing for each grade of open injury and each particular method of treatment a summarised estimate of effect size for the most important outcome measures of open tibial fractures, constitutes a useful tool of the practicing surgeon for optimal decision making when operative treatment of such fractures is contemplated.

Pelvic ring injuries with haemodynamic instability: efficacy of pelvic packing, a systematic review

OBJECTIVE To assess the role of pelvic packing as an emergency therapeutic intervention in pelvic fractures with concomitant haemodynamic instability. METHODS A systematic review of the literature in English from the past two decades yielded only three eligible studies. Clinical and methodological heterogeneity across the component studies was assessed by careful recording of certain descriptive characteristics. Statistical heterogeneity was detected using Cochran chi-square and I2 tests. The principal outcomes of interest were early mortality (within 24 hours of injury), late mortality (within the first month) and certain complications (infection and multiple organ failure (MOF)). RESULTS Methodological and clinical heterogeneity was evident across component studies, although it was not strongly associated with the observed results. All component studies were assigned a low to moderate quality score. The pooled estimates of effect size for mortality were as follows: early mortality rate 10% (95% confidence intervals [95 CI]: 3-18%), late mortality rate 13% (95 CI: 5-22%), overall mortality 28% (95 CI: 16.8-39.4%). As for the recorded complications, a pooled estimate of 35%, (95 CI: 21-48%) was calculated for infection rate and 9%, (95 CI: 2-16%) for MOF rate. Apart from one study, in which pelvic packing was used exclusively as an emergency resuscitative procedure, pelvic angiography played a significant complementary role to pelvic packing for final haemorrhage control in the other two studies. CONCLUSION Haemodynamically unstable pelvic ring injuries are characterised by significant mortality and complications. Pelvic packing, as a part of a damage control protocol, could potentially aid in early intrapelvic bleeding control and provide crucial time for a more selective management of haemorrhage.

Efficacy of autologous iliac crest bone graft and bone morphogenetic proteins for posterolateral fusion of lumbar spine: a meta-analysis of the results

Study Design. Meta analysis of randomized control trials. Objective. To evaluate the radiographic and clinical effectiveness of bone morphogenetic proteins (BMPs) within the context of posterolateral fusion of the lumbar spine (LS). Summary of Background Data. Various bone graft substitutes have been used in the setting of posterolateral lumbar fusions. Recently, great interest has been shown in BMPs. Clinical trials have tested the efficacy of BMPs to iliac crest bone graft (ICBG) in posterolateral fusion procedures of the LS. A cumulative result of these studies would give more credit to the final conclusions. Methods. A systematic search of electronic databases, and references from eligible articles was conducted. Comparative studies reporting on the results of posterolateral fusion for treatment of degenerative disease of LS and including 2 treatment groups either ICBG (control group) or BMP (experimental group) for achievement of fusion were regarded eligible. A pooled estimate of effect size was produced using both random and fixed effect model. Results. Seven randomized control trials (n = 331 patients) and 1 prospective comparative study (n = 52 patients) were included in the present study. BMPs appeared more efficacious to ICBG in achieving solid fusion [relative risk (RR) = 0.42, 95% confidence interval (CI) = 0.28–0.61, P < 0.00001], but with significant heterogeneity (I2 = 42.5%). rBMP-2 was more efficacious to ICBG in promoting fusion (RR = 0.29, 95% CI = 0.18–0.47, P < 0.00001), whereas rhBMP-7 (osteogenic protein-1) appeared equivalent to ICBG in that respect (RR = 1.17, 95% CI = 0.54–2.54, P = 0.70). Patients treated with BMPs had a shorter hospitalization (by 1.03 days, 95% CI = 0.61–1.45 days) compared with those that were treated with ICBG. BMPs appeared more efficient in instrumented than noninstrumented posterolateral fusions. Conclusion. Although the radiographic results appeared better in the group of BMPs, the exact role of type, dose and carrier of BMPs and the cost-effectiveness of their use need further clinical delineation.

The role of arterial embolization in controlling pelvic fracture haemorrhage: A systematic review of the literature

OBJECTIVE To evaluate the efficacy of emergency transcatheter arterial embolization (TAE) in controlling retroperitoneal arterial haemorrhage associated with unstable pelvic fractures. METHODS A systematic review of the English literature yielded 21 eligible studies published from 1979 to 2010. Evaluation of clinical and methodological heterogeneity was based on recording certain descriptive characteristics in the component studies. Statistical heterogeneity was detected using Cochran chi-square and I square tests and, when absent, a pooled estimate of effect size for each outcome of interest was calculated. The principal outcomes of interest were efficacy rate of TAE to control intrapelvic bleeding, mortality rates and frequency of associated complications. RESULTS All component studies were assigned a low to moderate quality score. Methodological and clinical heterogeneity was evident across component studies, but not strongly associated with the observed results. The efficacy rate of TAE ranged from 81 to 100%, while the frequency of repeat TAE for effective control of haemorrhage was 10% (95% CI: 7-13%, range: 0-19%). TAE was associated with an overall mortality ranging from 7 to 47%, and a 0-25% mortality due to intrapelvic bleeding (pooled estimate of effect size: 6%, 95% CI: 4-8%). A very low rate of associated complications were recorded in the component studies (pooled estimate of effect size: 1.1%, 95% CI: 0.1-2.1%). CONCLUSION TAE is an efficient acute intervention for controlling severe arterial bleeding related to pelvic trauma with a low complication rate. Repeat of the procedure is occasionally necessary before the effective haemorrhage control.

The role of "cell therapy" in osteonecrosis of the femoral head. A systematic review of the literature and meta-analysis of 7 studies.

Background and purpose — The value of core decrompression for treatment of osteonecrosis of the femoral head (ONFH) is unclear. We investigated by a literature review whether implantation of autologous bone marrow aspirate, containing high concentrations of pluripotent mesenchymal stem cells, into the core decompression track would improve the clinical and radiological results compared with the classical method of core decompression alone. The primary outcomes of interest were structural failure (collapse) of the femoral head and conversion to total hip replacement (THR). Patients and methods — All randomized and non-randomized control trials comparing simple core decompression with autologous bone marrow cell implantation into the femoral head for the treatment of ONFH were considered eligible for inclusion. The methodological quality of the studies included was assessed independently by 2 reviewers using the Cochrane Collaboration tool for assessing risk of bias in randomized studies. Of 496 relevant citations identified, 7 studies formed the basis of this review. Results — The pooled estimate of effect size for structural failure of the femoral head favored the cell therapy group, as, in this treatment group, the odds of progression of the femoral head to the collapse stage were reduced by a factor of 5 compared to the CD group (odds ratio (OR) = 0.2, 95% CI: 0.08–0.6; p = 0.02). The respective summarized estimate of effect size yielded halved odds for conversion to THR in the cell therapy group compared to CD group (OR = 0.6, 95% CI: 0.3–1.02; p = 0.06). Interpretation — Our findings suggest that implantation of autologous mesenchymal stem cells (MSCs) into the core decompression track, particularly when employed at early (pre-collapse) stages of ONFH, would improve the survivorship of femoral heads and reduce the need for hip arthroplasty.

Femoral-shaft fractures and nonunions treated with intramedullary nails: the role of dynamisation.

Dynamisation of a previously interlocked intramedullary nail is believed to stimulate an osteogenic response due to increased load across the fracture site. The purpose of this study was to retrospectively investigate fracture patterns that could tolerate dynamisation without the risk of major complications. Thirty patients (24 males) with an average age of 33 years (17-90) were studied. As many as 21 suffered from a fresh femoral fracture, whereas the remaining nine patients suffered from femoral nonunions. Four patterns of osseous lesion were recognised in terms of mechanical stability under a dynamic nail and biological activity at the fracture/nonunion site: stable/hypertrophic, stable/atrophic, unstable/hypertrophic and unstable/atrophic osseous lesions. Complete union (within 6 months) occurred in 21 patients. Six fractures united within the 7th-11th post-dynamisation month and, in the remaining three cases, a nonunion developed. Significant femur shortening (>20 mm) was noticed in four patients and rotational malalignment in one patient. Logistic regression analysis revealed high odds ratio (OR=70, 95% confidence interval (CI) 2.5-1998) for the unstable/atrophic pattern of osseous lesion to develop major complications. In the unstable/atrophic pattern of osseous lesion, dynamisation should never be done, as it could lead to significant complications.

Femoral biologic plate fixation

New techniques of fracture fixation such as indirect reduction, careful soft tissue handling, and elastic fixation are being used in place of older methods of mechanical stabilization. These new techniques led to the concept of biologic plate fixation. We systematically reviewed the literature and provide an overall evaluation of femoral biologic fixation for fracture treatment. We analyzed 19 studies with 687 patients with 697 femoral fractures. Twenty-three percent of the fractures were subtrochanteric, 29% were diaphyseal, and 48% were supracondylar. Twenty-two percent were open fractures. The majority (81%) were comminuted and AO Types B and C. The overall union rate was 98.4%, with a mean time to union ranging from 10.7 to 24 weeks. Primary or secondary bone-grafting procedures were reported in all but one study with a frequency ranging from 0-55%. The most frequently recorded complications were malunion (0-29%) and reoperation (0-23%). The high union rate, low infection rate (2%), and occasional need for bone graft indicate biologic plate fixation is a viable alternative to modern nailing techniques, particularly in patients with polytrauma.Level of Evidence: Therapeutic study, Level III. See the Guidelines for Authors for a complete description of levels of evidence.

Timing of internal fixation of femoral neck fractures. A systematic review and meta-analysis of the final outcome

The aim of the present study was to evaluate the effect of timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. We undertook a systematic review of the literature adhering to the PRISMA guidelines. There were 7 eligible reports for the final analysis. The methodological quality of component studies was assessed with the Coleman Methodology Score (CMS). Each included study was assigned a score independently by the two reviewers. The final score of each individual study constituted the average value of the scores given by the two reviewers. The agreement between the two assessors was tested with intraclass correlation coefficient (ICC). The CMS ranged from 37 to 64 within component studies (mean: 46.5, SD: 10.8, median: 41). The ICC was 0.94 (95% CI: 0.69-0.99), implying a nearly perfect agreement between the two assessors. Based on the available data regarding the timing of operative fixation of the femoral neck fractures, 4 discreet pairs of comparison groups could be created: (1) fractures fixed within 6h from injury versus fractures fixed after 6h from injury; (2) fractures fixed within 12h versus after 12h; (3) fractures fixed within 24h versus after 24h; and (4) fractures fixed within 6h versus after 24h. Outcome measures were analyzed within each one of the above pairs of treatment groups. The following subgroups analyses were a priori decided: (1) initial fracture displacement (displaced vs. undisplaced fractures); (2) fixation method (cannulated screws vs. sliding hip screw); (3) quality of reduction (anatomic vs non-anatomic reduction). This study failed to prove any essential association between timing of NOF fracture internal fixation and incidence of AVN. With respect to non-union though, it indicated that delay of internal fixation of more than 24h could increase substantially the odds of non-union.

The role of plating in the operative treatment of severe open tibial fractures: a systematic review

Open fractures of the tibial diaphysis are the result of high-energy trauma. They are usually associated with extensive soft tissue loss and represent serious clinical problems. Surgical treatment of these injuries has been associated with substantial complications such as osteomyelitis, delayed bone healing, poor functional outcome, soft-tissue failure, or even amputations. More recently a staged treatment, with initial application of spanning external fixators followed by definitive fixation at secondary phase, has been advocated. Plating of these fractures in the acute setting remains a topic of heated discussion. A systematic review of the literature was carried out in order to investigate the existing evidence concerning the efficacy and safety of this method of osteosynthesis. Eleven papers met the inclusion criteria, accumulating 492 open tibial fractures treated with plating. The overall union rate ranged from 62–95% across all studies, with time to union ranging from 13–42 weeks. The reoperation rate ranged from 8–69% and a pooled estimate of deep infection rate was calculated at 11%. Plate fixation for the treatment of open tibial fractures can be considered under specific conditions which need to be elicited and clarified with future well-designed and conducted clinical trials.RésuméLes fractures ouvertes de la diaphyse tibiale sont généralement secondaires à un traumatisme violent. Elles sont généralement associées avec des lésions ou des pertes de substance des tissus mous. Ceci entraîne de sérieux problèmes thérapeutiques. Le traitement chirurgical de ces traumatismes est émaillé de sérieuses complications: infections, retards de consolidation, problèmes fonctionnels, lésions persistantes des tissus mous, ces complications pouvant parfois conduire à une amputation. Récemment, un traitement en deux étapes a été mis au point avec mise en place initiale d’un fixateur externe, suivi secondairement par une fixation définitive. L’ostéosynthèse par plaques de ces fractures, en période aigue reste un domaine très discuté. Une revue systématique de la littérature nous a permis d’évaluer les résultats de cette méthode d’ostéosynthèse. 11 articles regroupant 492 fractures ouvertes traitées par plaque ont pu être recensés. Le taux de consolidation varie de 62 à 95% avec un temps de consolidation de 13 à 42 semaines. Le taux de réintervation varie également de 8 à 69% et le taux d’infection profonde peut être estimé à 11%. L’ostéosynthèse par plaque dans le traitement des fractures ouvertes peut être considérée, sous certaines conditions, comme un traitement dont les résultats peuvent être parfaitement définis ceci nécessitant également quelques études ultérieures.