Herman Johal

An evidence-based evaluation on the use of platelet rich plasma in orthopedics – a review of the literature

Within orthopedics, the use of platelet-rich plasma (PRP) has been rapidly increasing in popularity, however, its true effectiveness has yet to be fully established. Several studies find that injecting PRP to the site of injury does not provide any significant benefit with respect to clinical outcomes; however, many others report the contrary. Due to the conflicting evidence and multiple meta-analyses conducted on the topic, a literature review of high-quality evidence on the use of PRP for common orthopaedic conditions was performed. Thus far, the evidence appears to suggest that PRP may provide some benefit in patients who present with knee osteoarthritis or lateral epicondylitis. On the other hand, evidence appears to be inconsistent or shows a minimal benefit for PRP usage in rotator cuff repair, patellar and Achilles tendinopathies, hamstring injuries, anterior cruciate ligament (ACL) repair, and medial epicondylitis. There is limited confidence in the conclusions from the published meta-analyses due to issues with statistical pooling, and limited subgroup analyses exploring the substantial heterogeneity across studies. Evidence-based clinicians considering the use of PRP in their patients with musculoskeletal injuries should be weary that the literature appears to be inconsistent and thus far, inconclusive.

Cost-Effectiveness of Different Forms of Intra-Articular Injections for the Treatment of Osteoarthritis of the Knee.

IntroductionOsteoarthritis (OA), as one of the leading causes of disability, decreases the quality of life for those suffering from the disease and creates a substantial financial burden. Intra-articular hyaluronic acid (HA) can provide relief from the symptoms of OA and multiple HA products are prescribed. The purpose of this study is to examine the single payer cost-effectiveness of various HA products in the treatment of knee OA.MethodsA single payer economic evaluation was conducted comparing Synvisc® (Sanofi, USA), Durolane® (Bioventus, USA), Hyalgan® (Fidia Pharma Inc., USA), Supartz™ (Bioventus, USA), and Euflexxa® (Ferring Pharmaceuticals Inc., USA). Utility scores for HA products were obtained by extracting Western Ontario and McMaster Universities Arthritis Index pain, stiffness and function from randomized controlled trials and converting them to health utilities index mark 3 scores. The cost of a treatment included the cost of the HA injection, cost of a knee injection procedure and cost of a doctor’s visit for each required injection. Cost–utility in 2015 USD per quality-adjusted life years (QALY) saved was calculated for each HA product, and incremental cost-effectiveness ratios were calculated to compare the effectiveness of HA products to one another and to conventional care.ResultsWhen compared to conventional care, all investigated HA products were cost-effective, assuming a willingness-to-pay threshold of

A scoping review of the proximal humerus fracture literature.

50,000/QALY gained. The HA product Euflexxa had the most favorable cost–utility ratio (

Levels of evidence at the Orthopaedic Trauma Association annual meetings.

5785.52/QALY) when compared to all other HA brands.ConclusionThe present study showed several HA products to be cost-effective in comparison to conventional care, with Euflexxa having the most favorable cost/QALY gained ratio compared to the other HA products.FundingFerring Pharmaceutics Inc.

Viscosupplementation in Knee Osteoarthritis: Evidence Revisited

BackgroundProximal humerus fractures are a common fragility fracture that significantly affects the independence of older adults. The outcomes of these fractures are frequently disappointing and previous systematic reviews are unable to guide clinical practice. Through an integrated knowledge user collaboration, we sought to map the breadth of literature available to guide the management of proximal humerus fractures.MethodsWe utilized a scoping review technique because of its novel ability to map research activity and identify knowledge gaps in fields with diverse treatments. Through multiple electronic database searches, we identified a comprehensive body of proximal humerus fracture literature that was classified into eight research themes. Meta-data from each study were abstracted and descriptive statistics were used to summarize the results.Results1,051 studies met our inclusion criteria with the majority of research being performed in Europe (64%). The included literature consists primarily of surgical treatment studies (67%) and biomechanical fracture models (10%). Nearly half of all clinical studies are uncontrolled case series of a single treatment (48%). Non-randomized comparative studies represented 12% of the literature and only 3% of the studies were randomized controlled trials. Finally, studies with a primary outcome examining the effectiveness of non-operative treatment or using a prognostic study design were also uncommon (4% and 6%, respectively).ConclusionsThe current study provides a comprehensive summary of the existing proximal humerus fracture literature using a thematic framework developed by a multi-disciplinary collaboration. Several knowledge gaps have been identified and have generated a roadmap for future research priorities.

Positional Change in Displacement of Midshaft Clavicle Fractures: An Aid to Initial Evaluation.

Objective: To examine the strength of evidence presented at the Orthopaedic Trauma Association (OTA) annual meetings before and after the level of evidence guidelines became popular in the literature. Data Sources: 10 years of abstracts from OTA podium presentations, preguidelines (1998–2002), and postguidelines (2007–2011). Study Selection: All abstracts were blinded and randomized for review. Only therapeutic, diagnostic, prognostic, and economic study types were included. Data Extraction: Study type and level of evidence were determined for each abstract. Data Synthesis: Five hundred thirteen abstracts were included, primarily consisting of therapeutic studies (63%). The distribution of study types between the pre- and postguideline periods was similar (P = 0.37). The levels of evidence for podium presentations in the preguideline period were as follows: level I, 10%; level II, 16%; level III, 14%; and level IV, 60%. The distribution in the postguideline period was as follows: level I, 13%; level II, 2%; level III, 29%; and level IV, 36%. The differences between the pre- and postguideline presentations were significant (P < 0.0001), indicating an improvement in the strength of evidence presented at the annual meetings. Conclusions: The majority of podium presentations at the OTA annual meetings are level IV studies; however, there has been a measurable decrease in the number of uncontrolled case series presented at more recent meetings. Encouraging reporting of levels of evidence at future annual meetings has the potential to positively influence the orthopaedic trauma community by improving readers’ understanding of the strength of evidence presented, the study design hierarchy, and encouraging investigators to conduct controlled study designs when possible.

Why a decade of road traffic safety

&NA; ≫ The body of evidence surrounding the use of viscosupplementation in knee osteoarthritis is extensive and fraught with heterogeneous trials with conflicting conclusions. ≫ Attempts to aggregate the evidence through systematic reviews, meta‐analyses, and guidelines have also resulted in unclear, discordant recommendations. Closer examination reveals that the evidence around viscosupplementation favors clinically important reductions in pain among higher‐molecular‐weight and cross‐linked formulations and is a safe option in patients with knee osteoarthritis. ≫ Further large trials assessing the use of viscosupplementation across various formulations in knee osteoarthritis may confirm subgroup findings from meta‐analyses; however, immediate focus on improved knowledge translation is required to ensure evidence‐based approaches to the treatment of knee osteoarthritis.

Does Lumbopelvic Fixation Add Stability? A Cadaveric Biomechanical Analysis of an Unstable Pelvic Fracture Model

Objectives: To determine how change in position affects displacement of midshaft clavicle fractures. Design: Retrospective review. Setting: Level I Trauma Center. Patients: Eighty patients with displaced midshaft clavicle fractures and presence of supine and semiupright or upright chest radiographs taken within 2 weeks of each other. Intervention: Supine, semiupright, and upright chest radiographs. Main Outcome Measurements: Fracture shortening and vertical displacement on supine, semiupright, and upright radiographs. Results: Mean vertical displacement was 9.42 mm [95% confidence interval (95% CI), 8.07–10.77 mm], 11.78 mm (95% CI, 10.25–13.32 mm), and 15.72 mm (95% CI, 13.71–17.72 mm) in supine, semiupright, and upright positions, respectively. Fracture shortening was −0.41 mm (95% CI, −2.53 to 1.70 mm), 2.11 mm (95% CI, −0.84 to 5.07), and 4.86 mm (95% CI, 1.66–8.06 mm) in supine, semiupright, and upright positions, respectively. Change in position from supine to upright significantly increased both vertical displacement and fracture shortening (P < 0.001). In the upright position, the proportion of patients who met operative indications (fracture shortening >20 mm) was 3 times greater when compared with that in the supine position (upright 17.65%; supine 5.88%, P = 0.06). Positional changes in fracture displacement were not associated with body mass index, age, or gender. Conclusions: Patient position is associated with significant changes in fracture displacement. Over 3 times more patients meet operative indications when placed in the upright versus supine position. An upright chest radiograph should be obtained to evaluate midshaft clavicle fracture displacement, as it represents the physiologic stress across the fracture when considering nonoperative management. Level of Evidence: Prognostic level IV. See Instructions for Authors for a complete description of levels of evidence.

The Cost Effectiveness of Minimally Invasive Spine Surgery in the Treatment of Adult Degenerative Scoliosis: A Comparison of Trans-psoas and Open Techniques

Summary: Each year, 1.24 million people die as a result of road traffic collisions around the world, and millions more are left to suffer the resultant disabilities of their nonfatal typically musculoskeletal injuries. The most productive members of society are the ones affected the most, and the subsequent economic impact cannot be ignored. Reducing the morbidity and mortality associated with road traffic injuries will reduce suffering and increase available resources that can be used more effectively. Road traffic injuries are preventable, and the impact of those that do occur can be mitigated. Adequate national and global funding, strategy, and measurable targets are fundamental to a sustainable response to road safety. Over the last decade, the United Nations and World Health Organization have been part of the gaining momentum toward addressing this issue, through resolutions and coordinating global efforts. This is what brought about the “Decade of Action for Road Traffic Safety,” and as orthopaedic surgeons, our involvement is key for the collaborative public health response toward this effort.

Early Postoperative Displacement of Combined Pelvic Ring Injury With Acetabular Fracture

Objective: We sought to determine the role of lumbopelvic fixation (LPF) in the treatment of zone II sacral fractures with varying levels of sacral comminution combined with anterior pelvic ring (PR) instability. We also sought to determine the proximal extent of LPF necessary for adequate stabilization and the role of LPF in complex sacral fractures when only 1 transiliac–transsacral (TI–TS) screw is feasible. Materials and Methods: Fifteen L4 to pelvis fresh-frozen cadaveric specimens were tested intact in flexion-extension (FE) and axial rotation (AR) in a bilateral stance gliding hip model. Two comminution severities were simulated through the sacral foramen using an oscillating saw, with either a single vertical fracture (small gap, 1 mm) or 2 vertical fractures 10 mm apart with the intermediary bone removed (large gap). We assessed sacral fracture zone (SZ), PR, and total lumbopelvic (TL) stability during FE and AR. The following variables were tested: (1) presence of transverse cross-connector, (2) presence of anterior plate, (3) extent of LPF (L4 vs. L5), (4) fracture gap size (small vs. large), (5) number of TI–TS screws (1 vs. 2). Results: The transverse cross-connector and anterior plate significantly increased PR stability during AR (P = 0.02 and P = 0.01, respectively). Increased sacral comminution significantly affected SZ stability during FE (P = 0.01). Two versus 1 TI–TS screw in a large-gap model significantly affected TL stability (P = 0.04) and trended toward increased SZ stabilization during FE (P = 0.08). Addition of LPF (L4 and L5) significantly improved SZ and TL stability during AR and FE (P < 0.05). LPF in combination with TI–TS screws resulted in the least amount of motion across all 3 zones (SZ, PR, and TL) compared with all other constructs in both small-gap and large-gap models. Conclusions: The role of LPF in the treatment of complex sacral fractures is supported, especially in the setting of sacral comminution. LPF with proximal fixation at L4 in a hybrid approach might be needed in highly comminuted cases and when only 1 TI–TS screw is feasible to obtain maximum biomechanical support across the fracture zone.