Peter A. A. Struijs

Treatment of osteochondral lesions of the talus: a systematic review

The aim of this study was to summarize all eligible studies to compare the effectiveness of treatment strategies for osteochondral defects (OCD) of the talus. Electronic databases from January 1966 to December 2006 were systematically screened. The proportion of the patient population treated successfully was noted, and percentages were calculated. For each treatment strategy, study size weighted success rates were calculated. Fifty-two studies described the results of 65 treatment groups of treatment strategies for OCD of the talus. One randomized clinical trial was identified. Seven studies described the results of non-operative treatment, 4 of excision, 13 of excision and curettage, 18 of excision, curettage and bone marrow stimulation (BMS), 4 of an autogenous bone graft, 2 of transmalleolar drilling (TMD), 9 of osteochondral transplantation (OATS), 4 of autologous chondrocyte implantation (ACI), 3 of retrograde drilling and 1 of fixation. OATS, BMS and ACI scored success rates of 87, 85 and 76%, respectively. Retrograde drilling and fixation scored 88 and 89%, respectively. Together with the newer techniques OATS and ACI, BMS was identified as an effective treatment strategy for OCD of the talus. Because of the relatively high cost of ACI and the knee morbidity seen in OATS, we conclude that BMS is the treatment of choice for primary osteochondral talar lesions. However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. Further sufficiently powered, randomized clinical trials with uniform methodology and validated outcome measures should be initiated to compare the outcome of surgical strategies for OCD of the talus.

Treatment strategies in osteochondral defects of the talar dome: a systematic review.

The aim of this study was to investigate the results of different treatment strategies for osteochondral defects (OCD) of the talus. Electronic databases from 1966 to July 1998 were systematically screened. Based on our inclusion criteria 32 studies describing the results of treatment strategies for OCD of the talus were included. No randomized clinical trials (RCTs) were identified. Fourteen studies described the results of excision alone, 11 the results of (EC), 14 the results of (ECD), 1 the results of cancellous bone grafting after EC, 1 the results of osteochondral transplantation and 3 the results of fixation. The average success rate of non-operative treatment (NT) was 45%. Comparison of different surgical procedures shows that the average highest success rate was reached by excision, curettage and drilling (ECD) (85%) followed by excision and curettage (EC) (78%) and excision alone (38%). Based on this systematic review we conclude that NT and excision alone are not to be recommended in treating talar OCD. Both EC and ECD have been shown to lead to a high percentage good/excellent results. However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. Further prospective randomized controlled trials are required to compare the outcome of these two surgical strategies for OCD of the talus.

Arthroscopic treatment for osteochondral defects of the talus: RESULTS AT FOLLOW-UP AT 2 TO 11 YEARS

We reviewed 38 patients who had been treated for an osteochondral defect of the talus by arthroscopic curettage and drilling. The indication for surgical treatment was persistent symptoms after conservative treatment for at least six months. A total of 22 patients had received primary surgical treatment (primary group) and 16 had had failed previous surgery (revision group). The mean follow-up was 4.8 years (2 to 11). Good or excellent results, as assessed by the Ogilvie-Harris score, were found in 86% in the primary group and in 75% in the revision group. Two further procedures were required, one in each group. Radiological degenerative changes were seen in one ankle in the revision group after ten years. Arthroscopic curettage and drilling are recommended for both primary and revision treatment of an osteochondral defect of the talus.

Conservative Treatment of Lateral Epicondylitis Brace Versus Physical Therapy or a Combination of Both—A Randomized Clinical Trial

Background The authors evaluated the effectiveness of brace-only treatment, physical therapy, and the combination of these for patients with tennis elbow. Methods Patients were randomized over 3 groups: brace-only treatment, physical therapy, and the combination of these. Main outcome measures were success rate, severity of complaints, pain, disability, and satisfaction. Data were analyzed using both intention-to-treat and per-protocol analyses. Follow-up was 1 year. Results A total of 180 patients were randomized. Physical therapy was superior to brace only at 6 weeks for pain, disability, and satisfaction. Contrarily, brace-only treatment was superior on ability of daily activities. Combination treatment was superior to brace on severity of complaints, disability, and satisfaction. At 26 weeks and 52 weeks, no significant differences were identified. Conclusion Conflicting results were found. Brace treatment might be useful as initial therapy. Combination therapy has no additional advantage compared to physical therapy but is superior to brace only for the short term.

Immobilisation for acute ankle sprain. A systematic review.

Abstract The variation of practice with respect to the treatment of the acutely sprained ankle suggests a lack of evidence-based management strategies for this problem. The objective of this review was to assess the effectiveness of the various methods of immobilisation for acute ankle sprain. An electronic database search was conducted using MEDLINE, EMBASE, BIOSIS, CINAHL, Cochrane Controlled Trial Register and Current Contents. Randomised and quasi-randomised clinical trials describing skeletally mature individuals with an acute ankle sprain and comparing immobilisation for the treatment of injuries to the lateral ligament complex of the ankle were evaluated for inclusion. Two reviewers independently assessed the validity of included trials and extracted relevant data on the treatment outcome. Where appropriate, results of comparable studies were pooled. Individual and pooled statistics are reported as relative risks (RR) for dichotomous outcomes and weighted mean differences (WMD) for continuous outcome measures with 95% confidence intervals (95% CI). Heterogeneity between trials was tested using a standard chi-square test. A total of 22 studies met the inclusion criteria. Statistically significant differences were found for six outcome measures, all in favour of functional treatment compared with immobilisation: return to sports (RR: 1.85; 95% CI: 1.2 to 2.8), (WMD: 4.57 days; 95% CI: 1.5 to 7.6), return to work (WMD: 7.12 days; 95% CI: 5.6 to 8.7), persistent swelling (RR: 1.44; 95% CI: 1.1 to 2.0), objective instability by stress X-ray (WMD: 2.48; 95% CI: 1.3 to 3.6), range of motion (RR: 1.64; 95% CI: 1.1 to 2.6) and patient satisfaction (RR: 6.50; 95% CI: 1.8 to 24) . None of the other results were significantly in favour of immobilisation. Sensitivity analysis showed that a non-concealed treatment allocation did not influence the statistical significance of the overall results. Based on our results, functional treatment currently seems a more appropriate treatment and should be encouraged. Concerning effectiveness, immobilisation, if necessary, should be restricted to certain patients and for short time periods.

Reporting of outcomes in orthopaedic randomized trials : Does blinding of outcome assessors matter?

BACKGROUND Randomization, concealment of treatment allocation, and blinding are all known to limit bias in clinical research. Nonsurgical studies that fail to meet these standards have been reported to inflate the differences between treatment and control groups. While surgical trials can rarely blind surgeons or patients, they can often blind outcome assessors. The aim of this systematic review was threefold: (1) to examine the reporting of outcome measures in orthopaedic trials, (2) to determine the feasibility of blinding in published orthopaedic trials, and (3) to examine the association between the magnitude of treatment differences and the blinding of outcome assessors. METHODS We identified and reviewed thirty-two randomized, controlled trials published in The Journal of Bone and Joint Surgery (American Volume) in 2003 and 2004 for the appropriate use of outcome measures. These trials represented 3.4% of all 938 studies published during that time-period. All thirty-two trials were reviewed by two authors for (1) the outcome measures used and (2) the blinding of outcomes assessors. We calculated the magnitude of the treatment effect of the use of blinded compared with unblinded outcome assessors. RESULTS Ten (31%) of the thirty-two randomized controlled trials used a modified outcome instrument. Of the ten trials, four failed to describe how the outcome instrument was modified. Nine of the ten articles did not describe how the modified instrument was validated and retested. Sixteen of the thirty-two randomized controlled trials did not report blinding of outcome assessors when blinding would have been possible. Among the studies with continuous outcome measure, unblinded outcomes assessment was associated with significantly larger treatment effects than blinded outcomes assessment (standardized mean difference, 0.76 compared with 0.25; p = 0.01). Similarly, in the studies with dichotomous outcomes, unblinded outcomes assessments were associated with significantly greater treatment effects than blinded outcomes assessments (odds ratio, 0.13 compared with 0.42; p < 0.001). The ratio of odds ratios (unblinded to blinded outcomes assessment) was 0.31, suggesting that unblinded outcomes assessment was associated with a potential for exaggeration of the benefit of the effectiveness of a treatment in our cohort of studies. CONCLUSIONS In future orthopaedic randomized controlled trials, emphasis should be placed on detailed reporting of outcome measures to facilitate generalization and the outcome assessors should be blinded, when possible, to limit bias.

Does a "Level I Evidence" rating imply high quality of reporting in orthopaedic randomised controlled trials?

BackgroundThe Levels of Evidence Rating System is widely believed to categorize studies by quality, with Level I studies representing the highest quality evidence. We aimed to determine the reporting quality of Randomised Controlled Trials (RCTs) published in the most frequently cited general orthopaedic journals.MethodsTwo assessors identified orthopaedic journals that reported a level of evidence rating in their abstracts from January 2003 to December 2004 by searching the instructions for authors of the highest impact general orthopaedic journals. Based upon a priori eligibility criteria, two assessors hand searched all issues of the eligible journal from 2003–2004 for RCTs. The assessors extracted the demographic information and the evidence rating from each included RCT and scored the quality of reporting using the reporting quality assessment tool, which was developed by the Cochrane Bone, Joint and Muscle Trauma Group. Scores were conducted in duplicate, and we reached a consensus for any disagreements. We examined the correlation between the level of evidence rating and the Cochrane reporting quality score.ResultsWe found that only the Journal of Bone and Joint Surgery – American Volume (JBJS-A) used a level of evidence rating from 2003 to 2004. We identified 938 publications in the JBJS-A from January 2003 to December 2004. Of these publications, 32 (3.4%) were RCTs that fit the inclusion criteria. The 32 RCTs included a total of 3543 patients, with sample sizes ranging from 17 to 514 patients. Despite being labelled as the highest level of evidence (Level 1 and Level II evidence), these studies had low Cochrane reporting quality scores among individual methodological safeguards. The Cochrane reporting quality scores did not differ significantly between Level I and Level II studies. Correlations varied from 0.0 to 0.2 across the 12 items of the Cochrane reporting quality assessment tool (p > 0.05). Among items closely corresponding to the Levels of Evidence Rating System criteria assessors achieved substantial agreement (ICC = 0.80, 95%CI:0.60 to 0.90).ConclusionOur findings suggest that readers should not assume that 1) studies labelled as Level I have high reporting quality and 2) Level I studies have better reporting quality than Level II studies. One should address methodological safeguards individually.

Infected nonunion of the long bones

Background: Although definitions vary, infected nonunion has been defined as a state of failure of union and persistence of infection at the fracture site for 6 to 8 months.>).1 Infected nonunions of the supracondylar region of the femur are uncommon and are mostly due to a severe open fracture with extensive comminution and segmental bone loss or after internal fixation of a comminuted closed fracture.2 Associated factors include exposed bone devoid of vascularized periosteal coverage for more than 6 weeks, purulent discharge, a positive bacteriological culture from the depth of the wound, and histologic evidence of necrotic bone containing empty lacunae. Soft-tissue loss with multiple sinuses, osteomyelitis, osteopenia, complex deformities with limb-length inequality, stiffness of the adjacent joint, polybacterial multidrug-resistant infection, and smoking all complicate treatment and recovery.3 Although uncommon in incidence, infected nonunions of the long bones present a great challenge to the orthopaedic surgeon in providing optimal treatment of this entity. To give direction to the optimal strategy, this systematic review was performed. Objective: We aimed to review the highest level of available evidence on the operative management of infected nonunions of the long bones.

Functional treatments for acute ruptures of the lateral ankle ligament: a systematic review.

Our aim with this systematic review was to assess the effectiveness of various functional treatments for acute ruptures of the lateral ankle ligament in adults. We performed an electronic database search using MEDLINE, EMBASE, COCHRANE CONTROLLED TRIAL REGISTER and CURRENT CONTENTS. We evaluated randomized clinical trials describing skeletally mature subjects with an acute rupture of the lateral ankle ligament and compared functional treatments for inclusion in this study. 9 trials met our inclusion criteria. Two reviewers independently assessed the quality of these trials and extracted relevant data on treatment outcome. Where appropriate, results of comparable studies were pooled. Individual and pooled statistics are reported as relative risks (RR) for dichotomous outcome and (weighted) mean differences ((W)MD) for continuous outcome measures with 95% confidence intervals (95% CI). Heterogeneity between the trials was tested using a standard chi-square test. Persistent swelling at short-term follow-up was less with lace-up ankle support than with semi-rigid ankle support (RR 4.2 95% CI 1.3-14), an elastic bandage (RR 5.5; 95% CI 1.7-18) and tape (RR 4.1; 95% CI 1.2-14). A semi-rigid ankle support required a shorter period for return to work than an elastic bandage (WMD 4.2; 95% CI 2.4-6.1) (p = 0.7). One trial reported better results for subjective instability using the semi-rigid ankle support than the elastic bandage (RR 8.0; 95% CI 1.0-62). Treatment with tape resulted in more complications, mostly skin problems, than that with an elastic bandage (RR 0.1; 95% CI 0.0-0.8). We found no other statistically significant differences. We conclude that an elastic bandage is a less effective functional treatment. Lace-up supports seem better, but the data are insufficient as a basis for definite conclusions.

What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults?

CONTEXT Ankle sprains are common problems in acute medical care. The variation in treatment observed for the acutely injured lateral ankle ligament complex in the first week after the injury suggests a lack of evidence-based management strategies for this problem. OBJECTIVE To analyze the effectiveness of applying rest, ice, compression, and elevation (RICE) therapy begun within 72 hours after trauma for patients in the initial period after ankle sprain. STUDY SELECTION Eligible studies were published original randomized or quasi-randomized controlled trials concerning at least 1 of the 4 subtreatments of RICE therapy in the treatment of acute ankle sprains in adults. DATA SOURCES MEDLINE, Cochrane Clinical Trial Register, CINAHL, and EMBASE. The lists of references of retrieved publications also were checked manually. DATA EXTRACTION We extracted relevant data on treatment outcome (pain, swelling, ankle mobility or range of motion, return to sports, return to work, complications, and patient satisfaction) and assessed the quality of included studies. If feasible, the results of comparable studies were pooled using fixed- or random-effects models. DATA SYNTHESIS After deduction of the overlaps among the different databases, evaluation of the abstracts, and contact with some authors, 24 potentially eligible trials remained. The full texts of these articles were retrieved and thoroughly assessed as described. This resulted in the inclusion of 11 trials involving 868 patients. The main reason for exclusion was that the authors did not describe a well-defined control group without the intervention of interest. CONCLUSIONS Insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy for acute ankle sprains in adults. Treatment decisions must be made on an individual basis, carefully weighing the relative benefits and risks of each option, and must be based on expert opinions and national guidelines.