Seper Ekhtiari

Return to Work and Sport Following High Tibial Osteotomy: A Systematic Review.

BACKGROUND The purpose of this study was to examine (1) timelines for return to sport and work following high tibial osteotomy (HTO), and (2) whether patients return to sport and work at levels similar to preoperative levels. METHODS A systematic search was conducted across 3 databases (MEDLINE, Embase, and PubMed). Two reviewers independently screened the results for relevant articles. Data regarding patient demographics, indications, surgical technique, return to work and sport, and complication and failure rates were abstracted from eligible studies. RESULTS Nineteen studies were included, involving 1,189 patients (64% male, 21% female, 15% unspecified) and 1,224 knees. Mean age was 46.2 years (range, 16 to 80 years). Opening-wedge HTO was most commonly used, followed by closing-wedge HTO and hemicallotasis. Mean follow-up was 65.4 months (range, 8 to 253 months). Overall, 87.2% of patients returned to sport postoperatively, and 78.6% returned at an equal or greater level. Among competitive athletes, 54% returned to competition. Overall, 84.5% of patients returned to work postoperatively, and 65.5% returned at an equal or greater level. Approximately 90% of patients who returned to work or sport did so within 1 year. The complication rate was 5.8%, with infection being the most common complication; 7.0% of patients progressed to a total knee arthroplasty at a mean of 6.7 years (range, 0.8 to 15 years) following HTO. CONCLUSIONS The majority of patients undergoing HTO return to sport and work, and most return within 1 year of the operation. Most patients return to sport at a level equal to or greater than the preoperative level. Approximately two-thirds of patients return to an equal or greater level of physical work. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hip arthroscopic capsulotomy techniques and capsular management strategies: a systematic review.

PurposeHip arthroscopy is increasingly used to address hip joint pathology. Iatrogenic instability has been reported as a potential complication, leading to the evaluation of various capsular management strategies. The purpose of this review was to (1) report the techniques used for capsulotomy in hip arthroscopy, (2) understand techniques and indications for capsular closure, and (3) report outcomes based on capsular management strategy.MethodsMEDLINE, EMBASE, and PubMed were searched and screened in duplicate for relevant studies. Data regarding patient demographics, indications, surgical technique, rehabilitation strategies, and complication rates were obtained. Study quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies (MINORS) Criteria.ResultsEighty-two studies of primarily level IV evidence (80 %) and of fair quality involving 4504 patients with a mean age of 35 years old (range 1.2–82 years) were included. Fifty percent of patients were male. Mean follow-up was 24.9 months (range 5 days to 13 years). Of 68 studies reporting capsulotomy technique (only 7 % of all otherwise eligible studies), 55 % performed an interportal capsulotomy while 24 % performed a T-capsulotomy. Of 36 studies reporting capsular management strategy post-arthroscopy, 22 % did not repair the capsulotomy, 6 % routinely performed partial repair, and 50 % performed complete repair. Of three studies (206 patients) directly comparing capsular management strategies, only one study found a statistically significant difference between complete and partial repair on the Hip Outcome Score-Sport Specific Subscale, though this difference was less than the minimal clinically important difference (83.6 versus 87.3). The total rate of reported post-operative dislocation, instability, or instability was 0.3 % (5 patients).ConclusionsTechnical details regarding capsulotomy and capsular management post-hip arthroscopy are not consistently reported in the literature. Capsulotomies are most often performed using an interportal technique, and more recent studies report routine closure. Overall, post-operative instability is rare and there is no consistent trend for capsular management strategy. Given current evidence, there is little basis on which to establish the relationship between surgical technique and post-operative instability or long-term consequences (e.g., kinematic changes). Thus, while capsular closure/plication may be suitable for specific populations (i.e., dysplasia or laxity), evidence-based indications for capsular repair remain unclear.Level of evidenceLevel IV, systematic review of level I–IV Studies.

Preoperative physical examination and imaging of femoroacetabular impingement prior to hip arthroscopy—a systematic review

Abstract The purpose of this systematic review is to report current preoperative assessment for femoroacetabular impingement (FAI) including physical examination and imaging modalities prior to hip arthroscopy, and report current imaging measures used in the diagnosis of FAI. The electronic databases MEDLINE, EMBASE and PubMed were searched and screened in duplicate for relevant studies. Data regarding patient demographics, non-operative treatment, preoperative assessment including physical examination and imaging prior to hip arthroscopy were abstracted. Study quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies criteria. Sixty-eight studies of fair quality evidence that involved a total of 5125 patients (5400 hips) were included. In total, 56% of all patients were male and mean age was 36 years (SD ± 10.0). Within physical examination, FADIR impingement testing was reported in 57% of patients. All included studies reported plain radiographic imaging as a component of preoperative assessment with anterior–posterior pelvis view being the most commonly reported view, followed by the cross-table lateral and Dunn views. Magnetic resonance imaging was obtained for 52% of included patients and computed tomography for 26% of patients. The most commonly reported measure within imaging for the diagnosis of cam type impingement was alpha angle (66%), whereas for pincer type impingement, the cross-over sign (48%) was most reported. Preoperative assessment is underreported in the FAI literature. Improved reporting is warranted to develop a more consistent and validated diagnostic algorithm for FAI to enhance patient selection. Level of evidence: Level IV, Systematic Review of Level I–IV Studies.

The Learning Curve for the Latarjet Procedure: A Systematic Review

Background: Anterior shoulder instability, including recurrent instability, is a common problem, particularly in young, active patients and contact athletes. The Latarjet procedure is a common procedure to treat recurrent shoulder instability. Purpose: To identify the reported learning curves associated with the Latarjet procedure and to determine a point on the learning curve after which a surgeon can be considered to have achieved proficiency. Study Design: Systematic review; Level of evidence, 4. Methods: Three online databases (Embase, MEDLINE, PubMed) were systematically searched and screened in duplicate by 2 independent reviewers. The search included results from the inception of each database to January 23, 2017. Data regarding study characteristics, patient demographics, learning curve analyses, and complications were collected. Study quality was assessed in duplicate. Results: Two level 3 studies and 3 level 4 studies of fair methodological quality were included. Overall, 349 patients (350 shoulders) with a mean age of 25.1 years (range, 14-52 years) were included in the final data analysis. Patients were predominantly male (93.7%). After 22 open and 20 to 40 arthroscopic Latarjet procedures, surgeons achieved a level of proficiency as measured by decreased operative time. For open procedures, complication rates and lengths of hospital stay decreased significantly with increased experience (Spearman ρ = –0.3, P = .009 and Spearman ρ = –0.6, P < .0001, respectively). Conclusion: With experience, surgeons achieved a level of proficiency in performing arthroscopic and open Latarjet procedures, as measured by decreased operative time, length of hospital stay, and complication rate. The most commonly reported difference was operative time, which was significant across all studies. Overall, the Latarjet procedure is a safe procedure with low complication rates, although further research is required to truly characterize this learning curve.

Joint Specific Return to Play Recommendations: “Return to Play in Non-operative Hip/Groin Pain”

Groin pain represents a frequent cause of disability among footballers. Groin pain in footballers is most commonly due to overuse injury as opposed to traumatic injury. Athletic groin pain presents a diagnostic and therapeutic challenge for the sports medicine physician. The complex anatomy of the hip and groin region gives rise to an extensive list of possible pathologies that all may present very similarly. Adductor pathology represents the most common cause of groin pain in footballers, but other pathologies such as abdominal, intra-articular, inguinal, and iliopsoas-related pathologies may also cause groin pain in footballers. Although the majority of groin pain pathologies can be treated with an initial trial of conservative management, the evidence for non-operative management currently available is limited. Athletes who fail conservative treatment options may ultimately require operative management. This chapter discusses return to play in footballers following non-operative management of hip and groin pain.

Most elite athletes return to competition following operative management of meniscal tears: a systematic review

Importance Meniscal injuries are common among athletes. When operative management is indicated, the decision between meniscal repair and meniscectomy is not always clear, particularly in elite athletes. Objective The aim of this systematic review was to (1) compare outcomes for partial meniscectomy and repair for the management of meniscus tears in elite athletes and (2) describe return-to-play (RTP) rates and complications for each operation. Evidence review MEDLINE, Embase and PubMed were searched from inception through to 5 March 2017. All studies were screened in duplicate for eligibility. Data extracted included demographics, surgical technique and RTP rate and timeline. Findings Ten studies (725 athletes) were included involving 355 elite athletes undergoing meniscal repair (111 patients) or partial/total meniscectomy (244). The majority of athletes were men (82.8%) and had a mean age of 25.0 years (14–38). Athletes were followed for a mean of 5.3 years (range=3 months to 18.4 years). American football was the most common sport (153 athletes), followed by soccer (69) and basketball (67). Athletes undergoing meniscal repair demonstrated a pooled mean RTP time of 7.6 months in comparison to 4.3 months for those undergoing partial meniscectomy (P<0.0001). Of athletes undergoing meniscal repair, 86.5% RTP at their preoperative level, compared with 80.4% of athletes undergoing partial meniscectomy (P=0.24). Following meniscectomy, athletes who were taller, drafted in higher rounds and had played or started more games preoperatively were less likely to suffer negative career impacts postoperatively. Satisfaction rates (92% vs 76%) and clinical scores (8.8 vs 6.9, P=0.05) were higher among recreational than elite athletes. Conclusion Athletes undergoing partial meniscectomy RTP sooner than those undergoing meniscal repair. Both operations are safe and the majority of athletes RTP at their preoperative level of competition following either operation. Further research is required to identify when each option is preferable in this population. Relevance Based on the currently available evidence, meniscectomy and meniscal repair are both viable options for elite athletes with meniscal injuries. Each method has small advantages and disadvantages compared with the other, and thus a shared decision should be made with the athlete. Level of evidence Level IV, systematic review of level III and IV studies.

The use of antibiotic prophylaxis in hip arthroscopy is under-reported and lacks evidence-based guidelines: a systematic review and survey

Importance Hip arthroscopy is an increasingly common orthopaedic procedure with postoperative infection rates<5%. With the growing challenge of antibiotic resistance and rising healthcare costs, it is important to establish whether antibiotic prophylaxis is routinely used in hip arthroscopy, and whether it is necessary. Objective The objectives of this review were to (1) report current practice patterns with regard to antibiotic prophylaxis for hip arthroscopy and (2) present the available evidence regarding the use of antibiotic prophylaxis in hip arthroscopy. Evidence review The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in the execution and reporting of this study. The databases MEDLINE, EMBASE and PubMed were searched and screened in duplicate. Data regarding patient demographics, surgical indications, surgical techniques, use of antibiotic prophylaxis and adverse events were collected. Study quality was assessed in duplicate using Methodological Index for Non-Randomised Studies criteria. A survey was distributed to high-volume hip arthroscopists to gauge their practice patterns. Data were analysed and presented using descriptive statistics. Findings Nine studies of primarily level IV evidence (78%) and of fair quality were included. Overall, 592 patients (652 hips; 56.2% male) were included in the review, with a mean age of 40.6 years. Notably, 1069 otherwise eligible studies were excluded from this review because they did not report on their use (or lack thereof) of prophylactic antibiotics. Overall, 390 patients received routine antibiotic prophylaxis, 160 patients did not and 42 patients received prophylaxis only if an implant was used. Only three infections were reported among 652 operations, with all infections from studies that routinely used antibiotic prophylaxis. The survey had a 60% response rate (21/35), and revealed that 81% of respondents routinely provide prophylactic antibiotics, most commonly preoperative intravenous cefazolin (66.7%). The most common postoperative antibiotic was cephalexin. Conclusions and relevance Antibiotic prophlyaxis use in hip arthroscopy is very under-reported. Routine prophylaxis was the most common practice pattern in both the literature and the survey. Overall, postoperative infection rates are extremely low. Future studies are required to prospectively assess the role of antibiotic prophylaxis in hip arthroscopy. Level of evidence Level IV, systematic review of level III and IV studies

Dyslipidaemia is associated with an increased risk of rotator cuff disease: a systematic review

Importance Rotator cuff disease affects more than 50% of the population over 60 years of age. It has been suggested that dyslipidaemia is associated with the development of rotator cuff disease. Objective The aim of this review was to present the available literature on the relationship between lipid disorders and rotator cuff disease and to report on the implications of lipid disorders on the surgical management and postoperative healing of rotator cuff tears. Evidence review Medline, Embase and PubMed were searched from inception until 18 January 2017. Studies were screened and data were extracted in duplicate. A methodological assessment was performed for included studies. Findings Nine studies were found to meet the inclusion criteria. Seven of the included studies identified an association between the prevalence of dyslipidaemia and rotator cuff disease. Patients with dyslipidaemia were also found to have more severe rotator cuff tears. Conclusions and relevance The results of this study suggest an association between blood lipid levels and rotator cuff pathology. Specifically, patients with dyslipidaemia are potentially at higher risk for shoulder pain, rotator cuff tears and more severe rotator cuff tears. Further research is required to identify the effect of lipid-lowering medications on the natural history of rotator cuff disease and the impact on conservative and surgical treatment of rotator cuff pathology. Level of evidence LevelsII–IVclinical studies.

Early evidence reports positive outcomes after osteochondral grafts and chondrocyte transplantation in the hip: a systematic review

Importance To date, limited literature has explored the outcomes and indications for osteochondral grafts and chondrocyte transplantation in the hip. Objective The purpose of this study was to evaluate the indications, investigations, rehabilitation strategies and clinical outcomes associated with treatment of hip cartilage defects with either autologous chondrocyte transplantation, osteochondral allografts, osteochondral autografts or synthetic osteochondral grafts. Evidence review MEDLINE, EMBASE and PubMed were searched in duplicate for relevant studies, and data were abstracted from included studies. The Methodological Index for Non-Randomized Studies criteria were used to grade the quality of the studies. Findings A total of 32 studies were included, involving 268 hips and 262 patients. Osteochondral grafts and chondrocyte transplantation were most commonly used for the treatment of osteochondral defects. The chondral lesions treated varied in size from 1 to 15.7 cm2. Positive outcomes were reported across numerous standardised outcome scores at a mean follow-up of 28.6 months. The overall complication rate was 3.4%. The rate of patients requiring further surgery was 9.5%. Conclusions The outcomes reported in the literature on the treatment of hip chondral defects with osteochondral grafts and chondrocyte transplantation are generally positive at short-term to medium-term follow-ups. Low rates of complications and patients requiring further surgery were reported. The most common indications for these treatment options are full-thickness osteochondral defects larger than 2 cm2 in young patients. The indications remain unclear when using these techniques to treat other pathology, including avascular necrosis. A period of 6–12 weeks of restricted weight bearing is recommended in the literature following these procedures. The quality of the literature that currently exists on this topic remains quite low.