Is limited incision better than standard total hip arthroplasty? A meta-analysis

Enhanced Recovery after Total Joint Arthroplasty (TJA): A Contemporary Systematic Review of Clinical Outcomes and Usage of Key Elements

BACKGROUND

Enhanced recovery after surgery (ERAS) is a pathway designed to improve the care of surgical patients and achieve early recovery. The clinical outcomes and usage of key elements of ERAS pathways in total joint arthroplasty (TJA) need further reanalysis. This article aims to provide an overview of the latest clinical outcomes and current usage of key elements of ERAS pathways in TJA.

METHODS

We undertook a systematic review of the PubMed, OVID, and EMBASE databases in February 2022. Studies investigating the clinical outcomes and usage of key elements of ERAS in TJA were included. The components of successful ERAS programs and their usage were further determined and discussed.

RESULTS

Twenty-four studies involving 216,708 patients assessed ERAS pathways for TJA. A total of 95.8% (23/24) of studies reported a reduced length of stay (LOS), followed by reduce overall opioid consumption or pain (87.5% [7/8]), save costs (85.7% [6/7]), improvements in patient-reported outcomes or functional recovery (60% [6/10]), and reduced incidence of complications (50% [5/10]). In addition, preoperative patient education (79.2% [19/24]), anesthetic protocol (54.2% [13/24]), use of local anesthetics for infiltration analgesia or nerve blocks (79.2% [19/24]), perioperative oral analgesia (66.7% [16/24]), perioperative surgical factors including reduced use of tourniquets and drains (41.7% [10/24]), use of tranexamic acid (41.7% [10/24]) and early mobilization (100% [24/24]) were contemporary comparatively "active" components of ERAS.

CONCLUSIONS

ERAS for TJA has favorable clinical outcomes in terms of reducing LOS and overall pain, saving costs, accelerating functional recovery, and reducing complications, although the evidence is still low in quality. In the current clinical scenario, only some "active" components of the ERAS program are widely used.

Key Elements of Enhanced Recovery after Total Joint Arthroplasty: A Reanalysis of the Enhanced Recovery after Surgery Guidelines

Recent guidelines have produced a consensus statement for perioperative care in hip and knee replacement. However, there is still a need for reanalysis of the evidence and recommendations. Therefore, we retrieved and reanalyzed the evidence of each recommended components of enhanced recovery after surgery (ERAS) based on the guidelines of total joint arthroplasty. For each one, we included for the highest levels of evidence and those systematic reviews and meta-analyses were preferred. The full texts were analyzed and the evidence of all components were summarized. We found that most of the recommended components of ERAS are supported by evidence, however, the implementation details of each recommended components need to be further optimized. Therefore, implementation of a full ERAS program may maximize the benefits of our clinical practice but this combined effect still needs to be further determined.

Direct and indirect comparisons in network meta-analysis of SuperPATH, direct anterior and posterior approaches in total hip arthroplasty

SuperPATH is a novel approach to the hip joint that needs to be compared to other known surgical approaches. To conduct a network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing short-term outcomes of SuperPATH, direct anterior (DAA), and posterior/ posterolateral approaches (PA) in total hip joint arthroplasty (THA). We performed a systematic review on PubMed, CNKI, Embase, The Cochrane Library, Clinical trials, and Google Scholar up to November 30th, 2021. We assessed treatment effects between SuperPATH, DAA, and PA by performing a frequentist NMA, including a total of 20 RCTs involving 1501 patients. SuperPATH showed a longer operation time (MD = 16.99, 95% CI 4.92 to 29.07), a shorter incision length (MD = −4.71, 95% CI −6.21 to −3.22), a lower intraoperative blood loss (MD = −81.75, 95% CI  −114.78 to −48.72), a higher HHS 3, 6 and 12 months postoperatively (MD = 2.59, 95% CI 0.59–4.6; MD = 2.14, 95% CI 0.5–3.77; MD = 0.6, 95% CI 0.03–1.17, respectively) than PA. DAA showed a higher intraoperative blood loss than PA and SuperPATH (MD = 91.87, 95% CI  27.99–155.74; MD = 173.62, 95% CI 101.71–245.53, respectively). No other relevant differences were found. In conclusion, the overall findings suggested that the short-term outcomes of THA through SuperPATH were statistically superior to PA. DAA and PA as well as SuperPATH and DAA showed indifferent results.

Incidence and risk factors of delayed wound healing in patients who underwent unicompartmental knee arthroplasty

Unicompartmental knee arthroplasty (UKA) has been proven as an ideal alternative surgical procedure to treat symptomatic isolated knee osteoarthritis, and recently this technique has gained its popularity. However, postoperative complications would inevitably compromise the effectiveness and patients' satisfaction. The objective of this study is to demonstrate the incidence and risk factors of delayed wound healing (DWH) after UKA. This retrospective cohort study was conducted from February 2021 to May 2022 and a total of 211 patients were enrolled. Demographic characteristics, operation-related variables, and laboratory indexes were extracted. Receiver operating characteristic analysis was performed to detect the optimum cut-off value for continuous variables. Univariate and multivariate logistic regression analysis was performed to demonstrate the risk factors of DWH. There were 155 female and 56 male patients with an average age of 64. 6 ± 6.9 years included in this study. After 6.6 ± 4.9 months' follow-up, 12 cases of DWH were observed which indicated an incidence of DWH of 5.7%, mean wound healing duration for 12 patients was 43.1 ± 19.3 days. In the univariate analysis, age > 62.5 years, postoperative hospital stay < 5.5 days, surgical incision < 10.5 cm, barbed suture, body mass index (BMI) > 32.0 kg/m² , operation duration > 102.5 minutes, intraoperative blood loss > 102.5 mL, preoperative white blood cell count > 5.95*10⁹ /L, preoperative seroglobulin (GLB) > 29.6 g/L, postoperative total protein < 63.4 g/L, postoperative serum albumin < 36.4 g/L, and postoperative GLB > 26.8 g/L were significantly different between patients with and without DWH (P < .05). In final multivariate logistic analysis, results showed that intraoperative blood loss > 102.5 mL (odds ratio [OR], 3.09; P = .001), postoperative hospital stay < 5.5 days (OR, 1.74; P = .014), surgical incision < 10.5 cm (OR, 1.67; P = .000), and BMI > 32.0 kg/m² (OR, 4.47; P = .022) were independent risk factors for DWH. DWH prolongs hospital stay in UKA patients and increases healthcare expenditure; also affected the implementation schedule of postoperative functional exercise plans. Surgeons should identify patients at risk, meanwhile, make timely and correct clinical interventions to decrease the incidence of this complication.

Combined and Modified Gibson and Ilioinguinal Approaches in Type II + III Internal Hemipelvectomy for Periacetabular Tumors

Background

The routine iliofemoral approach and its modifications in type II+III resection require extensive skin incision and massive periacetabular muscle detachment, leading to prolonged hospital stay, increased complication incidence, and impaired lower limb function. Under the management of an enhanced recovery after surgery (ERAS) protocol, a combined and modified Gibson and ilioinguinal (MGMII) approach was used to avoid unnecessary soft tissue trauma during tumor resection and therefore advantageous to patients’ return to normal life.

Methods

Twenty-five patients with type II + III (including type II) periacetabular tumors who underwent reconstruction with 3D printed customized endoprostheses at our center between January 2017 and March 2019 were included in this study. There were 13 cases using MGMII approach and 12 cases using iliofemoral approach. The operation duration and blood loss were assessed by chart review. The surgical margin was evaluated by the histopathological studies. The reconstruction accuracy, the abductor muscle strength, the 1993 version of the Musculoskeletal Tumor Society (MSTS-93), the Harris Hip scores (HHS), and the limp score were evaluated. Complications were recorded after reviewing the patients’ records.

Results

The operative duration and blood loss in MGMII group were shorter than those in the iliofemoral group, but the postoperative hemoglobin was slightly higher than that in the iliofemoral group. The MGMII group had stronger postoperative hip abductors, better functional restoration, and relatively fewer patients with higher limp scores. No complication was observed in the MGMII group. In the iliofemoral group, three patients encountered wound healing delay, and one patient suffered deep infection.

Conclusions

The MGMII approach can better expose the posterior column of the acetabulum, especially the ischial tuberosity, which is beneficial for avoiding tumor rupture during resection. The MGMII approach also helps to preserve residual muscle function, such as the origin of the gluteus medius, while ensuring the extent of resection.

An Updated Meta-Analysis of Randomized Controlled Trials on Total Hip Arthroplasty through SuperPATH versus Conventional Approaches

The object was to conduct a systematic review and meta‐analysis of randomized controlled trials (RCTs) up to the present to draw reliable conclusions in the comparison between short‐term outcomes of total hip arthroplasty (THA) through supercapsular percutaneously assisted approach in THA (supercapsular percutaneously‐assisted total hip (SuperPATH)) versus conventional approaches (CAs). A systematic literature search was performed to identify RCTs comparing primary and secondary outcomes of THA through SuperPATH vs. CAs. Mean differences (MDs) were calculated for continuous outcomes and odds ratios (ORs) for dichotomous outcomes, using the DerSimonian and Laird method, the Mantel–Haenszel method and random effects model. A total of 14 RCTs involving 1021 patients met the inclusion criteria. Primary outcomes: SuperPATH reduced intraoperative blood loss (MD = −61.4, 95% CI −119.1 to −3.8). SuperPATH increased Harris hip score (HHS) 3, 6 and 12 months postoperatively (MD = 2.4, 95% CI 0.6–4.2; MD = 2.1, 95% CI 0.6–3.6; MD = 0.7, 95% CI 0.1–1.3; resp.). Both approaches did not differ in postoperative complication rates (OR = 0.7, 95% CI 0.2–3.3). Secondary outcomes: SuperPATH reduced pain visual analogue scale (VAS) 1 day and 3 days postoperatively (MD = −1.0, 95% CI −1.8 to −0.2; MD = −1.2, 95% CI −1.8 to −0.5; resp.). SuperPATH reduced incision length (MD = −5.2, 95% CI −7.0 to −3.4). SuperPATH increased operation time (MD = 14.3, 95% CI 3.7–24.8). Both approaches did not differ relevantly in acetabular cup inclination (MD = −1.8, 95% CI −3.8–0.2) and acetabular cup anteversion (MD = −0.6, 95% CI −1.2 to −0.1) angles. The overall findings of this meta‐analysis (Meta‐SuCAs‐2) suggested that the short‐term outcomes of THA through SuperPATH were superior to CAs. In the primary outcome, SuperPATH had a lower intraoperative blood loss and a higher HHS. Both approaches did not differ in postoperative complications. In the secondary outcome, SuperPATH had a lower pain VAS and a shorter incision length. Both approaches showed sufficient results in acetabular cup positioning. CAs had a shorter operation time than SuperPATH.

Direct anterior approach vs. SuperPATH vs. conventional approaches in total hip replacement: A network meta-analysis of randomized controlled trials

BACKGROUND

Two minimally invasive approaches showed some advantages in outcomes compared to conventional approaches (CAs) - the direct anterior approach (DAA) and the supercapsular percutaneously assisted approach in THA (SuperPATH). To the best of our knowledge, these three approaches have never been ranked in a network meta-analysis (NMA) before. Therefore, we conducted a systematic review and NMA of randomized controlled trials comparing short-term outcomes of DAA, SuperPATH and CAs in total hip joint arthroplasty (THA), using CAs as common comparator.

METHODS

A systematic literature search up to February 2021 was performed to identify randomized controlled trials (RCTs) comparing DAA with CAs and SuperPATH with CAs in THA. We measured surgical, functional and radiological outcomes. A NMA, using frequentist methods was performed to assess treatment effects between DAA, SuperPATH and CAs. Information was borrowed from the above-mentioned RCTs, using the CA group as a common comparator.

RESULTS

A total of 24 RCTs involving 2,074 patients met the inclusion criteria, six trials with a level I evidence, 18 trials with level II evidence. SuperPATH reduced operation time (fixed effects model: MD=8.1, 95% CI: 5.7 to 10.4), incision length (fixed effects model: MD=2.7, 95%CI: 2.5 to 2.9; random effects model: MD=4.1, 95%CI: 0.6 to 7.6), intraoperative blood loss (fixed effects model: MD=157, 95%CI: 139.2 to 174.2; random effects model: MD=129, 95%CI: 11.5 to 245.7) and early pain intensity (VAS 1 day postoperatively with a fixed effects model: MD=0.8, 95%CI: 0.4 to 1.2) compared to DAA. The two approaches did not differ in functional outcome and in acetabular cup inclination positioning.

CONCLUSIONS

Our overall findings suggest that short-term outcomes of THA through SuperPATH were superior to DAA and CAs and that short-term outcomes of THA through DAA were superior to CAs.

LEVEL OF EVIDENCE

II; systematic review with level I studies and level II studies.

Effect of Mobilization on the Day of Surgery After Total Hip Arthroplasty in Elderly, Obese, and Severely Diseased Patients

BACKGROUND

Mobilization on the day of surgery after total hip arthroplasty (THA) is widely used. However, elderly, obese and severely diseased patients are often excluded from early mobilization. Therefore, it was our aim to investigate the effect of mobilization on the day of surgery with focus on these patients.

METHODS

167 patients underwent THA via direct anterior approach. Exclusion criterion was the use of wound drainage. The patients were randomly allocated to two groups. Day 0 group was mobilized 4 hours after surgery, day 1 group the day after surgery. Primary outcome was the time to readiness for discharge (TRD). Secondary outcome was the occurrence of adverse events (vertigo, nausea, vomiting, severe pain) on the day of surgery. Group comparisons were calculated with respect to elderly (age ≥75 years), obese (BMI ≥30 kg/m²) and severely diseased patients (ASA≥3).

RESULTS

TRD was shorter in day 0 group (3.25 vs 3.99 days, P < .01). The rate of adverse events on the day of surgery was similar in both groups (0.28 vs 0.25, P = .73). TRD differences were higher within all subgroups (3.85vs4.81; 3.25vs4.39; 4.08vs5.11days) while the rate of immediate adverse events was reduced (0.15vs0.24; 0.25vs0.3; 0.25vs0.33). Within 90 days 3 patients of group 0 underwent revision surgery, none of group 1 (P = .12).

CONCLUSION

Mobilization on the day of surgery reduces the TRD without increasing the rate of immediate adverse events, regardless of age, BMI and ASA score. Future studies are needed to investigate if early mobility increases the 90-days complication rate.

Comparison of short-term outcomes between direct anterior approach (DAA) and SuperPATH in total hip replacement: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Two minimally invasive approaches showed some advantages in outcomes compared to conventional approaches (CAs)-the direct anterior approach (DAA) and the supercapsular percutaneously assisted approach in THA (SuperPATH). To the best of our knowledge, DAA and SuperPATH have never been compared, neither in clinical studies, nor in a meta-analysis. To conduct a systematic review and network meta-analysis of randomized controlled trials comparing short-term outcomes of DAA and SuperPATH in total hip joint arthroplasty (THA).

METHODS

A systematic literature search up to May 2020 was performed to identify randomized controlled trials (RCTs) comparing SuperPATH with CAs and DAA with CAs in THA. We measured surgical, functional, and radiological outcomes. A network meta-analysis, using frequentist methods, was performed to assess treatment effects between DAA and SuperPATH. Information was borrowed from the above-mentioned RCTs, using the CA group as a common comparator.

RESULTS

A total of 16 RCTs involving 1392 patients met the inclusion criteria, three trials with a level I evidence, 13 trials with a level II evidence. The overall network meta-analysis showed that SuperPATH reduced operation time (fixed effect model: MD = 12.8, 95% CI 9.9 to 15.7), incision length (fixed effect model: MD = 4.3, 95% CI 4.0 to 4.5; random effect model: MD = 4.3, 95% CI 0.2 to 8.4), intraoperative blood loss (fixed effect model: MD = 58.6, 95% CI 40.4 to 76.8), and early pain intensity (VAS 1 day postoperatively with a fixed effect model: MD = 0.8, 95% CI 0.4 to 1.2). The two approaches did not differ in acetabular cup positioning angles and in functional outcome.

CONCLUSIONS

Our overall findings suggested that the short-term outcomes of THA through SuperPATH were superior to DAA. SuperPATH showed better results in decreasing operation time, incision length, intraoperative blood loss, and early pain intensity. DAA and SuperPATH were equal in functional outcome and acetabular cup positioning.

Comparison of short-term outcomes between SuperPATH approach and conventional approaches in hip replacement: a systematic review and meta-analysis of randomized controlled trials

Background

It remains uncertain if the new SuperPATH approach benefits patients in artificial hip joint replacement. We conducted a systematic review and meta-analysis of randomized controlled trials to compare the short-term outcome of SuperPATH approach and conventional approaches in hip joint replacement.

Methods

A systematic literature search up to April 2020 was performed to identify randomized controlled trials comparing SuperPATH with conventional approaches in hip joint replacement. We measured surgical, functional, and radiological outcomes. Mean differences or odds ratios with 95% confidence intervals were calculated and pooled using random effects models and the Hartung-Knapp-Sidik-Jonkman method.

Results

A total of 12 RCTs involving 726 patients met the inclusion criteria, one trial with a level I evidence, 11 trials with level II evidence. The overall meta-analysis showed that SuperPATH approach reduced incision length (MD = − 4.84, 95% CI − 7.04 to − 2.64, p < 0.01), pain VAS 7 day postoperatively (MD = − 1.39, 95% CI − 2.57 to − 0.21, p = 0.03), and HHS 7 day postoperatively (MD = 10.24, 95% CI 0.27 to 20.21, p = 0.05). The two approaches did not differ in acetabular cup positioning angles, intra- and postoperative blood loss, hospitalization period, and postoperative complications. Hip replacement via SuperPATH approach had a longer operation time than hip replacement via conventional approaches.

Conclusions

SuperPATH approach showed better results in decreasing incision length and early pain intensity as well as improvement of short-term functional outcome. Long-term outcomes of SuperPATH approach need to be investigated.

Is platelet-rich plasma an ideal biomaterial for arthroscopic rotator cuff repair? A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Recently, many authors have reported the effects of platelet-rich plasma (PRP) on rotator cuff repair. Whether PRP treatment during arthroscopic rotator cuff repair improves tendon healing rates or restores full function remains unknown. The purpose of this meta-analysis was to evaluate the clinical improvement and radiological outcomes of PRP treatment in patients undergoing arthroscopic rotator cuff repair.

METHODS

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched. The study included only level 1 or 2 randomized controlled trials (RCTs) that compared the injection of platelet-rich plasma or platelet-rich fibrin matrix. The methodological quality of the trials was assessed using the Cochrane Handbook for Systematic Reviews of Interventions, 5.3. Continuous variables were analysed using the weighted mean difference, and categorical variables were assessed using relative risks. P < 0.05 was considered statistically significant.

RESULTS

The meta-analysis revealed a lower retear rate following PRP treatment than that following the control method (mean difference, 1.10; 95% CI, 1.03 to 1.18; P = 0.004). Constant shoulder scores improved with PRP (mean difference, 2.31; 95% CI, 1.02 to 3.61; P = 0.0005). PRP treatment also resulted in higher UCLA scores (mean difference, 0.98; 95% CI, 0.27 to 1.69; P = 0.007), and simple shoulder test scores were improved (mean difference, 0.43; 95% CI, 0.11 to 0.75; P = 0.008). Finally, lower visual analogue scale scores were observed with PRP augmentation (mean difference, - 0.35; 95% CI, - 0.57 to - 0.13; P = 0.002).

CONCLUSIONS

The current systematic review and meta-analysis reveals that PRP treatment with arthroscopic repair of rotator cuff tears decreases the retear rate and improves the clinical outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016048416.

Short stems in total hip replacement: evidence on primary stability according to the stem type

BACKGROUND:

As the prevalence of total hip replacement is increasing in younger patients, less invasive implants (short stems) are becoming more favourable. However, despite the advantages of these stems, clinical results with a follow-up of more than 10 years are limited to a very few stem designs. There has been an increase in publications recently - mechanical and clinical studies - concerning the primary stability of short stems. Primary stem stability is an important factor as it reflects final stem stabilisation and is related to the clinical results of the prosthesis.

METHOD:

We conducted a systematic review of the literature to retrieve evidence concerning primary implant stability in short stems - as expressed by implant micromotion and stem subsidence - according to our previously proposed short-stem classification.

RESULTS:

Mechanical in vitro studies on stem micromotion are very few and limited to type 2 "partial collum" short stems. The results are comparable to those of stems with a known long-term excellent clinical course. Clinical results concerning stem migration patterns are also limited to some of the commercially available short stems. Although comparative studies are very few, the results for most of the short stems are similar to those of standard stems.

CONCLUSION:

There are promising results concerning biomechanical studies of the initial micromotion of short stems, as well as clinical results of stem migration patterns. Long-term clinical studies are needed in order to confirm these findings. The existing literature concerns very few of the many commercially available implants.

Percutaneous Medial Ligament Reconstruction for Valgus and Rotational Knee Instability

The following surgical technique is intended for patients with chronic valgus laxity and rotational knee instability. It is a percutaneous 2-bundle ligament reconstruction method that uses the semitendinosus tendon, allowing it to remain pedicled to its distal tibial insertion. The aim is to correct the laxity without otherwise limiting the motion of the knee.

Pre-hospital medications in total hip arthroplasty: risk factors for poor outcomes

INTRODUCTION

The influence of co-morbidities on complication rates and length of hospitalisation after surgery is well recognised. Clinical instruments predicting this influence, are of increasing interest. We sought to determine whether a count of a patient's preoperative pharmaceuticals would be associated to postoperative outcomes.

MATERIAL AND METHODS

In this retrospective, consecutive case series, 668 patients undergoing elective primary total hip arthroplasty (THA) were analysed. Age, gender, BMI, ASA-classification, nicotine or alcohol abuse, and the number and type of medications were documented.

RESULTS

Mean age was 63 years (18-94), 53% were females. A total of 60 (8.9%) local and 19 (2.8%) systemic complications occurred during hospital stay. A total of 11 (1.6%) patients died, while 49 (7.3%) local complications occurred during the first postoperative year. Length of hospital stay, blood transfusions, and morbidity were found to be significantly related to the quantity of medications (p&lt;0.001). While the risk of an extended hospital stay (&gt;7 days) increased by a factor of 1.15 (CI: 1.08-1.22) with each medication, the risk of experiencing a complication within the first postoperative year was 1.19 times (CI: 1.07-1.29) for each additional medication. Type of medication also influenced morbidity: the odds ratio was 1.89 (CI: 1.05-3.41) for platelet inhibiting agents and 4.07 (CI: 1.96-8.42) for oral anticoagulants in early morbidity, which increased to 6.05 (CI:2.92-12.53) in 1-year follow-up.

CONCLUSIONS

The investigation illustrated the significant influence of the number and/or type of medication on complications, morbidity and prolonged hospital stay. This predictive tool may be useful, for physicians and non-health professionals, in estimating particular outcomes after elective THA.

Total hip arthroplasty using a posterior minimally invasive approach - results after six years

Objective

To evaluate the medium-term clinical–functional results (minimum follow-up of six years) from total uncemented hip arthroplasty performed by means of a posterior minimally invasive access, in comparison with the traditional right lateral access.

Methods

In a comparative prospective study, 224 adult patients underwent elective total hip arthroplasty due to a diagnosis of primary or secondary osteoarthrosis. A group of 103 patients with posterior minimally invasive access was compared with a group of 121 patients with the traditional right lateral access. The mean length of follow-up among the patients of this sample was 7.2 years. We evaluated the clinical–functional and radiographic results and occurrences of loosening, along with any complications that occurred, with a minimum follow-up of six years.

Results

The clinical–functional analyses before the surgical procedure and six years afterwards were similar in the two groups (p = 0.88 and p = 0.55). One patient in the minimally invasive group underwent revision of the acetabular component and two patients in the control group underwent the same procedure (p = 0.46). The Trendelenburg clinical test, which showed weakness of the hip abductor musculature, was present in five patients operated using the traditional lateral route and absent in all those who underwent the minimally invasive procedure (p = 0.06). There was no difference regarding the radiographic parameters obtained, either in acetabular or in femoral positioning (p = 0.32 and p = 0.58).

Conclusions

The medium-term clinical and radiographic results and the complication rates were similar between the patients who underwent total hip arthroplasty by means of the posterior minimally invasive access and those with the traditional lateral access.

Platelet-rich plasma in arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials

PURPOSE

The purpose of this study was to appraise the retear rate and clinical outcomes of platelet-rich plasma use in patients undergoing arthroscopic full-thickness rotator cuff repair.

METHODS

We searched the Cochrane Library, PubMed, and EMBASE databases for randomized controlled trials comparing the outcomes of arthroscopic rotator cuff surgery with or without the use of platelet-rich plasma. Methodological quality was assessed by the Detsky quality scale. When there was no high heterogeneity, we used a fixed-effects model. Dichotomous variables were presented as risk ratios (RRs) with 95% confidence intervals (CIs), and continuous data were measured as mean differences with 95% CIs. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the quality of evidence for each individual outcome.

RESULTS

Eight randomized controlled trials were included, with the sample size ranging from 28 to 88. Overall methodological quality was high. Fixed-effects analysis showed that differences were not significant between the 2 groups in retear rate (RR, 0.94; 95% CI, 0.70 to 1.25; P = .66), Constant score (mean difference, 1.12; 95% CI, -1.38 to 3.61; P = .38), and University of California at Los Angeles (UCLA) score (mean difference, -0.68; 95% CI, -2.00 to 0.65; P = .32). The strength of GRADE evidence was categorized respectively as low for retear, moderate for Constant score, and low for UCLA shoulder score.

CONCLUSIONS

Our meta-analysis does not support the use of platelet-rich plasma in the arthroscopic repair of full-thickness rotator cuff tears over repairs without platelet-rich plasma because of similar retear rates and clinical outcomes.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and II randomized controlled trials.

The minimal invasive direct anterior approach in combination with large heads in total hip arthroplasty - is dislocation still a major issue? a case control study

Background

There have been increasing numbers of publications in recent years on minimally invasive surgery (MIS) for total hip arthroplasty (THA), reporting results with the use of different head sizes, tribologic and functional outcomes. This study presents the results and early complication rates after THA using the direct anterior approach (DAA) in combination with head sizes ≥ 36 mm.

Methods

A total of 113 patients with THA were included in the study. The Harris Hip Score (HHS) was determined, a radiographic evaluation was carried out, and complications were recorded. The minimum follow-up period was 2 years (means 35 ± 7 months).

Results

The HHS improved from 43.6 (± 12) to 88.2 (± 14; P < 0.01). One early infection occurred, one periprosthetic fracture, and three cases of aseptic stem loosening. No incorrect positioning of the implants was observed, and there were no dislocations.

Conclusion

THA with the minimally invasive DAA in combination with large heads is associated with good to very good functional results in the majority of cases. The complication rates are not increased. The rate of dislocation mainly as an complication of the first two years can be markedly reduced in particular.

Enhanced recovery in total hip replacement: a clinical review

The outcome after total hip replacement has improved with the development of surgical techniques, better pain management and the introduction of enhanced recovery pathways. These pathways require a multidisciplinary team to manage pre-operative education, multimodal pain control and accelerated rehabilitation. The current economic climate and restricted budgets favour brief hospitalisation while minimising costs. This has put considerable pressure on hospitals to combine excellent results, early functional recovery and shorter admissions. In this review we present an evidence-based summary of some common interventions and methods, including pre-operative patient education, pre-emptive analgesia, local infiltration analgesia, pre-operative nutrition, the use of pulsed electromagnetic fields, peri-operative rehabilitation, wound dressings, different surgical techniques, minimally invasive surgery and fast-track joint replacement units.

Mini-incision versus standard incision total hip arthroplasty regarding surgical outcomes: a systematic review and meta-analysis of randomized controlled trials

Purpose

It remains controversial whether mini-incision (MI) benefits patients in total hip arthroplasty (THA). We performed a meta-analysis of randomized controlled trials (RCTs) to assess the effects of MI on surgical and functional outcomes in THA patients.

Methods

A systematic electronic literature search (up to May 2013) was conducted to identify RCTs comparing MI with standard incision (SI) THA. The primary outcome measures were surgical and functional outcomes. According to the surgical approach taken, MI THA patients were divided into four subgroups for sub-group meta-analysis. Standardized mean differences (SMDs) or risk differences (RDs) with accompanying 95% confidence intervals (CIs) were calculated and pooled using a fixed-effect or random-effect model according to the heterogeneity.

Results

A total of 14 RCTs involving THA 1,174 patients met the inclusion criteria. The trials were medium risk of bias. The overall meta-analysis showed MI THA reduced total blood loss (95% CI, -201.83 to -21.18; p=.02) and length of hospital stay ( 95% CI, -0.67 to -0.08; p=.01) with significant heterogeneity. However, subgroup meta-analysis revealed posterior MI THA had perioperative advantages of reduced surgical duration ( 95% CI, -8.45 to -2.67; P<.001), less blood loss ( 95% CI, -107.20 to -1.73; P=.04) and shorter hospital stay ( 95% CI, -0.74 to -0.06; p=.002) with low heterogeneity. There were no significant differences between MI and SI THA groups in term of pain medication dose, functional outcome (HHS), radiological outcome or complications (P>.05, respectively).

Conclusions

Although no definite overall conclusion can be arrived at on whether MI THA is superior to SI THA, posterior MI THA clearly result in a significant decrease in surgical duration, blood loss and hospital stay. It seems to be a safe minimally invasive surgical procedure without increasing the risk of component malposition or complications.