Complication and revision rates after reverse total shoulder revision from hemiarthroplasty: a systematic review

Background

Thus, the purpose of the present study was to (1) characterize common postoperative complications and (2) quantify the rates of revision in patients undergoing hemiarthroplasty to reverse total shoulder arthroplasty revisional surgery. We hypothesize that hardware loosenings will be the most common complication to occur in the sample, with the humeral component being the most common loosening.

Methods

This systematic review adhered to PRISMA reporting guideline. For our inclusion criteria, we included any study that contained intraoperative and/or postoperative complication data, and revision rates on patients who had undergone revision reverse total shoulder arthroplasty due to a failed hemiarthroplasty. Complications include neurologic injury, deep surgical site infections, hardware loosening/prosthetic instability, and postoperative fractures (acromion, glenoid, and humeral fractures).

Results

The study contained 22 studies that assessed complications from shoulders that had revision reverse total shoulder arthroplasty from a hemiarthroplasty, with a total sample of 925 shoulders. We found that the most common complication to occur was hardware loosenings (5.3%), and of the hardware loosenings, humeral loosenings (3.8%) were the most common. The revision rate was found to be 10.7%.

Conclusion

This systematic review found that revision reverse total shoulder arthroplasty for failed hemiarthroplasty has a high overall complication and reintervention rates, specifically for hardware loosening and revision rates.

Analysis of Social Media Perceptions Among Orthopaedic Surgery Residency Applicants and Social Media Use by Residency Programs During the 2020 to 2021 Cycle

Owing to the coronavirus 2019 pandemic limiting both applicants and residency programs in their ability to connect in-person, it is likely that a shift toward virtual connections was made. We aimed to query applicants regarding their perspectives of orthopaedic residency program social media use. Furthermore, we aimed to quantify the number of orthopaedic surgery residency programs with active social media accounts.

Levels of evidence backing the AAOS clinical practice guidelines

Purpose:

The American Academy of Orthopaedic Surgeons produces clinical practice guidelines for the treatment of orthopedic injuries. We examined the strength of the evidence underlying these recommendations in order to answer the following questions: (1) Have AAOS work groups improved guideline creation practices to locate evidence to generate strong recommendations? (2) Is there variability in the available evidence based on anatomic site or stage of care? (3) Has the level of evidence supporting improved over time?

Methods:

Twenty-two current guidelines of the Academy were examined which yielded 408 individual recommendations. These recommendations were assigned one of five strength of evidence ratings (strong, moderate, limited, inconclusive, consensus) by the guideline panel, based on the availability and quality of the supporting evidence. From these guidelines, we extracted all of the recommendations and their corresponding evidence ratings. We then classified the recommendations by stage of care, year, and anatomical site.

Results:

The distribution of the levels of evidence was as follows: 77 (18.9%) were based on consensus; 53 (13.0%) were inconclusive; 93 (22.8%) were based on limited evidence; 112 (27.5%) were based on moderate evidence; and 73 were based on (17.9%) strong evidence. Strong strength of evidence was found in 45.2% of the recommendations for preventive/screening/diagnostic care, 41.1% of nonsurgical treatment, 45.1% of surgical treatment, 51.1% of rehabilitation/postoperative treatment, and 45.5% of the recommendations that had mixed stages of care. Inconclusive strength of evidence was found to be prevalent from 2009–2013, but was eliminated starting in 2014.

Conclusions:

Only 73 (17.9%) recommendations generated by the Academy in its 22 clinical practice guidelines are based on a “strong” strength of evidence. More robust research is needed in orthopedics to bolster confidence in the recommendations in future guideline updates.

The use of systematic reviews to justify orthopaedic trauma randomized controlled trials: A cross-sectional analysis

OBJECTIVE

Orthopaedic trauma is one of the largest surgical fields in medicine, and as such, requires the latest evidence to ensure the best standard of care. Systematic reviews are an invaluable resource that compiles an exhaustive summary of the most current evidence on a given clinical question. The primary aim of this study is to evaluate the use of systematic reviews as justification in conducting randomized controlled trials published in high impact orthopaedic trauma journals.

METHODS

We analyzed randomized controlled trials published in the top three high impact orthopaedic trauma journals between 2015 and 2018. We performed data extraction blind, independent, and in duplicative manner to ensure the validity of the findings. For each trial, data was extracted by the number of systematic reviews cited in each clinical trial and whether or not the study used a systematic review as justification for conducting the trial. A subgroup of general orthopaedic clinical trials were included for comparison.

RESULTS

Of 144 articles retrieved, 128 were included. Overall, 71.1% (91/128; [95% CI, 63.2-78.9]) of included orthopaedic trauma randomized controlled trials referenced a systematic review and 28.9% (37/128) of studies did not cite a systematic review. Of the 91 trials that referenced a systematic review, 33.0% (30/91; [95% CI, 23.3-42.6]) of RCTs cited a systematic review as trial justification, whether that be "verbatim" or "inferred". "Verbatim" justifications occurred in 20.0% (6/30; [95% CI, 5.7-34.3]) of included trauma RCTs that cited a systematic review as justification for conducting the trial and "inferred" justifications occurred in 80.0% (24/30; [95% CI, 65.7-94.3]).

CONCLUSION

Systematic reviews are frequently cited in orthopaedic trauma RCTs but are not commonly cited as justification for conducting a clinical trial. Ideally, evidentiary uncertainty regarding a research question should be established by existing literature through a systematic review to reduce research waste.

An Evaluation of Publication Bias in High-Impact Orthopaedic Literature

Background:

Statistical analysis of systematic reviews allows the results of previous studies to be combined and synthesized to assess the overall health effect of the intervention in question. Systematic reviews can also be used to guide the creation of clinical practice guidelines and are considered to have a high level of evidence. Thus, it is important that their methodological quality is of the highest standard. Publication bias presents 2 problems: (1) studies with significant results may be overrepresented in systematic reviews and meta-analyses (“false positives”) and (2) studies without significant results may not be included in systematic reviews and meta-analyses (“false negatives”) because each study, on its own, was underpowered, meaning that some treatment options that may have clinical benefit will not be adopted.

Methods:

We performed a study to evaluate the techniques used by authors to report and evaluate publication bias in the top 10 orthopaedic journals as well as 3 orthopaedic-related Cochrane groups. Two authors independently screened the titles and abstracts to identify systematic reviews and meta-analyses. We assessed publication bias in the systematic reviews that did not assess publication bias themselves.

Results:

Our final sample included 694 systematic reviews or meta-analyses that met our inclusion criteria. Our review included 502 studies (72%) that focused on clinical outcomes, with the majority of the remaining studies focused on predictive and prognostic accuracy (20%) or diagnostic accuracy (5%). Publication bias was discussed in 295 (42.5%) of the included studies and was assessed in 135 (19.5%). Of the studies that assessed publication bias, 31.9% demonstrated evidence of publication bias. Only 43% and 22% of studies that involved use of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines discussed and assessed publication bias, respectively.

Conclusions:

Publication bias is infrequently discussed and assessed in the high-impact orthopaedic literature. Furthermore, nearly one-third of the studies that assessed for publication bias demonstrated evidence of publication bias. In addition to these shortcomings, fewer than half of these studies involved use of the PRISMA guidelines and yet only one-fourth of the studies assessed for publication bias.

Clinical Relevance:

By understanding the degree to which publication bias is discussed and presented in high-impact orthopaedic literature, changes can be made by journals and researchers alike to improve the overall quality of research produced and reported.

An Evaluation of the Rotator Cuff Repair Research Pipeline

BACKGROUND

We conducted a study of recommendations from the American Academy of Orthopaedic Surgeons (AAOS) guideline, "Optimizing the Management of Rotator Cuff Problems." Using these recommendations, we conducted searches of clinical trial registries and bibliographic databases to note the extent to which new research has been undertaken to address areas of deficiency.

HYPOTHESIS

Newly conducted research regarding rotator cuff repair and injury is available that will fill knowledge gaps identified by the AAOS guideline.

STUDY DESIGN

Cross-sectional study.

METHODS

For each recommendation in the AAOS guideline, we created PICO (participants, intervention, comparator, outcome) questions and search strings. Searches were conducted of ClinicalTrials.gov, the World Health Organization's International Clinical Trials Registry Platform, MEDLINE via PubMed, and EMBASE to locate studies undertaken after the final literature search performed by the AAOS work group.

RESULTS

We located 210 newly registered trials and 448 published studies that are relevant to the recommendations made in the rotator cuff guideline. The majority of the recommendations have been addressed by relevant registered trials or published studies. Of the 448 published studies, 185 directly addressed the guideline recommendations. Additionally, 71% of the 185 published studies directly addressing the recommendations were randomized trials or systematic reviews/meta-analyses. The most important finding of our study was that the recommendations in the AAOS rotator cuff guideline have been adequately addressed.

CONCLUSION

Orthopaedic researchers have adequately addressed knowledge gaps regarding rotator cuff repair treatment and management options. As such, the AAOS may consider a guideline update to ensure that recommendations reflect current findings in orthopaedic literature.

Tests of the precedence effect in sound localization reveal abnormalities in multiple sclerosis

The precedence effect in sound localization involves presenting identical sounds (e.g., clicks) from pairs of matched speakers situated on opposite sides of a subject's head, with the clicks from one speaker preceding those from the other by a short interval. With appropriate delays, normal subjects perceive a fused image which originates from the side of the leading speaker. This test was administered to 24 patients with multiple sclerosis (MS). Separate tests involving speaker delays ranging from 0 msec (simultaneous presentation) to 8 msec were presented. At 0 msec delay, normal subjects perceived the fused image to be located halfway between the two speakers; at progressively longer delays, the image was perceived closer to the leading speaker. In contrast to normal subjects, a large proportion of the MS subjects exhibited difficulties with the task. The discrimination deficit was limited to delays below 1 msec, suggesting a problem involving an increased threshold for lateralizing the fused image away from midline toward the side of the leading speaker. The neural instability produced by demyelination in MS patients might account for this pattern of results.