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.

Preparations with catastrophic side effects: A case of neck of femur fracture due to secondary osteoporosis with underlying hip osteonecrosis resulting from chronic jamu consumption

Jamu is commonly used to treat a variety of health conditions in South East Asia due to its efficacy, affordability and ease of access. Despite its effectiveness, little is known regarding its contents and adverse effects. Recent studies have found evidence of steroids within jamu preparations. Chronic jamu consumption may inadvertently manifest with adverse effects associated with long-term steroid intake. We describe a case of neck of femur fracture due to secondary osteoporosis with underlying hip osteonecrosis resulting from chronic jamu consumption hoping to increase awareness regarding the devastating effects of these preparations.

Masquelet’s induced membrane technique for the reconstruction of post-traumatic, open-grade distal femur fracture with bone defect

Introduction: Reconstruction of complex, open-grade distal femur fracture with bone defect presents an orthopaedic surgeon with a distinctive challenge as they are often associated with contaminated, compromised soft tissue and poor host condition. Conventional techniques like vascularized fibula transfer, autologous bone grafting or distraction osteogenesis focus mainly over bone union without taking infection control into consideration. The aim of this study is to evaluate the outcome of induced membrane technique in the reconstruction of open distal femur fracture with bone defect. Methods: 10 such patients were retrospectively evaluated. Union was considered when a minimum of two cortices were seen on a radiograph. Knee Society Score was used to evaluate the functional outcome. Results: The average length of the defect was 5.7cm (3–10 cm) with mean interval period between the two stages being 42.7 days (34–51 days). Internal fixation was carried out in all cases. In 7 patients we used a mixture of cancellous autograft and cancellous allograft mixed in a ratio of 3:1. In the remaining 3 patients we used only cancellous autograft. Radiological union was achieved in all patients with mean union time of 8.5 months (7–11 months). Mean knee score was 79 (69–86) and mean function score was 71.5 (60–80). Conclusion: The induced membrane technique is an economical, technically less demanding technique for reconstruction of distal femur fracture with bone defects. The results are reproducible with a high success rate and without the need of any special instrumentation. It bestows infection control and prevents graft resorption. Long reconstructive period and donor site morbidity are matters of concern.

Additional effects of core stability exercises on pain and function of patients with patellofemoral pain: A randomized controlled trial

Background/purpose: Recently, there is more emphasis on the role of core muscles in pathogenesis and rehabilitation of patellofemoral pain (PFP). We aimed to investigate whether increased core muscle strength and endurance improve clinical outcomes. Methods: In a randomized controlled trial, 60 patients (M/F: 25/35, age = 32.28 (5.9) years) with PFP were randomly allocated into two groups of routine exercise (control) and combined core plus routine exercise (intervention). Home exercise was scheduled at least 5 times/week for 12 weeks. We assessed the outcomes of pain (Visual analogue scale) and function (Anterior knee pain score) before and immediately after interventions. Results: Significant improvements were reported in both groups (P < 0.001). There were significant between-group differences in both outcomes in favor of the intervention (Pain: 12.4, CI 95%: 7.1–17.8, P < 0.001; Function: 6.4, CI 95%: 2.2–10.5, P = 0.003). Conclusion: Outcome improvements were significantly greater in intervention group. Inclusion of core stability exercises may lead to additional benefits.

Management of extra-abdominal fibromatosis in a musculoskeletal tumour centre in Hong Kong

Introduction: Fibromatosis is a benign disease yet prone to recurrence. The best treatment option remains controversial. The purpose of this study was to analyse the management approach in our musculoskeletal tumour centre. Materials and Methods: Thirty-four patients with extra-abdominal fibromatosis referred to our centre between 2000 to 2018 were included. Patients’ demographics, tumour location and size, year of diagnosis, treatment modalities, surgical margins, recurrence, and subsequent management were analysed. Results: Patients mostly presented in the second and third decade, with female predominance. Twenty-seven patients underwent excision. Other management options included ‘watchful waiting’, pharmacological treatment and radiotherapy. Recurrence rate was 51.9%. There was no statistically significant relationship between marginal status and recurrence. Conclusion: We report our experiences on management of fibromatosis, with strategy shifted from early excision to a conservative approach over the years. Surgical excision is still indicated in some situations. Tumour recurrence is not rare but second excision is not always necessary.

Biodegradable magnesium screws in elbow fracture fixation: Clinical case series

Biodegradable magnesium-based implants are innovative alternatives that potentially eliminate the need for implant removal. Recent studies have demonstrated the osteogenic properties and bacterial inhibition potentials of magnesium screws. We reported a clinical series of three elbow fracture cases, where magnesium screws were used in the treatment of one radial head and two capitellum fractures. Postoperative clinical courses were uneventful, and fracture healing occurred within 3 months. In all cases, radiolucencies were observed around implants especially in the screw head region at 2 months post-operation, but disappeared with consolidation at 1 year post-operation. All patients achieved near normal range of motion, minimal symptoms and good functional outcomes. No complication such as failure of fixation, loss of reduction, malunion or infection was seen. No implant revision or removal was necessary. Magnesium bioabsorbable screws are shown to be a viable option for these fractures.

Extensively hydroxyapatite-coated long femoral stem revision hip arthroplasty: Clinical outcome and survivorship in 11 to 17.5 years follow up

Extensively coated long femoral stem revision hip arthroplasty is based on the principle of distal fixation at diaphyseal region, which can overcome the problem of proximal femoral bone stock deficiencies causing inadequate support and unstable fixation when using conventional length femoral stem. We performed a retrospective cohort analysis of 43 cases of revision hip arthroplasties using extensively hydroxyapatite-coated long femoral stem performed in our department from Jan 1998 to Dec 2005. Patients’ background demographic data, operative details and clinical outcome were analyzed. The mean age at revision surgery was 63.7 (32–84). The mean follow-up period was of 13.8 years (11–17.5 years). In the latest follow up, all patients reported either no or mild hip or thigh pain. 29.2% of patients were able to walk unaided, 25.0% were able to walk with stick, and 33.3% were able to walk with quadripod. The average Harris hip score measured in the latest follow up was 78.8 (55–100). 4.7% were complicated with implant loosening requiring re-revision and 4.7% were complicated with implant infection requiring implant removal. The survival rate was 89.9% at 17.5 years. The femoral stem without femoral fixation augmentation had better survivorship as compared with those with augmentation (p = 0.038). Extensively hydroxyapatite-coated long femoral stem is a good option for revision hip arthroplasty with good clinical outcome and high survival rate.

A case of synovial chondromatosis of knee joint treated with total knee arthroplasty

Synovial Chondromatosis is a rare disease of the synovial membrane characterised by formation of multiple loose bodies in a joint. Knee is the most common joint to be affected by this disease. Though, this disease can be managed by synovectomy and removal of loose bodies with a favourable functional outcome but in some cases where there is damage of articular cartilage, simple synovectomy might not be sufficient. Here, we present a case of right knee pain in a 53 year old male since 4 years with a established diagnosis of synovial chondromatosis. No other joint was affected. Pain was associated with a fixed flexion deformity and restriction of knee range of motion and multiple slipping bodies. Radiography showed multiple loose bodies in the tibio-femoral as well as in patello femoral compartment. MRI of knee revealed several damaged areas in the knee articular surface. As a result, decision was taken to perform total knee arthroplasty. Intraoperatively all the loose bodies were removed along with the affected synovium and arthroplasty was done. Patient was discharged in fourth post operative day with proper instructions and was called for follow up at 1 month, 3 month, 6 month, 1 year. Functional outcome was assessed by Tegner Lysholm knee score, Knee Society score and Visual Assessment Scale.

Effectiveness of duloxetine on severity of pain and quality of life in chronic low back pain in patients who had posterior spinal fixation

Background: In this study, we want to search the effectiveness of Duloxetine on the severity of pain and quality of life in patients with chronic low back pain who had posterior spinal fixation. Methods: In this randomized, placebo-controlled trial done in 6 months 50 patients who had CLBP and were candidates for PSF surgery selected and divided into two groups (drug and placebo). They filled the VAS, SF-36, and Hamilton questionnaires before surgery and after 6 weeks from using 30 mg of duloxetine or placebo. Results: Significant differences were evidenced among groups for the Visual Analogue Scale (P = 0.005) and Verbal Analogue Scale (p = 0.003). Patients in the Duloxetine group have more visual and verbal pain scores than the placebo group. In the quality of life, there was a significant difference between the two groups before the intervention. Also, significant differences were evidenced among groups for the Hamilton Anxiety Rating Scale (p = 0.17). After the intervention, only the Hamilton Anxiety Rating Scale (p = 0.001) and ‘bodily pain’ and ‘general health’ subscales of quality of life (p = 0.008, 0.004, respectively) have a significant difference between the two groups. There was a significant difference between pre and post-intervention in the Hamilton Anxiety Rating Scale only in the duloxetine group. Also, in terms of quality of life, the subscales of ‘physical role’, ‘emotional role’, ‘physical pain’ and ‘total score of quality of life’ in the duloxetine and placebo groups were significantly different between pre and post-intervention. However, the subscales of ‘physical function’ and ‘general health’ were significantly different only in the duloxetine group between pre and post-intervention. Conclusion: The results suggest that the use of duloxetine in patients who had spinal surgery can help to better control back pain, on the other hand, it can cause a better psychological condition that affects the quality of life.

Efficacy and safety of nucleo-annuloplasty using radiofrequency ablation for discogenic back pain in a local Hong Kong population

Purpose: Degenerative disk disease is a global and common debilitating condition with substantial healthcare and economic costs. Disc-Fx is a relatively new minimally invasive, percutaneous nucleo-annuloplasty procedure aimed to alleviate symptoms of discogenic back pain via manual discectomy with nuclear and annular modification via means of radiofrequency ablation. The aim of this retrospective study is to report the 1-year outcomes, efficacy and safety of the percutaneous nucleo-annuloplasty procedure for treatment of discogenic back pain in the local Hong Kong population. Methods: This retrospective study consists of 16 patients with a total of 24 levels from 2017 to –2019 with at least 6 months of chronic back pain failing conservative management, MRI-confirmed disc degeneration, and who have undergone percutaneous nucleo-annuloplasty via Disc-Fx procedure. All patients had plain radiography and magnetic resonance imaging prior to procedure. Percutaneous nucleo-annuloplasty was only performed in patients with confirmed discogenic back pain via a positive provocative test on discography. Results: The mean functional outcome of Oswestry Disability Index improved from 46.25 points preoperatively to 24.12 at the of 1-year follow-up (p-value = 0.00). The Numerical Pain Rating Scale improved from 6.25 points to 4.4 points (p-value: 0.01) and 14.56 points to 8.85 points (p-value = 0.01) at preoperative to 1-year post-procedure respectively. There were no reported procedural related complications in the study population. Conclusion: The procedure of percutaneous nucleo-annuloplasty shows to be a relatively safe procedure that can be considered in patients with discogenic back pain. Larger studies would be desired to draw further conclusions about its efficacy.