Treatment strategies for ischiofemoral impingement: a systematic review

Abstract: Purpose: There has been relatively little information about the treatment for ischiofemoral impingement (IFI) because of its rarity as well as the uncertainty of diagnosis. The aim of this study was to provide the reader with the available treatment strategies and their related outcomes for IFI based on the best available evidence, whilst highlighting classically accepted ways of treatment as well as relatively new surgical and non-surgical techniques. Methods: A systematic review of the literature from Medline, Embase, AMED, Cochrane and Google Scholar was undertaken since inception to December 2017 following the PRISMA guidelines. Clinical outcome studies, prospective/retrospective case series and case reports that described the treatment outcome for IFI were included. Animal or cadaveric studies, trial protocols, diagnostic studies without any description of treatments, technical notes without any results, and review articles were excluded. Results: This systematic review found 17 relevant papers. No comparative studies were included in the final records for qualitative assessment, which means all the studies were case series and case reports. Eight studies (47.1%) utilised non-surgical treatment including injection and prolotherapy, followed by endoscopic surgery (5 studies, 29.4%) then open surgery (4 studies, 23.5%). Mean age of the participants was 41 years (11–72 years). The mean follow-up was 8.4 months distributed from 2 weeks to 2.3 years. No complications or adverse effects were found from the systematic review. Conclusion: Several treatment strategies have been reported for IFI, and most of them have good short- to medium-term outcomes with a low rate of complications. However, there are no comparative studies to assess the superiority of one technique over another, thus further research with randomised controlled trials is required in this arena. This study explores the wide variety and categories of different treatments used for IFI to guide physicians and shed light on what can be done for this challenging cohort of patients. Level of evidence: III

What are the outcomes of core decompression in patients with avascular necrosis? Protocol for a systematic review.

Background: Core decompression is a hip preserving surgical procedure that is used to treat avascular necrosis (AVN) of the femoral head. The eventual clinical and radiological outcome following this procedure is varied in literature. Also, the time to a total hip replacement (THR) from the index procedure and the percentage of patients subsequently undergoing a THR is controversial. Furthermore, there are multiple surgical methods along with multiple augmentation techniques and various classification and staging systems described. The purpose of this systematic review, therefore, is to analyse the outcomes following decompression only, excluding any augmentation techniques for non-traumatic AVN of the femoral head. Methods: This protocol is being developed in line with the PRISMA-P guidelines. The search strategy includes articles from Medline, Embase, Google Scholar, CINHAL and Cochrane library. The review and screening will be done by two independent reviewers. Review articles, editorials and correspondences will be excluded. Articles including patients with sickle cell disease and with core decompression where augmentation is used will be excluded. The risk of bias and quality of articles will be assessed using the Joanna Briggs Institute Critical Appraisal Checklist for the different study designs included. Discussion: This study will be a comprehensive review on all published articles having patients with AVN of the femoral head and undergoing core decompression surgery only. The systematic review will then define the outcomes of the core decompression surgery based on clinical and radiological outcomes. Each outcome will include the different stages within it and finally, the total mean time to THR will be calculated. This will then be followed by assessing the cumulative confidence in evidence from all the data collected using the GRADE tool.   Registration: This systematic review is registered in the International Prospective Register for Systematic Reviews and Meta-analysis (PROSPERO) under the registration number:  CRD42018100596

What are the outcomes of core decompression without augmentation in patients with nontraumatic osteonecrosis of the femoral head?

Funder: University of CambridgeAbstract: Purpose: Core decompression (CD) of the femoral head is performed to preserve the hip in avascular necrosis (AVN). The outcome following this procedure differs based on the medical centre and the technique. Also, the time to total hip replacement (THR) and the percentage of patients subsequently undergoing a THR are controversial. Methods: A systematic review was performed following PRISMA guidelines. The search included CENTRAL, MEDLINE, EMBASE, Scopus, AMED and Web of Science Core Collection databases. Studies reporting the outcome of CD for AVN were assessed. Studies using additional implants, vascularized grafts or any type of augmentation were excluded. Quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC) tool. Trial registration: International prospective register of systematic reviews (PROSPERO) - CRD42018100596. Results: A total of 49 studies describing 2540 hips were included. The mean weighted follow-up time was 75.1 months and the mean age at surgery was 39 years. Twenty-four of 37 studies reported improvement in all outcome scores, whilst 9/37 studies report only partial improvement post-operatively. Four studies (4/37) described poor clinical outcomes following intervention. Data was pooled from 20 studies, including 1134 hips with a weighted mean follow-up of 56 months. The percentage of hips undergoing THR averaged 38%. The time to THR had a weighted mean of 26 months after CD. Conclusion: Pooled results from 1134 hips and of these nearly 80% with early stage of osteonecrosis, showed that approximately 38% of patients underwent a total hip replacement at an average of 26 months following core decompression without augmentation

Why are patients dissatisfied following a total knee replacement? A systematic review

Funder: University of CambridgeAbstract: Background: Although total knee replacement (TKR) is an effective intervention for end-stage arthritis of the knee, a significant number of patients remain dissatisfied following this procedure. Our aim was to identify and assess the factors affecting patient satisfaction following a TKR. Materials and methods: In accordance with the PRISMA guidelines, two reviewers searched the online databases for literature describing factors affecting patient satisfaction following a TKR. The research question and eligibility criteria were established a priori. Any clinical outcome study that described factors relating to overall satisfaction after primary TKR was included. Quality assessment for the included studies was performed by two accredited orthopaedic surgeons experienced in clinical research. Results: The systematic review identified 181 relevant articles in total. A history of mental health problems was the most frequently reported factor affecting patient satisfaction (13 reportings). When the results of the quality assessment were taken into consideration, a negative history of mental health problems, use of a mobile-bearing insert, patellar resurfacing, severe pre-operative radiological degenerative change, negative history of low back pain, no/less post-operative pain, good post-operative physical function and pre-operative expectations being met were considered to be important factors leading to better patient satisfaction following a TKR. Conclusion: Surgeons performing a TKR should take these factors into consideration prior to deciding whether a patient is suitable for a TKR. Secondarily, a detailed explanation of these factors should form part of the process of informed consent to achieve better patient satisfaction following TKR. There is a great need for a unified approach to assessing satisfaction following a TKR and also the time at which satisfaction is assessed

Advanced rehabilitation technology in orthopaedics—a narrative review

Funder: University of CambridgeAbstract: Introduction: As the demand for rehabilitation in orthopaedics increases, so too has the development in advanced rehabilitation technology. However, to date, there are no review papers outlining the broad scope of advanced rehabilitation technology used within the orthopaedic population. The aim of this study is to identify, describe and summarise the evidence for efficacy for all advanced rehabilitation technologies applicable to orthopaedic practice. Methods: The relevant literature describing the use of advanced rehabilitation technology in orthopaedics was identified from appropriate electronic databases (PubMed and EMBASE) and a narrative review undertaken. Results: Advanced rehabilitation technologies were classified into two groups: hospital-based and home-based rehabilitation. In the hospital-based technology group, we describe the use of continuous passive motion and robotic devices (after spinal cord injury) and their effect on improving clinical outcomes. We also report on the use of electromagnetic sensor technology for measuring kinematics of upper and lower limbs during rehabilitation. In the home-based technology group, we describe the use of inertial sensors, smartphones, software applications and commercial game hardware that are relatively inexpensive, user-friendly and widely available. We outline the evidence for videoconferencing for promoting knowledge and motivation for rehabilitation as well as the emerging role of virtual reality. Conclusions: The use of advanced rehabilitation technology in orthopaedics is promising and evidence for its efficacy is generally supportive

Target prices for mass production of tyrosine kinase inhibitors for global cancer treatment

OBJECTIVE: To calculate sustainable generic prices for 4 tyrosine kinase inhibitors (TKIs). BACKGROUND: TKIs have proven survival benefits in the treatment of several cancers, including chronic myeloid leukaemia, breast, liver, renal and lung cancer. However, current high prices are a barrier to treatment. Mass production of low-cost generic antiretrovirals has led to over 13 million people being on HIV/AIDS treatment worldwide. This analysis estimates target prices for generic TKIs, assuming similar methods of mass production. METHODS: Four TKIs with patent expiry dates in the next 5 years were selected for analysis: imatinib, erlotinib, lapatinib and sorafenib. Chemistry, dosing, published data on per-kilogram pricing for commercial transactions of active pharmaceutical ingredient (API), and quotes from manufacturers were used to estimate costs of production. Analysis included costs of excipients, formulation, packaging, shipping and a 50% profit margin. Target prices were compared with current prices. Global numbers of patients eligible for treatment with each TKI were estimated. RESULTS: API costs per kg were $347–$746 for imatinib, $2470 for erlotinib,$4671 for lapatinib, and $3000 for sorafenib. Basing on annual dose requirements, costs of formulation/packaging and a 50$128–$216 for imatinib,$240 for erlotinib, $1450 for sorafenib, and$4020 for lapatinib. Over 1 million people would be newly eligible to start treatment with these TKIs annually. CONCLUSIONS: Mass generic production of several TKIs could achieve treatment prices in the range of $128–$4020 per person-year, versus current US prices of $75161–$139 138. Generic TKIs could allow significant savings and scaling-up of treatment globally, for over 1 million eligible patients

Protecting healthcare workers from COVID-19: learning from variation in practice and policy identified through a global cross-sectional survey.

AIMS: The COVID-19 pandemic presents an unprecedented burden on global healthcare systems, and existing infrastructures must adapt and evolve to meet the challenge. With health systems reliant on the health of their workforce, the importance of protection against disease transmission in healthcare workers (HCWs) is clear. This study collated responses from several countries, provided by clinicians familiar with practice in each location, to identify areas of best practice and policy so as to build consensus of those measures that might reduce the risk of transmission of COVID-19 to HCWs at work. METHODS: A cross-sectional descriptive survey was designed with ten open and closed questions and sent to a representative sample. The sample was selected on a convenience basis of 27 senior surgeons, members of an international surgical society, who were all frontline workers in the COVID-19 pandemic. This study was reported according to the Standards for Reporting Qualitative Research (SRQR) checklist. RESULTS: Responses were received by all 27 surgeons from 22 countries across six continents. A number of the study respondents reported COVID-19-related infection and mortality in HCWs in their countries. Differing areas of practice and policy were identified and organized into themes including the specification of units receiving COVID-19 patients, availability and usage of personal protective equipment (PPE), other measures to reduce staff exposure, and communicating with and supporting HCWs. Areas more specific to surgery also identified some variation in practice and policy in relation to visitors to the hospital, the outpatient department, and in the operating room for both non-urgent and emergency care. CONCLUSION: COVID-19 presents a disproportionate risk to HCWs, potentially resulting in a diminished health system capacity, and consequently an impairment to population health. Implementation of these recommendations at an international level could provide a framework to reduce this burden

Global, regional, and national burden of neurological disorders during 1990-2015 : a systematic analysis for the Global Burden of Disease Study 2015

Background Comparable data on the global and country-specific burden of neurological disorders and their trends are crucial for health-care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study provides such information but does not routinely aggregate results that are of interest to clinicians specialising in neurological conditions. In this systematic analysis, we quantified the global disease burden due to neurological disorders in 2015 and its relationship with country development level. Methods We estimated global and country-specific prevalence, mortality, disability-adjusted life-years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) for various neurological disorders that in the GBD classification have been previously spread across multiple disease groupings. The more inclusive grouping of neurological disorders included stroke, meningitis, encephalitis, tetanus, Alzheimer's disease and other dementias, Parkinson's disease, epilepsy, multiple sclerosis, motor neuron disease, migraine, tension-type headache, medication overuse headache, brain and nervous system cancers, and a residual category of other neurological disorders. We also analysed results based on the Socio-demographic Index (SDI), a compound measure of income per capita, education, and fertility, to identify patterns associated with development and how countries fare against expected outcomes relative to their level of development. Findings Neurological disorders ranked as the leading cause group of DALYs in 2015 (250.7 [95% uncertainty interval (UI) 229.1 to 274.7] million, comprising 10.2% of global DALYs) and the second-leading cause group of deaths (9.4 [9.1 to 9.7] million], comprising 16.8% of global deaths). The most prevalent neurological disorders were tensiontype headache (1505 9 [UI 1337.3 to 1681.6 million cases]), migraine (958.8 [872.1 to 1055.6] million), medication overuse headache (58.5 [50.8 to 67.4 million]), and Alzheimer's disease and other dementias (46.0 [40.2 to 52.7 million]). Between 1990 and 2015, the number of deaths from neurological disorders increased by 36.7%, and the number of DALYs by 7.4%. These increases occurred despite decreases in age-standardised rates of death and DALYs of 26.1% and 29.7%, respectively; stroke and communicable neurological disorders were responsible for most of these decreases. Communicable neurological disorders were the largest cause of DALYs in countries with low SDI. Stroke rates were highest at middle levels of SDI and lowest at the highest SDI. Most of the changes in DALY rates of neurological disorders with development were driven by changes in YLLs. Interpretation Neurological disorders are an important cause of disability and death worldwide. Globally, the burden of neurological disorders has increased substantially over the past 25 years because of expanding population numbers and ageing, despite substantial decreases in mortality rates from stroke and communicable neurological disorders. The number of patients who will need care by clinicians with expertise in neurological conditions will continue to grow in coming decades. Policy makers and health-care providers should be aware of these trends to provide adequate services.Peer reviewe

Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.

Traumatic brain injury (TBI) and spinal cord injury (SCI) are increasingly recognised as global health priorities in view of the preventability of most injuries and the complex and expensive medical care they necessitate. We aimed to measure the incidence, prevalence, and years of life lived with disability (YLDs) for TBI and SCI from all causes of injury in every country, to describe how these measures have changed between 1990 and 2016, and to estimate the proportion of TBI and SCI cases caused by different types of injury. METHODS: We used results from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016 to measure the global, regional, and national burden of TBI and SCI by age and sex. We measured the incidence and prevalence of all causes of injury requiring medical care in inpatient and outpatient records, literature studies, and survey data. By use of clinical record data, we estimated the proportion of each cause of injury that required medical care that would result in TBI or SCI being considered as the nature of injury. We used literature studies to establish standardised mortality ratios and applied differential equations to convert incidence to prevalence of long-term disability. Finally, we applied GBD disability weights to calculate YLDs. We used a Bayesian meta-regression tool for epidemiological modelling, used cause-specific mortality rates for non-fatal estimation, and adjusted our results for disability experienced with comorbid conditions. We also analysed results on the basis of the Socio-demographic Index, a compound measure of income per capita, education, and fertility. FINDINGS: In 2016, there were 27·08 million (95% uncertainty interval [UI] 24·30-30·30 million) new cases of TBI and 0·93 million (0·78-1·16 million) new cases of SCI, with age-standardised incidence rates of 369 (331-412) per 100 000 population for TBI and 13 (11-16) per 100 000 for SCI. In 2016, the number of prevalent cases of TBI was 55·50 million (53·40-57·62 million) and of SCI was 27·04 million (24·98-30·15 million). From 1990 to 2016, the age-standardised prevalence of TBI increased by 8·4% (95% UI 7·7 to 9·2), whereas that of SCI did not change significantly (-0·2% [-2·1 to 2·7]). Age-standardised incidence rates increased by 3·6% (1·8 to 5·5) for TBI, but did not change significantly for SCI (-3·6% [-7·4 to 4·0]). TBI caused 8·1 million (95% UI 6·0-10·4 million) YLDs and SCI caused 9·5 million (6·7-12·4 million) YLDs in 2016, corresponding to age-standardised rates of 111 (82-141) per 100 000 for TBI and 130 (90-170) per 100 000 for SCI. Falls and road injuries were the leading causes of new cases of TBI and SCI in most regions. INTERPRETATION: TBI and SCI constitute a considerable portion of the global injury burden and are caused primarily by falls and road injuries. The increase in incidence of TBI over time might continue in view of increases in population density, population ageing, and increasing use of motor vehicles, motorcycles, and bicycles. The number of individuals living with SCI is expected to increase in view of population growth, which is concerning because of the specialised care that people with SCI can require. Our study was limited by data sparsity in some regions, and it will be important to invest greater resources in collection of data for TBI and SCI to improve the accuracy of future assessments

Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016

The UN’s Sustainable Development Goals (SDGs) are grounded in the global ambition of “leaving no one behind”. Understanding today’s gains and gaps for the health-related SDGs is essential for decision makers as they aim to improve the health of populations. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016), we measured 37 of the 50 health-related SDG indicators over the period 1990–2016 for 188 countries, and then on the basis of these past trends, we projected indicators to 2030