Assessment of clinical practice guideline methodology for the treatment of knee osteoarthritis with intra-articular hyaluronic acid

© 2015 The Authors. Published by Elsevier HS Journals ,Inc. Introduction: Clinical practice guidelines are of increasing importance in the decision making for the treatment of knee osteoarthritis. Inconsistent recommendations regarding the use of intra-articular hyaluronic acid for the treatment of knee osteoarthritis have led to confusion among treating physicians. Methods: Literature search to identify clinical practice guidelines that provide recommendations regarding the use of intra-articular hyaluronic acid treatment for knee osteoarthritis was conducted. Included guidelines were appraised using the AGREE II instrument. Guideline development methodologies, how the results were assessed, the recommendation formation, and work group composition were summarized. Results: Overall, 10 clinical practice guidelines were identified that met our inclusion criteria. AGREE II domain scores were variable across the included guidelines. The methodology utilized across the guidelines was heterogeneous regarding the evidence inclusion criteria, analysis of evidence results, formulation of clinical practice recommendations, and work group composition. The recommendations provided by the guidelines for intra-articular hyaluronic acid treatment for knee osteoarthritis are highly inconsistent as a result of the variability in guideline methodology. Overall, 30% of the included guidelines recommended against the use of intra-articular hyaluronic acid in the treatment of knee osteoarthritis, while 30% deemed the treatment an appropriate intervention under certain scenarios. The remaining 40% of the guidelines provided either an uncertain recommendation or no recommendation at all, based on the high variability in reviewed evidence regarding efficacy and trial quality. Conclusion: There is a need for a standard appropriate methodology that is agreed upon for osteoarthritis clinical practice guidelines in order to prevent the development of conflicting recommendations for intra-articular hyaluronic acid treatment for knee osteoarthritis, and to assure that treating physicians who are utilizing these guidelines are making their clinical decisions on the best available evidence. At present, the inconsistent recommendations provided for intra-articular hyaluronic acid treatment make it difficult for clinical professionals to determine its appropriateness when treating patients with knee osteoarthritis

Closed Limb Fractures With Compromised Vascularization: A Narrative Review

© The Author(s) 2019. Vascular compromised fractures typically result in a high rate of healing complications, such as avascular necrosis, nonunion, delayed union, and arthritis, which severely affect a patient’s function and quality of life. The purpose of this review was to identify and describe the epidemiology and available treatment options for the most well-known vascular compromised closed fractures. The injuries discussed in detail in this review were scaphoid, lunate, femoral neck, and talar fractures. Current evidence suggests that optimal treatment for vascular compromised fractures is dependent on the degree of fracture displacement and comminution, and the patient’s post-injury functional demands, age, and bone quality. Conservative efforts generally include casting or splinting with a period of immobilization. Surgery is indicated for substantially displaced fractures, patients who require higher functional demands and an earlier return to activity, or if complications occur following nonoperative treatment; however, operative intervention is typically performed for femoral neck fractures regardless of the amount of displacement. Various surgical techniques exist, though internal fixation with screws is a common procedure among these injuries and can be used in combination with other implants, such as plating or Kirschner wires (k-wires), when needed. Severe fracture comminution, poor bone quality, or arthritis can contraindicate the use of screws and more invasive intervention will be required. Bone grafting is done in some cases to enhance vascularity. Salvage procedures exist for patients who develop severe complications, but these will permanently alter the anatomy of the injured area and should be considered a last resort

The impact of socioeconomic status on implant selection for patients undergoing hip arthroplasty

© 2015, UTMJ. All rights reserved. Hip resurfacing arthroplasty (HRA) is an alternative to total hip arthroplasty (THA) that preserves proximal femoral bone stock. Patient socioeconomic status (SES) has been demonstrated to impact access to care for numerous healthcare interventions but little is known about its impact on HRA when compared to THA. The aim of this study was to investigate whether there are disparities in SES for patients receiving HRA or THA. A retrospective database review was conducted comprising 617 hip arthroplasty patients (310 HRA, 307 THA). Patient postal code was used as a surrogate marker for patients’ SES and referenced against Canada Census Tract data to determine patient income. Patients greater than 70 years of age and those who underwent THA as revision or for fractures were excluded from the study. There were 465 patients included in the analysis comprised of 273 HRA and 192 THA patients. HRA patients ($33,240, SD$8,206) had a significantly higher mean income than THA patients ($29,365, SD$7,119, p\u3c0.001). The percentage of patients that underwent HRA compared to THA increased as patients’ SES increased. Patients with an income greater than $25,000 were significantly more likely to undergo HRA rather than THA (OR ≥1.76), compared to patients with an income less than$25,000 in whom THA was more likely. There appears to be a disparity in SES between patients who receive HRA and THA. Further work is needed to better understand the factors that influence the choice of hip replacement for patients requiring surgical intervention

Developing stem cell-based therapeutic strategies in orthopaedic surgery

open5siEDITORIAL - Developing Stem Cell-Based Therapeutic Strategies in Orthopaedic SurgeryopenAtesok, Kivanc; Ochi, Mitsuo; Baldini, Nicola; Schemitsch, Emil; Liebergall, MeirAtesok, Kivanc; Ochi, Mitsuo; Baldini, Nicola; Schemitsch, Emil; Liebergall, Mei

Internet Versus Mailed Questionnaires: A Randomized Comparison (2)

BACKGROUND Low response rates among surgeons can threaten the validity of surveys. Internet technologies may reduce the time, effort, and financial resources needed to conduct surveys. OBJECTIVE We investigated whether using Web-based technology could increase the response rates to an international survey. METHODS We solicited opinions from the 442 surgeon–members of the Orthopaedic Trauma Association regarding the treatment of femoral neck fractures. We developed a self-administered questionnaire after conducting a literature review, focus groups, and key informant interviews, for which we used sampling to redundancy techniques. We administered an Internet version of the questionnaire on a Web site, as well as a paper version, which looked similar to the Internet version and which had identical content. Only those in our sample could access the Web site. We alternately assigned the participants to receive the survey by mail (n=221) or an email invitation to participate on the Internet (n=221). Non-respondents in the mail arm received up to three additional copies of the survey, while non-respondents in the Internet arm received up to three additional requests, including a final mailed copy. All participants in the Internet arm had an opportunity to request an emailed Portable Document Format (PDF) version. RESULTS The Internet arm demonstrated a lower response rate (99/221, 45%) than the mail questionnaire arm (129/221, 58%) (absolute difference 13%, 95% confidence interval 4%-22%, P<0.01). CONCLUSIONS. Our Internet-based survey to surgeons resulted in a significantly lower response rate than a traditional mailed survey. Researchers should not assume that the widespread availability and potential ease of Internet-based surveys will translate into higher response rates.Department of Surgery, McMaster University, Hamilton, Ontario, Canad

Delayed Endothelial Progenitor Cell Therapy Promotes Bone Defect Repair in a Clinically Relevant Rat Model

© 2017 Brent D. Bates et al. The repair of segmental bone defects remains a significant challenge for orthopaedic surgeons. Endothelial progenitor cells (EPCs) have successfully promoted the repair of acute defects in animal models; however, the ability of EPCs to induce the repair of chronic nonhealing defects, such as those often encountered clinically, has not been investigated. Therefore, the purpose of this study was to investigate the ability of EPCs delivered in delayed fashion to induce the repair of nonhealing defects in a clinically relevant model. In order to simulate delayed treatment, 5 mm segmental defects in Fischer 344 rat femora were treated with bone marrow-derived EPCs on a Gelfoam scaffold at 3 weeks post creation of the defect. At ten weeks posttreatment, 100% of EPC-treated defects achieved union, whereas complete union was only achieved in 37.5% of defects treated with Gelfoam alone. Furthermore, significant increases in ultimate torque (p=0.022) and torsional stiffness (p=0.003) were found in EPC-treated defects compared to controls. Critically, no differences in outcomes were observed between acute and delayed EPC treatments. These results suggest that EPCs can enhance bone healing when applied in an acute or delayed fashion and that their use may represent a clinically translatable therapy for bone healing in humans

A Large-Scale Fifteen-Year Minimum Survivorship of a Cementless Triple Tapered Femoral Stem

© 2020 Elsevier Inc. Background: This study reports the long-term outcomes of a metaphyseal fit-and-fill cementless femoral component in total hip arthroplasty (THA) with a follow-up of 15-19 years. Methods: We conducted a retrospective review of 376 consecutive THAs (345 patients), using a triple tapered stem performed between 2000 and 2003 with a view to assessing survivorship and radiological and functional outcomes. Images were assessed for initial alignment, terminal osteolysis, or subsidence, while clinical outcomes were assessed using the St Michael\u27s Hip Score. Results: Forty-five (11.9%) hips were lost to follow-up, 20 (5.31%) had died before our 15-year cutoff follow-up, and 4 (1.06%) had declined follow-up early on, leaving 307 hips (81.64%, 276 patients) available for both clinical and radiological follow-up at a minimum of 15 years (range 15-19). The mean age at the time of operation was 49.6 years (range 19-71) and the cohort included 131 (42.67%) male and 145 (47.23%) female patients. Seven stems (2.28%) were revised: 4 due to periprosthetic fractures, 2 for periprosthetic joint infection, and 1 for adverse reaction to metal debris at the trunnion. The St Michael\u27s Hip Score improved from 14.2 (range 9-23) preoperatively to 22.3 (range 13 to 25) at the last documented follow-up (P = .000). Kaplan-Meier survivorship with stem revision for any reason as the end point was 97.70%. Worst-case scenario Kaplan-Meier survivorship, where all lost to follow-up are considered as failures, was 85.3%. No stem was revised for aseptic loosening. Conclusion: This triple tapered stem in THA shows excellent survivorship beyond a minimum of 15 years

The biomechanical analysis of three plating fixation systems for periprosthetic femoral fracture near the tip of a total hip arthroplasty

<p>Abstract</p> <p>Background</p> <p>A variety of techniques are available for fixation of femoral shaft fractures following total hip arthroplasty. The optimal surgical repair method still remains a point of controversy in the literature. However, few studies have quantified the performance of such repair constructs. This study biomechanically examined 3 different screw-plate and cable-plate systems for fixation of periprosthetic femoral fractures near the tip of a total hip arthroplasty.</p> <p>Methods</p> <p>Twelve pairs of human cadaveric femurs were utilized. Each left femur was prepared for the cemented insertion of the femoral component of a total hip implant. Femoral fractures were created in the femurs and subsequently repaired with Construct A (Zimmer Cable Ready System), Construct B (AO Cable-Plate System), or Construct C (Dall-Miles Cable Grip System). Right femora served as matched intact controls. Axial, torsional, and four-point bending tests were performed to obtain stiffness values.</p> <p>Results</p> <p>All repair systems showed 3.08 to 5.33 times greater axial stiffness over intact control specimens. Four-point normalized bending (0.69 to 0.85) and normalized torsional (0.55 to 0.69) stiffnesses were lower than intact controls for most comparisons. Screw-plates provided either greater or equal stiffness compared to cable-plates in almost all cases. There were no statistical differences between plating systems A, B, or C when compared to each other (p > 0.05).</p> <p>Conclusions</p> <p>Screw-plate systems provide more optimal mechanical stability than cable-plate systems for periprosthetic femur fractures near the tip of a total hip arthroplasty.</p

A biomechanical assessment of modular and monoblock revision hip implants using FE analysis and strain gage measurements

<p>Abstract</p> <p>Background</p> <p>The bone loss associated with revision surgery or pathology has been the impetus for developing modular revision total hip prostheses. Few studies have assessed these modular implants quantitatively from a mechanical standpoint.</p> <p>Methods</p> <p>Three-dimensional finite element (FE) models were developed to mimic a hip implant alone (Construct A) and a hip implant-femur configuration (Construct B). Bonded contact was assumed for all interfaces to simulate long-term bony ongrowth and stability. The hip implants modeled were a Modular stem having two interlocking parts (Zimmer Modular Revision Hip System, Zimmer, Warsaw, IN, USA) and a Monoblock stem made from a single piece of material (Stryker Restoration HA Hip System, Stryker, Mahwah, NJ, USA). Axial loads of 700 and 2000 N were applied to Construct A and 2000 N to Construct B models. Stiffness, strain, and stress were computed. Mechanical tests using axial loads were used for Construct A to validate the FE model. Strain gages were placed along the medial and lateral side of the hip implants at 8 locations to measure axial strain distribution.</p> <p>Results</p> <p>There was approximately a 3% average difference between FE and experimental strains for Construct A at all locations for the Modular implant and in the proximal region for the Monoblock implant. FE results for Construct B showed that both implants carried the majority (Modular, 76%; Monoblock, 66%) of the 2000 N load relative to the femur. FE analysis and experiments demonstrated that the Modular implant was 3 to 4.5 times mechanically stiffer than the Monoblock due primarily to geometric differences.</p> <p>Conclusions</p> <p>This study provides mechanical characteristics of revision hip implants at sub-clinical axial loads as an initial predictor of potential failure.</p