BackgroundClinical outcomes between the use of platelet-rich plasma (PRP), autologous blood (AB) and corticosteroid (CS) injection in lateral epicondylitis are still controversial.Materials and methodsA systematic review and network meta-analysis of randomized controlled trials was conducted with the aim of comparing relevant clinical outcomes between the use of PRP, AB and CS injection. Medline and Scopus databases were searched from inception to January 2015. A network meta-analysis was performed by applying weight regression for continuous outcomes and a mixed-effect Poisson regression for dichotomous outcomes.ResultsTen of 374 identified studies were eligible. When compared to CS, AB injection showed significantly improved effects with unstandardized mean differences (UMD) in pain visual analog scale (VAS), Disabilities of Arm Shoulder and Hand (DASH), Patient-Related Tennis Elbow Evaluation (PRTEE) score and pressure pain threshold (PPT) of −2.5 (95 % confidence interval, −3.5, −1.5), −25.5 (−33.8, −17.2), −5.3 (−9.1, −1.6) and 9.9 (5.6, 14.2), respectively. PRP injections also showed significantly improved VAS and DASH scores when compared with CS. PRP showed significantly better VAS with UMD when compared to AB injection. AB injection has a higher risk of adverse effects, with a relative risk of 1.78 (1.00, 3.17), when compared to CS. The network meta-analysis suggested no statistically significant difference in multiple active treatment comparisons of VAS, DASH and PRTEE when comparing PRP and AB injections. However, AB injection had improved DASH score and PPT when compared with PRP injection. In terms of adverse effects, AB injection had a higher risk than PRP injection.ConclusionsThis network meta-analysis provided additional information that PRP injection can improve pain and lower the risk of complications, whereas AB injection can improve pain, disabilities scores and pressure pain threshold but has a higher risk of complications.Level of evidenceLevel I evidence

Background Treatment of acute (B3 weeks) acromioclavicular joint dislocation type III-VI is still controversial. Currently, the two modern techniques that are widely used are hook plate (HP) fixation and coracoclavicular ligament fixation using a suspensory loop device that consists of either a tightrope (single or double), endo-button (single or double), or synthetic ligament and absorbable polydioxansulfate sling. Materials and methods This systematic review was conducted according to the PRISMA guidelines. Relevant studies that reported Constant-Murley score (CMS), Pain Visual Analog score (VAS) and postoperative complications of either technique were identified from Medline and Scopus from inception to 5 October 2015. Results Sixteen studies were included for the analysis of HP fixation, and 25 studies were included for analysis of loop suspensory fixation (LSF). Pooling of mean CMS and VAS scores gave 90.35 (95% CI 87.16, 93.54), 1.51 (95% CI 0.73, 2) in the HP group, and 92.48 (95% CI 90.91, 94.05), 0.32 (95% CI 0, 0.64) in the suspensory loop devices group, respectively. The pooled unstandardized mean differences (UMD) scores of CMS and VAS in LSF were 2.13 (95% CI -1.43, 5.69) and -1.19 (95% CI -2.03, -0.35) when compared to hook plating. The pooled prevalence of LSF and hook plating were 0.08 (95% CI 0.06, 0.10) and 0.05 (95% CI 0.02, 0.08) scores. The chance of having complications in the LSF group was 1.69 (95% CI 1.07, 2.60), which was statistically significantly higher than in the HP group. Conclusion LSF have higher shoulder function scores (CMS) and lower postoperative pain when compared to HP fixation; however, there are higher complication rates with LSF when compared to hook plating. Level of evidence IV.

I.

In short-term outcomes (5 years or less, with follow-up of 0-5 years), TKA had higher postoperative complications than UKA, but had lower revision rates. There was only one study that reported long-term survivorship (more than 5 years, with follow-up of 5-15 years). Further research that assesses long-term survivorship is necessary to better evaluate UKA and TKA in the treatment of unicompartmental knee osteoarthritis.

Total hip arthroplasty (THA) is generally considered to be one of the most successful orthopedic surgical procedures. THA patients continue to experience symptoms, most commonly pain, which prevent their return to full function and activity. Possible causes include failure of fixation, instability and damage to soft tissues, associated with the trauma of the surgical procedure. Choosing the optimal surgical approach can minimize these risks and therefore improve the outcome of THA. Surgical approaches in THA include anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson-Jones)], posterior (posterolateral and posterior) and posterior-2 techniques. However, there is no current consensus regarding which approach is the most suitable. Therefore, we conducted a systematic review and network meta-analysis to compare the postoperative outcomes and complications among THA approach and identify which approach is the best for THA. We searched all RCT studies that compared intra-operative and postoperative outcomes of anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson-Jones)], posterior (posterolateral and posterior) and posterior-2 approaches for THA from the PubMed and Scopus databases up to February 1, 2017. Data were independently extracted by two reviewers. A network meta-analysis was applied to assess treatment outcomes. Probability of being the best treatment was estimated using surface under the cumulative ranking curves (SUCRA). Fourteen RCTs (N = 1017 patients) met inclusion criteria. Interventions were anterior (N = 233 patients), lateral (N = 334 patients), posterior (N = 405 patients) and posterior-2 (N = 45 patients) approaches. A network meta-analysis showed that effects of anterior approach were higher to lateral, posterior and posterior-2 approaches with the pooled mean postoperative within 1 month and last follow-up of HHS of 2.56 (95% CI - 0.79, 5.91), 4.80 (95% CI 1.33, 8.26), 10.80 (95% CI 2.10, 19.49) and 6.40 (95% CI 0.72, 12.09), 2.22 (95% CI - 3.21, 7.66), 4.22 (95% CI - 6.81, 15.25), respectively. For VAS, lateral approach was lower to anterior, posterior and posterior-2 approaches. In terms of complication, posterior approach was the lowest risk with RR of 0.39 (95% CI 0.19, 0.81), 0.57 (95% CI 0.21, 1.57) and 1.74 (95% CI 0.36, 8.33) when compared to anterior, followed by lateral and posterior-2 approaches. Results of SUCRA indicated anterior and lateral approaches were the first and second ranks for postoperative HHS and VAS score, while posterior and lateral approaches were the first and second ranks for postoperative complications. We recommended using lateral approach that has an acceptable postoperative pain, function and complications (second rank for all outcomes) as a surgical technique for THA.

Surgical management is recommended for unstable distal clavicle fractures. A variety of methods have been previously reported, but there is no current consensus regarding which method is most suitable. Therefore, we have conducted a systematic review and network meta-analysis to compare postoperative shoulder function and complications between different fixation methods to identify which class of fixation is best for unstable distal clavicle fractures. We searched the literature systematically using eligibility criteria of all comparative studies that compared postoperative outcomes of coracoclavicular fixation (tight rope, screw or endobutton), hook plating, plate and screws, tension band wiring and transacromial pinning fixation for unstable distal clavicle fractures from PubMed, EMBASE, and Scopus databases up to February 10, 2018. Two reviewers independently extracted data. A network meta-analysis was applied to combine direct and indirect evidence and to estimate the relative effects of the treatment options. The probability of being the best treatment was estimated using surface under the cumulative ranking curves (SUCRA). Ten comparative studies (n = 505 patients) with one RCT study (n = 42) met the inclusion criteria. Intervention included coracoclavicular fixation (n = 111 patients), hook plating (n = 300 patients), plate and screws (n = 41 patients), tension band wiring (n = 81 patients) and transacromial pinning (n = 14 patients). A network meta-analysis showed that CM scores of coracoclavicular fixation were significantly higher when compared to hook plate and tension band wiring, with pooled mean of 2.98 (95% CI 0.05-5.91) and 7.11 (95% CI 3.04-11.18). For UCLA, CC fixation and plate and screw fixation had significantly higher scores compared to hook plating fixation with a mean score 2.22 (95% CI 0.44-3.99) and 3.20 (95% CI 0.28-6.12), respectively. In terms of complications, plate and screw fixation had lower risk with RRs of 0.63 (95% CI 0.20-1.98), 0.37 (95% CI 0.19-0.72), 0.11 (95% CI 0.04-0.30) and 0.02 (95% CI 0.002-0.16) when compared to coracoclavicular fixation, hook plating, tension band wiring and transacromial pinning. The SUCRA probabilities of CC fixation were in the first rank with 96.8% for CMS, while plate and screw fixation were in the first rank with 67.7 and 93.8% for UCLA score and complications. We recommend using plate and screw and CC fixation as the first- and second-line treatment of unstable distal clavicle fractures. As the quality of studies for this meta-analysis was not high, larger and higher-quality randomized controlled trials are required to confirm these conclusions for informed clinical decision making.

Treatment of calcific tendinitis using extracorporeal shock wave therapy (ESWT), ultrasound-guided percutaneous lavage (UGPL or barbotage), subacromial corticosteroid injection (SAI) and combined treatment is still controversial. This systematic review and meta-regression aimed to compare clinical outcomes between treatments. Relevant RCTs were identified using PubMed and Scopus search engines to date of September 23, 2015. Seven of 920 studies identified were eligible. Compared to the other treatments, the results of this study indicate that ESWT significantly improved CMS and VAS when compared to placebo. Barbotage plus ESWT significantly improved CMS, VAS and decreased size of calcium deposit when compared to ESWT, while barbotage plus SAI significantly improved CMS and decreased size of calcium deposit when compared to SAI. There have no different adverse effects of all treatment groups. Multiple active treatment comparisons indicated that barbotage plus SAI significantly improved VAS and size of calcium deposit when compared to other groups, while barbotage plus SAI improved CMS when compared to other groups. But there was no significant difference. The network meta-analysis suggested that combined US-guided needling and subacromial corticosteroid injection significantly decreased shoulder pain VAS, improved CMS score and decreased the size of calcium deposits, while also lowering risks of adverse event when compared to barbotage plus ESWT, ESWT and subacromial corticosteroid injection; therefore, the evidence points to UGPL as being the treatment of choice for nonsurgical options of treatment in calcific tendinitis of the shoulder. Level of evidence I.

The surgical procedures used for arthrodesis in the lumbar spine for degenerative lumbar diseases remain controversial. This systematic review aims to assess and compare clinical outcomes along with the complications and fusion of each technique (minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) or minimally invasive lateral lumbar interbody fusion (MIS LLIF)) for treatment of degenerative lumbar diseases. Relevant studies were identified from Medline and Scopus from inception to July 19, 2016 that reported Oswestry Disability Index (ODI), back and leg pain visual analog score (VAS), postoperative complications, and fusion of either technique. Fifty-eight studies were included for the analysis of MIS-TLIF; 40 studies were included for analysis of LLIF, and 1 randomized controlled trial (RCT) study was included for comparison of MIS-TLIF to LLIF. Overall, there were 9506 patients (5728 in the MIS-TLIF group and 3778 in the LLIF group). Indirect meta-analysis, MIS-TLIF provided better postoperative back and leg pain (VAS), disabilities (ODI), and risk of having complications when compared to LLIF technique, but the fusion rate was not significantly different between the two techniques. However, direct meta-analysis between RCT study and pooled indirect meta-analysis of MIS-TLIF have better pain, disabilities, and complication but no statistically significant difference when compared to LLIF. In LLIF, the pooled mean ODI and VAS back pain were 2.91 (95% CI 2.49, 3.33) and 23.24 (95% CI 18.96, 27.51) in MIS approach whereas 3.14 (95% CI 2.29, 4.04) and 28.29 (95% CI 21.92, 34.67) in traditional approach. In terms of complications and fusion rate, there was no difference in both groups. In lumbar interbody fusion, MIS-TLIF had better ODI, VAS pain, and complication rate when compared to LLIF with direct and indirect meta-analysis methods. However, in terms of fusion rates, there were no differences between the two techniques.