Early Postoperative Rapid Rehabilitation Yields More Favorable Short-term Outcomes in Patients Undergoing Patellar Realignment Surgery for Recurrent Patellar Dislocation: A Prospective Randomized Controlled Study.

BACKGROUND: Use of a rapid rehabilitation protocol for postoperative recovery after recurrent patellar dislocation (RPD) has gradually gained attention; nonetheless, evidence of its safety and effectiveness is lacking. PURPOSE: To compare the short-term postoperative outcomes of early rapid rehabilitation with those of conservative rehabilitation in patients with RPD. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A total of 50 patients with RPD who underwent tibial tubercle osteotomy combined with medial patellofemoral ligament reconstruction were enrolled between January 2018 and February 2019. Postoperatively, the patients were randomly assigned to either the early rapid group (rapid group; n = 25 patients) or the conservative group (control group; n = 25 patients) for rehabilitation training. The rapid group underwent faster progression in weightbearing and range of motion (ROM) training. Knee joint functional scores, ROM, bilateral thigh circumference differences, and imaging data were recorded preoperatively and at 6 weeks and 3, 6, 12, and 24 months postoperatively for comparison. Postoperative complications were recorded over the 24-month follow-up period. RESULTS: The baseline data did not significantly differ between the 2 groups. Postoperatively, compared with the control group, the rapid group had higher Tegner scores at 6 weeks and 3 months; higher Lysholm scores at 3 and 6 months; higher International Knee Documentation Committee scores at 6 weeks, 3 months, and 12 months; better ROM; and smaller bilateral thigh circumference differences at 24 months (P < .05 for all). However, no differences were observed in the Tegner, Lysholm, and International Knee Documentation Committee scores at 24 months postoperatively. At the 6-week and subsequent follow-up visits, the Caton and Insall indices were lower in the control group than in the rapid group (P < .01 for all). Moreover, compared with the control group, the rapid group had a lower incidence of patella baja at 24 months (0% vs 17%) and fewer complications during the whole follow-up period (P < .01). CONCLUSION: Early rapid postoperative rehabilitation appears to be safe and effective for patients who undergo tibial tubercle osteotomy combined with medial patellofemoral ligament reconstruction to treat RPD. In the short term, this approach was shown to be more advantageous than conservative rehabilitation in improving functional scores, allowing an earlier return to daily activities, although the lack of difference at 24 months implies no long-term benefits. In addition, it potentially helped to prevent the occurrence of complications, including patella baja. REGISTRATION: ChiCTR1800014648 (ClinicalTrials.gov identifier).

Comparison of Anterior Cruciate Ligament Reconstruction With Versus Without Anterolateral Augmentation: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Background: It is clear that the anterolateral ligament has an important role in rotational knee stability. However, whether patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) can benefit from anterolateral augmentation (ALA) is still controversial. Purpose: To compare the effects of isolated ACLR versus ACLR combined with ALA (ACLR+ALA) on clinical outcomes and knee stability. Study Design: Systematic review; Level of evidence, 1. Methods: The methodology followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of the PubMed, Embase, and Cochrane Library Central Register of Controlled Trials databases was undertaken to identify all randomized controlled trials (RCTs) comparing isolated ACLR with ACLR+ALA for the treatment of ACL injuries in the last 15 years. The Cochrane Collaboration risk-of-bias tool and the revised Jadad scale were utilized by 2 independent reviewers to determine the quality of RCTs. Relevant data were extracted and compared between procedures, and heterogeneity across the RCTs was assessed using the I 2 statistic. Results: The initial search yielded 849 articles. A total of 14 studies (1850 patients; 941 ACLR and 909 ACLR+ALA) satisfied the eligibility criteria for the meta-analysis. There were no significant differences between the procedures in terms of patient-reported outcomes (International Knee Documentation Committee score, Tegner score, Knee injury and Osteoarthritis Outcome Score) or return-to-sport rates. However, patients who underwent ACLR+ALA had better knee stability based on the pivot-shift test (risk ratio [RR], 1.06 [95% CI, 1.02 to 1.10]; P = .0008), Lachman test (RR, 1.03 [95% CI, 1.00 to 1.07]; P = .04), and side-to-side difference in anterior laxity (standardized mean difference, -0.55 [95% CI, -0.98 to -0.12]; P = .01) as well as a lower incidence of graft failure (RR, 0.30 [95% CI, 0.19 to 0.45]; P < .01) compared with patients who underwent isolated ACLR. Conclusion: ALA can be considered as a reinforcement of ACLR to improve anteroposterior and anterolateral rotational stability of the knee and reduce the risk of failure. The patient-reported outcomes of isolated ACLR were similar to those of ACLR+ALA, and both procedures provided improved knee function.

Construction of Vascularized Tissue Engineered Bone with nHA-Coated BCP Bioceramics Loaded with Peripheral Blood-Derived MSC and EPC to Repair Large Segmental Femoral Bone Defect.

The regenerative repair of segmental bone defect (SBD) is an urgent problem in the field of orthopedics. Rapid induction of angiogenesis and osteoinductivity after implantation of scaffold is critical. In this study, a unique tissue engineering strategy with mixture of peripheral blood-derived mesenchymal stem cells (PBMSC) and endothelial progenitor cells (PBEPC) was applied in a 3D-printed biphasic calcium phosphate (BCP) scaffold with highly bioactive nano hydroxyapatite (nHA) coating (nHA/BCP) to construct a novel vascularized tissue engineered bone (VTEB) for rabbit femoral SBD repair. The 2D coculture of PBMSC and PBEPC showed that they could promote the osteogenic or angiogenic differentiation of the cells from each other, especially in the group of PBEPC/PBMSC = 75:25. Besides, the 3D coculture results exhibited that the nHA coating could further promote PBEPC/PBMSC adhesion, proliferation, and osteogenic and angiogenic differentiation on the BCP scaffold. In vivo experiments showed that among the four groups (BCP, BCP-PBEPC/PBMSC, nHA/BCP, and nHA/BCP-PBEPC/PBMSC), the nHA/BCP-PBEPC/PBMSC group induced the best formation of blood vessels and new bone and, thus, the good repair of SBD. It revealed the synergistic effect of nHA and PBEPC/PBMSC on the angiogenesis and osteogenesis of the BCP scaffold. Therefore, the construction of VTEB in this study could provide a possibility for the regenerative repair of SBD.

A Scoping Review of Postoperative Rehabilitation Protocols After Superior Capsular Reconstruction for Irreparable Rotator Cuff Tears.

Background: Superior capsular reconstruction (SCR) is an option for patients with massive or irreparable rotator cuff tears. Purpose: To describe the literature on rehabilitation protocols after SCR of rotator cuff tears, with emphasis on the timing of the introduction of motion. Study Design: Scoping review; Level of evidence, 4. Methods: We conducted a scoping review of articles published on PubMed, Ovid, Embase, and the Cochrane Library from inception to October 2020. The methodological index for non-randomized studies (MINORS) was used to assess the individual studies. For each article, we summarized the study characteristics, patient demographics, and rehabilitation protocols after SCR: duration of immobilization, initiation of passive range of motion (ROM), active-assisted ROM, active ROM, strengthening, and return to activities. In a subgroup narrative analysis, rehabilitation protocols were stratified by graft type: autograft versus nonautograft (xenograft, allograft, and synthetic). Results: A total of 21 studies met the search criteria. Six studies had level 3 evidence and 15 had level 4 evidence; 16 studies were considered high quality according to the MINORS score. After SCR, an abduction immobilizer was recommended for a duration of 3 to 6 weeks. Of the 21 studies, 7 (33%) started passive ROM during the first week, and 5 reported strict immobilization without motion for up to 6 weeks. All 8 studies that reported return-to-sports timing recommended delaying return until at least 6 months postoperatively. Passive ROM was recommended earlier for patients with nonautograft versus autograft (χ2 = 225; P < .001). There was a high level of heterogeneity in the rehabilitation protocols after SCR. Conclusion: The majority of published protocols were descriptive. At present, there is little agreement on the published rehabilitation guidelines after SCR, precluding specific clinical best practice suggestions. Although there was a tendency of recommending early motion in nonautograft cases, the optimal protocols based on graft healing and functional outcomes require further verification based on the clinical outcomes from high-quality studies.

Demineralized Cortical Bone Matrix Augmented With Peripheral Blood-Derived Mesenchymal Stem Cells for Rabbit Medial Meniscal Reconstruction.

Tissue engineering is a promising treatment strategy for meniscal regeneration after meniscal injury. However, existing scaffold materials and seed cells still have many disadvantages. The objective of the present study is to explore the feasibility of peripheral blood-derived mesenchymal stem cells (PBMSCs) augmented with demineralized cortical bone matrix (DCBM) pretreated with TGF-ß3 as a tissue-engineered meniscus graft and the repair effect. PBMSCs were collected from rabbit peripheral blood and subjected to three-lineage differentiation and flow cytometry identification. DCBM was prepared by decalcification, decellularization, and cross-linking rabbit cortical bone. Various characteristics such as biomechanical properties, histological characteristics, microstructure and DNA content were characterized. The cytotoxicity and the effects of DCBM on the adhesion and migration of PBMSCs were evaluated separately. The meniscus-forming ability of PBMSCs/DCBM complex in vitro induced by TGF-ß3 was also evaluated at the molecular and genetic levels, respectively. Eventually, the present study evaluated the repair effect and cartilage protection effect of PBMSCs/DCBM as a meniscal graft in a rabbit model of medial meniscal reconstruction in 3 and 6 months. The results showed PBMSCs positively express CD29 and CD44, negatively express CD34 and CD45, and have three-lineage differentiation ability, thus can be used as tissue engineering meniscus seed cells. After the sample procedure, the cell and DNA contents of DCBM decreased, the tensile modulus did not decrease significantly, and the DCBM had a pore structure and no obvious cytotoxicity. PBMSCs could adhere and grow on the scaffold. Under induction of TGF-ß3, PBMSCs/DCBM composites expressed glycosaminoglycan (GAG), and the related gene expression also increased. The results of the in vivo experiments that the PBMSCs/DCBM group had a better repair effect than the DCBM group and the control group at both 12 and 24 weeks, and the protective effect on cartilage was also better. Therefore, the application of DCBM augmented with PBMSCs for meniscus injury treatment is a preferred option for tissue-engineered meniscus.

The Effect of Irreducible Dislocation on Functional Outcomes in Knees With Multiligament Injuries: A Matched-Cohort Analysis.

BACKGROUND: Most cases of bicruciate knee dislocation (KD) with associated posteromedial disruption (KD-IIIM) are reducible, but some cannot be reduced by closed reduction because of soft tissue incarceration. PURPOSE: To compare the clinical characteristics and functional outcomes of KD-IIIM injuries in patients with or without incarceration of soft tissue requiring open or arthroscopic reduction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This retrospective cohort study of patients with KD was conducted between January 2013 and December 2017 at a single large institution. We applied a 1:2 matching ratio between patients with irreducible KD-IIIM injuries (irreducible group; n = 14) and those with reducible KD-IIIM injuries (control group; n = 28). There were 13 patients in the irreducible group and 25 in the control group who completed follow-up (≥2 years) and were included in our analysis. The efficacy of treatment in patients with KD was evaluated based on range of motion, the Tegner score, the Lysholm score, and the International Knee Documentation Committee (IKDC) score. RESULTS: At the end of follow-up, the mean Tegner score was 4.5 (range, 4-6), the mean Lysholm score was 79.2 (range, 60-95), and the mean IKDC score was 78.6 (range, 60.9-95.4) in the irreducible group. The respective results in the control group were 4.6 (range, 3-8), 83.1 (range, 39-100), and 80.6 (range, 42.5-96.6). These scores did not differ significantly between the 2 groups. Similarly, mean range of motion was similar between groups (irreducible, 118.1°; control, 124.8°). In the irreducible group, the acute subgroup showed significantly higher Lysholm and IKDC scores than the chronic subgroup, while the acute and chronic subgroups in the control group showed no significant differences in these respective outcome scores. CONCLUSION: In the present study, the treatment of irreducible KD led to similar functional outcomes compared with reducible KD. However, the treatment of chronic irreducible KD led to worse outcomes compared with acute irreducible KD, and therefore, urgent reduction is recommended in these patients.

[Research progress in anterolateral ligament of knee].

OBJECTIVE: To review research progress in the anterolateral ligament (ALL) of knee, and provide a clinical reference for diagnosis and treatment of ALL injury. METHODS: The literature on the diagnosis and treatment of ALL injury was widely reviewed. The incidence, anatomy, biomechanics, injury mechanism, and treatment status of ALL were summarized. RESULTS: The ALL contributes to the effect of controlling the internal rotation and anterior translation of the tibia, which affects the axial migration of the knee. ALL injury can be diagnosed according to the signs and MRI examination. Currently, no consensus exists for the surgical indications of ALL injury, but most surgeons tend to perform ALL reconstruction in patients requiring anterior cruciate ligament (ACL) reconstruction or revision surgery with higher pivot-shift tests. At present, various techniques have been used for ALL reconstruction, and there is no optimal technique. In addition, the long-term effectiveness of ALL reconstruction is unclear due to the lack of high-quality studies and long-term postoperative follow-up. CONCLUSION: The ALL contributes to maintaining knee stability, and the ALL reconstruction technique and its effectiveness still need further research.

The Effectiveness and Safety of Barbed Sutures in the Bariatric Surgery: a Systematic Review and Meta-analysis.

BACKGROUND: Knotless barbed sutures can eliminate knot tying during the bariatric surgery (BS). Since effects reported on patients and surgeons are ambiguous, this study is determined to identify the effectiveness and safety of knotless barbed suture in BS. METHODS: PubMed, EMBASE, Cochrane Register of Clinical Studies, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) and cohort studies comparing barbed sutures with conventional sutures in BS (until July 2, 2018). Quality assessment was conducted due to Cochrane's recommendations. Review Manager was applied to analyze the data, and we performed subgroup analyses based on study design type and surgery type. RESULTS: A total of four cohort studies (25,505 patients, low to moderate risk of bias) and four RCTs (1480 patients, low to moderate risk of bias) proved eligible. BS includes laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy. Comparing to conventional suture, pooling data showed that suture time (MD = - 4.87, 95%CI - 8.82 to - 0.92, P = 0.02) and operative time (MD = - 7.88, 95%CI - 14.10 to - 1.67, P = 0.01) declined significantly in the barbed group. Although no significant change was in the overall postoperative complications and hospital stay, subgroup analysis of RCTs suggested that significantly, fewer bleeding conditions happened in barbed groups. CONCLUSIONS: Although quality of all the studies was relatively moderate and the number of the included studies was limited, the barbed suture may have the potentiality to be an effective and reliable technique and extend the application in other bariatric surgeries. More evidence with randomized design, larger sample sizes, and longer follow-up need to compel validations of this state-of-the-art in the future.

Carpal tunnel release with versus without flexor retinaculum reconstruction for carpal tunnel syndrome at short- and long-term follow up-A meta-analysis of randomized controlled trials.

BACKGROUND: Carpal tunnel syndrome is a common neuropathy disorder for which surgical treatment consists of release and reconstruction of the flexor retinaculum. Reports of postoperative clinical outcomes after carpal tunnel release with or without flexor retinaculum reconstruction in several studies are controversial. This meta-analysis aimed to compare the efficacy and safety of carpal tunnel release with or without flexor retinaculum reconstruction. METHODS: The PubMed, EMBASE, Web of Science, Ovid, Cochrane Library and Clinical Tri Org databases were searched for randomized controlled trials that compared carpal release with and without transverse carpal ligament reconstruction for carpal tunnel syndrome. Outcomes included postoperative Boston Carpal Tunnel Questionnaire Symptom Severity Scale (SSS), Functional Status Scale (FSS), grip strength and complications. The follow-up time was categorized into short-term (0-3mon) and long-term(>3mon). RESULTS: A total of 7 studies with 613 patients met the inclusion criteria and were analyzed in detail. Statistical analysis showed no significant difference between two groups on postoperative long-term grip strength (MD 5.85, 95% CI -1.05 to 12.76) long-term SSS (MD -0.31, 95% CI -0.75 to 0.13) and occurrence of complications (RR 1.14, 95% CI 0.84 to 1.54), whereas statistically significant difference was found between groups regarding short-term grip strength (MD 1.51, 95% CI 0.86 to 2.17) and long-term FSS (MD -0.34, 95% CI -0.47 to -0.21). CONCLUSION: Carpal tunnel release with flexor retinaculum reconstruction for carpal tunnel syndrome may result in improved long-term functional status while there's no advantage regarding grip strength, symptom severity and safety over individual carpal tunnel release in short- and long-term outcomes.

The application of barbed suture during the partial nephrectomy may modify perioperative results: a systematic review and meta-analysis.

BACKGROUND: Barbed sutures can avoid knot tying and speed the suture placement in the PN(partial nephrectomy). On account of the impact on clinical outcomes are ambiguous, this study is determined to identify the application of barbed suture during PN. METHODS: ClinicalTrials.gov, Cochrane Register of Clinical Studies, PubMed and EMBASE were searched for RCTs(randomized controlled trials) and cohort studies focusing on the comparison of barbed and traditional sutures in PN(last updated on Feb in 2015). According to Cochrane Library's suggestion, quality assessment was performed. Review Manager was applied to analyze all the data and sensitivity analyses were performed through omitting each study sequentially. RESULTS: Eight cohort studies and none of RCTs proved eligible (risk of bias: moderate to low,431 patients). Warm ischemia time(MD = - 6.55,95% CI -8.86 to - 4.24, P < 0.05) decreased statistically in the barbed suture group, as well as operative time(MD = - 11.29,95% CI -17.87 to-4.71, P < 0.05). Postoperative complications also reduced significantly(OR = 0.44, 95% CI 0.24 to0.80, P < 0.05). Unidirectional barbed suture resulted in fewer postoperative complications based on the subgroup analysis(OR = 0.48,95% CI 0.24 to 0.94, P < 0.05). CONCLUSIONS: The barbed suture may be a useful surgical innovation which can modify perioperative results for surgeons and patients. Randomly-designed studies with longer follow up and larger sample sizes are in the need of to explore the applicability.

Efficacy and safety of barbed suture in minimally invasive radical prostatectomy: A systematic review and meta-analysis.

As one of the earliest surgeries applying knotless barbed suture, the minimally invasive radical prostatectomy (MIRP) was reported to have various effects on the patients and the surgeons. This study reviewed the available evidence about the efficacy and safety of barbed sutures in MIRP. We searched ClinicalTrials.gov, Cochrane Register of Clinical Studies, PubMed, and Embase to identify randomized controlled trials (RCTs) and cohort studies addressing the application of barbed sutures and conventional sutures in MIRP (until August 2016). Quality assessment was performed according to Cochrane recommendations. The data were analyzed using Review Manager (Version 5.3), and sensitivity analysis was performed by sequentially omitting each study. A total of 12 studies, including three RCTs (low to moderate risk of bias, 211 patients) and nine cohort studies (low to moderate risk of bias, 698 patients), fulfilled the study criteria. The pooling of trials did not show statistical difference. Pooling data of cohort studies showed that suture time [mean difference (MD) = -8.52, 95% confidence interval (CI) = -12.60 to -4.43, p < 0.0001] and length of hospital stay (MD = -0.96, 95% CI = -1.80 to -0.11, p = 0.03) were significantly shorter in the barbed group. Results of continence rate varied according to different studies. Subgroup analysis by type of MIRP suggested that patients who underwent barbed suture during robot-assisted surgeries had a shorter hospital stay (MD = -1.13, 95% CI = -1.82 to -0.45, p = 0.001). During the laparoscopic surgery, patients in the barbed suture group had fewer postoperative complications [odds ratio = 0.29, 95% CI = 0.08-0.98, p = 0.05). However, more evidence is needed to validate this state-of-the-art technology.

The influence factors of medical professionalism: A stratified-random sampling study based on the physicians and patients in ambulatory care clinics of Chengdu, China.

As the relationship between physicians and patients deteriorated in China recently, medical conflicts occurred more frequently now. Physicians, to a certain extent, also take some responsibilities. Awareness of medical professionalism and its influence factors can be helpful to take targeted measures and alleviate the contradiction. Through a combination of physicians' self-assessment and patients' assessment in ambulatory care clinics in Chengdu, this research aims to evaluate the importance of medical professionalism in hospitals and explore the influence factors, hoping to provide decision-making references to improve this grim situation. From February to March, 2013, a cross-sectional study was conducted in 2 tier 3 hospitals, 5 tier 2 hospitals, and 10 community hospitals through a stratified-random sampling method on physicians and patients, at a ratio of 1/5. Questionnaires are adopted from a pilot study. A total of 382 physicians and 1910 patients were matched and surveyed. Regarding the medical professionalism, the scores of the self-assessment for physicians were 85.18 ±â€Š7.267 out of 100 and the scores of patient-assessment were 57.66 ±â€Š7.043 out of 70. The influence factors of self-assessment were physicians' working years (P = 0.003) and patients' complaints (P = 0.006), whereas the influence factors of patient-assessment were patients' ages (P = 0.001) and their physicians' working years (P < 0.01) and satisfaction on the payment mode (P = 0.006). Higher self-assessment on the medical professionalism was in accordance with physicians of more working years and no complaint history. Higher patient-assessment was in line with elder patients, the physicians' more working years, and higher satisfaction on the payment mode. Elder patients, encountering with physicians who worked more years in health care services or with higher satisfaction on the payment mode, contribute to higher scores in patient assessment part. The government should strengthen the medical professionalism for young physicians and improve the payment mode.

The Efficacy and Safety of Knotless Barbed Sutures in the Surgical Field: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

The knotless barbed suture is an innovative type of suture that can accelerate the placement of sutures and eliminate knot tying. However, the outcomes of previous studies are still confounding. This study reviewed the application of different types of barbed sutures in different surgeries. We searched PubMed, EMBASE, CENTRAL and ClinicalTrials.gov to identify randomized controlled trials (RCTs) addressing the application of barbed sutures up to Feb. 2015. Two reviewers independently screened the literature and assessed the risk of bias of included studies. Then meta-analysis was performed using RevMan 5.3 software. Sensitivity analysis and subgroup analysis was performed. Seventeen RCTs (low to moderate risk of bias) involving 1992 patients were included. Compared with conventional sutures, the barbed suture could reduce suture time (SMD=-0.95, 95%CI -1.43 to -0.46, P = 0.0001) and the operative time (SMD=-0.28, 95%CI -0.46 to -0.10, P = 0.003), not significantly increase the estimated blood loss (SMD=-0.09, 95%CI -0.52 to 0.35, P = 0.70), but could lead to more postoperative complications (OR = 1.43, 95%CI 1.05 to 1.96, P = 0.03), These results varied in subgroups. Thus, barbed sutures are effective in reducing the suture and operative time, but the safety evidences are still not sufficient. It need be evaluated based on special surgeries and suture types before put into clinical practice.