Early and 1-year mortality of native geriatric distal femur fractures: A systematic review and time-to-event meta-analysis.

Purpose: Distal femur fractures (DFF) account for 6% of all femoral fractures and predominate in females. The current 1-year mortality of DFF is currently reported to be between 10 and 38%, a wide margin, and confounded by multiple factors including age, high energy mechanisms, pathological and periprosthetic fractures. The purpose of this study was to assess and determine all-cause mortality following geriatric native distal femur fractures at 30 days, six months and one year. Methods: - The databases Cochrane CENTRAL, MEDLINE, EMBASE and NHS NICE Healthcare Databases Advanced Search Interface were searched in accordance with PRISMA guidelines. Original research articles relevant to mortality outcomes in native geriatric distal femur fractures following low energy trauma were included. A time-to-event data meta-analysis model was used to estimate pooled 30-day, six month and one-year mortality. A random effects meta-regression model was performed to assess potential sources of heterogeneity when studies reported on factors affecting the mortality observed in patients with geriatric distal femur fractures. Results: - Thirteen studies were included in the meta-analysis with a mean age of 79.6 years. Eight studies reported the 30-day mortality of distal femur fractures in patients as a pooled estimate of 8.14%. Pooled estimate for 6-month mortality reported was 19.5% and the one-year mortality reported by ten studies was 26.10%. Time-to-event modelling showed that risk of mortality at one year in elderly patients with distal femur fractures was significantly higher HR = 4.31 (p < 0.001). When evaluating prognostic predictors, age and Type C fracture were predictive of highest mortality rates. Conclusions: - This study is the first meta-analysis to evaluate the early and long-term mortality observed in elderly patients presenting with native distal femoral fractures. Through our results we have shown the quantifiable impact patient age and fracture configuration has on one-year mortality in this patient cohort.

The accuracy of digital templating in the preoperative planning of total knee arthroplasties: A systematic review and meta-analysis.

AIMS: Accurately predicting the implant size in total knee arthroplasties could increase the efficiency of the operation, decrease the costs associated with the procedure and result in improved patient outcomes. To substantiate its continued use, digital templating must demonstrate itself to be an accurate tool in predicting component size in order for surgeons to confidently use it to optimize the procedure. METHODS: A systematic literature review was performed and identified 16 studies within the Pubmed, Ebsco and Ovid-Embase databases, with 1189 TKR prostheses included for analysis. A quality of evidence assessment was performed on each study depending on the study design. A random effects meta-analysis model was used to pool overall implant accuracy and the reported inter-rater agreement when performing digital templating and displayed in a forest plot. Meta-regression was used analyze potential factors that may affect the accuracy of digital templating. RESULTS: The pooled proportion of accurate templates with 0 margin of error was found to be 56% (52-61, 95CI), which increases to 96% (0.94-0.98, 95CI) when allowing for a 1 size margin of error. Subgroup analysis between femoral and tibial components concluded no statistically significant difference. CONCLUSIONS: This study supports the continued use of digital templating for planning total knee arthroplasties and recommends further subgroup analysis of patient age, body mass index and sex against accuracy. This review was registered in the International Prospective Register of Systematic Reviews Database under ID: CRD420222367461. No funding was provided for the completion of this systematic review. BACKGROUND: Templating in the preoperative planning of total knee arthroplasties is a vital step in ensuring maximum operative efficiency. A method that can accurately predict the required implant size within 1 size could improve theatre turnover, decrease costs and benefit patient outcomes. The current literature on the accuracy of digital templating in total knee arthroplasties lacks a systematic review calculating the overall accuracy of the process, this study aims to address this gap.

The Impact of COVID-19 on the Choice of Treatment for Hand Fractures: A Single-Centre Concordance Study.

Background: Management of hand trauma has evolved to incorporate assessment, treatment and rehabilitation of patients in a 'one-stop' clinic on initial presentation. Our aim was to evaluate the effect of coronavirus disease 2019 (COVID-19) on the choice of treatment for hand fractures using inter-rater agreement between surgeons. Methods: All patients with hand fractures during the COVID-19 lockdown from March to May 2020 were included in the study. Two experienced hand surgeons blinded to management and outcomes independently reviewed radiographic images and relevant clinical history to provide their opinion on optimal treatment. Weighted kappa analysis was performed to determine concordance and inter-rater agreement between the two surgeons and actual management. Results: The study included 82 patients (62 men and 20 women) with a mean age of 40.3 (SD 19.7). The injuries occurred most often at home following an accident (34%) or a fall (28%). Fractures involved the metacarpals in 29 patients and the distal phalanx in 22 patients. Thirty-five patients underwent surgery, whereas 47 were managed conservatively. Overall agreement between actual management and consultant A and consultant B was moderate (κ = 0.55, p < 0.0001 and κ = 0.63, p < 0.0001, respectively). Subgroup analysis showed a weak agreement between actual management of metacarpal fractures and consultant A and consultant B (κ = 0.22, p = 0.29 and κ = 0.47, p = 0.02, respectively). Inter-rater agreement was substantial for management of metacarpal fractures (κ = 0.73, p < 0.0001), but weak for distal phalanx fractures (κ = 0.29, p = 0.03). Conclusion: Our study has shown that overall management of hand fractures remained optimised throughout the pandemic. However, a lack of concordance was observed in the management of metacarpals. Level of Evidence: Level IV (Therapeutic).

Can Weightbearing Cone-beam CT Reliably Differentiate Between Stable and Unstable Syndesmotic Ankle Injuries? A Systematic Review and Meta-analysis.

BACKGROUND: Ankle injuries are common presentations to the emergency department and may lead to syndesmotic instability. These have a high socioeconomic burden due to prolonged rehabilitation, chronic pain, and posttraumatic arthritis. Early diagnosis is essential to minimize these complications, and the assessment of instability in the clinical setting is often limited by pain and clinician experience. Cross-sectional imaging of the distal syndesmosis accurately evaluates the syndesmosis through abnormal bony relationships, which in the presence of instability, worsens during physiological loading. Cone-beam CT (CBCT) has gained popularity in the diagnosis of these injuries because it enables syndesmotic assessment under weightbearing conditions, it mitigates the high radiation dose, and it is time-efficient. QUESTIONS/PURPOSES: The purposes of this systematic review were: (1) to establish normal values for weightbearing CBCT of the syndesmosis in uninjured ankles and ascertain interobserver reliability and (2) to identify the impact of weightbearing on the syndesmosis in patients with occult ankle injuries and assess the effect of patient demographics on these metrics. METHODS: This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in PROSPERO (ID CRD42021248623). MEDLINE, PubMed, Embase, and Emcare databases were searched for studies assessing for syndesmotic instability, of which 307 studies were screened and 11 studies with 559 ankles in 408 uninjured patients and 151 patients with syndesmotic instability were included. All patients 18 years of age or older presenting with unilateral ankle injuries who underwent weightbearing CBCT for the diagnosis of an occult fracture or syndesmotic instability compared with the uninjured contralateral side were included. A control group of uninjured ankles was identified during weightbearing CBCT performed for other indications such as forefoot or midfoot injuries. Methodological assessment of the studies was performed using the Risk of Bias In Non-randomized Studies (ROBINS-1) tool and most included studies had a low risk of bias. Thus, a random-effects restricted maximum likelihood ratio model was used. RESULTS: In the uninjured ankle, the mean area of the tibiofibular syndesmosis was 112.5 ± 7.1 mm 2 , which increased to 157.5 ± 9.6 mm 2 after injury when compared with uninjured ankles with a standardized mean difference of 29.5 (95% confidence interval 19.5 to 39.5; p < 0.01), and an excellent interobserver agreement (κ = 1.0 [95% CI 0.9 to 1.0]). However, syndesmosis volume decreased with age (ß = -0.76; p = 0.04), and therefore, has a negative association with increasing age. CONCLUSION: Our study has shown that the syndesmotic area is the most reliable parameter in the assessment of syndesmotic injuries because it increases in the presence of instability during weightbearing status. It is a composite measurement that could potentially allow clinicians to use weightbearing CBCT as an adjunct when there is a clinical suspicion of syndesmotic instability. Thus, weightbearing CBCT has the potential of being diagnostic of syndesmotic instability and should be evaluated against current radiological modalities to evaluate its accuracy. LEVEL OF EVIDENCE: Level IV, prognostic study.

The use of cone-beam computed tomography (CBCT) in radiocarpal fractures: a diagnostic test accuracy meta-analysis.

OBJECTIVE: Occult radiocarpal fractures often present a diagnostic challenge to the emergency department. Accurate diagnosis of these injuries is crucial as a missed fracture can lead to significant morbidity. Cone-beam CT (CBCT) scan is a novel imaging modality, with minimal radiation exposure and comparatively fast acquisition time. Our aim was to evaluate its use in the diagnosis of cortical fractures in the upper limb extremity. MATERIALS AND METHODS: We conducted a systematic review of literature and included all studies that evaluated the use of CBCT in the diagnosis of radiocarpal fractures. We used a mixed-effects logistic regression bivariate model to estimate the summary sensitivity and specificity and constructed hierarchical summary receiver operative characteristic curves (HSROC). RESULTS: We identified 5 studies, with 439 patients, and observed CBCT to be 87.7% (95% CI 77.6-93.6) sensitive and 99.2% (95% CI 92.6-99.9) specific for scaphoid fractures. For carpal fractures, CBCT was observed to have a pooled sensitivity and specificity of 90.6% (95% CI 72.7-97.2) and 100% (95% CI 99-100) respectively. For distal radius fractures, CBCT sensitivity was 90% (95% CI 67-98) and specificity was 100% (95% CI 10-100). The overall inter-rater agreement effect was shown to be 0.89 (95% CI 0.82-0.96), which is deemed to be almost perfect. CONCLUSION: CBCT is an accurate diagnostic tool for occult radiocarpal cortical fractures, which could replace or supplement radiographs. We believe CBCT has a promising role in the acute radiocarpal fracture diagnostic algorithm in both emergency and trauma departments.

Meta-analysis of the normal diffusion tensor imaging values of the median nerve and how they change in carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) leads to distortion of axonal architecture, demyelination and fibrosis within the median nerve. Diffusion tensor imaging (DTI) characterises tissue microstructure and generates reproducible proxy measures of nerve 'health' which are sensitive to myelination, axon diameter, fiber density and organisation. This meta-analysis summarises the normal DTI values of the median nerve, and how they change in CTS. This systematic review included studies reporting DTI of the median nerve at the level of the wrist in adults. The primary outcome was to determine the normal fractional anisotropy (FA) and mean diffusivity (MD) of the median nerve. Secondarily, we show how the FA and MD differ between asymptomatic adults and patients with CTS, and how these differences are independent of the acquisition methods. We included 32 studies of 2643 wrists, belonging to 1575 asymptomatic adults and 1068 patients with CTS. The normal FA was 0.58 (95% CI 0.56, 0.59) and the normal MD was 1.138 × 10-3 mm2/s (95% CI 1.101, 1.174). Patients with CTS had a significantly lower FA than controls (mean difference 0.12 [95% CI 0.09, 0.16]). Similarly, the median nerve of patients with CTS had a significantly higher mean diffusivity (mean difference 0.16 × 10-3 mm2/s [95% CI 0.05, 0.27]). The differences were independent of experimental factors. We provide summary estimates of the normal FA and MD of the median nerve in asymptomatic adults. Furthermore, we show that diffusion throughout the length of the median nerve becomes more isotropic in patients with CTS.

Meta-analysis and metaregression of risk factors associated with mortality in hip fracture patients during the COVID-19 pandemic.

Incidence of hip fractures has remained unchanged during the pandemic with overlapping vulnerabilities observed in patients with hip fractures and those infected with COVID-19. We aimed to investigate the independent impact of COVID-19 infection on the mortality of these patients. Healthcare databases were systematically searched over 2-weeks from 1st-14th November 2020 to identify eligible studies assessing the impact of COVID-19 on hip fracture patients. Meta-analysis of proportion was performed to obtain pooled values of prevalence, incidence and case fatality rate of hip fracture patients with COVID-19 infection. 30-day mortality, excess mortality and all-cause mortality were analysed using a mixed-effects model. 22 studies reporting 4015 patients were identified out of which 2651 (66%) were assessed during the pandemic. An excess mortality of 10% was seen for hip fractures treated during the pandemic (OR 2.00, p = 0.007), in comparison to the pre-pandemic controls (5%). Estimated mortality of COVID-19 positive hip fracture patients was four-fold (RR 4.59, p < 0.0001) and 30-day mortality was 38.0% (HR 4.73, p < 0.0001). The case fatality rate for COVID-19 positive patients was 34.74%. Between-study heterogeneity for the pooled analysis was minimal (I2 = 0.00) whereas, random effects metaregression identified subgroup heterogeneity for male gender (p < 0.001), diabetes (p = 0.002), dementia (p = 0.001) and extracapsular fractures (p = 0.01) increased risk of mortality in COVID-19 positive patients.

Performance of infrared thermography and thermal stress test in perforator mapping and flap monitoring: A meta-analysis of diagnostic accuracy.

BACKGROUND: Accurate mapping of perforators prior to flap reconstruction and early detection of poor flap perfusion reduces the risk of flap failure. Infrared thermography (IRT) has recently regained popularity within reconstructive surgery to aid flap design, reduce operative time and assess flap viability based on surface temperature changes. The aim of this review is to quantify the diagnostic ability of IRT in perforator mapping preoperatively and monitor flap perfusion perioperatively. METHODS: We conducted a systematic review of literature and included all studies that evaluated the use of IRT for perforator mapping and flap perfusion monitoring. We used a mixed-effects logistic regression bivariate model to estimate the summary sensitivity and specificity and constructed hierarchical summary receiver operative characteristic (HSROC) curves. OUTCOME: We identified 18 studies and observed IRT to have sensitivities of 99.6% and 89.6% with specificities of 99.9% and 96.0% for perforator mapping and flap monitoring, respectively. Moreover, IRT recognises patterns of perfusion within interperforator zones through visualisation of angiosomal rewarming and may improve flap outcomes.

The role of ultrasonography in the assessment of ulnar collateral ligament injury of the thumb - a diagnostic test accuracy meta-analysis.

The accurate diagnosis of ulnar collateral ligament (UCL) injuries of the thumb is important in identifying patients requiring surgery. Stener lesion, the most severe form of such injuries, is debilitating and leads to chronic instability if misdiagnosed. We evaluated the diagnostic accuracy of ultrasonography (USS) in UCL injuries. A systematic review of existing literature was performed with a meta-analysis using a bivariate mixed-effects model to estimate summary sensitivity and specificity. All observational studies were assessed, with participants of any age, who sustained UCL injuries of the thumb. A hierarchical model was used to generate a hierarchical summary receiver operating characteristic (HSROC) curves. We identified 17 studies reporting a total of 593 UCL injuries. Pooled estimates for sensitivity and specificity were 0.96 (95% CI 0.89-0.99) and 0.90 (95% CI 0.81-0.94), respectively for the diagnosis of Stener lesions; 0.81 (95% CI 0.66-0.93) and 0.87 (95% CI 0.67-0.96), respectively for non-displaced complete ruptures and 0.82 (95% CI 0.66-0.92) and 0.94 (95% CI 0.85-0.98), respectively for complete ruptures without Stener lesion. The area under the curve (AUC) for Stener diagnosis using USS was 0.98, suggesting excellent diagnostic accuracy. Our meta-analysis suggests that USS is a reliable and accurate method of diagnosis for UCL injuries. Moreover, it has excellent diagnostic accuracy for Stener lesions and may be used in the diagnostic work-up of UCL injuries with magnetic resonance imaging being reserved for ambiguous cases.

Improving the efficiency of ankle fracture care through home care and day-surgery units: Delivering safe surgery on a value-based healthcare model.

OBJECTIVES: Preoperative home care for suitable patients with ankle fractures is becoming an increasingly common practice. It allows adequate time for reduction of ankle swelling following a decision to undertake operative fixation has been made. We aim to assess the safety, efficiency, cost-effectiveness and differences in clinical & patient outcomes of day surgery unit (DSU) care for ankle fracture treatment in selected patients. Our study combined home therapy treatment with DSU care for suitable ankle fractures. DESIGN: Prospective cohort study. SETTING: Trauma Centre. PATIENTS: Fifty-three patients requiring operative fixation for an ankle fracture were divided into 2 groups. Patients in group 1 entered the home care combined with DSU treatment pathway whilst in group 2 were treated as in patient in the main trauma theatre in our standard pathway. INTERVENTION: Comparison of Home Care & Day Case Surgery vs. in patient admission for patients requiring operative ankle fractures fixation. MAIN OUTCOME MEASURES: Prospective data collection was undertaken over a 2-year period, on fracture type, logistical outcomes including time to surgery and total length of stay in the hospital and clinical outcomes including the rate of post-operative complications, incidence of unplanned surgical revisions and objective patient satisfaction. Economic analysis was performed to compare the marginal cost saving per case for group 1 vs. group 2. RESULTS: There were 21 patients in group 1. They waited for on average 5.8 days at home for their operation and none were admitted pre or post operatively. There were no associated complications and the majority of patients were discharged from follow-up at 6 weeks post-surgery. In-group 2, there were 32 patients. They waited on average 2.4 days for their operation in the hospital and had an average length of stay of 4.9 days. One patient in group 2 suffered from a deep vein thrombosis. The benefit from our chargeable tariff for group 1 patients was £2295 per case while the margin for group 2 patients was £277 per case. The financial benefit to the health care provider was £2018 in favour of home care and DSU treatment, with high service satisfaction and low complication rates. DISCUSSION: This study provides focused evidence supporting the use of home care for the management of ankle fractures. The DSU pathway improves the value in healthcare delivery with high patient satisfaction scores when compared to the traditional pathway. Our model demonstrates predictably good clinical outcomes with a financial cost benefit over in-patient admission care model for selected patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Delays in surgery for cholesteatoma due to COVID-19: is there an impact on rates of recidivism and major complications?

PURPOSE: To evaluate the relationship between the waiting time for surgery, and cholesteatoma recidivism rates and major complications. The secondary aims were to identify any other prognostic factors for cholesteatoma recidivism. METHODS: A retrospective single-centre study of 312 patients who underwent cholesteatoma surgery under the care of a single-surgeon, between 2004 and 2018, was performed. Waiting times for surgery were categorised into ≤ 90 days, 91-180 days, 181-270 days and > 271 days. The outcome measures were cholesteatoma recidivism and major complications (facial nerve palsy or intracranial complications). RESULTS: The mean age was 36.1 years ± 21.5 with 242 adults (77.6%) and 70 children (22.4%). The mean waiting time for surgery was 126.2 days (4.1 months) ± 96.0 days and the overall rate of recidivism was 11.2% (35/312 patients). No instances of facial nerve palsy or intracranial complications were identified. Rates of recidivism by waiting time for surgery were: 15.3% for 118 patients who waited ≤ 90 days, 9.7% for 134 patients who waited 91-180 days, 6.7% for 30 patients who waited 181-270 days and 4.3% for 23 patients who waited > 271 days. There was no significant difference amongst the different waiting time groups for rates of recidivism (p = 0.266). CONCLUSION: Increased waiting times for cholesteatoma surgery do not appear to be associated with increased rates of recidivism or major complications. Clinical judgement will always be required for complicated disease or patients with additional risk factors. The other prognostic factors for recidivism identified in this study were age (< 15 years) and congenital cholesteatoma.