Comparison of the survivorship between arthroplasty and ORIF for basi-cervical femoral neck fractures in the overall population and in polymorbid patients.

BACKGROUND: Femoral neck fractures (FNFs) are associated with high mortality and can be treated with arthroplasty or open reduction and internal fixation (ORIF). For basi-cervical FNFs, there is no agreement on which procedure is better. Do arthroplasty and open reduction with internal fixation (ORIF) have different rates of survival? Do age and comorbidities influence survivorship? HYPOTHESIS: Patients who underwent arthroplasty and patients who underwent ORIF have different rates of survival. PATIENTS AND METHODS: Survivorship curves, complications, and hospitalisation length were analysed in 154 patients who received hip arthroplasty, and in 72 patients who received ORIF. Age and ASA score were used to divide the patients into sub-groups and perform secondary analyses. RESULTS: At 4.9±2.4 years after surgery, 74 patients in the arthroplasty group (48%) and 33 in the ORIF group (45%) had died. The survivorship curves of the two groups showed a non-significant difference. The hospitalisation length was 13.5±8.9 days, with a non-significant difference between groups. There were 130 complications in total: 97 in the arthroplasty patients (19 patients had multiple complications, 52 had only one), 33 in the ORIF patients (4 patients had multiple complications, 29 had only one); the odds ratio was therefore 2.1 (p=0.02). Age, ASA score, Sernbo score, Charlson comorbidity index, and sex (male) were the best predictors of mortality. In the ASA 3-4 sub-group, the survivorship curves showed a lower mortality in the arthroplasty group (p=0.02). DISCUSSION: Arthroplasty and ORIF are both valid procedures for the treatment of basi-cervical FNFs, but a high mortality rate is associated with either procedures. There is no difference in terms of survivorship between arthroplasty and ORIF in the overall population, but the presence of comorbidities may favour arthroplasty, which should be considered when managing patients with basi-cervical FNFs. LEVEL OF EVIDENCE: III; retrospective, observational study.

Bone Bruise and Anterior Cruciate Ligament Tears: Presence, Distribution Pattern, and Associated Lesions in the Pediatric Population.

BACKGROUND: Bone bruise characteristics after anterior cruciate ligament (ACL) injury have been correlated with the level of joint derangement in adults. However, the literature lacks information about younger patients, whose higher ligamentous laxity may lead to different lesion patterns. PURPOSE: To investigate the prevalence, size, location, and role of bone bruise associated with ACL rupture in the pediatric population. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Knee magnetic resonance imaging scans (MRIs) of patients aged 8 to 16 years with ACL tears from 2010 to 2018 were selected from the institution database. Inclusion criteria were open or partially open physes, less than 90 days between trauma and MRI, and no history of injury or surgery. Presence, localization, and size of bone bruise were analyzed by 2 blinded researchers and scored with the Whole-Organ Magnetic Resonance Imaging Score (WORMS) bone bruise subscale. Ligamentous, cartilaginous, meniscal, and other lesions were documented. RESULTS: Of the 78 pediatric patients selected from the database, 54 (69%) had bone bruise. The mean area of bone bruise was larger in males than in females (femur, 3.8 ± 2.8 vs 2.2 ± 1.4 cm2, respectively, P = .006; tibia, 2.6 ± 1.6 vs 1.5 ± 0.8 cm2, respectively, P = .007). The subregions most affected by bone bruise were the lateral posterior tibia and the lateral central femur (in 83% and 80% of the knees affected, respectively). A low correlation was found between age and bone bruise area (biggest areas r = 0.30, P = .03, and sum of areas r = 0.27, P = .04), but no correlation was found between age and WORMS (femur, r = -0.03, P = .85; tibia, r = -0.04, P = .76). The injuries most associated with bone bruise were 23 meniscal lesions (43%), 10 lesions of other ligaments (19.0%), 2 cartilage lesions (3.7%), and 2 patellar fractures (3.7%). CONCLUSION: The prevalence of bone bruises in pediatric patients with ACL tears is high, although it seems slightly lower than the prevalence documented in adults but with similar localization. The area and the distribution pattern of bone bruises are similar among different ages. The pediatric patients had a lower presence of cartilage and meniscal lesions compared with that reported in adults, which suggests a different effect of this trauma on the knee of pediatric patients.

Midshaft Clavicle Fractures: Surgery Provides Better Results as Compared With Nonoperative Treatment: A Meta-analysis.

BACKGROUND: There is no agreement on the best treatment for displaced midshaft clavicle fractures (MCFs), which are currently addressed by nonoperative or surgical approaches. PURPOSE: To compare fracture healing and functional outcome after surgical versus nonsurgical treatment of MCFs, to help specialists in deciding between these different strategies by providing a synthesis of the best literature evidence. STUDY DESIGN: Meta-analysis. METHODS: A systematic research of the literature was performed in different online databases: PubMed, Web of Science, Cochrane library, and grey literature. PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were used. The risk of bias was evaluated with the Cochrane Collaboration's "risk of bias" tool, and the quality of evidence was graded according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Randomized controlled trials investigating differences between surgery and nonoperative treatment for displaced MCFs were included. The primary outcome was the nonunion rate. Other outcomes analyzed were time to union and to return to activities, Constant score, and Disabilities of the Arm, Shoulder and Hand (DASH) index. Patients' satisfaction, secondary operations, and complications were also recorded. RESULTS: Out of 832 records found, 14 randomized controlled trials with 1546 patients were included. A significantly lower risk ratio was found for nonunion (10%; 95% CI, 6%-18%, P < .001) favoring surgery. Time to union was 5.1 weeks shorter with surgery (P = .007). The complication rate (including the number of reinterventions) was higher in the surgical group (31.3% vs 20.5%, P < .001). Shoulder function at short-term follow-up was significantly better in the surgical group (DASH index mean difference = 4.0 points), while no statistical difference was found in the Constant score and in the DASH index at midterm follow-up (P = .41 and .80, respectively). At long-term follow-up, both shoulder functional scores were significantly better in the surgery group: the overall Constant score mean difference was 5.3 points (95% CI, 2.3-8.4 points; P < .001), and the DASH index mean difference was 4.3 points (95% CI, 0.2-8.4 points; P = .04). CONCLUSION: Surgical treatment of MCFs significantly reduces the nonunion rate and shortens the time to union as compared with the nonoperative approach and, despite a slightly higher incidence of complications, leads to better shoulder functional scores at short- and long-term follow-up. Further studies should address the clinical significance of the documented improvement.

Recurrent patellar dislocations: trochleoplasty improves the results of medial patellofemoral ligament surgery only in severe trochlear dysplasia.

PURPOSE: Medial patellofemoral ligament (MPFL) surgery combined with trochleoplasty (TP), is often performed to restore the normal patellofemoral biomechanics avoiding recurrent lateral patellar dislocation (LPD) in patients with trochlear dysplasia (TD). However, it is still unclear whether combining TP and MPFL surgery would be more beneficial than performing MPFL surgery on its own. This meta-analysis quantitatively synthesizes and compares published data on the outcomes of recurrent LPD treatment using MPFL surgery without or with TP in patients affected by TD. METHODS: A systematic literature search about the treatment of recurrent LPD in the presence of TD was conducted. The primary outcome was redislocation rate, analyzed for different types of TD. Kujala, and IKDC scores, as well as complication rate, were also analyzed through a separate meta-analysis. RESULTS: No statistically significant difference was found in the overall redislocation rate of MPFL surgery without and with TP. There was, however, a statistically significant difference (p < 0.001) in redislocation rate after MPFL surgery without TP between patients with type A or B TD (2.7%) and in patients with type C or D TD (18.6%). In the analysis for every single type of TD, the following results were obtained: redislocation rate of 1.8% in type A, 3.2% in type B, 11.9% in type C, and 7.4% in type D. A statistically significant difference in the complication rate, favouring MPFL surgery without TP, was documented. Both surgical approaches provided a significant improvement with no difference in Kujala and IKDC scores. These results were confirmed when data were analyzed including only patients with type B, C, or D TD, or without additional bone remodelling procedures. CONCLUSION: Isolated MPFL is as effective as combined TP and MPFL surgery in preventing redislocation and improving clinical and functional outcomes in patients with recurrent LPD and knees affected by moderate TD. However, in case of severe TD, the redislocation rate is lower when TP is performed in combination with MPFL surgery, although with comparable clinical outcomes and a higher risk of post-operative range of motion (ROM) limitation. LEVEL OF EVIDENCE: Systematic review and meta-analysis, Level IV.