Natural history of degenerative cervical myelopathy: a meta-analysis and neurologic deterioration survival curve synthesis.

BACKGROUND CONTEXT: Cervical spine surgery is rapidly increasing, and our knowledge of the natural history of degenerative cervical myelopathy (DCM) is limited. PURPOSE: To synthesize accurate time-based estimates of meaningful neurologic decline in patients with DCM managed conservatively and to provide formulae to help communicate survivorship estimates to patients. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review and meta-analysis was conducted using Cochrane and PRISMA guidelines. A librarian-assisted search strategy using multiple databases with broad search terms and validated filter functions was used. All articles were reviewed in duplicate. RESULTS: A total of 9570 studies were captured in the initial search, which after deletion of duplicates and manual review of abstracts and full texts revealed 6 studies for analyses. All studies were prospective cohorts or randomized controlled trials. The pooled survival estimates for neurologic stability (95% CrI) for mild DCM patients are: 91% (83%-97%) at one year; 85% (72%-94%) at 2 years; 84% (70%-94%) at 3 years; 75% (54%-90%) at 5 years; 66% (40%-86%) at 15 years; and 65% (39%-86%) at 20 years. The pooled survival estimates for neurologic stability (95% CrI) for moderate/severe DCM patients are: 83% (76%-89%) at 1 year; 72% (62%-81%) at 2 years; 71% (60%-80%) at 3 years; 55% (41%-68%) at 5 years; 44% (27%-59%) at 15 years; and 43% (25%-58%) at 20 years. CONCLUSIONS: This is the first quantitative synthesis of the totality of published data on DCM natural history. Our review confirms a slow decline in neurologic function. We developed formulae which can be easily used by surgeons to communicate to patients their risk of neurologic deterioration. These formulae can be used to facilitate the shared decision-making process.

Plating as a reduction aid prior to intramedullary nailing of tibia fractures: a systematic review and meta-analysis.

PURPOSE: The purpose of this meta-analysis is to analyse the literature on plate-assisted reduction during intramedullary nailing of tibial shaft fractures and to compare the rates of infection and nonunion. METHODS: The databases Medline, Embase, and Web of Science were searched from inception to February 2022 for literature comparing plate-assisted reduction during intramedullary nailing of extra-articular tibia fractures to standard, closed means of reduction. Data were extracted and pooled in a random effects meta-analysis for the primary outcomes of nonunion and infection risk. RESULTS: Five comparative studies were identified including 520 total patients, of which 151 underwent tibial nailing with the use of plate-assisted reduction with an average follow-up time of 17.9 months. Approximately two-thirds of patients retained the plate used to assist reduction during intramedullary nailing (102 of 151). Pooled analysis of the infection rates found no significant difference with plate-assisted intramedullary nailing (Risk Ratio [RR] 0.90, 95% CI 0.49-1.65, p = 0.72), and for nonunion rates, there was also no significant difference with plate-assisted intramedullary nailing (Risk Ratio [RR] 0.80, 95% CI 0.40-1.60, p = 0.53). CONCLUSIONS: Plate-assisted reduction during intramedullary nailing of tibia shaft fractures was not associated with an increased risk for nonunion or infection, and can be safely applied as an adjunct for reduction in challenging fracture patterns, without the need for later removal. However, evidence is quite limited and further investigation into the use of provisional plating as a technique is needed as its use in intramedullary nailing continues to expand.

Management of Very Distal Ulna Fractures: A Systematic Review.

OBJECTIVES: To synthesize all-cause complications and reoperations data, and secondary clinical, functional, and radiographic outcomes after the management of very distal ulna fractures (VDUFs) either nonoperatively or operatively. DATA SOURCES: MEDLINE, Embase, and Web of Science were searched for English-language articles from inception to February 17, 2022. STUDY SELECTION: Studies reporting the nonoperative or operative management of VDUFs were eligible for inclusion. VDUFs were defined as either being Q2-Q5 distal ulna fractures using the OTA/AO Comprehensive Classification of Fractures for distal ulna fractures associated with distal radius fractures or being amenable to characterization by the classification system for ulnar head, neck and metaphyseal fractures by Biyani et al. DATA EXTRACTION: Two reviewers independently extracted data from included studies. Study validity was assessed using the methodological index for nonrandomized studies. DATA SYNTHESIS: Seventeen studies (512 VDUFs) were included for analysis. There were 209, 237, and 66 fractures in the nonoperative, open reduction internal fixation (ORIF), and distal ulna resection groups, respectively. Descriptive statistics including weighted mean values, standard deviations, and 95% confidence intervals were calculated. CONCLUSIONS: The treatment of VDUFs with nonoperative management, ORIF, or distal ulna resection may all be acceptable treatment options in specific patient populations. Nonoperative management of VDUFs is a promising treatment strategy even for complex fracture patterns in patients 65 years of age or older. Despite higher reoperation rates, ORIF may be considered for the younger, high-demand patient. Distal ulna resection presents with very favorable functional outcomes in patients 65 years of age or older presenting with a complex VDUF with the lowest reoperation rate across all groups. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-Term Survivorship of Cervical Spine Procedures; A Survivorship Meta-Analysis and Meta-Regression.

STUDY DESIGN: Systematic Review. OBJECTIVES: To conduct a meta-analysis on the survivorship of commonly performed cervical spine procedures to develop survival function curves for (i) second surgery at any cervical level, and (ii) adjacent level surgery. METHODS: A systematic review of was conducted following PRISMA guidelines. Articles with cohorts of greater than 20 patients followed for a minimum of 36 months and with available survival data were included. Procedures included were anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (ADR), laminoplasty (LAMP), and posterior laminectomy and fusion (PDIF). Reconstructed individual patient data were pooled across studies using parametric Bayesian survival meta-regression. RESULTS: Of 1829 initial titles, 16 citations were included for analysis. 73 811 patients were included in the second surgery analysis and 2858 patients in the adjacent level surgery analysis. We fit a Log normal accelerated failure time model to the second surgery data and a Gompertz proportional hazards model to the adjacent level surgery data. Relative to ACDF, the risk of second surgery was higher with ADR and PDIF with acceleration factors 1.73 (95% CrI: 1.04, 2.80) and 1.35 (95% CrI: 1.25, 1.46) respectively. Relative to ACDF, the risk of second surgery was lower with LAMP with deceleration factor .06 (95% CrI: .05, .07). ADR decreased the risk of adjacent level surgery with hazard ratio .43 (95% CrI: .33, .55). CONCLUSIONS: In cases of clinical equipoise between fusion procedures, our analysis suggests superior survivorship with anterior procedures. For all procedures, laminoplasty demonstrated superior survivorship.

Differential characteristics and management of pseudoseptic arthritis following hyaluronic acid injection is a rare complication: a systematic review.

IMPORTANCE: Acute pseudoseptic arthritis is a rare complication of hyaluronic acid (HA) injections that is not well documented in the literature. Practitioners initially suspect the symptoms of this complication to represent septic arthritis, cautiously prescribing antibiotics. This review identifies that time to presentation of symptoms postinjection, negative cell cultures and lack of crystallisation could be used as differentials to suspect pseudoseptic arthritis and to prescribe anti-inflammatory drugs while closely monitoring change of symptoms. OBJECTIVE: The purpose of this study was to describe the presentation, diagnosis and treatment of pseudoseptic arthritis. EVIDENCE REVIEW: A systematic review of the literature was conducted for studies reporting the use of HA injections for osteoarthritis resulting in pseudoseptic arthritis using the electronic databases MEDLINE, Embase and PubMed. Pertinent data were abstracted from the search yield. A unique case of a pseudoseptic reaction is also presented. FINDINGS: A total of 11 studies (28 cases), all of level IV and V evidence were included in this review. Reported cases of pseudoseptic arthritis in the literature present with severe joint pain (100%), effusion (100%), inability to weight-bear, functional impairment, and occasionally fever (22.2%). C reactive protein and erythrocyte sedimentation rate are generally elevated (71.4% and 85.7%, respectively), and leucocytosis above 10 000 was less common (50%). All reported cases in the literature identified aseptic growth on arthrocentesis, despite four cases (15.4%) reporting synovial leucocyte counts above 50 000. The presented case is the highest reported leucocyte count at 1 74 960 cells/mm3. CONCLUSIONS AND RELEVANCE: Acute pseudoseptic arthritis is rare, but a number of cases have been reported in the literature. A high degree of suspicion for pseudoseptic arthritis may be maintained in patients who present under 72 hours following HA injection. Initial antibiotic treatment, along with anti-inflammatory medications until cultures are confirmed to be negative at 5 days, is a cautious approach. However, the strength of this conclusion is limited by the few reported cases. Ultimately, this review is intended to inform practitioners of the symptoms, diagnosis and treatment of this complication, such that it could be safely differentiated from septic arthritis. LEVEL OF EVIDENCE: IV.

Athletes experience a high rate of return to sport following hip arthroscopy.

PURPOSE: The purpose of this systematic review was to evaluate the rate at which patients return to sport following arthroscopic hip surgery. METHODS: The databases MEDLINE, EMBASE, and PubMed were searched by two reviewers, and titles, abstracts, and full-text articles screened in duplicate. English language studies investigating hip arthroscopy with reported return to sport outcomes were included. A meta-analysis of proportions was used to combine the rate of return to sports using a random effects model. RESULTS: Overall, 38 studies with 1773 patients (72% male), with a mean age of 27.6 years (range 11-65) and mean follow-up of 28.1 months (range 3-144) were included in this review. The pooled rate of return to sport was: 93% [95% confidence interval (CI) = 87-97%] at any level of participation; 82% (95% CI = 74-88%) at preoperative level of sporting activity; 89% (95% CI = 84-93%) for competitive athletes; 95% (95% CI = 89-98%) in pediatric patients; and 94% (95% CI 89.2-98.0%) in professional athletes. There was significant correlation between a shorter duration of preoperative symptoms and a higher rate of return to sports (Pearson correlation coefficient = - 0.711, p = 0.021). CONCLUSION: Hip arthroscopy yields a high rate of return to sport, in addition to marked improvement in pain and function in the majority of patients. The highest rates of return to sport were noted in pediatric patients, professional athletes, and those with a shorter duration of preoperative symptoms. This study provides clinicians with evidence-based data on athletes' abilities to return to sport after arthroscopic hip surgery and identifies sub-populations with the highest rates of return to sport. LEVEL OF EVIDENCE: IV, systematic review of Level II-IV studies.

Risk of Stroke and Recurrence After AF Ablation in Patients With an Initial Event-Free Period of 12 Months.

INTRODUCTION: Because of the unclear prognostic effects of ablation of atrial fibrillation (AF), oral anticoagulation (OAC) is often continued after ablation even in asymptomatic patients. We sought to determine the frequency of stroke and AF recurrence in patients on and off therapeutic OAC 1 year after a successful AF ablation. METHODS AND RESULTS: Patients that underwent AF ablation and were free of AF 12 months after ablation were selected from our AF database. During follow-up (FU), patients were screened for recurrence of AF, changes in OAC or antiarrhythmic medication, and the occurrence of stroke or transient ischemic attack (TIA). A total of 398 patients (median age 60.7 years [50.8, 66.8], 25% female) were investigated. The median duration of FU was 529 (373, 111,3.5) days. OAC was discontinued in 276 patients (69.3%). During FU, 4 patients (1%) suffered from stroke and 55 patients (13.8%) experienced a recurrence of AF. Persistent AF was significantly associated with a greater chance of AF recurrence (49.1% vs. 26.8%; P = 0.001). Neither CHADS2 nor CHA2DS2-VASc-Score nor recurrence of AF were significantly different in patients with or without stroke. There was a trend toward a higher percentage of coronary artery disease among patients that experienced stroke (50% vs. 10%; P = 0.057). CONCLUSION: The overall risk of stroke and AF recurrence is low in patients with a recurrence free interval of at least 12 months after AF ablation. Of note, recurrence of AF was not associated with a higher risk of stroke in our study population.

Predictors for Progression of Atrial Fibrillation in Patients Awaiting Atrial Fibrillation Ablation.

BACKGROUND: Success rates of atrial fibrillation (AF) ablation have been shown to be significantly lower for patients with persistent AF. However, little is known about the risk factors predicting progression to persistent AF in patients awaiting AF ablation. METHODS: We performed a retrospective, single-centre investigation of patients with paroxysmal AF at the time of placement on the ablation waiting list. Patients were defined as having progressed if they had developed self-reported or electrocardiogram-recorded AF durations more than 7 days while awaiting ablation. After ablation, clinical visits at 3, 6, 9, 12, and 18 months were performed with a minimum of a 48-hour-Holter and electrocardiogram. Baseline characteristics including left atrial diameter (LA) and the HATCH score were analyzed by univariable and multivariable analysis for predicting progression to persistent AF. RESULTS: During a median waiting time of 9.7 (6.1, 14.2) months, 60 of 564 patients (11%) progressed to persistent AF. In patients who progressed, ablation took longer (180 [150, 249] minutes vs 157 [125, 210] minutes; P = 0.009) and was associated with a higher rate of recurrence after a median of 12 months (53.3% vs 39.1%; P < 0.001). The HATCH score was a poor predictor of AF progression (area under the curve 0.54), whereas an LA diameter of more than 45 mm (odds ratio 3.46, P < 0.001) and heart failure (odds ratio 3.11, P = 0.036) were strong and independent predictors of AF progression in multivariable analysis. CONCLUSIONS: Patients with an increased LA diameter or heart failure have a significantly increased risk of progression to persistent AF. These characteristics may define patients who should undergo earlier catheter ablation to optimize outcome.

Substrate-guided ablation of haemodynamically tolerated and untolerated ventricular tachycardia in patients with structural heart disease: effect of cardiomyopathy type and acute success on long-term outcome.

AIMS: The purpose of this study was to evaluate the outcomes of purely substrate-guided ventricular tachycardia (VT) ablation in patients with non-ischaemic dilated cardiomyopathy (NIDCM) and ischaemic cardiomyopathy (ICM) and the impact of acute procedural success on long-term outcome. METHODS AND RESULTS: One hundred and forty-two patients (65 ± 12 years old, 72% male) with ICM (n = 87) and with NIDCM (n = 55) underwent substrate-guided VT ablation. The ablation approach involved eliminating all LP regions and ablating all scar border zone regions with 10 or more out of 12 pace-matching. All patients were followed with regular implantable defibrillator interrogations for mean 641 ± 301 days. Complete acute success (no inducible VT) was achieved in 60 patients with ICM (69%) and in 29 patients with NIDCM (53%) (P = 0.03). Partial success (elimination of clinical VT only) was obtained in nine patients with ICM (10%) and in four patients with NIDCM (7%) (P = 0.14). Procedural failure (clinical VT still inducible) occurred in 18 patients within the ICM group (21%) and in 22 patients of the NIDCM (40%) (P = 0.04). Overall, 51 patients presented with recurrence of ventricular arrhythmias: 23 in the group with ICM (26%) and 28 in the group with NIDCM (51%) (P = 0.03). Long-term success was related to acute procedural outcome. CONCLUSIONS: Substrate-guided ablation is an effective approach in the treatment of VT with long-term outcome directly related to acute procedural success. Success rates are significantly lower in patients with NIDCM compared with those with ICM.

Comparison of outcomes after cardioversion or atrial fibrillation ablation in patients with differing periprocedural anticoagulation regimens.

BACKGROUND: There is a paucity of data that compare traditional vitamin K antagonist (VKA) with novel oral anticoagulant regimens in periprocedural management of cardioversion or ablation of atrial fibrillation (AF). We sought to compare outcomes of use of VKA, dabigatran (DABI), and rivaroxaban (RIVA) anticoagulation around the time of intervention. METHODS: We studied consecutive patients undergoing cardioversion or ablation of AF at our centre from October 2010 to October 2013. There were 3 different anticoagulation groups: warfarin (VKA), DABI, and RIVA. Safety was assessed according to number of strokes, transient ischemic attacks (TIAs), and clinically important and not important bleeding events. RESULTS: Baseline characteristics were well balanced between the groups. Average follow-up was 6 months (± 4 months). A total of 901 patients who underwent cardioversion were studied (VKA [n = 471], DABI [n = 288] and RIVA [n = 141]). In these patients there were no strokes seen during follow-up and 2 TIAs in the DABI group. Bleeding rates were low, with no significant difference between the 3 groups. A total of 680 patients who underwent ablation were studied (VKA [n = 319], DABI [n = 220] and RIVA [n = 171]). There were no strokes reported during follow-up and 3 TIAs: 2 in the VKA group and 1 in the DABI group not resulting in a significant difference between the groups. Bleeding rates were low, with no significant difference between the groups. CONCLUSIONS: Overall, there was a low incidence of adverse events for all anticoagulation regimens. Warfarin, DABI, and RIVA use around the time of the procedure are safe and reasonable options for patients who undergo cardioversion or AF ablation.