The purpose of this meta-analysis was to determine overall objective graft failure rate, failure rate by graft type (allograft vs autograft reconstruction), instrumented laxity, and patient outcome ...scores following revision anterior cruciate ligament (ACL) reconstruction. Outcomes of interest were collected for all studies meeting the study inclusion criteria, but lower-level studies (level III/IV) were not pooled for quantitative synthesis due to high levels of heterogeneity in these study populations.
A comprehensive search strategy was performed to identify studies reporting outcomes of revision ACL reconstruction. The primary outcome reported was graft failure. A meta-analysis comparing rate of failure by graft type was conducted using a random effects model. Studies also reported patient clinical outcome scores, including International Knee Documentation Committee (IKDC), Lysholm, and knee injury and osteoarthritis outcome scores (KOOS) and graft laxity.
Eight studies with 3,021 patients (56% male, 44% female) with an average age of 30 ± 4 years and mean follow-up time of 57 months were included. The overall objective failure rate was 6% (95% confidence interval CI, 1.8%-12.3%). Mean instrumented laxity as side-to-side difference was 2.5 mm (95% CI, 1.9-3.1 mm). Mean IKDC subjective score was 76.99 (95% CI, 76.64-77.34), mean KOOS symptoms score was 76.73 (95% CI, 75.85-77.61), and mean Lysholm score was 86.18 (95% CI, 79.08-93.28). The proportion of patients with IKDC grade A or B was 85% (95% CI, 77%-91%). When the available data for failure rate were analyzed by graft type, autograft reconstruction had a failure rate of 4.1% (95% CI, 2.0%-6.9%), similar to allograft reconstruction at 3.6% (95% CI, 1.4%-6.7%).
In this meta-analysis, revision ACL reconstruction had failure rates similar to autograft or allograft reconstruction. Overall outcome scores for revision reconstruction have improved but appear modest when compared with primary ACL reconstruction surgery.
Meta-analysis of Level II studies, Level II.
Loss of anterior tilt after a distal radial fracture can lead to carpal malalignment, which may cause functional impairment. The aim of this study was to establish whether distal radial osteotomy for ...malunion, which primarily restores the dorsal tilt, will also improve carpal malalignment as measured by capitate shift. Radiographs of 67 patients who underwent osteotomy after malunion of a distal radial fracture were reviewed. Measurements of capitate shift and dorsal tilt were recorded. Linear regression modelling was used to assess the relationship between dorsal tilt and capitate shift. Change in capitate shift was strongly associated with change in dorsal tilt following osteotomy. This relationship was maintained on long-term radiographs. Capitate shift is strongly related to dorsal tilt following a distal radial fracture. Correcting the dorsal tilt during an osteotomy, therefore, will improve capitate shift and carpal malalignment. Capitate shift is unrelated to age, sex and is easy to visually assess.
Level of evidence: IV
Distal radial fractures are the most common adult orthopaedic fracture. We sought to determine whether the incidence of this injury is changing and identify trends in its occurrence. We analysed data ...for all adult patients presenting to University Hospitals of Leicester with a distal radial fracture from 2007–2016. Incidence rates were calculated using United Kingdom population data. Poisson regression techniques were used to analyse weekly, seasonal and annual variation in fracture incidence. There was no significant change in average age or incidence of fracture. Increased incidence was associated with inclement weather conditions. Younger patients more commonly sustain fractures on weekends. We predict a 23% rise in the number of fractures in the United Kingdom in the next 20 years. The incidence of fracture does not appear to be changing, although the number of fractures is growing. Weekly and seasonal trends are apparent.
Level of evidence: III
We sought to establish whether carpal and cubital tunnel syndrome requiring surgery is associated with deprivation in England. Data from 10,496 adult patients who were treated in our hand unit over a ...20-year period were reviewed. The Index of Multiple Deprivation was used to measure deprivation from the patients’ postcode. The mean age at surgery in the most deprived three quintiles was significantly lower than in the least deprived two quintiles for carpal tunnel release (55 vs 59 years, respectively) and cubital tunnel release (52 vs 57 years, respectively). The incidence rate was significantly lower for the three least deprived quintiles when compared with the most deprived quintile for both conditions. The incidence rate ratio of the least deprived quintile compared with the most deprived quintile for carpal tunnel release was 0.70 for men and 0.76 for women. The incidence rate ratio of the least deprived quintile compared with the most deprived quintile for cubital tunnel release was 0.79 for men and 0.49 for women. Carpal tunnel and cubital tunnel syndrome requiring surgery is more common in deprived patients and occurs at an earlier age.
Level of evidence: IV
Carpal malalignment after a distal radial fracture occurs due to loss of volar tilt. Several studies have shown that this has an adverse influence on function. We aimed to investigate the magnitude ...of dorsal tilt that leads to carpal malalignment, whether reduction of dorsal tilt will correct carpal malalignment, and which measure of carpal malalignment is the most useful.
Radiographs of patients with a distal radial fracture were prospectively collected and reviewed. Measurements of carpal malalignment were recorded on the initial radiograph, the radiograph following reduction of the fracture, and after a further interval. Linear regression modelling was used to assess the relationship between dorsal tilt and carpal malalignment. Receiver operating characteristic (ROC) analysis was used to identify which values of dorsal tilt led to carpal malalignment.
A total of 250 consecutive patients with 252 distal radial fractures were identified. All measures of carpal alignment were significantly associated with dorsal tilt at each timepoint. This relationship persisted after adjustment for age, sex, and the position of the wrist. Capitate shift consistently had the strongest relationship with dorsal tilt and was the only parameter that was not influenced by age or the position of the wrist. ROC curve analysis identified that abnormal capitate shift was seen with > 9° of dorsal tilt.
Carpal malalignment is related to dorsal tilt following a distal radial fracture. Reducing the fracture and improving dorsal tilt will reduce carpal malalignment. Capitate shift is easy to assess visually, unrelated to age and sex, and appears to be the most useful measure of carpal malalignment. The aim during reduction of a distal radial fracture should be to realign the capitate with the axis of the radius and prevent carpal malalignment. Cite this article:
2020;102-B(1):137-143.
Social deprivation has been shown to be associated with increased incidence of many types of fracture but the causes for this have not been established. The aim of this study was to establish if ...distal radius fracture was associated with deprivation and investigate reasons for this.
Data was reviewed of 4463 adult patients who attended our Emergency Department over a four year period. The Index of Multiple Deprivation was used to measure deprivation for each patient. Modelling techniques were used to investigate the relationship between fracture rate and deprivation, gender, ethnicity and age.
Distal radius fracture rate was higher for patients in more deprived quintiles. Mean age in the most deprived two quintiles was 54.4 years compared to 60.1 years in the least deprived three quintiles. Modelling showed important differences between ethnic groups. Deprivation was an independent risk factor for distal radius fracture only in white patients. Deprived white women had a lower second metacarpal cortical index than women of other ethnicities suggesting increased bone fragility. Being male is a risk factor for fracture when deprivation, ethnicity and age are taken into account. Incidence rate ratio of the least deprived quintile compared to the most deprived was 0.33 (95% CI: 0.30–0.37) for white men and 0.47 (95% CI: 0.44–0.49) for white women.
Effective interventions exist to prevent further fragility fracture and this work allows geographical areas at risk to be identified. Presentation with a distal radius fracture provides an opportunity to implement interventions. In the current economic climate resources are scarce and must be used prudently. Resources should be targeted to those at risk patients from deprived areas and preventative strategies put in place.
•Social deprivation is strongly associated with distal radius fracture incidence•Deprived patients sustained their injuries at an earlier age•Modelling showed deprivation was a risk factor for distal radius fracture only in white patients•Deprivation has a larger effect on incidence of distal radius fracture in men
The relationship between surgery for cubital tunnel and carpal tunnel syndrome was examined in this retrospective study. Between 1997 and 2018, data from consecutive patients who underwent carpal ...tunnel release (8352 patients), cubital tunnel release (1681 patients) or both procedures (692 patients) were analysed. The relative risk of undergoing cubital tunnel release in the population who had carpal tunnel release compared with those with no carpal tunnel release was 15.3 (male 20.3; female 12.5). The relative risk of undergoing carpal tunnel release in the population who had cubital tunnel release compared with those who did not undergo carpal tunnel release was 11.5 (male 16.5; female 9.1). Our study showed that men and women who undergo carpal tunnel release are over 20 times and 10 times more likely to have cubital tunnel release than those who did not undergo carpal tunnel release, respectively. These findings suggest that the two conditions may share a similar aetiology.
Level of evidence: IV
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