The coronavirus disease 2019 pandemic has resulted in a rapid pivot toward telemedicine owing to closure of in-person elective clinics and sustained efforts at physical distancing worldwide. ...Throughout this period, there has been revived enthusiasm for delivering and receiving orthopaedic care remotely. Unfortunately, rapidly published editorials and commentaries during the pandemic have not adequately conveyed findings of published randomized trials on this topic.
In this systematic review and meta-analysis of randomized trials, we asked: (1) What are the levels of patient and surgeon satisfaction with the use of telemedicine as a tool for orthopaedic care delivery? (2) Are there differences in patient-reported outcomes between telemedicine visits and in-person visits? (3) What is the difference in time commitment between telemedicine and in-person visits?
In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review with the primary objective to determine patient and surgeon satisfaction with telemedicine, and secondary objectives to determine differences in patient-reported outcomes and time commitment. We used combinations of search keywords and medical subject headings around the terms "telemedicine", "telehealth", and "virtual care" combined with "orthopaedic", "orthopaedic surgery" and "randomized." We searched three medical databases (MEDLINE, Embase, and the Cochrane Library) in duplicate and performed manual searches to identify randomized controlled trials evaluating the outcomes of telemedicine and in-person orthopaedic assessments. Trials that studied an intervention that was considered to be telemedicine (that is, any form of remote or virtual care including, but not limited to, video, telephone, or internet-based care), had a control group that comprised in-person assessments performed by orthopaedic surgeons, and were reports of Level I original evidence were included in this study. Studies evaluating physiotherapy or rehabilitation interventions were excluded. Data was extracted by two reviewers and quantitative and qualitive summaries of results were generated. Methodological quality of included trials was assessed using the Cochrane Risk of Bias tool, which uniformly rated the trials at high risk of bias within the blinding categories (blinding of providers, patients, and outcome assessors). We screened 133 published articles; 12 articles (representing eight randomized controlled trials) met the inclusion criteria. There were 1008 patients randomized (511 to telemedicine groups and 497 to control groups). Subspecialties represented were hip and knee arthroplasty (two trials), upper extremity (two trials), pediatric trauma (one trial), adult trauma (one trial), and general orthopaedics (two trials).
There was no difference in the odds of satisfaction between patients receiving telemedicine care and those receiving in-person care (pooled odds ratio 0.89 95% CI 0.40 to 1.99; p = 0.79). There were also no differences in surgeon satisfaction (pooled OR 0.38 95% CI 0.07 to 2.19; p = 0.28) or among multiple patient-reported outcome measures that evaluated pain and function. Patients reported time savings, both when travel time was excluded (17 minutes shorter 95% CI 2 to 32; p = 0.03) and when it was included (180 minutes shorter 95% CI 78 to 281; p < 0.001).
Evidence from heterogeneous randomized studies demonstrates that the use of telemedicine for orthopaedic assessments does not result in identifiable differences in patient or surgeon satisfaction compared with in-person assessments. Importantly, the source studies in this review did not adequately capture or report safety endpoints, such as complications or missed diagnoses. Future studies must be adequately powered to detect these differences to ensure patient safety is not compromised with the use of telemedicine. Although telemedicine may lead to a similar patient experience, surgeons should maintain a low threshold for follow-up with in-person assessments whenever possible in the absence of further safety data.
Level I, therapeutic study.
Adhesive surgical drapes are purported to reduce the rates of surgical site infection. Despite that, international surgical guidelines generally recommend against the use of such drapes; however, ...this is primarily based on nonorthopaedic evidence.
(1) Does the use of adhesive drapes decrease the risk of wound contamination? (2) Does intraoperative drape peeling (intentional or inadvertent) increase the risk of wound contamination? (3) Does the use of adhesive drapes decrease the risk of surgical site infection?
A systematic review of the MEDLINE and Embase databases was performed according to the Cochrane Handbook methods for randomized controlled trials (RCTs) published since 2000 and comparing adhesive drapes with controls. All databases were searched from inception to March 1, 2021. A pooled meta-analysis was performed, where possible. The Cochrane Risk of Bias Assessment Tool was used to assess risk of bias among the included studies. From among 417 search results, five eligible RCTs were identified and included, all of which were published between 2018 and 2020. There were a total of 2266 patients, with 1129 (49.8%) in the adhesive drape groups, and 1137 (50.2%) in the control groups. The studies included hip and knee surgery trials (n = 3 trials; 1020 patients in intervention groups and 1032 patients in control groups) as well as trials on shoulder arthroscopy (n = 1 trial; 65 patients in the intervention group and 61 patients in the control group) and lumbar spine surgery (n = 1 trial; 44 patients in each group). The data for all three outcomes (wound contamination, impact of intraoperative peeling, and surgical site infection) revealed low heterogeneity based on random-effects models (I2 = 14%, 0%, and 0%, respectively).
Based on data from pooled wound swab culture results from four studies, a reduction in wound contamination was associated with the use of adhesive drapes (odds ratio 0.49 95% CI 0.34 to 0.72; p < 0.001). The available evidence was inconclusive to determine whether intraoperative drape peeling (intentional or inadvertent) influenced the risk of wound contamination. Three studies did not report on this outcome, one study found an increased infection rate with drape peel back, and another study found a reduced treatment effect of adhesive drapes when peel back occurred in a subgroup analysis. The two studies that analyzed surgical site infections reported no infections in either arm; therefore, we could not answer the question of whether adhesive drapes affect risk of surgical site infection.
The findings of this review suggest that adhesive drapes, including those with antimicrobial properties, decrease the risk of wound contamination during orthopaedic procedures. In circumstances where drape adhesion is compromised and peel back occurs at the wound edge, there is an increased risk of wound contamination with the use of adhesive drapes. The best currently available evidence is indeterminate as to the effect of adhesive drapes on the risk of surgical site infections; however, if used, care should be taken to avoid or minimize drape peel back.
Level I, therapeutic study.
There have been a growing number of landmark randomized controlled trials published in the orthopedic literature over the past decade. These large-scale trials have had a substantial impact on ...informing clinical orthopedic practice globally. This review highlights a selected sample of such pivotal trials, across the subspecialties of trauma, sports medicine, arthroplasty, spine, and the important topic of intimate partner violence.
Abstract
Purpose
Kneeling ability is among the poorest outcomes following total knee arthroplasty (TKA). The purpose of this meta-analysis was to: (1) quantify kneeling ability after TKA; (2) ...identify surgical approaches and prosthesis designs that improve kneeling ability following TKA; and (3) quantify the effectiveness of these approaches.
Methods
We performed a systematic review in accordance with the PRISMA guidelines of multiple medical databases. Data relating to demographics, TKA technique, prosthesis design, and kneeling-specific outcomes were extracted. Comparative outcomes data were pooled using a random effects model.
Results
Thirty-six studies met the eligibility criteria. The proportion of patients able to kneel increased with longer follow-up (36.8% at a minimum of 1 year follow-up versus 47.6% after a minimum of 3 years follow-up,
p
< 0.001). The odds of kneeling were greater for patients undergoing an anterolateral incision compared with an anteromedial incision (OR 3.0, 95% CI 1.3–6.9,
p
= 0.02); a transverse incision compared with a longitudinal incision (OR 3.5, 95% CI 1.4–8.7,
p
= 0.008); and a shorter incision compared with a longer incision (OR 8.5, 95% CI 2.3–30.9,
p
= 0.001). The odds of kneeling were worse for a mobile prosthesis compared with a fixed platform design (OR 0.3, 95% CI 0.1–0.7,
p
= 0.005).
Conclusion
A large majority of patients are unable to kneel following TKA, although the ability to kneel improves over time. This evidence may facilitate preoperative patient counseling. Variations in choice of incision location and length may affect ability to kneel; however, high-quality randomized trials are needed to corroborate our findings.
Background
Open tibial shaft fractures are one of the most devastating orthopaedic injuries. Surgical treatment options include reamed or unreamed nailing, plating, Ender nails, Ilizarov fixation, ...and external fixation. Using a network meta-analysis allows comparison and facilitates pooling of a diverse population of randomized trials across these approaches in ways that a traditional meta-analysis does not.
Questions/purposes
Our aim was to perform a network meta-analysis using evidence from randomized trials on the relative effect of alternative approaches on the risk of unplanned reoperation after open fractures of the tibial diaphysis. Our secondary study endpoints included malunion, deep infection, and superficial infection.
Methods
A network meta-analysis allows for simultaneous consideration of the relative effectiveness of multiple treatment alternatives. To do this on the subject of surgical treatments for open tibial fractures, we began with systematic searches of databases (including EMBASE and MEDLINE) and performed hand searches of orthopaedic journals, bibliographies, abstracts from orthopaedic conferences, and orthopaedic textbooks, for all relevant material published between 1980 and 2013. Two authors independently screened abstracts and manuscripts and extracted the data, three evaluated the risk of bias in individual studies, and two applied Grading of Recommendation Assessment, Development and Evaluation (GRADE) criteria to bodies of evidence. We included all randomized and quasirandomized trials comparing two (or more) surgical treatment options for open tibial shaft fractures in predominantly (ie, > 80%) adult patients. We calculated pooled estimates for all direct comparisons and conducted a network meta-analysis combining direct and indirect evidence for all 15 comparisons between six stabilization strategies. Fourteen trials published between 1989 and November 2011 met our inclusion criteria; the trials comprised a total of 1279 patients surgically treated for open tibial shaft fractures.
Results
Moderate confidence evidence showed that unreamed nailing may reduce the likelihood of reoperation compared with external fixation (network odds ratio OR, 0.38; 95% CI, 0.23–0.62; p < 0.05), although not necessarily compared with reamed nailing (direct OR, 0.74; 95% CI, 0.45–1.24; p = 0.25). Only low- or very low-quality evidence informed the primary outcome for other treatment comparisons, such as those involving internal plate fixation, Ilizarov external fixation, and Ender nailing. Method ranking based on reoperation data showed that unreamed nailing had the highest probability of being the best treatment, followed by reamed nailing, external fixation, and plate fixation. CIs around pooled estimates of malunion and infection risk were very wide, and therefore no conclusive results could be made based on these data.
Conclusion
Current evidence suggests that intramedullary nailing may be superior to other fixation strategies for open tibial shaft fractures. Use of unreamed nails over reamed nails also may be advantageous in the setting of open fractures, but this remains to be confirmed. Unfortunately, these conclusions are based on trials that have had high risk of bias and poor precision. Larger and higher-quality head-to-head randomized controlled trials are required to confirm these conclusions and better inform clinical decision-making.
Level of Evidence
Level I, therapeutic study.
Patients with a high body-mass index (BMI) are at increased risk for significant complications after total knee arthroplasty (TKA). We explored whether operative time is a modifiable risk factor for ...infectious and thromboembolic complications.
A retrospective observational cohort study of the ACS-NSQIP registry, including all patients who underwent primary TKA (2015-2018), and were morbidly obese (BMI 40 kg/m
or greater) was performed. We created four categories of operative time in minutes: less than 60, 60-90, 91-120, and greater than 120. The association of prolonged operative time with superficial/deep surgical site infection (SSI), DVT and PE within 30 days postoperatively was evaluated using multivariate logistic regression.
34,190 patients were included (median age 63 IQR 57-68, mean BMI of 44.6 kg/m
SD 4.4). The majority of patients had an operative time between 60-90 mins (n = 13,640, 39.9%) or 91-120 mins (n = 9908, 29.0%). There was no significant association between longer operative time and superficial/deep/organ-space SSI or PE. DVT risk was significantly increased. Patients with time exceeding 120 mins had nearly 2.5 greater odds of DVT compared to less than 60 minutes (OR 2.47, 95% CI: 1.39-4.39, P = 0.002). Odds of DVT were 1.73 times greater in those with time of 91-120 mins (OR 1.73, 95%CI: 0.98-3.05, P = 0.06).
Early infection and thromboembolic complications with prolonged operative time in morbidly obese patients remain low. We did not identify a significant association with increased operative time and superficial/deep SSI, or PE. There was a significantly increased risk for deep vein thrombosis with prolonged operative time.
Aims:
The objective of this review was to examine the relationship between osteoarthritis (OA) and mobility-related comorbidities, specifically diabetes mellitus (DM) and cardiovascular disease ...(CVD). It also investigated the relationship between OA and mortality.
Methods:
An overview of meta-analyses was conducted by performing two targeted searches from inception to June 2020. The association between OA and (i) DM or CVD (via PubMed and Embase); and (ii) mortality (via PubMed) was investigated. Meta-analyses were selected if they included studies that examined adults with OA at any site and reported associations between OA and DM, CVD, or mortality. Evidence was synthesized qualitatively.
Results:
Six meta-analyses met inclusion criteria. One meta-analysis of 20 studies demonstrated a statistically significant association between OA and DM, with pooled odds ratio of 1.41 (95% confidence interval: 1.21, 1.65; n = 1,040,175 patients). One meta-analysis of 15 studies demonstrated significantly increased risk of CVD among OA patients, with a pooled risk ratio of 1.24 (1.12, 1.37, n = 358,944 patients). Stratified by type of CVD, OA was shown to be associated with increased heart failure (HF) and ischemic heart disease (IHD) and reduced transient ischemic attack (TIA). There was no association reported for stroke or myocardial infarction (MI). Three meta-analyses did not find a significant association between OA (any site) and all-cause mortality. However, OA was found to be significantly associated with cardiovascular-related death across two meta-analyses.
Conclusion:
The identified meta-analyses reported significantly increased risk of both DM and CVD (particularly, HF and IHD) among OA patients. It was not possible to confirm consistent directional or causal relationships. OA was found to be associated with increased mortality, but mostly in relation to CVD-related mortality, suggesting that further study is warranted in this area.
Background
Infection is a truly devastating complication of total joint arthroplasty, causing most patients to undergo a revision surgery, and to bear significant psychological and financial burden. ...The purpose of this study is to systematically evaluate the literature to determine the efficacy and complication profile of local antibiotic application in primary total joint arthroplasty.
Methods
All studies of primary total joint arthroplasty which assessed local antibiotics in any form other than antibiotic-impregnated cement as an intervention were included. Studies that reported at least one outcome related to infection and were available in full text in English were eligible for inclusion. Studies which included both primary and revision cases but did not report the stratified data for each type of surgery and studies on fracture populations were excluded.
Results
A total of 9 studies involving 3,714 cases were included. The pooled deep infection rate was 1.6% in the intervention groups and 3.5% in the control groups. Meta-analysis revealed a RR of 0.53 (95%CI: 0.35–0.79, p = 0.002) with no heterogeneity (I
2
= 0%) for infection in the intervention groups. Meta-analysis revealed a non-significant reduction in superficial infection rates in the intervention groups; however, there was a significant increase in aseptic wound complications in the intervention groups.
Conclusion
Local antibiotic application results in a moderate reduction in deep infection rates in primary total joint arthroplasty, with no significant impact on superficial infection rates. However, local antibiotic application may be associated with a moderate increase in aseptic wound complications.
Purpose. Medical cannabis for patients with chronic noncancer pain (CNCP) has been the focus of numerous health care recommendations. We conducted a systematic review to identify and summarize the ...currently available evidence-based recommendations. Methods. We searched MEDLINE, EMBASE, PsycINFO, the Cochrane database of systematic reviews, and websites for clinical guidelines and recommendations. We summarized the type of the publications, developers, approach of health care recommendation development, year and country of publication, and conditions that were addressed. We categorized the direction and strength of each recommendation. Results. We identified 12 eligible publications. Publication years ranged from 2007 to 2019; four (33.3%) of them were published in 2018. Canada ranked first for the number of publications (n = 4, 33.3%). Most (n = 11, 92%) of the included recommendations were based on both a systematic review of the best evidence and expert consensus. All the included publications provided a recommendation supporting medical cannabis for CNCP in general and for the specific conditions of neuropathic pain, chronic pain in people living with Human Immunodeficiency Virus (HIV), and chronic abdominal pain, with detailed information sharing and comprehensive consideration of a patient’s own values and preferences. Conclusion. Clinicians can attend to the guidance currently offered, being aware that only weak recommendations are available for medical cannabis in patients with CNCP, as a third- or fourth-line therapy. Detailed discussions with patients regarding the benefits in reducing pain and potential adverse effects are required before its prescription.
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