As a result of the coronavirus disease 2019 (COVID-19) pandemic, tele-health for orthopedic care ... more As a result of the coronavirus disease 2019 (COVID-19) pandemic, tele-health for orthopedic care is expanding rapidly. The authors sought to identify the evidence describing the effectiveness, barriers, and clinical applications of telehealth for orthopedic assessments and consultations. MEDLINE, PubMed, EMBASE, and the Cochrane Library were searched from inception to March 2020. Forty-seven studies were included, with the most common conditions evaluated being trauma related and the primary modality being videoconferencing. Available literature supports the use of telehealth for orthopedic consultations and assessments because it yields moderate-to-high patient and provider satisfaction, accurate examinations, cost-effectiveness, and reduced wait times. Most commonly reported concerns were professional liability, network security, and technical issues. Given the COVID-19 pandemic, rapid implementation and uptake of virtual assessment for patient care has occurred. The current evide...
Context:The opioid epidemic has been well-documented in the general population, but the literatur... more Context:The opioid epidemic has been well-documented in the general population, but the literature pertaining to opioid use and misuse in the athletic population remains limited.Objectives:The objectives of this study were to seek answers to the following questions: (1) what are the rates of opioid use and misuse among athletes, (2) do these rates differ compared with the nonathletic population, and (3) are there specific subgroups of the athletic population (eg, based on sport, level of play) who may be at higher risk?Data Sources:The Embase, MEDLINE, and PubMed were used for the literature search.Study Selection:Records were screened in duplicate for studies reporting rates of opioid use among athletes. All study designs were included.Study Design:Systematic review.Level of Evidence:Level 4.Data Extraction:Data regarding rates of opioid use, medication types, prescription patterns, and predictors of future opioid use were collected. Study quality was assessed using the Methodologi...
Introduction: Moderate to severe postoperative pain and associated opioid use may interfere with ... more Introduction: Moderate to severe postoperative pain and associated opioid use may interfere with patients' well-being and course of recovery. Regional anesthetic techniques provide an opportunity for opioid sparing and improved patient outcomes. A new regional technique called the erector spinae plane (ESP) block has the potential to provide effective analgesia after shoulder arthroscopy with minimal risks and decreased opioid consumption. Our primary objective is to determine whether, in patients who undergo arthroscopic shoulder surgery, a preoperative ESP block reduces pain scores as compared to periarticular infiltration at the end of surgery. Additionally, we will also examine other factors such as opioid consumption, sensory block, adverse events, patient satisfaction, and persistent pain. Methods: This is a 2-arm, single-center, parallel-design, double-blind randomized controlled trial of 60 patients undergoing arthroscopic shoulder surgery. Eligible patients will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomized to either the ESP or periarticular infiltration group. Patients will be followed in hospital in the postanesthesia care unit, at 24 hours, and at 1 month. The study with be analyzed as intention-to-treat. Discussion: This study will inform an evidence-based choice in recommending ESP block for shoulder arthroscopy, as well as providing safety data. The merits of the study include its double dummy blinding to minimize observer bias, and its assessment of patient important outcomes, including pain scores, opioid consumption, and patient satisfaction. This study will also help provide an estimate of the incidence of side effects and complications of the ESP block.
BACKGROUND Stemless anatomic total shoulder arthroplasty (TSA) is used in the treatment of osteoa... more BACKGROUND Stemless anatomic total shoulder arthroplasty (TSA) is used in the treatment of osteoarthritis of the shoulder joint and other degenerative shoulder diseases. It has several proposed advantages over stemmed TSA including increased bone preservation, decreased operative time, and easier removal at revision. METHODS A systematic search was conducted using MEDLINE, Embase, PubMed, and CENTRAL (Cochrane Central Register of Controlled Trials) to retrieve all relevant studies. RESULTS The literature search yielded 1417 studies, of which 22 were included in this review, with 962 patients undergoing stemless TSA. Stemless TSA led to significant improvements in range of motion and functional scores in all included studies. Meta-analysis of comparative studies between stemless and stemmed TSA identified no significant differences in postoperative Constant scores (mean difference [MD], 1.26; 95% confidence interval [CI], -3.29 to 5.81 points; P = .59) or complication rates (odds ratio, 1.79; 95% CI, 0.71-4.54; P = .22). Stemless TSA resulted in a significantly shorter operative time compared with stemmed TSA (MD, -15.03 minutes; 95% CI, -23.79 to -6.26 minutes; P = .0008). Stemless TSA also resulted in significantly decreased intraoperative blood loss compared with stemmed TSA (MD, -96.95 mL; 95% CI, -148.53 to -45.36 mL; P = .0002). CONCLUSION Stemless anatomic TSA resulted in similar functional outcomes and complication rates to stemmed TSA with decreased operative time and lower blood loss. Further research is required to investigate the long-term durability of the stemless implant.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2020
Arthroscopy is a powerful tool in the management of the painful total shoulder arthroplasty and s... more Arthroscopy is a powerful tool in the management of the painful total shoulder arthroplasty and should be considered when evaluating cases in which a clear cause of pain is not present. Patients may present with a painful shoulder arthroplasty due to a number of causesdoccult infection, instability, component loosening, malposition, or rotator cuff pathology. In certain cases, advanced imaging may not be diagnostic, given the presence of metal artifact. It is our routine clinical practice to evaluate arthroscopically such cases in which the diagnosis is not readily evident. The most common indication for shoulder arthroscopy is pain with no clear cause or loss of motion (39%), followed by biopsy to rule out occult infection (25%), and finally rotator cuff assessment (19%).
Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine, 2018
ImportanceSuperior labrum from anterior to posterior (SLAP) pathology can result in significant p... more ImportanceSuperior labrum from anterior to posterior (SLAP) pathology can result in significant pain and functional limitation for a wide variety of patients. Although many different options have been described for the diagnosis and treatment of SLAP pathology, there is little high-quality evidence to support a given diagnosis/treatment method.ObjectiveThe aim of this study was to review the global demographics and trends of SLAP literature, diagnosis, management and consistency of reported outcomesEvidence reviewWe performed a systematic search for studies addressing SLAP pathology published over the last 10 years. Extracted data included sample size, study location, intervention, outcome measures reported, sex distribution and level of evidence. Management was compared between geographic areas.FindingsWe identified 363 studies reporting on SLAP management over the past decade that met our inclusion and exclusion criteria. The majority of studies originated from North America (50.4...
Background: Lower trapezius (LT) transfers were originally described to restore external rotation... more Background: Lower trapezius (LT) transfers were originally described to restore external rotation (ER) in the management of brachial plexus palsy; however, there is recent interest in the role of this transfer to restore shoulder function, specifically ER, in patients with a massive irreparable rotator cuff tear (RCT). The purpose of this systematic review is to summarize the current literature pertaining to LT transfers, including biomechanics, techniques, and clinical outcomes for patients with brachial plexus palsy and massive RCTs. Methods: MEDLINE, EMBASE, and PubMed were searched for biomechanical and clinical studies, as well as technique articles. Four biomechanical studies reported on moment arms, range of motion (ROM), and force vectors. Seven clinical studies reported postoperative ROM and functional outcomes, and weighted mean improvements in ROM were calculated. Results: Overall, 18 studies were included, and then subdivided into 3 themes: biomechanical, technique, and clinical. Biomechanical studies comparing LT and latissimus dorsi (LD) transfers observed an overall larger moment arm in abduction and ER in adduction for the LT transfer, with similar results in forward elevation. Clinical studies noted significant improvement in shoulder function following the LT transfer, including ROM and functional outcome scores. There were several described techniques for performing the LT transfer, including arthroscopically assisted and open approaches, and the use of both allograft and autograft augmentation. Conclusion: This study suggests that the LT transfer is generally safe, and the clinical and biomechanical data to date support the use of the LT transfer for restoration of function in these challenging patient populations.
Background: Superior labrum anterior to posterior (SLAP) tears are a very common shoulder injury.... more Background: Superior labrum anterior to posterior (SLAP) tears are a very common shoulder injury. The success rate of SLAP repair, particularly in the throwing athlete, has been variable in the literature. Questions/Purposes: The purpose of this systematic review was to evaluate the reported post-operative outcomes of management techniques for failed SLAP repair. Methods: The electronic databases MEDLINE, Embase, and PubMed were searched for relevant studies, and pertinent data was abstracted. Only studies reporting outcomes of management techniques for failed SLAP repairs were included. Results: A total of 10 studies (levels III to IV) evaluating 176 patients were included in this systematic review. Most subjects were male (86.6%), with a mean age at surgery of 36.3 years (range, 17 to 67 years). The most commonly reported reason for failed SLAP repair was persistent post-operative mechanical symptoms after index SLAP repair. Common techniques used in the management of failed SLAP repair include biceps tenodesis and revision SLAP repair. Return to activity was significantly higher after biceps tenodesis than after arthroscopic revision SLAP repair. However, compared to primary SLAP repair, biceps tenodesis demonstrated no statistically significant differences in return to work rates. Complications reported in one case were resolved post-operatively, and there was no reported revision failure or reoperation after revision surgery. Conclusion: The most common reason for failed SLAP repair is persistent postoperative mechanical symptoms. Revision surgery for failed SLAP repair has a high success rate. The rate of return to activity after biceps tenodesis was significantly higher than the rate after revision SLAP repair. Large high-quality randomized trials are required to provide definitive evidence to support the optimal treatment for failed SLAP repair.
Background: The number of total shoulder arthroplasties (TSAs) performed is increasing annually, ... more Background: The number of total shoulder arthroplasties (TSAs) performed is increasing annually, with a continued effort to improve outcomes using new techniques and materials. In anatomic TSAs, the main options for glenoid fixation currently involve keeled or pegged components. The aim of this review was to determine which fixation option provides optimal long-term functional outcomes with decreased rates of revision surgery and radiolucency. Methods: The MEDLINE, Embase, PubMed, and Cochrane databases were searched from 2007 to July 10, 2017, for all articles that examined TSAs using either pegged or keeled glenoid fixations. All studies were screened in duplicate for eligibility. Two separate analyses were completed examining noncomparative and comparative studies independently. Results: A total of 7 comparative studies and 25 noncomparative studies were included in the final analysis. Included in the analysis were 4 randomized (level I) studies, 1 level II study, 8 level III studies, and 19 level IV studies. Meta-analysis of the comparative studies demonstrated a higher rate of revision surgery with keeled fixations compared with pegged fixations (odds ratio, 6.22; 95% confidence interval [CI], 1.38-28.1; P ¼ .02). No significant difference was found with respect to functional outcomes, such as the American Shoulder and Elbow Surgeons score (mean difference, 9.54; 95% CI, e8.25 to 27.34; P ¼ .29) and Constant score (mean difference, 5.31; 95% CI, e12.28 to 22.89; P ¼ .55), as well as radiolucency rates (odds ratio, 1.89; 95% CI, 0.56À6.39; P ¼ .30). Conclusion: Pegged glenoid fixation may result in a decreased risk of revision TSAs, but no significant differences in patient-reported outcomes have been identified to date.
Objectives: Players in the National Basketball Association (NBA) subject their lower extremities ... more Objectives: Players in the National Basketball Association (NBA) subject their lower extremities to significant repetitive loading during the season as well as during off-season training. Little is known about the incidence and impact of lower extremity bony stress injuries in these athletes. Methods: Using the player injury database maintained by the NBA Players' Association, all bony stress injuries from 1992 to May 2016 were identified. Those not involving the lower extremity were excluded from the study. Stress fractures and stress reactions were grouped together. Number of games missed due to the injury as well as player statistics including points per game (ppg), assists per game (apg), steals per game (spg), and blocks per game (bpg) were collected from two years prior to the injury to two years after the injury. Results: 76 lower extremity bony stress injuries were identified involving 75 different NBA players with an average player age of 25.4 ± 4.1 years. 55.3% (42/76) involved the foot, 21.1% (16/76) involved the ankle or fibula, 17.1% (13/76) involved the tibia, and 6.6% (5/76) involved either the knee or patella. The majority of injuries occurred in season 82.9% (63/76) with half of the injuries occurring within the first 6 weeks of the season. 38.2% (29/76) of these injuries were managed surgically. An average of 25.1 ± 21.3 games were missed. 19.7% (15/76) of patients who sustained a stress fracture also had a subsequent injury. 29.2% (21/76) of players were not able to return to professional basketball after the season in which the injury was sustained; however, those who were able to return to the same level of play did not see a significant change in performance as measured by ppg, apg, spg, or bpg when comparing the season prior to the injury and either one or two years after the injury. Stress injuries to the foot carried the worst prognosis, 57.1% (12/21) of those unable to return to professional basketball sustained such an injury. Conclusion: While not extremely common in NBA players, lower extremity bony stress injuries may be careerending. However, if they are able to return to the NBA following this injury, then their level of play should return to their pre-injury level.
Clinical orthopaedics and related research, Jan 9, 2016
We are pleased to publish the next installment of Cochrane in CORR 1 , our partnership between CO... more We are pleased to publish the next installment of Cochrane in CORR 1 , our partnership between CORR 1 , The Cochrane Collaboration 1 , and McMaster University's Evidence-Based Orthopaedics Group. In this column, researchers from McMaster University and other institutions will provide expert perspective on an abstract originally published in The Cochrane Library that we think is especially important.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2015
The purpose of this systematic review was to evaluate the anatomic structure and function of the ... more The purpose of this systematic review was to evaluate the anatomic structure and function of the anterolateral ligament (ALL) of the knee. Methods: The Medline, Embase, and Cochrane databases were screened for all studies related to the ALL of the knee. Two reviewers independently reviewed all eligible articles and the references of these articles. Inclusion and exclusion criteria were applied to all searched studies. Quality assessment was completed for the included studies. Results: Nineteen studies were identified for final analysis. Pooled analysis identified the ALL in 430 of 449 knees (96%) examined. The ligament was found to originate from the region of the lateral femoral epicondyle and insert on the proximal tibia midway between the Gerdy tubercle and the fibular head. The ALL was found to be 34.1 to 41.5 mm in length, 5.1 to 8.3 mm in width above the lateral meniscus, and 8.9 to 11.2 mm in width below the lateral meniscus. By use of magnetic resonance imaging, the ALL was identified in 93% of knees examined (clinical, 64 of 70; cadaveric, 16 of 16). In one case study the ligament was clearly visualized by ultrasound examination. Histologic analysis across 3 studies showed characteristics consistent with ligamentous tissue. Though not shown in biomechanical studies, it is hypothesized that the ALL provides anterolateral stability to the knee, preventing anterolateral subluxation of the proximal tibia on the femur. One study identified a network of peripheral nerves, suggesting a proprioceptive function of the ALL. Conclusions: This systematic review shows the ALL to be a distinct structure with a consistent origin and insertion sites. The ALL is an extra-articular structure with a clear course from the lateral femoral epicondyle region, running anteroinferiorly, to the proximal tibia at a site midway between the Gerdy tubercle and the head of the fibula. The function of this ligament is theorized to provide anterolateral knee stability. Level of Evidence: Level IV, systematic review of cadaveric and imaging studies.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2014
The purpose of this study was to review the global pattern of surgical management of femoroacetab... more The purpose of this study was to review the global pattern of surgical management of femoroacetabular impingement (FAI), particularly in diagnosis, outcome measurement, and management. Methods: We performed a systematic search in duplicate for surgical studies addressing FAI published up to June 2013. Study parameters, including sample size, study location, surgical intervention technique, diagnostic imaging, outcome measures used, sex distribution, and level of evidence, were obtained. The number of trials and cumulative sample size were analyzed. The surgical interventions, sex distribution, outcome measures, and diagnostic imaging used were compared between geographic regions. Results: We identified 105 studies reporting surgical interventions for FAI. Most studies were completed in North America (52 studies, 3,629 patients) and in Europe (44 studies, 3,745 patients). Asia (3 studies, 49 patients) and Oceania (6 studies, 394 patients) had smaller contributions. There were no studies from South America or Africa. Most research performed in North America, Europe, and Oceania investigated arthroscopic FAI surgery (55% of studies) followed by surgical dislocation (33%), and miniopen (15%) and combined approaches (8%). Methods of diagnosis were consistent worldwide, with radiography being the mainstay of diagnosis (84% of studies). Case series were the most common type of study globally (75% of studies). Outcome measures varied by region; Harris hip scores were most common in North America, Oceania, and Asia, whereas Non-Arthritic Hip Scores and Western Ontario McMaster scores predominated in Europe. Conclusions: Global surgical trends for FAI show a predominance of North American and European studies, studies of lower level evidence, and inconsistent use of outcome measures. However, patterns of diagnostic imaging, sex proportions, and predominance of arthroscopic techniques are consistent worldwide. Future research should focus on development of reliable validated outcome measures and international collaboration to conduct high-quality research and improve our understanding of FAI diagnosis and management. Level of Evidence: Level IV, systematic review of Level I-IV studies. I nterest in femoroacetabular impingement (FAI)d particularly the nature of the disease as well as its surgical optionsdhas blossomed in the past decade since it was described by Ganz et al., 1 with an exponential increase in FAI-related publications in recent years. 2 Surgical intervention for FAI is designed to correct the impingement lesions by removing excess bone and bony prominences, as well as addressing associated pathologic conditions such as chondral and labral injuries, to prevent the progressive degenerative
to 0.99 (95 % CI 0.98-0.99) and beta angle ICC range 0.86 (95 % CI 0.76-0.92) to 0.97 (95 % CI 0.... more to 0.99 (95 % CI 0.98-0.99) and beta angle ICC range 0.86 (95 % CI 0.76-0.92) to 0.97 (95 % CI 0.95-0.98)]. Conclusions There is no statistical or functional relationship between readings of positive alpha and beta angles. The radiographic measurements resulted in high intraobserver and fair-to-moderate inter-observer reliability. Results of this study suggest that the presence of a CAM lesion on lateral radiographs as suggested by a positive alpha angle does not necessitate a decrease in clearance between the femoral head and acetabular rim as measured by the beta angle and thus may not be the best measure of functional impingement. Understanding the relationship between these two aspects of femoroacetabular impingement improves a surgeon's ability to anticipate potential operative management. Level of evidence III.
Evidence-Based Orthopaedics Group. In it, we will identify an abstract originally published in Th... more Evidence-Based Orthopaedics Group. In it, we will identify an abstract originally published in The Cochrane Library that we think is especially important, and researchers from McMaster University will provide expert perspective on it.
This review concluded that navigated total knee arthroscopy provided significant improvement in p... more This review concluded that navigated total knee arthroscopy provided significant improvement in prosthesis alignment, compared with conventional arthroscopy. The review was generally well conducted, but there was potential bias in the evidence and substantial variation, meaning that the conclusions should be considered to be tentative. Authors' objectives To compare the mechanical alignment of navigated versus conventional total knee arthroplasty. Searching PubMed, EMBASE, The Cochrane Library and major medical and publisher databases were searched, without language restriction, from 1986 to November 2009 for relevant studies; search terms were reported. The reference lists of recent meta-analyses were searched. Study selection Prospective randomised controlled trials (RCTs) with more than four patients per treatment group were eligible for the review if they compared navigation versus convention total knee arthroplasty and reported limb alignment as an outcome. The primary outcome of interest was alignment on full-limb-length radiographs of patients standing in full extension. Functional outcomes were assessed using various scales. In the included trials, the average age of participants was 69 years. Most trials were undertaken in Europe and were performed for primary osteoarthritis. Two reviewers independently selected trials for the review, and agreement between reviewers was assessed. Assessment of study quality The quality of trials was assessed, using the Detsky Quality Assessment Scale, for randomisation, outcome measures, eligibility criteria and reasons for exclusion, interventions, and statistical issues. There was a maximum of 20 points for these items, with an additional question on power calculations for trials that did not find a significant effect. Trials that scored more than 15 were considered to be of high quality. Two reviewers independently assessed trials for quality, and between-reviewer agreement was evaluated. Data extraction Data were extracted on the degree of deviance from 180° to enable calculation of relative risks, with corresponding 95% confidence intervals for deviations of more than 2° or more than 3°, on the mechanical axis and femoral and tibial component alignment. Data were extracted by one reviewer and independently reviewed by a second reviewer for accuracy. Methods of synthesis Trial data were combined in meta-analyses and summary effect relative risks, with corresponding 95% confidence intervals, were calculated using a DerSimonian and Laird random-effects model. Heterogeneity was quantified using Ι². Publication bias was assessed, but the methods were not reported. Results of the review Twenty-three RCTs (n=2,541 patients; range 30 to 467) were included in the review. Seven had scores over 16 and were regarded as high quality, but few reported allocation concealment or intention-to-treat analysis. Nine trials had sample size calculations. The mean duration of follow-up was 7.5 months. Mechanical axis: Compared with conventional arthroplasty, navigation arthroplasty was associated with a significantly reduced risk of deviation in the coronal plane greater than 2° (RR 0.54, 95% CI 0.42 to 0.69; Ι²=58%; 13 RCTs) and deviation in the coronal plane greater than 3° (RR 0.37, 95% CI 0.24 to 0.58; Ι²=85%; 20 RCTs).
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2013
The purpose of this systematic review is to evaluate the consistency of the reporting of clinical... more The purpose of this systematic review is to evaluate the consistency of the reporting of clinical and radiographic outcomes after arthroscopic management of femoroacetabular impingement (FAI). Methods: Two databases (Medline and EMBASE) were screened for clinical studies involving the arthroscopic management of FAI. A full-text review of eligible studies was conducted, and the references were searched. Inclusion and exclusion criteria were applied to the searched studies, and a quality assessment was completed for included studies. Results: We identified 29 eligible studies involving 2,816 patients. There was a lack of consensus with regard to reported outcomes (clinical and radiographic) after arthroscopic treatment of FAI. Clinical outcomes reported include the Harris Hip Score (45%) and the Non-Arthritic Hip Scale (28%), range of motion (34%), pain scores (24%), and patient satisfaction (28%). The most commonly reported radiographic outcomes included the alpha angle (38%), head-neck offset (14%), and degenerative changes (21%). Conclusions: There is significant variation in reported clinical and radiographic outcomes after arthroscopic treatment of FAI. This study highlights the need for consistent outcome reporting after arthroscopic FAI surgery. Level of Evidence: Level IV, systematic review of Level II, III, and IV studies.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2014
This systematic review explores management strategies for intraoperative anterior cruciate ligame... more This systematic review explores management strategies for intraoperative anterior cruciate ligament (ACL) graft contamination. Methods: Two databases (Medline and EMBASE) were screened for studies involving ACL graft contamination published between 1946 and April 2013. We included studies evaluating the management of a contaminated graft and excluded small case-series studies. We conducted a full-text review of eligible studies, and the references were searched for additional eligible studies. Inclusion and exclusion criteria were applied to the searched studies. Results: Our search yielded 6 laboratory investigations with a total of 495 graft samples used. These samples were contaminated and cleansed by various methods. The most successful sterilization protocols used chlorhexidine or mechanical agitation with a polymyxin Bebacitracin solution to achieve sterility in 100% of their respective experimental graft tissues. A chlorhexidine soak and plain bacitracin soak were also effective, at 97.5% and 97%, respectively. Povidone-iodine and an antibiotic soak of polymyxin-bacitracin were the least effective, with sterility rates of 48% and 57%, respectively. Conclusions: The results of this review suggest that the optimal agent for sterilizing a dropped graft is chlorhexidine. A protocol of mechanical agitation and serial dilution with a polymyxin Bebacitracin solution was also highly effective; however, the sample size was too small to realistically recommend its use. Bacitracin alone was also found to be an effective sterilization agent, as was a combined solution of neomycin and polymyxin B. Pooled results showed that normal saline solution, povidone-iodine, and a polymyxin Bebacitracin solution all yielded suboptimal sterilization. The available evidence, however, is laboratory based and may not accurately reflect clinical conditions; moreover, there is a lack of biomechanical studies evaluating sterilized grafts. As a result, the findings should be interpreted with caution.
Minimally invasive surgery for discectomy may accelerate recovery and reduce pain, but it also re... more Minimally invasive surgery for discectomy may accelerate recovery and reduce pain, but it also requires technical expertise and is associated with increased risks. We performed a meta-analysis to determine the effects of minimally invasive versus open surgery on functional outcomes, pain, complications and reoperations among patients undergoing cervical or lumbar discectomy. We searched MEDLINE, Embase and the Cochrane Library for reports of relevant randomized controlled trials published to Jan. 12, 2014. Two reviewers assessed the eligibility of potential reports and the risk of bias of included trials. We analyzed functional outcomes and pain using standardized mean differences (SMDs) that were weighted and pooled using a random-effects model. We included 4 trials in the cervical discectomy group (n = 431) and 10 in the lumbar discectomy group (n = 1159). Evidence overall was of low to moderate quality. We found that minimally invasive surgery did not improve long-term function (...
As a result of the coronavirus disease 2019 (COVID-19) pandemic, tele-health for orthopedic care ... more As a result of the coronavirus disease 2019 (COVID-19) pandemic, tele-health for orthopedic care is expanding rapidly. The authors sought to identify the evidence describing the effectiveness, barriers, and clinical applications of telehealth for orthopedic assessments and consultations. MEDLINE, PubMed, EMBASE, and the Cochrane Library were searched from inception to March 2020. Forty-seven studies were included, with the most common conditions evaluated being trauma related and the primary modality being videoconferencing. Available literature supports the use of telehealth for orthopedic consultations and assessments because it yields moderate-to-high patient and provider satisfaction, accurate examinations, cost-effectiveness, and reduced wait times. Most commonly reported concerns were professional liability, network security, and technical issues. Given the COVID-19 pandemic, rapid implementation and uptake of virtual assessment for patient care has occurred. The current evide...
Context:The opioid epidemic has been well-documented in the general population, but the literatur... more Context:The opioid epidemic has been well-documented in the general population, but the literature pertaining to opioid use and misuse in the athletic population remains limited.Objectives:The objectives of this study were to seek answers to the following questions: (1) what are the rates of opioid use and misuse among athletes, (2) do these rates differ compared with the nonathletic population, and (3) are there specific subgroups of the athletic population (eg, based on sport, level of play) who may be at higher risk?Data Sources:The Embase, MEDLINE, and PubMed were used for the literature search.Study Selection:Records were screened in duplicate for studies reporting rates of opioid use among athletes. All study designs were included.Study Design:Systematic review.Level of Evidence:Level 4.Data Extraction:Data regarding rates of opioid use, medication types, prescription patterns, and predictors of future opioid use were collected. Study quality was assessed using the Methodologi...
Introduction: Moderate to severe postoperative pain and associated opioid use may interfere with ... more Introduction: Moderate to severe postoperative pain and associated opioid use may interfere with patients' well-being and course of recovery. Regional anesthetic techniques provide an opportunity for opioid sparing and improved patient outcomes. A new regional technique called the erector spinae plane (ESP) block has the potential to provide effective analgesia after shoulder arthroscopy with minimal risks and decreased opioid consumption. Our primary objective is to determine whether, in patients who undergo arthroscopic shoulder surgery, a preoperative ESP block reduces pain scores as compared to periarticular infiltration at the end of surgery. Additionally, we will also examine other factors such as opioid consumption, sensory block, adverse events, patient satisfaction, and persistent pain. Methods: This is a 2-arm, single-center, parallel-design, double-blind randomized controlled trial of 60 patients undergoing arthroscopic shoulder surgery. Eligible patients will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomized to either the ESP or periarticular infiltration group. Patients will be followed in hospital in the postanesthesia care unit, at 24 hours, and at 1 month. The study with be analyzed as intention-to-treat. Discussion: This study will inform an evidence-based choice in recommending ESP block for shoulder arthroscopy, as well as providing safety data. The merits of the study include its double dummy blinding to minimize observer bias, and its assessment of patient important outcomes, including pain scores, opioid consumption, and patient satisfaction. This study will also help provide an estimate of the incidence of side effects and complications of the ESP block.
BACKGROUND Stemless anatomic total shoulder arthroplasty (TSA) is used in the treatment of osteoa... more BACKGROUND Stemless anatomic total shoulder arthroplasty (TSA) is used in the treatment of osteoarthritis of the shoulder joint and other degenerative shoulder diseases. It has several proposed advantages over stemmed TSA including increased bone preservation, decreased operative time, and easier removal at revision. METHODS A systematic search was conducted using MEDLINE, Embase, PubMed, and CENTRAL (Cochrane Central Register of Controlled Trials) to retrieve all relevant studies. RESULTS The literature search yielded 1417 studies, of which 22 were included in this review, with 962 patients undergoing stemless TSA. Stemless TSA led to significant improvements in range of motion and functional scores in all included studies. Meta-analysis of comparative studies between stemless and stemmed TSA identified no significant differences in postoperative Constant scores (mean difference [MD], 1.26; 95% confidence interval [CI], -3.29 to 5.81 points; P = .59) or complication rates (odds ratio, 1.79; 95% CI, 0.71-4.54; P = .22). Stemless TSA resulted in a significantly shorter operative time compared with stemmed TSA (MD, -15.03 minutes; 95% CI, -23.79 to -6.26 minutes; P = .0008). Stemless TSA also resulted in significantly decreased intraoperative blood loss compared with stemmed TSA (MD, -96.95 mL; 95% CI, -148.53 to -45.36 mL; P = .0002). CONCLUSION Stemless anatomic TSA resulted in similar functional outcomes and complication rates to stemmed TSA with decreased operative time and lower blood loss. Further research is required to investigate the long-term durability of the stemless implant.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2020
Arthroscopy is a powerful tool in the management of the painful total shoulder arthroplasty and s... more Arthroscopy is a powerful tool in the management of the painful total shoulder arthroplasty and should be considered when evaluating cases in which a clear cause of pain is not present. Patients may present with a painful shoulder arthroplasty due to a number of causesdoccult infection, instability, component loosening, malposition, or rotator cuff pathology. In certain cases, advanced imaging may not be diagnostic, given the presence of metal artifact. It is our routine clinical practice to evaluate arthroscopically such cases in which the diagnosis is not readily evident. The most common indication for shoulder arthroscopy is pain with no clear cause or loss of motion (39%), followed by biopsy to rule out occult infection (25%), and finally rotator cuff assessment (19%).
Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine, 2018
ImportanceSuperior labrum from anterior to posterior (SLAP) pathology can result in significant p... more ImportanceSuperior labrum from anterior to posterior (SLAP) pathology can result in significant pain and functional limitation for a wide variety of patients. Although many different options have been described for the diagnosis and treatment of SLAP pathology, there is little high-quality evidence to support a given diagnosis/treatment method.ObjectiveThe aim of this study was to review the global demographics and trends of SLAP literature, diagnosis, management and consistency of reported outcomesEvidence reviewWe performed a systematic search for studies addressing SLAP pathology published over the last 10 years. Extracted data included sample size, study location, intervention, outcome measures reported, sex distribution and level of evidence. Management was compared between geographic areas.FindingsWe identified 363 studies reporting on SLAP management over the past decade that met our inclusion and exclusion criteria. The majority of studies originated from North America (50.4...
Background: Lower trapezius (LT) transfers were originally described to restore external rotation... more Background: Lower trapezius (LT) transfers were originally described to restore external rotation (ER) in the management of brachial plexus palsy; however, there is recent interest in the role of this transfer to restore shoulder function, specifically ER, in patients with a massive irreparable rotator cuff tear (RCT). The purpose of this systematic review is to summarize the current literature pertaining to LT transfers, including biomechanics, techniques, and clinical outcomes for patients with brachial plexus palsy and massive RCTs. Methods: MEDLINE, EMBASE, and PubMed were searched for biomechanical and clinical studies, as well as technique articles. Four biomechanical studies reported on moment arms, range of motion (ROM), and force vectors. Seven clinical studies reported postoperative ROM and functional outcomes, and weighted mean improvements in ROM were calculated. Results: Overall, 18 studies were included, and then subdivided into 3 themes: biomechanical, technique, and clinical. Biomechanical studies comparing LT and latissimus dorsi (LD) transfers observed an overall larger moment arm in abduction and ER in adduction for the LT transfer, with similar results in forward elevation. Clinical studies noted significant improvement in shoulder function following the LT transfer, including ROM and functional outcome scores. There were several described techniques for performing the LT transfer, including arthroscopically assisted and open approaches, and the use of both allograft and autograft augmentation. Conclusion: This study suggests that the LT transfer is generally safe, and the clinical and biomechanical data to date support the use of the LT transfer for restoration of function in these challenging patient populations.
Background: Superior labrum anterior to posterior (SLAP) tears are a very common shoulder injury.... more Background: Superior labrum anterior to posterior (SLAP) tears are a very common shoulder injury. The success rate of SLAP repair, particularly in the throwing athlete, has been variable in the literature. Questions/Purposes: The purpose of this systematic review was to evaluate the reported post-operative outcomes of management techniques for failed SLAP repair. Methods: The electronic databases MEDLINE, Embase, and PubMed were searched for relevant studies, and pertinent data was abstracted. Only studies reporting outcomes of management techniques for failed SLAP repairs were included. Results: A total of 10 studies (levels III to IV) evaluating 176 patients were included in this systematic review. Most subjects were male (86.6%), with a mean age at surgery of 36.3 years (range, 17 to 67 years). The most commonly reported reason for failed SLAP repair was persistent post-operative mechanical symptoms after index SLAP repair. Common techniques used in the management of failed SLAP repair include biceps tenodesis and revision SLAP repair. Return to activity was significantly higher after biceps tenodesis than after arthroscopic revision SLAP repair. However, compared to primary SLAP repair, biceps tenodesis demonstrated no statistically significant differences in return to work rates. Complications reported in one case were resolved post-operatively, and there was no reported revision failure or reoperation after revision surgery. Conclusion: The most common reason for failed SLAP repair is persistent postoperative mechanical symptoms. Revision surgery for failed SLAP repair has a high success rate. The rate of return to activity after biceps tenodesis was significantly higher than the rate after revision SLAP repair. Large high-quality randomized trials are required to provide definitive evidence to support the optimal treatment for failed SLAP repair.
Background: The number of total shoulder arthroplasties (TSAs) performed is increasing annually, ... more Background: The number of total shoulder arthroplasties (TSAs) performed is increasing annually, with a continued effort to improve outcomes using new techniques and materials. In anatomic TSAs, the main options for glenoid fixation currently involve keeled or pegged components. The aim of this review was to determine which fixation option provides optimal long-term functional outcomes with decreased rates of revision surgery and radiolucency. Methods: The MEDLINE, Embase, PubMed, and Cochrane databases were searched from 2007 to July 10, 2017, for all articles that examined TSAs using either pegged or keeled glenoid fixations. All studies were screened in duplicate for eligibility. Two separate analyses were completed examining noncomparative and comparative studies independently. Results: A total of 7 comparative studies and 25 noncomparative studies were included in the final analysis. Included in the analysis were 4 randomized (level I) studies, 1 level II study, 8 level III studies, and 19 level IV studies. Meta-analysis of the comparative studies demonstrated a higher rate of revision surgery with keeled fixations compared with pegged fixations (odds ratio, 6.22; 95% confidence interval [CI], 1.38-28.1; P ¼ .02). No significant difference was found with respect to functional outcomes, such as the American Shoulder and Elbow Surgeons score (mean difference, 9.54; 95% CI, e8.25 to 27.34; P ¼ .29) and Constant score (mean difference, 5.31; 95% CI, e12.28 to 22.89; P ¼ .55), as well as radiolucency rates (odds ratio, 1.89; 95% CI, 0.56À6.39; P ¼ .30). Conclusion: Pegged glenoid fixation may result in a decreased risk of revision TSAs, but no significant differences in patient-reported outcomes have been identified to date.
Objectives: Players in the National Basketball Association (NBA) subject their lower extremities ... more Objectives: Players in the National Basketball Association (NBA) subject their lower extremities to significant repetitive loading during the season as well as during off-season training. Little is known about the incidence and impact of lower extremity bony stress injuries in these athletes. Methods: Using the player injury database maintained by the NBA Players' Association, all bony stress injuries from 1992 to May 2016 were identified. Those not involving the lower extremity were excluded from the study. Stress fractures and stress reactions were grouped together. Number of games missed due to the injury as well as player statistics including points per game (ppg), assists per game (apg), steals per game (spg), and blocks per game (bpg) were collected from two years prior to the injury to two years after the injury. Results: 76 lower extremity bony stress injuries were identified involving 75 different NBA players with an average player age of 25.4 ± 4.1 years. 55.3% (42/76) involved the foot, 21.1% (16/76) involved the ankle or fibula, 17.1% (13/76) involved the tibia, and 6.6% (5/76) involved either the knee or patella. The majority of injuries occurred in season 82.9% (63/76) with half of the injuries occurring within the first 6 weeks of the season. 38.2% (29/76) of these injuries were managed surgically. An average of 25.1 ± 21.3 games were missed. 19.7% (15/76) of patients who sustained a stress fracture also had a subsequent injury. 29.2% (21/76) of players were not able to return to professional basketball after the season in which the injury was sustained; however, those who were able to return to the same level of play did not see a significant change in performance as measured by ppg, apg, spg, or bpg when comparing the season prior to the injury and either one or two years after the injury. Stress injuries to the foot carried the worst prognosis, 57.1% (12/21) of those unable to return to professional basketball sustained such an injury. Conclusion: While not extremely common in NBA players, lower extremity bony stress injuries may be careerending. However, if they are able to return to the NBA following this injury, then their level of play should return to their pre-injury level.
Clinical orthopaedics and related research, Jan 9, 2016
We are pleased to publish the next installment of Cochrane in CORR 1 , our partnership between CO... more We are pleased to publish the next installment of Cochrane in CORR 1 , our partnership between CORR 1 , The Cochrane Collaboration 1 , and McMaster University's Evidence-Based Orthopaedics Group. In this column, researchers from McMaster University and other institutions will provide expert perspective on an abstract originally published in The Cochrane Library that we think is especially important.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2015
The purpose of this systematic review was to evaluate the anatomic structure and function of the ... more The purpose of this systematic review was to evaluate the anatomic structure and function of the anterolateral ligament (ALL) of the knee. Methods: The Medline, Embase, and Cochrane databases were screened for all studies related to the ALL of the knee. Two reviewers independently reviewed all eligible articles and the references of these articles. Inclusion and exclusion criteria were applied to all searched studies. Quality assessment was completed for the included studies. Results: Nineteen studies were identified for final analysis. Pooled analysis identified the ALL in 430 of 449 knees (96%) examined. The ligament was found to originate from the region of the lateral femoral epicondyle and insert on the proximal tibia midway between the Gerdy tubercle and the fibular head. The ALL was found to be 34.1 to 41.5 mm in length, 5.1 to 8.3 mm in width above the lateral meniscus, and 8.9 to 11.2 mm in width below the lateral meniscus. By use of magnetic resonance imaging, the ALL was identified in 93% of knees examined (clinical, 64 of 70; cadaveric, 16 of 16). In one case study the ligament was clearly visualized by ultrasound examination. Histologic analysis across 3 studies showed characteristics consistent with ligamentous tissue. Though not shown in biomechanical studies, it is hypothesized that the ALL provides anterolateral stability to the knee, preventing anterolateral subluxation of the proximal tibia on the femur. One study identified a network of peripheral nerves, suggesting a proprioceptive function of the ALL. Conclusions: This systematic review shows the ALL to be a distinct structure with a consistent origin and insertion sites. The ALL is an extra-articular structure with a clear course from the lateral femoral epicondyle region, running anteroinferiorly, to the proximal tibia at a site midway between the Gerdy tubercle and the head of the fibula. The function of this ligament is theorized to provide anterolateral knee stability. Level of Evidence: Level IV, systematic review of cadaveric and imaging studies.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2014
The purpose of this study was to review the global pattern of surgical management of femoroacetab... more The purpose of this study was to review the global pattern of surgical management of femoroacetabular impingement (FAI), particularly in diagnosis, outcome measurement, and management. Methods: We performed a systematic search in duplicate for surgical studies addressing FAI published up to June 2013. Study parameters, including sample size, study location, surgical intervention technique, diagnostic imaging, outcome measures used, sex distribution, and level of evidence, were obtained. The number of trials and cumulative sample size were analyzed. The surgical interventions, sex distribution, outcome measures, and diagnostic imaging used were compared between geographic regions. Results: We identified 105 studies reporting surgical interventions for FAI. Most studies were completed in North America (52 studies, 3,629 patients) and in Europe (44 studies, 3,745 patients). Asia (3 studies, 49 patients) and Oceania (6 studies, 394 patients) had smaller contributions. There were no studies from South America or Africa. Most research performed in North America, Europe, and Oceania investigated arthroscopic FAI surgery (55% of studies) followed by surgical dislocation (33%), and miniopen (15%) and combined approaches (8%). Methods of diagnosis were consistent worldwide, with radiography being the mainstay of diagnosis (84% of studies). Case series were the most common type of study globally (75% of studies). Outcome measures varied by region; Harris hip scores were most common in North America, Oceania, and Asia, whereas Non-Arthritic Hip Scores and Western Ontario McMaster scores predominated in Europe. Conclusions: Global surgical trends for FAI show a predominance of North American and European studies, studies of lower level evidence, and inconsistent use of outcome measures. However, patterns of diagnostic imaging, sex proportions, and predominance of arthroscopic techniques are consistent worldwide. Future research should focus on development of reliable validated outcome measures and international collaboration to conduct high-quality research and improve our understanding of FAI diagnosis and management. Level of Evidence: Level IV, systematic review of Level I-IV studies. I nterest in femoroacetabular impingement (FAI)d particularly the nature of the disease as well as its surgical optionsdhas blossomed in the past decade since it was described by Ganz et al., 1 with an exponential increase in FAI-related publications in recent years. 2 Surgical intervention for FAI is designed to correct the impingement lesions by removing excess bone and bony prominences, as well as addressing associated pathologic conditions such as chondral and labral injuries, to prevent the progressive degenerative
to 0.99 (95 % CI 0.98-0.99) and beta angle ICC range 0.86 (95 % CI 0.76-0.92) to 0.97 (95 % CI 0.... more to 0.99 (95 % CI 0.98-0.99) and beta angle ICC range 0.86 (95 % CI 0.76-0.92) to 0.97 (95 % CI 0.95-0.98)]. Conclusions There is no statistical or functional relationship between readings of positive alpha and beta angles. The radiographic measurements resulted in high intraobserver and fair-to-moderate inter-observer reliability. Results of this study suggest that the presence of a CAM lesion on lateral radiographs as suggested by a positive alpha angle does not necessitate a decrease in clearance between the femoral head and acetabular rim as measured by the beta angle and thus may not be the best measure of functional impingement. Understanding the relationship between these two aspects of femoroacetabular impingement improves a surgeon's ability to anticipate potential operative management. Level of evidence III.
Evidence-Based Orthopaedics Group. In it, we will identify an abstract originally published in Th... more Evidence-Based Orthopaedics Group. In it, we will identify an abstract originally published in The Cochrane Library that we think is especially important, and researchers from McMaster University will provide expert perspective on it.
This review concluded that navigated total knee arthroscopy provided significant improvement in p... more This review concluded that navigated total knee arthroscopy provided significant improvement in prosthesis alignment, compared with conventional arthroscopy. The review was generally well conducted, but there was potential bias in the evidence and substantial variation, meaning that the conclusions should be considered to be tentative. Authors' objectives To compare the mechanical alignment of navigated versus conventional total knee arthroplasty. Searching PubMed, EMBASE, The Cochrane Library and major medical and publisher databases were searched, without language restriction, from 1986 to November 2009 for relevant studies; search terms were reported. The reference lists of recent meta-analyses were searched. Study selection Prospective randomised controlled trials (RCTs) with more than four patients per treatment group were eligible for the review if they compared navigation versus convention total knee arthroplasty and reported limb alignment as an outcome. The primary outcome of interest was alignment on full-limb-length radiographs of patients standing in full extension. Functional outcomes were assessed using various scales. In the included trials, the average age of participants was 69 years. Most trials were undertaken in Europe and were performed for primary osteoarthritis. Two reviewers independently selected trials for the review, and agreement between reviewers was assessed. Assessment of study quality The quality of trials was assessed, using the Detsky Quality Assessment Scale, for randomisation, outcome measures, eligibility criteria and reasons for exclusion, interventions, and statistical issues. There was a maximum of 20 points for these items, with an additional question on power calculations for trials that did not find a significant effect. Trials that scored more than 15 were considered to be of high quality. Two reviewers independently assessed trials for quality, and between-reviewer agreement was evaluated. Data extraction Data were extracted on the degree of deviance from 180° to enable calculation of relative risks, with corresponding 95% confidence intervals for deviations of more than 2° or more than 3°, on the mechanical axis and femoral and tibial component alignment. Data were extracted by one reviewer and independently reviewed by a second reviewer for accuracy. Methods of synthesis Trial data were combined in meta-analyses and summary effect relative risks, with corresponding 95% confidence intervals, were calculated using a DerSimonian and Laird random-effects model. Heterogeneity was quantified using Ι². Publication bias was assessed, but the methods were not reported. Results of the review Twenty-three RCTs (n=2,541 patients; range 30 to 467) were included in the review. Seven had scores over 16 and were regarded as high quality, but few reported allocation concealment or intention-to-treat analysis. Nine trials had sample size calculations. The mean duration of follow-up was 7.5 months. Mechanical axis: Compared with conventional arthroplasty, navigation arthroplasty was associated with a significantly reduced risk of deviation in the coronal plane greater than 2° (RR 0.54, 95% CI 0.42 to 0.69; Ι²=58%; 13 RCTs) and deviation in the coronal plane greater than 3° (RR 0.37, 95% CI 0.24 to 0.58; Ι²=85%; 20 RCTs).
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2013
The purpose of this systematic review is to evaluate the consistency of the reporting of clinical... more The purpose of this systematic review is to evaluate the consistency of the reporting of clinical and radiographic outcomes after arthroscopic management of femoroacetabular impingement (FAI). Methods: Two databases (Medline and EMBASE) were screened for clinical studies involving the arthroscopic management of FAI. A full-text review of eligible studies was conducted, and the references were searched. Inclusion and exclusion criteria were applied to the searched studies, and a quality assessment was completed for included studies. Results: We identified 29 eligible studies involving 2,816 patients. There was a lack of consensus with regard to reported outcomes (clinical and radiographic) after arthroscopic treatment of FAI. Clinical outcomes reported include the Harris Hip Score (45%) and the Non-Arthritic Hip Scale (28%), range of motion (34%), pain scores (24%), and patient satisfaction (28%). The most commonly reported radiographic outcomes included the alpha angle (38%), head-neck offset (14%), and degenerative changes (21%). Conclusions: There is significant variation in reported clinical and radiographic outcomes after arthroscopic treatment of FAI. This study highlights the need for consistent outcome reporting after arthroscopic FAI surgery. Level of Evidence: Level IV, systematic review of Level II, III, and IV studies.
Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2014
This systematic review explores management strategies for intraoperative anterior cruciate ligame... more This systematic review explores management strategies for intraoperative anterior cruciate ligament (ACL) graft contamination. Methods: Two databases (Medline and EMBASE) were screened for studies involving ACL graft contamination published between 1946 and April 2013. We included studies evaluating the management of a contaminated graft and excluded small case-series studies. We conducted a full-text review of eligible studies, and the references were searched for additional eligible studies. Inclusion and exclusion criteria were applied to the searched studies. Results: Our search yielded 6 laboratory investigations with a total of 495 graft samples used. These samples were contaminated and cleansed by various methods. The most successful sterilization protocols used chlorhexidine or mechanical agitation with a polymyxin Bebacitracin solution to achieve sterility in 100% of their respective experimental graft tissues. A chlorhexidine soak and plain bacitracin soak were also effective, at 97.5% and 97%, respectively. Povidone-iodine and an antibiotic soak of polymyxin-bacitracin were the least effective, with sterility rates of 48% and 57%, respectively. Conclusions: The results of this review suggest that the optimal agent for sterilizing a dropped graft is chlorhexidine. A protocol of mechanical agitation and serial dilution with a polymyxin Bebacitracin solution was also highly effective; however, the sample size was too small to realistically recommend its use. Bacitracin alone was also found to be an effective sterilization agent, as was a combined solution of neomycin and polymyxin B. Pooled results showed that normal saline solution, povidone-iodine, and a polymyxin Bebacitracin solution all yielded suboptimal sterilization. The available evidence, however, is laboratory based and may not accurately reflect clinical conditions; moreover, there is a lack of biomechanical studies evaluating sterilized grafts. As a result, the findings should be interpreted with caution.
Minimally invasive surgery for discectomy may accelerate recovery and reduce pain, but it also re... more Minimally invasive surgery for discectomy may accelerate recovery and reduce pain, but it also requires technical expertise and is associated with increased risks. We performed a meta-analysis to determine the effects of minimally invasive versus open surgery on functional outcomes, pain, complications and reoperations among patients undergoing cervical or lumbar discectomy. We searched MEDLINE, Embase and the Cochrane Library for reports of relevant randomized controlled trials published to Jan. 12, 2014. Two reviewers assessed the eligibility of potential reports and the risk of bias of included trials. We analyzed functional outcomes and pain using standardized mean differences (SMDs) that were weighted and pooled using a random-effects model. We included 4 trials in the cervical discectomy group (n = 431) and 10 in the lumbar discectomy group (n = 1159). Evidence overall was of low to moderate quality. We found that minimally invasive surgery did not improve long-term function (...
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