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Lameire DL, Soeder J, Abdel Khalik H, Pinsker E, Atri N, Khoshbin A, Radomski L, Atrey A. Local vancomycin administration in Orthopaedic Surgery - A systematic review of comparative studies. J Orthop 2024; 55:44-58. [PMID: 38655540 PMCID: PMC11035019 DOI: 10.1016/j.jor.2024.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/29/2024] [Accepted: 03/31/2024] [Indexed: 04/26/2024] Open
Abstract
Background There is still controversy surrounding the routine use of vancomycin locally in primary orthopaedic surgery procedures. Therefore, the aim of this review is to assess how local vancomycin impacts the rates and microbiology of surgical site infections. Methods A systematic electronic search of MEDLINE, EMBASE, and Web of Science was carried out for all comparative studies comparing locally applied vancomycin to control for primary orthopaedic surgery procedures published before August 14, 2022. Results A total of 61 studies with 65,671 patients were included for analysis. Forty-six studies used vancomycin powder, 12 studies with grafts soaked in vancomycin, two studies used vancomycin irrigation, and one study administered vancomycin interosseously. There were 15 studies (of 26) in spine surgery, five (of 14) in arthroplasty, ten (of 11) in sports medicine, and two (of five) in trauma surgery that found statistically significant decreases in overall infection rates when applying local vancomycin. Only one study (in spine surgery) found significant increases in infection rates with local vancomycin application. For spine surgery, local vancomycin application had the greatest proportion of gram-negative bacteria (40.7%) isolated compared to S. aureus (42.4%) in controls. In arthroplasty and trauma surgery, there were increases in the proportions of gram-negative bacteria when vancomycin was added. There were no reported systemic adverse reactions associated with local vancomycin use in any of the studies. Conclusion Applying local vancomycin during primary orthopaedic surgery procedures may reduce the rates of infections in multiple different orthopaedic specialties, particularly in spine surgery and sports medicine. However, careful consideration should be applied when administering local vancomycin during specific orthopaedic procedures given the heterogeneity of included studies and breadth of surgeries included in this review. Level of evidence Level III. A systematic review of level I - III studies.
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Affiliation(s)
- Darius L. Lameire
- Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jack Soeder
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - Ellie Pinsker
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nipun Atri
- Department of Internal Medicine, Division of Infectious Diseases, Rush University Medical Centre, Chicago, Illinois, USA
| | - Amir Khoshbin
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Lenny Radomski
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Amit Atrey
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Khalik HA, Lameire DL, Leroux T, Bhandari M, Khan M. Arthroscopic Stabilization Surgery for First-Time Anterior Shoulder Dislocations: A Systematic Review and Meta-Analysis. J Shoulder Elbow Surg 2024:S1058-2746(24)00155-1. [PMID: 38430981 DOI: 10.1016/j.jse.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/04/2024] [Accepted: 01/18/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND The optimal management of first-time anterior shoulder dislocations (FTASDs) remains controversial. Therefore, the purpose of this study was to assess the efficacy of arthroscopic stabilization surgery for FTASDs through a systematic review and meta-analysis of existing literature. METHODS MEDLINE, EMBASE and Web of Science were searched from inception to December 18, 2022, for single-arm or comparative studies assessing FTASDs managed with arthroscopic stabilization surgery following first time dislocation. Eligible comparative studies included studies assessing outcomes following immobilization for a FTASD, or arthroscopic stabilization following recurrent dislocations. Eligible levels of evidence were I to IV. Primary outcomes included rates of shoulder re-dislocations, cumulative shoulder instability as well as subsequent shoulder stabilization surgery. RESULTS Thirty-four studies with 2,222 shoulder dislocation were included. Of these, five studies (n=408 shoulders) were randomized trials comparing immobilization to arthroscopic Bankart repair (ABR) after a first dislocation. Another 16 studies were non-randomized comparative studies assessing arthroscopic Bankart repair following first time dislocation (ABR-F) to either immobilization (studies=8, n=399 shoulders) or arthroscopic Bankart repair following recurrent dislocations (ABR-R) (studies=8, n=943 shoulder). Mean follow-up was 59.4±39.2 months across all studies. Cumulative loss to follow-up was 4.7% (range, 0%-32.7%). A composite rate of pooled re-dislocation, cumulative instability and re-operations across ABR-F studies was 6.8%, 11.2% and 6.1%, respectively. Meta-analysis found statistically significant reductions in rates of re-dislocation (OR 0.09, 95%CI 0.04-0.3, p=0.00), cumulative instability (OR 0.05, 95%CI 0.03-0.08, p=0.00), and subsequent surgery (OR 0.08, 95%CI 0.04-0.15, p=0.00) when comparing ABR-F to immobilization. Rates of cumulative instability (OR 0.32, 95%CI 0.22-0.47, p=0.00) and subsequent surgery rates (OR 0.27, 95%CI 0.09-0.76, p=0.01) were significantly reduced with ABR-F relative to ABR-R, with point estimate of effect favoring ABR-F for shoulder re-dislocation rates (OR 0.59, 95%CI 0.19-1.83, p=0.36). RTS rates to preoperative levels or higher were 3.87 times higher following ABR-F compared to immobilization (95%CI 1.57-9.52, p=0.00), with limited ABR-R studies reporting this outcome. The median fragility index of the five included RCTs was 2 meaning reversing only 2 outcome events rendered the trials findings no longer statistically significant. CONCLUSION Arthroscopic stabilization surgery for FTASDs leads to lower rates of re-dislocations, cumulative instability, and subsequent stabilization surgery relative to immobilization or arthroscopic stabilization surgery following recurrence. While a limited number of RCTs have been published on the subject matter to date, the strength of their conclusions is limited by a small sample size and statistically fragile results.
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Affiliation(s)
- Hassaan Abdel Khalik
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Darius L Lameire
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto , Toronto, ON, Canada
| | - Timothy Leroux
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto , Toronto, ON, Canada
| | - Mohit Bhandari
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Moin Khan
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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Abdel Khalik H, Lameire DL, Park LJ, Ayeni OR. The impact of surgical randomised controlled trials on the management of FAI syndrome: a citation analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:6006-6019. [PMID: 37816919 DOI: 10.1007/s00167-023-07608-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/25/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE To identify and assess the clinical impact of randomised controlled trials (RCTs) assessing the surgical management of femoroacetabular impingement syndrome (FAIS) through a citation analysis. METHODS MEDLINE, EMBASE and CENTRAL were searched from inception to April 22, 2023 for RCTs assessing the surgical management of FAIS. Study characteristics were directly abstracted from included trials and citation metrics were obtained from the Clarivate Web of Knowledge database on May 19, 2023. The continuous fragility index (CFI) was calculated for eligible outcomes. Univariate regression models were used to explore correlations between total citations per year and various study characteristics. RESULTS Ten studies comprising one thousand two hundred ninetypatients were eligible for analysis. Studies were published from 2013 to 2023. Eight countries were represented across various trials with 91% being either North American or European. The mean journal impact factor of published studies was 39.684 (median 2.982; range 1.31-202.73). The mean citation density was 14.17 (range 0.33-48.67). The median CFI was 4.8 (range 1-32.2). Correlation analysis demonstrated strong and statistically significant correlations to study sample size (R = 0.75, p = 0.012), journal impact factor (R = 0.80, p = 0.006) and continuous fragility index (R = 0.95, p = 0.015). CONCLUSION Trials assessing the surgical management of FAIS present with a wide range of clinical uptake based on citation density and are published in journals of broadly variable impact factor. Despite promising citation metrics, high-quality evidence on arthroscopy for FAIS is limited to the United States and Europe with an unclear international impact. Future knowledge translation efforts are warranted to maximise the international uptake of evidence regarding arthroscopic management of FAIS. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Hassaan Abdel Khalik
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Darius L Lameire
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, 149 College St Room 508-A, Toronto, ON, M5T 1P5, Canada
| | - Lily J Park
- Division of General Surgery, Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, ON, L8N 3Z5, Canada.
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Abdel Khalik H, Lameire DL, Kruse C, Hache PJ, Al-Asiri J. Management of Very Distal Ulna Fractures: A Systematic Review. J Orthop Trauma 2023; 37:e274-e281. [PMID: 36821446 DOI: 10.1097/bot.0000000000002584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES To synthesize all-cause complications and reoperations data, and secondary clinical, functional, and radiographic outcomes after the management of very distal ulna fractures (VDUFs) either nonoperatively or operatively. DATA SOURCES MEDLINE, Embase, and Web of Science were searched for English-language articles from inception to February 17, 2022. STUDY SELECTION Studies reporting the nonoperative or operative management of VDUFs were eligible for inclusion. VDUFs were defined as either being Q2-Q5 distal ulna fractures using the OTA/AO Comprehensive Classification of Fractures for distal ulna fractures associated with distal radius fractures or being amenable to characterization by the classification system for ulnar head, neck and metaphyseal fractures by Biyani et al. DATA EXTRACTION Two reviewers independently extracted data from included studies. Study validity was assessed using the methodological index for nonrandomized studies. DATA SYNTHESIS Seventeen studies (512 VDUFs) were included for analysis. There were 209, 237, and 66 fractures in the nonoperative, open reduction internal fixation (ORIF), and distal ulna resection groups, respectively. Descriptive statistics including weighted mean values, standard deviations, and 95% confidence intervals were calculated. CONCLUSIONS The treatment of VDUFs with nonoperative management, ORIF, or distal ulna resection may all be acceptable treatment options in specific patient populations. Nonoperative management of VDUFs is a promising treatment strategy even for complex fracture patterns in patients 65 years of age or older. Despite higher reoperation rates, ORIF may be considered for the younger, high-demand patient. Distal ulna resection presents with very favorable functional outcomes in patients 65 years of age or older presenting with a complex VDUF with the lowest reoperation rate across all groups. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Darius L Lameire
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada; and
| | - Colin Kruse
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Philip J Hache
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Jamal Al-Asiri
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
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McKeithan LJ, Lameire DL, Tagliero AJ, Chahal J, Gwathmey FW, Lee CA. What's New in Sports Medicine. J Bone Joint Surg Am 2023; 105:582-590. [PMID: 36853964 DOI: 10.2106/jbjs.22.01385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Affiliation(s)
- Lydia J McKeithan
- Department of Orthopaedic Surgery, University of California Davis Health, Sacramento, California
| | - Darius L Lameire
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Adam J Tagliero
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Jaskarndip Chahal
- University of Toronto Orthopaedic Sports Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - F Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Cassandra A Lee
- Department of Orthopaedic Surgery, University of California Davis Health, Sacramento, California
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Zakharia A, Lameire DL, Abdel Khalik H, Kay J, Uddandam A, Nagai K, Hoshino Y, de Sa D. Quadriceps tendon autograft for pediatric anterior cruciate ligament reconstruction results in promising postoperative function and rates of return to sports: A systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:3659-3672. [PMID: 35445330 DOI: 10.1007/s00167-022-06930-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/03/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the performance of the quadriceps tendon (QT) autograft in pediatric anterior cruciate ligament reconstruction (ACLR). METHODS A systematic search of MEDLINE, PubMed, and EMBASE was conducted on March 1, 2021. Studies of all levels of evidence reporting outcomes and/or complications after QT autograft ACLR in pediatric patients (≤ 18 years old) were eligible for inclusion. Study demographics, patient demographics, reported outcomes, and complications were abstracted. Screening and data abstraction were designed in accordance with PRISMA and R-AMSTAR guidelines. Descriptive statistics were presented when applicable, with data for heterogeneous outcomes presented in narrative summary fashion. RESULTS A total of 14 studies examining 596 patients (46.3% female), mean age 15.4 years, were included in this systematic review. Mean postoperative Lysholm scores ranged from 94.0 to 99.5. Mean postoperative IKDC subjective scores ranged from 75.9 to 94.0. Limb symmetry index ranged from 96.8 ± 10.4 to 100.4 ± 7.6% across multiple hop tests. Return to sports (RTS) rates ranged from 88.9 to 91.7%. Eleven studies reported postoperative complications, whereby 16 patients (4.8%) experienced contralateral complications and injuries. Forty-six patients (9.4%) experienced ipsilateral complications, including ten graft failures (2.5%) and two growth disturbances (0.6%). CONCLUSIONS QT autograft ACLR in the pediatric population retains the potential of regaining a preinjury level of knee stability, and yields promising postoperative function and rates of RTS, yielding comparable outcomes relative to HT autograft and the reference-standard BPTB ACLR that have previously been described in the literature. Moreover, use of the QT autograft is associated with low rates of postoperative complications, including graft failure and growth disturbances in this active and high-risk patient population in observational studies to date. Therefore, clinical equipoise exists to further appraise the influence of QT autograft on postoperative outcomes compared to aforementioned autograft options in a randomized control trial fashion. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Darius L Lameire
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - Hassaan Abdel Khalik
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Abhilash Uddandam
- MacSports Research Program, McMaster University, Hamilton, ON, Canada
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
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Abdel Khalik H, Lameire DL, Rubinger L, Ekhtiari S, Khanna V, Ayeni OR. Return to Sport and Work Following Distal Femoral Varus Osteotomy: A Systematic Review. HSS J 2022; 18:297-306. [PMID: 35645636 PMCID: PMC9096991 DOI: 10.1177/15563316211051295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/14/2021] [Indexed: 11/16/2022]
Abstract
Background: Distal femoral varus osteotomy (DFVO) is an effective surgical intervention for the management of symptomatic valgus malalignment of the knee. Because it preserves the native knee joint and its ligamentous stability, DFVO is preferred to total knee arthroplasty (TKA) in the young, active population. Purpose: We sought to assess return to work (RTW) and return to sport (RTS) rates following DFVO for valgus malalignment of the knee. Methods: For this systematic review, we searched EMBASE, MEDLINE, and Web of Science from inception through December 31, 2020. English language studies of all levels of evidence explicitly reporting on RTS and RTW rates following DFVO for valgus malalignment of the knee were eligible for inclusion. Results: Seven studies and 127 patients were included in our analysis. Mean age was 32.4 ± 8.8 years with men comprising 46.7% ± 22.3% of study populations. The mean RTS rate was 87.2% ± 10.7%, with a return to preoperative activity levels rate of 65.4% ± 26.8%. The mean RTW rate was 81.8% ± 23.3%, with a return to preoperative activity levels of 72.8% ± 18.1%. The mean reoperation rate was 35.6% ± 18.8% within a mean follow-up period of 5.5 ± 1.9 years. Conclusions: This systematic review of low-level studies found DFVO to be a safe and effective procedure for the management of genu valgum in young, active populations, with most patients returning to sport and/or work, although not all at their preoperative activity levels. A paucity of data surrounds RTS and RTW rates following DFVO. Future studies should explicitly report both return to activity rates and whether patients returned to their preoperative activity levels.
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Affiliation(s)
- Hassaan Abdel Khalik
- Michael G. DeGroote School of Medicine,
McMaster University, Hamilton, ON, Canada,Hassaan Abdel Khalik, BSc, MMI, Michael G.
DeGroote School of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada.
| | - Darius L. Lameire
- Michael G. DeGroote School of Medicine,
McMaster University, Hamilton, ON, Canada
| | - Luc Rubinger
- Division of Orthopaedic Surgery,
McMaster University, Hamilton, ON, Canada
| | - Seper Ekhtiari
- Division of Orthopaedic Surgery,
McMaster University, Hamilton, ON, Canada
| | - Vickas Khanna
- Division of Orthopaedic Surgery,
McMaster University, Hamilton, ON, Canada
| | - Olufemi R. Ayeni
- Division of Orthopaedic Surgery,
McMaster University, Hamilton, ON, Canada
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Lameire DL, Abdel Khalik H, Zakharia A, Kay J, Almasri M, de Sa D. Bone Grafting the Patellar Defect After Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction Decreases Anterior Knee Morbidity: A Systematic Review. Arthroscopy 2021; 37:2361-2376.e1. [PMID: 33771689 DOI: 10.1016/j.arthro.2021.03.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/05/2021] [Accepted: 03/14/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this systematic review was to evaluate the impact of bone grafting of patellar defects on reported anterior knee morbidity and subjective outcomes after bone-patellar tendon-bone autograft reconstruction of the anterior cruciate ligament. METHODS A systematic electronic search of MEDLINE, Embase, Web of Science, and the Cochrane Library was carried out. All English-language prospective randomized clinical trials published from January 1, 2000, to July 24, 2020, were eligible for inclusion. All studies addressing patellar defect grafting were eligible for inclusion regardless of the timing of surgery, graft type, surgical technique, or rehabilitation protocol. RESULTS A total of 39 studies with 1,955 patients were included for analysis. There were 796 patients in the no patellar grafting (NPG) group, with a mean age range of 22.7 to 33.0 years, and 1,159 patients in the patellar grafting (PG) group, with a mean age range of 17.8 to 34.7 years. The visual analog scale pain score ranged from 1.2 to 5.1 in the NPG group compared with 0.3 to 3.7 in the PG group. The proportion of patients with anterior knee pain ranged from 19% to 81% in the NPG group and from 15% to 32% in the PG group. Moderate to severe kneeling pain was reported in 22% to 57% of patients in the NPG group and 10% of those in the PG group. The percentage of patients with at least 3° of extension loss ranged from 4% to 43% in the NPG group and from 2% to 11% in the PG group. CONCLUSIONS PG favors decreased anterior knee pain, kneeling pain, and extension loss compared with non-grafted defects; however, the functional outcomes are comparable. Owing to the heterogeneity in reporting, statistical conclusions could not be drawn. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.
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Affiliation(s)
- Darius L Lameire
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hassaan Abdel Khalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alexander Zakharia
- MacSports Research Program, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mahmoud Almasri
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada; Mercy Health-Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, Ohio, U.S.A
| | - Darren de Sa
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada.
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