Evidence-Based Orthopedics E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Evidence-Based Medicine
• Sprache: Englisch

Seitenzahl: 3309

Veröffentlichungsjahr: 2021

Beschreibung

Evidence-Based Orthopedics is an up-to-date review of the best evidence for the diagnosis, management, and treatment of orthopedic conditions. Covering orthopedic surgery as well as pre- and post-operative complications, this comprehensive guide provides recommendations for implementing evidence-based practice in the clinical setting. Chapters written by leading clinicians and researchers in the field are supported by tables of evidence that summarize systematic reviews and randomized controlled trials. In areas where evidence is insufficient to recommend a practice, summaries of the available research are provided to assist in decision-making.

This fully revised new edition reflects the most recent evidence using the approved evidence-based medicine (EBM) guidelines and methodology. The text now places greater emphasis on GRADE—a transparent framework for developing and presenting summaries of evidence—to allow readers to easily evaluate the quality of evidence and the strength of recommendations. The second edition offers a streamlined presentation and an improved standardized format emphasizing how evidence in each chapter directly affects clinical decisions. Incorporating a vast amount of new evidence, Evidence-Based Orthopedics:

• Features thoroughly revised and updated content, including a new chapter on pediatric orthopedics and new X-ray images
• Provides the evidence base for orthopedic surgery as well as pediatric orthopedics and orthopedic conditions requiring medical treatment
• Covers the different methods for most orthopedic surgical procedures, such as hip replacements, arthroscopy, and knee replacements
• Helps surgeons and orthopedic specialists achieve a uniform optimum standard through a condition-based approach

Aligns with internationally accepted guidelines and best health economic principles Evidence-Based Orthopedics is an invaluable resource for orthopedic specialists, surgeons, trauma surgeons, trainees, and medical students.

Leseprobe

Table of Contents

Cover

Title Page

Copyright

Dedication

Contributors

Foreword

Preface

Abbreviations

I: Methodology of Evidence‐Based Orthopedics

1 Principles of Evidence‐Based Orthopedics

Introduction

Importance of evidence‐based orthopedics

Top four questions

Question 1: What are the most important principles of evidence‐based orthopedics?

Question 2: How do you apply evidence‐based orthopedics?

Question 3: What is an example of applying evidence‐based orthopedics?

Question 4: What are the misconceptions of evidence‐based orthopedics?

Summary of answers

References

2 Hierarchy of Evidence and Common Study Designs

Introduction

Top five questions

Question 1: What is the hierarchy of evidence for therapy studies?

Question 2: What are randomized controlled trials (RCTs)?

Question 3: What are observational studies?

Question 4: What are case series and case reports?

Question 5: What are systematic reviews and where do they fit in the hierarchy of evidence?

Summary

References

3 Systematic Reviews and Meta‐Analyses

Introduction

Top four questions

Question 1: What are the types of literature reviews?

Question 2: How is a systematic review performed?

Question 3: How is a meta‐analysis performed?

Question 4: How does one critically appraise a systematic review and meta‐analysis?

Summary of answers

References

4 Healthcare Recommendations: Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Approach

Case scenario

Top three questions

Question 1: What is GRADE?

Question 2: What are the components of a GRADE quality of evidence assessment, and how do you evaluate them for a body of evidence?

Question 3: How do you use your GRADE quality of evidence assessment to develop a clinical recommendation?

Summary of answers

Additional resources

References

5 Outcomes and Their Interpretations

Introduction

Top three questions

Question 1: What is an outcome measure?

Question 2: What properties of outcome measures do I have to know?

Question 3: How should I choose an outcome measure?

Biophysical/clinical outcome measures

Patient‐reported outcome measures (PROMs)

Objective physical function outcome measures

Summary of answers

References

6 Value‐Based Orthopedics

Introduction

Top four questions

Question 1: What is value‐based healthcare?

Question 2: How can value be improved?

Question 3: How can value‐based healthcare be applied to orthopedics?

Question 4: What are the practical challenges with value‐based orthopedics?

Summary of answers

References

Further reading

II: Orthopedic Medicine

7 Critical Issues in Osteoporosis Management

Clinical scenario

Importance of the problem

Top three questions

Question 1: In postmenopausal women aged >50 who have sustained fragility fractures, how does the diagnosis of osteoporosis determine the risk for future fracture?

Question 2: In postmenopausal women with low BMD or prior fragility fractures, which pharmacological therapies, compared to no medications, best reduce the risk for future fractures?

Question 3: In patients with low BMD or who have sustained a fragility fracture, what is the appropriate duration of pharmacotherapy to avoid adverse side effects?

Summary of answers

References

8 Venous Thromboembolic Events

Clinical scenario

Top three questions

Question 1: In patients undergoing major orthopedic surgery, does one modality, compared to others, most effectively reduce thromboembolic event rates?

Question 2: In patients undergoing major orthopedic surgery, does preoperative initiation of thromboprophylaxis, compared to peri‐ or postoperative initiation, reduce thromboembolic event rates?

Available literature and quality of the evidence

Question 3: In patients with isolated lower‐limb injuries who require immobilization, does thromboprophylaxis, compared to no prophylaxis, reduce thromboembolic event rates?

Summary of answers

References

9 Blood Transfusion

Clinical scenario

Top three questions

Question 1: Amongst patients undergoing orthopedic surgery, how common are perioperative blood transfusions compared to patients undergoing other types of surgery?

Question 2: In patients undergoing orthopedic surgery, are perioperative blood management strategies effective at reducing transfusion rates compared to usual care?

Question 3: In postoperative orthopedic surgery patients, what transfusion threshold results in optimal outcomes compared to usual care?

Summary of answers

References

10 Wound Infections

Clinical scenario

Question 1: In patients undergoing orthopedic surgery, does routine antibiotic prophylaxis, compared to antibiotic administration, prevent surgical site infections?

Question 2: In patients with a suspected surgical site infection, what is the optimal workup leading to accurate diagnosis and treatment?

Question 3: In patients with a surgical site infection and infected hardware, does hardware retention, compared to removal of hardware, result in improved outcomes?

Summary of answers

References

11 Smoking Cessation

Clinical scenario

Introduction

Top three questions

Question 1: In patients undergoing orthopedic procedures, do smokers, compared to nonsmokers, have worse outcomes?

Question 2: In patients undergoing orthopedic procedures, does smoking cessation, compared to persistent smoking, decrease the likelihood of a poor outcome?

Question 3: In orthopedic patients, are certain modalities, compared to others, more effective at initiating smoking cessation in orthopedic patients?

Summary of answers

References

12 Perioperative Medical Management

Top three questions

Question 1: In patients presenting with a fragility hip fracture, does routine preoperative echocardiography, compared to no echocardiography, improve survival?

Question 2: In fragility fracture patients, does orthopedic and medical co‐management, compared to usual care, improve outcomes such as length of stay, mortality, and readmission?

Question 3: In fragility fracture patients undergoing surgery, does early surgery, when compared to delayed surgery, have an effect on mortality risk?

Summary of answers

References

13 Orthobiologics

Clinical scenario 1

Clinical scenario 2

Top three questions

Question 1: In patients with open tibial shaft fractures, does the addition of bone‐morphogenetic protein (BMP) at the fracture site during intramedullary nailing reduce the risk of nonunion compared to intramedullary nailing alone?

Question 2: In patients with long‐bone nonunions, does the use of BMP during revision surgery improve the rate of union compared to revision surgery alone?

Question 3: In patients undergoing primary spinal fusion, does the use of BMP improve the rate of union compared to the use of iliac crest bone graft?

Summary of answers

References

14 Intimate Partner Violence

Clinical scenario

Top three questions

Question 1: In adult women with orthopedic injuries who present to fracture clinics, what is the prevalence of intimate partner violence (IPV), and how does this compare to the general population?

Question 2: Do specific educational programs, compared to traditional education, for healthcare professionals improve universal IPV identification and referral to assistance programs?

Question 3: In adult women who present to fracture clinics, are universal IPV identification and assistance interventions, compared to standard practice, effective at improving health outcomes for women?

References

15 Pain Management in Orthopedic Surgery

Clinical scenario 1

Clinical scenario 2

Top three questions

Question 1: In adult patients undergoing surgery, which acute perioperative pain management strategies, compared to others, are most effective at managing perioperative pain?

Systemic analgesia

Regional analgesia

Nonpharmacological options

Question 2: In adult patients undergoing surgery, which opioid‐sparing strategies, compared to standard care, are most effective?

Question 3: In adult patients undergoing surgery, what is the burden of persistent postoperative pain, and are there any interventions which, compared to usual care, can prevent persistent postsurgical pain?

Summary of answers

References

16 Post‐Traumatic Stress Disorder and Depression

Clinical scenario

Top three questions

Question 1: What are post‐traumatic stress disorder and depression, and does their presence, in orthopedic patients, have an impact on postoperative outcomes?

Question 2: How prevalent is PTSD and depression after acute trauma in the orthopedic trauma population?

Question 3: In orthopedic trauma patients with PTSD and/or depression, are there resources that, compared to usual care, improve outcomes?

Summary of answers

References

17 Nutrition and Supplements in Orthopedic Care

Clinical scenario

Top three questions

Question 1: In orthopedic surgery patients, do vitamin D and calcium supplementation, compared to no supplementation, confer a benefit in terms of fracture risk, fracture healing, or bone mineral density?

Question 2: Among patients undergoing orthopedic surgery, do those with a high BMI have a higher risk of complications compared to those with a normal BMI?

Question 3: Among patients undergoing orthopedic surgery, do those with undernutrition or malnutrition have poorer outcomes compared to those with adequate nutrition?

Summary of answers

References

III: Joint Reconstruction

18 Outpatient Total Joint Arthroplasty

Clinical scenario

Top three questions

Question 1: In eligible patients undergoing TJA, does performing the procedure and discharging the patient on the same day of the operation result in an additional risk of serious adverse events or readmissions compared to the same procedures performed on an inpatient basis?

Question 2: In eligible patients undergoing TJA, does performing the procedure on an outpatient basis result in cost savings compared to the same procedures performed on an inpatient basis?

Question 3: In patients undergoing an outpatient TJA, what factors are necessary to ensure a successful procedure compared to the general population undergoing TJA?

Summary of answers

References

19 Hip Preservation

Introduction

Clinical scenario

Top three questions

Question 1: In patients with femoroacetabular impingement, does hip preservation surgery, compared to nonoperative treatment, result in better functional outcomes?

Question 2: In young adults with acetabular dysplasia, does periacetabular osteotomy, compared to conservative care, result in better functional outcomes?

Question 3: Among patients with mild or borderline acetabular dysplasia, does hip arthroscopy, compared to conservative care, produce better functional outcomes?

Summary of answers

References

20 The Direct Anterior Approach

Clinical scenario

Top three questions

Question 1: In patients requiring THA for arthritis, does a DAA provide early and late functional benefit compared to posterior and lateral approaches?

Question 2: In patients requiring THA for arthritis, does a DAA provide acceptable radiographic alignment compared to other approaches?

Question 3: In patients who undergo THA, does a DAA have a higher complication rate compared to lateral or posterior approaches?

Summary of answers

References

21 Computer Navigation in Total Hip Arthroplasty

Clinical scenario

Top three questions

Question 2: In patients undergoing total hip arthroplasty, which surgical techniques, compared to other techniques, result in optimal implant positioning and biomechanical hip reconstruction to reduce impingement and dislocation?

Question 3: In patients undergoing total hip arthroplasty, does computer navigated surgery, compared to manual techniques, demonstrate superior implant positioning?

Summary of answers

References

22 Highly Crosslinked Polyethylene in Total Hip Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients receiving a THA, does highly crosslinked polyethylene (HCLPE) result in a reduction in the wear rate compared to standard UHMWPE?

Question 2: In patients receiving a THA, does HCLPE result in a reduction in osteolysis compared to UHMWPE?

Question 3: In patients with a THA, does the use of HCLPE result in the potential for mechanical failure compared to standard UHMWPE?

Summary of answers

References

23 Hip Resurfacing

Clinical scenario

Top three questions

Question 1: In young, active patients with advanced degenerative hip disease, does hip resurfacing result in superior patient‐reported outcome measures compared to total hip arthroplasty (THA)?

Question 2: In patients with advanced hip osteoarthritis, does hip resurfacing result in higher revision rates compared to THA?

Question 3: Does more surgeon experience or technique, compared to less surgeon experience or other techniques, impact the clinical outcome of patients undergoing hip resurfacing?

Summary of answers

References

24 Metal‐on‐Metal Hip Arthroplasty

Clinical scenario

Top three questions

Question 1: In young, active patients undergoing MoM‐HR, is the revision rate higher than those undergoing metal‐on‐metal total hip arthroplasty (MoM‐THA)?

Question 2: In patients who have undergone MoM‐HR, does monitoring metal ion levels, compared to no active monitoring, affect outcomes or revision rates?

Question 3: In patients with suspected pseudotumor and systemic toxicity, which diagnostic tests, compared to other tests, are most accurate?

Summary of answers

References

25 Ceramic in Total Hip Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients undergoing total hip arthroplasty (THA), do ceramic bearing surfaces, compared to metal or polyethylene, result in better outcomes?

Question 2: In patients undergoing THA, are ceramic bearing surfaces, compared to metal or polyethylene, associated with a unique set of complications?

Question 3: In patients who have undergone THA with ceramic bearing surfaces, compared to metal or polyethylene, are revisions more likely and/or more difficult to perform?

Summary of answers

References

26 Cement in Total Hip Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients undergoing primary total hip arthroplasty (THA), does a cemented femoral stem, compared to an uncemented femoral stem, provide better function and patient outcomes?

Question 2: In patients undergoing primary THA, does a cemented femoral stem, compared to an uncemented femoral stem, provide longer‐term survival?

Question 3: In patients undergoing cemented primary THA, does antibiotic cement, compared to plain cement, effectively prevent infection?

Summary of answers

References

27 Head Size in Total Hip Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients undergoing THA, does larger femoral head size, compared to smaller head size, result in improved stability?

Question 2: In patients undergoing THA, do certain bearing couples, compared to others, result in better outcomes depending on femoral head size?

Question 3: In patients undergoing THA, do larger femoral head sizes, compared to smaller sizes, result in greater levels of trunnion corrosion?

Summary of answers

References

28 Dual Mobility in Total Hip Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients undergoing primary total hip arthroplasty (THA), do some patient characteristics, compared to others, predict dislocation?

Question 2: In patients undergoing THA, do dual mobility (DM) implants, compared to standard implants, result in a different type of dislocation?

Question 3: In patients undergoing THA, do DM implants, compared to standard implants, have better long‐term survival?

Summary of answers

References

29 Trunnionosis

Clinical scenario

Top three questions

Question 1: In patients with metal‐on‐polyethylene (MoP) THA who develop an adverse local tissue reaction (ALTR), does the mechanism by which this occurs differ from that observed in metal‐on‐metal (MoM) THA?

Question 2: In patients undergoing THA, are there factors which increase the risk of trunnionosis and potential subsequent development of an ALTR in MoP THA when compared to ceramic‐on‐polyethylene (CoP)?

Question 3: In patients with MoP THA and radiological evidence of an ALTR secondary to trunnionosis, does management differ compared to that of patients with ALTRs from MoM THA?

Summary of answers

References

30 Periprosthetic Hip Fractures

Clinical scenario

Top three questions

Question 1: In patients who sustain a periprosthetic femur facture, are there factors that may be predictive of this complication after primary THA?

Question 2: In patients with periprosthetic fractures of the femur, is there a validated classification system that has satisfactory intraobserver and interobserver reliability and validity that aids in therapeutic planning?

Question 3: In patients with Vancouver type B periprosthetic femur fractures, does operative management, compared to nonoperative management, result in a better clinical outcome?

Summary of answers

References

31 The Infected Total Hip Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients with suspected PJI, are novel biomarkers such as alpha‐defensin and leukocyte‐esterase better screening tests for than ESR, CRP, and synovial fluid PMNs?

Available literature and quality of the evidence

Question 2: In patients with late PJI, do two‐stage revisions have better rates of infection eradication than one‐stage revisions?

Question 3: In patients who have undergone two‐stage revision, does an additional course of prophylactic oral antibiotics reduce the rates of reinfection compared to no additional antibiotics?

Summary of answers

References

32 The Painful Total Hip Arthroplasty

Clinical scenario

Introduction

Top three questions

Question 1: In patients presenting with a painful THA, what are the key features on history, clinical examination, and investigation, compared to others, that are pertinent to formulating the diagnosis?

Question 2: In patients presenting with a painful THA, which diagnostic tools, compared to others, are most evidence‐based to diagnose periprosthetic joint infection (PJI)?

Question 3: In patients presenting with a painful metal‐on‐polyethylene (MoP) THA, what is the role of metal ion levels, compared to other diagnostic tools, in diagnosing trunnionosis?

Summary of answers

References

33 Revision of the Femoral Component

Clinical scenario

Top three questions

Question 1: In patients undergoing revision arthroplasty with impaction grafting and segmental replacement, what are the technical aspects of impaction, compared to routine technique, that improve clinical outcome?

Question 2: In patients who are undergoing revision THA, how does impaction allografting for femoral revision, compared to no impaction allografting, perform in terms of outcomes?

Question 3: In patients who are undergoing revision THA, how does proximal femoral segmental allografting, compared to other treatments, perform in terms of clinical outcomes?

Summary of answers

References

34 Revision of the Acetabular Component

Clinical scenario

Top three questions

Question 1: In patients with acetabular bone loss, which classification system, compared to others, is most useful?

Question 2: In patients undergoing revision THA, which acetabular bone loss management techniques, compared to others, perform best in terms of outcomes?

Question 3: In patients undergoing revision THA, does the use of porous tantalum, compared to other alternatives, result in better outcomes?

Summary of answers

Acknowledgments

References

35 Antibiotic Cement in Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: For patients undergoing primary TKA, does the routine use of antibiotic-loaded bone cement (ALBC) reduce the rate of periprosthetic joint infection (PJI) compared to cement without antibiotics?

Question 2: In patients undergoing TKA, does the routine use of ALBC lead to higher aseptic mechanical failure rates compared to cement without antibiotics?

Question 3: In patients undergoing TKA, is the routine use of antibiotic‐impregnated cement cost‐effective compared to antibiotics without cement?

Summary of answers

References

36 Unicompartmental Knee Arthroplasty and Patellofemoral Resurfacing Arthroplasty

Clinical scenario 1

Clinical scenario 2

Top three questions

Question 1: Does unicompartmental knee arthroplasty (UKA) provide better patient‐reported outcomes despite worse survivorship than total knee arthroplasty (TKA) in patients under age 60 with isolated medial compartment OA?

Question 2: Is lateral UKA a better alternative to TKA for this patient under age 60 with respect to functional outcome?

Question 3: What are the patient‐reported outcomes for PF arthroplasty (PFA) versus TKA for patients under age 55 with isolated PF OA?

Summary of answers

References

37 Cemented versus Uncemented Fixation in Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: In total knee arthroplasty (TKA) in younger patients, is the survival of the implant improved with uncemented components as compared to cemented fixation?

Question 2: In patients undergoing TKA, are the clinical outcomes improved with cementless fixation versus those fixed with cement?

Question 3: In patients undergoing TKA, is the bone quality adjacent to the TKA improved following uncemented TKA as opposed to cemented TKA with intended benefit for future TKA revision?

Summary of answers

References

38 Cruciate Retaining versus Posterior Stabilized Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: In older active patients with osteoarthritis of the knee, is the use of CR TKA implants associated with differences in patient‐reported clinical outcomes as compared to PS designs?

Question 2: In older active patients with osteoarthritis of the knee, is the use of CR TKA implants associated with differences in implant survival as compared to PS designs?

Question 3: In older active patients with osteoarthritis of the knee, is the use of CR TKA implants associated with differences in ROM as compared to PS designs?

Summary of answers

References

39 Patellar Resurfacing in Total Knee Arthroplasty

Clinical scenario

Top four questions

Question 1: In older active patients with osteoarthritis of the knee, is patellar resurfacing associated with differences in patient‐reported clinical outcomes as compared to nonresurfacing?

Question 2: In older active patients with osteoarthritis of the knee, is patellar resurfacing associated with differences in objective functional outcomes as compared to nonresurfacing?

Question 3: In older active patients with osteoarthritis of the knee, is patellar resurfacing associated with differences in complications (anterior knee pain, and complications other than anterior knee pain) as compared to nonresurfacing?

Question 4: In older active patients with osteoarthritis of the knee, is patellar resurfacing associated with differences in reoperation rates as compared to nonresurfacing?

Summary of answers

References

40 Mechanical versus Kinematic Alignment in Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients undergoing TKA, does kinematic alignment provide better functional outcomes than mechanical alignment?

Question 2: In patients undergoing TKA, does kinematic alignment (KA) result in different complications compared to mechanical alignment (MA)

Question 3: In patients with knee degeneration, is KA TKA suitable for all patients' anatomies treated with MA TKA?

Summary of answers

References

41 Ligament Balancing in Total Knee Arthroplasty

Top three questions

Question 1: In subjects without knee pathology, what are the normal collateral ligaments' tensions/laxities during range of motion?

Question 2: In patients with knee degeneration treated with a total knee arthroplasty (TKA), do those with greater ligament stability, compared to those with laxer ligaments, have better clinical results?

Question 3: In patients with knee degeneration treated with a TKA, do some surgical techniques, compared to others, achieve better ligament balance and knee stability?

Summary of answers

References

42 Robotics in Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients undergoing knee arthroplasty, does robotic‐assisted surgery result in more accurate component positioning compared to conventional knee arthroplasty?

Question 2: In patients undergoing knee arthroplasty, does robotic‐assisted surgery result in improved patient‐centered outcomes compared to conventional knee arthroplasty?

Question 3: In patients undergoing knee arthroplasty, is robotic‐assisted surgery cost‐effective compared to conventional knee arthroplasty?

Summary of answers

References

43 Patient‐Specific Instrumentation in Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 3: In patients undergoing TKA with PSI, are CT‐based PSI systems more accurate than MRI‐based PSI systems?

Summary of answers

References

44 Metal Allergy in Total Knee Arthroplasty

Clinical scenario

Introduction

Top three questions

Question 1: Among patients awaiting TKA, does routine allergy screening, compared to no screening, affect management and/or outcomes?

Question 2: Among patients with suspected hypersensitivity reaction, does any diagnostic method perform better than others?

Question 3: Among patients with a confirmed hypersensitivity reaction, which treatment options, compared to others, result in the best outcomes?

Summary of answers

References

45 Perioperative Management in Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients scheduled for primary TKA, does preoperative bathing/showering or wiping with antiseptics result in fewer SSIs compared to nonantiseptic preparations?

Question 2: In patients after primary TKA, does a fast‐track (FT) early‐mobilization schedule lead to an improved outcome in functional scores and hospitalization time compared to a regular joint care protocol?

Question 3: In patients after primary TKA, does local cryotherapy have a positive effect on early postoperative parameters compared to protocols without cryotherapy application?

Summary of answers

References

46 Arthrofibrosis following Total Knee Arthroplasty

Top three questions

Question 1: In patients undergoing total knee arthroplasty (TKA), does continuous passive motion (CPM), compared to standard postoperative care, help prevent arthrofibrosis?

Available literature and quality of the evidence

Question 2: In patients undergoing manipulation under anesthesia (MUA) for stiffness after TKA, is early manipulation better than late manipulation at restoring range of motion (ROM)?

Question 3: In patients with arthrofibrosis following TKA, does open arthrolysis provide superior outcomes compared to arthroscopic arthrolysis?

Summary of answers

References

47 High‐Flexion Implants in Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: In a patient who is considering a total knee arthroplasty (TKA), what design rationale can be provided for HR implants and are patients more satisfied with such designs compared to a conventional knee prosthesis?

Question 2: Are functional outcomes superior in a patient who has undergone a TKA with a HF prosthesis compared to a conventional total knee prosthesis?

Question 3: In a patient who has undergone TKA with a HF TKA, what unique complications are encountered as compared to a conventional TKA?

Summary of answers

References

48 Venous Thromboembolism in Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients undergoing TKA, are newer generation anticoagulants superior to older agents for venous thromboembolism prophylaxis?

Question 2: In patients undergoing TKA, is routine postoperative screening, compared to no screening, for venous thromboembolic disease effective in preventing morbidity and mortality?

Question 3: In patients undergoing TKA, is extended duration venous thromboembolism prophylaxis more effective than short duration prophylaxis?

Summary of answers

References

49 Highly Cross‐Linked Polyethylene in Total Knee Arthroplasty

Top three questions

Question 1: For patients with total knee arthroplasty (TKA), is highly cross‐linked polyethylene (XLPE) more resistant to wear than conventional polyethylene (non‐XLPE)?

Question 2: For patients with TKA, does XLPE provide better clinical outcomes and a lower revision rate than conventional polyethylene (non‐XLPE)?

Question 3: For patients with TKA, does the addition of antioxidants to XLPE, compared to no antioxidants, make it more resistant to wear?

Summary of answers

References

50 Exposure and Implant Options in Revision Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients undergoing revision TKA, does one surgical approach, compared to others, result in optimal outcomes?

Question 2: In patients undergoing revision TKA, does a tibial tubercle osteotomy (TTO), compared to quadriceps snip (QS), result in improved functional outcomes and fewer complications?

Question 3: In patients undergoing revision TKA and requiring augmentation due to bone defects, do metaphyseal cones, compared to sleeves, result in better outcomes?

Summary of answers

References

51 The Painful Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: For patients with painful TKA, what are the best evidence‐based clinical investigations to assess for intra‐ and extra‐articular etiologies in the initial work‐up?

Question 2: Are SPECT scans superior to nuclear medicine imaging or plain computed tomography (CT) scans in the evaluation of the painful TKA?

Question 3: Are synovial biomarkers (i.e. alpha‐defensin) superior to aspiration for microbiology and serum laboratory investigations in the evaluation of the painful TKA?

Summary of answers

References

52 Diagnosing the Infected Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients with signs and symptoms of infection, what is the sensitivity and specificity of synovial fluid cytology, compared to preoperative serologic investigations, for diagnosis of TKA infection?

Question 2: In patients with signs and symptoms of TKA infection, what intraoperative measures can be used for identification of joint infection?

Question 3: For patients with failed two‐stage prosthetic exchange secondary to infection, how do patient outcomes compare for repeat attempts at implant exchange, compared to arthrodesis or amputation?

Summary of answers

References

53 Management of the Infected Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: What is the role of debridement, antibiotics, and implant retention in patients with early/acute hematogenous versus chronic prosthetic joint infection?

Question 2: Which type of revision surgery strategy provides the better outcome in chronically infected TKA: one‐stage or two‐stage revision?

Question 3: Which type of spacer leads to superior outcome after two‐stage revision TKA: a static or a dynamic knee spacer?

Summary of answers

Reference

54 Management of the Unstable Total Knee Arthroplasty

Top three questions

Question 1: In patients who have undergone total knee arthroplasty (TKA), which risk factors, compared to others, predict instability?

Question 2: Among patients with instability who undergo revision TKA, how do functional outcomes compare to primary TKA?

Question 3: In patients undergoing revision TKA for instability, which surgical techniques, compared to others, produce optimal outcomes?

Summary of answers

References

55 Stem Choices in Revision Total Knee Arthroplasty

Introduction

Clinical scenario

Top three questions

Question 1: In patients undergoing revision TKA, how do uncemented components, compared to cemented components, perform in terms of outcomes?

Question 2: In patients undergoing revision TKA, how do hybrid components, compared to fully cemented or uncemented components, perform in terms of outcomes?

Question 3: In patients undergoing revision TKA, how do cemented components, compared to uncemented components, perform in terms of outcomes?

Clinical scenario continued

Summary of answers

References

56 Periprosthetic Fractures: Knee

Clinical scenario

Top three questions

Question 1: In elderly patients with displaced periprosthetic distal femur fractures, are outcomes improved with open reduction and internal fixation (ORIF) compared to revision TKA?

Question 2: In elderly patients with displaced periprosthetic distal femur fractures, are outcomes improved with retrograde intramedullary nailing (RIMN) compared to periarticular locked plating?

Question 3: In elderly patients with displaced periprosthetic distal femur fractures, what is the minimal remaining bone stock required to successfully perform ORIF?

References

57 Femoral Bone Defects in Revision Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients with periprosthetic distal femoral bone defects, does computed tomography (CT) scan more accurately estimate defect size when compared to x‐ray?

Question 2: In large contained distal femoral defects with metaphyseal compromise, does metallic reconstruction (cones/sleeves) yield improved survivorship compared to structural allograft reconstruction?

Question 3: In patients with large, uncontained structural distal femoral defects (type 3), does distal femoral replacement revision knee arthroplasty yield superior clinical results compared to reconstruction with segmental allograft or allograft‐prosthetic composite?

Summary of answers

References

58 Management of Structural Defects in Revision Knee Arthroplasty: Tibial Side

Clinical scenario

Top three questions

Question 1: In patients with moderate tibial bone loss at revision TKA, are porous metal block augments a better option for implant survival compared to cement filling?

Question 2: In patients with moderate to severe tibial bone loss at revision TKA, is impaction bone grafting (IBG), compared to other options, a viable technique in terms of survival – specifically aseptic loosening?

Question 3: In patients with severe tibial bone loss at revision TKA, do metaphyseal trabecular metal (TM) sleeves and cone augments improve implant survival compared to structural allografts?

Summary of answers

References

59 Patellar Options in Revision Total Knee Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients with deficient patellar bone stock, does the use of bone grafting or trabecular metal‐backed components improve outcomes compared to patellectomy?

Question 2: In patients with anterior knee pain following TKA with an unresurfaced patella, does secondary resurfacing reduce anterior knee pain compared to conservative management?

Question 3: When revising a femoral component for aseptic loosening, does retaining a well‐fixed patellar component improve outcome compared to revision to compatible patellar and femoral components?

References

60 Implant Design Options in the Treatment of Shoulder Osteoarthritis

Clinical scenario

Top three questions

Question 1: In this patient with end‐stage shoulder osteoarthritis, what is the ideal surgical treatment?

Question 2: If an anatomic total shoulder arthroplasty (TSA) is elected, what is the ideal glenoid component design?

Question 3: If an anatomic TSA is chosen, what is the ideal humeral component design?

Summary of answers

References

61 Cement in Shoulder Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients with advanced shoulder osteoarthritis, does cemented fixation of the humeral component result in improved functional outcomes compared to uncemented fixation?

Question 2: In patients undergoing anatomic total shoulder arthroplasty (TSA), is there a difference in implant survival with a cemented versus uncemented technique?

Question 3: In patients undergoing anatomic TSA with a cemented glenoid and/or humeral component, is there a difference in infection rates with the use of antibiotic‐impregnated cement compared to plain cement?

Summary of answers

References

62 Management of Glenoid Bone Loss

Clinical scenario

Top three questions

Question 1: In patients with glenoid bone loss, does computed tomography (CT), compared to other imaging modalities, perform better diagnostically?

Question 2: In patients with glenohumeral bone loss, does reverse total shoulder arthroplasty (rTSA), compared to other treatment options, result in better outcomes?

Question 3: In patients undergoing rTSA, do any bone graft options, compared to others, result in the best outcomes?

Summary of answers

References

63 Reverse Total Shoulder Arthroplasty

Clinical scenario

Relevant anatomy

Importance of the problem

Top three questions

Question 1: Among patients with shoulder pain and dysfunction, which indications, compared to others, are most relevant for reverse total shoulder arthroplasty (rTSA)?

Question 2: In patients undergoing rTSA, do some surgical techniques, compared to others, result in better outcomes?

Question 3: In patients undergoing rTSA, what are the clinical outcomes?

Summary of answers

References

64 Glenoid Components in Total Shoulder Arthroplasty

Clinical scenario

Top three questions

Question 1: In patients with primary osteoarthritis, do keeled or pegged glenoid components correlate with lower revision rates?

Question 2: In patients with primary osteoarthritis, do patient‐specific components or intraoperative navigation, compared to traditional techniques, improve accuracy compared to traditional instrumentation?

Question 3: In patients with primary osteoarthritis, do all‐polyethylene cemented or metal‐backed uncemented glenoid components result in lower failure rates?

Summary of answers

References

65 Periprosthetic Joint Infection in Shoulder Arthroplasty

Clinical scenario

Top three questions

Question 1: Are infection prevention strategies, including modifiable patient factors and perioperative interventions, effective in reducing periprosthetic joint infection (PJI) in patients who undergo shoulder arthroplasty procedures?

Question 2: In patients with possible PJI, do preoperative serum indices, aspiration, or imaging aid in establishing the diagnosis of infection compared with preoperative tissue culture?

Question 3: In patients with shoulder PJI, does a two‐stage revision result in lower reinfection rates compared with one‐stage revision?

Summary of answers

References

66 Ankle Osteoarthritis

Clinical scenario

Top three questions

Question 1: In patients with ankle osteoarthritis, does age predict different outcomes for ankle fusion (AF) versus total ankle replacement (TAR)?

Question 2: For patients with ankle osteoarthritis, what is the best evidence to assess for AF or TAR according to the underlying cause of arthritis?

Question 3: For patients with ankle osteoarthritis who are treated surgically, how do medium‐ and long‐term outcomes compare between AF and TAR?

Summary of answers

References

67 Osteoarthritis of the 1st Metatarsophalangeal Joint

Clinical scenario

Top three questions

Question 1: In patients with 1st MTP joint osteoarthritis (OA), do any nonoperative treatment modalities result in better functional outcomes compared to other nonoperative treatment modalities?

Question 2: In patients undergoing surgery for 1st MTP OA, does arthroplasty result in better functional outcomes compared to arthrodesis?

Question 3: In patients undergoing surgery for 1st MTP OA, do some procedures offer faster or higher rates of return to activity compared to other procedures?

Summary of answers

References

68 Hallux Valgus

Clinical scenario

Top three questions

Question 1: In adult patients with HV, does percutaneous correction result in quicker recovery versus open surgery?

Question 2: In adult patients with HV, does long chevron (LC) osteotomy result in fewer complications versus scarf (SC) osteotomy ?

Question 3: In adult patients with severe HV, does modified Lapidus result in better functional outcomes than 1st metatarsophalangeal joint arthrodesis (MTP)?

Summary of answers

References

69 Cavovarus Foot

Clinical scenario

Top three questions

Question 1: In patients with cavovarus foot and Charcot‐Marie‐Tooth (CMT), does physiotherapy result in better functional scores compared to no physiotherapy?

Question 2: In patients undergoing peroneus longus (PL) to peroneus brevis (PB) tendon transfer, does running locked suture result in improved construct strength compared to vertical mattress sutures?

Question 3: In patients undergoing lateralizing calcaneal osteotomy, does prophylactic tarsal tunnel release result in less neurologic deficit compared to no tarsal tunnel release?

Summary of answers

References

IV: Trauma

70 Damage Control Orthopedics

Clinical scenario

Top three questions

Question 1: In patients with multiple injuries in a borderline or unstable condition, what parameters best describe a patient in danger for complications?

Question 2: In patients with multiple injuries in a borderline or unstable condition, which fracture is associated with the most complications?

Question 3: In patients with multiple injuries after placement of an external fixation on long‐bone fractures, does early or late conversion to intramedullary nailing lead to increased infections?

Summary of answers

References

71 Open Fractures

Clinical scenario

Top three questions

Question 1: In trauma patients with open fractures, does early antibiotic administration result in lower infection rates as compared to delayed antibiotic administration?

Question 2: In polytrauma patients with open fractures, does timely irrigation and debridement result in decreased complications and infection rates as compared to delayed irrigation and debridement?

Question 3: In patients with open fractures, does irrigation with normal saline versus an additive solution, and high pressure versus low pressure, result in lower infection/complication rates?

Clinical comment

Summary of answers

References

72 The Mangled Extremity

Clinical scenario

Top three questions

Question 1: In patients with a mangled extremity injury, does limb salvage necessitate greater resource investment than amputation?

Question 2: In patients with a mangled extremity injury, what patient factors influence the success of therapy and the rate of RTW?

Question 3: In patients with a mangled extremity injury, is limb salvage associated with better long‐term outcomes when compared to amputation?

Summary of answers

References

73 Acute Compartment Syndrome

Clinical scenario

Top three questions

Question 1: In patients with CS, do open fractures pose greater risk of missed diagnosis and delayed fasciotomy compared to closed fractures?

Question 2: In patients with CS, are patients who undergo compartment pressure monitoring diagnosed faster than patients undergoing clinical assessment?

Question 3: In patients with anterior CS of the leg, does a one‐incision fasciotomy of the anterior compartment achieve better decompression and fewer complications compared to the full two‐incision/four‐compartment release?

Summary of answers

References

74 Noninvasive Technologies for Fracture Repair

Clinical scenario

Top three questions

Question 1: In patients with acute tibial fractures, does low‐intensity pulsed ultrasound (LIPUS) accelerate fracture healing and improve health‐related quality of life (QOL) of the patient compared to no treatment to accelerate fracture healing?

Question 2: In patients with chronic tibial nonunion, does LIPUS promote fracture healing of nonunion and improve health‐related QOL of the patient compared to no treatment to accelerate fracture healing?

Question 3: In patients with acute tibial fractures, does pulsed electromagnetic field treatment (PEMF) and extracorporeal shockwave therapy (ESWT) accelerate fracture healing and improve health‐related QOL of the patient compared to no treatment to accelerate fracture healing?

Summary of answers

Reference

75 Calcium‐Based Bone Substitutes

Clinical scenario

Top three questions

Question 2: In patients with a fracture requiring bone graft augmentation, does the use of calcium phosphate cement instead of autogenous iliac crest bone graft result in fewer complications?

Question 3: In osteoporotic fractures, does calcium phosphate augmentation improve fixation of implants when compared with no augmentation of fixation?

Summary of answers

References

76 Scapula Fractures

Clinical scenario

Top three questions

Question 1: For patients with a scapula fracture, does CT, compared to plain X‐rays, provide an advantage in terms of diagnosis and management?

Question 2: In patients with scapula fractures, does operative management, compared to nonoperative management, result in better outcomes?

Question 3: In patients with scapula fracture, do rehabilitation protocols differ for those who have undergone surgery compared to those managed nonoperatively?

Summary of answers

References

77 Sternoclavicular Joint

Clinical scenario

Top three questions

Question 1: In patients with posterior SC joint dislocations does CT provide a better understanding of the injury severity when compared to plain radiographs?

Question 2: In patients with an SC joint dislocation undergoing closed reduction, is the shoulder abduction and traction technique more successful and have fewer complications than other closed reduction techniques?

Question 3: In patients with an SC joint dislocation, does open fixation with allograft or autograft result in improved patient outcomes when compared to open fixation with metal implants?

Findings

References

78 Clavicle Fractures

Clinical scenario

Top three questions

Question 1: In patients with clavicle fractures managed nonoperatively, do displaced fractures have worse outcomes than nondisplaced fractures?

Question 2: In patients with displaced clavicle fractures, does open reduction and internal fixation offer improved outcomes compared to nonoperative management?

Question 3: In patients with clavicle fractures managed operatively, does intramedullary nailing result in improved outcomes compared to plating?

Summary of answers

References

79 Acromioclavicular Joint

Clinical scenario

Top three questions

Question 1: In patients with AC joint injuries undergoing operative repair, do those with low‐grade injuries have worse functional outcomes compared to those with high‐grade injuries?

Question 2: In patients with high‐grade AC joint injuries treated operatively, do reconstruction methods offer improved results over temporary hook plate fixation?

Resolution of clinical scenario

Question 3: In patients with AC joint injuries treated operatively, does early intervention offer improved outcomes compared to delayed surgery?

Summary of answers

References

80 Proximal Humeral Fractures

Clinical scenario

Top three questions

Question 1: In patients with a proximal humerus fracture, does adding CT imaging improve classification of fractures or improve patient outcomes compared with radiographs alone?

Question 2: In patients choosing nonoperative treatment of a fracture of the proximal humerus, does early initiation of exercises (before one week) improve pain or patient‐reported function compared with delayed exercise programs (after three weeks)?

Question 3: In patients with displaced three‐ or four‐part humerus fractures, does nonoperative treatment lead to better outcomes than surgical treatment (open reduction and internal fixation, hemiarthroplasty, or reverse total shoulder arthroplasty)?

Summary of answers

References

81 Humeral Shaft Fractures

Clinical scenario

Top three questions

Question 1: In adult patients with displaced humeral shaft fractures, does operative treatment result in improved function compared to nonoperative treatment?

Question 2: In adult patients with displaced humeral shaft fractures undergoing operative treatment, how does plate osteosynthesis compare to intramedullary nailing in terms of fracture union and complication rates?

Question 3: In adult patients sustaining humeral shaft fractures with radial nerve palsy, is there a difference in the recovery rate with primary radial nerve palsy, as compared to secondary radial nerve palsy (i.e. with fracture manipulation) radial nerve palsy?

Summary of answers

References

82 Distal Humerus Fractures

Clinical scenario

Top three questions

Question 1: In patients with intra‐articular distal humerus fractures, does a triceps splitting approach result in better patient outcomes when compared to an olecranon osteotomy?

Question 2: In patients with distal humerus fractures, does parallel plating result in better outcomes when compared to orthogonal plating?

Question 3: In elderly patients with comminuted, intra‐articular, distal humerus fractures does total elbow arthroplasty (TEA) result in better outcomes than open‐reduction and internal fixation?

Summary of answers

References

83 Elbow Dislocations

Clinical scenario

Top three questions

Question 1: In patients with AMF fractures, does operative management result in improved outcomes compared to nonoperative management?

Question 2: In patients with terrible triad injuries, does surgical management of the coronoid improve clinical outcomes compared to nonoperative management?

Question 3: In patients with terrible triad injuries, does radial head arthroplasty lead to improved clinical outcomes compared to internal fixation?

Summary of answers

References

84 Radial Head Fractures

Clinical scenario

Top three questions

Question 1: In patients with radial head fractures, does aspiration/injection aid in the initial management compared to radiographs alone?

Question 2: In patients with displaced isolated partial radial head fractures, does operative treatment result in better outcomes compared to nonoperative treatment?

Question 3: In patients with unstable or displaced fractures of the radial head that are part of a complex injury, does open reduction internal fixation (ORIF) have better outcomes compared with excision with or without prosthetic replacement?

References

85 Olecranon Fractures

Clinical scenarios

Top three questions

Question 1: In patients with displaced olecranon fractures treated surgically, how do the outcomes compare between those treated with internal fixation vs fragment excision and triceps advancement?

Question 2: In low‐demand elderly patients with displaced olecranon fractures, does surgery result in improved outcomes compared with nonsurgical treatment?

Question 3: In patients with simple or minimally comminuted, stable, displaced olecranon fractures treated with surgery, how does tension‐band wiring (TBW) compare with dorsal plating in terms of outcomes, complications, and costs?

References

86 Forearm Fractures

Clinical scenarios

Top four questions

Question 1: In patients with radial shaft fractures/Galeazzi‐type fracture‐dislocations, does radiological radial shortening more accurately predict distal radioulnar joint (DRUJ) injury compared with radial shaft fracture location?

Question 2: In patients with isolated ulnar fractures, does surgical treatment lead to better functional outcomes compared with nonsurgical treatment?

Question 3: In patients with Galeazzi‐type fractures, does surgical reconstruction or temporary transfixion of the DRUJ prevent decrease in range of motion (ROM) of the forearm compared to nonsurgical treatment?

Question 4: In patients with forearm fractures treated with plate fixation, does plate removal after bony union lead to higher refracture/complication rates compared with patients who retain their hardware?

Summary of answers

References

87 Distal Radius Fractures

Clinical scenario

Top three questions

Question 1: In patients with displaced intra‐articular distal radius fractures, does open reduction and internal fixation (ORIF) with a plate result in improved outcomes as compared to temporary spanning external fixation with or without supplementary pin fixation?

Question 2: In patients with displaced intra‐articular distal radius fractures, does dorsal plating result in higher complication rates as compared to volar plating?

Question 3: In patients with displaced intra‐articular distal radius fractures, does arthroscopic reduction improve the outcomes over fluoroscopic reduction?

Resolution of clinical scenario

Summary of answers

References

88 Carpal Dislocations

Clinical scenario

Top three questions

Question 1: In patients with perilunate dislocations, does advanced imaging (such as CT scan, US, MRI, or arthroscopy) lead to changes in diagnosis or operative planning compared to radiographs alone?

Question 2: In patients with reducible perilunate dislocations, does delay in operative fixation lead to worse functional outcomes compared with early fixation?

Question 3: In patients with perilunate dislocations, does temporary fixation of the carpus with screws achieve better functional and radiographic outcomes than Kirschner wire (K‐wire) fixation?

Summary of answers

References

89 Carpal Fractures

Clinical scenario

Top three questions

Question 1: In patients with a suspected scaphoid fracture but negative findings on initial x‐rays, is magnetic resonance imaging (MRI) more sensitive and cost‐effective than temporary immobilization and repeated x‐rays after two weeks?

Resolution of clinical scenario

Question 2: In patients with a nondisplaced scaphoid fracture undergoing conservative treatment, does a short arm thumb spica cast achieve higher union rates compared to a below‐elbow casting without thumb?

Question 3: In patients with a nondisplaced fracture of the scaphoid, does conservative treatment achieve similar union rates to surgical treatment of the scaphoid?

Summary of answers

References

90 Metacarpal Fractures

Clinical scenario

Top three questions

Question 1: In adult patients with angulated fifth metacarpal neck fractures, does surgical treatment offer better final range of motion (ROM) or grip strength than nonsurgical treatment?

Question 2: In adult patients with angulated fifth metacarpal neck fractures, does closed reduction and casting improve ROM, grip strength, or patient‐reported outcomes compared to less rigid immobilization?

Question 3: In adult patients with a metacarpal neck fracture, does correction of angulation result in improved ROM or grip strength compared to consolidation without angulation correction?

Summary of answers

References

91 Pelvic Fractures

Clinical scenario

Top three questions

Question 1: During the initial management of patients with suspected pelvic bleeding, does the application of an invasive external fixator provide superior pelvic hemorrhage control when compared to a noninvasive external pelvic binder (PB)?

Question 2: For patients with ongoing pelvic bleeding after resuscitation, does giving priority to pre‐peritoneal pelvic packing (PPP), before angioembolization (AE), reduce mortality?

Question 3: In pelvic fracture patients at high risk of bleeding and pulmonary embolism (PE), is mechanical thromboprophylaxis or even prophylactic inferior vena cava (IVC) filter insertion safer than a chemical strategy?

Summary of answers

References

92 Acetabular Fractures

Clinical scenario

Top three questions

Question 1: In elderly patients (over 65 years old) with acetabular fractures, does surgical treatment achieve better functional outcomes compared to conservative treatment?

Question 2: In elderly patients (over 65 years old) with acetabular fractures, does surgical fixation delay the need for total hip arthroplasty (THA) compared to conservative treatment?

Question 3: In elderly patients (above 65 years) with acetabular fractures, does acute THA achieve better patient‐reported outcomes and fewer surgical complications compared to a delayed THA?

Summary of answers

References

93 Hip Dislocations

Clinical scenario

Top three questions

Question 1: In patients with a traumatic dislocation of the hip, does a delay in hip reduction increase the risk of femoral head osteonecrosis (avascular necrosis [AVN]) as compared with an earlier reduction?

Question 2: In patients with an isolated traumatic hip dislocation, do advanced imaging examinations (computed tomography [CT] and/or MRI) change treatment approach, as compared with X‐rays alone?

Question 3: In patients with hip dislocations who are diagnosed with an acetabular labral tear after closed reduction, does surgical treatment (with debridement and/or repair) achieve better functional outcomes than nonsurgical management?

Summary of answers

References

94 Femoral Head Fractures

Clinical scenario

Top three questions

Question 1: In patients with femoral head fractures, which types benefit from operative intervention more than others?

Question 2: In patients with operatively treated femoral head fractures, does a surgical dislocation utilizing an anterior surgical approach result in improved outcomes compared to the digastric trochanteric flip osteotomy?

Question 3: In patients with femoral head fractures, are there situations in which hip arthroplasty may have improved outcomes compared to open reduction and internal fixation?

Summary of answers

References

95 Femoral Neck Fractures in Younger Patients

Clinical scenario

Top three questions

Question 1: In young adult patients with displaced femoral neck fractures, does time to surgery of <6 hours result in lower rates of avascular necrosis (AVN) compared to surgery performed 6–24 hours from injury?

Question 2: In young adult patients with displaced femoral neck fractures, does treatment with open reduction provide superior outcomes compared to treatment with closed reduction?

Question 3: In young adult patients with displaced femoral neck fractures, does implant choice of cannulated screws (CS) result in higher complication rates when compared to an SHS?

Summary of answers

References

96 Femoral Neck Fractures in the Elderly

Clinical scenario

Top three questions

Question 1: In patients over the age of 65 undergoing treatment of a displaced femoral neck fracture, does arthroplasty result in decreased mortality and re‐operation rates compared to internal fixation?

Question 2: In patients over the age of 65 undergoing internal fixation for a displaced femoral neck fracture, does use of cancellous screws result in reduced risk of complications and re‐operation compared to sliding hip screws (SHSs)?

Question 3: In patients over the age of 65 undergoing arthroplasty for a displaced femoral neck fracture, does use of total hip arthroplasty (THA) result in decreased complications and improved outcomes compared to hemiarthroplasty?

Summary of answers

References

97 Extracapsular Hip Fractures

Clinical scenario

Top three questions

Question 1: In patients with extracapsular hip fractures undergoing fixation, does a cephalomedullary nail (CMN) result in a lower rate of re‐operation when compared with sliding hip screw (SHS) and stratified by fracture pattern?

Question 2: In patients with extracapsular hip fractures, do comprehensive orthogeriatric co‐management programs, compared to usual care, improve outcomes after hip fracture surgical fixation?

Available literature and quality of the evidence

Question 3: In patients with failed fixation of an extracapsular hip fractures, does revision fixation compared to arthroplasty lead to better long‐term function?

Summary of answers

References

98 Subtrochanteric Femur Fractures

Clinical scenario

Top three questions

Question 1: In patients with subtrochanteric femur fractures treated with an intramedullary nail (IMN), does a trochanteric start point provide superior outcomes to a piriformis fossa start point?

Question 2: In patients with subtrochanteric femur fractures treated with an IMN, does a nonanatomic reduction result in higher failure rates and higher mal/nonunion rates than anatomic reduction?

Question 3: In patients with subtrochanteric femur fractures treated with an IMN, does open reduction lead to increased complication rates (i.e. infection, nonunion) when compared to closed reduction and intramedullary nailing?

Summary of answers

References

99 Femoral Shaft Fractures

Clinical scenario

Top three questions

Question 1: In polytrauma patients with femoral shaft fractures, does early definitive fixation of the femoral fracture result in lesser systematic complications and decreased mortality compared to the damage control orthopedics (DCO) approach?

Question 2: Does early, simultaneous intramedullary nailing (IMN) of bilateral femur fractures predispose the patient to increased complication rates compared to the DCO approach?

Question 3: In open femur fractures, does early IMN result in increased complication rates compared to delayed IMN?

Summary of answers

References

100 Distal Femur Fractures

Clinical scenario

Top three questions

Question 1: In patients undergoing distal femoral fixation, do locking plates result in less construct failures and nonunions than nonlocking constructs?

Question 2: In geriatric patients with distal femur fractures, does early surgery result in improved morbidity and mortality in comparison with delayed surgery?

Question 3: In patients undergoing lateral locking plate fixation, are some patient and surgical factors, such as patient BMI, plate length, etc., more likely to result in nonunion and mechanical failure compared to other factors?

Summary of answers

References

101 Proximal Tibia Fractures

Clinical scenario

Top three questions

Question 1: Amongst adult patients presenting with bicondylar tibial plateau fracture, does open reduction and internal fixation, when compared to external fixation with use of limited open techniques, lead to fewer operative complications?

Question 2: Amongst adult patients who have proximal tibial fractures with metaphyseal bone defects, does iliac crest bone grafting (ICBG), when compared to bone substitute (calcium phosphate or other), improve patient‐reported and radiographic outcomes?

Question 3: Amongst adult patients who have undergone operative treatment for a tibial plateau fracture, what patient and injury‐specific factors, when compared to the general population, yield improvement in knee ROM at one‐year follow‐up?

Summary of answers

References

102 Tibial Shaft Fractures

Clinical scenario

Top three questions

Question 1: In tibial shaft fractures, does intramedullary (IM) nailing offer better outcomes compared with open reduction and internal fixation (ORIF)?

Question 2: In open tibial shaft fractures, does IM nailing offer improved outcomes compared to external fixation?

Question 3: In tibial shaft fractures (open and closed), what is the effect of reamed versus unreamed intramedullary (IM) nailing in the rates of major re‐operations and secondary complications?

Summary of answers

References

103 Intra‐Articular Distal Tibia (Pilon/Plafond) Fractures

Clinical scenario

Top three questions

Question 1: In patients undergoing operative management for distal tibia intra‐articular fractures, does staged open reduction and internal fixation (ORIF) result in better clinical and postsurgical outcomes compared to acute fracture management?

Question 2: In patients undergoing operative management for distal tibia intra‐articular fractures, does definitive management with limited internal fixation with external fixation result in better clinical and postsurgical outcomes compared to ORIF (early or delayed)?

Question 3: In patients undergoing operative management for distal tibia intra‐articular fractures, does any specific surgical exposure result in better clinical and postsurgical outcomes compared to other exposures?

Summary of answers

References

104 Malleolar Fractures

Clinical scenario

Top three questions

Question 1: Amongst adult patients presenting with low‐energy inversion ankle injuries, are the Ottawa Ankle Rules (OAR), when compared to other ankle injury screening tools, more accurate in diagnosing patients with ankle fractures?

Question 2: Amongst adult patients, who have syndesmotic injuries proven with intraoperative stress testing, do novel suture button devices, when compared to standard screw fixation, improve the reduction of syndesmosis and patient‐reported outcomes?

Question 3: Amongst adult patients who have posterior malleolar ankle fracture, at what percentage of articular surface involvement does operative intervention when compared to nonoperative management, yield improvement in patient‐reported outcomes at one‐year follow‐up?

Summary of answers

References

105 Talus Fractures

Clinical scenario

Top three questions

Question 1: In patients with displaced talar neck fractures, does urgent definitive fixation result in better outcomes and fewer complications, compared with delayed definitive fixation?

Question 2: In patients with displaced talar neck fractures, does surgery with dual approaches (anteromedial and anterolateral) result in better outcomes and fewer complications, compared with surgery with percutaneous fixation or arthroscopic‐assisted reduction and fixation?

Question 3: In patients with displaced talar neck fractures, does plate fixation result in better biomechanical stability compared with fixation using only screws?

Summary of answers

References

106 Calcaneal Fractures

Clinical scenario

Top three questions

Question 1: In adults with displaced intra‐articular calcaneal fractures, does nonoperative treatment provide long‐term functional outcomes as good as operative care (open reduction and internal fixation [ORIF])?

Question 2: In adults with displaced intra‐articular calcaneal fractures, does minimally invasive reduction and percutaneous fixation provide long‐term functional outcomes as good as ORIF?

Question 3: In adults with displaced intra‐articular calcaneal fractures, does primary fusion provide long‐term functional outcomes as good as ORIF?

Summary of answers

References

107 Lisfranc Injuries

Clinical scenario

Top three questions

Question 1: In a patient with a Lisfranc injury, does an anatomical reduction and fixation result in better outcomes than primary arthrodesis?

Question 2: In a patient with a Lisfranc injury, does delayed or misdiagnosis adversely affect the outcomes compared to successful diagnosis and treatment?

Question 3: In the active patient with a Lisfranc injury does, operative treatment allow for return to preinjury level of sport compared to nonoperative treatment?

Summary of answers

References

108 Fifth Metatarsal Fractures

Clinical scenario

Top three questions

Question 1: In patients with a proximal fifth metatarsal fracture, does the pattern of injury affect the clinical and radiological outcome?

Question 2: In patients with a proximal fifth metatarsal fracture, does operative fixation result in better outcomes than nonoperative management?

Question 3: In patients with a proximal fifth metatarsal fracture, does intramedullary screw fixation lead to better biomechanical and clinical outcomes than other operative treatment options?

Summary of answers

References

V: Spine

109 Mechanical Neck Pain

Clinical scenario

Top three questions

Question 1: In adults with nonwhiplash‐associated mechanical neck pain, do patient education strategies improve pain, function, and/or quality of life compared to no treatment?

Question 2: Have nonsteroidal anti‐inflammatory drugs (NSAIDs), muscle relaxants, or analgesics demonstrated efficacy compared to placebo or other treatments in treating patients with nonspecific neck pain?

Question 3: In adults with nonwhiplash‐associated mechanical neck pain, does the addition of exercise to mobilization/manipulation improve pain and function compared to mobilization/manipulation alone?

Summary of answers

References

110 Whiplash

Clinical scenario

Top three questions

Question 1: In athletes with whiplash and/or cervical spine injuries, what are the return‐to‐play criteria, and what injuries/conditions are contraindications to return to play?

Question 2: In athletes who sustain a cervical disc herniation, do those who undergo surgery have higher return‐to‐play rates than individuals treated nonoperatively?

Question 3: In athletes who sustain a burner/stinger injury, do preexisting factors contribute to an increased risk of this condition, and how do these factors impact resolution of symptoms and return to play?

Summary of answers

References

111 Cervical Radiculopathy and Myelopathy

Clinical scenario

Top three questions

Question 1: In patients with mild, moderate, or severe degenerative cervical myelopathy (DCM), does surgical decompression provide superior functional outcomes, as graded by the modified Japanese Orthopaedic Association (mJOA) scale, compared to nonoperative management strategies?

Question 2: In patients with asymptomatic cervical spinal cord compression (imaging evidence of cervical spinal cord compression without signs or symptoms of myelopathy or radiculopathy), what is the role of prophylactic surgery, and what are the frequency and timing of symptom development and clinical, radiological, and electrophysiological predictors of myelopathy development?

Question 3: In patients with imaging evidence of cervical spinal cord compression and clinical and/or electrophysiological evidence of radiculopathy, but without myelopathy, what is the role of surgery, and what are the frequency and timing of symptom development and clinical, radiological, and electrophysiological predictors of myelopathy development?

Summary of answers

References

112 Mechanical Low Back Pain: Operative Management

Clinical scenario

Top three questions

Question 1: In patients with isolated mechanical back pain, does fusion provide improved pain relief compared to nonoperative treatment?

Question 2: In patients with chronic low back pain (LBP), do some diagnostic tests more accurately select the right patient for spine fusion than other tests?

Question 3: In patients undergoing spine fusion, what risk factors are associated with poorer outcomes?

Summary of answers

References

113 Mechanical Low Back Pain: Nonoperative Management

Clinical scenario

Top three questions

Question 1: In patients presenting with acute or subacute LBP, does early advanced imaging, e.g. computed tomography (CT) and magnetic resonance imaging (MRI), lead to improved outcomes when compared to delayed imaging?

Question 2: For patients undergoing initial treatment of mechanical LBP, does skeletal manipulation prevent the progression of symptoms more effectively than medical care?

Question 3: Is there a role for spinal injections in the treatment of patients with mechanical LBP instead of oral medications?

Summary of answers

References

114 Neurogenic Claudication

Clinical scenario

Top three questions

Question 1: In elderly patients with lumbar spinal stenosis, does decompressive surgery result in better patient‐reported outcomes compared to nonoperative treatment?

Question 2: In elderly patients with lumbar spinal stenosis, does minimally invasive (midline‐sparing) decompression result in better patient‐reported outcomes compared to laminectomy?

Question 3: In elderly patients with lumbar spinal stenosis and concomitant spondylolisthesis, does surgical treatment with decompression and fusion result in better patient‐reported outcomes compared to decompression alone?

Summary of answers

References

115 Lumbar Radiculopathy

Clinical scenario

Top three questions

Question 1: In adult patients with lumbar radiculopathy, what work‐up is needed to establish a diagnosis?

Question 2: In adult patients with lumbar radiculopathy, do injections alter the natural history of the symptoms compared to noninvasive or surgical treatments?

Question 3: In adult patients with lumbar radiculopathy, does surgical treatment result in superior sustained symptom relief compared to nonsurgical treatment?

Summary of answers

References

116 Adolescent and Adult Spinal Deformity: Nonoperative Management

Clinical scenario

Top three questions

Question 1: In patients with adolescent idiopathic scoliosis (AIS), how does bracing influence health‐related quality of life (HRQoL)?

Question 2: In patients with AIS, does nonoperative management result in pulmonary compromise in adulthood?

Question 3: Which risk factors predict patients with adult scoliosis curves will progress and cause low back pain (LBP)?

Summary of answers

References

117 Adolescent and Adult Spinal Deformity: Operative Management

Clinical scenarios

Top three questions

Question 1: Have current classification systems improved preoperative planning and fusion level determination for AIS and ASD patients?

Question 2: For AIS and ASD patients, do minimally invasive surgical techniques have better operative and radiographic outcomes compared to traditional open techniques?

Question 3: For AIS and ASD patients, does operative management achieve better correction and quality of life outcomes compared to patients treated otherwise?

Summary of answers

References

118 Metastatic/Myeloma Disease

Clinical scenario

Top three questions