Jaskarndip Chahal

As an alternative to conducting multiple parallel group randomized controlled trials, the factorial design is an efficient means of evaluating multiple interventions. This review highlights when it is appropriate to conduct a factorial trial, considers the structure and nomenclature of factorial designs, and discusses various methodological considerations, including sample size calculation, the role of statistical interactions between different interventions, and statistical power. Several pertinent examples in orthopaedics and medicine are used to highlight the key concepts.

Purpose: Despite the theoretic basis and interest in using platelet‐rich plasma (PRP) to improve the potential for rotator cuff healing, there remains ongoing controversy regarding its clinical efficacy. The objective of this systematic review was to identify and summarize the available evidence to compare the efficacy of arthroscopic rotator cuff repair in patients with full‐thickness rotator cuff tears who were concomitantly treated with PRP. Methods: We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, and PubMed for eligible studies. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed using a random effects model to arrive at summary estimates of treatment effect with associated 95% confidence intervals. Results: Five studies (2 randomized and 3 nonrandomized with comparative control groups) met the inclusion criteria, with a total of 261 patients. Methodologic quality was uniformly sound as assessed by the Detsky scale and Newcastle‐Ottawa Scale. Quantitative synthesis of all 5 studies showed that there was no statistically significant difference in the overall rate of rotator cuff retear between patients treated with PRP and those treated without PRP (risk ratio, 0.77; 95% confidence interval, 0.48 to 1.23). There were also no differences in the pooled Constant score; Simple Shoulder Test score; American Shoulder and Elbow Surgeons score; University of California, Los Angeles shoulder score; or Single Assessment Numeric Evaluation score. Conclusions: PRP does not have an effect on overall retear rates or shoulder‐specific outcomes after arthroscopic rotator cuff repair. Additional well‐designed randomized trials are needed to corroborate these findings. Level of Evidence: Level III, systematic review of Level I, II, and III studies

There is increasing evidence that a significant proportion of randomized trials in medicine, and recently in orthopaedics, do not go on to publication. The objectives of this study were (1) to determine publication rates of randomized controlled trials in sports medicine that have been registered with ClinicalTrials.gov (CTG) and (2) to compare the registration summaries of randomized trials on CTG with final published manuscripts on pertinent methodological variables. Systematic review. Two independent investigators searched ClinicalTrials.gov for all closed and completed trials related to sports medicine until June 2009 using a text search strategy. The authors then searched for publications resulting from these registered trials in peer-reviewed journals that are indexed with MEDLINE and/or EMBASE as of February 2012 based on study authors and key words provided in the study protocol. Details of primary outcomes and secondary outcomes, study sponsors, and sample size were extracted and compared between registrations and publications. Of 34 closed and completed trials registered on CTG, there were 20 resultant publications in peer-reviewed journals (58.8%). There was no significant relationship between source of funding and rate of publication (P > .05). The authors found a discrepancy between the CTG registration summary and the manuscript in at least one methodological variable (primary/secondary outcomes, inclusion/exclusion criteria, sample size) in 16 of 20 (80.0%) articles and a discrepancy in the primary outcome in 8 of 20 (40.0%) published trials. Although registration of sports medicine trials in CTG does not consistently result in publication or disclosure of results at 32 months from the time of study completion, observed publication rates are higher than in other orthopaedic subspecialties. Changes are also frequently made to the final presentation of eligibility criteria and primary and secondary outcomes that are not reflected in the registered trial data.

Osteochondritis dissecans (OCD) lesions can progress to loose body formation for which treatment is controversial and may involve excision or fixation. There is a paucity of published data regarding long-term outcomes following OCD loose body fixation. This case report presents an interval follow-up of a patient from a previous small case series of individuals who underwent open reduction internal fixation of large, lateral OCD loose bodies. At 21-year follow-up the patient has full, pain-free range of motion, and has not required subsequent surgery. This case, to our knowledge, is the first to report over 20-year follow-up from fixation of an OCD loose body and demonstrates a good long-term outcome. Clinicians should consider replacement and fixation of an OCD loose body when possible, as this may provide the best chance of long-term function.

Purpose: The objective of this systematic review was to determine the efficacy of anatomic Bankart repair in patients with a first‐time shoulder dislocation compared with either arthroscopic lavage or traditional sling immobilization. Methods: We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL, Web of Science, LILACS, and a clinical trials registry for ongoing and completed randomized or quasi‐randomized controlled trials comparing anatomic Bankart repair with either rehabilitation or arthroscopic lavage. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed by use of a random‐effects model, and risk ratio (RR) and 95% confidence intervals (CIs) were computed. Results: We included 3 randomized trials and 1 quasi‐randomized trial comprising 228 patients. Of the included trials, 2 compared anatomic Bankart repair with sling immobilization whereas 2 compared Bankart repair with arthroscopic lavage. A meta‐analysis of all 4 trials showed that the rate of recurrent instability was significantly lower among participants undergoing anatomic Bankart repair compared with those undergoing either immobilization or arthroscopic lavage (RR, 0.18; 95% CI, 0.10 to 0.33). Subgroup analysis showed that this effect persisted when Bankart repair was compared with arthroscopic lavage alone (2 studies) (RR, 0.14; 95% CI, 0.06 to 0.31) or sling immobilization alone (2 studies) (RR, 0.26; 95% CI, 0.10 to 0.67). Western Ontario Shoulder Instability scores were better with anatomic Bankart repair compared with either arthroscopic lavage or immobilization (2 studies) (mean difference, –232; 95% CI, –317 to –146). Conclusions: There is evidence to suggest treatment of young patients with a first‐time shoulder dislocation with anatomic Bankart repair with the goal of lowering the rate of recurrent instability over the long‐term and improving short‐term quality of life. Level of Evidence: Level II, systematic review of Level I and II studies.

Purpose: The purpose of this study was to determine the efficacy of arthroscopic repair of full‐thickness rotator cuff tears with and without subacromial decompression. Methods: We searched the Cochrane Central Register of Controlled Trials (third quarter of 2011), Medline (1948 to week 1 of September 2011), and Embase (1980 to week 37 of 2011) for eligible randomized controlled trials. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed by use of a random effects and relative risk model with computation of 95% confidence intervals. Results: We included 4 randomized trials and 373 patients. Methodologic quality was variable as assessed by the CLEAR NPT (Checklist to Evaluate a Report of a Non‐pharmacological Trial) tool. One trial showed that there was no difference in disease‐specific quality of life (Western Ontario Rotator Cuff questionnaire) between the 2 treatment groups. A meta‐analysis of shoulder‐specific outcome measures (American Shoulder and Elbow Surgeons or Constant scores) or the rate of reoperation between patients treated with subacromial decompression and those treated without it also showed no statistically significant differences. Conclusions: On the basis of the currently available literature, there is no statistically significant difference in subjective outcome after arthroscopic rotator cuff repair with or without acromioplasty at intermediate follow‐up. Level of Evidence: Level I, systematic review of Level I studies.

Injury patterns to the posteromedial corner of the knee have not been previously studied in the context of multiligament knee injuries. We performed a retrospective magnetic resonance imaging and clinical review of a consecutive series of 27 dislocatable knees presenting to a single level‐one trauma center from 2005 to 2008. Post‐injury magnetic resonance imaging studies were reviewed by two fellowship‐trained musculoskeletal radiologists to assess injury patterns to the posteromedial corner. In our series, injury to at least one structure within the posteromedial corner was observed in 81% (22/27) of cases while injury to the superficial medial collateral ligament alone was seen in 63% (17/27) of cases. Furthermore, injuries to the posterior horn of the medial meniscus were associated with a tear of the meniscotibial ligaments in all cases and with a tear of the posterior oblique ligament in 67% of cases. All patients with grade III laxity (>10 mm medial opening) under an examination under anesthesia had a complete tear of the posterior oblique ligament and meniscotibial ligament in addition to a medial collateral ligament injury. Injury to the semimembranosus attachment alone was not associated with clinically significant laxity under an examination under anesthesia. Our findings demonstrate that injuries to the posteromedial corner are common in the setting of traumatic knee dislocations. Interestingly, high‐grade medial instability during an examination under anesthesia and injury to the posterior horn of the medial meniscus may be important indicators for further posteromedial corner injury.

Our case report highlights the complexity of treating multi‐ligament knee injuries in the setting of ipsilateral long bone trauma. We describe the use of the tibial inlay technique for PCL reconstruction in the setting of a tibial shaft fracture treated with an intramedullary nail. We also present a comprehensive treatment algorithm for the treatment of ligamentous knee injuries in the setting of long bone trauma.