Presented by OrthoEvidence

Good Morning.  Today’s newsletter features a great discussion on diversity and inclusion in orthopaedics. It’s a real concern in the field: females and minorities are underrepresented in orthopaedics. Encouraging the next generation – from all walks of life – to pursue a career in orthopaedics is in the interest of us all. 

In today's edition:

🦵🏼 Intramedullary nail vs. dynamic hip screw

🥼 Treating degenerative meniscus tears

🩸 Spinal vs. general anesthesia

With millions of hip fractures occurring every year, identifying the fixation method that provides the best clinical outcomes is a major question that needs answering. The intramedullary nail and dynamic hip screw are two of the dominant fixation tools. But, evidence is conflicting on which one provides the best outcomes: with new RCTs being published in recent years, a new meta-analysis was warranted.

30 studies with a total of 6,650 patients were included in this systematic review and meta-analysis comparing intramedullary nailing and dynamic hip screws for hip fracture (AO/OTA 31A1-A3) fixation. Outcomes of interest included intra-operative, post-operative and complication outcomes.

• Intramedullary nailing was associated with less blood loss and femoral neck shortening, and a lower likelihood of non-union compared to dynamic hip screws.

• Dynamic hip screws required less screening time, led to slightly greater mobility, and a lower likelihood of femoral fracture compared to intramedullary nailing.

Bottom line. Intramedullary nailing provides significant benefits in blood loss, femoral neck shortening and non-union compared to dynamic hip screws. However, the likelihood of femoral fracture is higher and dynamic hip screws may provide slightly better mobility. 

Check out the comprehensive analysis of this paper here.

One of the greatest debates in orthopaedics right now is the utility of arthroscopic partial meniscectomy (APM). Recent evidence suggests no value of APM compared to conservative methods. Despite the move away from APM, it is possible that certain patients may benefit from the procedure. This meta-analysis of individual patient data aimed to find out which populations with degenerative meniscus tears could benefit from the procedure.

Individual patient data from four RCTs was pooled in this analysis, comparing APM with non-surgical or sham treatment. Outcomes of interest included pain, knee function, health-related quality of life, and mental health. Subgroups were created for age, gender, BMI, affected knee (left; right), location of tear, KL grade, activity level, symptom levels, quality of life, and mental health scores.

• At 24 months, patients who received APM scored higher on knee pain than the control group. No benefit was observed in knee function, quality of life or mental health was observed.

• For pain, knee function, and mental health scores, no sub-group was found to benefit from APM compared to control.

• For health-related quality-of-life outcomes, none of the subgroups were found to benefit from APM except those with baseline mental health scores, however, this was not considered clinically relevant.

Bottom line. Whilst APM showed a benefit in knee pain at 2 years follow-up, no populations were found to benefit from APM vs. conservative treatment or sham surgery for the treatment of degenerative meniscal tears. The utility of APM is still unclear, and its use should be cautiously applied for patients with degenerative meniscal tears.

Read the full ACE Report on this study here.

Spinal and general anesthesia are the most commonly used methods in hip fracture surgery. With ongoing debate on which one is the safest and most effective, we ran a systematic review of the literature to see what the latest, high-quality evidence has to say on the topic.

We included 11 RCTs, with a total of 2,359 patients undergoing hip fracture surgery. Outcomes of interest included blood loss, length of hospitalization, opioid consumption, mortality, delirium, and the incidence of serious adverse events. 

• Patients who received spinal anesthesia experienced significantly less blood loss (p<0.001), had a shorter length of hospitalization (p=0.01), and consumed less opioids compared to general anesthesia (p=0.01).

• No differences in the risk of 60-day mortality (p=0.71), delirium (p=0.77) or serious adverse events were observed between the two anesthesia types (p=0.88)

Bottom line. Spinal anesthesia appears to be significantly better than general anesthesia for patients undergoing hip fracture surgery. In particular, it led to less blood loss, shorter hospital stay, and less opioid consumption post-operation. 

Read the full article here.

The Creativity Crisis in Surgery – Creativity: it’s one of the most essential skills in the 21st century. In a rapidly changing world, the creatives are the ones who will be highly sought after. But why don’t we value creativity like we should in surgery? In this OE Insight, we discuss the crisis of creativity in surgery. (Read)

Suture Button vs. Screw Fixation: A Cost-Utility Analysis – Syndesmosis injuries can be treated with screw fixation and suture button fixation. We found suture button to be safer and more effective than screw fixation. But is it cost-effective? We conducted a cost-utility analysis to find out. (Read)

Promoting Diversity in Orthopaedics – In this OrthoJoe, Mo & Marc sit down with Jennifer Green for a discussion on the importance of diversity, and how we can encourage people from all walks of life to pursue a career in orthopaedics for the betterment of patients and the profession.  (Watch)

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