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[...]a potential threat for less successful long-term outcome in patients over 70 years of age is the worldwide trend of increased use of cementless implants instead of cemented ones, which is paradoxical, as more and more reports show that in older patients this leads to higher revision rates and re-operation rates than with cemented hips.5,6 Explanations for this trend are the intensive marketing of the more expensive cementless implants by the orthopaedics industry, and the willingness of orthopaedic surgeons to adopt to the less time-consuming cementless surgical technique.5 The introduction of larger heads, in an attempt to overcome dislocations, might also generate higher revision rates.7 However, the real problem highlighted by Bayliss and colleagues is the increasing failure rates of both hip and knee implants at younger ages.

Purpose Recurrent patellofemoral instability is a common knee injury in skeletally immature patients. Many surgical techniques have been described in the literature, all with different success rates. Purpose of this study was to perform a systematic review and meta-analysis of the available literature to assess recurrent patellofemoral instability rates after surgical treatment using MPFL reconstruction techniques and other soft tissue realignment techniques in skeletally immature patients. Methods PubMed, Embase, Web of Science, and The Cochrane Library were searched to identify all original articles concerning the surgical treatment for patellofemoral instability in skeletally immature patients and that reported post-operative recurrent patellofemoral instability rates. Subsequently a risk of bias assessment was conducted and a meta-analysis was performed on reported post-operative recurrent patellofemoral instability rates after MPFL reconstruction techniques and other soft tissue realignment techniques. Results Of the 21 eligible studies (448 knees in 389 patients), 10 studies reported on MPFL reconstruction techniques using different grafts and fixation techniques and 11 reported on other soft tissue realignment procedures. In total, 62 of the 448 (13.8%) treated knees showed recurrent patellofemoral instability during follow-up. The overall pooled recurrent patellofemoral instability rate was estimated to be 0.08 (95% CI 0.02–0.16). For MPFL reconstruction techniques, the pooled recurrent patellofemoral instability rate was estimated to be 0.02 (95% CI 0.00–0.09). For the other soft tissue realignment techniques, the pooled rate was estimated to be 0.15 (95% CI 0.04–0.31). No statistically significant difference in recurrent patellofemoral instability rates between MPFL reconstruction techniques and other soft tissue realignment techniques were found (n.s.). There was a large variation in treatment effects over different settings, including what effect is to be expected in future patients. Conclusion This systematic review and meta-analysis found that recurrent patellofemoral instability rates after MPFL reconstruction techniques are in the range of instability rates after other soft tissue realignment techniques. The clinical relevance of this study is that it provides clinicians with the best currently available evidence on recurrent patellofemoral instability rates after surgical treatment for patellofemoral instability in skeletally immature patients. Level of evidence IV.

Background There are no published studies on the simultaneous effect of extent and location of positive surgical margins (PSMs) on biochemical recurrence (BCR) after robot-assisted laparoscopic prostatectomy (RALP). The aim was to report the incidence, extent, and location of PSMs over the inclusion period as well as the rates of BCR and cancer-related mortality, and determine if BCR is associated with PSM extent and/or location. Methods Retrospective review of 530 consecutive patients who underwent RALP between 2003 and 2012. Kaplan-Meier (KM) survival analyses and Cox regressions were performed to determine variables associated with BCR. Results For the 530 operated patients, evaluated at a median of 92 months (IQR, 87–99), PSMs were observed in 156 (29%), of which 24% were focal. Out of 172 PSMs, 126 (73%) were focal and 46 (27%) were extensive. The KM survival using BCR as endpoint was 0.81 (CI, 0.78–0.85) at 5 years and was 0.67 (CI, 0.61–0.72) at 10 years; and using cancer-related mortality as endpoint was 0.99 (CI, 0.99–1.00) at 5 years and 0.95 (CI, 0.92–0.98) at 10 years. Multi-variable analysis revealed the strongest predictors of BCR to be Gleason score ≥ 8 (HR = 7.97; CI, 4.38–14.51) and 4 + 3 (HR = 3.88; CI, 2.12–7.07), lymph nodes invasion (HR = 3.42; CI, 1.70–6.91), pT stage 3b or 4 (HR = 3.07; CI, 1.93–4.90), and extensive apical PSMs (HR = 2.62; CI, 1.40–4.90) but not focal apical PSMs (HR = 0.86; CI, 0.49–1.50; p  = 0.586). Conclusion Extensive apical PSMs significantly increased the risk of BCR, independently from pT stage, Gleason score and lymph nodes invasion, while focal apical PSMs had no significant effect on BCR.

Purpose The incidence of retear following rotator cuff repair remains a major concern, and the cause and timing of retear remain unclear. The aim of this study was to prospectively investigate the timing of retears following rotator cuff repair at multiple time intervals. The hypothesis was that the ‘critical period’ for retears extends beyond the first three post-operative months. Methods The authors prospectively studied 206 shoulders that underwent arthroscopic double-row (without suture bridge) suture anchor repair for rotator cuff tears. Patients were recalled to three follow-up visits at the following post-operative time intervals: 3, 6, and 12 months or longer. Ultrasonography was performed at each visit, and Constant score was collected during the last visit. Results A total of 176 shoulders attended all required follow-up visits with mean age 56.0 years. Ultrasonography revealed retears in 16 shoulders (9.1 %) at 3 months, in 6 shoulders (3.4 %) at 6 months, and in 5 others (2.8 %) at the last follow-up, while it confirmed intact rotator cuffs in 149 shoulders (84.7 %) at the last follow-up (median 35.5; range 12–61). The incidence of retears was significantly associated with tear size ( p  = 0.001) and tendon degeneration ( p  = 0.003). Conclusion The ‘critical period’ for healing following rotator cuff repair, during which risks of retears are high, extends to the first 6 months. The risk of retear is greatest for massive 3-tendon tears, which may require longer periods of protection. The clinical relevance of this study is the identification of patients at risk of retear and the adjustment of their rehabilitation strategy and time for return to work. Level of evidence III.

ObjectiveMinimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking.DesignWe combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%).ResultsAmong 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005).ConclusionIn high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.

Purpose The authors have previously published early outcomes of arthroscopic repairs of 86 massive rotator cuff tears (mRCTs) and aimed to determine whether their clinical scores are maintained or deteriorate after 5 more years. Methods Of the initial series of 86 shoulders, 2 had deceased, 16 lost to follow-up and 4 reoperated, leaving 64 for assessment. The repairs were complete in 44 and partial in 20, and 17 shoulders had pseudoparalysis. Preoperative assessment included absolute Constant score, shoulder strength, tear pattern, tendon retraction, and fatty infiltration. Patients were evaluated at 8.1 ± 0.6 years (range 7.1–9.3) using absolute and age-/sex-adjusted Constant score, subjective shoulder value (SSV), and simple shoulder test (SST). Results Absolute Constant score was 80.0 ± 11.7 at first follow-up (at 2–5 years) but diminished to 76.7 ± 10.2 at second follow-up (at 7–10 years) ( p  < 0.001). Adjusted Constant score was 99.7 ± 15.9 at first follow-up and remained 98.8 ± 15.9 at second follow-up (ns). Comparing other outcomes revealed a decrease in strength over time ( p  < 0.001) but no change in pain, SSV or SST. Partially-repaired shoulders had lower strength at both follow-ups ( p  < 0.05). Pseudoparalytic shoulders had lower absolute and adjusted Constant score at second follow-up ( p  < 0.05), but their net improvements in absolute Constant score were higher ( p  = 0.014). Conclusions Both partial and complete arthroscopic repairs grant satisfactory long-term outcomes for patients with mRCTs, regardless of their tear pattern, fatty infiltration and presence of pseudoparalysis. Absolute Constant score decreased over time for both repair types, but adjusted Constant score remained stable, suggesting that decline is due to aging rather than tissue degeneration. The clinical relevance of this study is that arthroscopic repair should be considered for mRCTs, even if not completely repairable, rather than more invasive and/or risky treatments, such as reverse shoulder arthroplasty. Level of evidence IV.

Background An alternative to the current gold standard in operative treatment of displaced midshaft clavicle fractures (DMCF) using plate osteosynthesis, is internal fixation by means of intramedullary fixation devices. These devices differ considerably in their specifications and characteristics and an evaluation of their clinical results is warranted. The aim of this systematic review is to generate an overview of functional outcomes and complications in the management of DMCF per available intramedullary device. Methods A systematic review was conducted to identify all papers reporting functional outcomes, union rates and/or complications using an intramedullary fixation device for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until February 2020. Meta-analysis was conducted based on functional outcomes and type of complication per type of intramedullary fixation device. Pooled estimates of functional outcomes scores and incidence of complications were calculated using a random effects model. Risk of bias and quality was assessed using the Cochrane risk of bias and ROBINS-I tools. The confidence in estimates were rated and described according to the recommendations of the GRADE working group. Results Sixty-seven studies were included in this systematic review. The majority of studies report on the use of Titanium Elastic Nails (TEN). At 12 months follow up the Titanium Elastic Nail and Sonoma CRx report an average Constant-Murley score of 94.4 (95%CI 93–95) and 94.0 (95%CI 92–95) respectively (GRADE High). The most common reported complications after intramedullary fixation are implant-related and implant-specific. For the TEN, hardware irritation and protrusion, telescoping or migration, with a reported pooled incidence 20% (95%CI 14–26) and 12% (95%CI 8–18), are most common (GRADE Moderate). For the Rockwood/Hagie Pin, hardware irritation is identified as the most common complication with 22% (95%CI 13–35) (GRADE Low). The most common complication for the Sonoma CRx was cosmetic dissatisfaction in 6% (95%CI 2–17) of cases (GRADE Very low). Conclusion Although most studies were of low quality, good functional results and union rates irrespective of the type of device are found. However, there are clear device-related and device-specific complications for each. The results of this systematic review and meta-analysis can help guide surgeons in choosing the appropriate operative strategy, implant and informing their patient. Level of Evidence IV

BackgroundRisk stratification in men with suspicion of prostate cancer (PCa) requires reliable diagnostic tests, not only to identify high-grade PCa, also to minimize the overdetection of low-grade PCa, and reduction of “unnecessary” prostate MRIs and biopsies. This study aimed to evaluate the SelectMDx test to detect high-grade PCa in biopsy-naïve men. Subsequently, to assess combinations of SelectMDx test and multi-parametric (mp) MRI and its potential impact on patient selection for prostate biopsy.MethodsThis prospective multicenter diagnostic study included 599 biopsy-naïve patients with prostate-specific antigen level ≥3 ng/ml. All patients underwent a SelectMDx test and mpMRI before systematic transrectal ultrasound-guided biopsy (TRUSGB). Patients with a suspicious mpMRI also had an in-bore MR-guided biopsy (MRGB). Histopathologic outcome of TRUSGB and MRGB was used as reference standard. High-grade PCa was defined as ISUP Grade Group (GG) ≥ 2. The primary outcome was the detection rates of low- and high-grade PCa and number of biopsies avoided in four strategies, i.e., (1) SelectMDx test-only, (2) mpMRI-only, (3) SelectMDx test followed by mpMRI when SelectMDx test was positive (conditional strategy), and (4) SelectMDx test and mpMRI in all (joint strategy). A positive SelectMDx test outcome was a risk score of ≥−2.8. Decision curve analysis (DCA) was performed to assess clinical utility.ResultsPrevalence of high-grade PCa was 31% (183/599). Thirty-eight percent (227/599) of patients had negative SelectMDx test in whom biopsy could be avoided. Low-grade PCa was not detected in 35% (48/138) with missing 10% (18/183) high-grade PCa. Yet, mpMRI-only could avoid 49% of biopsies, not detecting 4.9% (9/183) of high-grade PCa. The conditional strategy reduces the number of mpMRIs by 38% (227/599), avoiding biopsy in 60% (357/599) and missing 13% (24/183) high-grade PCa. Low-grade PCa was not detected in 58% (80/138). DCA showed the highest net benefit for the mpMRI-only strategy, followed by the conditional strategy at-risk thresholds >10%.ConclusionsSelectMDx test as a risk stratification tool for biopsy-naïve men avoids unnecessary biopsies in 38%, minimizes low-grade PCa detection, and misses only 10% high-grade PCa. Yet, using mpMRI in all patients had the highest net benefit, avoiding biopsy in 49% and missing 4.9% of high-risk PCa. However, if mpMRI availability is limited or expensive, using mpMRI-only in SelectMDx test positive patients is a good alternative strategy.

ObjectivesTo adjust for confounding in observational data, researchers use propensity score matching (PSM), but more advanced methods might be required when dealing with longitudinal data and time-varying treatments as PSM might not include possible changes that occurred over time. This study aims to explore which confounding adjustment methods have been used in longitudinal observational data to estimate a treatment effect and identify potential inappropriate use of PSM.DesignMapping review.Data sourcesWe searched PubMed, from inception up to January 2021, for studies in which a treatment was evaluated using longitudinal observational data.Eligibility criteriaMethodological, non-medical and cost-effectiveness papers were excluded, as were non-English studies and studies that did not study a treatment effect.Data extraction and synthesisStudies were categorised based on time of treatment: at baseline (interventions performed at start of follow-up) or time-varying (interventions received asynchronously during follow-up) and sorted based on publication year, time of treatment and confounding adjustment method. Cumulative time series plots were used to investigate the use of different methods over time. No risk-of-bias assessment was performed as it was not applicable.ResultsIn total, 764 studies were included that met the eligibility criteria. PSM (165/201, 82%) and inverse probability weighting (IPW; 154/502, 31%) were most common for studies with a treatment at baseline (n=201) and time-varying treatment (n=502), respectively. Of the 502 studies with a time-varying treatment, 123 (25%) used PSM with baseline covariates, which might be inappropriate. In the past 5 years, the proportion of studies with a time-varying treatment that used PSM over IPW increased.ConclusionsPSM is the most frequently used method to correct for confounding in longitudinal observational data. In studies with a time-varying treatment, PSM was potentially inappropriately used in 25% of studies. Confounding adjustment methods designed to deal with a time-varying treatment and time-varying confounding are available, but were only used in 45% of the studies with a time-varying treatment.

Purpose To evaluate the diagnostic accuracy between magnetic resonance arthrography (MRA) and arthroscopic examination for the assessment of pathologies of the long head of the biceps (LHB) prior to rotator cuff (RC) repair. The hypothesis was that MRA is suitable to identify biceps instabilities, due to improved visibility of the biceps pulley. Methods Sixty-six patients aged 58.5 ± 17.6 (range, 46–71) scheduled to have RC repair between 2016 and 2017 were prospectively enrolled. MRA images of the LHB were interpreted by one radiologist and two surgeons, then compared to arthroscopic findings. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated by comparing MRA axial readings to arthroscopic assessment in the neutral position (static instability), MRA sagittal readings to arthroscopic assessment in external rotation (dynamic s instability), MRA coronal and axial readings to arthroscopic assessment in the neutral position (tendinopathy). Results Among the three observers, the radiologist obtained the highest sensitivity and specificity for MRA, which were respectively: (1) for static instability, 62% (C.I. 35–85) and 77% (C.I. 63–88); (2) for dynamic instability, 50% (C.I. 29–71) and 62% (C.I. 46–77), and (3) for tendinopathy, 49% (C.I. 36–62) and 100% (C.I. 3–100). Conclusions MRA is not suitable for the diagnosis of LHB lesions prior to arthroscopic rotator cuff repair. Level of evidence Diagnostic study, Level I.