KKR (Korte Kliniske Retningslinjer)
Anne Thiel, Simone Rechter, Ilija Ban, Sinan Said, Peter Søndergaard
Herlev Hospital, Afd. f. Led- & Knoglekirurgi (Traumesektor); Bispebjerg Hospital, Ortopædkirurgisk Afd. (Idrætssektor); Hvidovre Hospital, Ortopædkirurgisk Afd. (Traumesektor); Aalborg Universitetshospital, Ortopædkirurgisk Afd. (Idrætssektor)
Background: Traumatic dislocation of the knee is a rare orthopaedic injury with often severe concomitant damage. In addition to the ligamentous injuries there is a significant risk of vascular injury (18% of total number) which can be potentially limb threatening if undiagnosed or late recognised. It is therefore crucial with a correct and safe diagnostic method in the acute phase.
Purpose / Aim of Study: To establish an evidence based and standardised guideline for diagnosing vascular injuries in the acute phase after dislocation of the knee (with or without associated fractures).
Materials and Methods: The investigated diagnostic methods were clinical examination by means of Ankle-Brachial-Index (ABI) compared to a defined golden standard, i.e., CT- or MR-angiography. A systematic Pubmed search for relevant literature published during the last 10 years was made (April 2020). Languages were English and German. In total 1383 articles were found, by title 1245 were excluded. The latest systematic review found was from 2014. Including this all articles published hereafter (99) were evaluated by abstract and/or full text and 98 excluded. The remaining systematic review was included. Additional search was made in Scopus (database of citations) using the identified seminal paper as object. The quality of the included studies was evaluated by using AMSTAR and QUADAS.
Findings / Results: Two relevant studies of sufficient quality were identified: 1 systematic review and 1 diagnostic study. No studies directly comparing the diagnostic modalities were identified. Yet the available data did not show any difference in sensitivity between the methods.
Conclusions: Based on existing evidence clinical examination combined with systematic observation and use of ABI is a safe alternative to CT- or MR-angiography in the acute phase after dislocation of the knee. There is however a need of more studies to sufficiently enlighten the field.
Herlev Hospital, Afd. f. Led- & Knoglekirurgi (Traumesektor); Bispebjerg Hospital, Ortopædkirurgisk Afd. (Idrætssektor); Hvidovre Hospital, Ortopædkirurgisk Afd. (Traumesektor); Aalborg Universitetshospital, Ortopædkirurgisk Afd. (Idrætssektor)
Background: Traumatic dislocation of the knee is a rare orthopaedic injury with often severe concomitant damage. In addition to the ligamentous injuries there is a significant risk of vascular injury (18% of total number) which can be potentially limb threatening if undiagnosed or late recognised. It is therefore crucial with a correct and safe diagnostic method in the acute phase.
Purpose / Aim of Study: To establish an evidence based and standardised guideline for diagnosing vascular injuries in the acute phase after dislocation of the knee (with or without associated fractures).
Materials and Methods: The investigated diagnostic methods were clinical examination by means of Ankle-Brachial-Index (ABI) compared to a defined golden standard, i.e., CT- or MR-angiography. A systematic Pubmed search for relevant literature published during the last 10 years was made (April 2020). Languages were English and German. In total 1383 articles were found, by title 1245 were excluded. The latest systematic review found was from 2014. Including this all articles published hereafter (99) were evaluated by abstract and/or full text and 98 excluded. The remaining systematic review was included. Additional search was made in Scopus (database of citations) using the identified seminal paper as object. The quality of the included studies was evaluated by using AMSTAR and QUADAS.
Findings / Results: Two relevant studies of sufficient quality were identified: 1 systematic review and 1 diagnostic study. No studies directly comparing the diagnostic modalities were identified. Yet the available data did not show any difference in sensitivity between the methods.
Conclusions: Based on existing evidence clinical examination combined with systematic observation and use of ABI is a safe alternative to CT- or MR-angiography in the acute phase after dislocation of the knee. There is however a need of more studies to sufficiently enlighten the field.
Christian Kastenskov, Jeppe Staghøj og Rasmus Kramer Mikkelsen
Fagområde: Idrætskirurgi
Background: There is concern about chondrotoxicity of intraarticular local anesthetics. Some surgeons have lowered the dose or discontinued the use but there is no national consensus.
Purpose / Aim of Study: The aim of this short clinical guideline is to report the effect of postoperative intraarticular injection of local anesthetics after arthroscopic knee surgery reported with a relevant pain score.
Materials and Methods: We conducted a search on PubMed database for systematic reviews. Then made another search for any clinical trials published after the latest systematic review. We included 3 systematic reviews (1 study on Morphine, 1 study on Bupivacaine and 1 study on Ropivacaine) and 1 clinical trial published later (Ketamine). The methodological quality of systematic reviews was assed using AMSTAR and the clinical trial was assessed using Cochrane risk of bias tool.
Findings / Results: Studies report small differences in VAS. Bupivacaine had the best effect 2 hours postoperatively, reducing VAS by 10,7mm. Ropivacaine showed similar effect and reduced VAS by 11,9mm 2-8 hours postoperatively. The study testing ketamine did not report a specific VAS reduction and was of low methodical quality. Morphine had no significant effect. When analyzing the reduction in VAS, it should be noticed that the Minimal Clinical Important Difference (MCID) for patients postoperatively is reported to
Conclusions: This short clinical guideline found a slight reduction in VAS when using Bupivacaine and Ropivacaine postoperative. This reduction might not be of clinical relevance. It is recommended to consider the adverse effects before administration of Ropivacain or Bupivacain.
Fagområde: Idrætskirurgi
Background: There is concern about chondrotoxicity of intraarticular local anesthetics. Some surgeons have lowered the dose or discontinued the use but there is no national consensus.
Purpose / Aim of Study: The aim of this short clinical guideline is to report the effect of postoperative intraarticular injection of local anesthetics after arthroscopic knee surgery reported with a relevant pain score.
Materials and Methods: We conducted a search on PubMed database for systematic reviews. Then made another search for any clinical trials published after the latest systematic review. We included 3 systematic reviews (1 study on Morphine, 1 study on Bupivacaine and 1 study on Ropivacaine) and 1 clinical trial published later (Ketamine). The methodological quality of systematic reviews was assed using AMSTAR and the clinical trial was assessed using Cochrane risk of bias tool.
Findings / Results: Studies report small differences in VAS. Bupivacaine had the best effect 2 hours postoperatively, reducing VAS by 10,7mm. Ropivacaine showed similar effect and reduced VAS by 11,9mm 2-8 hours postoperatively. The study testing ketamine did not report a specific VAS reduction and was of low methodical quality. Morphine had no significant effect. When analyzing the reduction in VAS, it should be noticed that the Minimal Clinical Important Difference (MCID) for patients postoperatively is reported to
Conclusions: This short clinical guideline found a slight reduction in VAS when using Bupivacaine and Ropivacaine postoperative. This reduction might not be of clinical relevance. It is recommended to consider the adverse effects before administration of Ropivacain or Bupivacain.
Ane Simony, Niels Wiesbech Pedersen, Mikkel Osterheden Andersen
Sector for Spine Surgery & Research, Middelfart Hospital
Background: In 2016 a short clinical guideline (KKR) was presented, regarding the choice off conservative treatment off Adolescent Idiopathic Scoliosis Patients. Night-time bracing was introduced as a treatment in 2007 in Denmark.
Purpose / Aim of Study: The purpose of this study was to revise the short clinical guideline (KKR) from 2016, and include research performed since 2016.
Materials and Methods: A systematic review off the literature was conducted with the original pubmed search string, but due to technical problems the search string was updated, and a new search was performed 3.3.2020. The answer to the PICO question, is the rate off curve progression in Patients with Adolescent Idiopathic Scoliosis similar, between patients treated with Night-time brace and Full-time brace was based on the findings.
Findings / Results: 195 abstracts were identified, and 44 papers was evaluated by the authors. 23 papers were found eligible to include. We were not able to find any systematic reviews or randomised controlled trials (RCT) comparing full time bracing and night-time bracing of AIS patients. 2 controlled trials and 21 retrospective studies were identified and included.
Conclusions: It is still our recommended to use night-time braces in the conservative treatment off AIS, but the recommendation is based on a weak scientific basic, since no systematic reviews or RCT was included.
CONTRAIS a RCT comparing fulltime bracing with Boston Braces and Night-time bracing with Providence Night time braces is currently performed, at Karolinska Hospital, Sweden. The findings from this study will influence the recommendation for conservative treatment off AIS patients and a further revision is recommended when the results from this study is performed.
Sector for Spine Surgery & Research, Middelfart Hospital
Background: In 2016 a short clinical guideline (KKR) was presented, regarding the choice off conservative treatment off Adolescent Idiopathic Scoliosis Patients. Night-time bracing was introduced as a treatment in 2007 in Denmark.
Purpose / Aim of Study: The purpose of this study was to revise the short clinical guideline (KKR) from 2016, and include research performed since 2016.
Materials and Methods: A systematic review off the literature was conducted with the original pubmed search string, but due to technical problems the search string was updated, and a new search was performed 3.3.2020. The answer to the PICO question, is the rate off curve progression in Patients with Adolescent Idiopathic Scoliosis similar, between patients treated with Night-time brace and Full-time brace was based on the findings.
Findings / Results: 195 abstracts were identified, and 44 papers was evaluated by the authors. 23 papers were found eligible to include. We were not able to find any systematic reviews or randomised controlled trials (RCT) comparing full time bracing and night-time bracing of AIS patients. 2 controlled trials and 21 retrospective studies were identified and included.
Conclusions: It is still our recommended to use night-time braces in the conservative treatment off AIS, but the recommendation is based on a weak scientific basic, since no systematic reviews or RCT was included.
CONTRAIS a RCT comparing fulltime bracing with Boston Braces and Night-time bracing with Providence Night time braces is currently performed, at Karolinska Hospital, Sweden. The findings from this study will influence the recommendation for conservative treatment off AIS patients and a further revision is recommended when the results from this study is performed.
A. H. Qvist & T. Falstie-Jensen
Background: Dislocation of the acromioclavicular (AC) joint is a common injury in the active population. Traditionally, management of complete dislocations has been nonoperative with satisfactory outcome. However, some patients experience unacceptable functional limitations and require secondary surgery. Currently, the role of primary surgical treatment in complete acute dislocations remains controversial.
Purpose / Aim of Study: The aim of this study was to revise the Danish short clinical guideline (KKR) for the treatment of acute complete AC joint dislocations.
Materials and Methods: The existing short clinical guideline was used as a framework for this study. A systematic search in PubMed was conducted to identify meta-analyses comparing nonoperative treatment with operative treatment for AC joint dislocations. The methodological quality of all meta-analyses was evaluated with AMSTAR. Only meta-analyses of high methodological quality were included in the revised guideline. Outcomes of interest extracted from the meta-analyses were: functional outcome, complications, pain and radiological outcome. Furthermore, a systematic search in PubMed was conducted to identify relevant randomized controlled trials published after the included meta-analyses.
Findings / Results: We found 5 relevant meta-analyses. One new meta-analysis was identified compared to studies evaluated in the existing KKR. This meta-analysis was the only of the five meta-analyses of high methodological quality and was the only included in this study. It is based on 5 randomized studies and one quasi randomized with a total of 357 patients. Overall, the meta-analysis found the evidence-level of all included randomized studies low. We identified no new randomized controlled trials not represented in the included meta-analysis. Operative treatment of AC joint dislocations improves radiological outcomes, but offers no long-term improvements in functional outcome and pain. Furthermore, operative treatment is associated with complications not seen after nonoperative treatment.
Conclusions: Currently, there is no evidence to support routine operative treatment for complete acute AC joint dislocations.
Background: Dislocation of the acromioclavicular (AC) joint is a common injury in the active population. Traditionally, management of complete dislocations has been nonoperative with satisfactory outcome. However, some patients experience unacceptable functional limitations and require secondary surgery. Currently, the role of primary surgical treatment in complete acute dislocations remains controversial.
Purpose / Aim of Study: The aim of this study was to revise the Danish short clinical guideline (KKR) for the treatment of acute complete AC joint dislocations.
Materials and Methods: The existing short clinical guideline was used as a framework for this study. A systematic search in PubMed was conducted to identify meta-analyses comparing nonoperative treatment with operative treatment for AC joint dislocations. The methodological quality of all meta-analyses was evaluated with AMSTAR. Only meta-analyses of high methodological quality were included in the revised guideline. Outcomes of interest extracted from the meta-analyses were: functional outcome, complications, pain and radiological outcome. Furthermore, a systematic search in PubMed was conducted to identify relevant randomized controlled trials published after the included meta-analyses.
Findings / Results: We found 5 relevant meta-analyses. One new meta-analysis was identified compared to studies evaluated in the existing KKR. This meta-analysis was the only of the five meta-analyses of high methodological quality and was the only included in this study. It is based on 5 randomized studies and one quasi randomized with a total of 357 patients. Overall, the meta-analysis found the evidence-level of all included randomized studies low. We identified no new randomized controlled trials not represented in the included meta-analysis. Operative treatment of AC joint dislocations improves radiological outcomes, but offers no long-term improvements in functional outcome and pain. Furthermore, operative treatment is associated with complications not seen after nonoperative treatment.
Conclusions: Currently, there is no evidence to support routine operative treatment for complete acute AC joint dislocations.
Martin Lind, Jens Christian Pörneki, Andreas Jørgensen, Christen Ravn
SAKS), Århus Universitetshospital; (SAKS), Sygehus Lillebælt – Vejle; (DSOI), Herlev Hospital; (DSOI), Odense Universitetshospital r />Dansk Selskab for Artroskopisk Kirurgi og Sportstraumatologi (SAKS) Dansk Selskab for Ortopædisk Infektionskirurgi (DSOI)
Background: Septic arthritis (SA) is a disease with significant joint destruction and mortality if not treated in time. The initial treatment of SA in the knee joint opens up several dilemmas regarding the level of surgical experience and timing.
Purpose / Aim of Study: 1. Can rinsing the joint via the aspiration cannula ensure sufficient treatment effect in the initial phase? 2. Is early treatment more important than a high level of experience in the initial surgical treatment?
Materials and Methods: The following two PICO questions were investigated: PICO1: Acute surgical treatment for septic knee arthritis - lavage or synovectomy? PICO 2: Timing of surgical intervention for septic knee arthritis - acute (<12 hours) or subacute (12-48 hours)?
Findings / Results: There are no controlled or randomized studies that shed light on the two PICO questions and the defined outcomes. And the literature quality is generally too low compared to making evidence-based recommendations regarding initial treatment of septic arthritis
Conclusions: The working group suggests initial treatment by joint lavage through the puncture needle until clear water returns in cases where bacterial knee arthritis is suspected without septicemia.
SAKS), Århus Universitetshospital; (SAKS), Sygehus Lillebælt – Vejle; (DSOI), Herlev Hospital; (DSOI), Odense Universitetshospital r />Dansk Selskab for Artroskopisk Kirurgi og Sportstraumatologi (SAKS) Dansk Selskab for Ortopædisk Infektionskirurgi (DSOI)
Background: Septic arthritis (SA) is a disease with significant joint destruction and mortality if not treated in time. The initial treatment of SA in the knee joint opens up several dilemmas regarding the level of surgical experience and timing.
Purpose / Aim of Study: 1. Can rinsing the joint via the aspiration cannula ensure sufficient treatment effect in the initial phase? 2. Is early treatment more important than a high level of experience in the initial surgical treatment?
Materials and Methods: The following two PICO questions were investigated: PICO1: Acute surgical treatment for septic knee arthritis - lavage or synovectomy? PICO 2: Timing of surgical intervention for septic knee arthritis - acute (<12 hours) or subacute (12-48 hours)?
Findings / Results: There are no controlled or randomized studies that shed light on the two PICO questions and the defined outcomes. And the literature quality is generally too low compared to making evidence-based recommendations regarding initial treatment of septic arthritis
Conclusions: The working group suggests initial treatment by joint lavage through the puncture needle until clear water returns in cases where bacterial knee arthritis is suspected without septicemia.
Morten Møller, Nanna Salling, Annie Primdahl
Sydvestjysk Sygehus, Esbjerg; Nykøbing Falster Sygehus; Sydvestjysk Sygehus, Esbjerg
Dansk Ortopædisk Traumeselskab (DOT)
Background: The algorithm from Hvidovre concluded that all stabile intertrochanteric fractures (AO 31 A1.1, A1.2, A 1.3 and A 2.1) benefit from osteosynthesis with a dynamic hip screw, while all unstable intertrochanteric fractures (AO 31 A2.2, A 2.3, A 3.1, A 3.2 and A 3.3) should be treated with an intramedullary nail. However, it has never been determined whether a long or short nail was the ideal method of osteosynthesis.
Purpose / Aim of Study: The aim of this short clinical guideline (KKR) was to answer the following research question: “Should unstable intertrochanteric fractures (AO 31 A 2.2, A 2.3, A 3.1, A 3.2 and A 3.3) be fixed with a long intramedullary nail (reaching the top of patella) or a short intramedullary nail.”
Materials and Methods: A search through literature according to a standardized search-protocol admitted by the Danish Orthopedic Society (DOS) was conducted via Pubmed on the 2. Of March 2020. We focused on clinical guidelines, systematic reviews and randomized control-studies (RCT), supported by the directives from DOS. The included studies were rated by GRADE.
Findings / Results: Three systematic reviews were found and included after evaluation by AMSTAR. The three systematic reviews had a large overlay of included primary studies. They all showed a longer duration of surgery and increased peroperative bleeding. There were no statistically significant differences regarding reoperations, refracture rates or infections leading to further surgery. These data support the treatment of AO 31 A2-subtypes, but the studies only included few A3-fractures. Further studies on AO 31 A3-fractures are needed for a conclusion on this subtype.
Conclusions: Long intramedullary nails should only be used after thorough considerations regarding intertrochanteric fractures of the AO 31 A2-subtypes, since there is no evidence supporting a better outcome for the patients compared to a short intramedullary nail.
Sydvestjysk Sygehus, Esbjerg; Nykøbing Falster Sygehus; Sydvestjysk Sygehus, Esbjerg
Dansk Ortopædisk Traumeselskab (DOT)
Background: The algorithm from Hvidovre concluded that all stabile intertrochanteric fractures (AO 31 A1.1, A1.2, A 1.3 and A 2.1) benefit from osteosynthesis with a dynamic hip screw, while all unstable intertrochanteric fractures (AO 31 A2.2, A 2.3, A 3.1, A 3.2 and A 3.3) should be treated with an intramedullary nail. However, it has never been determined whether a long or short nail was the ideal method of osteosynthesis.
Purpose / Aim of Study: The aim of this short clinical guideline (KKR) was to answer the following research question: “Should unstable intertrochanteric fractures (AO 31 A 2.2, A 2.3, A 3.1, A 3.2 and A 3.3) be fixed with a long intramedullary nail (reaching the top of patella) or a short intramedullary nail.”
Materials and Methods: A search through literature according to a standardized search-protocol admitted by the Danish Orthopedic Society (DOS) was conducted via Pubmed on the 2. Of March 2020. We focused on clinical guidelines, systematic reviews and randomized control-studies (RCT), supported by the directives from DOS. The included studies were rated by GRADE.
Findings / Results: Three systematic reviews were found and included after evaluation by AMSTAR. The three systematic reviews had a large overlay of included primary studies. They all showed a longer duration of surgery and increased peroperative bleeding. There were no statistically significant differences regarding reoperations, refracture rates or infections leading to further surgery. These data support the treatment of AO 31 A2-subtypes, but the studies only included few A3-fractures. Further studies on AO 31 A3-fractures are needed for a conclusion on this subtype.
Conclusions: Long intramedullary nails should only be used after thorough considerations regarding intertrochanteric fractures of the AO 31 A2-subtypes, since there is no evidence supporting a better outcome for the patients compared to a short intramedullary nail.
Tobias Aasvang (DOT), Bjarke Viberg (DOT), Søren Overgaard (DSHK), Thomas Jakobsen (DSHK)
Background: Displaced femoral neck fractures are typically treated with a hemiarthroplasty. The fixation of the femoral stem can be cemented or uncemented. Cemented fixation might be associated with increased risk for pulmonary embolism while uncemented fixation might be associated with increased risk for intra- and postoperative fracture. It is unclear whether stem fixation effects mortality, reoperation rate and patient reported outcome.
Purpose / Aim of Study: The aim of the short clinical guideline was to answer the question: “Does patients aged 65 years or above with a femoral neck fracture, and indication for surgery a with hemiarthroplasty, achieve better results with uncemented stem fixation compared to cemented fixation with respect to mortality, reoperation and patient reported outcome?”
Materials and Methods: A systematic literature search was conducted in Pubmed and Embase. Ten RCT and 16 register studies were included. Quality assessment of included articles was conducted using Cochrane Risk of Bias tool for RCT and ROBINS-I for register studies. Final assessment was performed using GRADE.
Findings / Results: The main finding was a reduced risk of reoperation within one and five years when using cemented fixation compared to uncemented fixation. No significant difference was found in mortality. Only few studies presented patient reported outcomes with no clinical relevant differences.
Conclusions: Use a cemented stem fixation for hemiarthroplasty surgery in patients above 65 years with a displaced femoral neck fracture in order to reduce the risk for reoperation.
Background: Displaced femoral neck fractures are typically treated with a hemiarthroplasty. The fixation of the femoral stem can be cemented or uncemented. Cemented fixation might be associated with increased risk for pulmonary embolism while uncemented fixation might be associated with increased risk for intra- and postoperative fracture. It is unclear whether stem fixation effects mortality, reoperation rate and patient reported outcome.
Purpose / Aim of Study: The aim of the short clinical guideline was to answer the question: “Does patients aged 65 years or above with a femoral neck fracture, and indication for surgery a with hemiarthroplasty, achieve better results with uncemented stem fixation compared to cemented fixation with respect to mortality, reoperation and patient reported outcome?”
Materials and Methods: A systematic literature search was conducted in Pubmed and Embase. Ten RCT and 16 register studies were included. Quality assessment of included articles was conducted using Cochrane Risk of Bias tool for RCT and ROBINS-I for register studies. Final assessment was performed using GRADE.
Findings / Results: The main finding was a reduced risk of reoperation within one and five years when using cemented fixation compared to uncemented fixation. No significant difference was found in mortality. Only few studies presented patient reported outcomes with no clinical relevant differences.
Conclusions: Use a cemented stem fixation for hemiarthroplasty surgery in patients above 65 years with a displaced femoral neck fracture in order to reduce the risk for reoperation.