Effects of Sensory Reeducation Programs on Functional Hand Sensibility after Median and Ulnar Repair: A Systematic Review

IntroductionThis is the first systematic review looking at the effectiveness of sensory re-education programmes on functional sensibility which focuses purely on clinical trials of adult patients with median and ulnar nerve injuries.MethodsA literature search of AMED, CINAHL, Embase and OVID Medline (from inception to July 2011) was undertaken. Studies were selected if they met the following inclusion criteria: controlled trials (with or without randomization) of sensory re-education, including early and late phase, in adults with median and/or ulnar nerve repair. Two independent assessors rated study quality and risk of bias using the 24 point MacDermid Evaluation Tool.ResultsA total of seven articles met the inclusion criteria representing five separate studies Study quality ranged from 13 to 33 out of 48 points on the Evaluation Tool. Due to heterogeneity of the interventions and outcomes assessed it was not possible to pool the results from all studies. There is limited evidence to support the use of early and late SR programmes.ConclusionFurther trials are needed to evaluate the effect of early and late sensory re-education which are adequately powered, include validated and relevant outcomes and which are reported according to CONSORT (Consolidated Standards of Reporting Trials) guidelines.Level of Evidence2b.     

Benefits and harms of treatments for chronic nonspecific low back pain without radiculopathy: systematic review and meta-analysis

Background contextCurrently, there are no published studies that compare nonpharmacological, pharmacological and invasive treatments for chronic low back pain in adults and provide summary statistics for benefits and harms.PurposeThe aim of this review was to compare the benefits and harms of treatments for the management of chronic low back pain without radiculopathy and to report the findings in a format that facilitates direct comparison (Benefit-Harm Scale: level 1 to 7).DesignSystematic review and meta-analysis of randomized controlled trials, including trial registries, from electronic databases up to 23^rd May 2022.Patient sampleAdults with chronic nonspecific low back pain, excluding radicular pain, in any clinical setting.Outcome measuresComparison of pain at immediate-term (≤2 weeks) and short-term (>2 weeks to ≤12 weeks) and serious adverse events using the Benefit-Harm Scale (level 1 to 7).MethodsThis was a registered systematic review and meta-analysis of randomized controlled trials. Interventions included nonpharmacological (acupuncture, spinal manipulation), pharmacological and invasive treatments compared to placebo. Best evidence criteria was used. Two independent reviewers conducted eligibility assessment, data extraction and quality appraisal.ResultsThe search retrieved 17,362 records. Three studies provided data on the benefits of interventions, and 30 provided data on harms. Studies included interventions of acupuncture (n=8); manipulation (n=2); pharmacological therapies (n=9), including NSAIDs and opioid analgesics; surgery (n=8); and epidural corticosteroid injections (n=3). Acupuncture (standardized mean difference (SMD) -0.51, 95%CI -0.88 to -0.14, n=1 trial, moderate quality of evidence, benefit rating of 3) and manipulation (SMD -0.39, 95%CI -0.56 to -0.21, n=2 trials, moderate quality of evidence, benefit rating of 5) were effective in reducing pain intensity compared to sham. The benefit of the other interventions was scored as uncertain due to not being effective, statistical heterogeneity preventing pooling of effect sizes, or the absence of relevant trials. The harms level warnings were at the lowest (eg, indicating rarer risk of events) for acupuncture, spinal manipulation, NSAIDs, combination ingredient opioids, and steroid injections, while they were higher for single ingredient opioid analgesics (level 4) and surgery (level 6).ConclusionsThere is uncertainty about the benefits and harms of all the interventions reviewed due to the lack of trials conducted in patients with chronic nonspecific low back pain without radiculopathy. From the limited trials conducted, nonpharmacological interventions of acupuncture and spinal manipulation provide safer benefits than pharmacological or invasive interventions. However, more research is needed. There were high harms ratings for opioids and surgery.     

Non-pharmacological aspects of blood pressure management: what are the data?

Hypertension affects 29% of US adults and is a significant risk factor for cardiovascular morbidity and mortality. Epidemiological data support contribution of several dietary and other lifestyle-related factors to the development of high blood pressure (BP). Several clinical trials investigated the efficacy of non-pharmacological interventions and lifestyle modifications to reduce BP. Best evidence from randomized controlled trials supports BP-lowering effects of weight loss, the Dietary Approaches to Stop Hypertension (DASH) diet, and dietary sodium (Na(+)) reduction in those with prehypertension, with more pronounced effects in those with hypertension. In hypertensive participants, the effects on BP of DASH combined with low Na(+) alone or with the addition of weight loss were greater than or equal to those of single-drug therapy. Trials where food was provided to participants were more successful in showing a BP-lowering effect. However, clinical studies with long-term follow-up revealed that lifestyle modifications were difficult to maintain. Findings from controlled trials of increased potassium, calcium, or magnesium intake, or reduction in alcohol intake revealed modest BP-lowering effects and are less conclusive. The reported effects of exercise independent of weight loss on BP are inconsistent.     

Surgical interventions of Freiberg’s disease: A systematic review

BackgroundFreiberg’s disease is an osteonecrosis of the metatarsal head bone. Numerous surgical interventions can be provided; however, the literature is limited in systematic reviews discussing the various options. The study aimed to systematically review the quantity and quality of literatures exploring the surgical interventions.MethodsFifty articles were found to be relevant for assessing the efficacy of common surgical interventions. The articles were assigned a level of evidence (I–V) to assess their quality. Next, the studies were reviewed to provide a grade of recommendation (A–C, I).ResultsTwo studies were found at level III that explored osteotomy and autologous transplantation; the other studies were level IV–V. There is poor evidence (grade C) in supporting of joint sparing and joint sacrificing for Freiberg’s disease.ConclusionPoor evidence exists to support the surgical interventions for Freiberg’s disease, higher quality trials are needed to support the increasing application of these surgical techniques.Level of EvidenceLevel IV, Systematic review.     

Understanding the choice of control group: A systematic review of vertebroplasty trials for osteoporotic vertebral compression fractures

ObjectivesTo better understand the choice of the comparator intervention in the design of clinical trials and its impact on the meaning of results we review randomized trials on vertebroplasty.MethodsWe conducted a systematic and narrative review of all randomized trials on vertebroplasty. Trials are categorized according to the comparator intervention (non-surgical management, placebo/sham vertebroplasty, and kyphoplasty).ResultsAll trials were too small to show a difference in objective clinical outcomes, and 20 of 23 RCTs used mean pain scores to compare interventions. Most trials comparing vertebroplasty with non-surgical management concluded that vertebroplasty was superior. Trials comparing kyphoplasty with vertebroplasty showed similar results for both interventions. However, 4 of 5 trials comparing vertebroplasty with placebo surgery failed to show a significant difference between groups.ConclusionThe clinical results of an intervention cannot be interpreted without a comparison that involves a control group. The choice of comparator intervention can change the meaning of the trial. A large pragmatic trial, using hard clinical outcomes such as morbidity and mortality as a primary outcome measure, would be needed to assess the potential clinical benefits of vertebroplasty.     

Caveats of bisphosphonate abuse

Background:Bisphosphonates (BPs) are the common drugs used for the treatment of postmenopausal osteoporosis. Short term benefits of the BPs are well known. However, there are concerns regarding their long term use. The aim of the study was to analyze the association between atypical femoral fractures and BP misuse/abuse as well as study the outcome of management of these fractures.Results:The mean duration of BP use was 6.6 years (range 4-10 years). BP treatment was initiated without sufficient indication and continued without proper review and followup in most cases. Most patients did not followup and continued to consume BPs without any review by the doctors. All patients had prodromal thigh pain of various duration, which was inadequately investigated and managed before the presentation. Two cases with an incomplete fracture and no thigh pain were managed successfully with conservative treatment. The rest were treated by surgery with intramedullary nailing. The average union time was longer and two fractures went into nonunion which required further surgical intervention.Conclusion:Atypical femoral fractures appear to be strongly related to abuse of BPs. Great care is to be exercised at initiation as well as the continuation of BP therapy, and regular review is required. There is a need for improved awareness among physicians about the possibility of such fractures, and interpretation of thigh pain and radiological findings, especially if the patient has been on BPs therapy. Internal fixation for complete fractures and for incomplete fractures with thigh pain is needed. Delayed union is common.     

Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group

STUDY DESIGN: A systematic review of randomized controlled trials was performed. SUMMARY OF BACKGROUND DATA: Exercise therapy is a widely used treatment for low back pain. OBJECTIVES: To evaluate the effectiveness of exercise therapy for low back pain with regard to pain intensity, functional status, overall improvement, and return to work. METHODS: The Cochrane Controlled Trials Register, Medline, Embase, PsycLIT, and reference lists of articles were searched. Randomized trials testing all types of exercise therapy for subjects with nonspecific low back pain with or without radiation into the legs were included. Two reviewers independently extracted data and assessed trial quality. Because trials were considered heterogeneous with regard to study populations, interventions, and outcomes, it was decided not to perform a meta-analysis, but to summarize the results using a rating system of four levels of evidence: strong, moderate, limited, or none. RESULTS: In this review, 39 trials were identified. There is strong evidence that exercise therapy is not more effective for acute low back pain than inactive or other active treatments with which it has been compared. There is conflicting evidence on the effectiveness of exercise therapy compared with inactive treatments for chronic low back pain. Exercise therapy was more effective than usual care by the general practitioner and just as effective as conventional physiotherapy for chronic low back pain. CONCLUSIONS: The evidence summarized in this systematic review does not indicate that specific exercises are effective for the treatment of acute low back pain. Exercises may be helpful for patients with chronic low back pain to increase return to normal daily activities and work.     

Effects of spinal manipulation versus therapeutic exercise on adults with chronic low back pain: a literature review

Background Context:

Chronic low back pain (CLBP) is a prevalent disorder that has a significant burden to society in terms of loss of work time and increased economic cost. Two common treatment choices of intervention for CLBP are spinal manipulation and prescribed exercise.

Purpose:

The purpose of this systematic review was to examine the effectiveness of spinal manipulation vs prescribed exercise for patients diagnosed with CLBP. Studies that compared head-to-head spinal manipulation to an exercise group were included in this review.

Methods:

A search of the current literature was conducted using a keyword process in CINAHL, Cochrane Register of Controlled Trials Database, Medline, and Embase. The search was conducted on, and included studies available up to August 29^th 2014. Studies were included based on PICOS criteria 1) individuals with CLBP defined as lasting 12 weeks or longer; 2) spinal manipulation performed by a health care practitioner; 3) prescribed exercise for the treatment of CLBP and monitored by a health care practitioner; 4) measurable clinical outcomes for reducing pain, disability or improving function; 5) randomized controlled trials. The quality of included articles was determined by the author using the criteria developed and used by the Physiotherapy Evidence Database (PEDro).

Results:

Three randomized controlled trials met the inclusion criteria of this systematic review and were included in this review. The outcomes used in these studies included Disability Indexes, Pain Scales and function improvement scales. The results included a mix of effects with one study finding spinal manipulation as more effective and another finding the exercises more so. The third study found both interventions offering equal effects in the long term.

Conclusion:

Based on the findings of this systematic review there is no conclusive evidence that clearly favours spinal manipulation or exercise as more effective in treatment of CLBP. More studies are needed to further explore which intervention is more effective.     

The Fragility of Statistically Significant Findings From Randomized Controlled Trials in Hip and Knee Arthroplasty

BackgroundThe Fragility Index (FI) is a method for evaluating the robustness of statistically significant findings from randomized controlled trials (RCTs) beyond the P value in trials with dichotomous outcomes. The FI is defined as the number of patients in one arm of a trial that would have to have a different outcome to change the results of the trial from statistically significant to nonsignificant. This review assessed the FI in arthroplasty RCTs.MethodsA systematic search was conducted in MEDLINE, Embase, and Web of Science for RCTs related to primary total joint arthroplasty (TJA) from 2010 to 2020. Trials with a statistically significant dichotomous primary outcome were included. The FI was calculated using Fisher’s exact test to determine how many events would need to be reversed to change a study from statistically significant to nonsignificant.ResultsA total of 34 RCTs were included. The median sample size was 103 patients (range 24-791). The median FI was 1 (range 0-45), meaning that reversing the outcome of just one patient in either treatment group of each trial would change it from a significant to a nonsignificant result.ConclusionHip and knee arthroplasty RCTs with statistically significant dichotomous outcomes in TJA are fragile. The median FI in TJA is lower than the FI in any of the other previously reported orthopedic subspecialties. Fragility is another reason to be cautious when conducting or interpreting small trials, and to continue to strive toward large trials to answer important questions in TJA.Level of EvidenceLevel I.     

Management options for proximal humerus fractures – A systematic review & network meta-analysis of randomized control trials

AimsThe purpose of this study is to systematically review the randomized controlled trials on the various treatment options that can be utilized in the management of displaced proximal humerus fractures.Materials & MethodsBased on the PRISMA guidelines, three independent reviewers performed a systematic review of the literature. Randomized control trials (RCTs) focusing on the outcomes of the following interventions in the management of PHFs were considered for inclusion; (1) non-operative or conservative (NOC) management, (2) open reduction and internal fixation (ORIF), (3) intra-medullary nailing (IMN), (4) shoulder hemi-arthroplasty (HA), and (5) reverse shoulder arthroplasty (RSA). Network meta-analyses were performed using R and studies were ranked according to their P-score.ResultsOur study included 13 RCTs. RSA had improvements in abduction, constant score, flexion, as well as lowest rates of malunion and osteonecrosis when compared to other management modalities (P-Score = 0.9786, P-Score = 0.9998, P-Score = 0.9909, P-Score = 0.9590 and P-Score = 0.8042 respectively). HA was found to have improvements in health-related quality of life scores when compared to other management modalities (P-Score = 0.9672). ORIF had the highest improvement in quick disability of arm, shoulder and hand scores and visual analogue scale scores (P-Score = 0.8209 and P-Score = 0.7155 respectively). NOC was found to have the lowest rate of conversion to surgical intervention, with RSA having the lowest rate of surgical interventions (P-Score = 0.9186 and P-Score = 0.7497 respectively).Discussion & ConclusionRSA offers satisfactory improvements in clinical and functional outcomes when compared to other non-operative and operative treatment options in the management of carefully selected proximal humerus fractures, with a minimal revision rate when compared to other surgical management modalities.Level of EvidenceI - Systematic Review & Meta-Analysis of Randomized Control Trials     

Rehabilitation Interventions to modify endocrine-metabolic disease risk in Individuals with chronic Spinal cord injury living in the Community (RIISC): A systematic review and scoping perspective

Context: Endocrine-metabolic disease (EMD) risk following spinal cord injury (SCI) is associated with significant multi-morbidity (i.e. fracture, diabetes, heart disease), mortality, and economic burden. It is unclear to what extent rehabilitation interventions can modify EMD risk and improve health status in community-dwelling adults with chronic SCI.

Objectives: To characterize rehabilitation interventions and summarize evidence on their efficacy/effectiveness to modify precursors to EMD risk in community-dwelling adults with chronic SCI.

Methods: Systematic searches of MEDLINE PubMed, EMBASE Ovid, CINAHL, CDSR, and PsychInfo were completed. All randomized, quasi-experimental, and prospective controlled trials comparing rehabilitation/therapeutic interventions with control/placebo interventions in adults with chronic SCI were eligible. Two authors independently selected studies and abstracted data. Mean differences of change from baseline were reported for EMD risk outcomes. The GRADE approach was used to rate the quality of evidence.

Results: Of 489 articles identified, 16 articles (11 studies; n=396) were eligible for inclusion. No studies assessed the effects of rehabilitation interventions on incident fragility fractures, heart disease, and/or diabetes. Individual studies reported that exercise and/or nutrition interventions could improve anthropometric indices, body composition/adiposity, and biomarkers. However, there were also reports of non-statistically significant between-group differences.

Conclusions: There was very low-quality evidence that rehabilitation interventions can improve precursors to EMD risk in community-dwelling adults with chronic SCI. The small number of studies, imprecise estimates, and inconsistency across studies limited our ability to make conclusions. A high-quality longitudinal intervention trial is needed to inform community-based rehabilitation strategies for EMD risk after chronic SCI.     

Therapist supervised clinic-based therapy versus instruction in a home program following distal radius fracture: A systematic review

PurposeThe primary purpose of this systematic review is to determine the effectiveness of a home program or a structured therapy program for patients following distal radius fracture.MethodsA search was performed using terms wrist fracture, supervised therapy, occupational therapy, physical therapy, splint, orthosis, distal radius fracture, exercise, and home program. Studies that met the inclusion criteria were evaluated for research quality using The Structured Effectiveness for Quality Evaluation of Study (SEQES).ResultsFive of the seven trials found no difference between outcomes for their subjects that had uncomplicated distal radius fractures. The population that has complications following distal radius fractures was not represented in the studies reviewed.ConclusionThe available evidence from randomized controlled trials is insufficient to support a home program or therapist supervised clinic-based program as a superior method of treatment for adults following a distal radius fracture without complications or the presence of comorbidities.     

Developing clinical guidelines for the physiotherapy management of whiplash associated disorder (WAD)

ObjectivesTo produce evidence-based guidelines for the physiotherapy management of whiplash associated disorder (WAD).MethodsA guideline development group was established to examine the evidence relating to the physiotherapy treatment of whiplash. A literature search in July 2002 was updated in March 2004, searching for studies from 1995. The databases searched were: Medline, Embase, AMED, CINAHL, PEDro, BIDS, and the Cochrane library. Before 1995, the studies were sourced from the Quebec Task Force document.Study selectionIncluded studies considered adults with WAD, presented separate results for this group, compared interventions with another treatment, or with a placebo or control group, were written in English, and were randomised controlled trials (RCT) or systematic reviews.Data extractionStudies were assessed using the PEDro scale. From an initial 1016 papers, 84 were selected, of which 11 were used to formulate the clinical guidelines.ConclusionsThere is evidence that the following may be helpful in treating people with WAD: exercise, advice to stay active, return to normal activity, multimodal interventions, and manual therapy. This review also highlights the need for larger, high quality studies into the management of people with WAD.     

Combined Intermittent Pneumatic Leg Compression and Pharmacological Prophylaxis for Prevention of Venous Thrombo-Embolism in High-Risk Patients

BackgroundIt has been suggested that combined modalities (methods of treatment) are more effective than single modalities in preventing venous thrombo-embolism (defined as deep vein thrombosis and pulmonary embolism, or both) in high-risk patients.ObjectivesTo assess the efficacy of intermittent pneumatic leg compression combined with pharmacological prophylaxis versus single modalities in preventing venous thrombo-embolism in high-risk patients.Search strategyThe Cochrane Peripheral Vascular Diseases (PVD) Group searched the reference lists of their Specialised Register (last searched 17 July 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched The Cochrane Library 2008, issue 3) for relevant articles to identify additional trials.Selection criteriaRandomised controlled trials (RCTs) or controlled clinical trials (CCTs) of combined intermittent pneumatic leg compression and pharmacological interventions used to prevent venous thrombo-embolism in high-risk patients.Data collection and analysisData extraction was undertaken independently by two review authors using data extraction sheets.     

Longitudinal changes in body composition and metabolic profile between exercise clinical trials in men with chronic spinal cord injury

Study design: Longitudinal design.

Objectives: The study was undertaken to determine the effects of cessation of exercise interventions on body composition and metabolic profiles in men with chronic SCI.

Settings: Clinical trials within a Medical Center.

Methods: Eleven men with motor complete SCI were followed on average over a period of 2.5 years. Six men were involved in two different exercise interventions (functional electrical stimulation cycling versus arm cycling ergometer), 5 days/week for 16 weeks (exercise group), and five men served as a control (control group). Anthropometrics and dual energy X-ray absorptiometry (DXA) were captured to measure changes in lean mass (LM), fat mass (FM), percentage FM before, immediately after exercise, and after a period of 2.5 years. Basal metabolic rate (BMR) and lipid panel were also measured.

Results: Thigh circumference increased by 8.5% following exercise (P?=?0.042) and remained 6.4% greater than baseline measurements (P?=?0.012). Leg LM increased by 9% following the exercise intervention (P?=?0.03) and decreased by 16% in the follow-up visit (P?=?0.02). Percentage trunk and total body FM increased by 4.5% (P?=?0.008) and 3.5% (P?=?0.019) in the follow-up visit, respectively, and whole body LM increased by 8.4% and decreased back by 5.4% following a 2.5 year-period. BMR significantly decreased by 15.5% following the exercise (P?=?0.029) interventions.

Conclusion: Exercise training is accompanied with positive changes in body composition as well as compensatory decrease in BMR, that regressed back following 2.5 years of exercise cessation. Participation in an exercise trial is unlikely to confound the measurements of a follow-up trial.     

Prolonged administration of bisphosphonates is well-tolerated and effective for skeletal-related events in Chinese breast cancer patients with bone metastasis

ObjectiveTo evaluate the long-term tolerability and activity of prolonged administration of bisphosphonates (BPs) in breast cancer (BrCa) patients with bone metastasis (BM).MethodsWe retrospectively analyzed safety data and activity of BPs in BrCa patients with BM who had received intravenous BPs for >24 months. Renal toxicity, osteonecrosis of the jaw (ONJ), and hypocalcemia were assessed. In addition, levels of creatinine (Cr) and calcium (Ca) in pre- and post-treatment sera were examined. The following parameters were also analyzed: the proportion of patients with at least one skeletal-related event (SRE), the distribution of each type of SRE, and the skeletal morbidity rate (SMR).Results181 patients from January 1, 2005 to May 31, 2009 were enrolled in the study. The median BP administration period was 36 (range: 25–133) months. Grades 1–2 and 3 renal toxicity occurred in 3.9% and 0.7% of patients, respectively. Only one patient was diagnosed with ONJ, the incidence rate of which was 0.6%. Hypocalcemia occurred in 29 patients (16.0%), most frequently after two years of BP therapy. Neither serum Cr levels nor the creatinine clearance rate were significantly increased by treatment. Furthermore, 50 patients (27.6%) experienced a new SRE between zero and 24 months after BP therapy. However, no notable increase in incidence rate of SREs was observed after the two years of BP treatment. Overall, 63 patients (34.8%) experienced at least one new SRE after initiation of BPs (p = 0.173). No significant difference was found among the different BP subgroups of pamidronate, ibandronate, and zoledronate. Radiation to bone was the most common cause of SREs (68.4%, 67/98). SMR was 0.10 events per year for 0–5 years after BP treatment.ConclusionsThis was the largest retrospective study of extended use of BPs in BrCa patients with BM. Intravenous administration of BPs was well-tolerated and remained active throughout the prolonged period of administration. The occurrence of SREs was similar among the pamidronate, ibandronate, and zoledronate subgroups after two years of BP treatment.     

Metal-backed versus all-polyethylene tibial components in primary total knee arthroplasty

Background and purpose The choice of either all-polyethylene (AP) tibial components or metal-backed (MB) tibial components in total knee arthroplasty (TKA) remains controversial. We therefore performed a meta-analysis and systematic review of randomized controlled trials that have evaluated MB and AP tibial components in primary TKA.

Methods The search strategy included a computerized literature search (Medline, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials) and a manual search of major orthopedic journals. A meta-analysis and systematic review of randomized or quasi-randomized trials that compared the performance of tibial components in primary TKA was performed using a fixed or random effects model. We assessed the methodological quality of studies using Detsky quality scale.

Results 9 randomized controlled trials (RCTs) published between 2000 and 2009 met the inclusion quality standards for the systematic review. The mean standardized Detsky score was 14 (SD 3). We found that the frequency of radiolucent lines in the MB group was significantly higher than that in the AP group. There were no statistically significant differences between the MB and AP tibial components regarding component positioning, knee score, knee range of motion, quality of life, and postoperative complications.

Interpretation Based on evidence obtained from this study, the AP tibial component was comparable with or better than the MB tibial component in TKA. However, high-quality RCTs are required to validate the results.     

Evidence for Using Bisphosphonate to Treat Legg-Calvé-Perthes Disease

Background

The rationale for using bisphosphonate (BP) therapy for Legg-Calvé-Perthes disease (LCPD) is the potential to prevent substantial femoral head deformity during the fragmentation phase by inhibiting osteoclastic bone resorption. However, it is unclear whether BP therapy decreases femoral head deformity.

Questions/purposes

In this systematic review, we answered the following questions: (1) Does bisphosphonate (BP) therapy decrease femoral head deformity and improve pain and function in LCPD or other juvenile osteonecrotic conditions? And (2) does BP therapy decrease femoral head deformity in experimental studies of juvenile femoral head osteonecrosis?

Methods

We searched the literature from 1966 to 2011 for clinical and experimental studies on BP therapy for juvenile femoral head osteonecrosis. Studies specifically addressing clinical and/or radiographic/histologic outcomes pertaining to pain and function and femoral head morphology were analyzed.

Results

Three Level IV clinical studies met our inclusion criteria. Only one study initiated BP therapy during the precollapsed stage of osteonecrosis and reported prevention of femoral head deformity in nine of 17 patients. All studies noted subjective improvements of pain and gait in patients treated with intravenous BPs. Of the eight experimental studies reviewed, seven reported reduced femoral head deformity and six found better preservation of trabecular framework in animals treated with BPs.

Conclusions

Clinical evidence lacks consistent patient groups and drug protocols to draw definitive conclusions that BP therapy can decrease femoral head deformity in juvenile osteonecrotic conditions. Experimental studies suggest BP therapy protects the infarcted femoral head from deformity, but it lacks bone anabolic effect. Further basic and clinical research are required to determine the potential role of BPs as a medical treatment for LCPD.