Operative vs non-operative management of displaced proximal humeral fractures in the elderly: A systematic review and meta-analysis of randomized controlled trials

AIM: To perform a systematic review and meta-analysis comparing operative vs non-operative treatment of displaced proximal humerus fractures in elderly patients.METHODS: A systematic literature search was performed using EMBASE and MEDLINE through the OVID interface,CINAHL,the Cochrane Central Register of Controlled Trials(CENTRAL),Proquest,Web of Science,SAE digital library,and Transportation Research Board's TRID database.Searches of conference proceedings were also conducted.All available randomized controlled trials comparing operative vs non-operative management of displaced three- and four-part proximal humerus fractures in elderly patients were included.The primary outcomes measures included physical function,pain,health related quality of life,mortality,and the re-operation rate.RESULTS: Six randomized controlled trials(n = 287) were included.There was no statistically significant difference in function(MD = 1.72,95%CI:-2.90-6.34,P = 0.47),as measured by the Constant score,between the operative and the non-operative treatment groups.There was no statistically significance difference insecondary outcomes of health related quality of life(standardized MD = 0.27,95%CI:-0.05-0.59,P = 0.09),and mortality(relative risk 1.29,95%CI: 0.50-3.35,P = 0.60).Operative treatment had a statistically significant higher re-operation rate(relative risk 4.09,95%CI: 1.50-11.15,P = 0.006),and statistically significant decreased pain(MD = 1.26,95%CI: 0.02-2.49,P = 0.05).CONCLUSION: There is moderate quality evidence to suggest that there is no difference in functional outcomes between the two treatments.Further high quality randomized controlled trials are required to determine if certain subgroup populations benefit from surgical management.

Emergent and delayed hybrid external fixation management of tibial pilon fractures: A multicentric retrospective analysis of 80 patients

Objective:To report our experience with the hybrid external fixator in emergency.Methods:We assessed 80 cases of pilon fracture treated with the external fixator during the period of January 2009 and December 2016:55 men (69%) and 30 women (33%) with a mean age of 40 years (range between 16 and 70 ). About 45 occurred as isolated trauma, 35 instead were politrauma. Each patient underwent standard radiographic examination and a CT examination. There were 28 open fractures (35%), (Gustilo type 1, 2 and 3) while closed fractures showed soft tissue involvement of various grade (2-3 Tscherne classification). In all cases, the external fixation, sometimes associated with other reduction and synthesis techniques, was used. The timing of surgery was dictated by the condition of the soft tissues. For clinical evaluation, the Mazur score with mean follow-ups at 12 months was utilized.Results:The final range of ankle motion was 15 dorsal and 10 plantar flexion. In about 80 cases there was an average Mazur score of83. The mean score was 90;in open fractures 85 to 72. Radiographic healing of fractures in 60 patients occurred in 120 days (mean 105 days), at the time when the external fixator was removed.Conclusion:Pilon fractures are complex and often present complications;the definitive treatment, in emergency or delayed, with hybrid external fixator permits a stable synthesis with minimal soft tissue damage. Weight bearing maybe allowed early and functional recovery is generally good.

Emergency department electric scooter injuries after the introduction of shared e-scooter services: A retrospective review of 3,331 cases

BACKGROUND: To determine the frequency, characteristics, and use of resources related to electric scooter(e-scooter) injuries in the emergency department(ED) of a major metropolitan area hospital.METHODS: We performed a retrospective review of all ED presentations related to e-scooter injuries at a level I trauma center between May 2017 and February 2020. We identified ED presentation data, injury-related data, patients’ clinical course after evaluation, injury diagnosis, surgical procedures, and ED readmissions.RESULTS: A total of 3,331 patients with e-scooter injuries presented to the ED over a 34-month period. There was a 6-fold increase in e-scooter-related injuries presenting to the ED, from an average of 26.9 injuries per month before the introduction of shared e-scooter services in August 2018 to an average of 152.6 injuries per month after its introduction. The average injury rate during weekdays was 3.27 per day, with the majority of injuries occurring in the afternoon. The most common mechanism of injury was rider fall(79.1%). There were a total of 2,637 orthopedic injuries, of which 599(22.7%) were fractures. A total of 296(8.9%) patients were hospitalized following the initial ED admission, and 462 surgeries were performed within 7 days of ED arrival.CONCLUSIONS: The introduction of the shared e-scooter services is associated with a dramatic increase in e-scooter injuries presenting to the ED. E-scooter use carries considerably underestimated injury risks of high-energy trauma and misunderstood mechanisms of injuries. These injuries challenge the healthcare system, with a major impact on both EDs and surgical departments.

Management of acute length-unstable Monteggia fractures in children:A case report

BACKGROUND Monteggia fractures are uncommon injuries in paediatric age.Treatment algorithms assert that length-unstable fractures are treated with plate fixation.In this case report,intramedullary fixation of an acute length-unstable Monteggia fracture allowed a stable reduction to be achieved,along with an appropriate ulnar length and alignment as well as radio capitellar reduction despite the fact that the orthopaedic surgeon did not use a plate for the ulnar fracture.The scope of treatment is to avoid the use of a plate that causes periosteal stripping and blood circulation disruption around the fracture.CASE SUMMARY A four-year-old girl presented at the Emergency Department following an accidental fall off a chair onto the right forearm.The X-ray highlighted a lengthunstable acute Bado type 1 Monteggia fracture of the right forearm.On the same day,the patient underwent surgical treatment of the Monteggia fracture.The surgeon preferred not to use a plate to avoid a delay in fracture healing and to allow the micromotion necessary for callus formation.The operation comprised percutaneous fixation with an elastic intramedullary K-wire of the ulnar fracture and,subsequently,humeroradial joint reduction through manual manipulation.The orthopaedic surgeon assessed the stability of the radial head reduction under fluoroscopic control through flexion,extension,pronation and supination of the forearm.Healing of the fracture occurred within six weeks after surgery,as indicated by the presence of calluses on at least three cortices on standard radiographs.Dislocation/subluxation or loss of ulnar reduction was not apparent at the final X-ray examination.CONCLUSION Intramedullary fixation of unstable Monteggia fractures results in excellent outcomes,provides reliable reduction and causes fewer complications.

Locking plates for distal fibula fractures in young and elderly patients:A retrospective study

BACKGROUND Ankle fractures are common injuries in the young and elderly populations.To prevent post-traumatic arthritis,an anatomic reconstruction of the ankle structure is mandatory.Open reduction and internal fixation is the treatment of choice among orthopaedics.Conventional plates allow stability of the fracture if bone quality is present.Locking plates might offer an advantage for the treatment of lateral malleolar fracture in patients with comminution,severe instability,distal fractures,or osteoporotic bone.Our hospital introduced a new locking plate for fracture of the distal fibula.AIM To evaluate locking plates in terms of outcomes and complications in young and elderly patients.METHODS We retrospectively reviewed a total of 67 patients treated for displaced distal fibula fractures.Demographic data,number of comorbidities,use of inter fragmentary screw,complication,time of fracture healing,partial or full weight bearing,and reoperation were recorded for all patients.Clinical outcome was assessed by the American Orthopedic Foot and Ankle Society clinical scoring system.Radiographs were obtained at 4,8,12,16,20,and 24 wk until radiographic union was obtained.RESULTS All patients displayed complete bony union on radiographic assessment,and no patients developed any serious complications.We observed two superficial infections,one delayed wound healing,and two plate intolerances.Significant differences were observed between the two age groups in terms of radiographic healing(11.9 wk in younger patients vs 13.7 wk in older patients;P=0.011)and in the American Orthopedic Foot and Ankle Society score at 6 mo after surgery(88.2 in younger patients vs 86.0 in older patients;P=0.001)and at 12 mo after surgery(92.6 in younger patients vs 90.0 in older patients;P=0.000).CONCLUSION Locking plates provide a stable and rigid fixation in multifragmentary and comminuted fractures or in the presence of poor bone quality.

Pediatric flexible flatfoot: Does obesity influence the outcomes of arthroereisis?

BACKGROUND Childhood obesity has emerged in the last decades as an important public health problem worldwide.Although relationships between obesity and flatfoot have been shown,no studies have investigated the influence of obesity on arthroereisis outcomes.AIM To evaluate correlations between childhood overweight/obesity and clinical and radiographic outcomes after subtalar arthroereisis with self-locking implants.METHODS This retrospective study included one hundred and sixty-nine pediatric patients(10-14 years old)who underwent subtalar arthroereisis(PEEK PitStop®device)for severe flexible flatfoot.Exclusion criteria were additional procedures,revision of previous corrective surgeries,rigid flatfoot with severe deformity,and neurologi-cal or post-traumatic flatfoot.Preoperative/postoperative European Foot and Ankle Society(EFAS)and visual analogue scale(VAS)scores were determined;radiographic assessment was conducted on weight-bearing foot X-rays:Kite angle,first metatarsal-talus angle,Meary angle,calcaneal pitch angle and lateral talo-calcaneal angle were analyzed.RESULTS EFAS and VAS scores improved post-operatively in the whole population.Only seven cases with complications were reported.Radiographic assessment revealed an improvement in all angles.Statistical analysis demonstrated that the impact of obesity was significant on arthroereisis outcomes:Relationships were reported between BMI and postoperative EFAS/VAS scores,postoperative calcaneal pitch angle,Kite angle,Meary angle and talo-first meta-tarsal angle.CONCLUSION Although arthroereisis represents a very effective and valid treatment for flatfoot both in normal weight and obese children,obesity significantly influences clinical and radiographic outcomes of arthroereisis,and obese children tend to perceive more pain and discomfort.

Fifth metatarsal fractures and current treatment

Metatarsal fractures are one of the most common injuries of the foot. There has been conflicting literatureon management of fifth metatarsal fractures due to inconsistency with respect to classification of these fractures. This article provides a thorough review of fifth metatarsal fractures with examination of relevant literature to describe the management of fifth metatarsal fractures especially the proximal fracture. A description of nonoperative and operative management for fifth metatarsal fractures according to anatomical region is provided.

Osteolysis in total hip arthroplasty in relation to metal ion release: Comparison between monolithic prostheses and different modularities

BACKGROUND Among the various complications associated with total hip arthroplasty(THA)periprosthetic osteolysis and wear phenomena due to the release of metal particles,are two of the most common and have been reported to be correlated because of inflammatory responses directed towards released particles that generally activate macrophagic osteolytic effects.Therein,new masses known as pseudotumors can appear in soft tissues around a prosthetic implant.To date,there is paucity of reliable data from studies investigating for any association between the above mentioned adverse events.AIM To investigate for the existence of any association between serum and urine concentrations of metal-ions released in THA and periprosthetic osteolysis for modular neck and monolithic implants.METHODS Overall,76 patients were divided into three groups according to the type of hip prosthesis implants:Monoblock,modular with metal head and modular with ceramic head.With an average f-up of 4 years,we conducted a radiological evaluation in order to detect any area of osteolysis around the prosthesis of both the femur and the acetabulum.Moreover,serum and urinary tests were performed to assess the values of Chromium and Cobalt released.Statistical analysis was performed to determine any association between the ion release and osteolysis.RESULTS For the 3 study groups,the monolithic,modular ceramic-headed and modular metal-headed implants had different incidences of osteolysis events,which were higher for the modular implants.Furthermore,the most serious of these(grade 3)were detected almost exclusively for the modular implants with metal heads.A mapping of the affected areas was performed revealing that the highest incidences of osteolysis were evidenced in the pertrochanteric region at the femur level,and in the supero-external region at the acetabular level.Regarding the evaluation of the release of metals-ions from wear processes,serum and urinary chromium and cobalt values were found to be higher in cases of modularity,and even more so for those with metal head.Statistical linear correlation test results suggested positive correlations between increasing metal concentrations and incidences areas of osteolysis.However,no cases of pseudo-tumor were detected.CONCLUSION Future studies are needed to identify risk factors that increase peri-prosthetic metal ion levels and whether these factors might be implicated in the triggering of local events,including osteolysis and aseptic loosening.

The damage control in tibial pilon open fractures with a new external fixator delta frame

Objective: To evaluate the effectiveness of the damage control, in emergency to treat the open tibial pilon fractures with Dolphix? External Fixator Frame(CITIEFFE?, Calderara di Reno, Bologna, Italy). Methods: From January 2017 to August 2017, at the Department of Orthopedics and Traumatology of Vito Fazzi Hospital Lecce, we treated 23 open tibial pilon fractures with Dolphix? External Fixator Frame(CITIEFFE?, Calderara di Reno, Bologna, Italy). The evaluation criteria of the case series were: the time needed to assemble the external fixator;the time taked to treat the ankle associated lesions;the time of skin healing;the ankle alignment;the subjective/objective Ovadia and Beals score;and complications. The Endpoint assessment was set at the days of the definitive surgery. Results: The results in terms of alignment, biomechanical stability of the frame, healing of soft tissue, complications were as good as the objective and subjective results according Ovadia and Beals score. Conclusion:Pilon fractures are complex and often present complications;the damage control treatment, in emergency, with Dolphix? External Fixator Frame(CITIEFFE?, Calderara di Reno, Bologna, Italy) permits a stable osteotaxis with minimal soft tissue damage and permit the repair of muscles, blood vessels and nerves with a stable bone and the soft tissue healing with vaccum therapy.

Changes of Hemoglobin and Hematocrit in Elderly Patients Receiving Lower Joint Arthroplasty without AIIogeneic Blood Transfusion

Background：It has rarely been reported about the changes of hemoglobin （Hb） and hematocrit （Hct） in elderly patients receiving total knee arthroplasty （TKA） or total hip arthroplasty （THA）.This study aimed to evaluate the changes of Hb and Hct after TKA or THA in elderly patients,and analyze its relationship with sex and type of arthroplasty.Methods：This is a prospective cohort study,including 107 patients receiving TKA or THA without allogeneic blood transfusion.There were 54 males and 53 females,with a mean age of 69.42 years.Levels of Hb and Hct were examined preoperatively and during the 6 months follow-up after operation.Results：Levels of Hb and Hct decreased postoperatively and reached their minimum points on postoperative day 4.Thereafter,Hb and Hct recovered to their preoperative levels within 6-12 weeks.No significant differences in the levels of Hb and Hct were noticed between different sexes.THA patients showed significantly greater drop in Hb and Hct than TKA patients in the first 4 days postoperatively （P 〈 0.05）.Conclusions：Levels of Hb and Hct decreased during the first 4 days after arthroplasty and gradually returned to their normal levels within 6-12 weeks postoperatively.THA may be associated with higher postoperative blood loss than TKA.

Cauda equina syndrome： a review of clinical progress

Objective To review the literature on the clinical progress in cauda equina syndrome （CES）, including the epidemic history, pathogenesis, diagnosis, treatment policy and prognosis. Data sources All reports on CES in the literature were searched in PubMed, Ovid, Springer, Elsevier, and the Chinese Biomedical Literature Disk using the key terms ＂cauda equina syndrome＂, ＂diagnosis＂, ＂treatment＂, ＂prognosis＂ and ＂evidence-based medicine＂. Study selection Original milestone articles and critical reviews written by major pioneer investigators about the cauda equina syndrome were selected. Results CES is rare, both atraumatically and traumatically. CES is variable, depending on the etiology of the syndrome. Males and females are equally affected. The incidence of The most common cause of CES is herniation of a lumbar intervertebral disc. CES symptoms may have sudden onset and evolve rapidly or sometimes chronic ally. Each type of CES has different typical signs and symptoms. Low back pain may be the most significant symptoms, accompanied by sciatica, lower extremities weakness, saddle or perianal hypoesthesia, sexual impotence, and sphincter dysfunction. MRI is usually the preferred investigation approach. Patients who have had CES are difficult to return to a normal status. Conclusions The diagnosis of CES is primarily based on a careful history inquiry and clinical examination, assisted by elective radiologic investigations. Early diagnosis and early surgical decompression are crucial for a favorable outcome in most CES cases.

Involvement of hydrogen sulfide in the progression of renal fibrosis

Objective:Renal fibrosis is the most common manifestation of chronic kidney disease(CKD).Noting that existing treatments of renal fibrosis only slow disease progression but do not cure it,there is an urgent need to identify novel therapies.Hydrogen sulfide(H2S)is a newly discovered endogenous small gas signaling molecule exerting a wide range of biologic actions in our body.This review illustrates recent experimental findings on the mechanisms underlying the therapeutic effects of H2S against renal fibrosis and highlights its potential in future clinical application.Data sources:Literature was collected from PubMed until February 2019,using the search terms including"Hydrogen sulfide,""Chronic kidney disease"MRenal interstitial fibrosis,"Kidney disease,""Inflammation factor,""Oxidative stress,""Epithelialto-mesenchymal transition,""H2S donor,""Hypertensive kidney dysfunction,""Myofibroblasts,""Vascular remodeling,""transforming growth factor(TGF)-beta/Smads signaling,"and"Sulfate potassium channels."Study selection:Literature was mainly derived from English articles or articles that could be obtained with English abstracts.Article type was not limited.References were also identified from the bibliographies of identified articles and the authors5 files.Results:The experimental data confirmed that H2S is widely involved in various renal pathologies by suppressing inflammation and oxidative stress,inhibiting the activation of fibrosis-related cells and their cytokine expression,ameliorating vascular remodeling and high blood pressure,stimulating tubular cell regeneration,as well as reducing apoptosis,autophagy,and hypertrophy.Therefore,H2S represents an alternative or additional therapeutic approach for renal fibrosis.Conclusions:We postulate that H2S may delay the occurrence and progress of renal fibrosis,thus protecting renal function.Further experiments are required to explore the precise role of H2S in renal fibrosis and its application in clinical treatment.

Confocal laser endomicroscopy as a new diagnostic tool for poorly differentiated gastric adenocarcinoma

Gastric cancer(GC)is a multifactorial disease,where both environmental and genetic features can have an impact on its occurrence and development.GC represents one of the leading causes of cancer-related deaths worldwide.GC is most frequent in males and is believed to arise from a series of premalignant lesions.The detection of GC at an early stage is crucial because early GC,which is an invasive stomach cancer confined to the mucosal or submucosal lining,may be curable with a reported 5-year survival rate of more than 90%.Advanced GC usually has a poor prognosis despite current treatment standards.The diagnostic efficacy of conventional endoscopy(with light endoscopy)is currently limited.Confocal laser endomicroscopy is a novel imaging technique that allows real-time in vivo histological examination of mucosal surfaces during endoscopy.Confocal laser endomicroscopy may be of great importance in the surveillance of precancerous gastric lesions and in the diagnosis of GC.In this editorial we commented on the article about this topic published by Lou et al in the recent issue of the World Journal of Clinical Cases.

肩关节手术后关节内应用酮洛酸、吗啡、罗哌卡因联合患者自控关节内镇痛对疼痛缓解影响的随机双盲研究

背景本研究评估关节内镇痛对手术后疼痛和镇痛药物需要量的影响。方法51例接受肩关节手术（Bankart）的患者纳入本随机双盲研究。手术结束后在关节内置入导管，随机分为3组分别注射下述药物：组1，罗哌卡因90mg（9ml）、吗啡4mg（10ml）、酮洛酸30mg（1ml）（总量20ml）；组2和组3，生理盐水（20ml）。此外，组1和组3的患者静脉注射1ml生理盐水；组2则静脉注射酮洛酸30mg（1ml）。手术后，组1通过关节内导管应用10ml 0．5％的罗哌卡因按需行手术后镇痛，而组2和组3应用生理盐水。组3是对照组。结果在最初的30和120分钟内，组1患者较组2和组3患者手术后静息和运动状态的疼痛减轻。组1患者较组2和组3手术后首次需要应用局麻药的时间延长（P〈0．001）。手术后最初24小时内，组1和组2患者的平均吗啡用量小于组3（P〈0．001）。组1和组2患者镇痛药物用量差异无显著性。与组2（P〈0．05）和组3（P〈0．001）相比，组1患者的平均满意度较高。结论与对照组相比，关节内联合应用罗哌卡因、吗啡、酮洛酸，随后按需间断应用罗哌卡因可以达到更好的疼痛缓解效果，较少的吗啡用量以及更高的患者满意度。与对照组患者相比，静脉注射酮洛酸组患者吗啡用量减少，并且治疗满意度也较高。