Hidden Inferior Vena Cava Injury: A Case of Missed Diagnosis after Preoperative CT and Laparotomy.

BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

Effect of plate design on maintenance of anterior and posterior gaps and posterior tibial slope after cyclic loading in medial open-wedge high tibial osteotomy: A biomechanical study using porcine's tibia.

Purpose: We aimed to investigate whether a plate adapted to the anatomy of the proximal medial porcine's tibia would provide maintenance of the anterior gap (AG), posterior gap (PG) and posterior tibial slope (PTS). Methods: Twenty-seven porcine tibias were biomechanically evaluated by performing MOWHTO and placing TOMOFIX (n = 9), AC plate (n = 9) and TriS (n = 9) anteromedially. Cyclic testing (800 N, 2000 cycles, 0.5 Hz) was performed to investigate the PTS over time for MOWHTO. The particular displacement calculated from the maximum to the minimum point with the load-displacement curve along the mechanical axis during cyclic testing, the final AG and PG changes at the osteotomy site, the increased PTS calculated by subtracting AG from PG after 2000 cycles were compared among the three groups. The displacement was evaluated by repeated-measures analysis of variance (ANOVA), and changes in AG and PG and increased PTS were evaluated by one-way ANOVA. The sample size for α and ß errors were <0.05 and <0.20, and the effect size was 0.64 for one-way ANOVA and 0.49 for repeated-measures ANOVA. Results: There were no significant differences in displacement among the groups. A significant difference was observed in the AG (p = 0.044) and PG (p = 0.0085) changes. There were no significant differences in increased PTS among the groups. Conclusion: When anteromedially placed, the AC plate and TriS resulted in significant maintenance of AG and PG compared with that of TOMOFIX in MOWHTO after cyclic loading. Level of Evidence: Level Ⅳ.

Biomechanical Comparison of Short-, Mid-, and Long-Length Proximal Femoral Nails for Femoral Intertrochanteric Fracture (AO/OTA 31A3.3) Fixation.

Introduction: In surgeries for unstable AO/OTA 31A3.3 fractures, surgeons use various lengths of intramedullary nails (IMNs). However, there is insufficient evidence regarding the appropriate nail length for these fractures. This study compared the biomechanical properties of IMNs of different lengths for AO/OTA 31A3.3 fractures. Methods: 30 synthetic femora of AO/OTA 31A3.3 fracture model were randomly assigned to the following three groups: short- (170 mm), mid- (235 mm), and long-length (300 mm) nail groups, and were performed fixation surgery. The translation patterns of the constructs were examined by cyclic testing and compared among three groups. Additionally, changes in the neck-shaft and shaft-nail angles after cyclic testing were evaluated using radiological images. Results: The translation patterns during cyclic loading did not differ among the groups. Conversely, one-way analysis of variance (ANOVA) revealed a significant difference in the neck-shaft angle change (5.8° ± 1.8°, 2.8° ± 1.3°, and 1.9° ± .9° in the short-, mid-, and long-length groups, respectively; P < .001), and post-hoc analysis revealed that the change was greater in the short-length group than in the mid- and long-length groups (P < .001 and P < .001, respectively). Furthermore, one-way ANOVA revealed a significant difference in the shaft-nail angle change (3.1° ± 2.1°, 1.4° ± 1.4°, and .1° ± .6° in the short-, mid-, and long-length groups, respectively; P < .001), and post-hoc analysis revealed that the change was greater in the short-length group than in the mid- and long-length groups (P = .044 and P < .001, respectively). Conclusions: Short-length nails were associated with relevant changes in the neck-shaft and shaft-nail angles in our AO/OTA 31A3.3 fracture model. Thus, the selection of mid- or long-length nails instead of short-length nails might be better in IMN surgery for these fractures to prevent postoperative varus deformity.

Postoperative improvement in patient-reported outcomes after neutral alignment medial open wedge high tibial osteotomy for medial compartment knee osteoarthritis in patients aged ≥70 years versus younger patients.

Purpose: To compare the postoperative clinical and radiological outcomes in patients aged ≥70 years following neutral alignment medial opening-wedge high tibial osteotomy (NA-MOWHTO) for medial compartment knee osteoarthritis (KOA) to those observed in younger patients. Methods: The data of patients who underwent NA-MOWHTO for medial compartment KOA between September 2018 and June 2022 were retrospectively analysed. The patients were categorised into groups Y (<70 years) and O (≥70 years). Age, sex, Kellgren-Lawrence classification, pre- and postoperative mechanical axis, weight-bearing line ratio, medial proximal tibial angle, preoperative Tegner Activity Score and pre- and postoperative Lysholm scores were compared between the groups. Results: Overall, 81 patients (60 and 21 in groups Y and O, respectively) who underwent NA-MOWHTO were included in this study. No significant differences were found in patient characteristics between the two groups, except for the preoperative Tegner Activity Score, which was significantly higher in group Y than in group O (3 [2-4] vs. 2 [2-2], respectively; p = 0.011). The two groups exhibited no significant differences in pre- and postoperative knee alignments. Postoperatively, Lysholm scores improved significantly in both groups without significant differences. Additionally, no correlation was found between age and pre- and postoperative Lysholm scores. Conclusions: The postoperative improvement following NA-MOWHTO for medial compartment KOA is comparable in patients aged ≥70 and younger. Level of Evidence: Level III, Retrospective comparative study.

The need to suspect tension gastrothorax as a cause of obstructive shock in trauma care: A case report.

INTRODUCTION: Traumatic tension gastrothorax is a type of obstructive shock similar to tension pneumothorax. However, tension gastrothorax is not well known among emergency physicians, and no consensus has yet been reached on management during initial trauma care. We present a case of traumatic tension gastrothorax in which tube thoracostomy was performed based solely on clinical findings very similar to tension pneumothorax, followed by emergency laparotomy. PRESENTATION OF CASE: A 24-year-old male motorcyclist was brought to our emergency medical center after being struck by a motor vehicle. He was in respiratory failure and hypotensive shock with findings suggestive of pneumothorax. Although the physical findings were not fully in line with tension pneumothorax, we immediately performed finger thoracostomy. Subsequent radiography revealed left diaphragmatic rupture with hernia. After unsuccessful attempts to decompress the stomach with a nasogastric tube, immediate emergency laparotomy was performed. During the operation, the stomach, which had prolapsed through the ruptured diaphragm into the thoracic cavity, was manually returned to the abdominal cavity. The ruptured diaphragm was repaired with sutures. DISCUSSION: Although distinguishing between tension pneumothorax and tension gastrothorax based on physical examination alone is difficult, tension gastrothorax requires careful attention to avoid intrapleural contamination from gastric injury. In addition, relying solely on stomach decompression with a nasogastric tube or delaying laparotomy could lead to cardiac arrest. CONCLUSION: When tension pneumothorax is suspected during initial trauma care, tension gastrothorax should also be considered as a differential diagnosis and treated with immediate diaphragmatic repair once identified.

Biomechanical comparisons of plate placement for medial tibial plateau fractures (Schatzker type IV): A biomechanical study using porcine tibias.

INTRODUCTION: Biomechanical studies on medial tibial plateau fractures (MTPFs) (Schatzker classification type IV) are currently few, while studies using locking plates (LPs) placed on medial proximal tibias are unavailable. Hence, we compared the biomechanical properties of plate osteosynthesis at the medial and anteromedial placements using large- and small-fragment LPs in porcine bones. MATERIALS AND METHODS: MTPFs were internally fixed using LPs on 40 porcine tibias. Specimens were equally divided into four groups: medial placement using a large-fragment LP (LPs for the medial (LM) group), anteromedial placement using a large-fragment LP (LAM group), medial placement using a small-fragment LP (SM group), and anteromedial placement using a small-fragment LP (SAM group). The translation patterns of the constructs in each group were examined by cycling loading test (displacement and translation along the mechanical axis at 10-100, 100-500, 500-1000, 1000-1500, and 1500-2000 cycles). Then, articular gaps and step-off changes after 2000 cycles were compared among the four groups. RESULTS: One-way analysis of variance (ANOVA) revealed no significant differences in displacement and translation during cyclic loading. One-way ANOVA followed by post hoc analysis revealed that the anterior gap was lower in LPs for the medial (LM) than in SM (P = 0.029) and SAM (P = 0.0026). The central gap was also lower in LM than in SM (P = 0.042) and SAM (P < 0.001), and it was lower in LAM than in SAM (P = 0.047). Likewise, the posterior gap was lower in LM than in LAM (P = 0.025) and SAM (P < 0.001). Furthermore, the central step-off of SAM was higher than that of LM, LAM, and SM (P < 0.001, P = 0.0014, and P = 0.0077, respectively). The posterior step-off was lower in LM than in SAM and LAM (P = 0.037 and P < 0.001), and it was also lower in SM than in SAM (P = 0.0082). CONCLUSION: Medial LP placement for MTPFs in porcine bones resulted in significantly lower posterior step-offs after cyclic loading than anteromedial placement, and large-fragment LPs for MTPFs caused significantly lower fracture gaps in the central articular after cyclic loading than small-fragment LPs.

Prevalence of perilymphatic fistula in patients with sudden-onset sensorineural hearing loss as diagnosed by Cochlin-tomoprotein (CTP) biomarker detection: its association with age, hearing severity, and treatment outcomes.

PURPOSE: To determine the prevalence of perilymphatic fistula (PLF) in sudden-onset sensorineural hearing loss (SSNHL) patients by employing the Cochlin-tomoprotein (CTP) detection test, a specific diagnostic marker for perilymph. We also analyzed the clinical characteristics associated with hearing outcomes in this cohort. METHODS: A total of 74 eligible patients were prospectively enrolled. Following myringotomy, middle ear lavage (MEL) samples underwent the CTP test to identify perilymph leakage. Intratympanic dexamethasone (IT-DEX) therapy was administered, and hearing outcomes were assessed. Control groups comprised patients with chronic otitis media (n = 40) and non-inflammatory middle ears (n = 51) with concurrent MEL sample collection. RESULTS: CTP was positive in 16 (22%) patients. No control samples showed positive results. Multiple regression analysis indicated that age and pre-treatment hearing levels significantly contributed to the CTP value. We found a positive correlation between CTP values, age, and pre-treatment pure-tone averages. Notably, CTP values in SSNHL cases aged 60 and above were significantly higher than in those below 60 years. Patients with positive CTP had significantly worse recovery rates after IT-DEX treatment. CONCLUSION: This study is the first prospective investigation demonstrating a positive relationship between CTP values, age, and hearing severity in SSNHL, indicating that PLF might be the essential cause of SSNHL, particularly in the elderly. Our findings suggest that IT-DEX may be less effective for PLF-associated SSNHL. Future research could reveal that PLF repair surgery is a viable treatment strategy for SSNHL. This study was registered under the UMIN Clinical Trials Registry (UMIN000010837) on 30/May/2013.

Epidemiology of fragility fracture of the pelvic ring: a regional population-based study in Northern Japan.

Using a regional population-based dataset in Japan, we identified the epidemiological characteristics of patients with fragility fractures of the pelvic ring. The incidence rate was 35.5-121.2 per 100,000 population/year. Age-specific incidence increased after 75 years. This fracture is associated with worse prognosis in terms of walking function and life expectancy. PURPOSE: Fragility fracture of the pelvic ring (FFP) is common among older patients; however, little information is available on the epidemiology of FFP worldwide. We aimed to identify the epidemiological characteristics of patients with FFP using a regional population-based dataset in Japan. METHODS: This descriptive epidemiologic study analyzed data obtained from clinical information of patients diagnosed with FFP from January 1, 2011 through December 31, 2020 at a regional dominant hospital in Japan. We calculated the crude and age-adjusted annual incidences and the age-specific incidence and described epidemiological date, injury characteristics, walking ability before and after FFP, and mortality. Additionally, we investigated factors associated with walking ability. RESULTS: We identified 66 FFP patients, of whom 55 (83.3%) were female, with a mean age of 82.2 years. The crude annual incidence of FFP ranged from 35.5-121.2 per 100,000 population/year during the study period. The age-specific incidence of FFP increased after 75 and 80 years in females and males, respectively. In total, 44.4% of patients had declines in walking ability 1 year after their FFP injuries. Patients with declining walking ability were significantly older (p < 0.01), and age ≥ 80 years was significantly associated with the decline in walking ability (p < 0.01). The 1- and 5-year mortality rates were 15.4% and 39.9%, respectively. CONCLUSION: The incidence rate of FFP was 35.5-121.2 per 100,000 population/year. Age-specific incidence of FFP increased after 75 years. Our results indicate that FFP is associated with worse prognosis of walking function and life expectancy.

Risk of peri­implant femoral fracture after cephalomedullary nailing in older patients with trochanteric fractures.

INTRODUCTION: Despite the recent increase in the use of cephalomedullary nails for trochanteric hip fractures, factors that may be associated with peri­implant femoral fracture (PIFF) after cephalomedullary nailing for trochanteric fractures remain unknown. We investigated the factors associated with PIFF after cephalomedullary nailing of trochanteric hip fractures in older patients. METHODS: A nested case-control study was conducted using a database of patients aged ≥65 years who underwent surgery with cephalomedullary nails for trochanteric fractures caused by low-energy trauma during 2005-2021. The cases were defined as patients who developed PIFF after surgery, while controls were patients who did not develop PIFF and who were followed up for ≥3 years after surgery. Four controls were randomly matched to each case for sex and age. First, potential factors associated with PIFF were compared between cases and controls. Second, multivariable conditional logistic regression analysis was employed to assess factors possibly associated with PIFF, controlling for potential confounding factors. RESULTS: Of 1531 patients who underwent surgery with cephalomedullary nails because of trochanteric fractures, we assessed 34 cases and 136 controls (N = 170; mean age 85.7 ± 7 years; and females, 94 %). PIFF was significantly associated with patients having undergone total knee arthroplasty (adjusted odds ratios [95 % confidence intervals], 4.41 [1.16-16.8]) and those with AO/OTA classification 31A3 fracture (A3 fracture) (2.3 [1.12-4.76]), after adjusting for potential confounding factors. CONCLUSIONS: Our results showed that PIFF was more likely to develop among older patients with a clinical history of total knee arthroplasty and A3 fracture. These findings suggest that such patients may require careful follow-up with rigorous assessments after cephalomedullary nailing for trochanteric fractures.

Use of a preoperative 3D templating and proximal lateral tibial fitting patient-specific instrumentation in fixed valgus complex primary total knee arthroplasty for a patient with retaining hardware for internal fixation to treat Schatzker type V tibial plateau fracture: A case report.

A 72-year-old female patient with a fixed valgus knee deformity due to a Schatzker type V tibial plateau fracture treated with bilateral locking plates 8 years ago was admitted to our clinic with complaints of chronic pain and knee instability when walking. Radiographs revealed Kellgren-Lawrence Classification grade 4 knee osteoarthritis and 20.5° of valgus knee deformity. She was treated with three-dimensional templating and proximal lateral tibial fitting patient-specific instrumentation-assisted mechanically aligned posterior sacrificing total knee arthroplasty with minimal removal of the retained hardware for the internal fixation of the tibial plateau fracture via a lateral approach, resulting in a favorable clinical outcome. The use of proximal lateral tibial fitting patient-specific instrumentation in fixed valgus complex primary total knee arthroplasty for patients with retaining hardware for internal fixation to treat tibial plateau fractures is considered a treatment option to decrease surgical invasion.

Spinal cord injury without radiological abnormality due to a fall while using an abdominal roller: A report of two cases.

Background: In recent years, various home-use health devices have gained popularity. The abdominal roller is one of these. Spinal cord injury without radiological abnormality is known to occur even with relatively minor injuries, but there are few reports of such injuries caused by a roller. Case Presentation: Two cases of spinal cord injuries caused by a roller are reported. In both cases, injuries occurred during the standing rollout by a patient in an inebriated state, and the patients were rushed to an emergency department. Conclusion: Because the use of abdominal rollers may result in extremely serious disabilities, it is necessary to emphasize the appropriate use of such equipment.

Effect of plate position on tibial displacement and posterior tibial slope after cyclic loading in medial open wedge high tibial osteotomy: A biomechanical study using porcine tibia.

BACKGROUND: Medial open wedge high tibial osteotomy is currently the most common osteotomy, but its complication is an increased posterior tibial slope over time. However, no study has clarified whether the plate position of medial open wedge high tibial osteotomy could reduce the increase in posterior tibial slope after cyclic loading. METHODS: Fourteen porcine bones were biomechanically evaluated by performing medial open wedge high tibial osteotomy and placing TOMOFIX medially and anteromedially. Cyclic testing was performed to investigate the posterior tibial slope over time for medial open wedge high tibial osteotomy with medial or anteromedial plate. The displacement along the mechanical axis during cyclic testing from 10 to 100th, 100-500th, 500-1000th, 1000-1500th, and 1500-2000th cycles, and changes in anterior and posterior gaps after 2000 cycles were compared between plate position. FINDINGS: There were no significant differences in displacement. A significant difference was found in posterior gap changes (-0.20 ± 0.84 mm in group of using medial plate, 1.07 ± 0.82 mm in group of using anteromedial plate) (P = 0.014), but none was found in anterior gap changes. INTERPRETATION: Medial plate placement in medial open wedge high tibial osteotomy resulted in significantly less increased posterior tibial slope than anteromedial plate placement after cyclic loading.

AO/OTA 31A3 fractures and postoperative complications in older patients.

BACKGROUND: AO/OTA 31A3 fractures (A3 fractures) have risk for postoperative complications with major impact on morbidity and mortality. For older patients, limited information is available for factors associated with postoperative complications. We aimed to assess factors associated with postoperative complications after surgery using cephalomedullary nails. METHODS: A retrospective cohort study was conducted using the information on patients aged ≥65 years who underwent surgery using cephalomedullary nails for trochanteric fractures due to low-energy trauma in three hospitals. Postoperative complications were diagnosed when patients were identified as nonunion, cutout of lag screw, or nail breakage. First, we compared differences including age, sex, body mass index, American Society of Anesthesiologists physical status classification system, preoperative waking ability, fracture type, nail length, neck shaft angle, reduction method, reduction quality and tip apex distance between patients with and without postoperative complications. Second, multivariable logistic regression analysis was employed to assess factors associated with postoperative complications resulting from A3 fractures. RESULTS: Among 120 patients with A3 fractures, postoperative complications were identified in 12 patients (10.0%). Postoperative complications were significantly more likely to develop among patients with poor reduction quality (adjusted odds ratio [95% confidence interval], 35.0 [4.43-275.9]) and a tip-apex distance ≥25 mm (16.4 [1.92-140.3]). CONCLUSIONS: These findings suggest that surgeons should aim to perform appropriate postoperative reduction and to prevent postoperative complications when using a cephalomedullary nail for A3 fractures among older patients.

Epidemiology of distal radius fracture: a regional population-based study in Japan.

BACKGROUND: Distal radius fracture (DRF) is very common worldwide. In particular, aging countries have numerous patients with DRF, resulting in an urgent need for active preventive measures. As few epidemiological studies have investigated DRF in Japan, we aimed to identify the epidemiological characteristics of patients of all ages with DRF in Japan. METHODS: This descriptive epidemiologic study analyzed data obtained from clinical information of patients diagnosed with DRF from January 1, 2011, to December 31, 2020, at a prefectural hospital in Hokkaido, Japan. We calculated the crude and age-adjusted annual incidences of DRF and described the age-specific incidence, injury characteristics (injury location and cause, seasonal differences, and fracture classification), and 1- and 5-year mortality rates. RESULTS: A total of 258 patients with DRF were identified, of which 190 (73.6%) were female and the mean age (standard deviation) was 67.0 (21.5) years. The crude annual incidence of DRF ranged from 158.0 to 272.6 per 100,000 population/year, and the age-adjusted incidence among female patients demonstrated a significant decreasing trend during 2011-2020 (Poisson regression analysis; p = 0.043). The age-specific incidence differed by sex, with peaks at 10-14 years for males and 75-79 years for females. The most common cause of injury was a simple fall in patients > 15 year of age and sports injuries in patients ≤ 15 years of age. DRFs were most frequently sustained outdoors and were more common in the winter season. In patients > 15 years of age, the proportions of AO/OTA fracture types A, B, and C were 78.7% (184/234), 1.7% (4/234), and 19.6% (46/234), respectively, and 29.1% (68/234) of patients received surgical treatment for DRF. The 1- and 5-year mortality rates were 2.8% and 11.9%, respectively. CONCLUSIONS: Our findings were mostly consistent with previous global studies. Although the crude annual incidence of DRF was relatively high because of recent population aging, the age-adjusted annual incidence among female patients showed a significant decreasing trend during this decade.

Anterior cruciate ligament reconstruction with retained internal fixation hardware for treating Schatzker type V tibial plateau fracture: Two case reports.

Despite the high incidence of anterior cruciate ligament injury in patients with tibial plateau fractures, we found no reports about anterior cruciate ligament reconstruction with retained internal fixation hardware for these fractures. Herein, we report 2 male patients with Schatzker type V tibial plateau fractures and describe the use of retained hardware for internal fixation in tibia. The patients underwent anterior cruciate ligament reconstruction using outside-in technique for the femoral tunnel. Throughout the follow-up, no radiological symptoms of suspected knee osteoarthritis were observed. Accordingly, surgical intervention can be reduced by creating an independent femoral tunnel.

Revision surgery in a middle-aged patient with pertrochanteric fracture nonunion due to wedge effect caused by cephalomedullary nail: A case report.

Trochanteric femur fractures have traditionally been treated surgically with compression hip screws or cephalomedullary nails. With the increasing use of cephalomedullary nails, potential complications from this technique have surfaced. One of them is the potential for varus malreduction of trochanteric femur fractures, known as the "wedge effect", which is the distraction of fracture fragments generated during reamer and nail passage resulting in varus malalignment at the neck-shaft angle. Although trochanteric nonunion in the non-elderly is exceedingly rare, we experienced one such case after nailing due to the wedge effect that was subsequently successfully treated with a compression hip screw without bone grafting. Therefore, in the case of stable pertrochanteric fractures (AO/OTA 31A1) in younger patients, compression hip screw surgery may be the better choice of initial surgery to avoid later nonunion.

Younger age is a significant factor for poorer adherence in fracture patients who received low-intensity pulsed ultrasound: A retrospective study.

BACKGROUND: The factors for poor adherence to therapy in patients with postoperative fracture who are treated with low-intensity pulsed ultrasound remain unknown. Therefore, we designed a retrospective cohort study to determine the various factors for poorer adherence to therapy in patients with postoperative fracture who were treated with low-intensity pulsed ultrasound therapy. METHODS: We retrospectively analyzed the data of postoperative patients who underwent low-intensity pulsed ultrasound after fracture surgery from January 2010 to May 2019. The patients were categorized into two groups as follows: group G, including those with a good adherence rate (>72%), and group P, including those with a poor adherence rate (<72%). Factors, such as age, sex, how the rental cost of low-intensity pulsed ultrasound was paid (by the patients themselves or by the insurance company), living (alone or with someone), insurance claim item (fractures within 3 weeks after osteosynthesis or delayed or non-union fractures), low-intensity pulsed ultrasound device-type (earlier- or next-generation), duration of low-intensity pulsed ultrasound use, fracture site (upper or lower limb), frequency of hospital visits (regular or irregular), and employment status (employed/unemployed) were compared between groups G and P. RESULTS: In total, 96 patients (74 and 22 patients in groups G and P, respectively) who underwent low-intensity pulsed ultrasound were included in the study. Univariate analysis revealed that younger patients (P < 0.001) and patients who did not regularly visit the hospital (P = 0.024) were more likely to have poorer adherence to therapy. Multiple logistic regression analysis revealed that age was the only independent, pertinent factor for poorer adherence to therapy (odds ratio, 8.570; 95% confidence interval, 2.770-26.50; P < 0.001), with a cutoff value of 41 years. CONCLUSIONS: Younger age is a significant factor for poorer adherence in patients undergoing low-intensity pulsed ultrasound therapy.

Combination of radiographic apparent bone gap and nonunion risk determination score improves accuracy of prediction of tibial shaft delayed union.

BACKGROUND: There is a need for a novel therapeutic strategy for an earlier prediction of long bone union failure as compared to previous methodologies. This study aimed to determine whether a combination of two diagnostic tools would result in a more accurate diagnosis of delayed union. METHODS: The inclusion criteria were as follows: patients with tibial shaft fracture who underwent treatment with intramedullary nailing (IMN) as definitive internal fixation (IF). The study included a total of 114 patients with 116 tibial shaft fractures treated with IMN as definitive IF. Radiographic apparent bone gap (RABG) and nonunion risk determination score (NURDS) can be used to predict nonunion. However, this study aimed to determine whether combination of RABG and NURDS could help deduce a more accurate prediction of delayed union. RESULTS: The union rate was found to be 85% (99 fractures), the delayed union rate was found to be 15% (17 fractures), and the rate of nonunion requiring additional surgical intervention was estimated to be 4% (5 out of the 17 delayed union cases). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RABG were found to be 82.3%, 76.0%, 36.8%, and 96.2%, respectively, when an RABG cutoff value of 5.0 mm was applied to our patient cohort. The sensitivity, specificity, PPV, and NPV of NURDS were found to be 47.1%, 82.0%, 30.8%, and 90.1%, respectively, when a NURDS cutoff value of 8.0% was applied to our patient cohort. When RABG and NURDS were above their respective cutoff values, the sensitivity and PPV were estimated to be 90.0% and 56.3%, respectively. When RABG and NURDS were below their respective cutoff values, the specificity and NPV were estimated to be 90.1% and 98.5%, respectively. CONCLUSIONS: The combination of RABG and NURDS evaluation immediately after surgery helps surgeons identify patients who are at a high risk of delayed union, facilitating careful monitoring of these patients and consideration of additional treatments.