Unexpected positive culture (UPC) in adults revision spine surgery: a systematic review and meta-analysis of incidence, risk factors, and management.

BACKGROUND: Without clear signs of infection, spinal implant failure is attributed to mechanical overloads and aseptic loosening. However, how low-grade infections contribute to seemingly aseptic implant failure is unclear. PURPOSE: The systematic review examined unexpected positive cultures (UPCs) in revision spine surgery regarding prevalence, isolated pathogens, risk factors, and strategies to reduce infection among asymptomatic patients undergoing revision spine surgery. METHODS: We followed the PRISMA guidelines and searched four main databases (PubMed, EMBASE, SCOPUS, Web of Science) comprehensively until January 2023 for articles reporting UPC after presumed aseptic adult revision spine surgery. The UPC rates were pooled, and risk factors were compared with the culture-negative control group and represented as odds ratio (OR) or mean difference (MD). RESULTS: Fifteen studies of 1057 individuals were included in two groups: culture-positive or UPCs (n = 317) and culture-negative or control (n = 740). The overall UPC prevalence was 33.2% (317/1057, range: 0 to 53%, 95% CI = 30.2%-36.4%), and Cutibacterium acnes (43.0%, 95% CI = 37.4%-48.8%), Coagulase-negative Staphylococci (CoNS), (39.5%, 95% CI = 33.2%-46.2%), and Staphylococcus species in general (49.5%, 95%CI = 43.7%-55.4%) were reported the most common isolated microbes. 16.1% of the UPCs were polymicrobial. Risk factors associated with UPC rates were female sex (OR = 2.62, 95%CI = 1.76-3.90, P < 0.001), screw loosening (OR = 4.43, 95%CI = 1.31-15.02, P = 0.02), number of operated levels (MD = 0.77, 95%CI = 0.33-1.22, P = 0.0007), and shorter time since index surgery (MD = - 8.57 months, 95%CI = - 14.76, -2.39, P = 0.02). CONCLUSIONS: One-third of patients undergoing spine revision surgery revealed UPC in this study. Each UPC pathogen interpretation and antibiotic use decision should be interpreted case by case. LEVEL OF EVIDENCE: IV.

Shoulder Arthroplasty After Previous Nonarthroplasty Surgery: A Systematic Review and Meta-Analysis of Clinical Outcomes and Complications.

BACKGROUND: Many patients who undergo shoulder arthroplasty (SA) have had at least 1 nonarthroplasty shoulder surgery before the surgery. There is conflicting evidence regarding the effects of previous shoulder surgery on the outcome of SA. A systematic review was conducted to compare functional outcomes and complications between SA patients with and without prior non-SA surgery on the ipsilateral shoulder. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE/PubMed, Embase, Scopus, and Web of Science comprehensively from inception to January 2023. Based on 9,279 records reviewed, 26 comparative studies were included in the meta-analysis consisting of 5,431 shoulders with prior nonarthroplasty procedures (cases) and 55,144 shoulders without previous surgery (controls). Variables such as functional scores, complications, and range of motion were compared between cases and controls using Review Manager Software. In addition, subgroup analysis was conducted based on prior surgery type (rotator cuff repair [RCR], open reduction and internal fixation [ORIF], soft tissue repairs, and not specified) and type of SA (hemiarthroplasty, anatomical total shoulder arthroplasty, and reverse total shoulder arthroplasty [RTSA]). The results were presented as odds ratios (ORs) or standardized mean differences (SMDs). RESULTS: Except for a higher rate of periprosthetic joint infection (PJI) in patients who had undergone previous arthroscopic surgery (OR, 2.58; 95% confidence interval [CI], 1.66-4.01; p < 0.01), a higher rate of complications was only observed in patients with previous ORIF. These complications included aseptic loosening (OR, 3.43; 95% CI, 2.14-5.50; p < 0.01), shoulder dislocation (OR, 2.25; 95% CI, 1.05-4.84; p = 0.04), overall complication (OR, 3.95; 95% CI, 2.38-6.55; p < 0.01), and revision (OR, 2.52; 95% CI, 1.28-4.97; p = 0.01). Patients with a history of previous surgery demonstrated inferior functional outcomes in comparison with the control group, including American Shoulder and Elbow Surgeons (SMD, -0.39; 95% CI, -0.51 to -0.27; p < 0.01; I2 = 36%), Constant-Murley score (SMD, -0.34; 95% CI, -0.44 to -0.24; p < 0.01; I2 = 0%), abduction (SMD, -0.26; 95% CI, -0.45 to -0.08; p = 0.01; I2 = 54%), and flexion (SMD, -0.33; 95% CI, -0.46 to -0.21; p < 0.01; I2 = 40%). Subgroup analysis by previous type of surgery was not possible regarding functional outcomes. CONCLUSION: Patients who have had prior fracture surgery are at a higher risk of complications, reoperations, and revisions after SA than controls. The normal shoulder anatomy may be disrupted by prior surgery, which makes arthroplasty technically challenging, particularly when it comes to soft tissue balance. On the other hand, RCR before SA did not negatively affect clinical outcomes after RTSA and did not have a higher rate of overall complications (except PJI). LEVEL OF EVIDENCE: Level III (Treatment Studies). See Instructions for Authors for a complete description of levels of evidence.

Association of neutrophil to lymphocyte ratio with bone mineral density in post-menopausal women: a systematic review and meta-analysis.

BACKGROUND: We conducted a systematic review and meta-analysis to compare the neutrophil lymphocyte ratio (NLR) levels between women with post-menopausal osteopenia or osteoporosis to those with normal bone mineral density (BMD). METHODS: We used Web of Science, PubMed, and Scopus to conduct a systematic search for relevant publications published before June 19, 2022, only in English language. We reported standardized mean difference (SMD) with a 95% confidence interval (CI). Because a significant level of heterogeneity was found, we used the random-effects model to calculate pooled effects. We used the Newcastle-Ottawa scale for quality assessment. RESULTS: Overall, eight articles were included in the analysis. Post-menopausal women with osteoporosis had elevated levels of NLR compared to those without osteoporosis (SMD = 1.03, 95% CI = 0.18 to 1.88, p = 0.017, I2 = 98%). In addition, there was no difference between post-menopausal women with osteopenia and those without osteopenia in neutrophil lymphocyte ratio (NLR) levels (SMD = 0.58, 95% CI=-0.08 to 1.25, p = 0.085, I2 = 96.8%). However, there was no difference between post-menopausal women with osteoporosis and those with osteopenia in NLR levels (SMD = 0.75, 95% CI=-0.01 to 1.51, p = 0.05, I2 = 97.5%, random-effect model). CONCLUSION: The results of this study point to NLR as a potential biomarker that may be easily introduced into clinical settings to help predict and prevent post-menopausal osteoporosis.

Catastrophic skin necrosis after total knee arthroplasty: a case report and review of the literature.

Introduction and importance: There have been few cases of post total knee arthroplasty (TKA) skin necrosis reported. Here, the authors present our patient with skin necrosis post TKA on account of its extreme rarity, considerable risk factors, and importance of its treatment. Case: This is a cautionary report on the rule of including previous single longitudinal incision in surgical approach. The authors included previous medial incision in ours and performed arthroplasty through medial parapatellar incisions. After noticing skin necrosis in front of patella, reoperation including flap and skin graft was done, leading to complete recovery. Clinical discussion: While skin necrosis post TKA is not common, it can be present in high-risk patients who should be considered for a decrease in their risk factors. Preoperatively, underlying diseases should be under control. Intraoperation risk factors, in particular incision selection, and considerations about lateral retinacular release are important. Conclusion: A balance must be achieved between the ability to expose the knee through a prior incision and avoiding extensive undermining of the subcutaneous flaps in patients with previous knee surgery. It may be a better approach to ignore medial incisions and use the classic midline incision.

Does Using Highly Porous Tantalum in Revision Total Hip Arthroplasty Reduce the Rate of Periprosthetic Joint Infection? A Systematic Review and Meta-Analysis.

Background: Studies suggest tantalum (Ta) implants may have inherent antibacterial properties. However, there is no consensus regarding the effectiveness of Ta in preventing periprosthetic joint infection (PJI) after revision total hip arthroplasty (rTHA). Methods: We searched 5 main databases for articles reporting the rate of PJI following rTHA using Ta implants from inception to February 2022. The PJI rates of the Ta group were meta-analyzed, compared with the control group, and represented as relative risks (RRs) in forest plots. Results: We identified 67 eligible studies (28,414 joints) for assessing the prevalence of PJI following rTHA using Ta implants. Among these studies, only 9 compared the Ta implant group with a control group. The overall PJI rate following rTHA using Ta implants was 2.9% (95% confidence interval [CI]: 2.2%-3.8%), while it was 5.7% (95% CI = 4.1%-7.8%) if only septic revisions were considered. Comparing the Ta and control groups showed a significantly lower PJI rate following all-cause rTHA with an RR = 0.80 (95% CI = 0.65-0.98, P < .05). There was a trend toward lower reinfection rates in the Ta group after rTHA in septic cases, although the difference was not statistically significant (RR = 0.75, 95% CI = 0.44-1.29, P = .30). Conclusions: Ta implants are associated with a lower PJI rate following all-cause rTHA but not after septic causes. Despite positive results, the clinical significance of Ta still remains unclear since the PJI rate was only reduced by 20%. Level of Evidence: IV.

Rate and Risk Factors for Contralateral Slippage in Adolescents Treated for Slipped Capital Femoral Epiphysis: A Comprehensive Analysis of 3,528 Cases.

BACKGROUND: After a unilateral slipped capital femoral epiphysis (SCFE), the contralateral hip is at risk for a subsequent SCFE. However, further information with regard to risk factors involved in the development of contralateral SCFE must be investigated. The purpose of this study was to report the rate and risk factors for subsequent contralateral SCFE in adolescents treated for unilateral SCFE by exploring a mix of known and potential risk factors. METHODS: A case-control study utilizing aggregated multi-institutional electronic medical record data between January 2003 and March 2023 was conducted. Patients <18 years of age diagnosed with SCFE who underwent surgical management were included. Variables associated with contralateral SCFE were identified using multivariable logistic regression models that adjusted for patient characteristics and time of the surgical procedure, providing adjusted odds ratios (ORs). The false discovery rate was accounted for via the Benjamini-Hochberg method. RESULTS: In this study, 15.3% of patients developed contralateral SCFE at a mean (and standard error) of 296.53 ± 17.23 days and a median of 190 days following the initial SCFE. Increased thyrotropin (OR, 1.43 [95% confidence interval (CI), 1.04 to 1.97]; p = 0.022), diabetes mellitus (OR, 1.67 [95% CI, 1.22 to 2.49]; p = 0.005), severe obesity (OR, 1.81 [95% CI, 1.56 to 2.57]; p < 0.001), history of human growth hormone use (OR, 1.85 [95% CI, 1.10 to 3.38]; p = 0.032), low vitamin D (OR, 5.75 [95% CI, 2.23 to 13.83]; p < 0.001), younger age in boys (under 12 years of age: OR, 1.85 [95% CI, 1.37 to 2.43]; p < 0.001) and in girls (under 11 years of age: OR, 1.47 [95% CI, 1.05 to 2.02]; p = 0.026), and tobacco exposure (OR, 2.43 [95% CI, 1.49 to 3.87]; p < 0.001) were significantly associated with increased odds of developing contralateral SCFE. CONCLUSIONS: In the largest study on this topic, we identified the rate, odds, and risk factors associated with development of contralateral SCFE. We found younger age, hypothyroidism, severe obesity, low vitamin D, diabetes mellitus, and a history of human growth hormone use to be independent risk factors. Our findings can aid clinical decision-making in at-risk patients. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Neutrophil to Lymphocyte Ratio and Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR) has shown promising results as a diagnostic tool for periprosthetic joint infection (PJI) after total joint arthroplasty. We conducted a systematic review and meta-analysis to determine the utility of NLR in the diagnosis of PJI. METHODS: We searched PubMed, Scopus, and Web of Science from inception up to 2022 and evaluated the quality of the included literature. RESULTS: Based on the 12 eligible studies, NLR levels were significantly higher in patients who had PJI compared to those who had aseptic loosening (standard mean difference (SMD) = 1.05, 95% Confidence Interval (CI) = 0.71 to 1.40, P < .001). In the subgroup analysis according to type of PJI, NLR levels were significantly higher in patients who had either acute (SMD = 1.04, 95% CI = 0.05 to 2.03, P < .001) or chronic PJI (SMD = 1.08, 95% CI = 0.55 to 1.61, P < .001), compared to those who had aseptic loosening. According to type of arthroplasty, NLR levels were significantly higher in patients who had either total knee arthroplasty (SMD = 1.81, 95% CI = 1.48 to 2.13, P < .001) or total hip arthroplasty (SMD = 1.76, 95% CI = 1.54 to 1.98, P < .001) compared to aseptic loosening. The pooled sensitivity of the 12 studies was 0.73 (95% CI, 0.65 to 0.79), and the pooled specificity was 0.75 (95% CI, 0.71 to 0.78). The pooled positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of NLR were 2.94 (95% CI = 2.44 to 3.54), 0.35 (95% CI = 0.27 to 0.46), and 8.26 (95% CI = 5.42 to 12.58), respectively. CONCLUSION: In summary, this meta-analysis indicates that NLR is a reliable marker in the diagnosis of PJI.

Efficacy of trigger point dry needling on pain and function of the hip joint: a systematic review of randomized clinical trials.

OBJECTIVE: The objective of this study was to assess the evidence for the impact of dry needling (DN) on hip pain and function. METHODS: Medline/PubMed, Embase, Scopus, Web of Science and Cochrane CENTRAL databases were searched systematically through June 2022 for randomized clinical trials (RCTs) investigating the impact of DN on hip pain and function. Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to assess risk of bias. Descriptive analysis was conducted to explain the outcomes and adverse events of DN in hip joint diseases. Meta-analysis was not feasible due to significant heterogeneity. RESULTS: A total of seven eligible studies (including 273 patients) were included out of 2152 screened records. Five studies were in participants with hip osteoarthritis (OA; n = 3), greater trochanteric pain syndrome (GTPS; n = 1) or piriformis syndrome (n = 1); the other two studies were conducted in healthy athletes (n = 2). Two articles assessed changes in participants' short-term visual analog scale (VAS) scores (<1 week), one of which showed that DN significantly reduced pain (P < 0.05). One-week VAS scores were analyzed in three studies, all of which demonstrated reduced scores following DN (P < 0.05). Hip range of motion (ROM) and muscle force were also improved following DN. No serious side effects were reported. CONCLUSION: DN may be safe and effective at relieving hip pain and improving hip function. DN performs significantly better than several different types of control intervention (including sham DN, no treatment, corticosteroid injections and laser). Strong evidence (high degree of certainty around the results) is lacking, and future studies should ideally use longer follow-up periods and larger sample sizes. REVIEW REGISTRATION NUMBER: CRD42022297845 (PROSPERO).

Subtrochanteric Shortening Osteotomy Provides Superior Function to Trochanter Slide Osteotomy in THA for Patients With Unilateral Crowe Type IV Dysplasia at a Minimum of 3 Years.

BACKGROUND: Performing THA in patients with high-riding developmental dysplasia of the hip (DDH) is associated with serious complications and technical challenges. Various methods of shortening osteotomy are available to facilitate femoral head reduction during THA in patients with high-riding hips; subtrochanteric shortening osteotomy and trochanteric slide osteotomy plus proximal shortening are the most common techniques. However, which approach is superior remains a topic of controversy. QUESTIONS/PURPOSES: (1) Is there any difference in clinical outcomes (defined as the Harris Hip Score [HHS] and residual limb length discrepancy) at a minimum of 3 years between subtrochanteric shortening osteotomy and trochanteric slide osteotomy in patients with Crowe Type IV DDH who underwent THA? (2) Is there any difference in the risk or type of complications between the two approaches? METHODS: We performed a retrospective, comparative study of two groups (subtrochanteric shortening osteotomy versus trochanteric slide osteotomy) matched for sex and preoperative HHS at a minimum of 3 years of follow-up. Between 2010 and 2018, we performed 67 THAs in patients with unilateral Crowe Type IV DDH. During that time, we generally used a trochanteric slide osteotomy for THA in all patients with Crowe Type IV hips and performed subtrochanteric shortening osteotomy when a conical stem was not available. A total of 42% (28) had THA with subtrochanteric shortening osteotomy, and 58% (39) had THA with trochanteric slide osteotomy. Of those, 89% (25) and 74% (29), respectively, were accounted for with complete datasets for possible matching at a minimum of 3 years of follow-up. Patients were matched for gender and preoperative HSS (within 10 points), leaving 22 patients in each group (79% of the subtrochanteric shortening osteotomy group and 56% of the trochanteric slide osteotomy group) for evaluation and analysis. Age (42 versus 46 years), gender (female: 73% versus 73%), preoperative HSS (40 versus 40), and preoperative leg length discrepancy (5.9 versus 5.3 cm) were comparable between the two groups (p > 0.05). The trochanteric slide osteotomy group exclusively received Cone Wagner (Zimmer) implants (100%), while Corail (DePuy Synthes) implants (77%) were the most commonly used in the subtrochanteric shortening osteotomy group. HHS at a minimum of 3 years as well as the presence or absence of a limp and Trendelenburg sign, functional leg length discrepancy, nonunion, nerve palsy, and other surgical complications were recorded and compared between the groups based on data drawn from a longitudinally maintained institutional database. RESULTS: At a mean follow-up of 73 months, improvement in HHS was greater in the subtrochanteric shortening osteotomy group than in the trochanteric slide osteotomy group (48 ± 4 points versus 36 ± 11 points, mean difference 12 points [95% CI 7 to 17 points]; p < 0.001). Although the preoperative leg length discrepancy was similar between the groups, there was a greater postoperative improvement in the subtrochanteric shortening osteotomy group (44 ± 8 mm and 38 ± 8 mm in the subtrochanteric shortening osteotomy and trochanteric slide osteotomy groups, respectively; p = 0.02). The risk of nonunion was higher with a trochanteric slide osteotomy than with a subtrochanteric shortening osteotomy (23% [5 of 22] versus 0% [0 of 22]; p = 0.048). Other complications, including intraoperative periprosthetic fractures, nerve palsy, heterotopic ossification, revision surgery, and dislocation, did not differ between the groups. CONCLUSION: In patients with Crowe Type IV hips undergoing THA, surgeons might consider subtrochanteric shortening osteotomy rather than trochanteric slide osteotomy to minimize the risk of nonunion and achieve superior hip function. Better correction of leg length discrepancy may also be possible with subtrochanteric shortening osteotomy. The long-term survivorship of hips after these two techniques, as well as the influence of the specific anatomy of the proximal femur on the choice of technique, remain to be explored in future studies. LEVEL OF EVIDENCE: Level III, therapeutic study.

The relationship of hip fracture and thyroid disorders: a systematic review.

Introduction: Bone density regulation is considered one of the systems affected by thyroid hormones, leading to low bone density that can result in pathologic fractures, including hip fractures. This review aimed to update clinicians and researchers about the current data regarding the relationship between hip fractures and thyroid disorders. Methods: English papers were thoroughly searched in four main online databases of Scopus, Web of Science, PubMed, and Embase. Data extraction was done following two steps of screening/selection using distinct inclusion/exclusion criteria. This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist and the Newcastle-Ottawa Scale (NOS) as bias assessment. Results: In total, 19 articles were included in the research. The risk of hip fractures in women with differentiated thyroid cancer (DTC) is higher than hip fractures caused by osteoporosis. Men with hyperthyroidism and subclinical hyperthyroidism are at higher risk for hip fracture. Also, a decrease in serum thyroid stimulating hormone (TSH) may be associated with an increased risk of hip fracture. Conclusion: Reaching a consensus conclusion regarding the association between subclinical thyroid dysfunction and hip fracture is not feasible due to the heterogenicity of evidence; however, there may be a higher risk of fracture in individuals with subclinical hyperthyroidism.

Cross-Cultural Adaptation and Validation of the Persian Version of the Harris Hip Score.

Background: The Persian language, also known as Farsi, is a pluricentric language spoken in Iran, Afghanistan, and Tajikistan by about 140 million people. This study aims to translate the Harris hip score (HHS) into Persian with cross-cultural adaptation and to evaluate its validity and reliability. Methods: One hundred fifty-six total hip arthroplasty patients completed the Persian version of the HHS, Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and visual analog scale (VAS) for pain and satisfaction postoperatively. Using Cronbach's alpha (α) coefficient, internal consistency was evaluated. Correlations (Spearman's Rho) were used to assess validity. A test-retest reliability assessment of the Persian HHS was conducted (n = 47) using the intraclass correlation coefficient. Content validity was evaluated using the floor and ceiling effects of the HHS. Results: The final translation of the Persian HHS was approved to be used. The preoperative and postoperative Cronbach's alpha were 0.71 and 0.70, respectively, and showed acceptable internal consistency. The intraclass correlation coefficient was excellent (0.869, P < .001). Insignificant ceiling effects (13.5%) and no floor effects (0) were observed. The HHS score was significantly and strongly correlated with Western Ontario and McMaster Universities Osteoarthritis Index (r = 0.696, P < .001), VAS pain (r = 0.654, P < .001), VAS satisfaction (r = 0.634, P < .001), and Forgotten Joint Score (r = 0.648, P < .001). Conclusions: The Persian HHS demonstrated excellent reliability and validity properties. Accordingly, Persian HHS may be a helpful tool for assessing patients undergoing total hip arthroplasty.

Bilateral total hip arthroplasty in a case with fibrous dysplasia: a case report.

BACKGROUND: Fibrous dysplasia (FD) is a benign neoplasm with a broad spectrum of presentations. The treatment of FD in the hip region is controversial among orthopedic surgeons. Several treatment options exist, including curettage and grafting, valgus osteotomy, medial displacement osteotomy, and so on. Performing total hip arthroplasty (THA) on these patients and their subsequent outcome is still in infancy. CASE PRESENTATION: The patient is a 32-year-old white female with bilateral proximal femur FD who underwent bilateral THA with long stem implants. A year following surgery, she had no complications and had satisfactory radiological, pain, and functional outcomes. CONCLUSION: A bilateral THA with a long stem prosthesis showed promising results when performed following appropriate curettage of the proximal bone in an FD case. A cementless long stem could have enabled better diaphyseal fixation distal to the lesion site.

Early versus late physiotherapy following arthroscopic repair of small and medium size rotator cuff tear: a randomized clinical trial.

PURPOSE: We compared early and late physiotherapy for patients with small and medium size rotator cuff tears following arthroscopic repair. METHODS: A single-centre, single-blinded, prospective parallel RCT was performed with two arms: early physiotherapy (start within the first week) versus late physiotherapy (start 4 weeks after surgery). Patients with small- to medium-sized isolated full-thickness superior rotator cuff tears were included and followed for 12 months. The primary outcome measures were shoulder function and range of motion (ROM) measured by the Constant-Murley score (CMS) at three months, six months, and 12 months. The other outcomes were the visual analog scale (VAS) pain and the rotator cuff ultrasound (US) evaluation by the Sugaya classification. RESULTS: In three and six month follow-ups, CMS was significantly superior in the intervention group compared to controls (P < 0.05). However, only at the three month follow-up between-group difference met the minimal clinically important difference (MCID) (MCID = 10.4) (59.8 vs. 48.9). The intervention group experienced less pain than controls in the first six months (P < 0.001), and only the three month follow-up was clinically meaningful based on MCID (MCID = 1.4). Moreover, in the first six months, the shoulder ROM favoured the intervention group (P < 0.05). US grading of the supraspinatus and infraspinatus was similar between groups (P = 0.07). One retear occurred in the intervention group and another in the controls, detected by examination and US evaluation. CONCLUSION: Following the arthroscopic repair of a small- to medium-sized rotator cuff tear, early physiotherapy showed promising results for pain, function, and range of motion. LEVEL OF EVIDENCE: Level I therapeutic.

Osteomalacia Prevalence, Biochemical Profile, and Histology in Patients with Low-Energy Hip Fractures Over the Age of 45.

Our objective was to determine the prevalence of osteomalacia in low-energy hip fracture patients over the age of 45, based on biochemical and histological measures. This cross-sectional study included 72 patients over 45 with low-energy mechanism hip fractures. Samples of fasting venous blood were taken for hemograms and serum biochemistry analyses. Bicortical biopsies of the iliac crest were obtained, processed, and evaluated by an expert pathologist for osteomalacia. Biochemical osteomalacia (b-OM) is defined according to a distinct criterion. A low level of serum calcium, phosphorus, albumin, and 25OHD was found in 43.1, 16.7, 73.6, and 59.7% of patients, respectively. 50.0% of patients had high serum alkaline phosphatase (ALP) levels. b-OM was found in 30 (41.7%), and no significant association was found with PTH, Cr, Alb, age, sex, fracture type, side of the trauma, and season were not associated with osteomalacia. Osteomalacia was diagnosed on histopathological analysis in 19/72 (26.7%), and 54/72 (75.0%) of all cases fulfilled b-OM criteria. In the histologic evaluation, osteoid seam width, osteoid surface, and osteoid volume were 28.5 µm, 25.6, and 12.1%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the biochemical test for detecting osteomalacia were 73.6, 64.2, 42.4, 87.2, and 66.7%, respectively. Up to 30% of elderly patients with low-energy hip fractures are affected by osteomalacia. A biochemical screening along with a bone biopsy and histopathologic evaluation may be logical in a high-risk population for osteomalacia diagnosis.

Slight pelvic obliquity is normal in a healthy population: a cross-sectional study.

PURPOSE: Pelvic obliquity (PO) has not been extensively investigated, and there is no gold standard for measurement. The PO is essential for surgeons in planning hip arthroplasty, which includes the restoration of leg length discrepancy (LLD). We aimed to establish a normative range of PO angles by measuring healthy individuals without musculoskeletal disorders. METHODS: Our study included 134 consecutive cases (70 females) referred to our institution between April 2020 and September 2021 for non-orthopedic problems. Patients were screened for normal gait and posture using the visual observation method (VOM) and the Modified Gait Abnormality Rating Scale (GARS-M). In standing standard radiographs, the PO angle was measured as the angle between the horizontal plane and the inter-teardrop line. RESULTS: Patients' mean age and Body Mass Index (BMI) were 39.7 ± 16.8 and 22.3 ± 3.1, respectively. PO angles did not follow a normal distribution, with a median (IQR) of 2.0° (0.9°-3.1°). According to the Wilcoxon one-sample test, the median PO angle differed significantly from zero (P < 0.001). The PO angle did not differ significantly between males and females (2° vs. 2°, P = 0.46), nor did it correlate significantly with age (P = 0.24). Considering the 95% percentile of PO angles was 5.6°, this range (0°-5.6°) was regarded as a normative value. CONCLUSION: Normative values for PO in the normal healthy population range from 0° to 5.6°, with a median value of 2.0°. The PO angle was independent of age and sex and differed significantly from 0°. Slight pelvic obliquity may be normal, and physicians should not always assume that it is caused by pain, scoliosis, or weakness of the abductors. LEVEL OF EVIDENCE: III.

Comparison of low-dose (162 mg) and high-dose (650 mg) Aspirin prophylaxis following total joint arthroplasty: a prospective cohort study.

Since Aspirin's adverse effects are dose-dependent, and evidence supporting the use of low-dose (LD) Aspirin in preventing venous thromboembolism (VTE) after total hip arthroplasty (THA) is weak, the authors do not know what the minimal effective dosage of Aspirin is to prevent VTE. This study aimed to compare the rates of 90-day symptomatic VTE following THA and total knee arthroplasty in healthy patients taking LD Aspirin vs. high-dose (HD) Aspirin for 6 weeks postoperatively. Materials and methods: A prospective cohort of patients with THA and total knee arthroplasty was conducted at two tertiary centres. Symptomatic VTE within 90 days of index arthroplasty was the primary outcome; gastrointestinal bleeding (GIB) and mortality were secondary outcomes. Results: The final analysis included 312 consecutive patients: 158 in the LD group and 154 in the HD group. Two groups were similar regarding preoperative data, including sex, age, BMI, smoking, diabetes mellitus, Hgb and platelet count, and type of surgery. The LD group had one deep vein thrombosis (0.6%), and the HD group had two (1.3%) (P=0.62). Neither group had PTE. Therefore, VTE rates are the same as deep vein thrombosis rates and similar between the groups (0.6% vs. 1.3%, P=0.62)Regarding GIB due to anticoagulant therapy, no patient in the LD group reported GIB, whereas two (1.3%) patients in the HD group reported GIB within 90 days of arthroplasty. GIB rates did not differ significantly between groups (P=0.24). Considering VTE + GIB combined, the HD groups showed a higher rate of complications (N=4, 2.6%) than the LD groups (N=1, 0.6%) but not statistically significant (P=0.21). Conclusions: Prophylactic administration of Aspirin with low doses (81 mg BID) and high doses (325 mg BID) for six weeks is equally effective at reducing VTE in total joint arthroplasty patients and had similar adverse effects. Level of Evidence: Therapeutic Level II.

Telemedicine technologies and applications in the era of COVID-19 pandemic: A systematic review.

INTRODUCTION: Telemedicine services saw substantial surges in their use during the COVID-19 pandemic due to the lockdowns and characteristics of the pandemic. Therefore, the authors aimed to systematically review the telemedicine services provided during the COVID-19 pandemic and their potential applications. METHODS: The authors searched PubMed, Scopus, and Cochrane databases on September 14, 2021. Then, the retrieved records underwent two-step title/abstract and full-text screening processes, and the eligible articles were included for qualitative synthesis. RESULTS: The review of studies demonstrated that the telephone is listed 38 times, making it the most common technology used in telemedicine. Video conferencing is also mentioned in 29 articles, as well as other technologies: Mobile-health (n = 15), Virtual reality (n = 7). According to the findings of the present study, Tele-follow-up (n = 24), Tele-consulting (n = 20), Virtual visits (20), and Tele-monitoring (n = 18) were the most widely used telemedicine applications. CONCLUSION: Telemedicine has been an effective approach to COVID-19 management. Telemedicine technology is going to play a key role in the future of health medicine, patient consultation, and many other extended applications of health care in remote rural locations.

Management of a floating shoulder accompanied by a scapular surgical neck fracture: a case report and review of the literature.

In this article, we want to present a floating shoulder case accompanied by a scapular surgical neck fracture and review the literature about its diagnosis and management. Case Presentation: Our patient was a 40-year-old man who suffered a severe left shoulder injury as a result of a car-to-pedestrian accident. Computed tomography scan revealed a scapular surgical neck and body fracture, a spinal pillar fracture, and a dislocation of the acromioclavicular (AC) joint. The medial-lateral displacement and glenopolar angle were 21.65 mm and 19.8°, respectively. There was a 37° angular displacement and a greater than 100% translational displacement.Initially, the AC joint dislocation was approached via a superior incision on the clavicle and reduced with a single hook plate. A Judet approach was then used to expose the scapula fractures. The scapular surgical neck was fixed with a reconstruction plate. The spinal pillar was stabilized with two reconstruction plates following reduction.Following a year of follow-up, the patient's shoulder range of motion was acceptable, and an American Shoulder and Elbow Surgeons score of 88 was achieved. Discussion and Conclusion: Floating shoulder management is still controversial. Floating shoulders are often treated surgically due to their consequent instability and potential risk of nonunion and malunion. As shown in this article, the indications for operating on isolated scapula fractures may also apply to floating shoulders. A well-planned approach to fractures is also imperative, and the AC joint should always be a priority.

Intramedullary nail versus minimally invasive plate osteosynthesis for displaced extraarticular proximal tibia fractures: a prospective comparative cohort study.

PURPOSE: The treatment of extraarticular proximal tibial fractures is challenging. As the optimal fixation technique is still debated, the purpose of this study was to compare minimally invasive plate osteosynthesis (MIPO) and intramedullary nail (IMN) fixation. METHODS: A prospective matched comparative study was conducted on patients with displaced extraarticular proximal tibia fractures treated with MIPO (n = 29) versus IMN (n = 30) fixation. Outcomes collected were the Johner-Wruhs grading, range of motion (ROM), union rate, time to union, malunion, coronal and sagittal alignment, and post-operative complications. RESULTS: Union rates were similar between the MIPO and IMN groups (93% vs. 97%, P = 1.0). The IMN group had an earlier time to union (15 vs. 18 weeks, P < 0.001) and superior functional outcomes at one year (effective Johner-Wruhs score: 80% vs. 55%, P = 0.04). There was a significantly higher incidence of anterior knee pain in the IMN group (23% vs. 0%, P = 0.02) and there was a trend for more infections in the MIPO group (21% vs. 13%, P = 0.73). CONCLUSION: IMN fixation of extraarticular proximal tibia fractures was associated with a shorter union time and better functional scores compared to MIPO.