Intramedullary Nailing Versus Open Reduction and Plate Fixation for Lateral Malleolar Fractures: A Meta-Analysis.

The fixation for lateral malleolar fracture in ankle fractures is still controversial. The purpose of this meta-analysis is to compare clinical and radiological outcomes between intramedullary nail (IMN) and plate for lateral malleolar fractures in ankle fractures. The PubMed, EMBASE, and Cochrane Library were searched for randomized controlled trials (RCTs) from databases inception to June 2023. Data on outcomes were extracted and the methodological quality of the included studies were assessed. A meta-analysis was performed using RevMan 5.3 software when the data extracted from included studies could be synthesized. Seven RCTs were included. The methodological quality of the included studies was moderate to high. The meta-analysis results showed that the infection rate of the IMN group was significantly lower than that of the plate group (RR = 0.38; 95%CI 0.18-0.82; p = .01). There were no significant differences between the 2 groups in Olerud and Molander Ankle Score (OMAS), union rate, radiological outcomes, nerve injury rate, reoperation rate, loss of reduction, and total complication rate. Our present meta-analysis demonstrated that the IMN might be a better method for the fixation of lateral malleolar fracture in ankle fracture, as the infection rate was significantly lower than a plate.

Does Distal Clavicle Resection Decrease Pain or Improve Shoulder Function in Patients With Acromioclavicular Joint Arthritis and Rotator Cuff Tears? A Meta-analysis.

BACKGROUND: Acromioclavicular joint arthritis is a common, painful, and often missed diagnosis, and it often accompanies other shoulder conditions such as rotator cuff disease. Whether distal clavicle resection is important to perform in patients undergoing surgery for rotator cuff tears and concomitant acromioclavicular joint arthritis is controversial. QUESTIONS/PURPOSES: The purpose of this study was to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of distal clavicle resection on (1) outcome scores; (2) shoulder ROM, joint pain or tenderness, and joint instability; and (3) risk of reoperation among patients treated surgically for rotator cuff tears who had concomitant acromioclavicular joint arthritis. METHODS: We systematically searched the PubMed, EMBASE, and Cochrane databases to find RCTs that met our eligibility criteria, which, in summary, (1) compared rotator cuff repair plus distal clavicle resection with isolated rotator cuff repair for patients who sustained a full- or partial-thickness rotator cuff tear and concomitant acromioclavicular joint arthritis; and (2) the followup period was at least 2 years. Two reviewers screened the studies, extracted the data and evaluated the methodological quality, and performed data analysis. Statistical heterogeneity among studies was quantitatively evaluated with the I index. No heterogeneity was detected (I = 0%; p = 0.75) in terms of acromioclavicular joint pain or tenderness, Constant score, forward flexion, external rotation, and risk of reoperation, so fixed-effect models were used in these endpoints. Heterogeneity was moderate for the American Shoulder and Elbow Surgeons (ASES) score (I = 53%; p = 0.12) and low for the visual analog scale (VAS) score (I = 35%; p = 0.22), so random-effect models were used in these endpoints. Subgroup analysis was stratified by the symptom of acromioclavicular joint arthritis. Three RCTs with 208 patients were included. We evaluated the risk of bias using the Cochrane risk-of-bias tool; in aggregate, the three RCTs included showed low to intermediate risk, although not all parameters of the Cochrane tool could be assessed for all studies. RESULTS: There was no difference between the distal clavicle resection plus rotator cuff repair group and the isolated rotator cuff repair group in ASES score (mean difference =1.41; 95% confidence interval [CI], -3.37 to 6.18; p = 0.56) nor in terms of the VAS score and Constant score. Likewise, we found no difference in ROM of the shoulder (forward flexion, internal rotation, and external rotation) or acromioclavicular joint pain or tenderness between the groups (pooled results of acromioclavicular joint pain or tenderness: risk ratio [RR], 1.59; 95% CI, 0.67-3.78; p = 0.30). Acromioclavicular joint instability was only detected in the rotator cuff repair plus distal clavicle resection group. Finally, we found no difference in the proportion of patients undergoing repeat surgery between the study groups (pooled results of risk of reoperation for the rotator cuff repair plus distal clavicle resection and isolated rotator cuff repair: one of 52 versus two of 78; RR, 0.86; 95% CI, 0.11-6.48; p = 0.88). CONCLUSIONS: Distal clavicle resection in patients with rotator cuff tears did not result in better clinical outcome scores or shoulder ROM and was not associated with a lower risk of reoperation. Distal clavicle resection might cause acromioclavicular joint instability in patients with rotator cuff tears and concomitant asymptomatic acromioclavicular joint arthritis. Arthroscopic distal clavicle resection is not recommended in patients with rotator cuff tears and concomitant acromioclavicular joint arthritis. Additional well-designed RCTs with more participants, long-term followup, and data on patient-reported outcomes are needed. LEVEL OF EVIDENCE: Level I, therapeutic study.

Plate versus screws fixation for the posterior malleolar fragment in trimalleolar ankle fractures.

BACKGROUND: The fixation methods of posterior malleolar fracture (PMF) in trimalleolar ankle fractures is still controversial. We aim to compare clinical and radiological outcomes between plate fixation and screws fixation for PMF in trimalleolar ankle fractures. METHODS: Literature search was performed through PubMed, EMBASE, Cochrane Library and CNKI database from databases inception to May 2022 to identify randomized controlled trial (RCT) and comparative clinical study in English or Chinese. A meta-analysis was performed using RevMan 5.1 software, and systematic review was performed when the data extracted from included studies could not be synthesized. RESULTS: Two RCTs and six cohort studies were included. The meta-analysis results showed that articular step-off or gap in plate fixation was superior to antero-posterior screws fixation (RR = 0.28; 95%CI: 0.11, 0.76; P = 0.01). there were no significant differences in American Orthopaedic Foot & Ankle Society scores (MD = -0.19; 95%CI: -2.43, 2.05; P = 0.87), arthritis (RR = 1.67; 95%CI: 0.61, 4.55; P = 0.32), infection and total complication (RR = 1.42; 95%CI: 0.89, 2.25; P = 0.14). CONCLUSION: Plate fixation might have better articular step-off or gap, compared with "A to P" screws fixation for the posterior malleolus in trimalleolar ankle fractures. Screw fixation could achieve shorter surgical time than plate fixation. However, no significant differences were found in AOFAS scores, arthritis, infection, sural nerve injury and total complication during the comparisons.

LncRNA-H19 Modulates Wnt/ß-catenin Signaling by Targeting Dkk4 in Hindlimb Unloaded Rat.

OBJECTIVE: To investigate the biological functions of long noncoding RNA-H19 (H19) in the pathogenesis of disuse osteoporosis (DOP). METHODS: Fifty-four male Sprague Dawley (SD) rats were randomly divided into three groups: baseline control (BC, 6), age-matched control (AC, 24), and hindlimb unloading (HLU, 24). The rats in the BC group were sacrificed at the beginning of the experiment, while the AC and HLU rats were sacrificed at different times (7, 14, 21 and 28 days after HLU). The DOP model was verified by micro-CT scan, and quantitative real-time polymerase chain reaction (qRT-PCR) was used to quantify the expression of osteogenic genes (OPG, RunX2 and OPG). Gene sequencing and bioinformatic analysis were performed to find H19 target genes and the associated signaling pathway, which were first verified on tissue samples. Further verification was performed by knocking down the H19 and related gene in rat osteoblast cell line (UMR106 cell). Then, the changes of associated signaling pathway and osteogenic function were examined to confirm the prediction of the bioinformatic analysis. RESULTS: Micro-CT scans and quantitative real-time polymerase chain reaction (qRT-PCR) tests showed progressively deteriorated trabecular bone and decreased level of osteogenic genes in the metaphysis of distal femur during HLU, indicating the successful establishment of a DOP model. According to RNA sequencing, 1351 mRNA and 464 lncRNA were abnormally expressed in response to mechanical unloading, in which the H19 decreased 2.86 fold in HLU rats. There were 1426 mRNA predicted to be the target genes of H19, and KEGG pathway analysis suggested that Wnt signaling pathway (Wnt signaling) was the top pathway responsible for these target genes. In the Wnt-associated genes targeted by H19, 11 were differentially expressed between HLU and AC rats, among which Dkk4 increased 2.44 fold in HLU rats when compared to normal controls. These results of sequencing and bioinformatic analysis were confirmed by the low expression of H19, overexpression of Dkk4 and inhibited Wnt signaling observed in DOP rats. Subsequent in vitro cell assay further demonstrated that knockdown of H19 led to upregulation of Dkk4, and inhibition of Wnt signaling and osteogenic function in UMR106 cell. These effects can be greatly reversed after application of knocking down Dkk4. CONCLUSION: Our findings demonstrated that low expression of H19, induced by mechanical unloading, leads to development of DOP through inhibition of Wnt signaling by promoting Dkk4 expression.

Biomechanical Evaluation of Four Methods for Internal Fixation of Comminuted Subtrochanteric Fractures.

Subtrochanteric fractures are common and result in significant morbidity and mortality. Various kinds of implants have been used to fix it. The aim of this study was to compare the biomechanical performance of PFN, DHS, DCS, and the PFLP in the treatment of subtrochanteric comminuted fractures.A total of 32 antiseptic human femurs from 16 donors were randomly allocated to 4 groups for fixation with PFN, DHS, DCS, and PFLP. A 2-cm cylindrical bone fragment was removed 1 cm below the lesser trochanter to simulate OTA/AO 32-C3.2 post instrumentation fracture. All specimens in single-leg stance situation were preloaded 5 times at 100 N in the axial direction to eliminate the time effect of relaxation and settling, followed by cyclic testing at a rate of 1 Hz with stepwise increasing load. Keeping the valley load at a constant level of 100 N during the entire cyclic test, the peak load, starting at 200 N, was increased by 100 N at 300-cycle steps until a maximum of 1500 cycles or until failure of the bone-implant construct occurred. Each specimen was kept unloaded under 100 N compression for 30 minutes between the 300-cycle steps.Femoral head displacement after 1500 cycles was 1.09 mm ±â€Š0.13 for PFN, 1.78 mm ±â€Š0.25 for DHS, 2.63 mm ±â€Š0.46 for DCS, and 2.26 mm ±â€Š0.16 for PFLP, with significant difference between any 2 implants (P < 0.01). The required load to reach 1-mm femoral head displacement was 563.04 N ±â€Š158.34 for PFN, 485.73 N ±â€Š147.27 for DHS, 258.44 N ±â€Š97.23 for DCS, and 332.68 N ±â€Š100.34 for PFLP. Significant differences were detected between any 2 implants (P < 0.001), except between DCS and PFLP and between DHS and PFN. The number of cycles until 1-mm femoral head displacement was 1458 ±â€Š277 for PFN, 908 ±â€Š184 for DHS, 369 ±â€Š116 for DCS, and 603 ±â€Š162 for PFLP. Significant differences were detected between any 2 implants (P < 0.01), except between DCS and PFLP.From biomechanical point of view, comminuted subtrochanteric fractures OTA/AO 32-C3.2 revealed in the current test setup highest fixation strength with PFN, followed by DHS, PFLP, and DCS.

Association between rs7517847 and rs2201841 polymorphisms in IL-23 receptor gene and risk of ankylosing spondylitis: a meta-analysis.

To comprehensively evaluate the association between rs7517847 and rs2201841 polymorphisms in the Interleukin-23 (IL-23) receptor gene and ankylosing spondylitis (AS), a meta-analysis was performed. The Pubmed, Embase, MEDLINE, Cochrane, China National Knowledge Infrastructure (CNKI), VIP, Wanfang and China Biology Medicine disc (CBMdisc) databases were searched to identify eligible studies on rs7517847 and rs2201841 polymorphisms in the IL-23 receptor gene and AS that were published through September 2014. Data of interest were extracted from each study, and the meta-analysis was performed using STATA 12.0. Four studies were eligible for the meta-analysis and included a total patient population of 2,465. With regards to rs7517847, the current study showed that the genotype GG and allele G might play a protective role during AS (OR = 0.76, 95% CI [0.59-0.99]; OR = 0.88, 95% CI [0.78-0.99] for homozygote and allelic models, respectively). However, according to the meta-analysis, there was no statistical association between the genotype or allele of rs2201841 and an individual's susceptibility to AS in all genetic models. In conclusion, it was the IL-23 rs7517847 polymorphism rather than the rs2201841 polymorphism that had a statistical association with AS. Nevertheless, more evidence is needed to confirm this result. Consequently, it is necessary to carry out more high-quality studies to confirm the associations between these two single nucleotide polymorphisms and AS.

Identification of long noncoding RNA associated with osteoarthritis in humans.

OBJECTIVE: Long noncoding RNAs (lncRNAs) are an important class of genes involved in various biological functions; however, knowledge about lncRNAs in osteoarthritis (OA) is limited. Therefore, the present study aimed to identify which lncRNAs are expressed in OA versus normal cartilage. METHODS: To identify lncRNAs specifically expressed in OA cartilage, expression of lncRNAs in OA cartilage was compared with that in normal cartilage using microarray analysis. The identified differences in expression of lncRNAs were validated by real time polymerase chain reaction (RT-PCR). Furthermore, expression of several key mRNAs associated with OA, including those for matrix metalloproteinase (MMP)-9, MMP-13, bone morphogenetic protein (BMP)-2, COL2A1 and ADAMTS5, was investigated by RT-PCR in OA and normal cartilage. RESULTS: Microarray analysis identified 121 lncRNAs that were up- or down-regulated in OA compared with normal tissue, 73 being upregulated and 48 downregulated compared with normal cartilage. Twenty-one of the above differently expressed lncRNAs were up-regulated twofold. Expression of six lncRNAs, including HOTAIR, GAS5, PMS2L2, RP11-445H22.4, H19 and CTD-2574D22.4, was up-regulated in OA compared with normal tissue as validated by RT-PCR after microarray analysis. Expression of mRNA for MMP-9, MMP-13, BMP-2, and ADAMTS5 in OA was significantly greater than in normal cartilage. However, expression of mRNA for COL2A1 was lower in OA than in normal cartilage. CONCLUSION: The differently expressed lncRNAs may be associated with the pathogenesis of OA. Further functional studies are critical to confirming the function of lncRNAs in OA and to exploring new potential targets for therapy.

Biomechanical analysis of four types of internal fixation in subtrochanteric fracture models.

OBJECTIVE: To compare the biomechanical properties of four types of internal fixation (proximal femoral nail [PFN], dynamic hip screw [DHS], dynamic condylar screw [DCS], and proximal femoral locking plate [PFLP]) for different types of subtrochanteric fractures. METHODS: Thirty-two antiseptic femurs were randomly divided into four groups. After internal fixation had been implanted, different types of subtrochanteric fracture models were produced and each tested under vertical, torsional and vertical damage loads. RESULTS: The stiffness ratio of PFN in each fracture model and failure load were the highest in the four groups; however, the torsional stiffness ratio was the lowest. Tension strain ratios of DHS and DCS on the lateral side became compression strain ratios with restoration of the medial fragment. The stiffness ratio of DHS was lower than PFLP in each fracture model, torsional stiffness ratio was the highest in fracture models II to V and the failure load was lower only than PFN. The stiffness ratio and failure load of DCS were both the lowest, torsional stiffness ratio was similar to PFLP's in fracture models II to V. The stiffness ratio of PFLP was only lower than PFN's in each fracture model, but the failure load was lower than DHS's. CONCLUSION: Four types of internal fixation achieve better stabilities for type I subtrochanteric fractures. PFN and PFLP produce reliable stability in type IIIA subtrochanteric fractures. If the medial buttress is restored, DCS can be considered. For type IV subtrochanteric fractures, only PFN provides stable fixation. PFLP is suitable for comminuted fractures with large fragments.