Lack of efficacy of aprotinin over tranexamic acid in type A aortic dissection repair.

BACKGROUND: The role of aprotinin in modern cardiac surgery is not well defined. While licensed for use in isolated coronary artery bypass grafting it is more commonly used for cases deemed to be at an increased risk of bleeding. The relative efficacy, and safety profile, of aprotinin as compared to other antifibrinolytics in these high-risk cases is uncertain. STUDY DESIGN AND METHODS: A retrospective observational study with propensity matching to determine whether aprotinin versus tranexamic acid reduced bleeding or transfusion requirements in patients presenting for surgical repair of type A aortic dissection (TAD). RESULTS: Between 2016 and 2022, 250 patients presented for repair of TAD. A total of 231 patients were included in the final analysis. Bleeding and transfusion were similar between both groups in both propensity matched and unmatched cohorts. Compared to tranexamic acid, aprotinin use did not reduce transfusion requirements for any product. Rates of bleeding in the first 12 h, return to theater and return to intensive care unit with an open packed chest were similar between groups. There was no difference in rates of renal failure, stroke, or death. CONCLUSION: Aprotinin did not reduce the risk of bleeding or transfusion requirements in patients undergoing repair of type A aortic dissections. Efficacy of aprotinin may vary depending on the type of surgery performed and the underlying pathology.

The European Nucleotide Archive in 2021.

The European Nucleotide Archive (ENA, https://www.ebi.ac.uk/ena), maintained at the European Molecular Biology Laboratory's European Bioinformatics Institute (EMBL-EBI) provides freely accessible services, both for deposition of, and access to, open nucleotide sequencing data. Open scientific data are of paramount importance to the scientific community and contribute daily to the acceleration of scientific advance. Here, we outline the major updates to ENA's services and infrastructure that have been delivered over the past year.

The European Nucleotide Archive in 2020.

The European Nucleotide Archive (ENA; https://www.ebi.ac.uk/ena), provided by the European Molecular Biology Laboratory's European Bioinformatics Institute (EMBL-EBI), has for almost forty years continued in its mission to freely archive and present the world's public sequencing data for the benefit of the entire scientific community and for the acceleration of the global research effort. Here we highlight the major developments to ENA services and content in 2020, focussing in particular on the recently released updated ENA browser, modernisation of our release process and our data coordination collaborations with specific research communities.

Metabolic syndrome and the likelihood of knee pain and functional disability: evidence from a large middle eastern population-based study.

OBJECTIVES: Metabolic Syndrome (MetS) has been associated with knee osteoarthritis (KOA) in animal studies, but epidemiologic evidence of the association remains controversial. We investigated the association between MetS and knee pain and functional disability, the hallmarks of KOA, in a Middle Eastern population with high reported MetS rates. METHODS: A population-based study of adult individuals was conducted between 01/2016 and 03/2019. Data collected included age, sex, blood pressure, body mass index (BMI), waist circumference (WC), and comprehensive metabolic panel blood tests. Knee symptoms were assessed using The Western Ontario and McMaster Arthritis index (WOMAC) The Adult Treatment Panel III criteria was applied to determine if participants had MetS. Multivariable regression was used to determine the association of MetS, and its components, with the WOMAC total and subscale scores. RESULTS: Of 6,000 participants enrolled, 15.5% had MetS. The multivariate regression demonstrated that participants with MetS had significantly higher WOMAC total and subscale scores after adjusting for demographic variables; however, these associations were not significant after adjusting for BMI. Multivariate regression examining the association between MetS components and the WOMAC scores showed sex-based significant differences with WOMAC scores; however, the differences were not larger than the minimally clinical important differences. CONCLUSIONS: This study demonstrated that after adjustment for BMI, neither MetS nor its individual parameters were associated with worse knee symptoms. As such, the association between MetS and worse knee symptoms requires further study.

Avascular Necrosis and Time to Surgery for Unstable Slipped Capital Femoral Epiphysis: A Systematic Review and Meta-analysis.

BACKGROUND: Avascular necrosis (AVN) is a well-known complication of unstable slipped capital femoral epiphysis (SCFE) and its cause is multifactorial. Higher AVN rates have been reported with surgery undertaken between 24 hours to 7 days from the onset of symptoms. The current evidence regarding time to surgery and AVN rate remains unclear. The aim of our study was to investigate the rate of AVN and time to surgery in unstable SCFE. METHODS: A literature search of several databases was conducted. Eligibility criteria included all studies that reported AVN rates and time to surgery in unstable SCFE patients. We performed a meta-analysis using a random-effects model to pool the rate of AVN in unstable SCFE using different time to surgery subgroups (≤24 h, 24 h - 7 d and >7 d). Descriptive, quantitative and qualitative data were extracted. RESULTS: Twelve studies matched our eligibility criteria. In total, there were 434 unstable SCFE of which 244 underwent closed reduction (CR). The pooled AVN rates were 24% [95% CI: 16%-35%] and 29% [95% CI: 16%-45%] for the total and CR groups, respectively. The highest AVN rates were with surgery between 24 hours to 7 days, 42% and 54% for the total and CR groups, respectively. The lowest rates of AVN were with time to surgery ≤24 hours (22% and 21% respectively) and >7 days (18% and 29% respectively). These differences were not statistically significant. There was significant subgroup heterogeneity which was highest in the 24 hours - 7 days subgroup and lowest in the >7 days subgroup. CONCLUSIONS: The cumulative evidence was not conclusive for an association between AVN rate and time to surgery. The overall AVN rates were lower in unstable SCFE patients who had surgery ≤24 hours and >7 days. However, treatment techniques were very variable and there was significant heterogeneity in the included studies. Multi-centre prospective studies are required with well-defined time to surgery outcomes. LEVEL OF EVIDENCE: Level III/IV.

Scapular Fractures at a Level 1 Trauma Center: A Cross-Sectional Study.

PURPOSE: Scapular fractures are uncommon injuries that account for up to 1% of all fractures and 5% of all shoulder girdle fractures. Moreover, most of the evidence on the treatment of scapular fractures stems from case series, with paucity of comparative studies. Despite the lack of standardized criteria for the operative treatment of scapular fractures, a set of suggested radiological parameters has been recently reported. The primary aim of this study was to compare the treatment implemented for scapular fractures in comparison with standard published criteria. The secondary aim was to investigate epidemiological parameters of scapular fractures at a level 1 trauma center. METHODS: In this cross-sectional study of scapular fractures at a level 1 trauma center, data were collected between December 2012 and January 2016. Data of all scapular fractures that presented to our center were retrospectively collected through electronic medical records. Identified cases of scapular fractures were then evaluated whether surgical treatment was indicated in accordance with recent standard operative criteria. Percentages were used to express the number of cases that were operatively indicated according to the predefined criteria and the number of cases operatively treated at our institution. RESULTS: A total of 52 patients met the inclusion criteria of having scapular fractures documented on radiography and Computed tomography (CT). The mean age of the patients was 38.5 years, with the majority being men (92.3%). The most common mechanism of injury was a fall from a considerable height in 26% of the cases. Of the included patients, 53.8% were polytraumatized, and the most frequent concomitant traumatic injury was rib fractures (26.9%). Only 33% of intra-articular glenoid fractures with significant displacement were treated operatively. Furthermore, non-operative treatment was undertaken in indicated extra-articular scapular body and neck fractures, acromion or coracoid process fractures, or superior shoulder suspensory complex double disruptions. CONCLUSION: A significant discrepancy was found between the treatments implemented at our institution and the current standard criteria for the operative treatment of scapular fractures. This study emphasizes the need to educate surgeons on scapular fractures and to treat such fractures in accordance with standard published criteria. Furthermore, scapular fractures that require surgery should be referred to a surgeon experienced in scapular fracture fixation.

Amputation Versus Limb Reconstruction for Fibula Hemimelia: A Meta-analysis.

PURPOSE: Fibula hemimelia is the most common congenital deficiency of long bones. Primary treatment options include amputation with prosthetic fitting or limb reconstruction. The aim of our study was to conduct a systematic review comparing amputation with limb reconstruction for fibula hemimelia. METHODS: MEDLINE, EMBASE, Web of Science, Elsevier Scopus, and the Cochrane Registry of Clinical Trials were searched from 1951 to 2019 for studies that evaluated amputation versus limb reconstruction for fibula hemimelia. Random effect models were utilized for the meta-analytic comparisons of amputation versus limb reconstruction for patient satisfaction and surgical complications. Descriptive, quantitative, and qualitative data were extracted. RESULTS: Seven retrospective cohort studies were eligible for the meta-analysis, with a total of 169 fibula hemimelia cases. Amputation resulted in an odds ratio of 6.8 (95% confidence interval: 2.4, 19.2) when compared with limb reconstruction in terms of patient satisfaction. Furthermore, limb reconstruction was found to have an odds ratio of 28 (95% confidence interval: 7.8, 100.3) for complications. The total surgical complication rates in the amputation and limb reconstruction groups were 0.2 and 1.2 complications per limb. The rate of surgical procedures per patient was 1.5 and 4.2 for amputation and limb reconstruction, respectively. CONCLUSIONS: The cumulative evidence at present indicates better patient satisfaction with less surgical complications and less number of procedures with amputation for fibula hemimelia when compared with limb reconstruction. Absence of uniform protocols make it difficult to compare results accurately. LEVEL OF EVIDENCE: Level III-therapeutic.

Anthropometric correlation with hamstring graft size in anterior cruciate ligament reconstruction among males.

PURPOSE: Pre-operative knowledge of hamstring graft size for anterior cruciate ligament reconstruction (ACL) is of clinical importance and useful in making appropriate decisions about graft choice. This study investigated if there is any correlation between anthropometric measurements such as height, weight, body mass index, thigh length, and circumference with the size of hamstring tendon graft in anterior cruciate ligament reconstruction. METHODS: The anthropometric data of 50 consecutive adult males, who underwent primary ACL reconstruction using quadruple hamstring autograft, were collected prospectively. Data analysis using Pearson's correlation test was performed and multiple logistic regression analysis was used to investigate any correlation not detected by Pearson's test and to eliminate confounders. RESULTS: Patient's height and thigh length demonstrated a positive correlation with gracilis graft length (r = .464, P = .001, r = .456, P = .001, respectively) and semitendinosus graft length (r = .541, P = 000, r = .578, P = .000, respectively). While the patient's age was the only independent factor which had a positive correlation with the quadrupled hamstring graft diameter (r = .412, P = .004), multiple regression analysis showed abdominal girth had a significant negative correlation with gracilis (P = .04) and semitendinosus (P = .006) graft thickness. CONCLUSION: This study demonstrated that some anthropometric measurements had a positive correlation with the hamstring graft length and diameter in male patients. Hence, these results provide preliminary support for the use of some anthropometric measurements in the preoperative planning and prediction of the hamstring graft length and diameter in anterior cruciate ligament reconstruction.

Early versus late treatment of paediatric femoral neck fractures: a systematic review and meta-analysis.

PURPOSE: Femoral neck fractures in children represent less than 1% of all paediatric fractures. Osteonecrosis of the femoral head is one of the devastating complications of this fracture. Time to treatment is one of the most important predictors of this outcome with no clear consensus in the literature. The aim of this study was to determine whether early treatment (< 24 hours) of pediatric femoral neck fractures is associated with a lower rate of osteonecrosis of the femoral head compared to late treatment (> 24 hours). METHODS: We searched several databases (PubMed, Embase, and Cochrane library), from January 1966 to November 2017 for any comparative studies that evaluated early (< 24 hours) versus late (> 24 hours) treatment of paediatric femoral neck fractures. We pooled the effect sizes using fixed effects model that compared the rate of osteonecrosis of the femoral head between children undergoing early versus late treatment, open versus closed reduction, displaced versus non-displaced and different Delbet type femoral neck fractures. Descriptive and qualitative data was also extracted. RESULTS: Of the 391 articles identified, six studies (prospective and retrospective cohort studies) were eligible for the meta-analysis, with a total of 231 paediatric femoral neck fractures. The pooled odds ratio (OR) for osteonecrosis of the femoral head did not show any statistically significant difference between early (< 24 hours) versus late (> 24 hours) treatment (OR = 1.19, 95% CI 0.56, 2.51, I2 = 23.6%), nor between open versus closed reduction of paediatric femoral neck fractures (OR = 1.62, 95% CI 0.82, 3.22, I2 = 19.57%). Displaced and Delbet type I/II femoral neck fractures were 3.8 (OR = 3.81, 95% CI 1.49, 9.78, I2 = 0.00%) and 2.4 (OR = 2.43, 95% CI 1.28, 4.61, I2 = 0.57%) times more associated with osteonecrosis of the femoral head compared to non-displaced and Delbet type III/IV fractures respectively. CONCLUSIONS: The cumulative evidence at present does not indicate an association between the time to treatment or method of reduction of femoral neck fractures in children and the risk of osteonecrosis of the femoral head. However, initial expedient treatment of femoral neck fractures in children should always remain the rule especially for displaced and Delbet type I/II femoral neck fractures. LEVEL OF EVIDENCE: II/III.

Applicability of the AAOS appropriate-use criteria for distal radius fractures in surgical practice.

PURPOSE: The appropriate-use criteria (AUC) for distal radius fracture (DRF) was developed by the American Academy of Orthopedic Surgeons (AAOS) to aid surgeons in making evidence-based treatment decisions for DRFs. The aim of our study was to cross-reference the management of operatively treated DRFs with the web-based AAOS published AUC recommendations. METHODS: The AUC for DRF evaluates the appropriateness of ten treatment options for each of 240 mutually exclusive patient scenarios based on the combination of five factors. For every scenario, each treatment is classified as appropriate, maybe appropriate or rarely appropriate. We retrospectively reviewed the medical charts and radiographs of all adult patients ≥19 years who underwent surgery for DRFs between 1 January and 31 December 2014 and determined the rate of appropriateness of treatment in this consecutive series of patients. RESULTS: Over the study period, 108 patients (83.3% men; mean age 39.8 years) with 113 DRFs (five bilateral) were treated surgically. The most frequent scenario was represented by a type C fracture, high-energy mechanism, normal functional demand, American Society Anesthesiologists (ASA) status 1-3 and no associated injuries. The most frequently used treatment was volar locking plate (54.0%). Based on the AUC, treatment was appropriate for 96 cases (85.0%), maybe appropriate for 15 (13.2%), and rarely appropriate for two (1.8%). CONCLUSIONS: A web-based electronic AUC application can be an attractive and easy decision-making aid for orthopaedic surgeons. Application of the AUC to clinical data was relatively simple, and most operatively treated DRFs were managed appropriately. LEVEL OF EVIDENCE: IV.

Open versus closed treatment of distal tibia physeal fractures: a systematic review and meta-analysis.

AIMS: Distal tibia physeal fractures can lead to growth complications such as premature physeal closure (PPC), angular deformity and leg length discrepancy. The aim of our study was to systematically review the literature to assess whether open reduction and internal fixation (ORIF) is associated with lower rates of PPC compared to closed treatment. MATERIALS AND METHODS: We searched several databases from 1966 to 2016 for studies that evaluated ORIF versus closed treatment of distal tibia physeal fractures. We performed a meta-analysis using a random effects model to pool odds ratios (OR) for the comparison of PPC rate between children undergoing ORIF versus closed treatment. We also investigated the PPC rate in Salter-Harris (S-H) type I and II fractures. Descriptive, quantitative and qualitative data were extracted. RESULTS: Out of the 253 articles identified, six retrospective cohort studies were eligible, with a total of 970 distal tibia physeal fractures. The pooled OR of PPC between ORIF and closed treatment showed no statistically significant difference [OR = 0.98, 95% confidence interval (CI) 0.48, 1.97; I 2 = 49.8%, p = 0.076]. No significant difference in the rate of PPC was detected in S-H type I and II fractures with ORIF and closed treatment [OR = 1.25, 95% CI 0.72, 2.16; I 2 = 32.1%, p = 0.22]. CONCLUSIONS: The cumulative evidence at present does not indicate an association between the method of treatment of distal tibia physeal fractures and the risk of PPC. Both treatment types are feasible, but less surgical-related complications are associated with closed treatment. LEVEL OF EVIDENCE: III.

Utility of the AAOS Appropriate Use Criteria (AUC) for Pediatric Supracondylar Humerus Fractures in Clinical Practice.

BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) recently developed an Appropriate Use Criteria (AUC) for pediatric supracondylar humerus fractures (PSHF). The AUC is intended to improve quality of care by informing surgeon decision making. The aim of our study was to cross-reference the management of operatively treated PSHF with the AAOS-published AUC. METHODS: The AUC for PSHF include 220 patient scenarios, based on different combinations of 6 factors. For each patient scenario, 8 treatment options are evaluated as "appropriate," "maybe appropriate," and "rarely appropriate." We retrospectively reviewed the medical charts and radiographs of all operatively treated PSHF at our hospital from January 2013 to December 2014 and determined the appropriateness of the treatment. RESULTS: Over the study period, 94 children (mean age: 5.2 y; 51 male, 43 female) were admitted with PSHF and underwent a surgical procedure (type IIA: 7, type IIB: 14, type III: 70, flexion type: 3). Only 8 of the 220 scenarios were observed in our patient cohort. The most frequent scenario was represented by a type III fracture, palpable distal pulse, no nerve injury, closed soft-tissue envelope, no radius/ulna fracture, and typical swelling. Of the 94 fractures, the AUC was "appropriate" for 84 cases and "maybe appropriate" for 9 cases. There was only 1 case of "rarely appropriate" management. Closed reduction with lateral pinning and immobilization was the most prevalent treatment option (58.5%). The rate of appropriateness was not affected by the operating surgeon. However, the definition of a case as emergent had a significant impact on the rate of appropriateness. CONCLUSIONS: Application of the AUC to actual clinical data was relatively simple. The majority of operatively treated PSHF (89.4%) were managed appropriately. With the introduction of electronic medical charts, an AUC application becomes attractive and easy for orthopaedic surgeons to utilize in clinical practice. However, validity studies of the AUC in different clinical settings are still required. LEVEL OF EVIDENCE: Level IV.

Late versus early reduction in traumatic hip dislocations: a meta-analysis.

AIMS: Traumatic hip dislocations are considered orthopaedic emergencies that are treated with urgent reduction to decrease the rate of osteonecrosis of the femoral head. The aim of our study was to systematically review the literature that compares late (>6 h from the time of injury) to early (<6 h from the time of injury) reduction in all traumatic hip dislocations. MATERIALS AND METHODS: We searched five databases from 1951 to 2016 for studies that evaluated timing of reduction and osteonecrosis of the femoral head in all traumatic hip dislocations. We performed a meta-analysis using a random-effects model to pool odds ratios (ORs) for a comparison of osteonecrosis of the femoral head between patients undergoing late versus early hip reduction. We also investigated the osteonecrosis rate in low- and high-grade traumatic hip dislocations. Descriptive, quantitative and qualitative data were extracted. RESULTS: Of the 13 articles identified, five studies (retrospective cohort studies) were eligible for the meta-analysis, encompassing a total of 236 traumatic hip dislocations. The pooled odds ratio for osteonecrosis of the femoral head between late and early reduction was in favour of early hip reduction and statistically significant (OR = 5.00, 95% CI: 1.30, 19.29). No significant difference in the rate of osteonecrosis of the femoral head was detected between low- and high-grade traumatic hip dislocations according to the time threshold (OR = 1.71, 95% CI: 0.22, 13.22). CONCLUSIONS: The cumulative evidence at present does indicate an association between late hip reduction and higher rate of osteonecrosis of the femoral head in all traumatic hip dislocations. Hence, all traumatic hip dislocations should be reduced as soon as possible to decrease the rate of osteonecrosis of the femoral head. However, the evidence does not indicate an association between the grade of dislocation and rate of osteonecrosis of the femoral head. LEVEL OF EVIDENCE: III.

The prevalence of developmental dysplasia of the hip in idiopathic clubfoot: a systematic review and meta-analysis.

PURPOSE: Developmental dysplasia of the hip (DDH) and idiopathic clubfoot are both common paediatric orthopaedic conditions. There is conflicting evidence in the literature as to whether the prevalence of DDH is higher in children with idiopathic clubfoot. The aim of our study was to systematically review the literature and determine the prevalence of DDH in idiopathic clubfoot. METHODS: We searched several databases from 1946 to 2014 for observational studies that reported the prevalence of DDH in idiopathic clubfoot. We performed a meta-analysis using random effects model to pool the prevalence of DDH in idiopathic clubfoot. We also investigated the imaging modality utilised to diagnose and treat DDH in idiopathic clubfoot. Descriptive, quantitative and qualitative data were extracted. RESULTS: Twelve studies (ten case series, one retrospective cohort and one retrospective case-control) were eligible for the meta-analysis, with a total of 2,549 children with idiopathic clubfoot including 83 with DDH. The pooled prevalence estimate of DDH in children with idiopathic clubfoot was 4.1% (95% CI, 2.1-7.7%). There was a substantial amount of between study heterogeneity (I (2) = 87.1%, p < 0.001) due to variability between studies rather than chance variability. Sensitivity analyses showed that the pooled prevalence estimate was 3.5% (95% CI, 1.1-10.8 %) and 3.8% (95% CI, 1.0-13.7%) for studies utilising ultrasound as the imaging modality of diagnosis and treatment with a Pavlik harness respectively. CONCLUSIONS: The overall pooled prevalence of DDH in idiopathic clubfoot is similar to the normal population. The cumulative evidence at present does not indicate an association between DDH and idiopathic clubfoot. Therefore, we do not recommend routine screening for DDH in children with idiopathic clubfoot. However, future retrospective and/or prospective cohort studies of better quality will be able to answer this question with more certainty.

Open reduction and internal fixation versus radial head arthroplasty in the treatment of adult closed comminuted radial head fractures (modified Mason type III and IV).

BACKGROUND: The purpose of our study was to compare the outcome of radial head fractures (modified Mason type III and IV) treated by open reduction and internal fixation (ORIF) versus radial head arthroplasty (RHA). PATIENTS AND METHODS: A retrospective review of 36 patients with closed comminuted radial head fractures treated either by ORIF or RHA with an average of 15-months' follow-up was undertaken. The primary outcome was the QuickDASH, the shortened version of the Dissabilities of the Arm, Shouler and Hand score. Other outcomes included regain of functional range of motion (ROM) of the elbow and duration of surgery. Surgical complications were noted. RESULTS: Thirty-six patients with a mean age of 36 years were evaluated. Nineteen patients underwent ORIF and 17 RHA. The two treatment groups were comparable with regards to gender, side of injury, Mason type and mechanism of injury. Patients who underwent RHA were slightly older (p < 0.001). At follow-up, the QuickDASH score was similar between groups (p = 0.58). Regain of functional ROM of the elbow (p = 0.13) and complication rate (p = 0.57) were similar. CONCLUSION: The treatment of closed comminuted radial head fracture (modified Mason type III and IV) with ORIF and RHA demonstrates similar findings despite less surgical time for performing RHA.

Reliability of the Lisfranc injury radiological classification (Myerson-modified Hardcastle classification system).

PURPOSE: The objective of our study was to assess the reliability of the radiological classification system (Myerson-modified Hardcastle Classification System) for Lisfranc injury. The classification system is a three-grade ordinal scale based on fracture displacement. METHODS: Thirty-nine Lisfranc injury radiographs were evaluated by 38 independent observers consisting of consultant orthopaedic surgeons (18), orthopaedic surgery residents (17) and consultant musculoskeletal radiologists (3) on two separate occasions after receiving training in the use of the classification. RESULTS: The intra- and inter-observer reliability was assessed using the intraclass correlation coefficient (ICC) and found to be excellent. The mean weighted intra- and inter-observer ICCs were 0.94 (95 % CI 0.89-0.97, p < 0.01) and 0.81 (95 % CI 0.68-0.89, p < 0.01), respectively. CONCLUSION: The Myerson-modified Hardcastle classification system in our study was shown to be reliable and can be used in outcome studies and provide standard terminology among clinicians for Lisfranc injuries.

Prosthesis-Patient Mismatch and Aortic Root Enlargement: Indications, Techniques and Outcomes.

Prosthesis-patient mismatch (PPM) is defined as implanting a prosthetic that is insufficiently sized for the patient receiving it. PPM leads to high residual transvalvular gradients post-aortic valve replacement and consequently results in left ventricular dysfunction, morbidity and mortality in both the short and long term. Younger patients and patients with poor preoperative left ventricular function are more vulnerable to increased mortality secondary to PPM. There is debate over the measurement of valvular effective orifice area (EOA) and variation exists in how manufacturers report the EOA. The most reliable technique is using in vivo echocardiographic measurements to create tables of predicted EOAs for different valve sizes. PPM can be prevented surgically in patients at risk through aortic root enlargement (ARE). Established techniques include the posterior enlargement through Nicks and Manouguian procedures, and aortico-ventriculoplasty with the Konno-Rastan procedure, which allows for a greater enlargement but carries increased surgical risk. A contemporary development is the Yang procedure, which uses a Y-shaped incision created through the non- and left-coronary cusp commissure, undermining the nadirs of the non- and left-coronary cusps. Early results are promising and demonstrate an ability to safely increase the aortic root by up to two to three sizes. Aortic root enlargement thus remains a valuable and safe tool in addressing PPM, and should be considered during surgical planning.

Below- versus above-elbow cast treatment of displaced distal forearm fractures in children: A systematic review and meta-analysis of randomized controlled trials.

Objectives: Distal forearm fractures are the most common pediatric fractures. This study aimed to investigate the effectiveness of below-elbow cast treatment for displaced distal forearm fractures in children compared to above-elbow cast through meta-analysis of randomized controlled trials. Methods: Several databases from January 1, 2000 until October 1, 2021 were searched for randomized controlled trials that assessed below versus above-elbow cast treatment of displaced distal forearm fractures in pediatric patients. The main meta-analysis comparison was based on the relative risk of loss of fracture reduction between children undergoing below versus above-elbow cast treatment. Other outcome measures including re-manipulation and cast-related complications were also investigated. Results: Nine studies were eligible of the 156 articles identified, with a total of 1049 children. Analysis was undertaken for all included studies with a sensitivity analysis conducted for studies with high quality. In the sensitivity analysis, the relative risks of loss of fracture reduction (relative risk = 0.6, 95% confidence interval = 0.38, 0.96) and re-manipulation (relative risk = 0.3, 95% confidence interval = 0.19, 0.48) between the below and above-elbow cast groups were in favor of below-elbow cast and statistically significant. Cast-related complications were in favor of below-elbow cast but did not attain statistical significance (relative risk = 0.45, 95% confidence interval = 0.05, 3.99). Loss of fracture reduction was noted in 28.9% of patients treated with above-elbow cast and 21.5% in below-elbow cast. Re-manipulation was attempted in 48.1% versus 53.8% of children who lost fracture reduction in the below-elbow cast and above-elbow cast groups, respectively. Conclusion: Below-elbow cast treatment was favored, with statistical significance, in terms of loss of fracture reduction and re-manipulation, and was not associated with a higher risk of cast-related complications. The accumulative evidence currently does not support above-elbow cast treatment and below-elbow cast treatment should be the mainstay for displaced distal forearm fractures in children. Level of evidence: Level I, meta-analysis of therapeutic level I studies.

In vitro and in vivo study on fine-grained Mg-Zn-RE-Zr alloy as a biodegradeable orthopedic implant produced by friction stir processing.

Magnesium alloys containing biocompatible components show tremendous promise for applications as temporary biomedical devices. However, to ensure their safe use as biodegradeable implants, it is essential to control their corrosion rates. In concentrated Mg alloys, a microgalvanic coupling between the α-Mg matrix and secondary precipitates exists which results in increased corrosion rate. To address this challenge, we engineered the microstructure of a biodegradable Mg-Zn-RE-Zr alloy by friction stir processing (FSP), improving its corrosion resistance and mechanical properties simultaneously. The FS processed alloy with refined grains and broken and uniformly distributed secondary precipitates showed a relatively uniform corrosion morphology accompanied with the formation of a stable passive layer on the alloy surface. In vivo corrosion evaluation of the processed alloy in a small animal model showed that the material was well-tolerated with no signs of inflammation or harmful by-products. Remarkably, the processed alloy supported bone until it healed till eight weeks with a low in vivo corrosion rate of 0.7 mm/year. Moreover, we analyzed blood and histology of the critical organs such as liver and kidney, which showed normal functionality and consistent ion and enzyme levels, throughout the 12-week study period. These results demonstrate that the processed Mg-Zn-RE-Zr alloy offers promising potential for osseointegration in bone tissue healing while also exhibiting controlled biodegradability due to its engineered microstructure. The results from the present study will have profound benefit for bone fracture management, particularly in pediatric and elderly patients.

Percutaneous curettage and suction for pediatric extremity aneurysmal bone cysts: is it adequate?

BACKGROUND: The purpose of our study was to evaluate the effectiveness of treating extremity aneurysmal bone cysts (ABC) by percutaneous curettage compared with open intralesional excision. METHODS: A retrospective review of 17 patients with histologically proven primary ABCs and no evidence of a secondary lesion treated either by percutaneous curettage or open intralesional excision with at least 24-month follow-up was undertaken. The percutaneous curettage group was uniformly treated on an outpatient basis using angled curettes under image guidance followed by intralesional evacuation. The primary outcome was radiographic healing using the Neer/Cole 4-grade classification. Complications were noted. RESULTS: Seventeen patients with a mean age of 11.7 years (range, 1.7 to 17.5) were evaluated. Nine patients underwent percutaneous curettage and 8 had an open intralesional excision. The 2 treatment groups were comparable with regard to age, sex, number of procedures, morphologic type of ABC, and follow-up period. At follow-up, the proportion of patients with satisfactory healing (Neer/Cole grades I and II) were similar among the 2 groups (P = 0.74). In the percutaneous curettage group, 2 cases recurred necessitating repeat procedures, whereas 1 case recurred in the open intralesional excision group and was successfully treated percutaneously. CONCLUSIONS: Percutaneous curettage is a safe and minimally invasive alternative for extremity ABCs that can be performed as an outpatient procedure. Not all ABCs require wide exposure and an open intralesional excision. LEVEL OF EVIDENCE: III.