Establishment and validation of an artificial intelligence web application for predicting postoperative in-hospital mortality in patients with hip fracture: a National cohort study of 52,707 cases.

BACKGROUND: In-hospital mortality following hip fractures is a significant concern, and accurate prediction of this outcome is crucial for appropriate clinical management. Nonetheless, there is a lack of effective prediction tools in clinical practice. By utilizing artificial intelligence and machine learning techniques, this study aims to develop a predictive model that can assist clinicians in identifying geriatric hip fracture patients at a higher risk of in-hospital mortality. METHODS: A total of 52,707 geriatric hip fracture patients treated with surgery from 90 hospitals were included in this study. The primary outcome was postoperative in-hospital mortality. The patients were randomly divided into two groups, with a ratio of 7:3. The majority of patients, assigned to the training cohort, were used to develop the AI models. The remaining patients, assigned to the validation cohort, were used to validate the models. Various machine learning algorithms, including logistic regression (LR), decision tree (DT), naïve Bayesian (NB), neural network (NN), eXGBoosting machine (eXGBM), and random forest (RF), were employed for model development. A comprehensive scoring system, incorporating 10 evaluation metrics, was developed to assess the prediction performance, with higher scores indicating superior predictive capability. Based on the best machine learning-based model, an AI application was developed on the Internet. In addition, a comparative testing of prediction performance between doctors and the AI application. FINDINGS: The eXGBM model exhibited the best prediction performance, with an AUC of 0.908 (95% CI: 0.881-0.932), as well as the highest accuracy (0.820), precision (0.817), specificity (0.814), and F1 score (0.822), and the lowest Brier score (0.120) and log loss (0.374). Additionally, the model showed favorable calibration, with a slope of 0.999 and an intercept of 0.028. According to the scoring system incorporating 10 evaluation metrics, the eXGBM model achieved the highest score (56), followed by the RF model (48) and NN model (41). The LR, DT, and NB models had total scores of 27, 30, and 13, respectively. The AI application has been deployed online at https://in-hospitaldeathinhipfracture-l9vhqo3l55fy8dkdvuskvu.streamlit.app/ , based on the eXGBM model. The comparative testing revealed that the AI application's predictive capabilities significantly outperformed those of the doctors in terms of AUC values (0.908 vs. 0.682, P <0.001). CONCLUSIONS: The eXGBM model demonstrates promising predictive performance in assessing the risk of postoperative in-hospital mortality among geriatric hip fracture patients. The developed AI model serves as a valuable tool to enhance clinical decision-making.

The clinical efficacy of Medial Sustain Nail(MSN) and Proximal femoral nail anti-rotation(PFNA) for fixation of medial comminuted trochanteric fractures: a prospective randomized controlled trial.

PURPOS: To evaluate the clinical efficacy of the Medial Sustain Nail (MSN) for medial comminuted trochanteric fractures fixation in comparison to Proximal Femoral Nail Antirotation (PFNA) through a clinical study. METHODS: A non-inferiority randomized controlled trial was conducted at a single centre between July 2019 and July 2020. Fifty patients diagnosed comminuted trochanteric fractures were randomly assigned to either the MSN group (n = 25) or the PFNA group (n = 25). A total of forty-three patients were included in the final study analysis. The primary outcome measure was Short Form 36 health surgery physical component summary (SF-36 PCS) score. Secondary outcomes included the Oxford Hip Scores (OHS), weight bearing, complication relate to implant and so on. This study was not blined to surgeons, but to patients and data analysts. RESULTS: The MSN demonstrated significantly better functional outcomes as measured by SF-36 PCS and OHS at six months postoperative compared to PFNA (p < 0.05). Union of fractures in the MSN group reached 90.9% at three months after surgery, whereas the PFNA group achieved a union rate of 57.1% (p < 0.05). Furthermore, weight-bearing time of MSN group was earlier than PFNA group (p < 0.05). Additionally, complications related to implant usage were more prevalent in the PFNA group (33.3%) compared to the MSN group (4.5%) (p < 0.05). CONCLUSION: MSN exhibited superior quality of life outcomes compared to PFNA at six months postoperative. This indicates that MSN effectively reconstructs medial femoral support in patients with comminuted trochanteric fractures, which facilitates early weight-bearing and accelerates the recovery process. TRIAL REGISTRATION: Trial registration number: NCT01437176, Date of the trial registration:2011-9-1, Date of commencement of the study:2011-9, Date of enrolment/recruitment of the study subjects:2019-7.

CHRONIC CRITICAL ILLNESS-INDUCED MUSCLE ATROPHY: INSIGHTS FROM A TRAUMA MOUSE MODEL AND POTENTIAL MECHANISM MEDIATED VIA SERUM AMYLOID A.

ABSTRACT: Background: Chronic critical illness (CCI), which was characterized by persistent inflammation, immunosuppression, and catabolism syndrome (PICS), often leads to muscle atrophy. Serum amyloid A (SAA), a protein upregulated in critical illness myopathy, may play a crucial role in these processes. However, the effects of SAA on muscle atrophy in PICS require further investigation. This study aims to develop a mouse model of PICS combined with bone trauma to investigate the mechanisms underlying muscle weakness, with a focus on SAA. Methods: Mice were used to examine the effects of PICS after bone trauma on immune response, muscle atrophy, and bone healing. The mice were divided into two groups: a bone trauma group and a bone trauma with cecal ligation and puncture group. Tibia fracture surgery was performed on all mice, and PICS was induced through cecal ligation and puncture surgery in the PICS group. Various assessments were conducted, including weight change analysis, cytokine analysis, hematological analysis, grip strength analysis, histochemical staining, and immunofluorescence staining for SAA. In vitro experiments using C2C12 cells (myoblasts) were also conducted to investigate the role of SAA in muscle atrophy. The effects of inhibiting receptor for advanced glycation endproducts (RAGE) or JAK2 on SAA-induced muscle atrophy were examined. Bioinformatic analysis was conducted using a dataset from the GEO database to identify differentially expressed genes and construct a coexpression network. Results: Bioinformatic analysis confirmed that SAA was significantly upregulated in muscle tissue of patients with intensive care unit-induced muscle atrophy. The PICS animal models exhibited significant weight loss, spleen enlargement, elevated levels of proinflammatory cytokines, and altered hematological profiles. Evaluation of muscle atrophy in the animal models demonstrated decreased muscle mass, grip strength loss, decreased diameter of muscle fibers, and significantly increased expression of SAA. In vitro experiment demonstrated that SAA decreased myotube formation, reduced myotube diameter, and increased the expression of muscle atrophy-related genes. Furthermore, SAA expression was associated with activation of the FOXO signaling pathway, and inhibition of RAGE or JAK2/STAT3-FOXO signaling partially reversed SAA-induced muscle atrophy. Conclusions: This study successfully develops a mouse model that mimics PICS in CCI patients with bone trauma. Serum amyloid A plays a crucial role in muscle atrophy through the JAK2/STAT3-FOXO signaling pathway, and targeting RAGE or JAK2 may hold therapeutic potential in mitigating SAA-induced muscle atrophy.

Biomechanical Research of Three Parallel Cannulated Compression Screws in Oblique Triangle Configuration for Fixation of Femoral Neck Unstable Fractures.

OBJECTIVE: Surgical treatment with internal fixation, specifically percutaneous fixation with three cannulated compression screws (CCSs), is the preferred choice for young and middle-aged patients. The mechanical advantage of the optimal spatial configuration with three screws provides maximum dispersion and cortical support. We suspect that the spatial proportion of the oblique triangle configuration (OTC) in the cross-section of the femoral neck isthmus (FNI) may significantly improve shear and fatigue resistance of the fixed structure, thereby stabilizing the internal fixation system in femoral neck fracture (FNF). This study aims to explore the mechanical features of OTC and provide a mechanical basis for its clinical application. METHODS: Twenty Sawbone femurs were prepared as Pauwels type III FNF models and divided equally into two fixation groups: OTC and inverted equilateral triangle configuration (IETC). Three 7.3 mm diameter cannulated compression screws (CCSs) were used for fixation. The specimens of FNF after screw internal fixation were subjected to static loading and cyclic loading tests, respectively, with five specimens for each test. Axial stiffness, 5 mm failure load, ultimate load, shear displacement, and frontal rotational angle of two fragments were evaluated. In the cyclic loading test, the load sizes were 700 N, 1400 N, and 2100 N, respectively, and the fracture end displacement was recorded. Results were presented as means ± SD. Data with normal distributions were compared by the Student's t test. RESULTS: In the static loading test, the axial stiffness, ultimate load, shear displacement, and frontal rotational angle of two fragments were (738.64 vs. 620.74) N/mm, (2957.61 vs. 2643.06) N, (4.67 vs. 5.39) mm, and (4.01 vs. 5.52)° (p < 0.05), respectively. Comparison between the femoral head displacement after 10,000 cycles of 700N cyclic loading and total displacement after 20,000 cycles of 700-1400N cyclic loading showed the OTC group was less than the IETC group (p < 0.05). A comparison of femoral head displacement after 10,000 cycles of 1400N and 2100N cycles and total displacement after 30,000 cycles of 700-2100N cycles showed the OTC group was less than another group, but the difference was not significant (p > 0.05). CONCLUSION: When three CCSs are inserted in parallel to fix FNF, the OTC of three screws has obvious biomechanical advantages, especially in shear resistance and early postoperative weight-bearing, which provides a mechanical basis for clinical selection of ideal spatial configuration for unstable FNF.

[Research progress of pubic symphysis diastasis].

Objective: To review the research progress of pubic symphysis diastasis and provide effective reference for orthopedic surgeons in the diagnosis and treatment of pubic symphysis diastasis. Methods: The anatomy, injury mechanism, treatment, and other aspects of pubic symphysis diastasis were summarized and analyzed by reviewing the relevant research literature at domestically and internationally in recent years. Results: The incidence of pubic symphysis diastasis is high in pelvic fractures, which is caused by the injury of the ligaments and fibrocartilage disc around the pubic symphysis by external force. The treatment plan should be individualized according to the pelvic stability and the needs of patients, aiming to restore the stability and integrity of the pelvis and improve the quality of life of patients after surgery. Conclusion: At present, the research on pubic symphysis diastasis still needs to be improved. In the future, high-quality, multi-center, and large-sample studies are of great significance for the selection of treatment methods and the evaluation of effectiveness for patients with pubic symphysis diastasis.

Effect of denosumab on glucose metabolism in postmenopausal osteoporotic women with prediabetes: a study protocol for a 12-month multicenter, open-label, randomized controlled trial.

BACKGROUND: Participants with prediabetes are at a high risk of developing type 2 diabetes (T2D). Recent studies have suggested that blocking the receptor activator of nuclear factor-κB ligand (RANKL) may improve glucose metabolism and delay the development of T2D. However, the effect of denosumab, a fully human monoclonal antibody that inhibits RANKL, on glycemic parameters in the prediabetes population is uncertain. We aim to examine the effect of denosumab on glucose metabolism in postmenopausal women with osteoporosis and prediabetes. METHODS: This is a 12-month multicenter, open-label, randomized controlled trial involving postmenopausal women who have been diagnosed with both osteoporosis and prediabetes. Osteoporosis is defined by the World Health Organization (WHO) as a bone mineral density T score of ≤ - 2.5, as measured by dual-energy X-ray absorptiometry (DXA). Prediabetes is defined as (i) a fasting plasma glucose level of 100-125 mg/dL, (ii) a 2-hour plasma glucose level of 140-199 mg/dL, or (iii) a glycosylated hemoglobin A1c (HbA1c) level of 5.7-6.4%. A total of 346 eligible subjects will be randomly assigned in a 1:1 ratio to receive either subcutaneous denosumab 60 mg every 6 months or oral alendronate 70 mg every week for 12 months. The primary outcome is the change in HbA1c levels from baseline to 12 months. Secondary outcomes include changes in fasting and 2-hour blood glucose levels, serum insulin levels, C-peptide levels, and insulin sensitivity from baseline to 12 months, and the incidence of T2D at the end of the study. Follow-up visits will be scheduled at 3, 6, 9, and 12 months. DISCUSSION: This study aims to provide evidence on the efficacy of denosumab on glucose metabolism in postmenopausal women with osteoporosis and prediabetes. The results derived from this clinical trial may provide insight into the potential of denosumab in preventing T2D in high-risk populations. TRIAL REGISTRATION: This study had been registered in the Chinese Clinical Trials Registry. REGISTRATION NUMBER: ChiCTR2300070789 on April 23, 2023. https://www.chictr.org.cn .

A New Technology Using Mixed Reality Surgical Navigation with the Unlocking Closed Reduction Technique Frame to Assist Pelvic Fracture Reduction and Fixation: Technical Note.

BACKGROUND: Pelvic ring disruption (PRD) is a serious trauma associated with high mortality and disability rates. Poor reduction can lead to complications such as pelvic deformity and delayed fracture healing. Here, we introduce a new technology using mixed reality surgical navigation (MRSN) with an unlocking closed reduction technique (UCRT) frame to assist pelvic fracture reduction and fixation. METHODS: Thirty patients with PRD were enrolled in this study. All of the patients underwent preoperative CT scans, with the pelvis and tracker segmented into three-dimensional models. Under MRSN guidance, auxiliary reduction screws were inserted to grasp the pelvic bone. An ideal trajectory for closed reduction was planned, and suitable CS screws were used for stable fixation after good reduction. Operation time, fluoroscopy frequency, and both Matta and Majeed scores were analyzed. RESULTS: The mean follow-up period was 10.8 months (7.5, 12.25 months) (range 6-24 months). The average duration of operation was 212.5 min (187.5, 272.8 min) (range 133-562 min), and the average reduction time was 23.0 min (15.0, 42.5 min) (range 10-70). The average fluoroscopy frequency was 34.0 times (31.5, 52.5 times) (range 23-68 times). One hundred and fifty screws were successfully inserted on the first attempt. All the fractures healed well with no complications. Excellent reduction quality (Matta score ≤4 mm) was achieved in 29/30 cases, and good reduction quality (Matta score between 4 and 10 mm) was achieved in 1/30 cases. All patients achieved bone healing after an average of 4.0 months (3.5, 5.9 months) (range 3-6), as well as good function recovery with an average Majeed score of 91.0 (87.8, 95.0) (range 71-100). CONCLUSION: The MRSN technique described improved reduction accuracy and radiation exposure without considerable extension of operation time.

[Early effectiveness of computer navigation system-assisted transiliac-transsacral screws placement for posterior pelvic ring injuries].

Objective: To investigate the early effectiveness of transiliac-transsacral screws internal fixation assisted by augmented reality navigation system HoloSight (hereinafter referred to as "computer navigation system") in the treatment of posterior pelvic ring injuries. Methods: A retrospective analysis was made in the 41 patients with posterior pelvic ring injuries who had been treated surgically with transiliac-transsacral screws between June 2022 and June 2023. The patients were divided into navigation group (18 cases, using computer navigation system to assist screw implantation) and freehand group (23 cases, using C-arm X-ray fluoroscopy to guide screw implantation) according to the different methods of transiliac-transsacral screws placement. There was no significant difference in gender, age, body mass index, causes of injuries, Tile classification of pelvic fracture, days from injury to operation, usage of unlocking closed reduction technique between the two groups ( P>0.05). The time of screw implantation, the fluoroscopy times, the guide wire adjustment times of each screw, and the incidence of complications were recorded and compared between the two groups. The position of the transiliac-transsacral screw was scanned by CT within 2 days after operation, and the position of the screw was classified according to Gras standard. Results: The operation was successfully completed in both groups. The time of screw implantation, the fluoroscopy times, and the guide wire adjustment times of each screw in the navigation group were significantly less than those in the freehand group ( P<0.05). There were 2 cases of incision infection in the freehand group, and the incision healed by first intention after active dressing change; there was no screw-related complication in the navigation group during operation and early period after operation; the difference in incidence of complications between the two groups (8.7% vs. 0) was not significant ( P=0.495). According to the Gras standard, the screw position of the navigation group was significantly better than that of the freehand group ( P<0.05). Conclusion: Compared with the traditional freehand method, the computer navigation system assisted transiliac-transsacral screws internal fixation in the treatment of posterior pelvic ring injuries has advantages of improving the accuracy of screw implantation and reducing radiation damage and the time of screw implantation.

Prognostic nutritional index with postoperative complications and 2-year mortality in hip fracture patients: an observational cohort study.

BACKGROUND: The prognostic nutritional index (PNI) has been proposed as a useful prognostic tool in multiple populations. However, its prognostic value has not been fully evaluated in the hip fracture population. We aimed to assess the relationship between PNI and postoperative complications as well as 2-year all-cause mortality in the hip fracture population. MATERIALS AND METHODS: We included patients aged 45 or older who underwent surgery for hip fracture between 2000 and 2022. The baseline serum albumin and total lymphocyte count were used to calculate PNI with the following formula: 10×serum albumin level (g/dl)+0.005×total lymphocyte count (per mm 3 ). Patients were classified into low, medium, and high categories based on tertiles of PNI (≤43.23, 43.23-47.35, and >47.35, respectively). Logistic regression and Cox proportional hazards models were used to calculate the odds ratio (OR) for postoperative compilations and the hazard ratio (HR) for mortality, adjusting for potential confounders. RESULTS: Of 3351 hip patients, 236 (7.04%) developed postoperative complications, and 305 (9.10%) died during the 2-year follow-up. Compared to the low-category patients, the medium-category and high-category patients showed lower odds of postoperative complications (ORs 0.69, 95% CI 0.48-0.98; and 0.61, 95% CI 0.40-0.93, respectively), and lower hazards of 2-year mortality (HRs 0.66, 95% CI 0.49-0.88; and 0.61, 95% CI 0.42-0.88, respectively). These associations were robust across a series of analyses, including subgroup analyses and dose-response sensitivity analyses. CONCLUSION: PNI is an independent predictor of postoperative complications and 2-year all-cause mortality in hip fracture patients. PNI can be used to identify patients who may be at high risk of a poor prognosis.

Exosomes promote hFOB1.19 proliferation and differentiation via LINC00520.

BACKGROUND: Osteoporosis remains a significant clinical challenge worldwide. Recent studies have shown that exosomes stimulate bone regeneration. Thus, it is worthwhile to explore whether exosomes could be a useful therapeutic strategy for osteoporosis. The purpose of this study was to investigate the effects of exosomes derived from human umbilical cord mesenchymal stem cells (hucMSCs) on osteoblast proliferation and differentiation. METHODS: Exosomes were isolated from hucMSCs. Bioinformatics analysis was performed to identify the differentially expressed lncRNAs in myeloma-derived mesenchymal stem cells. Plasmids encoding LINC00520 or short hairpin RNA of LINC00520 were transfected into hucMSCs and then exosomes were isolated. After human osteoblasts hFOB1.19 were exposed to the obtained exosomes, cell survival, cell cycle, apoptosis and calcium deposits of hFOB1.19 cell were detected by MTT, 7-aminoactinomycin D, Annexin V-FITC/propidium iodide and Alizarin red staining, respectively. RESULTS: In hFOB1.19 cells, 10 × 109/mL hucMSC-derived exosomes inhibited cell proliferation, arrested cell cycle, and promoted apoptosis, while hucMSCs or 1 × 109/mL exosomes promoted cell proliferation, accelerated cell cycle, and promoted calcium deposits and the expression of OCN, RUNX2, collagen I and ALP. In hFOB1.19 cells, exosomes from hucMSCs with LINC00520 knockdown reduced the survival and calcium deposits, arrested the cell cycle, and enhanced the apoptosis, while exosomes from hucMSCs overexpressing LINC00520 enhance the proliferation and calcium deposits and accelerated the cell cycle. CONCLUSIONS: LINC00520 functions as a modulator of calcium deposits, and exosomes derived from hucMSCs overexpressing LINC00520 might be a novel therapeutic approach for osteoporosis.

Clinical Guidelines for the Diagnosis and Treatment of Fragility Fractures of the Pelvis.

BACKGROUND: Fragility fractures of the pelvis (FFPs) are osteoporotic pelvic fractures or insufficiency pelvic fractures caused by the low energy injury or stress fracture in daily livings in the elderly more than 60 years, which the incidence is increasing with the aging population in our country. FFPs result in considerable morbidity and mortality and as well as massive financial burden on the already strained health systems throughout the world. METHODS: This clinical guideline was initiated by the Trauma Orthopedic Branch of Chinese Orthopedic Association; the External Fixation and Limb Reconstruction Branch of Chinese Orthopedic Association; the National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation; Senior Department of Orthopedics of Chinese PLA general hospital; the Third Hospital of Hebei Medical University. The grading of recommendations assessment, development and evaluation (GRADE) approach and the reporting items for practice guidelines in healthcare (RIGHT) checklist were adopted. RESULTS: 22 evidence based recommendations were formulated based on 22 most concerned clinical problems among orthopedic surgeons in China. CONCLUSION: Understanding these trends through this guideline will facilitate better clinical care of FFP patients by medical providers and better allocation of resources by policy makers.

Preoperative Anemia and Risk of In-hospital Postoperative Complications in Patients with Hip Fracture.

Purpose: To evaluate the impact of preoperative anemia on postoperative complications after hip fracture surgery. Patients and Methods: We conducted a retrospective study including hip fracture patients at a teaching hospital between 2005 and 2022. We defined preoperative anemia as the last hemoglobin measurement level before surgery < 130 g/L for men and < 120 g/L for women. The primary outcome was a composite of in-hospital major complications, including pneumonia, respiratory failure, gastrointestinal bleeding, urinary tract infection, incision infection, deep venous thrombosis, pulmonary embolism, angina pectoris, arrhythmia, myocardial infarction, heart failure, stroke, and death. Secondary outcomes were cardiovascular events, infection, pneumonia, and death. We used multivariate negative binomial or logistic regression to evaluate the impact of anemia and its severity, categorized as mild (90-130 g/L for men, 90-120 g/L for women) or moderate-to-severe (< 90 g/L for both) anemia on outcomes. Results: Of the 3540 included patients, 1960 had preoperative anemia. 188 anemic patients experienced 324 major complications, while 63 non-anemic patients had 94 major complications. The risk of major complications was 165.3 (95% CI, 149.5-182.4) and 59.5 (95% CI, 48.9-72.3) per 1000 persons in anemic and non-anemic patients, respectively. Anemic patients were more likely to have major complications than non-anemic patients (adjusted incidence rate ratio (aIRR), 1.87; 95% CI, 1.30-2.72), which was consistent in mild (aIRR, 1.77; 95% CI, 1.22-2.59) and moderate-to-severe (aIRR, 2.97; 95% CI, 1.65-5.38) anemia. Preoperative anemia also increased the risk of cardiovascular events (aIRR, 1.96; 95% CI, 1.29-3.01), infection (aIRR, 1.68; 95% CI, 1.01-2.86), pneumonia (adjusted odds ratio (aOR), 1.91; 95% CI, 1.06-3.57), and death (aOR, 3.17; 95% CI, 1.06-11.89). Conclusion: Our findings suggest that even mild preoperative anemia is associated with major postoperative complications in hip fracture patients. This finding highlights considering preoperative anemia as a risk factor in surgical decision-making for high-risk patients.

Age-Related changes in the morphological features of medial column of the proximal humerus in the Chinese population.

Background: Age-related changes in the medial column (MC) of the proximal humerus have a major impact on fracture management; however, the changes in the morphological features remain unclear. This study aimed to investigate the age-related changes in the morphological features of MC and present the morphological grading. Methods: One hundred computed tomography (CT) images of the proximal humerus of 100 individuals (19-95 years) were retrospectively obtained. The individuals were categorized into five age groups to quantify the differences among different ages; the youngest group (18-44 years) served as the baseline group. Parameters of the morphological features were measured on CT images with multiplanar reconstruction based on an explicit definition of MC, including length, thickness, width, oblique thickness (DSM), humeral head diameter (DHM), and ratio (RSM) of DSM to DHM. The morphological grading of MC was presented based on the value of RSM deviating different standard deviations (SD) from the mean value in the baseline group. Results: Significant negative correlations were observed between age and the morphological parameters of MC (r ranged from -0.875 to -0.926; all P < 0.05), excluding DHM (r = 0.081, P = 0.422). Significant differences in the values of morphological feature parameters were detected among the five age groups (all P < 0.001). The highest mean values of morphological feature parameters were observed in the youngest group (18-44 years), which decreased gradually with increasing age until the lowest mean values were observed in the oldest group (≥90 years) (all P < 0.05). The morphological features of MC were categorized into three grades based on the value of RSM deviating 1.5 SD or 3 SD from the mean value in the baseline group. Conclusion: Our study shows that the parameter values of morphological features of MC decreased with increasing age. The morphological features of MC could be categorized into three grades. Our findings may provide a more comprehensive insight into age-related changes in the morphological features of MC that facilitate risk stratification and optimize the management of proximal humeral fractures.

Does computer-assisted orthopaedics system (ADAPT system) improve outcomes of intertrochanteric hip fractures?

INTRODUCTION: Intramedullary nailing (IMN) is a general treatment for intertrochanteric hip fractures. The computer-assisted orthopaedics system (CAOS), ADAPT system (Stryker, NJ), has been developed to facilitate lag screw insertion. When compared to the conventional freehand method, the efficacy of CAOS has not been clearly clarified. Therefore, we conducted this systematic review and meta-analysis to answer: does the CAOS performed better than freehand method in IMN. MATERIALS AND METHODS: Studies published up to January 2023 were searched in the PubMed, Embase, Web of Science and Cochrane Library databases with predetermined key words. Comparative clinical studies between CAOS (ADAPT system) and freehand method were included. The primary outcomes of interest were the tip-apex-distance (TAD) and positions of lag screw. Fluoroscopy use, operation duration and intraoperative/postoperative complications were also extracted. A meta-analysis was performed for pooled analysis. RESULTS: There were seven studies with 326 fractures in CAOS group and 325 fractures in Freehand group. All studies included presented high qualities. The CAOS group showed a statistically smaller TAD than Freehand group (weighted mean difference = -3.24 mm; 95% confidence interval [CI] -5.10 to -1.37 mm; p = 0.0007) and a better lag screw position (83/92 [90.2%] VS 64/92 [69.6%]; RR = 1.3; 95% CI 1.12 to 1.51; p = 0.0007). The operative time and radiation use revealed no difference between two groups. CONCLUSIONS: The current evidence indicated that ADAPT system could help to perform a more accurate lag screw than freehand manipulation while the operative time and radiation time was not reduced as expectations on such new technique. Long-term follow-up studies are appealed.

Prospective randomized multicenter noninferiority clinical trial evaluating the use of TFN-advancedTM proximal femoral nailing system (TFNA) for the treatment of proximal femur fracture in a Chinese population.

PURPOSE: To evaluate whether the 24-weeks postoperative fracture union rate for the investigational TFNA intramedullary nail was non-inferior compared to the control product PFNA-II. METHODS: The study was a prospective, randomized, single-blind, noninferiority dual-arm study drawing from 9 trauma centers across China, between November 2018 and September 2020, with follow-up measurements at 24 weeks after internal fixation. The full analysis data set (FAS [Intent-to-Treat]) was analyzed and is summarized here. The primary outcome was fracture union rate, a composite score combining clinical and radiographic assessment. Secondary endpoints comprised (a) clinical outcomes including (1) SF-12, (2) Harris Hip, and (3) EQ-5D Scores, (b) radiographic incidence of complications such as loosening or cut-out requiring revision, (c) revision rates, (d) reoperation rates, and (e) adverse events, including 24-weeks revision and reoperation rates. RESULTS: Both TFNA and PFNA-II group fracture healing rates were 100% at 24 weeks; TFNA was therefore shown to be non-inferior to PFNA-II. With baseline data matched in all parameters except age in both the TFNA and PFNA-II groups, comparisons of union rates, SF-12, Harris Hip, and EQ-5D Scores yielded p values > 0.05 indicating no significant difference between the two groups, further supporting the noninferiority of TFNA. In both groups, revision and re-operation rates were 0, and the incidences of serious adverse events were 19.4% and 17.4%, respectively. CONCLUSION: In terms of fracture union rate at 24 weeks, the DePuy Synthes Trochanteric Fixation Nail Advanced (TFNA) was not inferior to the marketed Proximal Femoral Nail Antirotation (PFNA-II) device produced by the same manufacturer. Secondary and safety outcomes showed no significant differences between the two groups. REGISTRATION: Registration was completed at ClinicalTrials.gov NCT03635320.

[Effectiveness of three-dimensional visible technique without fluoroscopy versus two-dimensional fluoroscopy in reduction of unstable pelvic fractures].

Objective: To compare the reduction qualities of three-dimensional visible technique without fluoroscopy and two-dimensional fluoroscopy for unstable pelvic fractures during operations. Methods: The clinical data of 40 patients with unstable pelvic fractures, who met the selection criteria in three clinical centers between June 2021 and September 2022, were retrospectively analyzed. According to the reduction methods, the patients were divided into two groups. Twenty patients in trial group were treated with unlocking closed reduction system combined with three-dimensional visible technique without fluoroscopy; 20 patients in control group with unlocking closed reduction system under two-dimensional fluoroscopy. There was no significant difference in the gender, age, injury mechanism, Tile type of fracture, Injury Severity Score (ISS), and the time between injury to operation between the two groups ( P>0.05). The qualities of fracture reduction according to the Matta criteria, operative time, intraoperative blood loss, fracture reduction time, times of fluoroscopy, and System Usability Scale (SUS) score were recorded and compared. Results: All operations were successfully completed in both groups. According to the Matta criteria, the qualities of fracture reduction were rated as excellent in 19 patients (95%) in trial group, which was better than that in the control group (13 cases, 65%), with a significant difference ( χ 2=3.906, P=0.048). The operative time and intraoperative blood loss had no significant differences between the two groups ( P>0.05). The fracture reduction time and times of fluoroscopy were significantly less in trial group than in control group ( P<0.05), and SUS score in trial group was significantly higher in trial group than in control group ( P<0.05). Conclusion: Compared to using unlocking closed reduction system under two-dimensional fluoroscopy, three-dimensional visible technique without fluoroscopy can significantly improve the reduction quality of unstable pelvic fractures without prolonging the operative time, and is valuable to reduce iatrogenic radiation exposure for patients and medical workers.

Augmented Stability in Leaving Original Internal Fixation with Multidimensional Cross Locking Plate through Mini-Open Femoral Anterior Approach for Aseptic Femoral Shaft Nonunion: A Retrospective Cohort Study.

OBJECTIVE: Aseptic femoral shaft nonunion constitutes approximately 1%-10% of all femoral shaft fractures treated with intramedullary nail (IMN) fixation, possibly attributable to the lack of anti-rotational stability. Although a lateral locking plate (LP) with retainment of original IMN has shown the most success, lateral LP inflicts significant surgical trauma on patients. Therefore, the Multidimensional Cross Locking Plate (MDC-LP) was designed based on a mini-open femoral anterior approach. We aim to report and compare the technical aspects and clinical outcomes of using anterior MDC-LP or lateral LP with retention of original IMN for the treatment of aseptic femoral shaft nonunion. METHODS: In this single center retrospective cohort study, records of 49 patients who had undergone revision of femoral shaft aseptic nonunion with anterior MDC-LP or lateral LP while retaining the original IMN from January 2015 to October 2019 were retrospectively reviewed. Information on patients' demographics, clinical data, and surgical outcomes were gathered and analyzed. X-ray and CT scans were used for bone union evaluation and the lower extremity functional scale (LEFS) was used for follow-up functional evaluation. For quantitative data, the Student's t-test was used if the data were normally distributed. The Mann-Whitney U-test was used for non-normally distributed data. For qualitative data, the Chi-square test was used for comparisons. RESULTS: Twenty-seven patients were treated with anterior MDC-LP, and 22 patients were treated with lateral LP. There are no significant differences in age, sex, BMI, time since initial femoral shaft fracture, initial fracture type (close/open), nonunion type, or nonunion location between patients' group. Among patients treated with anterior MDC-LP, an average of 2-months advantage in time to union was observed (4.09 months vs. 6.8 months in the lateral LP group: P = 0.000), smaller incision was required for MDC-LP installment (7.7 cm vs 17.1 cm in lateral LP group: P = 0.000). CONCLUSIONS: For the treatment of aseptic femoral shaft nonunion with retainment of original IMN, anterior MDC-LP via mini-open femoral anterior approach described in this study is a better option than lateral LP for achieving faster bone union and satisfactory functional outcome with less surgical trauma.

Treatment of elderly comminuted proximal humeral fracture using endosteal anatomical support system: A case report.

INTRODUCTION: Intramedullary anatomical medial strut with allograft bone (IAMSAB), which accommodates the shape of the proximal humeral cavity and provides rotational stability and direct support to the medial column, was successfully introduced to augment Lateral locking plate (LLP) in the treatment of elderly comminuted proximal humeral fractures. Based on the LLP-IAMSAB construct, a newly titanium endosteal anatomical support system (EASS) was developed. CASE PRESENTATION: Reported here is a single case of a highly comminuted proximal humeral fracture. The fractures were treated with EASS. The patient's fracture healed properly. The 24-month follow-up demonstrated no pain and a good functional outcome, with no signs of reduction loss, absorption of greater tuberosity, varus displacement and avascular necrosis of humeral head. CLINICAL DISCUSSION: The newly developed EASS had several special considerations contributing to satisfactory surgical outcome. The flat plane construct of the proximal end of the EASS directly support humeral head to prevent varus displacement of the humeral head, instead of the purchase between the screw thread and the cancellous bone inside the humeral head in the nail or plate fixation. Medial anatomical shape of proximal end helps to reduce medial cortex reduction. Greater tuberosity support block with rotator cuff suture fixation might promote greater tuberosity healing and prevent its absorption. However, there is no similar construct in the nail or plate fixation. CONCLUSION: The newly developed endosteal anatomical support system might be a promising option in the treatment of elderly comminuted proximal humeral fractures. Although the effectiveness of this system requires additional evaluation upon more patients being treated with this surgical method, the newly developed EASS may serve as a humeral head-preserving method for elderly patients with comminuted proximal humeral fractures.

Intramedullary nailing versus plating fixation for the treatment of midshaft clavicular fractures: A meta-analysis of randomized controlled trials.

PURPOSE: This study was to test the hypothesis that intramedullary (IM) nailing fixation of midshaft clavicle fractures could result in better clinical outcomes and lower complications rates than plating fixation. METHODS: PubMed, Embase, and the Cochrane Library database were used to search all English language published randomized controlled trials (RCTs) of midshaft clavicle fractures using plating versus IM nailing. The characteristics of the study participants were collected. Outcomes of postoperative shoulder functional measurements, operative data and complications rates were meta-analyzed. RESULTS: Eight hundred and ninety-five patients in ten RCTs and three quasi-RCTs were involved in the meta-analysis. The results of meta-analysis of these studies showed that the functional outcome evaluated by the Constant Shoulder and Disabilities of the Arm, Shoulder and Hand (DASH) scores after accepting IM nailing was significantly better than that of plating fixation at one year post-operatively (P < 0.01), with the heterogeneity of 43% and 91%, respectively. Sensitivity analyses of the pooled results of Constant and DASH scores displayed that the functional advantage of IM nailing fixation comes from the subgroup of locked IM nailing. Further, regarding the operative statistics, operative time, blood loss and wound length were significantly less in the IM nailing group than the plating group (P < 0.001). The rates of infection, major complications and complications-related revision surgery were significantly higher in the plating group than the IM nailing group; however, there were no significantly statistical differences in other complications, e.g., nonunion, refracture after hardware removal, implant failure, symptomatic hardware, etc. (P > 0.05). CONCLUSION: The observations in this review suggested that IM nailing, especially locked IM nailing, could provide better shoulder functional outcome at one-year follow-up. Moreover, IM nailing fixation could effectively reduce operative time, blood loss, rates of infection, major complications, and revision surgery than plating. Further high-quality clinical trials with large samples and consistent designs are still needed to verify the long-term functional advantage of locked and unlocked IM nailing for midshaft clavicle fractures. LEVEL OF EVIDENCE: Level II.

Prophylactic tamsulosin can reduce the risk of urinary retention after surgery in male patients: A systematic review and meta-analysis.

Objective: The meta-analysis aimed to estimate the efficacy of prophylactic tamsulosin on postoperative urinary retention (POUR) in male patients. Methods: Papers were searched in the PubMed, Embase, Web of Science, and Cochrane Library databases with predetermined keywords up to March 1, 2022. The studies reporting the preventive efficacy of prophylactic tamsulosin on POUR among men were identified. Pooled risk ratios (RRs) were calculated based on the random-effects model. Meta-regression was performed to explore potential sources of heterogeneity. Results: There were 11 studies with 1,046 patients in the tamsulosin group and 1,113 patients in the control group. The risk of POUR was significantly lower in the tamsulosin group (123/1,046 [11.8%] vs. 238/1,119 [19.0%]; RR = 0.61; 95% confidence interval [CI] 0.43 to 0.87; P = 0.006; heterogeneity: I 2 = 57%; P = 0.009). Administration of tamsulosin was related to higher risk of adverse events (57/688 [8.3%] vs. 33/624 [5.3%]; RR = 1.68; 95% CI: 1.13 to 2.48; P = 0.010; heterogeneity: I 2 = 33%; P = 0.20). The level of evidence and mean age of the included patients were identified as the potential sources of heterogeneity. Conclusion: The present meta-analysis indicated that prophylactic tamsulosin helps in preventing POUR and younger patients might benefit more from this preventive regimen. Administrating tamsulosin was also associated with a possibly higher risk of adverse events.