Incidence and risk factors of preoperative deep venous thrombosis in closed tibial shaft fracture: a prospective cohort study.

OBJECTIVE: To investigate the preoperative morbidity of deep venous thrombosis (DVT) and predictive risk factors associated with DVT after closed tibial shaft fracture. METHODS: Ultrasonography and blood analyses were performed preoperatively in patients who sustained tibial shaft fracture between October 2014 and December 2018. Univariate analyses were used in the data of demographics, comorbidities, mechanism of injury, concomitant fractures and laboratory biomarkers. Multivariate logistic regression analyses were conducted to determine the independent risk factors associated with DVT. RESULTS: In total, 918 patients with an operatively treated tibial shaft fracture were included, among whom 122 patients had preoperative DVTs, indicating a crude morbidity of 13.3%. Ninety-two of 758 (12.1%) patients with isolated tibial shaft fracture developed DVT, while 30 of 160 (18.8%) patients with concurrent fracture presented with DVT. The average interval between fracture and initial diagnosis of DVT was 3.1 days (median, 2 days), ranging from 0 to 33 days. Among DVT-positive patients, 16 (13.1%) patients presented with proximal DVT and 106 (86.9%) patients had distal DVT. Multivariate logistic regression analysis showed four independent risk factors were significantly correlated to the development of DVT, including increased age (OR = 1.17, p = 0.003), diabetes (OR = 1.99, p = 0.009), serum hydroxybutyrate dehydrogenase > 182 U/L (OR = 1.83, p = 0.008), and delay to DUS (in each day) (OR = 1.13, p < 0.001). CONCLUSION: In the present cohort study, the incidence of DVT was 12.1% in patients with isolated tibial shaft fracture. We suggest individualized risk stratification and early anticoagulation for patients with high risk factors including pre-existing diabetes, HBDH > 182 U/L, delay to DUS and older age. LEVEL OF EVIDENCE: Level III, a prospective cohort study.

An Analysis of the Morphology of Bony Bicipital Groove Fractures in Proximal Humeral Fractures.

OBJECTIVE: Research on proximal fractures in the humeral bicipital groove (BG), a region in which bones are not commonly fractured, is considered sparse in the literature. The objective of this research was to present the definite characteristics and distribution of BG fractures. METHODS: This retrospective study included and enrolled 119 proximal humeral fractures in adult patients with complete radiography data to identify the fracture distribution in the BG from January 2021 to August 2021. The bicipital region was divided into three parts, i.e. the upper 1/3, middle 1/3, and lower 1/3 of the BG, and the distribution of fracture lines was transcribed on the male or female template, as appropriate. In addition, the normal contralateral humerus was used to calculate the cortical thickness of the supratubercular groove and different parts of the BG (upper, middle, and lower parts). The Mann-Whitney test or one-way ANOVA along with LSD tests were used to determine differences in the fracture distribution and cortical thickness between men and women. RESULTS: Fractures of the BG in both men and women were mainly located in the upper 2/3 region of the BG, especially in the middle 1/3 of the BG. There were significant differences in the cortical thickness of the BG in men compared with that in women. The cortical thickness was highest in the supratubercular ridge but not the BG in men and women, respectively. CONCLUSION: This research concluded that bony BG fractures were always observed in the middle part of the BG and were mainly found in patients with four fractures of the proximal humerus. As a unique fracture pattern, the existence of a bony BG fracture always means that a patient has been injured by a relatively severe mechanism, and more attention should be given to these proximal humeral fractures.

The Reliability and Reproducibility of a New Revised Edelson Classification.

OBJECTIVE: Edelson classification is a 3D classification of proximal humeral fractures, but there is a scarcity of application of this classification in large samples, and the accuracy of classification was also not testified. The objective of this research was to verify whether a revised Edelson classification produces satisfactory agreement for proximal humeral fracture classification in adult patients. METHODS: A total of 827 proximal humeral fractures (304 male and 520 female patients, 58.0 ± 16.2 years) were found retrospectively from January 2014 to December 2019, and classified according to the traditional and newly proposed Edelson classification. The three-dimensional CT images were processed, rotated and visualized within software. Five shoulder surgeons classified each fracture. After data collection, radiographic classifications results were compared by inter- and intraobserver analysis with the method of weighted kappa coefficients. Fracture classification based on Edelson and revised Edelson classification was presented and compared. RESULTS: The mean k value for the interobserver reliability was 0.748 (range, 0.583 to 0.958) compared with Edelson classification (0.548, range, 0.48 to 0.635), indicating satisfactory agreement. The mean k value for intraobserver reliability was 0.906 (range, 0.823 to 0.943) compared with Edelson classification (0.762, range, 0.666 to 0.808), indicating excellent agreement when using the newly revised Edelson classification. The mechanism was categorized as the shoulder being in a position of forward flexion, abduction, and internal rotation in Edelson I-IV and bicipital fractures. For the greater tuberosity fracture, the mechanism was classified into two mechanisms based on the presence of a combined dislocation. Bicipital groove fracture is a commonly observed fracture pattern, and included in the revised Edelson classification. CONCLUSIONS: The revised Edelson classification proposed was more in line with the injury mechanism of the fracture, was beneficial in identifying more fracture types such as bicipital groove fracture, and verified to be a good proximal humeral fracture classification with good reliability compared with the traditional Edelson classification.

Morphological characteristics of the surgical neck region in the proximal humerus at different ages.

BACKGROUND: The objective of the study was to demonstrate the cortical thickness character in the humeral surgical neck region using 3D cortical bone mapping technique and try to illustrate its morphological changes with age. MATERIAL AND METHODS: Normal individuals, including 11 volunteers younger than 18 years, 87 adult men and 46 adult women, were enrolled. The cortical thickness and height of the surgical neck region was measured with Mimic and 3 Matic software. The height of the region was compared and measured. People with an age of 18-30 years was identified as Group I, people in 31-40 years as Group II, people in 41-50 years as Group III, people in 51-60 years as Group IV, and Group V including people ≥ 61 years. RESULTS: Compared with the baseline Group I, cortical thickness was significantly decreased by 0.52 mm (P = 0.006) in Group III, by 0.76 mm (P < 0.001) in Group IV, and by 0.77 mm (P < 0.001) in Group V. Age moderately predicted cortical thickness with r = -0.5481. The height of the cortical change region was significantly decreased by 2.25 mm (P = 0.007) in Group II, by 2.98 mm (P < 0.001) in Group III, and by 2.07 mm (P = 0.02) in Group IV. However, no significant decrease was illustrated in Group V (0.57 mm) (P = 0.891). The relation between age and the height of the cortical thickness change region was nonlinear. CONCLUSIONS: This study identified an obvious decrease in cortical thickness with aging, and the height was curve fitted with aging in surgical neck region.

Dynamics of the Gut Bacteria and Fungi Accompanying Low-Carbohydrate Diet-Induced Weight Loss in Overweight and Obese Adults.

BACKGROUND: Low-carbohydrate (e.g., Atkins) dietary pattern is one of the most effective diets for weight loss, but little is known about the characteristics of the gut microbiota accompanying low-carbohydrate diets-induced weight loss. This study aims to profile dynamics of gut bacteria and fungi accompanying modified Atkins diets-induced weight loss among overweight and obese adults. METHODS: Overweight and obese adults were screened to follow a modified Atkins diet plan (30% of energy from protein, 40% from carbohydrate and 30% from fat). We longitudinally profiled dynamics of gut bacteria and fungi based on 16S rRNA and ITS rRNA gene sequencing data, respectively. RESULTS: A total of 65 participants followed the modified Atkins diets for 20-231 days, with 61 and 27 participants achieving a weight loss of at least 5 and 10%, respectively. Most of the participants who achieved 10% weight loss also experienced improvements on metabolic health. The diversity of gut bacteria and fungi increased after a weight loss of 5% and kept stable thereafter. Bacteria genera including Lachnoclostridium and Ruminococcus 2 from Firmicutes phylum were depleted, while Parabacteroides and Bacteroides from Bacteroidetes phylum were enriched after weight loss. The inter-kingdom analysis found an intensive covariation between gut fungi and bacteria, involving more than half of the weight loss-associated bacteria. CONCLUSIONS: This study confirmed the modulation of bacterial and fungal composition during weight loss with the low-carbohydrate diets and showed previously unknown links between intestinal bacteria and fungi accompanying the weight loss.

Triplanar Chevron Osteotomy: A Newly Proposed Method to Treat Hallux Valgus Deformities.

OBJECTIVE: To present a novel method called triplanar chevron osteotomy to treat hallux valgus (HV). METHODS: This is a retrospective study. In this study, the CT data of HV patients with painful callosities were evaluated retrospectively between 1 June 2018 and 1 June 2020. CT data from 49 consecutive patients (59 feet) with HV were evaluated. The average age at the time of surgery was 49.6 years (range, 30-63 years). The apex of the chevron osteotomy procedure was located at the center of the first metatarsal and was defined as the line formed by the central point perpendicular to the fourth metatarsal bone. The cut planes of the plantarward oblique chevron osteotomy (POCO) were defined as follows: chevron osteotomy along with 20° of plantarward obliquity. The triplanar osteotomy incision was made using the POCO method, with the direction inclined by 10° distally. The intermetatarsal angle (IMA), the HV angle (HVA), the projection of the second metatarsal (PSM), the metatarsal protrusion index (MPI), and the metatarsal protrusion distance (MPD) were all calculated before and after the operations. The length of the first metatarsal was measured and calculated with an equation. RESULTS: The results showed that the HVA was significantly decreased after surgery (32.7° ± 4.6° vs 14.9° ± 2.1°, t = 25.583, P < 0.001) in the triplanar, traditional, and POCO groups. The IMA was also significantly decreased (14.7° ± 2.0°) compared with the results before surgery (8.0° ± 1.1°, t = 22.739, P < 0.001) in these groups. Compared with traditional osteotomy and POCO, there were no differences in correcting deformities on axial planes for the HVA (14.5° ± 1.7° vs 14.9° ± 2.1°, t = 1.835, P = 0.072) and IMA (8.1° ± 1.1° vs 8.0° ± 1.1°, t = -0.97, P = 0.336). There was a statistically significant decrease following surgery in terms of the PSM, MPI, and MPD after triplanar osteotomy. The length of the first metatarsal increased (10.9 ± 1.3 mm), as measured through three-dimensional images in the triplanar osteotomy group. The length was calculated as follows: H = L2 * Tan θ ≈ L/COS ß * Tan θ. CONCLUSION: The new triplanar osteotomy technique is safe and effective for treating HV, and in simulation experiments reveals potential benefits of correction and preventing transfer metatarsalgia.

Incidence and Hematological Biomarkers Associated With Preoperative Deep Venous Thrombosis Following Foot Fractures.

BACKGROUND: This study was designed to investigate the incidence and hematological biomarker levels that are associated with deep venous thrombosis (DVT) following closed foot fractures (except calcaneal fractures). METHODS: A retrospective analysis of data on patients presenting with closed foot fractures (excluding the calcaneus) between October 2014 and December 2018 was conducted. Duplex ultrasonography was used to screen preoperative DVT of bilateral lower extremities. Data on demographics, comorbidities, types of fracture, and laboratory biomarkers at admission were collected. Univariate analyses and multivariate logistic regression analyses were carried out to determine the independent risk factors associated with DVT. RESULTS: A total of 537 patients were included, among whom 28 patients had preoperative DVTs, indicating a crude incidence rate of 5.2%. In isolated closed foot fractures, DVT occurred in 12 (2.9%) out of 410 patients, while in patients with concurrent fracture in other locations, 16 (12.6%) out of 127 patients developed DVT. The average interval between fracture occurrence and diagnosis of DVT was 4.2 days (median, 2 days), ranging from 0 to 17 days. Twenty-four patients (85.7%) developed DVT in the injured extremity, 3 (10.7%) in the uninjured extremity, and 1 (3.5%) in bilateral extremities. Seven risk factors were identified to be associated with DVT, including alcohol consumption, concomitant other fractures, platelet distribution width (PDW) <12%, high-density lipoprotein cholesterol (HDL-C) <1.1mmol/L, serum alkaline phosphatase (ALP) >100 U/L, serum sodium concentration (Na+) <135 mmol/L, and D-dimer >0.5 mg/L. CONCLUSION: Being aware of the prevalence of DVT in closed foot fractures can help physicians to carry out the overall assessment, risk stratification, and individual prevention programs. LEVEL OF EVIDENCE: Level III, a prospective cohort study.