Open posterior approach versus endoscopic approach for thoracic ligamentum flavum ossification: a systematic review and meta-analysis.

BACKGROUND: Thoracic ossification of the ligamentum flavum (TOLF), a rare condition more prevalent in East Asia, is managed through open and endoscopic surgical approaches. Determining the superior surgical option remains unclear. This study assesses the safety and clinical outcomes associated with these approaches in TOLF patients. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic literature search up to August 5, 2023, across PubMed, Scopus, EMBASE, Web of Science, Cochrane, and ClinicalTrials.gov. We included randomized controlled trials and cohort studies reporting complication rates, mJOA (modified Japanese Orthopedic Association) scores, JOA scores, VAS (Visual Analog Scale) scores, or hospitalization duration for both open and endoscopic surgeries in TOLF patients. RESULTS: We analyzed 37 studies encompassing 1,646 TOLF patients using a random-effects model. Our findings revealed a significant difference in complication rates (overall complication rates: 0.12; 95% CI: 0.07, 0.19; p < 0.01; I2: 69%; quality of evidence: moderate), with lower complication rates in the endoscopy group. However, no significant differences were observed in JOA scores (overall JOA: 8.35; 95% CI: 7.16, 9.54; p = 0.12; I2: 99%; quality of evidence: very low), VAS scores (overall VAS: 1.31; 95% CI: 1.03, 1.59; p = 0.35; I2: 91%; quality of evidence: very low), or hospitalization duration (hospital stay: 10.83 days; 95% CI: 6.86, 14.80; p = 0.35; I2: 91%; quality of evidence: very low) between the open and endoscopic groups. CONCLUSIONS: This meta-analysis reports lower complication rates and improved postoperative mJOA scores for endoscopic surgery in TOLF patients compared to open surgery. It represents the first comprehensive evaluation of clinical outcomes and safety of different surgical approaches for TOLF patients. Further randomized controlled trials are essential to validate these findings.

Shots fired: evaluation of vascular injury, compartment syndrome, and transfusion rates among civilian ballistic orthopaedic fracture patients presenting to two Level I trauma centres.

PURPOSE: This study investigates baseline patient demographics and predictors of vascular injury, blood transfusion, and compartment syndrome in patients with orthopaedic fractures secondary to GSWs at two high-volume Level I trauma centres. METHODS: A retrospective chart review of all GSW-related trauma patients at two Level I trauma centres between July 2019 and September 2021 was conducted. Chi-squared and two-tailed independent t tests were used for data analysis, and logistic regression with odds ratios (OR) determined predictors of primary outcomes. RESULTS: Among 478 GSW patients, 94 (19.7%) sustained 130 orthopaedic fractures, most commonly at the lower extremity (77.7%). Orthopaedic fracture patients showed significantly higher rates of vascular injury (29.8 vs. 4.7%, p < 0.001), transfusion (27.7 vs. 12.8%, p = 0.006), and compartment syndrome (3.2 vs. 0.3%, p = 0.011) compared to non-orthopaedic injury patients. Univariable analysis identified ankle (OR = 47.50, p < 0.001) and hip/femur fractures (OR = 5.31, p < 0.001) as predictors of vascular injury. Multivariable logistic regression revealed lower extremity vascular injury (OR = 54.69, p = 0.006) and anatomic fracture sites of the humerus (OR = 15.17, p = 0.008), clavicle/scapula (OR = 11.30, p = 0.009), and acetabulum/pelvis (OR = 7.17, p = 0.025) as predictors of blood transfusion. Univariable analysis showed lower extremity vascular injury (OR = 30.14, p = 0.007) as a predictor of compartment syndrome. CONCLUSION: These findings underscore the importance of diagnosing and managing vascular injuries and compartment syndrome in GSW-related orthopaedic fractures, emphasizing the necessity for targeted transfusion strategies in such cases.

Trauma Center Outcomes After Transition From Level 2 to Level 1: A National Trauma Data Bank Analysis.

BACKGROUND: Previous US-based studies have shown that a trauma center designation of level 1 is associated with improved patient outcomes. However, most studies are cross-sectional, focus on volume-related issues and are direct comparisons between levels. This study investigates the change in patient characteristics when individual trauma centers transition from level 2 to level 1 and whether the patients have similar outcomes during the initial period of the transition. STUDY DESIGN: We performed a retrospective cohort study that analyzed hospital and patient records included in the National Trauma Data Bank from 2007 to 2016. Patient characteristics were compared before and after their hospitals transitioned their trauma level. Mortality; complications including acute kidney injury, acute respiratory distress syndrome, cardiac arrest with CPR, deep surgical site infection, deep vein thrombosis, extremity compartment syndrome, surgical site infection, osteomyelitis, pulmonary embolism, and so on; ICU admission; ventilation use; unplanned returns to the OR; unplanned ICU transfers; unplanned intubations; and lengths of stay were obtained following propensity score matching, comparing posttransition years with the last pretransition year. RESULTS: Sixteen trauma centers transitioned from level 2 to level 1 between 2007 and 2016. One was excluded due to missing data. After transition, patient characteristics showed differences in the distribution of race, comorbidities, insurance status, injury severity scores, injury mechanisms, and injury type. After propensity score matching, patients treated in a trauma center after transition from level 2 to 1 required significantly fewer ICU admissions and had lower complication rates. However, significantly more unplanned intubations, unplanned returns to the OR, unplanned ICU transfers, ventilation use, surgical site infections, pneumonia, and urinary tract infections and higher mortality were reported after the transition. CONCLUSIONS: Trauma centers that transitioned from level 2 to level 1 had lower overall complications, with fewer patients requiring ICU admission. However, higher mortality and more surgical site infections, pneumonia, urinary tract infections, unplanned intubations, and unplanned ICU transfers were reported after the transition. These findings may have significant implications in the planning of trauma systems for administrators and healthcare leaders.

Comparison between vertebroplasty with high or low viscosity cement augmentation or kyphoplasty in cement leakage rate for patients with vertebral compression fracture: a systematic review and network meta-analysis.

PURPOSE: This study aims to determine whether outcomes following vertebroplasty with high viscosity cement are superior to low viscosity cement and non-inferior to kyphoplasty in the setting of vertebral compression fractures. METHODS: We searched for randomized controlled trials and cohort studies assessing cement leakage rate in adult patients with VCFs who underwent vertebroplasty with high (HVCV) or low viscosity cement (LVCV) augmentation, or kyphoplasty (KP) in PubMed, Embase, Ovid, The Cochrane Library, and Web of Science from inception up to December 2019. Two authors extracted data and appraised risk of bias. We performed pairwise meta-analyses in R to compare differences between three treatments and network meta-analysis using frequentist random-effects models for indirect comparison. We used P-score to rate the overall certainty of evidence. The primary outcome was cement leakage rate. RESULTS: Five RCTs and eight cohort studies with 840 patients and a total of 1280 vertebral bodies were included in the systematic review and network meta-analysis. Compared to LVCV, the relative risk for cement leakage following HVCV and KP was 0.42 (95% CI 0.28-0.61) and 0.83 (95% CI 0.40-1.68), respectively. Our pooled results suggested that HVCV (P-score = 0.99) was better than KP (P-score = 0.36) in cement leakage rate. CONCLUSIONS: The present network meta-analysis demonstrated that HVCV may be associated with lower risk of cement leakage among patients with VCFs as compared to other augmentation techniques. Future prospective studies will validate the findings of this analysis and further elucidate the risk of symptomatic cement leakage.

E-scooter use continues to rev up fracture diagnoses and hospital admissions compared to other modes of transportation.

Introduction: The COVID-19 pandemic was associated with an increase in popularity of e-scooter usage and a rise in e-scooter related injuries. Recent studies have elucidated trends within e-scooter injuries but there are few epidemiological studies that evaluate injury rates amongst multiple modes of transportation. This study seeks to investigate trends of e-scooter orthopedic fracture injuries compared to other traditional methods of transportation using a national database. Methods: The National Electronic Injury Surveillance System (NEISS) database was queried between 2014 and 2020 for patients who were injured after usage of e-scooters, bicycles, or all-terrain vehicles. Primary analysis included patients with a diagnosis of fracture and utilized univariate/multivariate models to evaluate risk of hospital admission. Secondary analysis included all isolated patients to evaluate the odds of fracture development amongst modes of transportation. Results: A total of 70,719 patients with injuries associated with e-scooter, bicycle, or all-terrain vehicle use were isolated. 15997 (22.6%) of these patients had a fracture diagnosis. Both e-scooters and all-terrain vehicles reported increased odds of fracture-related injury and direct hospitalization when compared to bicycles. E-scooter users reported a greater odds of both associated fracture (OR 1.25; 95%CI 1.03-1.51; p = 0.024) and hospital admission (OR: 2.01; 95%CI: 1.26-3.21; p = 0.003) in 2020 compared to 2014-2015. Discussion: E-scooter related orthopedic injuries and hospital admissions had the largest incidence rate increase compared to bicycle and all-terrain vehicles between 2014 and 2020. E-scooter fractures were most commonly located in the lower leg in 2014-2017, the wrist in 2018-2019, and the upper trunk in 2020. In comparison, bicycle and all-terrain vehicle fractures was most commonly shoulder and upper trunk within the study period. Further research will help to promote further understanding of the e-scooter health care burden and in prevention of these injuries. Level of evidence: 3.

The Effect of Congruent Tibial Inserts in Total Knee Arthroplasty: A Network Meta-Analysis of Randomized Controlled Trials.

Objective: The aim of this study was to determine whether modern congruent tibial inserts are associated with superior outcomes in total knee arthroplasty (TKA). Background: Ultracongruent fixed-bearing (UCFB) and medial congruent fixed-bearing (MCFB) inserts have been known to be effective in total knee arthroplasty with patient satisfaction. Nonetheless, no supporting evidence to date exists to rank the clinical outcomes of these various congruent inserts in TKA compared with other important considerations in TKA including cruciate-retaining fixed-bearing (CRFB) and posterior-stabilized fixed-bearing (PSFB) inserts. Methods: We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and Scopus up to 15 May 2022. We selected studies involving an active comparison of UCFB or MCFB in TKAs. We performed a network meta-analysis (NMA) of randomized controlled trials (RCTs) and compared different congruent inserts. We ranked the clinical outcomes by SUCRA score with the estimate of the best treatment probability. Our primary outcomes were revision rates and radiolucent lines. Secondary outcomes were functional scores, including the range of motion (ROM), the Knee Society Score (KSS), the Oxford Knee Score (OKS), and WOMAC. Results: Eighteen RCTs with 1793 participants were analyzed. Our NMA ranked MCFB, CRFB, and UCFB with the lowest revision rates. CRFB and UCFB had the fewest radiolucent lines. UCFB had overall the best ROM. UCFB and MCFB had the best OKS score overall. Conclusions: The ranking probability for better clinical outcomes in congruent inserts demonstrated the superiority of congruent tibial inserts, including UCFB and MCFB. UCFB may be associated with better ROM and postoperative functional outcomes. However, integrating future RCTs for high-level evidence is necessary to confirm these findings.

Analgesic efficacy of collagen peptide in knee osteoarthritis: a meta-analysis of randomized controlled trials.

BACKGROUND: The management of knee osteoarthritis involves various treatment strategies. It is important to explore alternative therapies that are both safe and effective. Collagen peptides have emerged as a potential intervention for knee osteoarthritis. This study aims to evaluate the analgesic effects and safety of collagen peptide in patients diagnosed with knee osteoarthritis. METHODS: We conducted a systematic literature search following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Multiple databases including PubMed, Scopus, EMBASE, Web of Science, Cochrane, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) published up to 27 May 2023 that focused on the analgesic outcomes and adverse events associated with collagen peptides or hydrolyzed collagen in patients with osteoarthritis. We assessed the quality of the included studies and the strength of evidence using the Cochrane ROB 2.0 tool and Grading of Recommendations, Assessment, Development, and Evaluations. RESULTS: Four trials involving 507 patients with knee osteoarthritis were included and analyzed using the random-effects model. All these trials were considered to have a high risk of bias. Our results revealed a significant difference in pain relief between the collagen peptide group and the placebo group in patients with knee osteoarthritis (standardized mean difference: - 0.58; 95% CI - 0.98, - 0.18, p = 0.004; I2: 68%; quality of evidence: moderate). However, there was no significant difference in the risk of adverse events between collagen peptide and placebo (odds ratio: 1.66; 95% CI 0.99, 2.78, p = 0.05; I2: 0%; quality of evidence: very low). CONCLUSIONS: Our findings demonstrate significant pain relief in patients with knee osteoarthritis who received collagen peptides compared to those who received placebo. In addition, the risk of adverse events did not differ significantly between the collagen peptide group and the placebo group. However, due to potential biases and limitations, well-designed randomized controlled trials are needed to validate and confirm these findings.

Is There a Role for Anti-factor Xa Activity Assay in Venous Thromboembolism Prophylaxis Management Among Orthopaedic Trauma Patients? Systematic Review and Meta-analysis.

OBJECTIVES: To determine the effect of anti-factor Xa assay dosing of low-molecular-weight heparin (LMWH) on rates of venous thromboembolism (VTE), deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, and mortality among orthopaedic trauma patients. DATA SOURCES: PubMed/MEDLINE, Embase, Ovid, Cochrane Central Register of Controlled Trials (CENTRAL), clinicaltrials.gov , and Scopus were systematically searched from inception of the database to 2021. STUDY SELECTION: Prospective, retrospective, and randomized controlled trial studies were included if they compared rates of VTE, DVT, PE, bleeding, and/or mortality between orthopaedic trauma patients receiving anti-factor Xa-based LMWH dosing and those receiving standard dosing. DATA EXTRACTION: Two independent reviewers screened titles and abstracts for eligibility. Study characteristics including study design, inclusion criteria, and intervention were extracted. DATA SYNTHESIS: Meta-analysis was performed using pooled proportion of events (effect size) with 95% confidence intervals. A random-effects model was used. Heterogeneity was quantified by Higgins I 2 . Heterogeneity and variability between subgroups indicated differences in the pooled estimate represented by a P -value. RESULTS: Six hundred eighty-five studies were identified, and 10 studies including 2870 patients were included. In total, 30.3% and 69.7% received an adjusted and nonadjusted dose of LMWH, respectively. The rate of VTE and DVT were significantly lower in the anti-factor Xa-adjusted cohort, whereas there was no statistically significant difference in rates of PE, bleeding, or mortality between the cohorts. CONCLUSIONS: This systematic review and meta-analysis demonstrates that anti-factor Xa activity assay dosing of LMWH among orthopaedic trauma patients leads to a reduction in overall DVT rates, although not PE rates, without an increased risk of bleeding events. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Willow Bark (Salix spp.) Used for Pain Relief in Arthritis: A Meta-Analysis of Randomized Controlled Trials.

This study intends to assess the analgesic effects, physical facilitation, and safety of willow bark use in patients with arthritis. Our study was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. PubMed, Scopus, EMBASE, Web of Science, Cochrane, and ClinicalTrials.gov were searched for relative randomized controlled trials (RCTs) describing the efficacy or adverse events of willow bark in patients with arthritis until 12 April 2023. We used Cochrane ROB 2.0 and the Grading of Recommendations, Assessment, Development, and Evaluations system to evaluate the quality of studies and evidence. The meta-analysis was carried out by the fix-effects model. This study included five studies with six RCTs consisting of 329 patients with arthritis. The results showed significant differences in pain relief and improvement in physical status for patients with arthritis between willow bark treatment and placebo groups, and no significant differences in the risk of all adverse events in patients with arthritis between willow bark treatment and placebo. Owing to the potential bias, the certainty and evidence of our findings are still inadequate. Therefore, further RCTs are needed to confirm our results.

The Use of Ultrasonic Bone Scalpel (UBS) in Unilateral Biportal Endoscopic Spine Surgery (UBESS): Technical Notes and Outcomes.

STUDY DESIGN: Case Series and Technical Note, Objective: UBS has been extensively used in open surgery. However, the use of UBS during UBESS has not been reported in the literature. The aim of this study was to describe a new spinal surgical technique using an ultrasonic bone scalpel (UBS) during unilateral biportal endoscopic spine surgery (UBESS) and to report the preliminary results of this technique. METHODS: We enrolled patients diagnosed with lumbar spinal stenosis who underwent single-level UBESS. All patients were followed up for more than 12 months. A unilateral laminotomy was performed after bilateral decompression under endoscopy. We used the UBS system after direct visualization of the target for a bone cut. We evaluated the demographic characteristics, diagnosis, operative time, and estimated blood loss of the patients. Clinical outcomes included the visual analog scale (VAS), the Oswestry Disability Index (ODI), the modified MacNab criteria, and postoperative complications. RESULTS: A total of twenty patients (five males and fifteen females) were enrolled in this study. The mean follow-up period was 13.2 months (range 12-17 months). The VAS score, ODI, and modified MacNab criteria classification improved after the surgery. A minimal mean blood loss of 22.1 mL was noted during the operation. Only one patient experienced neuropraxia, which resolved within 2 weeks. There was no durotomy, iatrogenic pars fracture, or infection. CONCLUSIONS: In conclusion, our study represents the first report of the use of UBS during UBESS. Our findings demonstrate that this technique is safe and efficient, with improved clinical outcomes and minimal complications. These preliminary results warrant further investigation through larger clinical studies with longer follow-up periods to confirm the effectiveness of this technique in the treatment of lumbar spinal stenosis.

Different Gabapentin and Pregabalin Dosages for Perioperative Pain Control in Patients Undergoing Spine Surgery: A Systematic Review and Network Meta-Analysis.

IMPORTANCE: Patients undergoing spine surgery often experience severe pain. The optimal dosage of pregabalin and gabapentin for pain control and safety in these patients has not been well established. OBJECTIVE: To evaluate the associations of pain, opioid consumption, and adverse events with different dosages of pregabalin and gabapentin in patients undergoing spine surgery. DATA SOURCES: PubMed/MEDLINE, Embase, Web of Science, Cochrane library, and Scopus databases were searched for articles until August 7, 2021. STUDY SELECTION: Randomized clinical trials conducted among patients who received pregabalin or gabapentin while undergoing spine surgery were included. DATA EXTRACTION AND SYNTHESIS: Two investigators independently performed data extraction following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) reporting guideline. The network meta-analysis was conducted from August 2022 to February 2023 using a random-effects model. MAIN OUTCOMES AND MEASURES: The primary outcome was pain intensity measured using the Visual Analog Scale (VAS), and secondary outcomes included opioid consumption and adverse events. RESULTS: Twenty-seven randomized clinical trials with 1861 patients (median age, 45.99 years [range, 20.00-70.00 years]; 759 women [40.8%]) were included in the systematic review and network meta-analysis. Compared with placebo, the VAS pain score was lowest with gabapentin 900 mg per day, followed by gabapentin 1200 mg per day, gabapentin 600 mg per day, gabapentin 300 mg per day, pregabalin 300 mg per day, pregabalin 150 mg per day, and pregabalin 75 mg per day. Additionally, gabapentin 900 mg per day was found to be associated with the lowest opioid consumption among all dosages of gabapentin and pregabalin, with a mean difference of -22.07% (95% CI, -33.22% to -10.92%) for the surface under the cumulative ranking curve compared with placebo. There was no statistically significant difference in adverse events (nausea, vomiting, and dizziness) among all treatments. No substantial inconsistency between direct and indirect evidence was detected for all outcomes. CONCLUSIONS AND RELEVANCE: These findings suggest that gabapentin 900 mg per day before spine surgery is associated with the lowest VAS pain score among all dosages. In addition, no differences in adverse events were noted among all treatments.

Cannabinoid Use for Pain Reduction in Spinal Cord Injuries: A Meta-Analysis of Randomized Controlled Trials.

Background: Spinal cord injury (SCI) often involves multimodal pain control. This study aims to evaluate the efficacy and safety of cannabinoid use for the reduction of pain in SCI patients. Methods and Findings: This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. We searched PubMed, EMBASE, Scopus, Cochrane, Web of Science, and ClinicalTrials.gov for relevant randomized controlled trials (RCTs) reporting the efficacy (e.g., pain relief) or safety (e.g., adverse events) of cannabinoids in patients with SCI, from inception to 25 December 2021. The study quality and the quality of evidence were evaluated by Cochrane ROB 2.0 and the Grading of Recommendations, Assessment, Development, and Evaluations system (GRADE), respectively. We used the random-effects model to perform the meta-analysis. From a total of 9,500 records, we included five RCTs with 417 SCI patients in the systematic review and meta-analysis. We judged all five of the included RCTs as being at high risk of bias. This meta-analysis indicated no significant difference in pain relief between the cannabinoids and placebo in SCI patients (mean difference of mean differences of pain scores: -5.68; 95% CI: -13.09, 1.73; p = 0.13; quality of evidence: very low), but higher odds of adverse events were found in SCI patients receiving cannabinoids (odds ratio: 3.76; 95% CI: 1.98, 7.13; p < 0.0001; quality of evidence: moderate). Conclusion: The current best evidence suggests that cannabinoids may not be beneficial for pain relief in SCI patients, but they do increase the risks of adverse events, including dizziness, somnolence, and dysgeusia, compared to the placebo. Cannabinoids should not be regularly suggested for pain reduction in SCI patients. Updating the systematic reviews and meta-analyses by integrating future RCTs is necessary to confirm these findings.

Total hip arthroplasty has higher complication rates in stiff spine patients: a systematic review and network meta-analysis.

BACKGROUND: Ankylosing spondylitis (AS) and spinal fusion (SF) classified as stiff spines have been associated with the increased rate of complications following total hip arthroplasty (THA). However, the differences between the two cohorts have inconsistent evidence. METHODS: We searched for studies comparing complications among stiff spine patients, including SF and AS, who underwent THA in PubMed/MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and Scopus until March 2021. Studies detailing rates of mechanical complications, aseptic loosening, dislocation, infection, and revisions were included. We performed network meta-analyses using frequentist random-effects models to compare differences between cohorts. We used P-score to rank the better exposure with the lowest complications. RESULTS: Fourteen studies were included in the final analysis. A total of 740,042 patients were included in the systematic review and network meta-analysis. Mechanical complications were highest among SF patients (OR 2.33, 95% CI 1.86, 2.92, p < 0.05), followed by AS patients (OR 1.18, 95% CI 0.87, 1.61, p = 0.82) compared to controls. Long Spinal Fusions had the highest aseptic loosening (OR 2.33, 95% CI 1.83, 2.95, p < 0.05), dislocations (OR 3.25, 95% CI 2.58, 4.10, p < 0.05), infections (OR 2.14, 95% CI 1.73, 2.65, p < 0.05), and revisions (OR 5.25, 95% CI 2.23, 12.32, p < 0.05) compared to AS and controls. Our results suggested that SF with longer constructs may be associated with higher complications in THA patients. CONCLUSIONS: THAs following SFs have higher mechanical complications, aseptic loosening, dislocations, and infections, especially with longer constructs. AS patients may have fewer complications compared to this cohort.

Risk of intraoperative floppy iris syndrome among selective alpha-1 blockers-A consistency model of 6,488 cases.

Selective α1-blockers are commonly administered to patients with lower urinary tract syndrome and benign prostatic hyperplasia, but may increase the risk of intraoperative floppy iris syndrome (IFIS). The purpose of this study aimed to clarify the risk of IFIS among various selective α1-blockers. Four databases were searched for prospective studies comparing alpha-1-antagonists. Data were pooled using the consistency model, and used risk ratio (RR) and mean difference (MD) for IFIS and pupil diameter, respectively. This study finally included 25 prospective comparative studies. Based on 51 direct comparisons with 6488 cases, risks of IFIS in patients who received tamsulosin [RR, 13.85; 95% confidence interval (CI): 7.34 to 26.11], terazosin (RR, 8.94; 95% CI 2.88 to 27.74), alfuzosin (RR, 7.73; 95% CI: 3.05 to 19.62), and doxazosin (RR, 3.88; 95% CI: 1.13 to 13.28) were significantly higher than those did not receive α1-antagonists. Based on 11 direct comparisons with 564 cases, as compared to no α1-antagonists, patients who received tamsulosin (MD, -0.36; 95% CI: -0.71 to -0.01) and alfuzosin (MD, -0.34; 95% CI: -0.62 to -0.07) showed smaller pupil diameter under mesopic light levels, while those received silodosin did not show significantly smaller mesopic pupil diameter than people without α1-antagonists. IFIS seems to be inevitable with the usage of α1-antagonists, and tamsulosin needs to be cautious due to the significantly higher risk of severe IFIS. With regard to silodosin, there is no strong evidence to support the uses of italthough it does not significantly decrease mesopic pupil diameter.

Comparative Risks of Fracture Among Direct Oral Anticoagulants and Warfarin: A Systematic Review and Network Meta-Analysis.

Importance: Previous studies have shown the effectiveness and safety of direct oral anticoagulants (DOACs), including lower fracture risks, compared to warfarin. However, direct or indirect comparisons between different DOACs are scarce in the literature. Objective: This study aims to compare fracture risks among different DOACs and warfarin, including apixaban, rivaroxaban, dabigatran, and edoxaban, in patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE). Methods: We searched PubMed/MEDLINE, Embase, Cochrane CENTRAL, and Web of Science for randomized controlled trials and cohort studies comparing the fracture risks among patients who used warfarin or DOACs, up to March 2021. Two authors extracted data and appraised the risk of bias of included studies. The primary outcome was fracture risk. We performed pairwise meta-analyses to compare differences between medications and network meta-analyses using frequentist random-effects models to compare through indirect evidence. We used surface under the cumulative ranking curve (SUCRA) and mean ranks to determine the probability of a DOAC ranking best in terms of fracture risk. Results: Thirty-one studies were included in the final analysis. Twenty-four randomized controlled trials and seven cohort studies with 455,343 patients were included in the systematic review and network meta-analysis. Compared to warfarin, the risk of any fractures was lowest with apixaban [relative risk (RR) = 0.59; 95% confidence interval (CI): 0.48-0.73], followed by rivaroxaban (RR: 0.72; 95% CI: 0.60-0.86), edoxaban (RR: 0.88; 95% CI: 0.62-1.23), and dabigatran (RR = 0.90; 95% CI: 0.75-1.07). No substantial inconsistency between direct and indirect evidence was detected for all outcomes. Conclusions: All DOACs were safer than warfarin concerning the risk of fracture; however, apixaban had the lowest relative risk of fracture within the class of DOACs. Further head-to-head prospective studies should confirm the comparative safety profiles of DOACs regarding fractures.

Does Direct Surgical Repair Benefit Pars Interarticularis Fracture? A Systematic Review and Meta-analysis.

BACKGROUND: Promising results have been shown in previous studies from direct pars interarticularis repair. These include Scott wiring, Buck repair, pedicle screw repair, and Morscher techniques. In addition, several minimally invasive techniques have been reported to show high union rates, low rates of implant failure and wound complications, shorter length of stay, a lower postoperative pain score with faster recovery, and minimal blood loss. OBJECTIVES: To compare the evidence on techniques for direct pars interarticularis repair. STUDY DESIGN: Systematic review and meta-analysis. SETTING: Review article. METHODS: We conducted a comprehensive search of databases to identify studies assessing outcomes of direct pars interarticularis defect repair. Two authors independently screened electronic search results, performed study selection, and extracted data for meta-analysis. Sensitivity and subgroup analyses were performed to assess risk of bias. RESULTS: Forty studies were included in the final analysis. Union rate was higher in the pedicle screw repair group (effect size [ES] 95%; 95% CI, 86% to 100%), followed by the Buck repair group (ES 93%; 95% CI, 86% to 98%), Scott wiring (ES 85%; 95% CI, 63% to 99%), and Morscher method group (ES 63%; 95% CI, 2% to 100%). Positive functional outcome was higher for the Morscher method (ES 91%; 95% CI, 86% to 96%), followed by the Buck repair group (ES 85%; 95% CI, 68% to 97%), pedicle screw repair (ES 84%; 95% CI, 59% to 99%) and Scott repair group (ES 80%; 95% CI, 60% to 95%). Complication rates were highest among the Scott repair group (ES 12%; 95% CI, 4% to 22%) and Morscher method group (ES 12%; 95% CI, 0% to 34%). LIMITATIONS: Heterogeneity of the included studies were noted. However, we performed sensitivity analyses from the available data to address this issue. CONCLUSION: Our results indicate that pedicle screw repair and Buck repair may be associated with a higher union rate and lower complication rates compared to the Scott repair and Morscher method. Ultimately, the choice of technique should be based on the surgeon's preference and experience.

Does Surgical Repair Benefit Pipkin Type I Femoral Head Fractures?: A Systematic Review and Meta-Analysis.

Background: Femoral head fractures are rare injuries with or without traumatic dislocations. The management of these fractures is crucial to prevent the development of severe complications and to achieve optimal functional outcomes. Wide treatment options for Pipkin 1 femoral head fractures range from fragment excision, fixation following open reduction with internal fixation, or conservative treatment such as close reduction alone after fracture dislocation. However, the best decision making remains controversial not only due to lack of large trials, but also inconsistent results reported. Therefore, we aim to compare the operative with nonoperative outcomes of Pipkin type 1 patients. Patients and Methods: We systemically searched MEDLINE, EMBASE, Cochrane library, In-Process & Other Non-Indexed Citations to identify studies assessing outcomes of Pipkin type 1 patients after conservative treatment, and open reduction with excision or fixation. Data on comparison of clinical outcomes of each management were extracted including arthritis, heterotopic ossification (HO), avascular necrosis (AVN), and functional scores (Thompson Epstein, Merle' d Augine and Postel Score). We performed a meta-analysis with the available data. Results: Eight studies (7 case series and 1 RCT) were included in this study. In a pooled analysis, the overall rate of arthritis was 37% (95% CI, 2-79%), HO was 20% (95% CI, 2-45%), and AVN was 3% (95% CI, 0-16%). In comparison of management types, the excision group reached the best functional outcomes including Thompson Epstein Score (poor to worse, 9%; 95% CI, 0-27%) and Merle d' Aubigne and Postel Score (poor to worse, 18%; 95% CI, 3-38%); ORIF group had the highest AVN rate (11%; 95% CI, 0-92%); conservative treatment had the highest arthritis rate (67%; 95% CI: 0-100%) and lowest HO rate (2%; 95% CI, 0-28%). Discussion: This meta-analysis demonstrates that different procedures lead to various clinical outcomes: fragment excision may achieve better function, conservative treatment may result in a higher arthritis rate, while ORIFs may have a higher AVN rate. These findings may assist surgeons in tailoring their decision-making to specific patient profiles. Future RCTs with multicenter efforts are needed to validate associations found in this study. Level of Evidence: II, systematic review and meta-analysis.

Fat Embolism Syndrome and in-Hospital Mortality Rates According to Patient Age: A Large Nationwide Retrospective Study.

Introduction: Fat embolism syndrome (FES) is a rare life-threatening condition that can develop after traumatic orthopedic injuries. Controversy remains concerning the epidemiology in the elderly population. Therefore, this study aims to report FES related to in-hospital mortality stratified by age. Methods: A retrospective trauma cohort study was conducted using data from the National Trauma Data Bank (NTDB) from 2007 to 2014. All FES cases were included in the study with the diagnosis of FES (ICD9 958.1). Death on arrival cases were excluded. Patients were stratified by age cohort: less than 40 (G1), 40-64 (G2), and greater than 65 (G3) years of age. The primary outcome evaluated was in-hospital mortality. Multivariable regression models were performed to adjust for potential confounders. Results: Between 2007 and 2014, 451 people from a total of 5,836,499 trauma patients in the NTDB met the inclusion criteria. The incidence rate was 8 out of 100,000. The inpatient mortality rate was 11.8% for all subjects with the highest mortality rate of 17.6% in patients over 65. Multivariable analyses demonstrated that age greater than 65 years was an independent predictor of mortality (aOR 24.16, 95% CI 3.73, 156.59, p=0.001), despite higher incidence and injury severity of FES among patients less than 40. No significant association with length of hospital stay, length of intensive unit care, or length of ventilation use was found between the groups. Subgroup analysis of the elderly population also showed a higher mortality rate for FES in femoral neck fracture patients (18%) than other femoral fractures (14%). Conclusion: In this retrospective cohort analysis, old age (≥ 65 years) was found to be an independent risk factor for in-hospital mortality among fat embolism syndrome patients. Elderly patients specifically with femoral neck fractures should be monitored for the development of FES.

The analgesic effect of intravenous lidocaine versus intrawound or epidural bupivacaine for postoperative opioid reduction in spine surgery: A systematic review and meta-analysis.

BACKGROUND: Pain management following spine surgery remains a challenge. The significant use of opioids may lead to opioid-related adverse events. These complications can increase perioperative morbidity and rapidly expend health care resources by developing chronic pain. Although intraoperative pain control for surgery has been studied in the literature, a thorough assessment of the effect in spine surgery is rarely reported. The objective of the present study was to examine the outcomes of intraoperative intravenous lidocaine and intrawound or epidural bupivacaine use in spine surgery. METHODS: An electronic literature search was conducted for studies on the use of lidocaine and bupivacaine in spine surgery for all years available. Only articles in English language were included. Postoperative opioid consumption, VAS score, nausea/vomiting, and length of hospital stay comprised the outcomes of interest. Pooled descriptive statistics with Risk Ratios (RR), Mean Differences (MD) and 95 % confidence interval were used to synthesize the outcomes for each medication. RESULTS: A total of 10 studies (n = 579) were included in the analysis. Comparison of the opioid consumption revealed a significant mean difference between lidocaine and bupivacaine (MD: -12.25, and MD: -0.4, respectively, p = 0.01), favoring lidocaine. With regard to postoperative VAS, the pooled effect of both groups decreased postoperative pain (MD: -0.61 (95 % CI: -1.14, -0.08)), with a more significant effect in the lidocaine group (MD: -0.84, (95 % CI: -1.21, -0.48)). There was no significant effect in length of stay, and postoperative nausea/vomiting. CONCLUSIONS: The results of the present meta-analysis indicate that lidocaine and bupivacaine use may decrease postoperative pain and opioid consumption. Lidocaine had a stronger effect on the reduction of opioid consumption compared to bupivacaine.

Distal femur fractures have a higher mortality rate compared to hip fractures among the elderly: Insights from the National Trauma Data Bank.

INTRODUCTION: The comparison of mortality and morbidity between distal femur (DF) and hip fracture in the old age is rarely reported in the literature. We aim to analyze a nationwide database among the elderly to compare the outcomes between hip fractures and distal femur fractures in the United States. MATERIALS AND METHODS: A retrospective analysis of the National Trauma Data Bank was queried between 2007-2014 to identify distal femur (DF) and hip fracture patients greater than 65 years of age. Outcomes analyzed included in-hospital mortality, total hospital length of stay(LOS), intensive care unit length of stay(ICU-LOS), length of ventilation use and hospital discharge disposition. Multivariable regression models were performed to adjust for potential confounders. Statistical significance was established at p < 0.001. RESULTS: 26,325 (10.1%) and 233,213 (89.9%) patients reported a diagnosis of DF and hip fracture, respectively. The inpatient mortality rate was significantly higher in the distal femur fracture group (8.3% vs. 6.7%), with significantly longer LOS (7.87 vs. 6.65), ICU-LOS (1.50 vs. 0.73), and required ventilation days (0.74 vs. 0.27). Multivariable analyses demonstrated that hip fracture patients had a lower mortality (adjusted odds ratio [aOR], 0.80; 95% CI [0.76, -0.85]; p < 0.001), shorter LOS ([aOR], -0.31; 95% CI [-0.39, -0.23]; P < 0.001), and more likely to be discharged home ([aOR], 0.88; 95% CI, 0.85, 0.91; P < 0.001, compared to DF fracture patients. CONCLUSION: After adjusting for potential factors, DF fracture patients have a significantly higher mortality, longer LOS, and less likely to be discharged home compared to hip fractures among the elderly. These results may suggest clinicians and caregivers for closely monitoring of clinical conditions for these patients. LEVEL OF EVIDENCE: III.