Intramedullary versus plate fixation of both bone forearm fractures in skeletally immature patients: a systematic review and meta-analysis.

BACKGROUND: Both bone forearm fractures (BBFFs) are a common injury amongst the pediatric population. The main indications of surgical fixation are open, irreducible, or unstable fractures. The two most commonly used surgical techniques are closed or open reduction with intramedullary fixation (IMF) and open reduction with plate fixation (PF). The aim of this systematic review and meta-analysis was to determine which fixation method is superior for BBFFs. METHODS: PubMed, Scopus, Web of Science, and CENTRAL were searched to identify studies comparing IMF and PF. We extracted data on union rates, complications, early hardware removal rates, reoperation rates, and radiographic, clinical, and perioperative outcomes. RESULTS: Sixteen studies were included in the analysis, with a total of 922 patients (539 IMF and 383 PF). Similar union rates were achieved by both fixation technique. IMF was associated with a higher incidence of symptomatic hardware, and early hardware removal. Better restoration of the radial bow was observed with the PF group, especially in older children and adolescents. The rate of excellent function was comparable between groups, whereas better cosmesis was reported with the IMF group. Despite shorter fluoroscopy time and immobilization time, PF demonstrated longer tourniquet time, operating time, and hospital stay compared to IMF. CONCLUSIONS: We found no significant difference between IMF and PF in terms of union rates and functional outcomes taking in consideration the merits and demerits of each technique. High-quality randomized controlled trials are, therefore, necessary to determine the superiority of one fixation technique over the other. LEVEL OF EVIDENCE: III.

Comparison of the clinical and radiological outcomes of Puddu and TomoFix plates for medial opening-wedge high tibial osteotomy: A two-year follow-up of a randomized controlled trial.

PURPOSE: Opening-wedge high tibial osteotomy (OWHTO) requires fixation devices for stabilization of the osteotomy gap. The two most commonly used fixation devices are the Puddu and the TomoFix plates. Based on its design, each implant generates a characteristic stability profile. The aim of this randomized controlled trial (RCT) was to investigate the short-term clinical and radiological outcomes of OWHTO using the Puddu and TomoFix plating systems. We hypothesized that the TomoFix plate would achieve superior clinical and radiographic results compared to the Puddu plate. METHODS: A total of 60 patients were randomly allocated to undergo OWHTO either using the Puddu plate or the TomoFix plate if conservative treatment failed with symptomatic medial compartment knee osteoarthritis (OA) stage I or II according to Ahlbäck classification, and varus malalignment. All patients underwent clinical and radiological assessment preoperatively, and at 3, 6, 12, and 24months postoperatively. Radiological measurement of the hip-knee-ankle (HKA) angle, and posterior tibial slope (PTS) was performed. Functional assessment was carried out using the Hospital for Special Surgery Knee-Rating Scale (HSS) and the Western Ontario McMaster Universities (WOMAC) Osteoarthritis Index. Patients were also evaluated for intraoperative and postoperative complications throughout the follow-up period. RESULTS: The mean angular correction was 9.6±4°, and 10.5±4.8° in the Puddu and TomoFix groups, respectively (p=0.488). The mean PTS change was significantly higher in the Puddu group (3.4±1.1°) compared to the TomoFix group (0.8±0.7°) (p<0.001). There was a statistically significant improvement in the mean HSS and WOMAC in both groups until one year postoperatively. Neither HSS nor WOMAC showed a statistically significant difference between the Puddu and TomoFix groups at any time during the first two postoperative years. The overall complication rate was not significantly different between the Puddu and TomoFix groups. However, the TomoFix group demonstrated higher incidence of symptomatic hardware (23% vs. 3.3%) and removal of metalwork (17% vs. 0%) than the Puddu group (p=0.023 and 0.020, respectively). CONCLUSION: This RCT suggests that the implant choice for OWHTO has no significant impact on functional outcomes during the first 2years postoperatively. While the Puddu plate was associated with an unintentional increase in the PTS during the surgery, both implants allowed coronal and sagittal plane corrections to be preserved postoperatively. The overall complication rates were similar, but the TomoFix required more material to be removed because it is more cumbersome. However, these results need to be confirmed on a larger scale. LEVEL OF EVIDENCE: II; randomized controlled trial.

Superior survivorship and plate-related results of TomoFix compared to Puddu plate fixation for opening-wedge high tibial osteotomy: A systematic review of the literature.

PURPOSE: This systematic review aimed to compare survivorship and plate-related results of Puddu and TomoFix plates in opening-wedge high tibial osteotomy (OWHTO). METHODS: PubMed, Scopus, EMBASE, and CENTRAL databases were searched from January 2000 until September 2021 for clinical studies involving patients with medial compartment knee disease and varus deformity undergoing OWHTO using the Puddu or TomoFix plating systems. We extracted survival data, plate-related complications, and functional and radiological outcomes. The risk of bias assessment had been carried out using Cochrane Collaboration's quality assessment tool for randomised controlled trials (RCTs) and Methodological Index for Non-Randomised Studies (MINORS). RESULTS: Twenty-eight studies were included. The total number of knees was 2568 in 2372 patients. The Puddu plate was used in 677 knees, while the TomoFix plate was used in 1891. The follow-up ranged from 5.8 to 147.6 months. Both plating systems were able to delay conversion to arthroplasty at different follow-up intervals. However, osteotomies fixed by the TomoFix plate achieved higher survival rates, especially at mid-term and long-term follow-ups. In addition, fewer complications were reported with the TomoFix plating system. Although both implants achieved satisfactory functional outcomes, high scores could not be maintained throughout long-term intervals. Regarding radiological results, TomoFix plate was able to achieve and maintain larger degrees of varus deformity, while preserving the posterior tibial slope. CONCLUSIONS: This systematic review demonstrated the superiority of the TomoFix over the Puddu system as a safer and more effective fixation device in OWHTO. Nevertheless, these results should be interpreted with caution due to the lack of comparative evidence through high-quality RCTs.

Dorsal bridge plating versus bridging external fixation for management of complex distal radius fractures.

INTRODUCTION: Distal radius fractures are the most frequent upper limb injuries encountered by orthopedic surgeons. Surgical treatment of distal radius fractures is preserved for unstable and displaced fractures. A randomized controlled trial was conducted to compare the radiological and functional outcomes of bridge plating (BP) to external fixation (EF) in comminuted intra-articular distal radius fractures. METHODS: Sixty patients with distal radius fractures were eligible for treatment by means of ligamentotaxis using either a dorsal bridge plate (30 patients) or an external fixator (30 patients) with or without supplementary Kirschner wires (K-wires). Radiological evaluation was done using the radial inclination angle, radial length, and the volar tilt. Clinical evaluation was performed using ranges of wrist motion, grip strength, Visual Analogue Scale (VAS), and a validated Arabic version of the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire RESULTS: Patients were followed up for 12 months. No significant difference was found in terms of radiographic parameters or ranges of wrist motion. At 3-months follow-up, bridge plating group had stronger grip strength, lower Disability of the Arm, Shoulder, and Hand scores, and lower Visual Analogue Scale. However, both groups had similar functional outcomes at last follow-up. External fixation group had a higher rate of postoperative complications. CONCLUSION: In comparison to external fixation, bridge plating may provide earlier functional recovery with lower complication rates. However, no functional or radiological superiority were demonstrated at 12-months follow-up.

Long- versus short-segment fixation with an index vertebral screw for management of thoracolumbar fractures.

The choice of the best stabilization technique for thoracolumbar fractures remains controversial. While LSF includes too many motion segments, SSF is associated with a high rate of fixation failure and subsequent loss of kyphotic correction. Our objective is to compare the surgical, clinical, and radiological outcomes of thoracolumbar spine fixation using long-segment fixation (LSF) versus short-segment fixation (SSF) with a screw in the fractured vertebra. We retrospectively evaluated 63 patients with single- level thoracolumbar fracture types A and B treated during the period between 2010 and 2017 in our institution. Group A (30 patients) was treated by SSF with an intermediate screw in the fractured vertebra, while group B (33 patients) was treated by LSF. Both groups were compared in terms of surgical, clinical, and radiological outcomes. The mean operative blood loss was significantly lower in group A than in group B (451.3 ± 79.9 and 690 ± 92.1 ml, respectively). The mean operative time in Group A was significantly shorter than in group B (58.4 ± 14.8 and 81.5 ± 12.3 minutes, respectively). Both groups achieved a similar Visual Analogue Scale (VAS) for pain and Oswestry Disability Index (ODI) score. No significant difference was found as regards the kyphotic angle correction and the correction loss at final follow-up. In conclusion, SSF with a screw in the fractured vertebra achieved comparable functional and radiological outcomes to LSS with less blood loss and operative time.

Efficacy and safety of monopolar versus bipolar radial head arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Radial head replacement is the main line of treating complex unstable elbow injuries. Radial head prostheses are either monopolar or bipolar. The difference between both designs in patients' clinical outcomes and postoperative complications is not yet clear. So, a systematic review and meta-analysis was conducted to evaluate the efficacy and safety of monopolar vs. bipolar implants. MATERIALS AND METHODS: PubMed, EMBASE, Cochrane, and Scopus were searched to identify studies comparing monopolar and bipolar implants. Data on clinical outcomes, postoperative complications, revision, and removal rates were extracted. RESULTS: Nine studies met our inclusion criteria, with a total of 591 patients (365 monopolar and 226 bipolar). Both prostheses achieved similar ranges of motion; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder, and Hand score; and visual analog scale for pain. Incidence of postoperative complications was also similar between both designs. Revision and removal rates were 24%, 8% and 29%, 14% for monopolar and bipolar implants, respectively, but no statistically significant difference could be detected. CONCLUSIONS: No significant difference was found between monopolar and bipolar radial head prostheses in terms of efficacy and safety. Therefore, high-quality randomized controlled trials are required to determine the superiority of one design over the other.

Posterolateral Fusion Versus Posterior Lumbar Interbody Fusion: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: Arthrodesis has been a valid treatment option for spinal diseases, including spondylolisthesis and lumbar spinal stenosis. Posterolateral and posterior lumbar interbody fusion are amongst the most used fusion techniques. Previous reports comparing both methods have been contradictory. Thus, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to establish substantial evidence on which fusion method would achieve better outcomes. METHODS: Major databases including PubMed, Embase, Web of Science and CENTRAL were searched to identify studies comparing outcomes of interest between posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF). We extracted data on clinical outcome, complication rate, revision rate, fusion rate, operation time, and blood loss. We calculated the mean differences (MDs) for continuous data with 95% confidence intervals (CIs) for each outcome and the odds ratio with 95% confidence intervals (CIs) for binary outcomes. P < 0.05 was considered significant. RESULTS: We retrieved 8 studies meeting our inclusion criteria, with a total of 616 patients (308 PLF, 308 PLIF). The results of our analysis revealed that patients who underwent PLIF had significantly higher fusion rates. No statistically significant difference was identified in terms of clinical outcomes, complication rates, revision rates, operation time or blood loss. CONCLUSIONS: This systematic review and meta-analysis provide a comparison between PLF and PLIF based on RCTs. Although PLIF had higher fusion rates, both fusion methods achieve similar clinical outcomes with equal complication rate, revision rate, operation time and blood loss at 1-year minimum follow-up.

Correlation of radiographic parameters with clinical correction in idiopathic congenital talipes equinovarus undergoing Ponseti treatment.

PURPOSE: Idiopathic congenital talipes equinovarus is the most commonly encountered congenital deformity of the foot. Ponseti technique of manipulation is the treatment of choice. The Pirani classification is a reliable scoring system for clinical evaluation of clubfeet. The role of radiographic parameters in the evaluation and treatment of clubfeet is still controversial. The aim of this study was to evaluate the correlation of radiological parameters with clinical correction in patients with idiopathic clubfeet undergoing correction using Ponseti method. METHODS: Between March 2018 and March 2019, 42 feet in 27 patients with idiopathic clubfeet were treated in our hospital. We used the Pirani scoring system for clinical evaluation. Anteroposterior and lateral views of the feet were taken before and after correction and at the last follow-up. The anteroposterior view was evaluated for the talocalcaneal angle and talo-first metatarsal angle, while the lateral view was only evaluated for the talocalcaneal angle. RESULTS: Twelve were boys (44.4%), and 15 were girls (55.6%). The deformity was bilateral in 15 patients (55.6%) and unilateral in 12 patients (44.4%). The average age was three months. According to the Pirani score, the mean Pirani Total score was 4.4 before correction and reduced to 0.4 after correction. The mean talocalcaneal angle in anteroposterior and lateral views was 15.1° and 7.8° before correction, increased to 32.7° and 31.8° after correction, respectively. The mean talocalcaneal index increased from 23.2 before correction to 64.5 after correction. The mean talo-first metatarsal angle in anteroposterior view improved from 25.7° before correction to - 1.6° after correction. The relation between the differences in Pirani scores before and after correction and the differences in measured radiographic parameters before and after correction revealed a statistically significant correlation. CONCLUSION: Radiographic parameters showed a statistically significant correlation with the clinical outcome. Thus, evaluation of clubfeet correction treated by Ponseti technique can rely mainly on clinical scores with limited utilization of radiological assessment.

Radial shortening, bone grafting and vascular pedicle implantation versus radial shortening alone in Kienböck's disease.

We prospectively compared outcomes of two surgical procedures for Stage II and IIIa Kienböck's disease with negative ulnar variance. Group I (13 wrists) was treated with radial shortening alone, and Group II (14 wrists) with combined radial shortening, bone grafting and implantation of a vascular pedicle. At follow-up 3 to 7 years (mean 4.5) after operation, scores by the Quick version of the Disability of Arm, Shoulder and Hand questionnaire and scores for pain and grip strength were significantly better in Group II, but the differences were rather small. On MRI all patients in Group II had revascularization, but 11 patients in Group I had not. We conclude that combining radial shortening with the revascularization procedure improved revascularization. Clinically, both treatments were efficient, and the additional bone grafting and vascular pedicle insertion did not greatly improve function, although statistically there were differences in several follow-up variables. This study also could not identify the independent role of the three procedures (drilling, grafting and artery insertion) in Group II, because decompression or bone grafting alone may be effective.Level of evidence: II.

Technical Note on Using Intraoperative Smartphone Applications to Adjust Cup Inclination Angle during Total Hip Arthroplasty (THA).

Acetabular cup optimum position is paramount for total hip arthroplasty (THA) good outcomes. Although controversial, Lewinnek proposed safe zone for cup placement still the most widely accepted target. Cup placement can be improved using specific anatomical landmarks, computer navigation system and handheld navigation devices. As using a smartphone on daily bases became popular among orthopedic surgeons, in this technical note, we describe how to use smartphone specific applications intraoperatively during total hip arthroplasty to adjust cup inclination angle, which we believe to be easy, cheap and beneficial for young less experienced surgeons.

Reconstruction of complex hand defects using trapezoidal osteocutaneous free fibular flap.

BACKGROUND: Traumatic defects of multiple metacarpal bones can be addressed using conventional or vascularized bone grafts. When associated with extensive skin and tendon loss, the treatment becomes more challenging. The aim of the study was to describe the results of using free osteocutaneous fibular flap placed in a new fashion for the reconstruction of complex hand defects. PATIENTS AND METHODS: Six patients with complex hand defects underwent reconstruction using free osteocutaneous fibular flap placed in trapezoidal fashion with two-stage tendon reconstruction using fascia lata graft. The mean age at the time of injury was 34.7 years (range: 14-54 years). The injury was caused by motor vehicle accident in four patients, machine injury in one patient, and falling from height in one patient. All patients had extensive three or four metacarpal bones defects, segmental loss of tendons, and large skin defect ranging from 6 × 10 cm to 10 × 15 cm. The fibular graft was divided into three segments and positioned in a trapezoidal fashion with the middle bone segment placed transversely to support the bases of the proximal phalanges while the first and third bone segments were placed obliquely along the metacarpal axis converging toward the remaining metacarpal bases and/or carpal bones. At final follow-up visit, the finger range of motion was assessed using the total active motion (TAM) scoring system. Functional outcome was evaluated by the disabilities of the arm, shoulder and hand (DASH) score. Active range of motion (AROM) of the pseudo-metacarpophalangeal (MP) joint was measured. The handgrip strength was measured using Jamar hydraulic dynamometer. RESULTS: The mean length of the harvested fibular graft was 18 cm (range: 17-19). The mean size of the skin paddle was 7.5 × 13.1 cm (range: 6 × 10 cm to 10 × 15 cm). Fibular flaps survived in all patients. The mean follow-up period was 30.8 months (range: 24-40 months). The mean time to achieve bone healing was 3.8 months (range: 3-5 months). The mean TAM was 185° (range: 165-204°) and TAM percentage was described as excellent in two patients and good in four patients. The mean AROM at the pseudo-MP joint was 53.8° (range: 42-70°). The mean injured handgrip strength was 27.3 kg (range: 23-31 kg) and the mean grip strength ratio was 74.8% (range: 69-80%). The mean DASH score was 19.6 (range: 11.67-26.67). Pin tract infection, partial skin paddle necrosis, and wound infection were reported. CONCLUSION: The fibular osteocutaneous flap arranged in trapezoidal fashion is a viable choice for the reconstruction of complex hand defects, particularly when the metacarpophalangeal joints are not preserved.

Reprogramming of gene expression during compression wood formation in pine: coordinated modulation of S-adenosylmethionine, lignin and lignan related genes.

BACKGROUND: Transcript profiling of differentiating secondary xylem has allowed us to draw a general picture of the genes involved in wood formation. However, our knowledge is still limited about the regulatory mechanisms that coordinate and modulate the different pathways providing substrates during xylogenesis. The development of compression wood in conifers constitutes an exceptional model for these studies. Although differential expression of a few genes in differentiating compression wood compared to normal or opposite wood has been reported, the broad range of features that distinguish this reaction wood suggest that the expression of a larger set of genes would be modified. RESULTS: By combining the construction of different cDNA libraries with microarray analyses we have identified a total of 496 genes in maritime pine (Pinus pinaster, Ait.) that change in expression during differentiation of compression wood (331 up-regulated and 165 down-regulated compared to opposite wood). Samples from different provenances collected in different years and geographic locations were integrated into the analyses to mitigate the effects of multiple sources of variability. This strategy allowed us to define a group of genes that are consistently associated with compression wood formation. Correlating with the deposition of a thicker secondary cell wall that characterizes compression wood development, the expression of a number of genes involved in synthesis of cellulose, hemicellulose, lignin and lignans was up-regulated. Further analysis of a set of these genes involved in S-adenosylmethionine metabolism, ammonium recycling, and lignin and lignans biosynthesis showed changes in expression levels in parallel to the levels of lignin accumulation in cells undergoing xylogenesis in vivo and in vitro. CONCLUSIONS: The comparative transcriptomic analysis reported here have revealed a broad spectrum of coordinated transcriptional modulation of genes involved in biosynthesis of different cell wall polymers associated with within-tree variations in pine wood structure and composition. In particular, we demonstrate the coordinated modulation at transcriptional level of a gene set involved in S-adenosylmethionine synthesis and ammonium assimilation with increased demand for coniferyl alcohol for lignin and lignan synthesis, enabling a better understanding of the metabolic requirements in cells undergoing lignification.

Prognosis prediction of uterine torsion mechanical treatment (rolling) after estimation of calcium and creatinine level in the serum of buffaloes (bubalus bubalis).

The present study was carried out to investigate the relationship between creatinine and calcium concentration in buffalo serum in cases of uterine torsion before rolling, and 1 h and 24 h after calving. The degree, duration and site of uterine torsion, as well as fetus viability, time needed for cervical dilation, and the occurrence of uterine rupture were recorded. A total of 150 pregnant buffaloes suffering from colic and anorexia were brought to our clinic and clinically examined. Of these, 35 buffaloes were diagnosed with uterine torsion (different durations, directions and degrees) and the viability of the foeti and any evidence of uterine rupture were determined using ultrasonography and the serum levels of creatinine and calcium were estimated using calorimetric method. The animals were also examined for incidence of uterine rupture after rolling and calving. The calcium level significantly (P < 0.05) decreased with increasing duration and severity of uterine torsion, however, it was higher in cases where a live fetus was delivered compared with a dead one. Conversely, the creatinine level significantly (P < 0.05) increased with increasing duration and severity of uterine torsion but was lower in cases that delivered a live fetus compared with a dead one. The calcium and creatinine levels returned to approximately normal concentration within 24 h after calving. In conclusion, calcium and creatinine serum concentration have a correlation with duration and severity of uterine torsion. Animals with low levels of calcium (below 8.44 mg/dL) and high levels of creatinine (above 2.25 mg/dL) did not usually respond to rolling or suffer from uterine rupture during calving. The calcium and creatinine levels can be used as indicators for the prognosis of mechanical treatment of uterine torsion in buffaloes.

Influence of vitamin C supplementation on lead-induced histopathological alterations in male rats.

This study is intended to evaluate the efficacy of vitamin C (VC) in ameliorating the detrimental effects of long-term lead intoxication on the liver, kidneys, brain and testes as assessed by histopathology. A total of forty male Wistar rats (six-weeks-old) was divided into 4 groups: control group; lead-acetate (PbAc)-treated group (20 mgPbAc/kgbwt); PbAc+VC-treated group (20 mgPbAc/kgbwt plus 20 mg VC/kgbwt); and VC-treated group (20 mgVC/kgbwt). The Experimental period was lasted for 60 successive days in which PbAc was administered once daily while VC was supplemented every other day using intra-gastric intubation. At the end of the experimental period, all rats were sacrificed and pathological examinations were performed. Control and VC-supplemented rats showed normal liver, kidney, brain, and testes histology. In contrast, the liver of PbAc-intoxicated rats exhibited degenerated hepatocytes and portal inflammatory cell infiltrations. The kidneys showed degenerated glomeruli and formation of karyomegalic cells containing intranuclear inclusions in the proximal tubular epithelium. Cerebellar edema, cerebral satellitosis and encephalomalacia observed in the brain. Testicular tissues showed arrest of spermatogenesis and interstitial edema. Co-administration of VC with PbAc diminished the severity of pathological changes and reduced the number of affected organs compared to PbAc-intoxicated rats. These results show that low level of VC ameliorated and mitigated the adverse pathological impacts of chronic lead toxicity.