The efficacy of pediatric elbow radiographic guidance in diagnosis of lateral humeral condyle fracture.

Although lateral humeral condyle fracture is common, the incidence of missed diagnosis is very high. Delayed and missed diagnosis led to significant morbidities and loss of functions. We designed a pediatric elbow radiographic guidance aiming to improve the accuracy of diagnosis. This study was aimed to evaluate the efficacy of the radiographic guidance for the diagnosis of lateral condyle fracture. A cross-sectional study was conducted after defining the essential parameters as a guidance for assessing the pediatric elbow radiographs. We included medical students, emergency medicine, orthopedic, and radiology residents and fellows into this study. A questionnaire was used to evaluate the efficacy of the guidance. All participants underwent a pretest evaluation, followed by studying the guidance, and then finished a posttest evaluation. Baseline characteristics, diagnostic scores, and parameter evaluation scores were collected. The pretest and posttest scores were analyzed using paired t-test. Association between baseline characteristics and diagnostic scores were analyzed using multiple regression analysis. We included 177 participants. Average diagnostic score was significantly increased after using the guidance, from 12.2 ± 1.9 to 13.0 ± 1.7 (p < 0.0001). Medical students showed the most improvement, from 11.9 ± 1.9 to 13.1 ± 1.3 (p <0.001). All means of essential parameter evaluation scores were significantly improved in overall participants.The pediatric elbow radiographic guidance is useful for evaluation and diagnosis of lateral condyle fracture, especially for young physicians and trainees. Therefore, this should be recommended in routine medical education and general practice.

Effect of knee bracing on clinical outcomes following anterior cruciate ligament reconstruction: A prospective randomised controlled study.

Objectives: While there is a consensus against bracing after anterior cruciate ligament (ACL) reconstruction, the question of its potential benefits, especially in cases involving meniscus repair, as well as its routine use by the majority of clinicians, remains a topic of debate. This study aims to assess the effectiveness of bracing in relation to clinical scores after ACL reconstruction, regardless of meniscus surgery. Methods: This randomised controlled study involved patients aged 15-55 years who underwent arthroscopic ACL reconstruction surgery. All eligible patients were assigned into two groups: one group received an adjustable frame with a four-point fixation knee brace for a four-week period, while the other did not.A single experienced surgeon performed standard anatomical single-bundle ACL reconstruction. All patients, irrespective of whether they underwent meniscus repair, followed the same rehabilitation protocol. Knee functional questionnaires, including the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner Activity Scale, Visual Analogue Scale (VAS), and examinations, were collected preoperatively, at six months, one year, and two years postoperatively. The study employed an intention-to-treat analysis and multilevel mixed-effects generalised linear models to compare continuous outcomes between the groups, adjusting for the times of follow-up. Results: A total of 84 patients (42 patients per group) comprised of 75 males (89 %) and average age of 30 ± 9.4 years old. Patient-reported function, physical examination findings, and surgical characteristics were comparable between the two groups. (P-value >0.05) Both groups demonstrated significant improvement in IKDC and Lysholm scores at the end of the two-year follow-up period. (P-value <0.0001) In multivariate analysis, bracing was significantly associated with lower Tegner activity scale than the non-brace group after adjustment for VAS and time (coefficient -0.49, 95 % confidence interval -0.87, -0.10, P-value = 0.013). None of the graft ruptures were reported, and there was no significant difference of return to sports between the groups at the end of the follow-up. Conclusion: The study suggests that knee bracing after ACL reconstruction, regardless of any additional meniscus procedures, fails to enhance subjective or objective outcomes and could potentially have a negative impact on the Tegner activity scale, although the difference is not clinically significant. The routine use of a postoperative brace should be discontinued. Level of evidence: Level I, Randomised controlled trial with no negative criteria.

Which approach of total hip arthroplasty is the best efficacy and least complication?

BACKGROUND: Total hip arthroplasty is as an effective intervention to relieve pain and improve hip function. Approaches of the hip have been exhaustively explored about pros and cons. The efficacy and the complications of hip approaches remains inconclusive. This study conducted an umbrella review to systematically appraise previous meta-analysis (MAs) including conventional posterior approach (PA), and minimally invasive surgeries as the lateral approach (LA), direct anterior approach (DAA), 2-incisions method, mini-lateral approach and the newest technique direct superior approach (DSA) or supercapsular percutaneously-assisted total hip (SuperPath). AIM: To compare the efficacy and complications of hip approaches that have been published in all MAs and randomized controlled trials (RCTs). METHODS: MAs were identified from MEDLINE and Scopus from inception until 2023. RCTs were then updated from the latest MA to September 2023. This study included studies which compared hip approaches and reported at least one outcome such as Harris Hip Score (HHS), dislocation, intra-operative fracture, wound complication, nerve injury, operative time, operative blood loss, length of hospital stay, incision length and VAS pain. Data were independently selected, extracted and assessed by two reviewers. Network MA and cluster rank and surface under the cumulative ranking curve (SUCRA) were estimated for treatment efficacy and safety. RESULTS: Finally, twenty-eight MAs (40 RCTs), and 13 RCTs were retrieved. In total 47 RCTs were included for reanalysis. The results of corrected covered area showed high degree (13.80%). Among 47 RCTs, most of the studies were low risk of bias in part of random process and outcome reporting, while other domains were medium to high risk of bias. DAA significantly provided higher HHS at three months than PA [pooled unstandardized mean difference (USMD): 3.49, 95% confidence interval (CI): 0.98, 6.00 with SUCRA: 85.9], followed by DSA/SuperPath (USMD: 1.57, 95%CI: -1.55, 4.69 with SUCRA: 57.6). All approaches had indifferent dislocation and intraoperative fracture rates. SUCRA comparing early functional outcome and composite complications (dislocation, intra-operative fracture, wound complication, and nerve injury) found DAA was the best approach followed by DSA/SuperPath. CONCLUSION: DSA/SuperPath had better earlier functional outcome than PA, but still could not overcome the result of DAA. This technique might be the other preferred option with acceptable complications.

The knee kinematic patterns and associated factors in healthy Thai adults.

BACKGROUND: Reference values for normal knee kinematics were limited in Asian population and were influenced by race and other factors. This study was aimed to establish the reference values and identify the factors associated with knee kinematics in healthy Thai adults, aged 18-40 years. METHODS: A retrospective cohort study was conducted between 2016 and 2020. Healthy Thai adults aged 18-40 years old with body mass index (BMI) between 18.5 and 24.9 kg/m2 were included. All eligible participants were attached with reflective markers. Their walking was captured by 8-digital cameras, and assessed by motion analysis software. The primary outcomes were average knee kinematic data (degrees) in three dimensional planes as valgus-varus, flexion-extension, and internal-external rotation. Paired t-test and multiple linear regression were applied to compare the outcomes and to determine their associated factors. RESULTS: Ninety-eight participants (60 females and 38 males) were included with mean age 28.5 ± 5.4 years, and BMI 21.1 ± 2.0 kg/m2. Knee kinematics showed slight adduction during the swing phase, flexion during the stance phase, and obvious external rotation throughout the gait cycle, with a peak of 30-31 degrees during mid-swing. Right knee was significantly more adducted, flexed and externally rotated than the left side, particularly at mid-stance (P = 0.047, 0.017, and < 0.001, respectively). Females had more knee abduction, flexion and external rotation than males. Age, sex, and BMI were significantly correlated with knee abduction at terminal stance (correlation coefficient - 0.12, 95% confidence interval (CI) -0.23, -0.01; -1.37, 95%CI -2.54, -0.20; and - 0.32, 95%CI -0.61, -0.39, respectively), and rotation at mid-swing (correlation coefficient - 0.36, 95%CI -0.69, -0.02; -7.37, 95%CI -10.82, -3.92; and 0.89, 95%CI 0.01, 1.78, respectively). CONCLUSION: Knee kinematics demonstrates external tibial rotation throughout the gait cycle, significant side differences, and are associated with age, sex, and BMI. Reference values from this study will be useful for functional gait assessment in healthy Thais. However, further comprehensive knee kinetic study including spatio-temporal parameter is recommended.

Limb occlusion pressure versus standard tourniquet inflation pressure in minor hand surgery: a randomized controlled trial.

BACKGROUND: In minor hand surgery, tourniquet is typically inflated to 250 mmHg. The pressure may be too high and cause unnecessary adverse effects. Limb occlusion pressure plus safety margin or recommended tourniquet pressure (RTP), has been reported as optimal pressure to provide bloodless field in limb surgeries. This study aimed to compare the RTP with the standard tourniquet pressure of 250 mmHg in minor hand surgery. METHODS: A double-blinded randomized control trial was conducted from July to December 2019 and June 2020 to May 2021. Patients were randomly assigned into two groups: RTP and 250 mmHg with 3:1 ratio allocation. The outcomes were measurement of cuff pressure reduction, time to develop of tourniquet pain and discomfort, pain score, discomfort score, motionless and bloodless of operative field determined by the surgeon's satisfaction. RESULTS: A total of 112 patients were included, 84 were in RTP and 28 were in 250 mmHg group. Mean of tourniquet pressure was significantly lower in the RTP group (228.3 ± 17.2 mmHg) (P < 0.001). Even though, time to develop pain was not significantly different, the RTP group reported significantly less pain and discomfort, according to the pain score (P = 0.02) and discomfort score (P = 0.017). The RTP group provided better motionless field, while both groups equally created a bloodless field. CONCLUSION: The RTP significantly reduced tourniquet related pain and discomfort during minor hand surgeries. It provided better motionless operative field and adequate bloodless field. Therefore, the RTP should be considered as optimal tourniquet pressure for minor hand surgeries. TRIAL REGISTRATION: TCTR20210519001 (retrospectively registered). LEVEL OF EVIDENCE: I.

Platelet-rich plasma injection for the treatment of ankle osteoarthritis: a systematic review and meta-analysis.

BACKGROUND: Platelet-rich plasma (PRP) injection for ankle osteoarthritis (OA) treatment showed contradictory results. This review was aimed to pool individual studies which assessed the efficacy of PRP for ankle OA treatment. METHODS: This study was conducted following the preferred report items of systematic review and meta-analysis guideline. PubMed and Scopus were searched up to January 2023. Meta-analysis, or individual randomised controlled trial (RCT), or observational studies were included if they involved ankle OA with aged ≥ 18 years, compared before-after receiving PRP, or PRP with other treatments, and reported visual analog scale (VAS) or functional outcomes. Selection of eligible studies and data extraction were independently performed by two authors. Heterogeneity test using Cochrane Q test and the I2-statistic were assessed. Standardised (SMD) or unstandardised mean difference (USMD) and 95% confidence interval (CI) were estimated and pooled across studies. RESULTS: Three studies from meta-analysis and two individual studies were included, which consisted of one RCT and four before-after studies with 184 ankle OAs and 132 PRP. The average age was 50.8-59.3 years, and 25-60% of PRP injected cases were male. The number of primary ankle OA was accounted to 0-100%. When compared to before treatment, PRP significantly reduced VAS and functional score at 12 weeks with pooled USMD of - 2.80, 95% CI - 3.91, - 2.68; p < 0.001 (Q = 82.91, p < 0.001; I2 96.38%), and pooled SMD of 1.73, 95% CI 1.37, 2.09; p < 0.001 (Q = 4.87, p = 0.18; I2 38.44%), respectively. CONCLUSION: PRP may beneficially improve pain and functional scores for ankle OA in a short-term period. Its magnitude of improvement seems to be similar to placebo effects from the previous RCT. A large-scale RCT with proper whole blood and PRP preparation processes is required to prove treatment effects. Trial registration PROSPERO number CRD42022297503.

Deep vein thrombosis screening in pediatric orthopedic patients.

Background: Deep vein thrombosis (DVT) is an important clinical condition that leads to subsequent morbidity and mortality in children, particularly those who involved operative procedures. The preoperative assessment for DVT in children may vary among different population risk factors and types of surgery. This study aimed to evaluate the screening methods for DVT in pediatric orthopedic patients. Method: We performed a retrospective cohort study of orthopedic patients aged <18 years at Ramathibodi Hospital, Bangkok, Thailand, from 2015 to 2019. The inclusion criteria were children scheduled for orthopedic surgery; who performed a D-dimer test, Wells score, and Caprini score; and who underwent Doppler ultrasonography for DVT screening. The exclusion criteria were incomplete data or inconclusive ultrasonographic results. Age and results of the D-dimer test, Wells score, and Caprini score were collected from all patients. The outcome assessment was ultrasound-proven DVT. The screening abilities of each test were analyzed in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR) for positive and negative tests, and area under the receiver operating characteristic curve (AUC). Results: A total of 419 children were included in the study. Five (1.19%) patients were diagnosed with DVT. The mean age was 10.16 ± 4.83 years. D-dimer ≥500 ng/mL had a sensitivity of 100% (95% CI: 47.8%-100%), a specificity of 36.7% (95% CI: 32.1%-41.6%), a PPV of 1.9% (95% CI: 0.6%-4.3%), and an NPV of 100% (95% CI: 97.6%-100%). Wells score ≥3 demonstrated a sensitivity of 0% (95% CI: 0%-52.2%), a specificity of 99.3% (95% CI: 97.9%-99.9%), and an LR for a negative test of 1.00 (95% CI: 1.00-1.01). Caprini score ≥11 had a sensitivity of 0% (95% CI: 0%-52.2%) and a specificity of 99.8% (95% CI: 98.7%-100%). The parallel test included D-dimer ≥500 ng/mL, Wells score ≥3, or Caprini score ≥11 points, generating a sensitivity of 100% (95% CI: 47.8%-100%), a specificity of 36.7% (95% CI: 32.1%-41.6%), an LR for a positive test of 1.58 (95% CI: 1.47-1.70), and an AUC of 0.68 (95% CI: 0.66-0.71). Conclusions: The D-dimer test exhibited moderate ability in predicting the development of DVT among pediatric orthopedic patients requiring surgery. The Wells score and Caprini score had low performance in identifying hospitalized children at increased risk of DVT events.

The preferable shoulder position can isolate supraspinatus activity superior to the classic empty can test: an electromyographic study.

BACKGROUND: Supraspinatus (SSP) strength tests are an important shoulder examination tool for clinical evaluations of patients with a suspected SSP tear. While the empty can (EC) test is widely used to diagnose SSP dysfunction, the test cannot selectively activate SSP activity. The aim of this study was to access the electromyographic (EMG) activity within SSP, deltoid, and surrounding periscapular muscles after resisted abduction force to determine which shoulder position helps best isolate SSP from deltoid activity. METHODS: A controlled laboratory EMG study was conducted. Specifically, we conducted an EMG analysis of the seven periscapular muscles (i.e., the middle deltoid, anterior deltoid, SSP, upper trapezius, posterior deltoid, infraspinatus, and pectoralis major) in 21 healthy participants, without any history of shoulder disorder, aged 29 ± 0.9 years old with a dominant-right arm. EMG activities were measured during resisted abduction force according to comprehensive shoulder positions in abduction, horizontal flexion, and humeral rotation. The supraspinatus to middle deltoid (S:D) ratio was calculated using the standardized weighted EMG and the maximum voluntary isometric contraction of the SSP and middle deltoid muscles, for each shoulder position to determine the best isolated SSP muscle strength test position. Results were analyzed with the Kruskal-Wallis test for non-normally distributed data. RESULTS: Shoulder abduction, horizontal flexion, and humeral rotation significantly affected the activity of the middle deltoid, SSP, and S:D ratio (P < 0.05). The S:D ratio increased significantly in lower degrees of shoulder abduction, lower degrees of horizontal flexion, and external humeral rotation over internal rotation. The greatest S:D ratio (3.4 (0.5-9.1)) occurred at the shoulder position of 30° shoulder abduction combined with 30° horizontal flexion and external humeral rotation. Conversely, the classic EC position manifested nearly the smallest S:D ratio (0.8 (0.2-1.2)). CONCLUSION: Application of the SSP strength test in the shoulder position of 30 degrees abduction, 30 degrees horizontal flexion, and external humeral rotation offers the best position to isolate the abducting activity of the SSP from that of the deltoid, which could help with diagnosis among patients with chronic shoulder pain with a suspected SSP tear condition.

The efficacy of gait rehabilitations for the treatment of incomplete spinal cord injury: a systematic review and network meta-analysis.

BACKGROUND: Recent pieces of evidence about the efficacy of gait rehabilitation for incomplete spinal cord injury remain unclear. We aimed to estimate the treatment effect and find the best gait rehabilitation to regain velocity, distance, and Walking Index Spinal Cord Injury (WISCI) among incomplete spinal cord injury patients. METHOD: PubMed and Scopus databases were searched from inception to October 2022. Randomized controlled trials (RCTs) were included in comparison with any of the following: conventional physical therapy, treadmill, functional electrical stimulation and robotic-assisted gait training, and reported at least one outcome. Two reviewers independently selected the studies and extracted the data. Meta-analysis was performed using random-effects or fixed-effect model according to the heterogeneity. Network meta-analysis (NMA) was indirectly compared with all interventions and reported as pooled unstandardized mean difference (USMD) and 95% confidence interval (CI). Surface under the cumulative ranking curve (SUCRA) was calculated to identify the best intervention. RESULTS: We included 17 RCTs (709 participants) with the mean age of 43.9 years. Acute-phase robotic-assisted gait training significantly improved the velocity (USMD 0.1 m/s, 95% CI 0.05, 0.14), distance (USMD 64.75 m, 95% CI 27.24, 102.27), and WISCI (USMD 3.28, 95% CI 0.12, 6.45) compared to conventional physical therapy. In NMA, functional electrical stimulation had the highest probability of being the best intervention for velocity (66.6%, SUCRA 82.1) and distance (39.7%, SUCRA 67.4), followed by treadmill, functional electrical stimulation plus treadmill, robotic-assisted gait training, and conventional physical therapy, respectively. CONCLUSION: Functional electrical stimulation seems to be the best treatment to improve walking velocity and distance for incomplete spinal cord injury patients. However, a large-scale RCT is required to study the adverse events of these interventions. TRIAL REGISTRATION: PROSPERO number CRD42019145797.

Long-term outcomes of anti-thyroid drug treatment in childhood-onset Graves' disease.

OBJECTIVE: Outcomes of childhood-onset Graves' disease (GD) and suggested duration of anti-thyroid drug (ATD) therapy have been controversial. This study aimed to determine long-term outcomes following ATD therapy, including remission and relapse rates. DESIGN, PATIENTS AND MEASUREMENTS: A retrospective study of 265 paediatric patients with GD who were initially treated with ATD was conducted. Long-term outcomes were analysed. RESULTS: Median (IQR) age at diagnosis was 11.5 (9.4, 13.7) years. Duration of ATD treatment was 4.3 (2.3, 6.7) years and time since diagnosis to the enrolment was 7.1 (3.8, 10.9) years. There were 77, 93 and 95 patients who underwent definitive treatment, had ATD discontinuation, and were still being treated with ATD, respectively. The remission rate was 21% (56 out of 265 patients) and relapse rate was 40% (37 out of 93 patients). Cumulative incidence of first remission increased with the duration of ATD treatment with maximum remission rate at 5.3 years following ATD therapy. Among patients who experienced relapse, approximately 50% had disease relapse which occurred within 1 year after ATD discontinuation. Patients with goitre size of less than 3.5 cm, thyroid-stimulating hormone receptor antibody of less than 10 IU/L, no ophthalmopathy at diagnosis and methimazole dose requirement of less than 0.25 mg/kg/day at 1 year after treatment were more likely to achieve remission. CONCLUSIONS: Remission rate of childhood-onset GD was relatively low following ATD treatment. Longer-term ATD therapy was associated with increased remission rate. Approximately 50% of patients with relapse had disease relapse within 1 year following ATD discontinuation.

Factors for selective ultrasound screening in newborns with developmental dysplasia of the hip (DDH).

Background: Hip ultrasound screening for DDH provides better sensitivity compared to physical examination. Due to a lower prevalence and limited resources, selective hip ultrasound in newborns at risk could be considered a proper screening protocol in Thailand and Asian countries. Objective: This study was aimed to evaluate risk factors and define criteria for selective screening. Methods: A case-control study was conducted in 2020. All newborns with hip ultrasound screening were included. Cases were defined as newborns with abnormal hip ultrasounds, while controls were those with normal studies. Inter and intra-rater reliability were evaluated. All factors were analyzed using univariate and multivariate logistic regression. The model performance was tested by Hosmer-Lemeshow goodness of fit. Internal validity was performed by the split data method. Area under the receiver operating characteristic (ROC) curve was estimated. Results: Ninety-five newborns (29 cases and 66 controls) were included. Eighty percent of cases and 58% of controls were female. The gestational age was 36.6 and 37.7 weeks in case and control, respectively. Female, breech presentation, positive Ortolani test, positive Barlow test, and limited hip abduction were significant factors with odds ratio of 2.82, 5.12, 34.21, 69.64, and 5.48, respectively. The final model included breech presentation, positive Ortolani test, and positive Barlow test. The model cut-off value 15.02 provided sensitivity (93.10%) and specificity were (80.30%). The area under the ROC curve was 0.9308. The split data remained significant internal validity for all factors with p-value < 0.05. Conclusion: Careful history taking and physical examination are essential to identify the risk factors for DDH. Newborns with breech presentation, positive Ortolani test and positive Barlow test should be screened by hip ultrasound.

Efficacy of conservative treatment for spastic cerebral palsy children with equinus gait: a systematic review and meta-analysis.

BACKGROUND: Comparisons between various conservative managements of spastic equinus deformity in cerebral palsy demonstrated limited evidences, to evaluate the efficacy of conservative treatment among cerebral palsy children with spastic equinus foot regarding gait and ankle motion. METHODS: Studies were identified from PubMed and Scopus up to February 2022. Inclusion criteria were randomized controlled trial (RCT), conducted in spastic cerebral palsy children with equinus deformity, aged less than 18 years, compared any conservative treatments (Botulinum toxin A; BoNT-A, casting, physical therapy, and orthosis), and evaluated gait improvement (Physician Rating Scale or Video Gait Analysis), Observational Gait Scale, Clinical Gait Assessment Score, ankle dorsiflexion (ankle dorsiflexion at initial contact, and passive ankle dorsiflexion), or Gross Motor Function Measure. Any study with the participants who recently underwent surgery or received BoNT-A or insufficient data was excluded. Two authors were independently selected and extracted data. Risk of bias was assessed using a revised Cochrane risk-of-bias tool for randomized trials. I2 was performed to evaluate heterogeneity. Risk ratio (RR), the unstandardized mean difference (USMD), and the standardized mean difference were used to estimate treatment effects with 95% confidence interval (CI). RESULTS: From 20 included studies (716 children), 15 RCTs were eligible for meta-analysis (35% had low risk of bias). BoNT-A had higher number of gait improvements than placebo (RR 2.64, 95% CI 1.71, 4.07, I2 = 0). Its combination with physical therapy yielded better passive ankle dorsiflexion at knee extension than physical therapy alone (USMD = 4.16 degrees; 95% CI 1.54, 6.78, I2 = 36%). Casting with or without BoNT-A had no different gait improvement and ankle dorsiflexion at knee extension when compared to BoNT-A. Orthosis significantly increased ankle dorsiflexion at initial contact comparing to control (USMD 10.22 degrees, 95 CI% 5.13, 15.31, I2 = 87%). CONCLUSION: BoNT-A and casting contribute to gait improvement and ankle dorsiflexion at knee extension. BoNT-A specifically provided gait improvement over the placebo and additive effect to physical therapy for passive ankle dorsiflexion. Orthosis would be useful for ankle dorsiflexion at initial contact. Trial registration PROSPERO number CRD42019146373.

The ankle kinematic reference of normal gait pattern in Thai adults.

Objective: This study was aimed to establish the reference values of ankle kinematics and factors associated with ankle kinematics of healthy Thai adults. Methods: A prospective cohort was conducted among healthy volunteers aged between 18 and 40 years and evaluated gait analysis between 2016 and 2020. After applying the modified Halen Hayes marker set, participants were assigned to walk 8-10 rounds with their preferred speed. Demographic data i.e., age, gender and body mass index (BMI) and ankle kinematics (varus-valgus, dorsiflexion-plantar flexion, foot progression, and ankle rotation) using motion analysis software were recorded and analyzed. Results: 98 volunteers (60 females and 38 males) aged 28.6 ± 5.4 years with body mass index 21.2 ± 2.0 kg/m2 were included. The average ranges of ankle kinematics entire gait cycle were varus-valgus -1.62 to 3.17 degrees, dorsiflexion-plantar flexion 0.67 to 14.52 degrees, foot progression -21.73 to -8.47 degrees, and ankle rotation 5.22 to 9.74 degrees. The ankle kinematic data in this study population was significantly different from the normal values supplied by OrthoTrak software of the motion analysis program, especially more ankle internal rotation at mid-stance (5.22 vs. -12.10 degrees) and terminal stance (5.48 vs. -10.74 degrees) with P < 0.001. Foot progression significantly exhibited more external rotation for 1.5 degrees on the right compared to the left side, and for 5 degrees more in males than females. One increment in age was significantly correlated with ankle internal rotation at mid-swing (coefficient 0.21 degrees, P = 0.039). BMI had no statistical association with ankle kinematics. Statistical parametric mapping for full-time series of angle assessments showed significantly different foot progression at initial contact and terminal stance between sides, and our ankle kinematics significantly differed from the reference values of the motion analysis program in all planes (P < 0.05). Conclusion: The reference of ankle kinematics of Thai adults was established and differences between sides and the normal values of the motion analysis program were identified. Advanced age was associated with ankle internal rotation, and male gender was related to external foot progression. Further studies are needed to define all-age group reference values.

Validation of the height-width measurement in Perthes disease among interpreters of different experience levels.

The epiphyseal height and metaphyseal width ratio estimated lateral pillar involvement with limited generalizability among various interpreters. The aim of the study was to evaluate the reliability and the validity of height-width ratio measurement in Perthes disease among interpreters of different experience levels. A cross-sectional study was conducted between 2019 and 2020. We included four groups of interpreters: orthopaedic residents, orthopaedic fellows, radiology residents and radiology fellows who were unaware of radiographic study materials. Each interpreter blindedly evaluated Perthes hip radiographs twice at 1-month intervals using the height-width ratio method. Patients' and interpreters' characteristics, height-width ratio and height-width ratio converted to lateral pillar classification (A, B and C) were collected. Intra- and interobserver reliability validated with the paediatric orthopaedist were estimated. Twenty-four interpreters assessed 18 Perthes radiographs. Intraobserver level of agreement (95% confidence interval) for height-width ratio was 0.022 (-0.017 to 0.062), -0.027 (-0.074 to 0.019), -0.010 (-0.095 to 0.074) and 0.019 (-0.109 to 0.146); and interobserver reliability compared with the paediatric orthopaedist was -0.007 (-0.091 to 0.077), 0.003 (-0.056 to 0.061), -0.021 (-0.077 to 0.035) and -0.002 (-0.090 to 0.086) for orthopaedic residents and fellows, radiology residents and fellows, respectively. Kappa statistics of height-width ratio converting to lateral pillar classification indicated intraobserver agreement of orthopaedic residents and fellows, radiology residents and fellows was 0.83, 0.75, 0.54 and 0.91; and interobserver agreement compared with the paediatric orthopaedist was 0.92, 0.83, 0.42 and 0.83, orderly. Height-width ratio and lateral pillar estimation by orthopaedic and radiology trainees have moderate to excellent reliability. Level of evidence: Level II - diagnostic study.

Fracture fixation versus hemiarthroplasty for unstable intertrochanteric fractures in elderly patients: A systematic review and network meta-analysis of randomized controlled trials.

INTRODUCTION: There are three common types of operative options for unstable intertrochanteric fracture (ITF), i.e. dynamic hip screw (DHS), proximal femoral nail (PFN), and bipolar hemiarthroplasty (BHA). Results of these operations are still inconclusive. This systematic review and network meta-analysis was therefore conducted to compare the efficacy among those operative strategies. HYPOTHESIS: These three operative techniques (i.e., DHS, PFN, and BHA) were not different in operative failure, reoperation, and Harris Hip Score (HHS) for unstable ITF. MATERIAL AND METHODS: Randomized controlled trials (RCTs) comparing outcomes among DHS, PFN, and BHA in patients with unstable ITFs were searched from Medline and Scopus databases. Primary outcomes included operative failure, reoperation, and HHS. Direct meta-analysis (DMA) and network meta-analysis (NMA) were performed to compare among three operative techniques. Qualitative and quantitative evidences of all included studies were tested for heterogeneity, transitivity, and consistency in NMA. The surface under the cumulative ranking curve (SUCRA) was used to estimate the probability of being the best in lowering poor clinical outcomes, but high HHS. RESULTS: Seven RCTs (n=528) were eligible. DMA showed that DHS and PFN were significantly higher risk of operative failure compared with BHA with risk ratio (RR) and 95% confidence interval of 7.98 (1.35, 47.06) and 3.08 (1.00, 9.51), respectively. Compared with BHA, PFN was 4.47 (1.04, 21.60) times significantly higher risk of reoperation, and lower HHS at 3-6months [mean difference (MD)=-5.41 (-15.91, 5.10)], but higher HHS at>6-12months [MD 11.67 (2.98, 20.36)], although these HHSs were not significant. NMA and SUCRA demonstrated the highest ranks for operative failure and reoperation were DHS and PFN, whereas the highest HHS was BHA. DISCUSSION: In specific group of unstable ITF, BHA might be the best operative technique in term of lower operative failure and reoperation, and highest HHS during short to intermediate period comparing with PFN and DHS. However, PFN had higher long-term HHS than BHA. LEVEL OF EVIDENCE: I, meta-analysis of RCTs.

Network meta-analysis of management of trigger thumb in children.

To estimate and rank cure and recurrence rates between conservative and operative treatments for trigger thumb in children. A systematic review was conducted by searching PubMed and Scopus. Eligible criteria were comparative studies included non-syndromic trigger thumbs, aged up to 10 years, reported at least 20 thumbs and followed up at least 12 months. Two assessors independently extracted data and appraised for cure, recurrence rates among observation, stretching, splinting, open surgery, and percutaneous surgery. We assessed the risk of bias in non-randomized studies of interventions. A network meta-analysis, and probability of being the best outcomes were estimated with surface under the cumulative ranking curves (SUCRA). From 6853 searched articles, eight studies (799 children and 981 thumbs) were included. Mean age was 1.87-2.83 years and average followed up time was 1-5.7 years. Open surgery, percutaneous release, splinting, and stretching had higher cure rate than observation; pooled risk ratio (95% confidence interval) of 2.06 (1.53-2.78), 1.79 (1.26-2.53), 1.76 (1.30-2.36), and 1.37 (0.93-2.03), respectively. Percutaneous release increased risk of recurrence 3.29 times (1.42-7.60) when compared with open surgery. The best cure rates were open surgery (SUCRA = 95) followed by splint (SUCRA = 63.4), and percutaneous technique (SUCRA= 62.8). The highest recurrence rates were percutaneous (SUCRA = 97.3), and open surgery (SUCRA = 62.4). Splint is the most appropriate intervention for pediatric trigger thumb. After failed conservative methods, open surgery is considered for operative treatment. Level of evidence: Therapeutic study level II-III.

Is ankle fracture related to low bone mineral density and subsequent fracture? A systematic review.

OBJECTIVES: Ankle fractures are common in the elderly. However, their association with osteoporosis remains controversial. This systematic review aims to determine the relationship between ankle fracture and bone mineral density (BMD), and to investigate the risk of subsequent fractures after ankle fracture. METHODS: MEDLINE and Scopus publications were searched from inception to March and April 2019, respectively. Articles were selected by 2 independent reviewers for cross-sectional, cohort, or case-control studies comparing BMD or subsequent fracture risk in low-energy ankle fractures patients with that of the normal population. Data extraction was performed by 2 investigators. Discrepancies were resolved with the third reviewer. Quality assessment was conducted using the modified Newcastle-Ottawa Scale. RESULTS: Overall, 19 articles were included. The quality assessment showed a generally low-to-moderate risk of bias among studies, mainly due to potential confounders and inadequate follow-up. Of 13 studies exploring BMD in ankle fractured-patients, lower central and peripheral BMD was found in 3 and 2 studies, respectively. The risk of subsequent fracture was examined in 11 studies with relative risks ranging from 0.7 to 4.59. An increased risk of any subsequent fractures in women, both genders, and men was found in 5, 2, and 1 articles, respectively. CONCLUSIONS: Despite the lack of clear association with BMD, the contribution of ankle fracture to increased subsequent fracture risk and its associated microarchitectural changes cannot be overlooked. Moreover, its potential role as an early predictor of future fracture may promote secondary prevention. Further studies with longer follow-up and stricter confounder control are recommended.

Effect of Multimodal Drugs Infiltration on Postoperative Pain in Split Laminectomy of Lumbar Spine: A Randomized Controlled Trial.

STUDY DESIGN: A randomized, double-blinded controlled trial. OBJECTIVE: This study tested the effect of single-dose wound infiltration with multiple drugs for pain management after lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Patients undergoing spine surgery often experience severe pain especially in early postoperative period. We hypothesized that intraoperative wound infiltration with multiple drugs would improve outcomes in lumbar spine surgery. METHODS: Fifty-two patients who underwent one to two levels of spinous process splitting laminectomy of lumbar spine, were randomized into two groups. Infiltration group received intraoperative wound infiltration of local anesthetics, morphine sulfate, epinephrine, and nonsteroidal anti-inflammatory drugs at the end of surgery, and received patient-controlled analgesia (PCA) postoperatively. The control group received only PCA postoperatively. The primary outcome measures were amount of morphine consumption and visual analogue scale (VAS) for pain. The secondary outcome measures were Oswestry Disability Index (ODI), Roland-Morris Low Back Pain and Disability Questionnaire (RMDQ), patient satisfaction, length of hospital stay, and side effects. RESULTS: A total of 49 patients (23 patients for local infiltration group, and 26 patients for control group) were analyzed. There were statistically significant [P < 0.001, the effect size -5.0, 95% CI (-6.1, -3.9)] less morphine consumptions in the local infiltration group than the control group during the first 12 hours, 12 to 24 hours, and 24 to 48 hours after surgery. The VAS of postoperative pain reported by patients at rest and during motion was significantly lower in the local infiltration group than the control group at all assessment times (P < 0.001). The effect size of VAS of postoperative pain at rest and during motion were -2.0, 95% CI (-2.5, -1.4) and -2.0, 95% CI (-2.6, -1.4) respectively. ODI and RMDQ at 2 week and 3 month follow-ups in both groups had significant improvement from baseline (P < 0.001). No significant differences were found between groups (P = 0.262 for ODI and P = 0.296 for RMDQ). There were no significant differences of patient satisfaction, length of stay, and side effects between both groups (P = 0.256, P = 0.262, P = 0.145 respectively). CONCLUSION: Intraoperative wound infiltration with multimodal drugs reduced postoperative morphine consumption, decreased pain score with no increased side effects. LEVEL OF EVIDENCE: 1.

Effectiveness of Extracorporeal Shockwave Therapy in the Treatment of Chronic Insertional Achilles Tendinopathy.

BACKGROUND: Extracorporeal shockwave therapy (ESWT) has been proposed as a conservative treatment for insertional Achilles tendinopathy from limited evidence without placebo controls. Our objective was to assess the effectiveness of ESWT compared with sham controls in chronic insertional Achilles tendinopathy. METHODS: A double-blind, randomized sham-controlled trial was conducted between 2016 and 2018. The inclusion criteria were patients aged 18 to 70 years diagnosed with chronic insertional Achilles tendinopathy who failed standard conservative treatment. After computerized randomization, patients were allocated into either low-energy ESWT or sham control. Pain, function, and other complaints were assessed using visual analog scale (VAS) and VAS foot and ankle (VAS-FA) at preintervention and weeks 2, 3, 4, 6, 12, and 24. Intention-to-treat analysis and repeated measurement were performed using STATA 15.0. RESULTS: Sixteen patients in ESWT and 15 patients in sham control groups had nonsignificant different baseline characteristics with preintervention VAS (6.0 ± 2.6 vs 5.2 ± 2.2) and VAS-FA (64.8 ± 16.6 vs 65.3 ± 12.7). There was no significant difference in VAS, VAS-FA, and its domains in the long term between the 2 groups. In addition, the ESWT group had significant improvement in VAS (2.9 ± 2.2) at weeks 4 to 12, and sham controls group had significantly improved VAS (2.3 ± 2.6) at weeks 12 to 24. Complications were found only after ESWT treatment. CONCLUSION: There was no difference at 24 weeks with the use of low-energy ESWT for chronic insertional Achilles tendinopathy, especially in elderly patients. However, it may provide a short period of therapeutic effects as early as weeks 4 to 12. LEVEL OF EVIDENCE: Level I, randomized controlled study.