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Objective To investigate the factors, surgical treatment methods and clinical effect of internal fixation failure of intertrochanteric and subtrochanteric fractures. Methods From June 2015 to May 2019, arthroplasty and internal fixation revision were used to treat 18 cases of internal fixation failure of intertrochanteric and subtrochanteric fractures. There were 10 males and eight females, with an average age of 67.3 years (38–92 years). The 16 cases of initial intertrochanteric fractures were classified according to AO/OTA:13 cases of A2 and 3 cases of A3, the other 2 cases were subtrochanteric fractures (Seinsheimer type IV). The internal fixation failure was treated with total hip arthroplasty (6 cases), bipolar hemiarthroplasty (4 cases), revision with proximal femoral lockingplate (4 cases) and extend intramedullary nail (4 cases). Results All patients were followed up for an average of 24.7 months (range, 12 to 36 months). The average operative time was 111.4 min (range, 72 to 146 min) and the average intraoperative blood loss was 403.6 mL (range, 200 to 650 mL). The average time of fracture union was 6.9 months (range, 5 to 9 months) for cases of internal fixation revision. The operative time of the arthroplasty group was shorter than the revision group (P, Internal fixation revision and arthroplasty for failure of peritrochanteric fractures respectively.

Chronic β-alanine supplementation leads to increased levels of muscle histidine-containing dipeptides. However, the majority of ingested β-alanine is, most likely, degraded by two transaminases: GABA-T and AGXT2. In contrast to GABA-T, the in vivo role of AGXT2 with respect to β-alanine metabolism is unknown. The purpose of the present work is to investigate if AGXT2 is functionally involved in β-alanine homeostasis.Muscle histidine-containing dipeptides levels were determined in AGXT2 overexpressing or knock-out mice and in human subjects with different rs37369 genotypes which is known to affect AGXT2 activity. Further, plasma β-alanine kinetic was measured and urine was obtained from subjects with different rs37369 genotypes following ingestion of 1400 mg β-alanine.Overexpression of AGXT2 decreased circulating and muscle histidine-containing dipeptides ( 70% decrease; p 0.05), while AGXT2 KO did not result in altered histidine-containing dipeptides levels. In both models, β-alanine remained unaffected in the circulation and in muscle (p 0.05). In humans, the results support the evidence that decreased AGXT2 activity is not associated with altered histidine-containing dipeptides levels (p 0.05). Additionally, following an acute dose of β-alanine, no differences in pharmacokinetic response were measured between subjects with different rs37369 genotypes (p 0.05). Interestingly, urinary β-alanine excretion was 103% higher in subjects associated with lower AGXT2 activity, compared to subjects associated with normal AGXT2 activity (p 0.05).The data suggest that in vivo, β-alanine is a substrate of AGXT2; however, its importance in the metabolism of β-alanine and histidine-containing dipeptides seems small.

Background Tuberculosis (TB) in the atlantoaxial joint is a rare disease. However, the treatment of atlantoaxial TB with neurologic impairment is controversial. The aim of this review is to provide clinical outcomes of surgical and nonsurgical management of atlantoaxial TB. Methods Databases including PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched for English literature describing the treatment of atlantoaxial TB with neurologic deficits. The outcomes of conservative and surgical treatment approaches, including treatment failure, death, changes in neurologic impairment, and complications, were compared by performing odds ratio (OR) analysis. Results Overall, 24 studies (247 patients) meeting the inclusion criteria were analyzed. Ninety-four patients (38%) were treated conservatively and 153 (62%) patients were treated surgically. The rate of poor outcomes was greater in the conservative group (14.89%) than in the surgery group (1.3%) (OR, 0.081; 95% confidence interval [CI], 0.016–0.39).There was no significant difference in mortality between the conservative (1.06%) and surgery (3.27%) groups (OR, 3.28; 95% CI, 0.494–27.381). There was no significant difference in muscle power improvement between the 2 treatments (conservative, 95.7%; surgery:, 94.8%; OR, 1.353; 95% CI, 0.291–4.925). Conclusions Conservative and surgical treatments both significantly improved neurologic deficits in most patients. Compared with conservative treatment, surgical treatment reduced treatment failures without significantly increasing the rates of neurologic deficit improvement or mortality.

Background Knee osteoarthritis (OA) is one of the most common joint diseases, and pharmacotherapy is necessary to control its symptoms. Aim To evaluate efficacy and tolerability of duloxetine in patients with knee OA. Methods PubMed, Web of Science, Embase, Cochrane Library and ClinicalTrials.gov were searched to identify randomised controlled trials comparing duloxetine with placebo for knee OA. Data including pain, stiffness, physical function, and adverse events were extracted for meta-analysis. The protocol was prospectively registered in PROSPERO (CRD42018097110). Results Data from six randomised controlled trials including 2059 participants were pooled. Duloxetine achieved significant reductions in primary outcomes including Brief Pain Inventory 24-h average pain score (weighted mean difference (WMD) = -0.74, 95% confidence interval (CI) = -0.92 to -0.57), weekly mean of the 24-h average pain score (WMD = -0.76, 95% CI = -0.96 to -0.56), WOMAC stiffness score (WMD = -0.47, 95% CI = -0.60 to -0.34) and WOMAC physical function score (WMD = -4.44, 95% CI = -5.24 to -3.64). Furthermore, duloxetine demonstrated a higher number of treatment-emergent adverse events (risk ratio (RR) = 1.31, 95% CI = 1.20-1.44) and discontinuations (RR = 2.26, 95% CI = 1.63-3.12); however, no difference in serious adverse events (RR = 0.92, 95% CI = 0.40-2.11) was observed. Conclusion Duloxetine is effective in the management of chronic pain and loss of physical function in knee OA with acceptable adverse events despite having no advantage in treating joint stiffness. Future trials should focus on determining the optimal treatment regimen.

Objective To compare the functional status and quality of life (QoL) between patients who underwent an early mobilization scheme and those who underwent a late mobilization scheme after hip fracture fixation surgery in elderly Chinese patients. Methods This was a prospective cohort study. Patients (≥65 years old) with unstable intertrochanteric fractures treated with intramedullary nails were recruited from nine centers in China. Study centers either performed early mobilization or late mobilization scheme. All patients performed immediate in-bed mobilization after surgery and followed a standardized daily exercise program at home during the first 12 weeks. Functional status was measured by the Modified Barthel Index at postoperative visit, 6 weeks, and 12 weeks. QoL was measured by the EuroQol-5D (EQ-5D) at 12 weeks. Results One hundred and forty-eight patients were enrolled to early mobilization, and 136 to late mobilization. At 6 weeks, early mobilization resulted in a significantly better Modified Barthel Index than late mobilization (mean [SD]: 83.7 [12.0] vs. 67.0 [17.5], p < .001). Adjusted mixed effects model showed significantly higher Modified Barthel Index for early mobilization at postoperative visit, 6 weeks, and 12 weeks (all p < .001). Patients in the early mobilization group had slightly better EQ-5D Index at 12 weeks than patients in the late mobilization group (mean: 0.91 vs 0.87, p = .002). Conclusions Early postoperative mobilization resulted in better functional outcomes up to 12 weeks. QoL was rated statistically significantly better in the early mobilization group, but the difference was small and may not be clinically relevant.

Background The pelvis is the most common site of chondrosarcoma (CS), and the prognosis for patients with pelvic CS is worse than that for patients with CS in the extremities. However, clinicians have had few tools for estimating the likelihood of survival in patients with pelvic CS. Our aim was to develop nomograms to predict survival of patients with pelvic CS. Methods Data from the Surveillance, Epidemiology, and End Results (SEER) database of patients with pelvic CS between 2004 and 2016 were retrieved for retrospective analysis. Univariate and multivariate Cox analyses were used to identify independent prognostic factors. On the basis of the results of the multivariate analyses, nomograms were constructed to predict the likelihood of 3‐ and 5‐year overall survival (OS) and cancer‐specific survival (CSS) of patients with pelvic CS. The concordance index (C‐index) and calibration curves were used to test the models. Results In univariate and multivariate analyses of OS, sex, pathologic grade, tumor size, tumor stage, and surgery were identified as the independent risk factors. In univariate and multivariate analyses of CSS, pathologic grade, tumor size, tumor stage, and surgery were identified as the independent risk factors. These characteristics except surgery were integrated in the nomograms for predicting 3‐ and 5‐year OS and CSS, and the C‐indexes were 0.758 and 0.786, respectively. Conclusion The nomograms precisely and individually predict OS and CSS of patients with pelvic CS and could aid in personalized prognostic evaluation and individualized clinical decision‐making., Independent prognostic factors associated with overall survival and cancer‐specific survival of pelvic chondrosarcoma were identified.This is the first time to develop and validate nomograms to predict prognosis in patients with pelvic chondrosarcoma, and it could be beneficial to clinicians in making personalized survival evaluation.

Background Elderly patients are at a higher risk for hip fracture. Moreover, hospitalized elderly patients with hip fracture are vulnerable to adverse outcomes including higher mortality rate and long-term disability. Treatment decision-making with respect to surgical procedure and perioperative management of these patients is typically challenging owing to the presence of multiple comorbid conditions. Aims The purpose of this study was to investigate the relationship between comorbidities in elderly patients with hip fracture and the treatment decision-making. Methods 884 geriatric patients (age ≥ 60 years) with hip fracture were included. Comorbidities related to age were measured using the Charlson Co-morbidity Index (CCI) and age-adjusted CCI. The CCI of each geriatric hip fracture patient was calculated based on data retrieved from the medical records. The relationship of CCI and age-adjusted CCI with surgical procedure, time-to-surgery, length of hospital stay, and perioperative management (transfusion, anti-coagulation, and analgesia) was assessed. Results Mean age of patients was 78.01 ± 8.62 years. The mean CCI was 0.79 ± 0.036; the mean age-adjusted CCI was 4.15 ± 0.047. The CCI was significantly associated with time-to-surgery (P = 0.004), surgical treatment (P

To estimate the prevalence of depression in degenerative spine disease (DSD) patients. The PubMed, EMBASE, and PsycINFO were systematically searched, the relevant studies that reported the depression prevalence of in DSD patients were identified. Data were extracted independently by 2 reviewers. Subgroup analysis and sensitivity analysis were also performed. 24 articles met the inclusion criteria and were selected for the current study. The pooled prevalence estimate of depression in DSD patients before operative treatment was 30.8% [95% CI 24.0–38.5%]. Nine articles reported the prevalence rate in DSD patients after operative treatment, and the pooled prevalence estimate was 27.0% [95% CI 19.9–35.4%]. There were significant differences for prevalence estimates before operative treatment in types of disorders (Q = 4.56, P = 0.10), spine surgery history (Q = 5.55, P = 0.02), representativeness of sample (Q = 11.00, P = 0.00), and validity of assessment method (Q = 3.32, P = 0.07). The prevalence estimates in patients with lumbar spine stenosis, lumbar disc herniation and cervical spondylotic myelopathy were 24.0%, 40.9% and 37.3%, respectively. Studies that included patients with a history of spine surgery yielded a more extreme prevalence estimate than studies excluding those (36.9% vs 24.3%). For results of patients after operative treatment, significant differences for prevalence estimates were showed in different degrees of pain (Q = 4.72, P = 0.03), screening instruments (Q = 4.83, P = 0.09), and representativeness of sample (Q = 15.70, P = 0.00). The systematic review indicated increased prevalence of depression in DSD patients. In consideration of the relationship between depression and poor surgical outcome, we should pay more attention to identifying strategies for preventing and treating depression in DSD patients.

Objective: Femoral head fractures are rare injuries that are often associated with poor functional outcome and complications. Fracture management and surgical methods for these fractures are variable. The purpose of this study was to evaluate the incidence, treatment methods and approaches, complications and functional outcomes of femoral head fractures.Methods: We conducted a retrospective review of fifty patients who sustained femoral head fractures from January 2011- December 2018. There were thirty-seven males and thirteen females with median age of 40 years. A surgical approach and fixation method were recorded. Patients were classified according to the Pipkin Classification system. Clinical results were evaluated for patients with two years or greater follow-up using the Modified Harris Hip Score (MHHS). Results: Eight patients (16%) were managed successfully with closed reduction without surgery and thirty-seven (74%) patients required operative reduction and internal fixation (ORIF) of the femoral head and acetabulum, 5 (10%) patients required immediate Total Hip Replacement (THR). Six (12%) developed AVN, four (8%) requiring secondary total hip replacement (THR). Sixteen patients (33%) developed PTA, eight (16%) developed HO and six patients (12 %) had sciatic nerve injury, none requiring operative treatment. Overall functional results, according to modified Harris hip score were excellent in two (4%) patients, good in sixteen (32%) patients, fair in twenty-two (44%) patients, and poor in ten (20%) patients. A statistically significant difference in outcome was observed among four pipkin subtypes. Conclusion: Femoral head fracture are a rare injury that are often associated with poor outcome. In this study we report the functional outcomes and complications of all treatment approaches for femoral head fracture based on Pipkin classification. This study, adds to the growing literature on femoral head fractures and provide reference for the clinical treatment to guide patient management.

Objective To investigate the feasible effect of a preoperative mobilization program for older hip fracture patients who waited more than two days before surgery. Methods A total of 38 patients with hip fracture were analyzed in this retrospective descriptive pilot study. The modified Barthel index (MBI) was used to measure functional outcome. Visual analogue scale (VAS) was used to evaluate the changes of pain degree during preoperative mobilization. The perioperative complications were recorded. Results After the preoperative mobilization program was implemented, the MBI score was improved immediately and further improved after surgery until 3 months after discharge. On the premise of analgesia, no patient experienced severe pain during preoperative mobilization. Perioperative complications occurred in 2 (5.3%) patients. Conclusion For older patients with hip fracture, the preoperative mobilization program may be a feasible method, which may have a positive effect on promoting functional recovery and preventing perioperative complications.

Background With the global determination to eliminate tuberculosis (TB), the treatment for end-stage TB of the knee joint is still a great clinical challenge. This study aims to retrospectively determine the clinical and radiographic outcomes after use of the Ilizarov technique for knee joint arthrodesis as a treatment for end-stage knee TB. Methods Twenty-six patients with end-stage knee TB treated by external fixation with the Ilizarov fixator between 2012 and 2017 were examined. Anti-TB drugs were administered preoperatively, intraoperatively, and postoperatively. Clinical and radiologic examinations were performed for comprehensive evaluations, and these include C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), flexion and valgus angle of the knee, leg-length discrepancy, and Lysholm score. Results Twenty-four patients were followed up for an average of 5.8 years (2.2–7 years). All patients achieved bone fusion within a mean of 6.4 months (4–16 months). The ESR and CRP concentrations were observed to return to normal within 5.1 ± 1.1 months postoperatively. There was no recurrence of TB. At last follow-up, the mean leg-length discrepancy was 2.7 ± 1.4 cm, and the mean alignment was 8.7 ± 2.6° flexion and 5.3 ± 1.0° valgus. No patient had a significant rotational deformity. The average Lysholm score was seen to improve significantly from 36.8 ± 18.4 preoperatively to 79.5 ± 5.9 at final follow-up (p Conclusion This study has demonstrated that the Ilizarov technique for knee joint arthrodesis as a treatment of end-stage knee TB achieved promising outcomes with minimal complications.

To investigate the association between iron supplementation and blood transfusion risks, hospital length of stay, postoperative infection, and mortality in geriatric patients with hip fracture surgeries. Data from this meta-analysis suggest that iron supplementation, especially preoperative intravenous use of iron at 200–300 mg, is associated with a reduction in the rate and volume of blood transfusions, infections and length of hospital stay in older patients with hip fracture surgeries. These findings support the preoperative intravenous use of iron at 200–300 mg in older adults undergoing hip fracture surgeries. To assess the efficacy and safety of iron supplementation for perioperative anemia in geriatric patients with hip fracture. A systematic search was conducted for studies published using PubMed, EMBASE and Cochrane Library Databases that compared iron supplementation with placebo in patients undergoing hip fracture surgery. The outcomes were blood transfusion rate and volume, length of stay, infection and mortality (last follow-up). Sub-group and sensitivity analyses were performed in cases of substantial heterogeneity. The meta-analysis (6 studies: 1201 patients) indicated that iron supplements were not associated with reducing blood transfusion rate (OR 0.92, 95% CI 0.60–1.41; P = 0.69), but high heterogeneity (I2 = 61%) was detected and a significant association was found in sensitivity analysis of four studies (n = 637; OR 0.68, 95% CI 0.49–0.95; P = 0.02). A significant reduction was detected in transfusion volume (two studies: n = 234; MD − 0.45 units/patient, 95% CI − 0.74 to − 0.16; P = 0.002), hospital stay (five studies: n = 998; MD − 1.42, 95% CI − 2.18 to − 0.67; P = 0.0002) and caused no increased risk of mortality (five studies: n = 937; OR 0.94, 95% CI 0.65–1.36; P = 0.76) and infection (four studies: n = 701; OR 0.58, 95% CI 0.38–0.90; P = 0.01). Sub-group analyses of four studies showed that the preoperative intravenous use of iron at 200–300 mg (two studies) may be the beneficial option for hip fractures patients. Iron supplementation, especially preoperative intravenous use of 200–300 mg iron, is safe and associated with reducing transfusion requirement and hospital stay. Unfortunately, data were too limited to draw a definite conclusion. Further evaluation is required before recommending iron supplementation for older patients with hip fracture surgeries.

Introduction: Floating joint injury is an unusual injury pattern that is hard to deal with and often caused by high-energy trauma. In this report, a patient had a homolateral floating hip injury (FHI), floating knee injury (FKI), and hip dislocation at our hospital, and there was no case reported before. Case Presentation: A 48-year-old driver who encountered a traffic accident was seen. Radiologic examination revealed acetabulum comminuted fractures and hip joint posterior dislocation with some fracture pieces in the joint space on the left side. The femur, tibia, and fibula were simultaneously disrupted with open trauma of the left calf. Open reduction and screw-plate fixation of the acetabulum fracture, intramedullary nail fixation of the femoral fracture, and external fixator for his tibia and fibula fracture were carried out. Conclusion: The treatment of multiple fractures should focus on life-threatening injuries above all, and then deal with the fractures according to the situation of the patient. Open reduction and internal fixation are priority choices except in some special cases like where soft tissue is in poor condition. Individual therapy and early rehabilitation are effective for homolateral FHI and FKI.

Purpose: To investigate the early and mid-term results of open reduction and internal fixation (ORIF) with transarticular external fixation (TEF) but no deltoid ligament repair (DLR) in the treatment of supination-external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B 3.1) and provide evidence for clinical practice. Methods: This study cohort consisted of 22 patients with SER IV E ankle fractures that underwent ORIF with TEF but no DLR between December 2011 and December 2014. There were 13 males and 9 females, mean age 38.9 years (range, 17-73 years). Eight cases involved the left side and 14 the right side. The causes of fractures included road traffic accidents (11 cases), falling from height (6 cases) and sports injuries (5 cases). The mean period of hospitalization was 9.8 days (range, 6-14 days). For all the patients, MRI and three-dimensional CT were done before surgery and X-rays done preoperatively and during follow-ups. The external frame was kept for 8-10 weeks. The preoperative American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 56.86 ± 4.400, the Medical Outcomes Short Form 36-item (SF-36) questionnaire score was 57.41 ± 4.102 and the visual analog score (VAS) was 5.50 ± 1.058. Patients' main complaints about inconvenience of daily life were also recorded. Results: All the 22 patients were followed up for 24-63 months (mean, 33.6 months). None of them developed nonunion during the follow-up; pin site infection was observed in one patient and posttraumatic osteoarthritis in another. At the final follow-up, the average AOFAS score, SF-36 score and VAS score were respectively 90.59 ± 5.096, 79.59 ± 5.394 and 1.82 ± 1.181, which were significantly improved compared with the preoperative data (t = 26.221, p < 0.001; t = 11.910, p < 0.001; t = 11.571, p < 0.001). The therapeutic effect was excellent in 13 cases, good in 7 cases and fair in 2 cases, with a good-excellent rate of 90.9%. Patients' main complaints were inconvenience of clothing (17 cases) and extremity cleaning (5 cases). Conclusion: In the treatment of SER IV E ankle fractures, ORIF with TEF but no DLR can achieve satisfactory outcome, but long-term effect should be confirmed by large sample randomized controlled trials. Key words: Ankle fractures; Supination-external rotation; Deltoid ligament; Fracture fixation, external

Purpose: To investigate the mid-term curative effects of the treatment of Pipkin type IV femoral head fractures using a reconstruction plate and bioabsorbable screws and provide the evidence for clinical practice. Methods: From February 2010 to September 2014, 21 patients with Pipkin type IV femoral head fractures were treated surgically. There were 13 males and 8 females with an average age of 41.1 years (range, 20–65 years). The causes of the fractures included traffic accidents (13 cases), falls from a height (four cases), heavy lifting injuries (three cases), and sport injury (one case). All patients were followed up with radiography and three-dimensional reconstruction computed tomography and other checks and any complications were actively managed. Closed reduction of fracture-dislocation of the hip was attempted under general anesthesia using the Kocher-Langenbeck approach. Femoral head fractures were treated with internal fixation or excision based on the size of the fracture fragments, whereas acetabular fractures were fixed with a reconstruction plate and screws following anatomic reduction. Results: The incisions healed by primary intention in all patients after surgery, without any infection, deep venous thrombosis, or other complications. All 21 patients were followed up for 36–76 months, with an average follow-up duration of 49 months. Postoperative imaging data showed that all dislocations and fractures were anatomically reduced, and bony union of the fractures was achieved. Heterotopic ossification was found in four patients, post-traumatic osteoarthritis in three, and avascular necrosis of the femoral head in two. At the final follow-up, the assessment of hip joint function according to the Thompson-Epstein scoring scale was excellent in 10 cases, good in six cases, fair in three cases, and poor in two cases. The rate of excellent and good functional outcomes was 76.1%. Conclusion: The mid-term curative effects of a reconstruction plate and bioabsorbable screws in the treatment of Pipkin type IV femoral head fractures is significant, and such the treatment can significantly improve the patient's joint function and quality of life. Keywords: Femoral head fractures, Acetabular fractures, Pipkin classification, Fracture fixation, internal

Bone cancer including primary bone cancer and metastatic bone cancer, remains a challenge claiming millions of lives and affecting the life quality of survivors. Conventional treatments of bone cancer include wide surgical resection, radiotherapy, and chemotherapy. However, some bone cancer cells may remain or recur in the local area after resection, some are highly resistant to chemotherapy, and some are insensitive to radiotherapy. Phototherapy (PT) including photodynamic therapy (PDT) and photothermal therapy (PTT), is a clinically approved, minimally invasive, and highly selective treatment, and has been widely reported for cancer therapy. Under the irradiation of light of a specific wavelength, the photosensitizer (PS) in PDT can cause the increase of intracellular ROS and the photothermal agent (PTA) in PTT can induce photothermal conversion, leading to the tumoricidal effects. In this review, the progress of PT applications in the treatment of bone cancer has been outlined and summarized, and some envisioned challenges and future perspectives have been mentioned. This review provides the current state of the art regarding PDT and PTT in bone cancer and inspiration for future studies on PT.

Background Iatrogenic vertebral artery injury (VAI) during anterior cervical surgery is rare but potentially catastrophic. Methods Causes, presentation, diagnosis, management, prognosis, and prevention of VAI were reviewed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. English language studies and case reports published from 1980 to 2017 were retrieved. Data on diagnosis, surgical procedures and approach, site and cause of VAI, management, outcomes, and vertebral artery (VA) status were extracted. Results In 25 articles including 54 patients, VAI was diagnosed during or after surgery commonly indicated for cervical degenerative diseases (64%), tumors (14%), and trauma (9%). The incidence of VAI for each side was similar regardless of approach. Common presentations were unexpected copious surgical bleeding, delayed hemorrhage of pseudoaneurysm with neck swelling, dyspnea, hypotension, and cervical bruits caused by arteriovenous fistula. Causes included drilling (61%), instrumentation (16%), and soft tissue retraction (8%). Direct exposure or angiography confirmed VAI. Ten patients had VA anomalies; collateral status was verified in 9 before definitive treatment. Tamponade was adopted for urgent hemostasis in most cases but with a high incidence of pseudoaneurysm (48%). Unknown VA status increased occlusion risk and neurologic sequelae (41%). VA repair and stent placement had excellent outcomes. Conclusions Extensive lateral decompression, loss of landmarks, and anatomic variations or pathologic status of VA increased VAI risk. Evaluation of collateral vessels before definitive treatment helped determine appropriate management and avoid neurologic sequelae. Tamponade was not recommended as definitive treatment. Meticulous preoperative evaluation, cautious intraoperative manipulation, and real-time radiographic guidance reduced VAI risk.

Objective To evaluate the efficacy of classical pulsed electromagnetic field therapy on patients with knee osteoarthritis. Methods The databases PubMed, EMBASE, Web of Science and Cochrane Library were searched for relevant studies. Randomized controlled trials comparing classical pulsed electromagnetic field with placebo for patients with knee osteoarthritis were included. Data for primary outcomes, including pain, stiffness and physical function, were extracted. Data from 8 randomized controlled trials involving 421 patients were pooled. Results Pulsed electromagnetic field therapy had an effect on improving physical function (weighted mean difference; WMD = -5.28, 95% confidence interval; 95% CI -9.45 to -1.11, p = 0.01), but showed no advantage in the reduction of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score (WMD = -7.80, 95% CI -16.08 to 0.47, p = 0.06), WOMAC pain score (WMD = -1.06, 95% CI -2.30 to 0.17, p = 0.09), visual analogue scale pain score (WMD=-0.88, 95% CI -2.06 to 0.31, p = 0.15) or WOMAC stiffness score (WMD = -0.50, 95% CI -1.09 to 0.09, p = 0.1). Conclusion Pulsed electromagnetic field therapy is beneficial for improving physical function despite having no advantage in treating pain and stiffness. Further randomized controlled trials are needed to confirm these findings and determine the optimal parameters and treatment regimen for pulsed electromagnetic field therapy.

Background Currently, few studies focus on the treatment of Parkinson's disease (PD) patients after a fracture. The effect of PD on geriatric patients with intertrochanteric fracture remains unclear. Therefore, we performed a study to focus on two questions as follow: (1) would PD increase the operation difficulty and perioperative complications in Chinese elderly patients with intertrochanteric fracture? (2) is there any difference between the clinical outcome of patients with and without PD? Hypothesis PD would increase perioperative complications and influence the postoperative rehabilitation in elderly patients with intertrochanteric fracture. Materials and methods There were 445 elderly intertrochanteric fracture patients treated with proximal femoral nail anti-rotation during January 2010 and December 2017. After propensity score matching, twenty-four geriatric intertrochanteric fracture patients with PD and forty-eight geriatric intertrochanteric fracture patients without PD were enrolled in this retrospective study. Intraoperative and postoperative comparison were conducted between patients with and without PD. Results Compared with 63 months for geriatric intertrochanteric fracture patients without PD, patients with PD had a median survival time of 31 months. The Harris Hip Score and Barthel Index of patients with PD were significantly lower than that of patients without PD. In addition, the Depression subscale score of patients with PD were significantly higher that of patients without PD. Discussion The effect of PD on geriatric patients with intertrochanteric fracture is not the operation itself, but the postoperative rehabilitation. In addition, multi-disciplinary treatment, personal rehabilitation training, more intensive outpatient care, and meticulous nursing were recommended in treatment for elderly patients with intertrochanteric fracture and PD. Level of evidence III, Cohort comparative study.

Background Recently, there has been a series of clinical studies focusing on the perioperative administration of tranexamic acid (TXA) in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery. However, the safety and efficacy of TXA in these patients remains controversial. Therefore, we performed a systematic review to focus on two questions: (1) would TXA reduce perioperative blood loss in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery? and (2) would TXA increase the rate of perioperative complications in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery? Patients and methods We systematically searched electronic databases (MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials) up to April 20, 2019. The perioperative blood loss and complication data were extracted and analysed by RevMan Manager 5.3. Results Finally, five randomized controlled studies, involving 539 geriatric intertrochanteric fracture patients undergoing proximal femoral intramedullary nail surgery, were enrolled in this systematic review. Compared with the control group, the TXA group had significantly lower total perioperative blood loss (WMD = −172.84; 95% CI, −241.44 to −104.24; I2 = 0%), intraoperative blood loss (WMD = −34.20; 95% CI, −46.04 to −22.36; I2 = 0%), total perioperative hidden blood loss (WMD = −139.05; 95% CI, −213.67 to −64.43; I2 = 0%), perioperative transfusion rates (RR =−0.16; 95% CI, −0.24 to −0.08; I2 = 22%), length of hospital stay (WMD = −1.18; 95% CI, −1.91 to −0.46; p =0.001; I2 = 12%), and postoperative wound haematoma rates (RD = −0.05; 95% CI, −0.09 to 0.00; p =0.03; I2 = 0%). In addition, there were no significant differences between TXA and control groups in the terms of surgical time, postoperative mortality, total thromboembolic events, wound infections, cerebrovascular accidents, respiratory infections, and renal failure. Discussion TXA in geriatric trauma patients undergoing intramedullary nail surgery is effective for perioperative haemostasis without increasing the incidence of postoperative complications. Level of evidence II, Systematic review and Meta-analysis.

Measurement of total kidney volume (TKV) plays an important role in the early therapeutic stage of autosomal dominant polycystic kidney disease (ADPKD). As a crucial biomarker, an accurate TKV can sensitively reflect the disease progression and be used as an indicator to evaluate the curative effect of the drug. However, manual contouring of kidneys in magnetic resonance (MR) images is time-consuming (40 minutes), which greatly hinders the wide adoption of TKV in clinic. In this paper, we propose a multi-resolution 3D convolutional neural network to automatically segment kidneys of ADPKD patients from MR images. We adopt two resolutions and use a customized V-Net model for both resolutions. The V-Net model is able to integrate both high-level context information with detailed local information for accurate organ segmentation. The V-Net model in the coarse resolution can robustly localize the kidneys, while the VNet model in the fine resolution can accurately refine the kidney boundaries. Validated on 305 subjects with different loss functions and network architectures, our method can achieve over 95% Dice similarity coefficient with the groundtruth labeled by a senior physician. Moreover, the proposed method can dramatically reduce the measurement of kidney volume from 40 minutes to about 1 second, which can greatly accelerate the disease staging of ADPKD patients for large clinical trials, promote the development of related drugs, and reduce the burden of physicians.

This retrospective study aimed to use preoperative and contrast-enhanced ultrasound (CEUS) factors to assess and reveal risk factors of early recurrence (ER) in patients with hepatocellular carcinoma (HCC). We enrolled 141 patients with primary HCC who had undergone surgical resection. The assessment of the CEUS scan includes (a) the maximum diameter of the lesion, (b) the tumor echogenicity of gray-scale ultrasound (US), (c) the morphology of the tumor, (d) the margin of the tumor, (e) the peripheral hypoechoic halo, (f) tumor necrosis, (g) nutritional arteries shown by tumors, (h) ultrasonography for diagnosis of cirrhosis, and (i) the timer on the US screen displayed the time elapsed from the saline flush and was used to determine time to washout. According to the degree of the phase, the washout rate is divided into four grades, namely, levels 1 to 4. ER is defined as the time between resection and recurrence within 12 months after surgery. Risk factors for ER HCC were analyzed. Predictors of ER on a univariate logistic regression analysis in CEUS are size, washout rate, morphology, center necrosis, and feeding artery appearing in the tumor. Multivariate analysis results indicated that feeding artery, microvascular invasion (MVI), and washout rate were independent risk factors for ER. The relative high risk of ER for washout rate 1, 2, 3, and 4 were 29.3%, 43.2%, 53.1%, and 71.4%, respectively. The appropriateness of hepatectomy in the treatment of single lesion HCC should be carefully considered when the washout rate was 4.

Introduction Recently, many studies used the Charlson comorbidity index (CCI) to predict the postoperative mortality rate of elderly patients with hip fractures. However, as a predictor, CCI did not include other preoperative risk factors, resulting in decreasing its predictive value. Therefore, we performed a study to focus on two questions as follows: (1) What is the one-year mortality rate of elderly Chinese patients who underwent surgery for hip fracture? (2) Could risk-adjusted CCI act as a new predictor to predict the one-year mortality rate? Hypothesis The risk-adjusted CCI could exhibit a good predictive value for one-year mortality of elderly Chinese patients who underwent surgery for hip fracture. Material and methods This retrospective observational cohort study is based on data collected from July 2012 to April 2016. Patients aged 65 years and older who underwent hip fracture surgery were included. The clinical patient data were obtained, including gender, age, BMI, types of fracture, smoking, injury side, time from injury to surgery, and CCI. Stepwise multiple logistic regression analysis was used to identify risk factors contributed to the occurrence of postoperative death at one-year follow-up. The risk-adjusted CCI scores of patients were calculated by the formula based on the coefficient regression and independent variables. Receiver operating characteristic (ROC) curve analysis was used for determining the diagnostic value of different factors. Results A total of 445 elderly patients who underwent surgery for hip fracture, including 171 males and 274 females, were enrolled in the study cohort. The mean CCI scores of all enrolled patients were 1.20 ± 1.62. Sixty-four patients died within one year, and the one-year mortality rate was 14.38 %. The multivariate logistic regression analysis reported that age, time from injury to surgery, and CCI were associated with death after surgical treatment within one year. The risk-adjusted CCI scores of patients = 0.099 × age (years) + 0.355 × time from injury to surgery (days) + 0.434 × CCI scores. The predictive value of the risk-adjusted CCI was highest among these risk predictors, whose AUC value was 0.816. Discussion The risk-adjusted Charlson comorbidity index could be used as a guide to predict one-year mortality rate in elderly Chinese patients after the surgical treatment of hip fractures. Level of evidence III; cohort comparative study.

Background Currently, few studies focus on the treatment of Parkinson's disease (PD) patients after a fracture. The effect of PD on geriatric patients with intertrochanteric fracture remains unclear. Therefore, we performed a study to focus on two questions as follow: (1) would PD increase the operation difficulty and perioperative complications in Chinese elderly patients with intertrochanteric fracture? (2) Is there any difference between the clinical outcome of patients with and without PD? Hypothesis PD would increase perioperative complications and influence the postoperative rehabilitation in elderly patients with intertrochanteric fracture. Materials and methods There were 445 elderly intertrochanteric fracture patients treated with proximal femoral nail anti-rotation during January 2010 and December 2017. After propensity score matching, twenty-four geriatric intertrochanteric fracture patients with PD and forty-eight geriatric intertrochanteric fracture patients without PD were enrolled in this retrospective study. Intraoperative and postoperative comparison were conducted between patients with and without PD. Results Compared with 63 months for geriatric intertrochanteric fracture patients without PD, patients with PD had a median survival time of 31 months. The Harris Hip Score and Barthel Index of patients with PD were significantly lower than that of patients without PD. In addition, the Depression subscale score of patients with PD were significantly higher that of patients without PD. Discussion The effect of PD on geriatric patients with intertrochanteric fracture is not the operation itself, but the postoperative rehabilitation. In addition, multi-disciplinary treatment, personal rehabilitation training, more intensive outpatient care, and meticulous nursing were recommended in treatment for elderly patients with intertrochanteric fracture and PD. Level of proof III, Cohort Comparative Study.

Background Recently, there has been a series of clinical studies focusing on the perioperative administration of tranexamic acid (TXA) in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery. However, the safety and efficacy of TXA in these patients remains controversial. Therefore, we performed a systematic review to focus on two questions: (1) would TXA reduce perioperative blood loss in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery? and (2) would TXA increase the rate of perioperative complications in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery? Patients and methods We systematically searched electronic databases (MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials) up to April 20, 2019. The perioperative blood loss and complication data were extracted and analysed by RevMan Manager 5.3. Results Finally, five randomized controlled studies, involving 539 geriatric intertrochanteric fracture patients undergoing proximal femoral intramedullary nail surgery, were enrolled in this systematic review. Compared with the control group, the TXA group had significantly lower total perioperative blood loss (WMD = − 172.84; 95% CI, − 241.44 to − 104.24; I2 = 0%), intraoperative blood loss (WMD = − 34.20; 95% CI, − 46.04 to − 22.36; I2 = 0%), total perioperative hidden blood loss (WMD = − 139.05; 95% CI, − 213.67 to − 64.43; I2 = 0%), perioperative transfusion rates (RR = − 0.16; 95% CI, − 0.24 to − 0.08; I2 = 22%), length of hospital stay (WMD = − 1.18; 95% CI, − 1.91 to − 0.46; p = 0.001; I2 = 12%), and postoperative wound haematoma rates (RD = − 0.05; 95% CI, − 0.09 to 0.00; p = 0.03; I2 = 0%). In addition, there were no significant differences between TXA and control groups in the terms of surgical time, postoperative mortality, total thromboembolic events, wound infections, cerebrovascular accidents, respiratory infections, and renal failure. Discussion TXA in geriatric trauma patients undergoing intramedullary nail surgery is effective for perioperative haemostasis without increasing the incidence of postoperative complications. Level of evidence II, Systematic review and meta-analysis.

Objective To assess the efficacy and safety of epsilon-aminocaproic acid (EACA) in reducing the blood loss and transfusion volume during open spinal deformity surgery. Methods A systematic search was conducted for all studies written in English published on or before October 2018 in PubMed, EMBASE, and the Cochrane Library that compared antifibrinolytic agents with placebos for open spinal deformity surgeries. The primary outcomes included the total blood loss, intraoperative, and postoperative blood loss, transfusions volume and complication rate. Results Seven studies that included 525 patients who were diagnosed with spinal deformity. Compared with placebo, the patients who received EACA showed a reduction in the postoperative blood loss (mean difference [MD] −249.80; 95% confidence interval [CI] −375.65 to −123.95; P = 0.0001) and total blood loss (MD −670.30; 95% CI −1142.63 to −197.98; P = 0.005). Furthermore, the patients treated with EACA received approximately 1.67 fewer units of blood (MD −1.67; 95% CI −3.10 to −0.24; P = 0.02). However, in this cohort, no statistically significant differences were observed in the intraoperative blood loss (MD −452.19; 95% CI −1082.21 to 177.83; P = 0.16) and complication rate (odds ratio 0.73; 95% CI 0.16–3.24; P = 0.68). Conclusions This meta-analysis demonstrated that EACA could be safe and potentially efficacious for reducing blood loss and transfusions volume in patients with spinal deformity surgeries when compared with placebo. In light of the significant heterogeneity, the findings of this meta-analysis should be confirmed in methodologically rigorous and adequately powered clinical trials.

No consensus had been reached about the optimal treatment for syndesmotic fixation. We performed a review of randomized controlled trials (RCTs) to assist in clarifying many of the controversies that were debated for years despite new technology and options. PubMed, Embase, and the Cochrane Library were searched through specific terms and limits. Only RCTs were selected for final inclusion. Study screening and data extraction were performed independently by 2 reviewers. Thirteen RCTs, including 828 cases, met the inclusion criteria and are summarized in this review. Pooled results demonstrated that dynamic fixation had better functional outcomes as well as lower rates of malreduction and complications compared with syndesmotic screw fixation. Both absorbable screw and tricortical screw fixation showed similar results to quadricortical metallic screws. Therefore, dynamic fixation is recommended for the treatment of syndesmosis injuries.

Mesenchymal stem cells (MSCs) and hyaluronic acid (HA) have been found in previous studies to have great potential for medical use. This study aimed to investigate the therapeutic effects of bone marrow mesenchymal stem cells (BMSCs) combined with HA on articular cartilage repair in canines. Twenty-four healthy canines (48 knee-joints), male or female with weight ranging from 5 to 6 kg, were operated on to induce cartilage defect model and divided into 3 groups randomly which received different treatments: BMSCs plus HA (BMSCs-HA), HA alone, and saline. Twenty-eight weeks after treatment, all canines were sacrificed and analyzed by gross appearance, magnetic resonance imaging (MRI), hematoxylin-eosin (HE) staining, Masson staining, toluidine blue staining, type II collagen immunohistochemistry, gross grading scale and histological scores. MSCs plus HA regenerated more cartilage-like tissue than did HA alone or saline. According to the macroscopic evaluation and histological assessment score, treatment with MSCs plus HA also lead to significant improvement in cartilage defects compared to those in the other 2 treatment groups (P

Stem cell therapy is considered an optimistic approach to replace current treatments for cartilage defects. Recently, human urine-derived stem cells (hUSCs), which are isolated from the urine, are studied as a promising candidate for many tissue engineering therapies due to their multipotency and sufficient proliferation activities. However, it has not yet been reported whether hUSCs can be employed in cartilage defects. In this study, we revealed that induced hUSCs expressed chondrogenic-related proteins, including aggrecan and collagen II, and their gene expression levels were upregulated in vitro. Moreover, we combined hUSCs with hyaluronic acid (HA) and injected hUSCs-HA into a rabbit knee joint with cartilage defect. Twelve weeks after the injection, the histologic analyses (HE, toluidine blue, and Masson trichrome staining), immunohistochemistry (aggrecan and collagen II), and histologic grade of the sample indicated that hUSCs-HA could stimulate much more neocartilage formation compared with hUSCs alone, pure HA, and saline, which only induced the modest cartilage regeneration. In this study, we demonstrated that hUSCs could be a potential cell source for stem cell therapies to treat cartilage-related defects in the future.

Objective The giant calcified herniated thoracic disc (HTD), a rare disease, is a challenge for surgeons because of its complications. This review aimed to confirm the surgical treatment, including surgical approach, results, and complications of HTDs. Methods This systematic review of the literature complies with the PRISMA guidelines and involves a search of PubMed, Embase, and the Cochrane Library for all papers describing surgical treatment of giant calcified HTDs in ≥3 patients. Data on the surgical approach, change in neurologic impairment, and complications were extracted from the search results. Results A total of 11 studies, including 164 patients with giant calcified HTDs that met the inclusion criteria, were included in this systematic review. Of the 164 patients, 145 had myelopathy in giant calcified HTDs, and 8 surgical approaches were included. After the surgical treatment, the neurologic grades were improved in 69% of patients, remained unchanged in 22% of patients, and worsened further in 3% of patients at the final follow-up. Also, of the total patients analyzed, 3% had permanent neurologic deterioration, 4% patients had subarachnoid–pleural cerebrospinal fluid fistula complications, 30% had other complications, 4% had reoperation via transthoracic approach, 13% had permanent neurologic deterioration via the posterolateral approach, and 25% had permanent neurologic deterioration via the thoracoscopy approach. Conclusions Surgical treatment can improve or stabilize neurologic impairment for most patients with giant calcified HTDs. We thus recommend the anterior thoracotomy approach for giant calcified HTDs because of the theoretical advantages over other approaches and the low rate of neurologic deterioration, subarachnoid–pleural cerebrospinal fluid fistula, and reoperation.

Endothelial progenitor cells (EPC) derived from the circulation may be used to enhance neovascularization. Since the combination of granulocyte colony-stimulating factor (GCSF) and CXCR4 antagonist AMD3100 efficiently mobilizes hematopoietic stem cells into peripheral circulation, it may increase the pool of endogenously circulating EPC. We tested this hypothesis by administering GCSF and AMD3100 to adult rabbits and rats, isolating mononuclear cells from peripheral blood by Ficoll density gradient centrifugation, and characterizing the blood-derived EPC based on morphology, immunophenotyping, gene expression and other functional analyses. These EPC showed clonal growth similar to that of human umbilical vein endothelial cells when cultured in complete EGM-2 medium on collagen I-precoated culture plates. The EPC exhibited a typical cobblestone-like morphology and were relatively homogeneous by the third passage. The cells expressed the typical endothelial marker CD31 based on flow cytometry and fluorescence microscopy, formed capillary-like structures when cultured in Matrigel, internalized DiI-acetylated low-density lipoprotein, bound Ulex europaeus agglutinin-1, and expressed CD31 and several other endothelial markers (VEGFR2, VE-cadherin, Tie-2, eNOS, vWF) at significantly higher levels than bone marrow-derived mesenchymal stem cells. These results suggest that the combination of GCSF and AMD3100 can efficiently release stem cells into peripheral circulation and generate EPC that show the desired morphological, immunophenotypic and functional characteristics. This minimally invasive approach may be useful for autologous cell transplantation for postnatal neovasculogenesis and tissue repair.

Aim To determine the accuracy of MRI versus ultrasound for Morton's neuroma. Materials and methods A search was undertaken for clinical studies published in any language in PubMed up to the date of December 2013. Studies assessing the accuracy of the ultrasound or MRI for the diagnosis of Morton's neuroma were included. Data were pooled for meta-analysis. Study selection, data collection, and extraction were performed independently by two authors. Meta-disc 1.4 and Revman 5.2 software were applied for statistical analysis. Results The study included 12 studies; 217 patients underwent MRI and 241 underwent ultrasound examinations. There appeared greater diagnostic accuracy for ultrasound than MRI for the diagnosis of Morton's neuroma (ultrasound sensitivity 90%, specificity 88%, positive likelihood ratio 2.77, negative likelihood ratio 0.16 versus MRI sensitivity 93%, specificity 68%, positive likelihood ratio 1.89, negative likelihood ratio 0.19). Conclusions The available evidence suggests that ultrasound can provide better accuracy for the diagnosis of Morton's neuroma than MRI.

To evaluate the effectiveness and safety of arthroscopic and open Bankart repair for recurrent anterior shoulder dislocation using meta-analysis of data from clinical trials.Cochrane Register of Controlled Trials, PUBMED and EMBASE were used to search and identify clinical trials that evaluated arthroscopic and open Bankart repair for recurrent anterior shoulder dislocation. Methodological qualities of studies were assessed by Cochrane Collaboration tool for assessing risk of bias and Newcastle-Ottawa Scale. Publication bias was detected using Begg's test and Egger's test.Sixteen trials involving 827 shoulders were included in the study. Based on Cochrane Collaboration tool for assessing risk of bias, three studies were rated as high quality and one study was rated as moderate quality among the randomized controlled trials. Another twelve case-control studies were rated as high quality based on Newcastle-Ottawa Scale. No significant publication bias was detected by Begg's test or Egger's test. Meta-analysis results indicated that arthroscopic repair has a significantly better recovery rate for external rotation at 90° of abduction, external rotation at side (P0.05) and forward flexion. However, arthroscopic repair had higher rates of recurrence and reoperation than open Bankart repair.Meta-analysis of available randomized controlled trials and case-control studies demonstrated that arthroscopic repair and open Bankart repair were similar in safety. Arthroscopic repair resulted in better recovery of range of motion, but recurrence and reoperation rates were higher than open Bankart repair.

BackgroundRepair of soft tissue in favour of the posterior approach for total hip arthroplasty is still under discussion and few studies are assessing this issue. Therefore, we performed a meta-analysis to compare the effectiveness and safety of the posterior approach for total hip arthroplasty with and without soft tissue repair. We focused on these questions as follows: does primary posterior approach for total hip arthroplasty with soft tissue repair has better result regarding dislocation rate, Harris hip score and the sciatic nerve palsy rate compared with posterior approach without soft tissue repair.Patients and methodsWe conducted electronic literature searches using CENTRAL (Issue 1 of 12, Jan 2014), PUBMED (1980 to Jan 2014), and EMBASE (1980 to Jan 2014). Clinical studies evaluating the posterior approach for total hip arthroplasty with and without soft tissue repair were collected. After independent study selection by 2 authors, data were collected and extracted independently. The methodological quality of the studies was assessed by the Cochrane Collaboration's tool for assessing risk of bias and the Newcastle-Ottawa Scale.ResultSeven clinical trials with 4594 hips using the posterior approach for total hip arthroplasty were included. The pooled data indicated a lower rate of dislocation (OR: 0.14, 95% CI: 0.08–0.26, P

Background Cervical intradural disc herniation (CIDH) is rare, and diagnosis and treatment are challenging. We conducted a systematic review and meta-analysis of the literature on the diagnosis and treatment of CIDH. Method The presentation, imaging manifestations, diagnosis, management, prognosis and possible pathogenesis were reviewed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. English-language studies and case reports published from inception to 2017 were retrieved. Data on presentation, imaging characteristics, diagnosis, management, outcomes and pathogenesis were extracted. Results Twenty articles involving 23 patients were selected. The most common involved level was C5-6 (43.5%), followed by C6-7 (30.4%), C4-5 (13%), and C3-4 (13%). Spontaneous IDH occurred in 61% of the patients, and relevant cervical trauma was present in 39%. Brown–Sequard’s syndrome (56.5%), quadriparesis (34.8%), and radiculopathy (8.7%) were the main presentations. Magnetic resonance imaging (MRI) was the most commonly used diagnostic technique, and the “halo” and “Y-sign” were strong indicators of CIDH. Three (13%) patients were diagnosed as having CIDH preoperatively, and 87% were confirmed intraoperatively. All patients underwent surgical intervention primarily (73.9%) through an anterior approach. Neurological function improved postoperatively in all patients but one. Dural and arachnoid mater tears were managed by direct suture or covering with a substitute, and only one patient sustained cerebrospinal fluid (CSF) leakage after surgery. Conclusion IDH mostly involves the lower cervical spine. More than half of the patients had spontaneous CIDH, and some had a relevant cervical trauma history. BSS was the main presentation. It is difficult to diagnose CIDH depending on clinical presentations and radiographic findings. Surgery was an effective treatment for CIDH and can provide a definitive diagnosis. With meticulous management of dural and arachnoid tears, the postoperative incidence of CSF leakage was found to be low.

Objective: The aim of this meta-analysis was to explore the difference between and compare intramedullary fixation (IF) and extramedullary fixation (EF) for unstable intertrochanteric fractures. Methods: We searched Pubmed database and Cochrane library following by including and excluding articles based from inception to December, 2016. All randomized controlled trials (RCTs) comparing IF and EF for unstable intertrochanteric fractures were assessed and selected by two researchers independently. Data were analyzed using Review Manager 5.1 version. Results: 17 RCTs were enrolled in our meta-analysis comparing IF and EF and showed evidence that IF had lower rate of implant failure RR = 0.2695%CI 0.13–0.51, P

Postoperative occipital neuralgia (PON) after upper cervical spine surgery can cause significant morbidity and may be overlooked. The causes, presentation, diagnosis, management, prognosis, and prevention of PON were reviewed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. English-language studies and case reports published from inception to 2017 were retrieved. Data on surgical procedures, incidence, cause of PON, management, outcomes, and preventive technique were extracted. Sixteen articles, including 591 patients, were selected; 93% of the patients with PON underwent C1 lateral mass screw (C1LMS) fixation, with additional 7% who underwent occipitocervical fusion without C1 fixation. PON had an incidence that ranged from 1 to 35% and was transient in 34%, but persistent in 66%. Five articles explained the possible causes. The primary presentation was constant or paroxysmal burning pain located mainly in the occipital and upper neck area and partially extending to the vertical, retroauricular, retromandibular, and forehead zone. Treatment included medications, nerve block, revision surgery, and nerve stimulation. Two prospective studies compared the effect of C2 nerve root transection on PON. PON in upper cervical spine surgery is a debilitating complication and was most commonly encountered by patients undergoing C1LMS fixation. The etiology of PON is partially clear, and the pain could be persistent and hard to cure. Reducing the incidence of PON can be realized by improving technique. More high-quality prospective studies are needed to define the effect of C2 nerve root transection on PON.

This meta-analysis was conducted to investigate whether helical blade implant system had advantages in terms of cut-out rate when compared to screw implant system for trochanteric fractures of elderly population.The databases of MEDLINE, Cochrane Library and OVID were searched from inception to September 2013, and all randomized controlled trials comparing outcomes between helical blade system and screw system in treating trochanteric fractures were selected. Three researchers assessed the methodological quality and extracted data of the enrolled studies independently. Data were analysed using Review Manager 5.1 version.Six studies including 759 patients were involved. Results revealed that compared with screw group, blade group had similar outcomes of "centre-centre" position (95% CI 0.89-1.06, P = 0.48) and tip-apex distance (95% CI-0.08 to 1.31, P = 0.08). Cut-out and other complications were also comparable between the two groups (95% CI 0.34-1.54, P = 0.41; 95% CI 0.73-1.32, P = 0.90). Operation time and fluoroscopy time of blade group were significantly less than that of screw group (95% CI -5.13 to -3.70, P0.00001; 95% CI -32.50 to -27.07, P0.00001). Outcome of post-operative function was similar between two groups (95% CI 0.94-1.15, P = 0.45).Blade group required less operation time and fluoroscopy time than that of screw group treating trochanteric fractures in the elderly, but the differences observed could be biased due to grouping and other limitations. Outcomes of cut-out complication, other complications, position of implant and post-operative function were similar between two groups.

Objectives Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are treatment choices for end-stage shoulder osteoarthritis. The decision of whether to use TSA or HA is controversial. The objective of this study was to compare the effects of TSA and HA for shoulder osteoarthritis. Methods We conducted a search for clinical studies that had been published in any language in December 2012 or before. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and several other databases. Randomized and quasi-randomized controlled clinical studies that evaluated different methods were included. At least two review authors independently performed the study selection, data collection, and data extraction. The software Revman 5.1 was used for the statistical analysis. Results This study included 4 clinical trials. Two of the trials were published clinical trials, and the other 2 clinical trials were presented as unpublished abstracts. A total of 146 patients with 153 shoulders were included in the trials. Compared with HA, TSA presents with a higher UCLA shoulder scale (MD 3.10, 95% CI 1.13–5.08) and a higher ASES (MD 10.17, 95% CI 1.40–18.87). There was no significant difference between TSA and HA for revision (RR 0.35, 95% CI 0.10–1.19), WOOS (MD 9.10, 95% CI −2.72 to 20.92), and incidence of instability (RR 0.88, 95% CI 0.19–3.98). HA had a lower operation time (MD 39.00, 95% CI 17.05–60.95). Conclusion The available evidence suggests that TSA is more effective than HA for patients with shoulder arthritis.

Anterior cervical discectomy and fusion is a standard treatment for symptomatic cervical disc disease, but pseudarthrosis and accelerated adjacent-level disc degeneration may develop. Cervical disc arthroplasty was developed to preserve the kinematics of the functional spinal unit. Trials comparing arthroplasty with anterior cervical discectomy and fusion have shown unclear benefits in terms of clinical results, neck motion at the operated level, adverse events, and the need for secondary surgical procedures.Only randomized clinical trials were included in this meta-analysis, and the search strategy followed the requirements of the Cochrane Library Handbook. Two reviewers independently assessed the methodological quality of each included study and extracted the relevant data.Twenty-seven randomized clinical trials were included; twelve studies were Level I and fifteen were Level II. The results of the meta-analysis indicated longer operative times, more blood loss, lower neck and arm pain scores reported on a visual analog scale, better neurological success, greater motion at the operated level, fewer secondary surgical procedures, and fewer such procedures that involved supplemental fixation or revision in the arthroplasty group compared with the anterior cervical discectomy and fusion group. These differences were significant (p0.05). The two groups had similar lengths of hospital stay, Neck Disability Index scores, and rates of adverse events, removals, and reoperations (p0.05).The meta-analysis revealed that anterior cervical discectomy and fusion was associated with shorter operative times and less blood loss compared with arthroplasty. Other outcomes after arthroplasty (length of hospital stay, clinical indices, range of motion at the operated level, adverse events, and secondary surgical procedures) were superior or equivalent to the outcomes after anterior cervical discectomy and fusion.

Since 2002, the Trinity Mode has been adopted in China to include safe drinking water and sanitation services in order to change the services into public products of rural communities. These products would contain multi-valued attributes of miniature infrastructure constructions, primary health care, and ecological protection. Poverty reduction demands different policies with extended connotation and changed features, from increasing income to improving welfare services, from a macroscopic to a microscopic viewpoint, from the national level to that of communities, and from the indistinguishable to an individual. Against such background, A Ba Prefecture is selected as the case study area. Safe drinking water and sanitation services, the most important components of basic public health services, are selected as the research object in the study, and both sanitation and health are included in the framework to analyze poverty. Altogether, 5637 valid questionnaires of “The Investigation on Poverty Alleviation in A Ba Prefecture in2009”have been carefully studied. The study shows that great achievements have been made in alleviating poverty in A Ba by improving the drinking water in rural areas. However, a huge amount of work is needed to apply hygiene facilities and popularize clean energy. Hence, the government’s antipoverty policies should be strengthened in the latter two aspects.

Purpose Network meta-analysis (NMA) is a comparatively new evidence-based technique in medical disciplines which compares the relative benefits associated with multiple interventions and obtains hierarchies of these interventions for various treatment options. We evaluated the effectiveness and safety of open reduction and internal fixation (ORIF), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), intramedullary nailing (IN) and non-operative treatment (NOT) of displaced proximal humeral fractures in adults using Bayesian NMA of data from clinical trials. Method PUBMED, EMBASE and CENTRAL in July 2016 were searched and clinical trials that evaluated interventions for treating adults with displaced proximal humeral fractures were identified. Methodological qualities of studies were assessed by the Newcastle—Ottawa Scale and risk of bias using the Cochrane Collaboration tool. Result Thirty-four trials involving 2165 participants were included in the study. RSA had significantly the highest Constant score and lower total incidence of complications than ORIF, HA and IN. Moreover, RSA resulted in a lower incidence of additional surgery than ORIF and IN. The rank of treatments in terms high Constant score was: RSA, ORIF, IN, NOT and HA. The rank for reduction in total incidence of complications was: RSA, NOT, HA, IN and ORIF. For lowering the risk of additional surgery, the rank was: RSA, NOT, HA, IN and ORIF. Conclusion RSA had the highest probability for improving functional outcome and reduction in the total incidence of complications and requiring additional surgery among the five interventions for treating adults with displaced proximal humeral fracture.

BACKGROUND Subtrochanteric fractures of the femur complicated with segmental bone defects are uncommon injuries and challenging to manage. We evaluated the effect of reconstructing extensive bone defect in the subtrochanteric area (mean, 6.9 cm) with folded free vascularized fibular graft (FVFG). METHODS Between 2001 and 2007, 14 cases of subtrochanteric fractures complicated with huge bone defects treated by folded FVFG transfer in our hospital were retrospectively reviewed. The defect was reconstructed by folded FVFG transfer and locking plate stabilization in 10 patients with no sign of infection at admission (group 1). In the other four patients presented with infections (group 2), the defect was reconstructed by folded FVFG transfer and external fixator fixation. The average follow-up period was 67.4 months. RESULTS Bone union was achieved in all of the cases at an average of 5.4 months (range, 4-6 months). Primarily, bone union was achieved in all of the cases in group 1, but one stress fracture occurred in group 2. The full weight bearing time was 5.4 months (range, 5-6 months) in group 1 and 8.5 months (range, 8-9 months) in group 2. Seven patients in group 1 had the locking plate removed in an average of 27 months (range, 18-38 months). In group 2, the external fixator removal time was 13 months (range, 10-18 months). There was no varus deformity at the final follow-up in group 1. The neck-shaft angle measured during the postoperative period and at final follow-up was 129.6 degrees and 129.4 degrees, respectively. In group 2, the neck-shaft angle at the final follow-up was significantly less than the angle measured at the postoperative period (115.5 vs. 129.5 degree, p = 0.021). The range of motion of the hip and knee joint (extend and flex) was 100 degrees or more in all patients at the final follow-up. CONCLUSIONS The results of this study showed that huge subtrochanteric bone defects reconstructed by folded FVFG and locking plate were highly successful in achieving bone union, reducing risks of postoperative stress fracture and preventing malunion. When huge bone defects in the subtrochanteric area complicated with acute or chronic infections, the technique of external fixator offers an alternative to reconstruct the stability of the proximal femur after folded FVFG. However, because of the inadequate stabilization, the risks of varus malunion and postoperative stress fracture could be increased after external fixator fixation. LEVEL OF EVIDENCE V, therapeutic study.

There are two generally accepted techniques, antegrade locked intramedullary nailing and dynamic compression plating, for the treatment of humeral shaft fractures in adults. However, which technique is superior remains controversial. The aim of this meta-analysis is to compare the clinical outcomes of the two techniques and to present the best evidence currently available. We conducted an electronic search of using databases including the Cochrane registry of clinical trials, Medline, and Embase. Studies were selected, and data were extracted independently by two investigators. Four trials were found, which matched the inclusion criteria. Statistical heterogeneity was not detected among these included trials. The available evidence demonstrated that dynamic compression plating may lead to fewer complications and shoulder impairments but may cause higher risk of infection than antegrade locked intramedullary nailing. Incidences of nerve palsy and nonunion were comparable between the two methods. Future high-quality trials are required to overcome the limitation of mall population size currently presented.

Fractures of femoral fracture are among the most common fractures encountered in orthopedic practice. Intramedullary nailing is the treatment choice for femoral shaft fractures in adults. The objective of this article is to determine the effects of reamed intramedullary nailing versus unreamed intramedullary nailing for fracture of femoral shaft in adults.Cochrane Central Register of Controlled Trials (October 2010), PubMed (October 2010) and EMBASE (October 2010) were searched. Randomized and quasi-randomized controlled clinical trials were included. After independent study selection by two authors, data were collected and extracted independently. The methodological quality of the studies was assessed. Pooling of data was undertaken where appropriate.Seven trials with 952 patients (965 fractures) were included. Compared with unreamed nailing, reamed nailing was significantly lower reoperation rate (RR 0.25, 95% CI 0.11-0.59, P = 0.002), lower non-union rate (RR 0.20, 95% CI 0.05-0.77, P = 0.02) and lower delay union rate(RR 0.30, 95% CI 0.14-0.64, P = 0.002). There was no significant difference when comparing reamed nailing with unreamed nailing for implant failure (RR 0.51, 95% CI 0.16-1.61, P = 0.25), mortality(RR 0.94, 95% CI 0.19-4.58, P = 0.94) and acute respiratory distress syndrome(RR 1.53, 95% CI 0.37-6.29, P = 0.55). Unreamed nailing was significantly less blood loss (SMD 119.23, 95% CI 59.04-180.43, P = 0.0001).Reamed intramedullary nailing has better treatment effects than unreamed intramedullary nailing for shaft fracture of femur in adults.

No surgical procedure perfectly treats advanced Kienböck disease. Although vascularized os pisiform transferring (VOPT) is one of the main therapeutic approaches, reports on long-term follow-up and case series for this technique are scarce. We collected postoperative results in 11 patients with advanced Kienböck disease who underwent VOPT between 1986 and 2001 in our Hospital. Follow-up durations ranged from 15 to 26 years. At the last follow-up, excellent and good results were found in 81.8% according to the Modified Green and O’Brien score. Postoperative imaging revealed significantly reduced pisiform bone; carpal height ratio and Nattrass index were decreased, while the radioscaphoid angle was increscent, compared with preoperative and mid-term follow-up results. The favorable long-term results demonstrated that VOPT is a dependable and durable procedure for the treatment of advanced Kienböck disease, with pain relief and functional improvement despite some radiographic findings such as wrist osteoarthritis occurrence.

A 40-year-old woman had her right extremity avulsed at the proximal upper arm level and the wrist and hand of her left extremity irretrievably injured in a traffic accident. The right distal forearm was surgically amputated and replanted onto the stump of the left distal forearm. New strategy for nerve repair was applied and the function recovery of the cross-replanted hand was favorable. We thought that cross-extremity replantation was indicated when the patient suffered from bilateral total or subtotal amputation at different levels and orthotopic replantation was impossible.