Hidden blood loss and the influential factors after intramedullary nail fixation of extra-articular tibial fractures - a retrospective cohort study.

PURPOSE: There were few reports in the literature about the hidden blood loss (HBL) after intramedullary nail (IMN) fixation for extra-articular tibial fractures. Our purpose was to evaluate the amount of hidden blood loss after intramedullary nail fixation for extra-articular tibial fractures, meanwhile, identified the influential factors causing HBL. METHODS: From January 2015 to December 2017, 122 consecutive extra-articular tibial fracture patients fixed with IMN and 96 met all inclusion criteria for the chosen analysis. Preoperative hematocrit (Hct) levels on admission and postoperative Hct levels on the third day after surgery to calculate the amount of HBL. RESULTS: The mean HBL was 473.29 ± 102.75 ml after IMN fixation of extra-articular tibial fractures, the multiple regression analysis showed gender, surgical duration, and the diameter of the medullary cavity at the narrowest part of the tibia had an independent influence on HBL. CONCLUSIONS: A significant amount of postoperative HBL has occurred after IMN fixation of extra-articular tibial fractures. Surgeons should be aware that more HBL can be developed in patients who have male sex, small medullary cavity, and long-time surgical duration. HBL deserves attention to ensure patients' safety in the perioperative period of IMN fixation for extra-articular tibial fractures.

Indirect 3D printing technology for the fabrication of customised ß-TCP/chitosan scaffold with the shape of rabbit radial head-an in vitro study.

BACKGROUND: With the development of indirect three-dimensional (3D) printing technology, it is possible to customise individual scaffolds to be used in bone transplantation and regeneration. In addition, materials previously limited to the 3D printing (3DP) process due to their own characteristics can also be used well in indirect 3DP. In this study, customised ß-TCP/chitosan scaffolds with the shape of rabbit radial head were produced by indirect 3D printing technology. METHODS: Swelling ability, porosity, mechanical characterisation, and degradation rate analysis were performed, and in vitro studies were also implemented to evaluate the proliferation and osteogenic differentiation of bone marrow mesenchymal stem cells (MSCs) on the scaffolds. CCK8 cell proliferation assay kit and alkaline phosphatase (ALP) staining solution were used to study cell proliferation and early ALP content at the scaffold surface. Moreover, the osteogenic differentiation of MSCs on scaffolds was also evaluated through the scanning electron microscopy analysis. RESULTS: ß-TCP/chitosan scaffold has good performance and degradation rate, and in vitro cell experiments also confirm that the scaffold has adequate cytocompatibility and bioactivity. CONCLUSION: This study provides a promising new strategy for the design of customised scaffolds for the repair of complex damaged tissues.

Evaluating the Quality, Content, and Readability of Online Resources for Failed Back Spinal Surgery.

STUDY DESIGN: An Internet-based assessment of websites using recognized score systems. OBJECTIVE: To assess the quality, content, and readability of online information for failed back spinal surgery (FBSS). SUMMARY OF BACKGROUND DATA: A significant amount of patients still suffer from chronic or recurrent back pain with or without radicular symptoms after spinal surgery. More and more patients use the Internet to find health-related information. Low-quality or inaccurate information may not only misleading patients but also have a negative impact on the trust between patients and physicians. METHODS: The terms "chronic pain after spinal surgery," "chronic pain after back surgery," "failed back surgery syndrome," "post spinal surgery syndrome," and "post laminectomy syndrome" were entered into three search engines (Google, Yahoo!, and Bing). The first 25 websites from each search were reviewed. The quality, content, and readability of each website were evaluated using DISCERN score, FBSS-specific content score, and the Journal of the American Medical Association (JAMA) benchmark criteria, the first two score systems were assessed by three reviewers independently. The Flesch-Kincaid grade level (FKGL) was used to assess the readability. Each website with or without the Health on the Net Code (HONcode) was also recorded. RESULTS: Seventy-two websites were analyzed in our study. The average DISCERN score for all websites was 35.26 ±â€Š11.45, indicating the quality of the websites was poor. The DISCERN score of physician websites was 31.25 ±â€Š9.08, lower than that of media (36.50 ±â€Š0.71, P = 0.017) and commercial websites (42.55 ±â€Š10.93, P = 0.045). The mean FBSS-specific content score was 9.58 ±â€Š3.90 out of maximum 25. We failed to find any difference of FBSS-specific content score among different type of website. Websites with HONcode certification were associated with higher DISCERN score, FBSS-specific content score, and JAMA benchmark criteria score than non-certified websites. The mean FKGL was 12.19 ±â€Š2.20, and none of the websites' FKGL was lower than the six grade level. CONCLUSION: The quality and content of available online information for FBSS were poor. The readability of online information in our results showed a significantly higher reading level than the sixth-grade level recommended by the AMA and NIH. LEVEL OF EVIDENCE: 4.

Comparison of plate and intramedullary nail fixation of extra-articular tibial fractures: A retrospective study exploring hidden blood loss.

PURPOSE: To explore the hidden blood loss (HBL) in treatment of extra-articular tibial fractures with plate and intramedullary nail fixation. METHODS: We conducted a retrospective study including 209 consecutive patients treated by plate (Group LCP) or intramedullary nail fixation (Group IMN) for extra-articular tibial fractures between January 2015 to December 2017. Demographics, intraoperative data, perioperative laboratory values, transfusion rate, and early complications were collected and analyzed. RESULTS: Of 209 patients, 96 patients fixed with IMN and 113 fixed with LCP. The average HBL was 272.71 ± 57.88 ml in Group LCP and 507.66 ± 109.81 ml in Group IMN, and there was statistical difference in the HBL between two groups (p < 0.001). The Hb and Hct loss, surgical duration, and postoperative number of anemic patients in Group IMN were significantly higher than in Group LCP (p < 0.001), and IMN fixation has a significantly higher rate of transfusion (p = 0.027), whereas patients in group IMN has significantly less VBL (p < 0.001), shorter postoperative hospital stay (p < 0.001), and less superficial infection (p = 0.014). CONCLUSIONS: There was a significant amount of hidden blood loss after reamed intramedullary nail fixation for extra-articular tibial fractures, which was much higher than expected. In view of the morbidity of acute anaemia and transfusion, we suggest that for patients who suffer from extra-articular tibial fractures with multiple injuries, or those with low haemoglobin preoperatively, plates might be more suitable than nail fixation.

Serial changes in the head-shaft angle of proximal humeral fractures treated by placing locking plates: a retrospective study.

BACKGROUND: Although the proximal humeral fractures (PHFs) treated with locking plate have been well applied, there are few studies concerning on the serial HSA changes after locking plate placement. The purpose of this retrospective study was to explored the clinical significance of serial HSA changes after surgery. METHODS: We retrospectively analyzed the clinical data of 122 patients between January 2012 to December 2016 in our hospital. The serial change of the HSA and Neer's score of 122 patients were recorded and analyzed. Then, we evaluated the HSA changes affected functional recovery in conjunction with medial support (MS). Moreover, multivariable linear regression analysis was performed to identify any potential confounding factors that may influence functional recovery. RESULTS: Of 146 patients, 122 (50 males and 72 females) patients were finally enrolled in our study. Our preliminary data suggested that the most decrease of HSA occurred in the period of 1 to 3 months (p < 0.001) postoperatively, and functional recovery was significantly related with the change of HSA (R2 = 0.647, p < 0.001). The presence of MS plays an important role in maintaining postoperative HSA and restoring function. Moreover, Neer type 4 fracture, the difference between the postoperative HSA (on the injured side) and that of the uninjured side (the ΔHSA), and the HSA change to the end of follow-up were all significantly associated with functional recovery. CONCLUSIONS: Serial HSA changes were evident in PHF patients in whom locking plates had been inserted; it is essential to maintain reduction for 1-3 months postoperatively. MS is important in this context and surgeons must maximally restore MS. Furthermore, the functional outcome tended to improve when the HSA of the injured side was restored to a value close to that of the uninjured side.

Hidden blood loss and its risk factors after hip hemiarthroplasty for displaced femoral neck fractures: a cross-sectional study.

PURPOSE: Several authors have reported the degree of total blood loss (TBL) following hemiarthroplasty for displaced femoral neck fracture; however, the research specifically investigating on hidden blood loss (HBL) after hip hemiarthroplasty is still lacking. The purpose of this study is to evaluate the HBL in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures and to analyze its risk factors. PATIENTS AND METHODS: From January 2015 to December 2016, 212 patients (57 males and 155 females) with displaced femoral neck fracture undergoing hip hemiarthroplasty were included in this study. The demographic and relevant clinical information of the patients were collected. According to the Gross's formula, each patient's height, weight, and preoperative and postoperative hematocrit were recorded and used for calculating the total perioperative blood loss and HBL. Risk factors were further analyzed by multivariate linear regression. RESULTS: The HBL was 525±217 mL, with 61.0%±13.6% in the total perioperative blood loss (859±289 mL), and the perioperative hemoglobin (Hb) loss was 23.8±7.4 g/L. Multivariate linear regression analysis revealed that HBL was positively associated with higher American Society of Anesthesiologists (ASA) classification (regression coefficient=62.169, 95% CI=15.616-108.722; P=0.009), perioperative gastrointestinal bleeding/ulcer (regression coefficient=155.589, 95% CI=38.095-273.083; P=0.010), and transfusion (regression coefficient=192.118, 95% CI=135.578-248.659; P<0.001). Compared with females, males had a risk of increased HBL (regression coefficient=87.414, 95% CI=28.547-146.280; P=0.004), and general anesthesia had an increased HBL compared with spinal anesthesia (regression coefficient=68.920, 95% CI=11.707-126.134; P=0.018). CONCLUSION: HBL should not be ignored in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures in the perioperative period, because it is a significant portion of TBL. Female patients, patients with higher ASA classification and perioperative gastrointestinal bleeding/ulcer, patients who were administered general anesthesia, or patients who underwent transfusion had a greater amount of HBL after hip hemiarthroplasty was performed. Having a correct understanding of HBL may help surgeons improve clinical assessment capabilities and ensure patients' safety.

Arthroscopic-assisted balloon tibioplasty versus open reduction internal fixation (ORIF) for treatment of Schatzker II-IV tibial plateau fractures: study protocol of a randomised controlled trial.

INTRODUCTION: Arthroscopic-assisted balloon tibioplasty is an emerging technology that has shown advantages in recovering depression of the articular surface. However, studies evaluating clinical outcomes between arthroscopic-assisted balloon tibioplasty and traditional open reduction internal fixation (ORIF) are sparse. This is the first randomised study to compare arthroscopic-assisted balloon tibioplasty with ORIF, and will provide guidance for treating patients with Schatzker types II, III and IV with depression of the medial tibial plateau only. METHODS AND ANALYSIS: A blinded randomised controlled trial will be conducted and a total of 80 participants will be randomly divided into either the arthroscopic-assisted balloon tibioplasty group or the ORIF group, at a ratio of 1:1. The primary clinical outcome measures are the knee functional scores, Rasmussen radiological evaluation scores and the quality of reduction based on postoperative CT scan. Secondary clinical outcome measures are intraoperative blood loss, surgical duration, visual analogue scale score after surgery, hospital duration after surgery, complications and 36-Item Short-Form Health Survey score. ETHICS AND DISSEMINATION: This study has been reviewed and approved by the Institutional Review Board of the Second Affiliated Hospital of Wenzhou Medical University (batch: 2017-12). The results will be presented in peer-reviewed journals after completion of the study. TRIAL REGISTRATION NUMBER: NCT03327337, Pre-results.

The Role of Unilateral Balloon Kyphoplasty for the Treatment of Patients with OVCFS: A Systematic Review and Meta-Analysis.

BACKGROUND: An increasing number of studies have been conducted to apply unilateral balloon kyphoplasty in the treatment of ostroporotic vertebral compression fractures (OVCFs). However, the efficacy and safety of unilateral kyphoplasty and whether a unilateral or a bilateral approach is superior is controversial. OBJECTIVES: The purpose of this study was to evaluate the role of unilateral balloon kyphoplasty and use meta-analysis to compare the efficacy and safety of unilateral and bilateral kyphoplasty in patients with OVCFs. STUDY DESIGN: A systematic literature search was conducted from 1970 to April 2017 using Medline database and the Cochrane Central Register of Controlled Trials. Articles were limited to those published in English. Randomized controlled trials and nonrandomized comparative studies were also included. SETTING: The following search terms were used: "osteoporotic vertebral compression fractures," or "OVCF," and "unilateral kyphoplasty," or "unipedicular approach," or "single balloon kyphoplasty," or "one balloon kyphoplasty." A comprehensive search of reference lists of retrieved articles and previous published reviews was also performed to ensure inclusion of all possible studies. METHODS: All potential articles were independently reviewed by 2 investigators for inclusion into the final analysis. MINORS score was used for nonrandomized studies, and Detsky quality index was applied for prospective randomized controlled trials. Systematic review and meta-analysis was performed for the included studies. RESULTS: After unilateral balloon kyphoplasty the mean postoperative visual analog score (VAS) was from 1.74 to 4.77, mean postoperative kyphotic angle was from 5.9º to 11.22º, and complications involving cement leaks was from 6.8 to 21.9% or adjacent level fractures was from 0 to 5.6%). Unilateral kyphoplasty had significantly lower operative time, and less bone cement volume; however, the postoperative VAS, Oswestry Disability Index (ODI), vertebral height restoration rate, and cement leakage and adjacent vertebral fracture rate, were similar to bilateral kyphoplasty. LIMITATIONS: Only 6 randomized controlled trials and 3 retrospective comparative studies were selected for analysis. Heterogeneity was detected among the studies when we pooled the outcomes. CONCLUSIONS: Based on the available evidence, the clinical and radiological results of unilateral balloon kyphoplasty were as good as those of bilateral balloon kyphoplasty for the treatment of OVCFs. And unilateral kyphoplasty had advantages in terms of operation time, radiation exposure, and cost. KEY WORDS: Unilateral balloon kyphoplasty, bilateral balloon kyphoplasty, osteoporotic vertebral compression fractures, complications of balloon kyphoplasty, meta-analysis.

Sirt6 overexpression suppresses senescence and apoptosis of nucleus pulposus cells by inducing autophagy in a model of intervertebral disc degeneration.

Treatment of intervertebral disc degeneration (IDD) seeks to prevent senescence and death of nucleus pulposus (NP) cells. Previous studies have shown that sirt6 exerts potent anti-senescent and anti-apoptotic effects in models of age-related degenerative disease. However, it is not known whether sirt6 protects against IDD. Here, we explored whether sirt6 influenced IDD. The sirt6 level was reduced in senescent human NP cells. Sirt6 overexpression protected against apoptosis and both replicative and stress-induced premature senescence. Sirt6 also activated NP cell autophagy both in vivo and in vitro. 3-methyladenine (3-MA) and chloroquine (CQ)-mediated inhibition of autophagy partially reversed the anti-senescent and anti-apoptotic effects of sirt6, which regulated the expression of degeneration-associated proteins. In vivo, sirt6 overexpression attenuated IDD. Together, the data showed that sirt6 attenuated cell senescence, and reduced apoptosis, by triggering autophagy that ultimately ameliorated IDD. Thus, sirt6 may be a novel therapeutic target for IDD treatment.

Gastrodin reduces IL-1ß-induced apoptosis, inflammation, and matrix catabolism in osteoarthritis chondrocytes and attenuates rat cartilage degeneration in vivo.

Therapeutics for osteoarthritis (OA) are intended to restore chondrocyte function and inhibit cell apoptosis. Previous studies have shown that gastrodin had anti-apoptotic and anti- inflammatory effects. However, little is known about whether gastrodin has protective effects against the processes of OA. We studied the potential effects of gastrodin on chondrocytes and the underlying mechanisms. Our results showed that gastrodin could prevent chondrocyte apoptosis induced by IL-1ß. Additionally, gastrodin suppressed the nuclear factor kappa B (NF-κB) pathway, decreased the release of inflammatory mediators (IL-6, TNF-α), and reduced matrix catabolism in IL-1ß-treated chondrocytes. Furthermore, gastrodin ameliorated rat cartilage degeneration in an OA model of knee joints in vivo, suggesting its potential as a candidate therapeutic for OA.

Panax quinquefolium saponin inhibits endoplasmic reticulum stress-induced apoptosis and the associated inflammatory response in chondrocytes and attenuates the progression of osteoarthritis in rat.

Treatments for osteoarthritis (OA) seek to restore chondrocyte function and inhibit cell apoptosis. Panax quinquefolium saponin (PQS) is the major active ingredient of Radix panacis quinquefolii (American ginseng), and has been demonstrated to exert anti-inflammatory and anti-apoptotic effects in various diseases. However, any potential effect of PQS on the pathological process of OA remains unclear. This work aimed to explore the role of PQS in chondrocytes and to clarify its potential mechanisms. We showed that PQS treatment could protect chondrocytes against endoplasmic reticulum (ER) stress and associated apoptosis induced by interleukin (IL)-1ß. Also, PQS further attenuated triglyceride (TG)-induced ER stress and associated apoptosis. Moreover, PQS may inhibit the ER stress-activated NF-κB pathway and associated inflammatory response in chondrocytes. Finally, PQS abolished rat cartilage degeneration in an in-vivo OA model of the knee joint. Our results indicate that PQS may be a potential novel treatment for OA.

Learning Curve and Clinical Outcomes of Performing Surgery with the InterTan Intramedullary Nail in Treating Femoral Intertrochanteric Fractures.

Purpose. The purpose of this study is to evaluate the learning curve of performing surgery with the InterTan intramedullary nail in treating femoral intertrochanteric fractures, to provide valuable information and experience for surgeons who decide to learn a new procedure. Methods. We retrospectively analyzed data from 53 patients who underwent surgery using an InterTan intramedullary nail at our hospital between July 2012 and September 2015. The negative exponential curve-fit regression analysis was used to evaluate the learning curve. According to 90% learning milestone, patients were divided into two group, and the outcomes were compared. Results. The mean operative time was 69.28 (95% CI 64.57 to 74.00) minutes; with the accumulation of surgical experience, the operation time was gradually decreased. 90% of the potential improvement was expected after 18 cases. In terms of operative time, intraoperative blood loss, hospital stay, and Harris hip score significant differences were found between two groups (p = 0.009, p = 0.000, p = 0.030, and p = 0.002, resp.). Partial weight bearing time, fracture union time, tip apex distance, and the number of blood transfusions and complications were similar between two groups (p > 0.5). Conclusion. This study demonstrated that the learning curve of performing surgery with the InterTan intramedullary nail is acceptable and 90% of the expert's proficiency level is achieved at around 18 cases.

Intramedullary and extramedullary fixations for the treatment of unstable femoral intertrochanteric fractures: a meta-analysis of prospective randomized controlled trials.

PURPOSE: Intramedullary and extramedullary fixation methods are widely used to treat unstable femoral intertrochanteric fractures, but the optimal surgical method remains controversial. The aim of this study was to estimate the outcomes of intramedullary fixation versus extramedullary fixation in treating unstable femoral intertrochanteric fractures. METHODS: Electronic literature databases were used for searching including MEDLINE (Ovid interface), EMBASE (Ovid interface) and the Cochrane Central Register of Controlled Trials (CENTRAL) (Wiley Online Library) (up to March 30, 2016). Only human studies, which were designed as randomized controlled clinical trials, were included. Two authors independently evaluated the quality of original literature and extracted data from eligible literature. RESULTS: Eleven randomized controlled trials involving 1,543 patients were included. Intramedullary fixation was significantly better in functional scores (SMD 0.43, 95 % CI 0.14-0.73, P = 0.004) and had less blood loss (SMD -0.96, 95 % CI -1.77 to -0.11, P = 0.03) in contrast with extramedullary fixation. No obvious discrepancies were found in adverse events, operative time, blood transfusion, and hospital stay between intramedullary and extramedullary fixations. CONCLUSION: Our meta-analysis of 11 prospective randomized controlled trials suggested: no obvious discrepancies were found in adverse events, operative time, blood transfusion, and hospital stay between intramedullary and extramedullary fixations. Given the better results of intramedullary fixation in terms of functional scores and blood loss, we recommend the intramedullary fixation technique in treating unstable femoral intertrochanteric fractures. Large multi-center RCTs, which focused on unstable femoral intertrochanteric fractures, are needed to evaluate the efficiency of alternative internal fixation strategies in the future.

Reamed versus unreamed intramedullary nailing for the treatment of femoral fractures: A meta-analysis of prospective randomized controlled trials.

BACKGROUND AND OBJECTIVE: Intramedullary nailing is commonly used for treating femoral shaft fractures, one of the most common long bone fractures in adults. The reamed intramedullary nail is considered the standard implant for femoral fractures. This meta-analysis was performed to verify the superiority of reamed intramedullary nailing over unreamed intramedullary nailing in fractures of the femoral shaft in adults. Subgroup analysis of implant failure and secondary procedure was also performed. METHODS: Electronic literature databases were used to identify relevant publications and included MEDLINE (Ovid interface), EMBASE (Ovid interface), and the Cochrane Central Register of Controlled Trials (CENTRAL; Wiley Online Library). The versions available on January 30, 2016, were utilized. Only human studies, which were designed as randomized controlled clinical trials, were included. Two authors independently evaluated the quality of original research publications and extracted data from the studies that met the criteria. RESULTS: Around 8 randomized controlled trials involving 1078 patients were included. Reamed intramedullary nailing was associated with shorter time to consolidation of the fracture (SMD = -0.62, 95% CI = -0.89 to -0.35, P < 0.00001), lower secondary procedure rate (OR = 0.25, 95% CI 0.10-0.62, P = 0.003), lower nonunion rate (OR = 0.14, 95% CI = 0.05-0.40, P < 0.01), and lower delayed-union rate (OR = 0.19, 95% CI = 0.07-0.49, P < 0.01) compared to unreamed intramedullary nailing. The 2 groups showed no significant differences in risk of implant failure (OR = 0.50, 95% CI 0.14-1.74, P = 0.27), mortality risk (OR = 0.94, 95% CI 0.19-4.68, P = 0.94), risk of acute respiratory distress syndrome (ARDS; OR = 1.55, 95% CI 0.36-6.57, P = 0.55), or blood loss (SMD = 0.57, 95% CI = -0.22 to 1.36, P = 0.15). CONCLUSION: Reamed intramedullary nailing is correlated with shorter time to union and lower rates of delayed-union, nonunion, and reoperation. Reamed intramedullary nailing did not increase blood loss or the rates of ARDS, implant failure, and mortality compared to unreamed intramedullary nailing. Therefore, the treatment of femoral fractures using reamed intramedullary nailing is recommended.

Plate Versus Intramedullary Fixation Care of Displaced Midshaft Clavicular Fractures: A Meta-Analysis of Prospective Randomized Controlled Trials.

In recent decades, there has been a growing trend to the operative treatment of displaced midshaft clavicular fractures. Open reduction and internal plate fixation, and intramedullary nailing fixation are 2 of the widely used techniques for operative treatment, but the optimal fixation method for these types of fractures remains a topic of debate. The objective of this study was to determine the effectiveness of plate fixation versus intramedullary nailing fixation for displaced midshaft clavicle fractures by comparing their clinical results.Literature searches of the Pubmed, EMBASE, and Web of Science were performed from 1966 to April, 2015. Only randomized controlled clinical trials comparing plate and intramedullary nailing treatment for displaced midshaft clavicle fractures were included. Literature was screened, data were extracted, and methodological quality of the eligible trials was assessed by 2 independent reviewers accordingly.Seven randomized controlled trials involving 421 patients were included. Compared to intramedullary nailing fixation, plate fixation had a relatively longer mean surgical time and a trend towards a faster functional improvement during the first 6 months after surgery; apart from this, the pooled results revealed no significant differences in functional scores after 6 months postoperatively, complication rate and patients' satisfaction between plate fixation and intramedullary fixation.Our results demonstrated that these 2 methods were comparable and safe in the treatment of displaced midshaft clavicle fractures. We advocate both techniques for the treatment of displaced midshaft clavicle fractures, and the superior surgical technique was those that the surgeon was originally trained to perform.

Operative versus nonoperative treatment for displaced midshaft clavicle fractures: a meta-analysis based on current evidence.

Literature searches of the Cochrane Library, PubMed, EMBASE, Web of Science, LILACS, China National Knowledge Infrastructure, and Wanfang Data databases were performed from 1966 to September 2014. Only randomized and quasi-randomized controlled clinical trials comparing operative and nonoperative treatments for displaced midshaft clavicle fractures were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards. Thirteen studies were considered in the meta-analysis. Constant scores and the Disabilities of the Arm, Shoulder and Hand scores were improved in the operative fixation group at a follow up of one year or more. The nonunion and symptomatic malunion rates were significantly lower in the operative group. Additionally, the nonoperative group had a higher likelihood of neurological symptoms compared with the operative group. A significantly higher risk of complications was found in patients treated conservatively than in those who underwent operative fixation. However, when patients with nonunion and symptomatic malunion were excluded from the analysis, no significant differences in the complication rate were found. We concluded that based on the current clinical reports, operative treatment is superior to nonoperative treatment in the management of displaced midshaft clavicle fractures. However, we do not support the routine use of primary operative fixation for all displaced midshaft clavicle fractures in adults.

Operative versus nonoperative treatment for displaced midshaft clavicle fractures: a meta-analysis based on current evidence

Literature searches of the Cochrane Library, PubMed, EMBASE, Web of Science, LILACS, China National Knowledge Infrastructure, and Wanfang Data databases were performed from 1966 to September 2014. Only randomized and quasi-randomized controlled clinical trials comparing operative and nonoperative treatments for displaced midshaft clavicle fractures were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards. Thirteen studies were considered in the meta-analysis. Constant scores and the Disabilities of the Arm, Shoulder and Hand scores were improved in the operative fixation group at a follow up of one year or more. The nonunion and symptomatic malunion rates were significantly lower in the operative group. Additionally, the nonoperative group had a higher likelihood of neurological symptoms compared with the operative group. A significantly higher risk of complications was found in patients treated conservatively than in those who underwent operative fixation. However, when patients with nonunion and symptomatic malunion were excluded from the analysis, no significant differences in the complication rate were found. We concluded that based on the current clinical reports, operative treatment is superior to nonoperative treatment in the management of displaced midshaft clavicle fractures. However, we do not support the routine use of primary operative fixation for all displaced midshaft clavicle fractures in adults.

[Manipulative reduction and percutaneous pin fixation for the treatment of severely displaced distal tibial fractures in children].

OBJECTIVE: To study the therapeutic efficacy of manipulative reduction and percutaneous pin fixation for the treatment of severely displaced distal tibial fractures in children. METHODS: From May 2009 to December 2012,56 children with severely displaced distal tibial fractures were analyzed, who had been treated with manipulative reduction and percutaneous pin fixation. Preoperative fractures were confirmed as severely displaced fractures by X-ray apparatus. There were 33 boys and 23 girls,ranging in age from 3 to 14 years, with an average of 10.1 years. All the fractures were closed without vascular or nerve injuries. According to the bone fracture type, under C-arm fluoroscopy, functional reduction was achieved by manipulative reduction. The fractures were fixed with percutaneous pins. Postoperative X-ray confirmed the functional reduction. Follow-up indexes were recorded: intra-operative and postoperative complications,postoperative radiographic examination, lower extremity length and range of ankle motion. Ankle score system of Teeny was used to evaluate ankle function. RESULTS: All the patients were followed up, and the duration ranged from 3 to 46 months, with an average duration of 19.4 months. According to the Teeny score standard, 35 patients got an excellent result, 7 good and 3 fair. Pin track reaction was found in 4 cases. The X-ray showed all the fractures healed without shortening deformity or epiphyseal arrest at early stage. All the patients could participate in the normal physical activities, having a normal range of motion and excellent strength of the ankle joint. CONCLUSION: The method of manipulative reduction and percutaneous pin fixation is a safe and convenient treatment for severely displaced distal tibial fractures in children. It has several advantages as follow: micro-trauma, tiny tissue damage, firm fixation, and the patients can exercise the function of ankle early, suggesting that it is an effective treatment method.

[Treatment type C fracture of the distal radius with locking compression plate and external fixators].

OBJECTIVE: To compare efficacy of unilateral external fixators and locking compression plates in treating type C fractures of the distal radius. METHODS: From January 2009 to June 2010, 76 patients with distal radius fracture were treated with LCP and external fixators, 54 patients were followed up. Among them, 29 cases were male and 25 cases were female with an average age of 45.31 (ranged, 24 to 68) years old. There were 29 patients in LCP group. According to AO classification, 8 cases were type C1, 7 cases were type C2 and 14 cases were type C3. There were 25 cases in external fixators group. According to AO classification, 6 cases were type C1, 8 cases were type C2 and 11 cases were type C3. Radial height, volar tilt and radial inclination were compared, advanced Gartland-Werley scoring were used to assessed wrist joint function after 6 and 12 months' following up. RESULTS: Two cases were suffered from nail infection in external fixators group. Fifty-four patients were followed up from 12 to 24 months with an average of 21.3 months. Radial height was (9.60 +/- 0.72) mm, volar tilt was (9.55 +/- 0.80) degrees and radial inclination was (21.40 +/- 0.78) degrees in LCP group,while those were (9.40 +/- 0.70) mm, (9.47 +/- 0.71) degrees and (21.20 +/- 0.73) degrees in external fixtors group, and with no statistical significance (P>0.05). Advanced Gartland-Werley score after 6 months' following up was 3.31 +/- 1.17 in LCP group, 5.56 +/- 1.58 in external fixtors group, and with significant difference (t=-5.99,P<0.05); after 12 months' following up, advanced Gartland-Werley score was respectively 2.66 +/- 1.01 and 3.08 +/- 1.00, but with no statistical meaning (t=-1.55, P>0.05). CONCLUSION: LCP and external fixtors can receive good curative effects in treating type C distal radius fracture, and LCP can obtain obviously short-term efficacy, while there is no significant difference between two groups in long-term results. For serious distal radius comminuted fracture which unable to plate internal fixation, external fixators is a better choice.