Comparison of dynamic versus static fixation of intramedullary nailing in tibial diaphyseal fractures: A systematic review and meta-analysis.

Introduction: Tibial fractures are common long bone injuries, often surgically fixed with intramedullary nails. Modern intramedullary tibial nails allow for two different fixation modes, namely static and dynamic modes. While studies have demonstrated benefits of using either fixation modes, there has been no consensus as to which fixation mode would produce better outcomes and less complications. This systematic review and meta-analysis aims to compare the efficacy and safety of dynamic versus static fixation of intramedullary nails in the operative fixation of tibial diaphyseal fractures. Methods: A meta-analysis was conducted with a multi-database search (PubMed, OVID, EMBASE, Medline) according to PRISMA guidelines on April 15, 2021. Data from all published literature meeting inclusion criteria were extracted and analysed with fixed- and random-effects models.Findings/results: A total of 478 statically fixed and 234 dynamically fixed patients were included in this meta-analysis. Dynamically fixed patients had a significantly shorter mean time to union (mean difference, MD = 5.18 weeks, 95%CI: 1.95-8.41 weeks, p = 0.002) and reoperation rates (OR = 0.21, 95%CI: 0.10-0.47, p < 0.001) than statically fixed patients. No significant difference was found between both groups in terms of malrotation (OR = 0.57, 95% CI: 0.07-4.41, p = 0.59), non-union (OR = 1.10, 95% CI: 0.24-5.05, p = 0.91), delayed union (OR = 1.15, 95%CI: 0.19-7.17, p = 0.88) and malunion (OR = 2.73, 95% CI: 0.29-25.26, p = 0.38). Conclusion: While acknowledging that there is widespread surgeon preference to dyanamise or statically fix intramedullary nails in certain tibial fracture configurations, primary dynamic fixation of intramedullary tibial nails demonstrated significantly shorter times to bony union and less complications than static nailing in our meta-analysis. Further research on identifying patient factors and fracture patterns that would best benefit from dynamic fixation is required.

Multiple Endocrine Tumors Associated with Germline MAX Mutations: Multiple Endocrine Neoplasia Type 5?

CONTEXT: Pathogenic germline MAX variants are associated with pheochromocytoma and paraganglioma (PPGL), pituitary neuroendocrine tumors and, possibly, other endocrine and nonendocrine tumors. OBJECTIVE: To report 2 families with germline MAX variants, pheochromocytomas (PCs) and multiple other tumors. METHODS: Clinical, genetic, immunohistochemical, and functional studies at University hospitals in Australia on 2 families with germline MAX variants undergoing usual clinical care. The main outcome measures were phenotyping; germline and tumor sequencing; immunohistochemistry of PC and other tumors; functional studies of MAX variants. RESULTS: Family A has multiple individuals with PC (including bilateral and metastatic disease) and 2 children (to date, without PC) with neuroendocrine tumors (paravertebral ganglioneuroma and abdominal neuroblastoma, respectively). One individual has acromegaly; immunohistochemistry of PC tissue showed positive growth hormone-releasing hormone staining. Another individual with previously resected PCs has pituitary enlargement and elevated insulin-like growth factor (IGF-1). A germline MAX variant (c.200C>A, p.Ala67Asp) was identified in all individuals with PC and both children, with loss of heterozygosity in PC tissue. Immunohistochemistry showed loss of MAX staining in PCs and other neural crest tumors. In vitro studies confirmed the variant as loss of function. In Family B, the proband has bilateral and metastatic PC, prolactin-producing pituitary tumor, multigland parathyroid adenomas, chondrosarcoma, and multifocal pulmonary adenocarcinomas. A truncating germline MAX variant (c.22G>T, p.Glu8*) was identified. CONCLUSION: Germline MAX mutations are associated with PCs, ganglioneuromas, neuroblastomas, pituitary neuroendocrine tumors, and, possibly, parathyroid adenomas, as well as nonendocrine tumors of chondrosarcoma and lung adenocarcinoma, suggesting MAX is a novel multiple endocrine neoplasia gene.

A Hemodynamic Safety Checklist Can Improve Blood Pressure Monitoring in Patients with Acute Spinal Cord Injury.

OBJECTIVE: The American Association and Congress of Neurological Surgeons recommended mean arterial blood pressure (MAP) in patients with acute spinal cord injury (SCI) should be 85-90 mm Hg for the first 7 days. We evaluated whether hemodynamic management differed between a primary-receiving and tertiary hospital in the first 24 hours for patients with acute SCI and assessed whether use of a checklist could improve hemodynamic management. METHODS: Observational review was performed of 79 patients with acute SCI before and after introduction of a blood pressure monitoring checklist and staff educational program designed to improve tertiary center management. Hemodynamic management in the primary-receiving hospital was compared with the tertiary center before and after checklist introduction. RESULTS: At the primary-receiving center, mean number of documented MAP readings/hour was 2.2 and 3 before and after checklist introduction. The proportion having >50% of MAP recordings <80 mm Hg was 26% and 22%. The proportion having >50% of MAP recordings <70 mm Hg was 8.5% and 7%. At the tertiary center, mean number of MAP readings/hour was 1.3 and 2.7 before and after checklist introduction (P = 0.02). The proportion having >50% of MAP recordings <80 mm Hg decreased from 36.5% to 16% after checklist introduction (P = 0.05). The proportion having >50% of MAP recordings <70 mm Hg decreased from 9% to 5.5% (P = 0.6). Polytrauma, inotrope use, and head injury significantly correlated with low MAP recordings (P < 0.05). Polytrauma was an independent risk predictor for low MAP recordings (P < 0.05). CONCLUSIONS: Achieving MAP targets for patients with acute SCI is challenging. Checklist use and staff education were associated with improved hemodynamic management. Presence of polytrauma identified patients at particular risk.