Association of Low Back Pain with Shift Work: A Meta-Analysis

Shift work (SW) is the main working schedule worldwide, and it may cause sleep disorders, breast cancer, and cardiovascular disease. Low back pain (LBP) is a common problem in the workplace; however, the association between LBP and SW remains unclear. Therefore, we conducted a meta-analysis to determine the association between SW and LBP. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed, Embase, and Web of Science databases using a set of associated keywords were queried. The inclusion criteria were as follows: (1) adult employees hired by a company or organization; (2) SW exposure; and (3) the outcome of LBP according to examination or assessment. A total of 40 studies were included that met the inclusion criteria for the meta-analysis. SW was significantly associated with LBP (odds ratio [OR]: 1.31, 95% confidence interval [CI]: 1.18−1.47, p < 0.00001). Furthermore, it was observed that LBP was significantly associated with night shift (NS) (OR: 1.49, 95% CI: 1.24−1.82, p < 0.0001) but not with rotating shift (RS) (OR: 0.96, 95% CI: 0.76−1.22, p = 0.49). Moreover, LBP was significantly associated with SW in health care workers (HCWs) (OR: 1.40, 95% CI: 1.20−1.63, p < 0.0001) but not in non-HCWs (OR: 1.19, 95% CI: 0.94−1.50, p = 0.14). SW was significantly associated with LBP. Furthermore, the subgroup analysis showed that NS, but not RS, was associated with LBP. Compared with SW in non-HCWs, SW in HCWs was significantly associated with LBP.

Effect of the traditional Chinese herb Helminthostachys zeylanica on postsurgical recovery in patients with ankle fracture: A double-blinded randomized controlled clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Helminthostachys zeylanica (HZ), which is also called "Dao-Di-U-Gon" in Taiwan, has anti-inflammatory and antiedema effects and is commonly used to treat edema in patients with fractures. The ugonin K component of HZ can induce osteogenesis and promote bone mineralization, its therapeutic effect, however, its therapeutic effect remains unclear. Therefore, the purpose of the present study was to investigate the effect of HZ on functional recovery in patients with ankle fractures requiring surgical treatment.

METHODS

A double-blinded, randomized, controlled study was conducted. A total of 45 patients with ankle fractures requiring surgical treatment were assigned to either the control group (n = 23 patients), which received the oral administration of HZ placebo 1.0 g t.i.d. for 42 days continuously, or to the treatment group (22 patients), which received HZ for 42 days.

RESULTS

The serum amino-terminal propeptide of type 1 procollagen (PINP) levels were similar in the first assessment (V1) between the control (45.90 ± 16.31 ng/mL) and treatment groups (52.61 ± 21.02 ng/mL; p = 0.240); the differences in PINP level between the third assessment (V3) and V1 were greater in the treatment group (35.84 ± 24.56 ng/mL) than in the control group (16.34 ± 11.97 ng/mL; p = 0.002). Radiographic healing time (RHT) was 9.09 ± 1.15 weeks in the treatment group, which was shorter than the 9.91 ± 0.79 weeks (p = 0.012) in the control group.

CONCLUSION

Oral administration of HZ for 42 days can increase serum PINP level and reduce the RHT. Therefore, HZ can be used to treat patients with ankle fractures requiring surgical treatment. However, a larger sample size is needed in future studies.

A versatile method for dorsal-approach plantar plate repair using standard operative instruments

Background

The plantar plate is an important static stabilizer of the lesser metatarsophalangeal joints, and disruptions of the plantar plate can lead to significant instability and lesser toe deformities. In recent years, direct plantar plate repair has been proposed. Although direct repair via a dorsal approach is attractive, a torn plantar plate is small and difficult to access using regular instruments in a restricted operative field.

Methods

In this report, a unique method for plantar plate repairs was used to repair various configurations of plantar plate tears with standard operative instruments that are available in most operating rooms.

Results

Using this method, 10 patients underwent plantar plate repairs, and the mean follow-up period was 24 (range, 14–38) months. The mean visual analog scale score for pain preoperatively was 4.1 (range, 0–6) and decreased to 0.6 (range, 0–3) at last follow-up. Postoperatively, the mean visual analog scale score for satisfaction was 9.6 (range, 8–10) and the mean American Orthopedic Foot and Ankle Society forefoot score was 88.8 (range, 75–100).

Conclusions

Our study proposes an inexpensive and versatile method for plantar plate repair via a dorsal approach that uses standard operative instruments.

Trial registration

ClinicalTrials.gov, NCT04949685. July 2, 2021 - Retrospectively registered,

Level of clinical evidence

4

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04951-w.

Shockwave Treatment Enhanced Extracellular Matrix Production in Articular Chondrocytes Through Activation of the ROS/MAPK/Nrf2 Signaling Pathway

OBJECTIVE

Shockwave application is a potential treatment for osteoarthritis (OA), but the underlying mechanism remains unknown. Oxidative stress and a counterbalancing antioxidant system might be the key to understanding this mechanism. We hypothesized that reactive oxygen species (ROS) and the transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2),which is an important regulator of cellular redox homeostasis, are plausible elements.

DESIGN

Porcine chondrocytes were cultured in a 3-dimensional pellet model and subjected to shockwaves. The effects of shockwaves with various energy-flux densities on optimal extracellular matrix (ECM) synthesis were assessed. ROS, mitogen-activated protein kinase (MAPK) signaling, and the redox activity of Nrf2 were measured. To investigate the signaling mechanism involved in the shockwave treatment in chondrocytes, specific inhibitors of ROS, MAPK signaling, and Nrf2 activity were targeted.

RESULTS

Shockwaves increased ECM synthesis without affecting cell viability or proliferation. Furthermore, they induced transient ROS production mainly through xanthine oxidase. The phosphorylation of ERK1/2 and p38 and the nuclear translocation of Nrf2 were activated by shockwaves. By contrast, suppression of ROS signaling mitigated shockwave-induced MAPK phosphorylation, Nrf2 nuclear translocation, and ECM synthesis. Pretreatment of chondrocytes with the specific inhibitors of MEK1/2 and p38, respectively, mitigated the shockwave-induced nuclear translocation of Nrf2 and ECM synthesis. Nrf2 inhibition by both small hairpin RNA knockdown and brusatol reduced the shockwave-enhanced ECM synthesis.

CONCLUSIONS

Shockwaves activated Nrf2 activity through the induction of transient ROS signaling and subsequently enhanced ECM synthesis in chondrocytes. This study provided fundamental evidence confirming the potential of shockwaves for OA management.

Clinical Outcomes of Total Ankle Arthroplasty Versus Ankle Arthrodesis for the Treatment of End-Stage Ankle Arthritis in the Last Decade: a Systematic Review and Meta-analysis

Ankle arthrodesis (AA) and total ankle arthroplasty (TAA) are the 2 primary surgical treatments for patients with end-stage ankle arthritis. The comparative outcomes between AA and TAA using modern techniques remain unclear. A systematic search to identify all relevant articles comparing AA with TAA was conducted through 3 online databases. The clinical outcomes were extracted for meta-analysis, including AOFAS (American Orthopaedic Foot & Ankle Society) score, VAS (visual analog scale), AOS (Ankle Osteoarthritis Scale), gait analysis, ROM (range of motion), satisfaction, complication, and reoperation. Our meta-analysis shows no heterogeneity in any subgroup analyses. There were no significant differences in AOFAS total, pain, and alignment scores between the AA and TAA groups. The TAA group had significant improvement in AOFAS function score compared with the AA group. There was no significant difference in VAS and AOS total scores between the 2 groups. No significant differences in gait analysis were observed between the 2 groups. The TAA group had significant improvement in both ROM and change in ROM compared with the AA group. There was no significant difference in satisfaction rate between the 2 groups. The TAA group had significantly higher complication and reoperation rates compared with the AA group. Our meta-analysis provides updated evidence on clinical outcomes comparing AA with TAA using third-generation implants. The TAA group had better improvement in AOFAS function and ROM than the AA group. No significant differences in pain relief, gait analysis, or patient satisfaction were observed between the 2 groups.

Application of microRNA in Human Osteoporosis and Fragility Fracture: A Systemic Review of Literatures

MicroRNAs (miRNAs) could serve as ideal entry points to the deregulated pathways in osteoporosis due to their relatively simple upstream and downstream relationships with other molecules in the signaling cascades. Our study aimed to give a comprehensive review of the already identified miRNAs in osteoporosis from human blood samples and provide useful information for their clinical application. A systematic literature search for relevant studies was conducted in the Pubmed database from inception to December 2020. We set two essential inclusion criteria: human blood sampling and design of controlled studies. We sorted the results of analysis on human blood samples according to the study settings and compiled the most promising miRNAs with analyzed diagnostic values. Furthermore, in vitro and in vivo evidence for the mechanisms of the identified miRNAs was also illustrated. Based on both diagnostic value and evidence of mechanism from in vitro and in vivo experiments, miR-23b-3p, miR-140-3p, miR-300, miR-155-5p, miR-208a-3p, and miR-637 were preferred candidates in diagnostic panels and as therapeutic agents. Further studies are needed to build sound foundations for the clinical usage of miRNAs in osteoporosis.

Efficacy and Safety of Extracorporeal Shockwave Therapy for Treatment of Knee Osteoarthritis: A Systematic Review and Meta-analysis

OBJECTIVE

The objective of this study was to assess the efficacy and safety of extracorporeal shockwave therapy (ESWT) for treatment of knee osteoarthritis (OA) using a systemic review and meta-analysis.

METHODS

An extensive search of relevant articles from electronic databases Pubmed, Embase, and Cochrane Library from inception to March 2019 was conducted. The treatment outcomes (visual analog scale [VAS] and the Western Ontario and McMaster Universities Arthritis Index [WOMAC]) of the included articles were pooled to calculate effect sizes. The assessment of heterogeneity among articles was evaluated using I2. Statistical analyses were conducted using RevMan software.

RESULTS

The results showed that the ESWT group had significant improvement in pain relief compared with the control group through 12 months based on WOMAC and VAS scores. Compared with the baseline level, the patients had significant improvement in pain relief at most follow-up points (one week to 12 months) based on WOMAC and VAS scores. The patients showed significant improvement in physical function at six- and 12-month follow-up when compared with the control group and for all follow-up (one to 12 months) when compared with the baseline level. Additionally, only minor complications were observed after ESWT treatment.

CONCLUSIONS

The use of ESWT for treatment of knee OA had a beneficial effect on pain relief and physical function improvement for up to 12 months, and only minor complications occurred after ESWT treatment. However, there remains a lack of clarity regarding the frequency and dosage levels of ESWT required to achieve the maximum improvement.

Hemoglobin A1c Levels Associated with Age and Gender in Taiwanese Adults without Prior Diagnosis with Diabetes

Several studies have reported that Hemoglobin A1c (HbA1c) levels increase with age for people without diabetes. However, HbA1c levels associated with age and gender have not been well investigated for Taiwanese adults. The objective of this study was to investigate the sex-specific association between HbA1c levels and age for Taiwanese adults without diabetes. The data were collected from the Taiwan Biobank database with inclusive criteria being participants without diabetes. The association between HbA1c values and age was conducted by linear regression analysis, HbA1c values between sexes were compared by two-sample t-test, and HbA1c levels among age groups were compared using one-way ANOVA. The results showed that HbA1c levels were positively correlated with age, and the levels for males were significantly higher than for females among all participants. However, there was no significantly positive correlation between HbA1c levels and age in males for age group of 50–70 years. The levels of males were significantly higher than females for age groups of 30–39 and 40–49 years. There were significant differences in HbA1c levels among age groups for all participants, males, and females except for the two age groups of 50–59 and 60–70 years in males. Age and gender were important factors affecting HbA1c levels. Our results suggested that the HbA1c cut-point levels for the diagnosis of diabetes should vary by age and gender.

Impact of the COVID-19 pandemic and its related psychological effect on orthopedic surgeries conducted in different types of hospitals in Taiwan

AIM

Taiwan's response to the coronavirus disease 2019 (COVID-19) differed in that it successfully prevented the spread without having to shutdown or overburden medical services. Patients' fear regarding the pandemic would be the only reason to reduce surgeries, so Taiwan could be the most suitable place for research on the influence of psychological factors. This study aimed to assess the impact of patients' fear on orthopedic surgeries in Taiwan amid the peak period of the COVID-19 pandemic.

PATIENTS AND METHODS

The investigation period included the COVID-19 pandemic (March 2020 to April 2020) and the corresponding period in the previous year. The following data on patients with orthopedic diseases were collected: outpatient visits, hospital admission, and surgical modalities.

RESULTS

The COVID-19 pandemic led to a 22%-29% and 20%-26% reduction in outpatients, 22%-27% and 25%-37% reduction in admissions, and 26%-35% and 18%-34% reduction in surgeries, respectively, at both hospitals. The weekly mean number of patients was significantly smaller during the COVID-19 pandemic for all types of surgery and elective surgeries at the university hospital, and for all types of surgery, elective surgeries, and total knee arthroplasties at the community hospital. Further, patients visiting the community hospital during the pandemic were significantly younger, for all types of surgery, elective surgeries, and total knee arthroplasties.

CONCLUSIONS

The reduction in orthopedic surgeries in Taiwan's hospitals during COVID-19 could be attributed to patients' fear. Even without restriction, the pandemic inevitably led to a reduction of about 20%-30% of the operation volume.

Management of nonunion of humeral medial condyle fracture: A case series and review of the literature

Pediatric humeral medial condyle fracture (HMCF) is a rare condition and is difficult to detect, especially in young children. The management of late presentation of HMCF is challenging and lacks consensus. Herein, we reported four cases of HMCF nonunion received open reduction and internal fixation (ORIF) or supracondyle osteotomy from our institution. In addition, 12 cases of ORIF and 4 cases of osteotomy reported in the previous studies were also reviewed. The HMCF nonunion can heal after ORIF, but the indication and the optimal techniques need to be clarified. Supracondylar osteotomy alone is an effective and safe treatment option to improve the functional and cosmetic outcomes of HMCF nonunion.

Comparative effectiveness of various treatment strategies for trigger finger by pairwise meta-analysis

OBJECTIVE

To compare the efficacy of various strategies in the treatment of trigger finger.

DATA SOURCES

A systematic literature search for randomized controlled trials to compare treatments for trigger finger was conducted through three online databases, Pubmed, Embase and Cochrane Library, from their inception dates to 22 May 2020.

METHODS

Relative risk (RR) with 95% confidence interval (CI) was used to evaluate the effect sizes in success rate for included articles.

RESULTS

Sixteen articles (n = 1185) were included in our meta-analysis. The results showed that the efficacy of steroid injection was significantly better than the placebo group at short-term follow-ups (RR = 19.00, 95% CI = 1.17-309.77 for one-week; RR = 3.70, 95% CI = 3.70, 95% CI = 1.61-8.53 for one-month), and then became non-significant at four months (RR = 3.21, 95% CI = 0.88-11.79). There was no significant difference in success rate between steroid injection and nonsteroidal anti-inflammatory drug injection, and between open surgery and percutaneous release at all the follow-ups. Only surgical treatment had significantly better efficacy in success rate than steroid injection at all follow-ups (RR = 0.48, 95% CI = 0.34-0.66 for one-month; RR = 0.87, 95% CI = 0.80-0.96 for three-month; RR = 0.58, 95% CI = 0.48-0.68 for six-month; RR = 0.38, 95% CI = 0.20-0.72 for 12-month).

CONCLUSION

There were no differences in efficacy between steroid injection and shockwave or nonsteroidal anti-inflammatory drug injection. The surgical treatments had the best efficacy among these treatments.

A comparison of efficacy among different radiofrequency ablation techniques for the treatment of lumbar facet joint and sacroiliac joint pain: A systematic review and meta-analysis

OBJECTIVE

To compare the efficacy of different radiofrequency techniques (thermal, pulsed, and cooled radiofrequency) for treating lumbar facet joint (LFJ) or sacroiliac joint (SIJ) pain.

PATIENTS AND METHODS

The inclusion criteria were as follows: (1) age > 18 years; (2) patients suffering from LFJ or SIJ pain; and (3) patients receiving radiofrequency treatments. Four electronic databases, including Pubmed, Embase, Cochrane Library, and ISI Web of Knowledge were systematically searched from inception until December 2019 for relevant articles. The search was conducted on 2 January 2020. When the outcomes among articles showed heterogeneity, then a random-effects model was adopted to calculate the effect size; otherwise, a fixed-effects model was adopted.

RESULTS

All the three techniques showed significant improvements in LFJ or SIJ pain for up to 12 months compared with the baseline level. However, no significant differences among the three techniques were observed at any follow-up visits except for possibly a trend for variance in efficacy. For treating LFJ pain, cooled radiofrequency was the most effective, followed by thermal radiofrequency and then pulsed radiofrequency as the least respectively for the follow-up visit at 6 months. No serious complications were reported after receiving treatment using the three techniques.

CONCLUSION

Sequentially, cooled radiofrequency followed by thermal radiofrequency and then pulsed radiofrequency for treating LFJ pain were identified as most to least effective at the 6-month follow-up.

Contracture of extensor hallucis longus after fracture of distal tibia and fibula: A case report

Post-traumatic isolated big toe extensor contracture after tibiofibular fracture is uncommon and only a few cases have been reported. Major causes of it include anterior compartment syndrome, direct injury, entrapment or adhesion of the muscle or tendon.

We present an uncommon case of isolated extensor hallucis longus (EHL) tendon contracture following a distal tibiofibular shaft fracture without compartment syndrome of the affected leg or foot. The clinical outcome is good after Z-lengthening of the EHL tendon and abductor hallux tendon in 1-year follow-up.

Level of clinical evidence

5.

Impact of orthogeriatric care, comorbidity, and complication on 1-year mortality in surgical hip fracture patients: An observational study

After acute hip surgery, the 1-year mortality rate is high. Therefore, this study evaluated the risk factors for 1-year mortality. The purposes of this study was first to examine the effect of integrated care on 1-year mortality in surgical patients and secondly to explore magnitude of comorbidity and complication on mortality.This retrospective cohort study included 313 patients received surgery for hip fragility fracture. Patients with multiple fractures or combined trauma were excluded. The patients were grouping into integrated (n = 106) and non-integrated care group (n = 207) models. Univariate and multiple Cox regression were used to examine effect of care model, comorbidity, and complication event.One-year mortality in integrated and non-integrated patients was 4.7% and 14.0% respectively. After adjustments, patients in non-integrated care, have 2.89 times (95% confidence interval [CI] 1.07-7.81) likely to die 1-year after discharged.Patients had elevated comorbidity or postoperative complications contributed to the mortality. Our study found the effect of patients treated by integrated care models, compared with usual model, significantly reduced 1-year mortality rate. Appropriated treatment of comorbidities during hospitalization and after discharge is critical to post-surgical survival. The findings imply that the co-care for hip fracture of hip surgical patients with orthogeriatricians is strongly recommended, particularly for those with >3 comorbidities.

Pretreatment of ankle nerve block provides better postoperative analgesia than peri-incisional local anesthetic infiltration in hallux valgus correction surgery

Adequate postoperative analgesia after hallux valgus (HV) correction surgery improves early mobilization and decreases hospital stay. Peripheral nerve block and peri-incisional local anesthetic (LA) infiltration are both widely used for pain management in orthopedic surgeries. The aim of this study was to compare the analgesic effects between the ankle block and peri-incisional infiltration technique in patients undergoing HV correction surgery. Ninety patients scheduled for hallux valgus correction surgery were randomly allocated into three groups. In group N, patients were pretreated with tibial and peroneal nerve blocks with 8-10 mL of 0.25% bupivacaine before surgery. In group P, patients received the same LA for peri-incisional infiltration preoperatively. In group C, patients underwent surgery without regional analgesic pretreatment. All patients had intravenous fentanyl patient control analgesia as part of multimodal postoperative pain management. Fentanyl consumption, rest and moving pain scale, and adverse effects were evaluated at postoperative 6 h (Poh6), Poh12, Poh 24, and Poh36, respectively. Patients receiving bilateral feet surgeries were excluded in this study. Seventy-five patients were enrolled into final analysis. The patients in group N expressed lower resting and moving pain scores at Poh6, but the pain scores turned similarly among the three groups following Poh12 and then. The total fentanyl consumption was significantly less in group N than in group P. The postoperative activities and mood disturbance were not significantly different between groups after Poh12 and then. We conclude that ankle block is better than peri-incisional LA infiltration in HV correction surgery in pain relief and fentanyl consumption.

(-)-Epigallocatechin-3-Gallate Decreases Osteoclastogenesis via Modulation of RANKL and Osteoprotegrin

Osteoporosis is the second most common epidemiologic disease in the aging population worldwide. Previous studies have found that frequent tea drinkers have higher bone mineral density and less hip fracture. We previously found that (-)-epigallocatechin gallate (EGCG) (20⁻100 µmol/L) significantly suppressed receptor activator of nuclear factor-kB ligand (RANKL)-induced osteoclastogenesis and pit formation via inhibiting NF-κB transcriptional activity and nuclear transport of NF-κB in RAW 264.7 cells and murine primary bone marrow macrophage cells. The most important regulation in osteoclastogenesis is the receptor activator of nuclear factor-kB/RANKL/osteoprotegrin (RANK/RANKL/OPG) pathway. In this study, we used the coculture of RAW 264.7 cells and the feeder cells, ST2, to evaluate how EGCG regulated the RANK/RANKL/OPG pathway in RAW 264.7 cells and ST2 cells. We found EGCG decreased the RANKL/OPG ratio in both mRNA expression and secretory protein levels and eventually decreased osteoclastogenesis by TRAP (+) stain osteoclasts and TRAP activity at low concentrations-1 and 10 µmol/L-via the RANK/RANKL/OPG pathway. The effective concentration can be easily achieved in daily tea consumption. Taken together, our results implicate that EGCG could be an important nutrient in modulating bone resorption.

Outcomes of percutaneous trigger finger release with concurrent steroid injection

Percutaneous release (PR) of the A1 pulley is a quick, safe, and minimally invasive procedure for treating trigger fingers. The purpose of this study is to identify if PR with additional steroid injections can shorten the recovery to reach unlimited range of motion. Between January 2013 and December 2013, we included 432 trigger fingers with actively correctable triggering or severer symptoms without previous surgical release or steroid injections from two hand clinic offices (A and B). The same experienced surgeon performed PR at the office. Patients from Clinic A received PR with steroid injections and those from Clinic B received PR without steroid injections. Patients returned for follow-up 1 week, 6 weeks, and 12 weeks after the procedure. Between the steroid group and the nonsteroid group, there is no significant difference in the mean time for patients to return to normal work and the rate of residual extensor lag. Middle fingers showed a 5.09-fold chance of having a residual extensor lag over that of the other fingers. High grade trigger fingers recovered more slowly than low grade ones. The success rate of a 12-week follow-up was 98.4%. There was no significant difference between the steroid group (97.5%) and the nonsteroid group (99.1%). PR can treat trigger fingers effectively, but additional steroid injection does not provide more benefit. Some fingers showed temporary extensor lag, especially in middle fingers and high grade trigger fingers, but 85% of those will eventually reach full recovery after self-rehabilitation without another surgical release.

Modified Mitchell Osteotomy Alone Did Not Have Higher Rate Of Residual Metatarsalgia Than Combined First And Lesser Metatarsal Osteotomy

Category:

Bunion

Introduction/Purpose:

Transfer metatarsalgia (TM) is a common forefoot disorder secondary to hallux valgus (HV), and the best treatment for HV related TM remains controversy. Some authors suggested a combined lesser metarsal osteotomy while undergoing HV surgery, but some authors didn’t agree with it and concluded that isolated HV corrective osteotomy can improve symptomatic metatarsalgia. The main purpose of the retrospective study was to compare clinical outcomes in the patients with and without combined lesser metatarsal osteotomy while they received HV correction surgery.

Methods:

We retrospectively reviewed the patients who underwent osteotomy for HV correction between January 2000 and December 2010. All the patients underwent HV correction with Modified Mitchell osteotomy. Clinical evaluations including the American Orthopaedic Foot and Ankle Society (AOFAS) score and residual metatarsalgia were assessed, and hallux valgus angle, 1st-2nd intermetatarsal angle, metatarsal shortening, and plantar shifting of metatarsal head were measured.

Results:

Sixty-five patients ( 83 feet ) meeting the selection criteria were enrolled. Thirty feet receiving a combined lesser metatarsal osteotomy were grouped as combined surgery group, and the others were grouped as control group ( 53 feet ). The overall rate of persistent symptomatic metatarsalgia was 19.28 % after operative treatment. There were 6 feet with residual metatarsalgia in combined surgery group, and 10 feet in control group. There was no significant difference in the rate of persistent symptoms between groups ( p=0.9).

Conclusion:

According to this result, modified Mitchell osteotomy alone didn’t have higher rate of residual metatarsalgia than combined surgery. Besides, we also found that the average recovery rate of transfer metatarsalgia was about 80.7% and the patients, whose preoperative hallux valgus angle was more than 30 degrees, had the higher risk of residual metatarsalgia after surgery.

Tapentadol immediate-release for acute postbunionectomy pain: a phase 3, randomized, double-blind, placebo-controlled, parallel-group study in Taiwan

OBJECTIVE

To evaluate the efficacy and safety of tapentadol immediate-release (IR) for treating acute pain following orthopedic bunionectomy surgery in a Taiwanese population.

METHODS

This was a phase 3, randomized, double-blind, placebo-controlled, parallel-group bridging study in which Taiwanese patients (N = 60) with moderate-to-severe pain following bunionectomy were randomized (1:1:1) to receive tapentadol IR 50 or 75 mg or placebo orally every 4-6 hours over a 72 hour period. The primary endpoint was the sum of pain intensity difference over 48 hours (SPID48), analyzed using analysis of variance.

RESULTS

Out of 60 patients randomized (mainly women [96.7%]; median age 44 years), 41 (68.3%) completed the treatment. Mean SPID48 values were significantly higher for tapentadol IR (p ≤ 0.006: 50 mg, p ≤ 0.004: 75 mg) compared with placebo. Between-group differences in LS means of SPID48 (vs. placebo) were tapentadol IR 50 mg: 105.6 (95% CI: 32.0; 179.2); tapentadol IR 75 mg: 126.6 (95% CI: 49.5; 203.7). Secondary endpoints including SPID at 12, 24, and 72 hours, time to first use of rescue medication, cumulative distribution of responder rates, total pain relief and sum of total pain relief and sum of pain intensity difference at 12, 24, 48, and 72 hours, and patient global impression of change showed numerically better results supporting that tapentadol IR (50 and 75 mg) was more efficacious than placebo in relieving acute pain. The most frequent treatment emergent adverse events reported in ≥ 10% patients in either group were dizziness, nausea, and vomiting. A limitation of this study may possibly include more controlled patient monitoring through 4-6 hour dosing intervals, which reflects optimal conditions and thus may not approximate real-world clinical practice. However, all treatment groups would be equally affected by such bias of frequent monitoring, if any, since it was a randomized and double-blind study.

CONCLUSIONS

Tapentadol IR treatment significantly relieved acute postoperative pain and was well tolerated in a Taiwanese population. ClinicalTrials.gov identifier: NCT01813890.

Component spectra extraction from terahertz measurements of unknown mixtures

The aim of this work is to extract component spectra from unknown mixtures in the terahertz region. To that end, a method, hard modeling factor analysis (HMFA), was applied to resolve terahertz spectral matrices collected from the unknown mixtures. This method does not require any expertise of the user and allows the consideration of nonlinear effects such as peak variations or peak shifts. It describes the spectra using a peak-based nonlinear mathematic model and builds the component spectra automatically by recombination of the resolved peaks through correlation analysis. Meanwhile, modifications on the method were made to take the features of terahertz spectra into account and to deal with the artificial baseline problem that troubles the extraction process of some terahertz spectra. In order to validate the proposed method, simulated wideband terahertz spectra of binary and ternary systems and experimental terahertz absorption spectra of amino acids mixtures were tested. In each test, not only the number of pure components could be correctly predicted but also the identified pure spectra had a good similarity with the true spectra. Moreover, the proposed method associated the molecular motions with the component extraction, making the identification process more physically meaningful and interpretable compared to other methods. The results indicate that the HMFA method with the modifications can be a practical tool for identifying component terahertz spectra in completely unknown mixtures. This work reports the solution to this kind of problem in the terahertz region for the first time, to the best of the authors' knowledge, and represents a significant advance toward exploring physical or chemical mechanisms of unknown complex systems by terahertz spectroscopy.

The efficacy of combined use of intraarticular and intravenous tranexamic acid on reducing blood loss and transfusion rate in total knee arthroplasty

The purpose of this study is to investigate the effect of preoperative intravenous (IV) and intraoperative topical administration of tranexamic acid (TXA) in total knee arthroplasty (TKA). A total of 120 patients were and randomly allocated to either topical group, combined group, or control group. The mean total blood loss was lower in the combined and topical groups (705 mL and 579 mL, respectively) in comparison with control group (949 mL, P < 0.001). There was a significant difference in transfusion rate among groups (P = 0.009). The postoperative hemoglobin drop and total drain amount were significantly less in the combined group compared to other groups. In conclusion, combining preoperative IV injection and topical administration of TXA can effectively reduce blood loss and transfusion rate.

Modified Mitchell osteotomy alone does not have higher rate of residual metatarsalgia than combined first and lesser metatarsal osteotomy

Transfer metatarsalgia (TM) is a common forefoot disorder secondary to hallux valgus (HV). Some authors suggest that a combined lesser metatarsal osteotomy while undergoing HV surgery improves metatarsalgia, whereas others concluded that isolated HV corrective osteotomy can improve symptomatic metatarsalgia. The main purpose of this retrospective study was to compare clinical outcomes in patients with and without combined lesser metatarsal osteotomy while receiving HV correction surgery. We retrospectively reviewed the patients who underwent osteotomy for HV correction between January 2000 and December 2010. All patients underwent HV correction with modified Mitchell osteotomy. Clinical evaluations including the American Orthopaedic Foot and Ankle Society score and residual metatarsalgia were assessed, and radiographic measurements were carried out. Sixty-five patients (83 feet) meeting the selection criteria were enrolled. Thirty feet receiving a combined lesser metatarsal osteotomy were classified as the combined surgery (CS) group, and the others were classified as the control (CN) group (53 feet). The overall rate of persistent symptomatic metatarsalgia was 19.28% after operative treatment. There were six feet with residual metatarsalgia in the CS group, and 10 feet in the CN group. There was no significant difference in the rate of persistent symptoms between the two groups (p = 0.9). According to this result, modified Mitchell osteotomy alone did not have a higher rate of residual metatarsalgia than CS. We also found that the average recovery rate of TM was about 80.7% and those patients whose preoperative HV angle was > 30° had the higher risk of residual metatarsalgia after surgery.

Open reduction and internal fixation of acute intra-articular displaced calcaneal fractures: a retrospective analysis of surgical timing and infection rates

The choice of surgical timing in open reduction for calcaneal fractures has been proposed to be associated with soft-tissue complications and infection. This study analysed the correlation between surgical timing and postoperative infection rates. We performed a retrospective single-surgeon single-facility study (Kaohsiung Medical University Hospital, KMUH) between January 2006 and January 2010. Fifty patients with 53 close intra-articular calcaneal fractures were included. They received open reduction and internal fixation via the extensile lateral L-shaped approach. We assessed the duration between heel trauma and operation from the medical records and sorted our patients into early (within 3 days), intermediate (from 3 to 10 days) and delayed (over 10 days) surgical groups. The mean follow-up period was 13 months. Only one of the 50 patients, a 74-year-old female with diabetes mellitus, developed deep infection requiring hardware removal and serial debridement. Overall, we did not find a statistical difference in postoperative infection rates in the different timing groups. Our conclusion is that in experienced hands, surgical timing may not affect postoperative infection rates in calcaneal fracture among strictly selected patients who do not have potential risk factors for wound complication. Therefore, early operation may be helpful to these patients.

An alternative technique for the management of phalangeal enchondromas with pathologic fractures

PURPOSE

Enchondroma of the hand with a pathologic fracture is generally treated by tumor curettage and bone grafting after the fracture has healed. However, delayed surgery postpones definitive diagnosis and prolongs the period of disability. We have treated pathologic fractures in a single stage through a modified lateral surgical approach with curettage of the tumor and stabilization using injectable calcium sulfate cement. The aim of this study was to report the outcomes of treatment with this material and the modified approach.

METHODS

Between 2006 and 2010, we enrolled 8 patients with solitary hand enchondromas and pathologic fractures. The surgical procedure involved a lateral approach, an extended lateral cortical window, thorough tumor evacuation, and reconstruction of the bone defects using commercially available injectable calcium sulfate cement. We performed evaluations before surgery and in the postoperative follow-up series by radiographs and clinical assessments, including measurement of joint motion by goniometry and a visual analog pain scale.

RESULTS

The average time of follow-up was 19 months (range, 12-36 mo). The pathologic fractures of all patients healed clinically and radiographically within 8 weeks after surgery, and the mean active motion arcs of the metacarpophalangeal joints and proximal interphalangeal joints of the involved digit were 90° and 94°, respectively at 3-month follow-up. All patients returned to ordinary daily activities without obvious pain by 3 months postoperatively. We found no major complications, such as unacceptable alignment, nonunion, infection, or tumor recurrence, during follow-up.

CONCLUSIONS

This study demonstrated the outcomes of early management of phalangeal enchondromas with pathologic fractures using a lateral approach and injectable calcium sulfate cement for reconstruction. This combined approach avoided the need for supplemental internal fixation, allowed early mobilization, and resulted in minimal joint stiffness.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Modified Mitchell osteotomy with screw fixation for correction of hallux valgus

BACKGROUND

The authors have performed more than 1500 cases of a Mitchell osteotomy and traditionally used two crossed pins for fixation. The previous series showed some complications related to pin tract infection, pin migration, and transfer metatarsalgia. Since 2009, the authors have used a compression screw for fixation and made some technical modifications and the results are reported in this article.

METHODS

A total of 95 patients underwent a Mitchell ostotomy to correct hallux valgus deformity with fixation with multi-use compression (MUC) screws. Hallux valgus angle (HVA), intermetatarsal angle (IMA), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale were measured preoperatively and postoperatively.

RESULTS

~There were statistically differences between the preoperatively and postoperatively HVA, first IMA, and AOFAS hallux metatarsophalangeal-interphalangeal scores. Five patients (8/137 feet, 5.8%) underwent removal of the screw because of screw tip irritation. Eight patients (9/137 feet, 6.5%) had transfer metatarsalgia of the second metatarsal, with two of them caused by dorsal tilt of the metatarsal head. One patient (1/137 feet, 0.7%) had undercorrection. There was no superficial infection, deep infection, nonunion, or osteonecrosis of the first metatarsal head.

CONCLUSION

On the basis of the results observed in this study, it appears that the use of a multi-use compression screw provides satisfactory stabilization of the modified Mitchell osteotomy and was not associated with any serious complications. The modified technique also helped reduce transfer metatarsalgia.

Successful treatment of a delayed presentation of a gunshot injury to the femoral neck in an elderly man: a case report

Gunshot wounds involving major joints can be lethal as a result of the disruption to major neurovascular tracts. We report on a high-energy ballistic injury resulting in a comminuted femoral neck fracture in an elderly patient with a surgical delay exceeding 20 h. The patient underwent bipolar hemiarthroplasty and led a functional, satisfactory life after surgery. Lead intoxication was also identified, and the blood lead concentration was almost two times the positive diagnostic value (25 μg/dL). The rebound in lead concentration suggested delayed lead toxicity. The patient did not have symptoms of plumbism at the last follow-up 4 years after the injury.

Atypical femoral fracture after long-term alendronate treatment: report of a case evidenced with magnetic resonance imaging

Postmenopausal osteoporosis is commonly treated with alendronate, one of the bisphosphonates used for the prevention and treatment of osteoporotic fractures. However, the correlation between atypical femoral fractures and long-term bisphosphonate therapy has not been clearly identified. We report here the case of a 69-year-old woman with postmenopausal osteoporosis who presented with an atypical femoral subtrochanteric fracture on magnetic resonance imaging (MRI) confirmation after having received alendronate therapy for about 3 years. The fracture united after refixation and after administration of alendronate was stopped. Several published reports were reviewed, and some clinical characteristics of this atraumatic fracture were revealed, including the clinical symptoms of thigh pain, stress reaction or stress fracture, and transverse fracture with unicortical beak in an area of cortical hypertrophy. In addition to a regular radiographic survey, MRI, which may provide early information, and bone biopsy for pathologic analysis may be used as tools for early detection and final diagnosis. Once an insufficiency fracture is suspected or proved to be related to bisphosphonate, the withholding of bisphosphonate should be highly recommended to enhance fracture healing. Prophylactic fixation should be considered if fracture healing is not good or if the patient cannot tolerate protection of weight-bearing.

Radiographic evaluation of minimally invasive distal metatarsal osteotomy for hallux valgus

BACKGROUND

The use of minimally invasive surgical technique for hallux valgus is controversial. The purpose of this study was to retrospectively evaluate the radiographic results of a minimally invasive distal metatarsal osteotomy for correction of hallux valgus.

MATERIALS AND METHODS

From September 2005 to March 2008, a minimally invasive distal metatarsal osteotomy was performed in 82 patients (125 feet) for hallux valgus. The average age was 40.8 (range, 13 to 71) years. The mean followup period was 18.3 (range, 9 to 38) months. These patients were categorized into groups based on their gender, age, preoperative hallux valgus angle, and preoperative 1-2 intermetatarsal angle. The radiographs were reviewed for preoperative and final followup hallux valgus angle, 1-2 intermetatarsal angle, and malunion or nonunion. A final followup hallux valgus angle greater than 20 degrees was defined as ``recurrence of deformity'' and represented a poor radiographic result.

RESULTS

There were no nonunions but one case of plantarflexion malunion. One case had skin irritation due to prominent bone. A poor radiographic result occurred in 29 feet (23.2%). Of those 36 feet whose preoperative hallux valgus angle was equal or greater than 30 degrees, 23 feet had a poor radiographic result (63.9%). Of those 89 feet whose preoperative hallux valgus angle was less than 30 degrees, only six feet had a poor radiographic result (6.7%) (p = 0.0001). The preoperative 1-2 intermetatarsal angle was found to have no statistically significant influence on poor radiographic results (p = 0.0539). Both the age and sex of the patients had no statistically significant influence (p = 0.8048 and 0.8604, respectively).

CONCLUSION

Based on our results, we do not recommend use of this technique to treat moderate to severe hallux valgus (hallux valgus angle, 30) degrees. We believe a traditional open osteotomy with formal capsulorrhaphy would be a better choice of treatment.

Percutaneous antegrade screwing for anterior column fracture of acetabulum with fluoroscopic-based computerized navigation

INTRODUCTION

Open reduction and internal fixation has been the gold standard for displaced fracture involving weightbearing dome and fractures with intra-articular fragments. However, extensile exposure can lead to complications. Fracture with minimal displacement can be fixed by a minimally invasive method. Percutaneous screwing for an anterior column fracture of acetabulum under conventional 2D fluoroscopy is a demanding technique. With fluoroscopic-based computerized navigation, we can determine the position of a screw real time intra-operatively with less exposure to radiation. We proposed that a fluoroscopy-based computerized navigational system would simplify operation procedures. The purpose of this study is to test the application of the fluoroscopy-based computerized navigational system for anterior column fracture of acetabulum.

MATERIALS AND METHODS

A prospective cohort study was conducted. Three patients with mildly displaced or non-displaced anterior column fracture of acetabulum were treated with a retrograde lag screw under a fluoroscopy-based computer navigation system. There were two males and one female with a mean age of 39 years and all patients were followed up for more than 1 year. Patients were allowed to perform joint movement exercises and to walk with partial weightbearing on the first day post-operatively.

RESULTS

The mean operation time was 40 min (range 30-45 min) from the use of fluoroscopy to wound closure and the mean total fluoroscopy time was 38 s (range 35-45 s). Total blood loss was less than 10 ml. The patients were pain free 1 week after the operation and had good functional recovery thereafter. No complication was noted postoperatively.

CONCLUSION

Though the indication for this procedure is limited, we think that there should be potential to apply the screw with less radiation by fluoroscopic-based computerized navigation. Once anatomic reduction can be achieved by the close method in the anterior column fracture of the acetabulum, percutaneous screw fixation under fluoroscopic-based computerized navigation could be a reliable method; however; validating the position of the guide pin and screw by fluoroscopy is suggested.

Optical characterization of a Cd(0.85)Mg(0.15)Se mixed crystal

We present an optical characterization of a Bridgman-grown wurtzite-type Cd(0.85)Mg(0.15)Se mixed crystal in the near-band-edge interband transitions using temperature-dependent contactless electroreflectance (CER) and photoreflectance (PR) in the temperature range 15-400 K. The interband excitonic transitions A and C originating from the band edge and spin-orbital splitting critical points of the sample, respectively, have been observed in the CER/PR spectra. The transition energies and broadening function of the excitonic features are determined via a lineshape fit to the CER/PR spectra. The parameters that describe the temperature dependence of the transition energies of excitons A and C, and the broadening function of exciton A, are evaluated and discussed.

Surgical treatment of type II floating knee: comparisons of the results of type IIA and type IIB floating knee

The prognosis of type II floating knee injuries was not as good as that of type I. Our purpose is to clarify the factors affecting the outcome of type II floating knee injuries. Thirty-five patients (36 limbs) with type II floating knee injury were studied with a mean follow-up of 52 months (26-96). Blake and McBryde had classified these injuries into type I for pure diaphyseal (true type) fracture and type II if the intra-articular involvements are one or more including hip, knee and ankle joints (variant type). According to this classification, we divided these patients into two groups depending on whether their knees were involved or not. Those cases with intra-articular knee involvement were classified as type IIA, while those without intra-articular knee involvement were classified as type IIB. Of the 36 cases, 21 were classified as type IIA and 15 were type IIB. The functional outcomes of these injuries were evaluated by using the criteria of Karlström and Olerud and analyzed with multivariate analysis. After multivariate analysis with logistic regression, we show the following results: first, the poor functional outcome of type II floating knee is contributed by type IIA. Second, the type IIA group has severer femoral open fracture grading (P = 0.027) and poorer functional outcome (P = 0.009) than type IIB. Third, the significant contributing factors to final outcome are the group (P = 0.013) and the fixation time after injury in femur (P = 0.015). Intra-articular knee involvement is the most important factor contributing to poor outcome of type II floating knee. The treatment of floating knee injuries with intra-articular knee involvement is still difficult. Further efforts to search better methods of treatment are required for these complex injuries in the future.

Hindfoot Arthrodesis for Neuropathic Deformity

Acquired neurologic disorders of the foot lead to arthrosis, deformities, instabilities, and functional disabilities. Hindfoot arthrodesis is the current option available for irreducible or nonbraceable deformities of neuropathic feet. However, the role of ankle arthrodesis in these patients has been questioned because of high nonunion and complication rates. From 1990 to 2001, 17 cases of acquired neuropathic foot deformities were treated by four tibiotalocalcaneal (TTC) arthrodeses and 13 ankle arthrodeses. TTC arthrodesis was performed on cases with combined ankle and subtalar arthritis or cases whose deformities or instabilities could not be corrected by ankle fusion alone. There was no nonunion of TTC arthrodesis and seven ununited ankle arthrodeses were salvaged by two TTC-attempted arthrodeses and five revision ankle-attempted arthrodeses. Eventually in these cases, there was one nonunion in TTC arthrodesis and one nonunion in revision ankle arthrodesis. The final fusion rate was 88% (15 of 17 cases) with average union time of 6.9 months (range, 2.5-18 months). The American Orthopaedic Foot and Ankle Society ankle hindfoot functional scores were evaluated: one was excellent (5.8%), seven were good (41%), eight were fair (53.3%), and one was poor (5.8%) in terms of total functional outcome. We conclude that TTC arthrodesis is indicated for cases with ankle and subtalar involvement and ankle arthrodesis is an alternative for cases with intact subtalar joint. We recommend revision ankle arthrodesis if the ankle fails to fuse and the bone stock of the talus is adequate. TTC arthrodesis is reserved for ankles with poor bone stock of the talus with fragmentation.

Angle analysis of Haglund syndrome and its relationship with osseous variations and Achilles tendon calcification

BACKGROUND

Haglund syndrome is a cause of posterior heel pain. The prominent posterosuperior projection into the retrocalcaneal bursa is thought to be a major etiology. Many methods have been proposed to measure the posterosuperior projection of the tuberosity into this bursa. The Fowler angle and the parallel pitch lines are the most frequently used. However, the relation between symptomatic Haglund syndrome and the measuring methods, especially the Fowler angle and parallel pitch lines, is not clear. The purposes of this paper were to study the predictive value of the most frequently used measurement methods to evaluate bursal impingement and to determine if other osseous variations and Achilles tendon calcification are associated with the development of Haglund syndrome.

METHODS

From October, 1996, to March, 2003, we evaluated 37 heels in 31 patients with symptomatic Haglund syndrome, and 40 heels in 27 individuals without posterior heel pain. On a lateral view radiograph, the Fowler angle, and the parallel pitch lines were measured, in addition to Achilles tendon calcification and the osseous variations, such as a posterior calcaneal step spur or plantar osseous projection.

RESULTS

The average Fowler angles in the control group and study group were 62.31 +/- 7.79 degrees and 60.14 +/- 7.01 degrees, respectively. There was no statistically significant difference (p = 0.490). The positive parallel pitch lines in the symptomatic group were 56.8% and in the control group 42.5%. There was no statistically significant difference (p = 0.474) between the groups.

CONCLUSIONS

No statistically significant differences were noted between the groups concerning the Fowler angle and parallel pitch lines. The posterior calcaneal step spur and Achilles tendon calcification were statistically significant between these two groups. The Fowler angle and parallel pitch lines were of little predictive value for the Haglund syndrome.

Freiberg's Infraction — Treatment with Metatarsal Neck Dorsal Closing Wedge Osteotomy: Report of Two Cases

Freiberg's infraction is a disease of avascular necrosis that most commonly involves the head of the second or third metatarsal. Several mechanisms have been proposed for its pathogenesis, but stress overloading is the most widely accepted etiology. Nonoperative treatment is thought to be effective in the early stages but not in the late stages of the disease. The methods of operative treatment for symptomatic Freiberg's infraction remain controversial. We report two cases of late stage Freiberg's infraction treated by metatarsal neck dorsal closing wedge osteotomy with good results, and we infer that this operation may be recommended for patients with symptomatic Freiberg's infraction in whom conservative treatments have little effect.

De novo 617G-A nucleotide mutation in the ACVR1 gene in a Taiwanese patient with fibrodysplasia ossificans progressiva

Fibrodysplasia ossificans progressiva (FOP) is a rare congenital disease with autosomal dominant transmission characterized by the presence of malformations of the big toes and of postnatal progressive heterotopic endochondral osteogenesis. We report the case of 3-year-old girl with dysplasia of the first metatarsal bones and progressive heterotopic ossificans of the right thigh due to previous diphtheria-tetanus-pertussis immunizations and several inappropriate surgical interventions. Direct sequence analysis identified a 617G-A nucleotide mutation in the patient but not in her parents or brother. Pedigree analysis suggests that a de novo mutation in the ACVR1 gene is responsible for the disease in this family. This is the first report of the results of a mutation analysis in a sporadic case of FOP in a Taiwanese patient.

Supracondylar dome osteotomy for cubitus valgus deformity associated with a lateral condylar nonunion in children. Surgical technique

BACKGROUND

Open reduction, autogenous bone-grafting, and internal fixation for the treatment of established nonunion of the lateral condyle associated with a cubitus valgus deformity has a high rate of complications. As a consequence, we developed a new technique that includes in situ compression fixation of the lateral condylar nonunion and a dome-shaped supracondylar osteotomy of the distal aspect of the humerus through a single posterior incision.

METHODS

Eight consecutive patients were treated with the new surgical technique between 1994 and 2000. The mean age at the time of surgery was 8.6 years. The mean interval between the lateral condylar fracture and surgery was 4.9 years. The mean preoperative radiographic humerus-ulna angle was 31 degrees of valgus. The postoperative results were classified with a modification of the scoring system described by Dhillon et al., which assesses pain, weakness, range of motion, the humerus-ulna angle, and prominence of the medial epicondyle on a 12-point scale.

RESULTS

All eight lateral condylar nonunions achieved union within three months postoperatively. The mean postoperative humerus-ulna angle was 5.5 degrees of valgus. All of the supracondylar dome osteotomies healed uneventfully, and there was no loss of correction postoperatively. The mean duration of follow-up was 4.5 years. The overall results were excellent in two patients, good in four patients, and fair in two patients.

CONCLUSIONS

With better exposure of the lateral condylar nonunion through a posterior approach, we can effectively stabilize the lateral condylar nonunion and avoid postoperative loss of motion and osteonecrosis of the condyle. With a dome-shaped supracondylar osteotomy, we can correct the cubitus valgus deformity and avoid the development of a medial epicondylar prominence. With careful selection of patients, this new technique can be an effective method to treat this clinically challenging problem.

Use of an External Fixation Combined with the Buttress-Maintain Pinning Method in Treating Comminuted Distal Radius Fractures in Osteoporotic Patients

BACKGROUND

It is difficult to keep the alignment of a distal radius fracture in patients with osteoporosis and prevent malunion. Therefore, we hoped to design better method to maintain alignment.

METHODS

Thirty-two patients over 65 years old with a displaced unstable distal radius fracture were treated by the external fixator combined with buttress-maintain pinning method and were compared with a group of 66 patients less than 60 years old treated by the same method.

RESULT

The radiologic results demonstrated that postoperative and final radial length and volar tilt were not statistically different between both groups. The functional result (excellent and good) in the elderly group was 87.5% and 89% to that of the control group. There was only one complication of pin tract infection in the elderly group.

CONCLUSIONS

External fixation for unstable distal radius fracture combined with buttress-maintain pinning method can be used in the osteoporotic bone of older adults with results similar to those for young adults at 18 months follow-up.

Investigation of management models in elite athlete injuries

This cross-sectional study investigated management models among elite athletes participating in sports including baseball, basketball, soccer, volleyball, tennis, softball, football, handball, track and field, swimming, judo, tae-kwon-do, gymnastics, archery, and weight lifting at the Tsoying National Sport Training Center. Data were collected by questionnaire. Of the 393 athletes investigated, 56% were male and 44% were female, with an average age of 20.9 years and average length of athletic experience of 9.8 years. At the time of the survey, 74.8% had sporting injuries and were being treated with Chinese and/or Western medicine. Among injured athletes, 14.5% chose Western treatment, 8.1% chose Chinese medicine, and 75.4% received combined treatment. There were various reasons for choosing the management model. Most athletes had ordinary self-recognition of sports injury prevention. Their qualified ability for sports injury prevention was 70%. This ability was significantly correlated with age, education, and sports experience. Within Taiwan's current medical and social environment, elite athletes prefer a combination of Eastern and Western treatments for sports injuries. Each of the medical approaches are widely accepted by elite athletes and their coaches. Doctors trained in Western medicine should learn these alternative treatment methods and apply them effectively in athletes, so that a better medical network can be established.

Delayed surgical treatment for neglected or mal-reduced talar fractures

From 1993 to 2002, we treated nine patients for neglected or mal-reduced talar fractures. Average patient age was 39 (20-64) years and average follow-up 53 months. The time interval between injury and index operation ranged from 4 weeks to 4 years. Surgical procedures included open reduction with or without bone grafting in six cases, open reduction combined with ankle fusion in one case, talar neck osteotomy in one case, and talar neck osteotomy combined with subtalar fusion in one case. All cases had solid bone union. One patient developed avascular necrosis of the talus needing subsequent ankle arthrodesis. In six patients, adjacent hindfoot arthrosis occurred. The overall AOFAS ankle-hindfoot score was in average 77.4. We conclude that in neglected and mal-reduced talar fractures, surgical treatment can lead to a favourable outcome if the hindfoot joints are not arthritic.

Lower extremity kinematics and kinetics during level walking and stair climbing in subjects with triple arthrodesis or subtalar fusion

The purpose of this study was to identify the kinematic and kinetic strategies used by patients with unilateral triple arthrodesis or subtalar fusion during level walking, stair ascent, stair descent and to determine the influence of these different conditions on kinematics and kinetics. Nine subjects with unilateral triple or subtalar fusion and five normal control subjects were recruited for this experiment. Temporal distance, kinematic and kinetic data were collected using a six camera 3-D motion analysis system and a custom fabricated set of stairs with five steps; the second and third steps were each instrumented with one force platform. During level walking, affected limbs lost all of the plantarflexion at the ankle joint during push-off and showed greater knee flexion angle during the same period of stance. During stair ascent, affected limbs showed a different movement pattern at the knee, a greater knee flexion angle during the whole stance phase and a near zero degree of plantarflexion angle during the forward continuance (FCN) phase. During descent, affected limbs showed a greater knee flexion angle during the whole stance phase and less ankle dorsiflexion angle during the same period of stance phase. At the ankle, peak moment and power values were significantly different between the affected side and the limbs of the control subjects during level walking in the push-off phase, stair ascent in the FCN phase, and stair descent in the weight acceptance (WA) phase, where the affected limbs had a lower plantarflexion moment and power values.

Surgical reconstruction for chronic lateral instability of the ankle

We have treated 56 patients (56 ankles) for symptomatic chronic lateral ankle instability by the surgical reconstruction procedure. The operation included lateral shift of the entire lateral capsule-ligament complex, suture to anterior border of fibula, and reinforcement by an elevated periosteal flap of distal fibula. These patients were reviewed at a mean period of 3.1 years (range, 9 months to 5 years) after the operation. There were 29 males and 27 females with an average age of 29 years (range, 16-49 years). The clinical results were graded according to the AOFAS Ankle-Hindfoot scales. There were 35 patients who were excellent (above 90 points), 16 who were good (between 76 and 90 points), 4 who were fair (between 60 and 75 points), and 1 who was poor (below 60 points). The excellent and good results amounted to 91.1% (51/56). Therefore, we concluded that symptomatic chronic lateral ankle instability could be successfully managed with this easy and effective surgical reconstruction method.

Surgical treatment for ipsilateral fractures of the hip and femoral shaft

Concomitant ipsilateral femoral shaft and neck fractures are difficult to treat. There is still no consensus on the optimal treatment of these complex fractures. Forty-seven patients with these complex fractures were treated in Kaohsiung Medical University Hospital between the periods of 1982 and 1998. Our standard treatment protocol is plate fixation for femoral shaft fracture and lag screw or dynamic hip screw (DHS) fixation for hip fracture. Among 42 cases treated with this protocol, 34 were males and 8 were females with an average age of 36 years and average follow-up period of 55 months. We divided hip fractures into two groups: femoral neck fracture as group I and intertrochanteric fracture as group II. There were no non-union and osteonecrosis of the hip in either group. One diaphyseal non-union was observed in group I and four in group II. There were 92 and 76% good functional results in groups I and II, respectively. The result shows that our standard method can yield a reliable outcome in group I, but not in group II.

Revision of ankle arthrodesis

From 1989 to 1996, we treated 18 cases (10 males, eight females; average age 48.2 years) of failed ankle arthrodesis by revision of ankle arthrodesis and followed their progress for at least two years. The average time interval between original surgery and revision was 17.3 months. Revisions were needed due to infection in one case, nonunion in 10 cases, and malalignment in seven cases. The salvage operations included debridement in the infected case, refreshed pseudoarthrosis in nonunion cases, and corrective osteotomy in malalignment cases. Sixteen cases were fixed by crossed screws with internal compression, one infected case was fixed by an external fixator, and one case with bone loss was fixed with buttress plate. The average follow-up period was 40.4 months. There was one nonunion and two delayed unions, with an ultimate fusion rate of 94%. The average AOFAS ankle-hindfoot score was 70.9 at final follow up. There was one excellent result (5.6%), five good results (27.8%), 11 fair results (61%), and one poor result (5.6%), and the overall results were poorer compared with our series of primary arthrodesis. The time to fusion also took longer in the revision cases (average 2.7 months in primary cases and 4.8 months in revision cases). Fusion techniques that ensure solid union in a functional position are essential. If an ankle arthrodesis fails, however, revision is a salvage procedure that can achieve an acceptable result.