bluuebunny/crossref_metadata_2025 huggingface dataset:
Systemic Inflammatory Response Syndrome After Surgery: Mechanisms and Protection
Authors: Margraf Andreas , Ludwig Nadine , Zarbock Alexander , Rossaint Jan
Published: November 2020

The immune system is an evolutionary hallmark of higher organisms that defends the host against invading pathogens and exogenous infections. This defense includes the recruitment of immune cells to the site of infection and the initiation of an inflammatory response to contain and eliminate pathogens. However, an inflammatory response may also be triggered by noninfectious stimuli such as major surgery, and, in case of an overshooting, still not comprehensively understood reaction, lead to tissue destruction and organ dysfunction. Unfortunately, in some cases, the immune system may not effectively distinguish between stimuli elicited by major surgery, which ideally should only require a modest inflammatory response, and those elicited by trauma or pathogenic infection. Surgical procedures thus represent a potential trigger for systemic inflammation that causes the secretion of proinflammatory cytokines, endothelial dysfunction, glycocalyx damage, activation of neutrophils, and ultimately tissue and multisystem organ destruction. In this review, we discuss and summarize currently available mechanistic knowledge on surgery-associated systemic inflammation, demarcation toward other inflammatory complications, and possible therapeutic options. These options depend on uncovering the underlying mechanisms and could include pharmacologic agents, remote ischemic preconditioning protocols, cytokine blockade or clearance, and optimization of surgical procedures, anesthetic regimens, and perioperative inflammatory diagnostic assessment. Currently, a large gap between basic science and clinically confirmed data exists due to a limited evidence base of translational studies. We thus summarize important steps toward the understanding of the precise time- and space-regulated processes in systemic perioperative inflammation.
Musculoskeletal Trauma in Critically Injured Patients: Factors Leading to Delayed Operative Fixation and Multiple Organ Failure
Authors: Richards Justin E. , Medvecz Andrew J. , O’Hara Nathan N. , Guillamondegui Oscar D. , O’Toole Robert V. , Obremskey William T. , Galvagno Samuel M. , Scalea Thomas M.
Published: November 2020

BACKGROUND:

Musculoskeletal injuries are common following trauma and variables that are associated with late femur fracture fixation are important to perioperative management. Furthermore, the association of late fracture fixation and multiple organ failure (MOF) is not well defined.

METHODS:

We performed a retrospective cohort investigation from 2 academic trauma centers. Inclusion criteria: age 18–89 years, injury severity score (ISS) >15, femoral shaft fracture requiring operative fixation, and admission to the intensive care unit >2 days. Admission physiology variables and abbreviated injury scale (AIS) scores were obtained. Lactate was collected as a marker of shock and was described as admission lactate (LacAdm) and as 24-hour time-weighted lactate (LacTW24h), which reflects an area under the curve and is considered a marker for the overall depth of shock. The primary aim was to evaluate clinical variables associated with late femur fracture fixation (defined as ≥24 hours after admission). A multivariable logistic regression model tested variables associated with late fixation and is reported by odds ratio (OR) with 95% confidence interval (CI). The secondary aim evaluated the association between late fixation and MOF, defined by the Denver MOF score. The summation of scores (on a scale from 0 to 3) from the cardiac, pulmonary, hepatic, and renal systems was calculated and MOF was confirmed if the total daily sum of the worst scores from each organ system was >3. We assessed the association between late fixation and MOF using a Cox proportional hazards model adjusted for confounding variables by inverse probability weighting (a propensity score method). A P value <.05 was considered statistically significant.

RESULTS:

One hundred sixty of 279 (57.3%) patients received early fixation and 119 of 279 (42.7%) received late fixation. LacTW24h (OR = 1.66 per 1 mmol/L increase, 95% CI, 1.24-2.21; P < .001) and ISS (OR = 1.07 per 1-point increase, 95% CI, 1.03-1.10; P < .001) were associated with higher odds of late fixation. Late fixation was associated with a 3-fold increase in the odds of MOF (hazard ratio [HR] = 3.21, 95% CI, 1.48-7.00; P < .01).

CONCLUSIONS:

In a cohort of multisystem trauma patients with femur fractures, greater injury severity and depth of shock, as measured by LacTW24h, were associated with late operative fixation. Late fixation was also associated with MOF. Strategies to reduce the burden of MOF in this population require further investigation.
Preoperative Point-of-Care Assessment of Left Ventricular Systolic Dysfunction With Transthoracic Echocardiography
Authors: Stenberg Ylva , Wallinder Lina , Lindberg Anne , Walldén Jakob , Hultin Magnus , Myrberg Tomi
Published: November 2020

BACKGROUND:

Left ventricular (LV) systolic dysfunction is an acknowledged perioperative risk factor and should be identified before surgery. Conventional echocardiographic assessment of LV ejection fraction (LVEF) obtained by biplane LV volumes is the gold standard to detect LV systolic dysfunction. However, this modality needs extensive training and is time consuming. Hence, a feasible point-of-care screening method for this purpose is warranted. The aim of this study was to evaluate 3 point-of-care echocardiographic methods for identification of LV systolic dysfunction in comparison with biplane LVEF.

METHODS:

One hundred elective surgical patients, with a mean age of 63 ± 12 years and body mass index of 27 ± 4 kg/m2, were consecutively enrolled in this prospective observational study. Transthoracic echocardiography was conducted 1–2 hours before surgery. LVEF was obtained by automatic two-dimensional (2D) biplane ejection fraction (EF) software. We evaluated if Tissue Doppler Imaging peak systolic myocardial velocities (TDISm), anatomic M-mode E-point septal separation (EPSS), and conventional M-mode mitral annular plane systolic excursion (MAPSE) could discriminate LV systolic dysfunction (LVEF <50%) by calculating accuracy, efficiency, correlation, positive (PPV) respective negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC) for each point-of-care method.

RESULTS:

LVEF<50% was identified in 22% (21 of 94) of patients. To discriminate an LVEF <50%, AUROC for TDISm (mean <8 cm/s) was 0.73 (95% confidence interval [CI], 0.62-0.84; P < .001), with a PPV of 47% and an NPV of 90%. EPSS with a cutoff value of >6 mm had an AUROC 0.89 (95% CI, 0.80-0.98; P < .001), with a PPV of 67% and an NPV of 96%. MAPSE (mean <12 mm) had an AUROC 0.80 (95% CI, 0.70-0.90; P < 0.001) with a PPV of 57% and an NPV of 98%.

CONCLUSIONS:

All 3 point-of-care methods performed reasonably well to discriminate patients with LVEF <50%. The clinician may choose the most suitable method according to praxis and observer experience.
Application of a High-Flow Nasal Cannula for Prevention of Postextubation Atelectasis in Children Undergoing Surgery: A Randomized Controlled Trial
Authors: Lee Ji-Hyun , Ji Sang-Hwan , Jang Young-Eun , Kim Eun-Hee , Kim Jin-Tae , Kim Hee-Soo
Published: November 2020

BACKGROUND:

General anesthesia-induced atelectasis is common, and persistent postoperative atelectasis is associated with pulmonary complications. We aimed to evaluate the preventive effects of a high-flow nasal cannula (HFNC) on postoperative atelectasis and respiratory complications in infants and small children.

METHODS:

In this prospective randomized controlled trial, children (≤2 years) receiving general anesthesia (>2 hours) were randomized into the control and HFNC groups. At the end of the surgery, the first lung ultrasound evaluation was performed in both groups. In the postanesthetic care unit (PACU), the control group received conventional oxygen therapy, while the HFNC group received oxygen via HFNC, with a flow rate of 2 L kg−1 min−
1. Before discharge to the ward, a second lung ultrasound examination was performed. The primary outcome was the lung ultrasound score at PACU discharge. The secondary outcomes included the lung ultrasound score at the end of surgery, the incidence of significant atelectasis at PACU discharge, and other postoperative outcomes.

RESULTS:

Lung ultrasound score and the incidence of atelectasis at the end of surgery did not differ significantly between the control (n = 38) and HFNC (n = 40) groups. After staying in the PACU, both groups showed a reduced lung ultrasound score and atelectasis incidence. However, the HFNC group had a significantly lower consolidation score than the control group (0; interquartile range [IQR] = 0–1 vs 3; IQR = 2–4; P< .001). Additionally, none of the patients had significant atelectasis in the HFNC group, compared to 6 patients in the control group (0% vs 15.8%; odds ratio [OR] = 0.444; 95% confidence interval for OR, 0.343–0.575; P = .011). Incidence of desaturation (oxygen saturation [Spo
2] ≤ 95%), postoperative complications, and the length of hospital stay did not differ between the groups.

CONCLUSIONS:

Preventive use of HFNC after surgery improves the lung ultrasound score and reduces postoperative atelectasis compared to conventional oxygen therapy in infants and small children.
Chest CT features and progression of patients with coronavirus disease 2019
Authors: Xie Linjun , Hou Keke , Xu Huayan , Fu Hang , Xu Rong , Liu Hui , Zhou Zhongqin , Li Zhenlin , Yang Ming , Guo Yingkun
Published: November 2020

Objectives:

Coronavirus disease 2019 (COVID-19) is a major public health emergency. It poses a grave threat to human life and health. The purpose of the study is to investigate the chest CT findings and progression of the disease observed in COVID-19 patients.

Methods:

Forty-nine confirmed cases of adult COVID-19 patients with common type, severe and critically severe type were included in this retrospective single-center study. The thin-section chest CT features and progress of the disease were evaluated. The clinical and chest imaging findings of COVID-19 patients with different severity types were compared. The CT severity score and MuLBSTA score (a prediction of mortality risk) were calculated in those patients.

Results:

Among the 49 patients, 35 patients (71%) were common type and 14 patients (28%) were severe and critically severe type. Nearly all patients (98%) had pure ground-glass opacities (GGO) in CT imaging. Of the severe and critically severe type patients, 86% exhibited GGO with consolidation, in comparison with 54% of the patients with common type. Fibrosis presented in 79% of the severe and critically severe type patients and 43% of the common type patients. The severe and critically severe type patients were significantly more prone to experience five-lobe involvement compared to the common type patients (p = 0.002). The severe and critically severe type patients also had higher CT severity and MuLBSTA scores than the common type patients (5.43 ± 2.38 vs 3.37 ± 2.40, p < 0.001;and 10.21 ± 3.83 vs 4.63 ± 3.43, p < 0.001, respectively). MuLBSTA score was positively correlated with admittance to the intensive care unit (p = 0.005, r = 0.351). Nineteen patients underwent three times CT scan. The interval between first and second CT scan was 4[4,8] days, second and third was 3[2,4] days. There were greater improvements in the third CT follow-up findings compared to the second (p = 0.002).

Conclusions:

The severe and critically severe type patients often experienced more severe lung lesions, including GGO with consolidation. The CT severity score and MuLBSTA score may be helpful for the assessment of COVID-19 severity and progression.

Advances in knowledge:

Chest CT has the value of evaluated radiographical features of COVID-19 and allow for dynamic observation of the disease progression. Considering coagulation disorder of COVID-19, MuLBSTA score may need to be updated to increase new understanding of COVID-19.
Case Report: Complete heart block as a manifestation of cardiac metastasis of oral cancer
Authors: Andrianto Andrianto , Mulia Eka Prasetya Budi , Suwanto Denny , Rachmi Dita Aulia , Yogiarto Mohammad
Published: November 2020

Metastatic tumors of the heart presenting with complete heart block (CHB) is an extremely uncommon case. There are no available guidelines in managing CHB in terminal cancer. Permanent pacemaker implantation in such cases is a challenge in terms of clinical utility and palliative care.

We report a case of a 24-year-old man suffering from tongue cancer presenting with CHB. An intracardiac mass and moderate pericardial effusion were present, presumed as the metastatic tumor of tongue cancer. We implanted a temporary pacemaker for his symptomatic heart block and cardiogenic shock, and pericardiocentesis for his massive pericardial effusion. We decided that a permanent pacemaker would not be implanted based on the low survival rate and significant comorbidities.

Multiple studies report a variable number of cardiac metastasis incidence ranging from 2.3% to 18.3%. It is rare for such malignancies to present with CHB. The decision to implant a permanent pacemaker is highly specific based on the risks and benefits of each patient. It needs to be tailored to the patient’s functional status, comorbid diseases, prognosis, and response to conservative management.
Identification of 6-(piperazin-1-yl)-1,3,5-triazine as a chemical scaffold with broad anti-schistosomal activities
Authors: Padalino Gilda , Chalmers Iain W. , Brancale Andrea , Hoffmann Karl F.
Published: November 2020

Background: Schistosomiasis, caused by infection with blood fluke schistosomes, is a neglected tropical disease of considerable importance in resource-poor communities throughout the developing world. In the absence of an immunoprophylactic vaccine and due to over-reliance on a single chemotherapy (praziquantel), schistosomiasis control is at risk should drug insensitive schistosomes develop. In this context, application of in silico virtual screening on validated schistosome targets has proven successful in the identification of novel small molecules with anti-schistosomal activity.  

Methods: Focusing on the Schistosoma mansoni histone methylation machinery, we herein have used RNA interference (RNAi), ELISA-mediated detection of H3K4 methylation, homology modelling and in silico virtual screening to identify a small collection of small molecules for anti-schistosomal testing. A combination of low to high-throughput whole organism assays were subsequently used to assess these compounds’ activities on miracidia to sporocyst transformation, schistosomula phenotype/motility metrics and adult worm motility/oviposition readouts.

Results: RNAi-mediated knockdown of smp_138030/smmll-1 (encoding a histone methyltransferase, HMT) in adult worms (~60%) reduced parasite motility and egg production. Moreover, in silico docking of compounds into Smp_138030/SmMLL-1’s homology model highlighted competitive substrate pocket inhibitors, some of which demonstrated significant activity on miracidia, schistosomula and adult worm lifecycle stages together with variable effects on HepG2 cells. Particularly, the effect of compounds containing a 6-(piperazin-1-yl)-1,3,5-triazine core on adult schistosomes recapitulated the results of the smp_138030/smmll-1 RNAi screens.

Conclusions: The biological data and the structure-activity relationship presented in this study define the 6-(piperazin-1-yl)-1,3,5-triazine core as a promising starting point in ongoing efforts to develop new urgently needed schistosomicides.
Point-of-care testing for bacterial infection in diabetic foot ulcers: a prospective cohort study
Authors: Jonker Leon , Smith Danielle , Mark Emma , Schutter Jose , Thornthwaite Sarah , Johnston Shona
Published: November 2020

Objective:

To appraise the performance of a new point-of-care wound infection detection kit in diabetic foot ulcers (DFUs), using clinician opinion as the primary comparator. The proprietary swab-based chromatic Glycologic (Glycologic Ltd., UK) detection kit used in this study is designed to detect host response to pathogenic levels of bacteria in wounds.

Method:

In high-risk podiatry clinics, patients with DFUs were recruited and infection detection kit test results compared with initial clinician opinion. Chi-squared tests, principal component analysis (PCA) and multiple regression analysis were performed to determine which variables were possibly associated with infection. The variables considered were patients' wound parameters, wider vascular comorbidity and demographics.

Results:

A total of 136 patients, providing 383 wound swabs, were included in the study. Total agreement in terms of DFU wound assessment for infection—between podiatrists' clinical opinion and Glycologic kit test result—was observed in 79% of cases (301/383). For 56 of the 349 negative infection detection kit test results (16%), podiatrists identified a ‘possible’ or ‘definite’ infection. Conversely, in 14 of the 307 cases (4.6%) where podiatrists deemed the wound ‘not infected’, the infection detection kit test showed a colour change. Regression analysis and PCA showed that clinical signs of wound infection, namely erythema, purulence and odour, were all significantly associated with both a positive clinical opinion and infection detection kit test result. However, in the case of the infection detection kit, a patient's number of lesions and vascular comorbidities were also significantly correlated with a positive test result.

Conclusion:

A host response to critical pathological levels of bioburden in a wound—as detected with the infection detection kit—may partly be determined by an individual patient's (vascular) health and therefore be person-specific. Further research is indicated to determine the relationship between an infection detection kit test result and the microbiological status of the wound.
Parameterized Structure-Preserving Transformations of Matrix Polynomials
Authors: Kawano Daniel T.
Published: November 2020

This paper examines the relationship between the companion forms of regular matrix polynomials with singular leading coefficients. When two such polynomials have the same underlying finite and infinite Jordan structures, it is shown that their companion forms are connected by a strict equivalence transformation that can be parameterized using the commutant of the companion forms' common Weierstrass canonical form. The process developed herein for generating such parameterized transformations is applied to the useful class of diagonalizable quadratic polynomials.
The association between hospital case volume and in-hospital and one-year mortality after hip fracture surgery
Authors: Yoo Seokha , Jang Eun Jin , Jo Junwoo , Jo Jun Gi , Nam Seungpyo , Kim Hansol , Lee Hannah , Ryu Ho Geol
Published: November 2020

Aims

Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery.

Methods

Data for all patients who underwent surgery for hip fracture from January 2008 to December 2016 were extracted from the Korean National Healthcare Insurance Service database. According to mean annual case volume of surgery for hip fracture, hospitals were classified into very low (< 30 cases/year), low (30 to 50 cases/year), intermediate (50 to 100 cases/year), high (100 to 150 cases/year), or very high (> 150 cases/year) groups. The association between hospital case volume and in-hospital mortality or one-year mortality was assessed using the logistic regression model to adjust for age, sex, type of fracture, type of anaesthesia, transfusion, comorbidities, and year of surgery.

Results

Between January 2008 and December 2016, 269,535 patients underwent hip fracture surgery in 1,567 hospitals in Korea. Compared to hospitals with very high volume, in-hospital mortality rates were significantly higher in those with high volume (odds ratio (OR) 1.10, 95% confidence interval ((CI) 1.02 to 1.17, p = 0.011), low volume (OR 1.22, 95% CI 1.14 to 1.32, p < 0.001), and very low volume (OR 1.25, 95% CI 1.16 to 1.34, p < 0.001). Similarly, hospitals with lower case volume showed higher one-year mortality rates compared to hospitals with very high case volume (low volume group, OR 1.15, 95% CI 1.11 to 1.19, p < 0.001; very low volume group, OR 1.10, 95% CI 1.07 to 1.14, p < 0.001).

Conclusion

Higher hospital case volume of hip fracture surgery was associated with lower in-hospital mortality and one-year mortality in a dose-response fashion. Cite this article: Bone Joint J 2020;102-B(10):1384–1391.
Preoperative Staphylococcus aureus screening and eradication
Authors: Scholten Ruben , Hannink Gerjon , Willemsen Karin , Mascini Ellen M. , Somford Matthijs P. , Schreurs B. Willem , van Susante Job L. C.
Published: November 2020

Aims

Preoperative nasal Staphylococcus aureus screening and eradication reduces surgical site infections (SSIs) but its impact on reducing early prosthetic joint infection (PJI) remains controversial. This study aims to assess the effect of preoperative nasal S. aureus screening and eradication on the incidence of early PJI in general and S. aureus-induced early PJI.

Methods

All primary total hip arthroplasties (THA) and total knee arthroplasties (TKA) performed from January 2006 to April 2018 were retrospectively reviewed for the incidence of early PJI. Demographic parameters, risk factors for PJI (American Society of Anaesthesiologists classification, body mass index, smoking status, and diabetes mellitus) and implant types were collected. A preoperative screening and eradication protocol for nasal colonization of S. aureus was introduced in October 2010. The incidence of early PJI was compared before and after the implementation of the protocol. Missing data were imputed via multiple imputation by chained equations. Inverse probability weighting was used to account for differences between patients in both groups. Weighted univariate logistic regression was used to evaluate the incidence of early PJI for both groups.

Results

In total, 10,486 THAs and TKAs were performed in the research period. After exclusion, a cohort of 5,499 screened cases and 3,563 non-screened cases were available for analysis. Overall, no significant reduction in early PJI was found in the screened group (odds ratio (OR) 0.78, 95% confidence interval (CI) 0.55 to 1.11; p = 0.173). However, the incidence of S. aureus-induced PJI was significantly reduced (OR 0.58, 95% CI 0.36 to 0.92; p = 0.027) in the screened group.

Conclusion

A preoperative nasal S. aureus screening and eradication protocol did not significantly reduce the overall incidence of early PJI after THA or TKA. However, a decreased incidence of S. aureus-induced early PJI was established. These findings can help to establish better consensus around the value of these screening protocols. Cite this article: Bone Joint J 2020;102-B(10):1341–1348.
Quantification of intra-articular fibrosis in patients with stiff knee arthroplasties using metal-reduction MRI
Authors: Attard Veronica , Li Cheuk Yin , Self Alexander , Mann Derek A. , Borthwick Lee A. , O’Connor Phil , Deehan David J. , Kalson Nicholas S.
Published: November 2020

Aims

Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties.

Methods

Well-functioning primary TKAs (n = 11), failed non-fibrotic TKAs (n = 5), and patients with a clinical diagnosis of fibrosis 1 (n = 8) underwent an MRI scan with advanced metal suppression (Slice Encoding for Metal Artefact Correction, SEMAC) with gadolinium contrast. Fibrotic tissue (low intensity on T1 and T2, low-moderate post-contrast enhancement) was quantified (presence and tissue thickness) in six compartments: supra/infrapatella, medial/lateral gutters, and posterior medial/lateral.

Results

Fibrotic tissue was identified in all patients studied. However, tissue was significantly thicker in fibrotic patients (4.4 mm ± 0.2 mm) versus non-fibrotic (2.5 mm ± 0.4 mm) and normal TKAs (1.9 mm ± 0.2 mm, p = < 0.05). Significant (> 4 mm thick) tissue was seen in 26/48 (54%) of compartments examined in the fibrotic group, compared with 17/30 (57%) non-fibrotic, and 10/66 (15%) normal TKAs. Although revision surgery did improve range of movement (ROM) in all fibrotic patients, clinically significant restriction remained post-surgery.

Conclusion

Stiff TKAs contain intra-articular fibrotic tissue that is identifiable by MRI. Studies should evaluate whether MRI is useful for surgical planning of debridement, and as a non-invasive measurement tool following interventions for stiffness caused by fibrosis. Revision for stiffness can improve ROM, but outcomes are sub-optimal and new treatments are required. Cite this article: Bone Joint J 2020;102-B(10):1331–1340.
Mid-term results of a modified self-growing rod technique for the treatment of early-onset scoliosis
Authors: Mehdian Hossein , Haddad Sleiman , Pasku Dritan , Nasto Luigi Aurelio
Published: November 2020

Aims

To report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS).

Methods

We carried out a retrospective analysis of 16 consecutive patients with EOS treated with an SGR construct at a single hospital between September 2008 and December 2014. General demographics and deformity variables (i.e. major Cobb angle, T1 to T12 length, T1 to S1 length, pelvic obliquity, shoulder obliquity, and C7 plumb line) were recorded preoperatively, and postoperatively at yearly follow-up. Complications and revision procedures were also recorded. Only patients with a minimum follow-up of five years after surgery were included.

Results

A total of 16 patients were included. Six patients had an idiopathic EOS while ten patients had a neuromuscular or syndromic EOS (seven spinal muscular atrophy (SMA) and three with cerebral palsy or a syndrome). Their mean ages at surgery were 7.1 years (SD 2.2) and 13.3 years (SD 2.6) respectively at final follow-up. The mean preoperative Cobb angle of the major curve was 66.1° (SD 8.5°) and had improved to 25.5° (SD 9.9°) at final follow-up. The T1 to S1 length increased from 289.7 mm (SD 24.9) before surgery to 330.6 mm (SD 30.4) immediately after surgery. The mean T1 to S1 and T1 to T12 growth after surgery were 64.1 mm (SD 19.9) and 47.4 mm (SD 18.8), respectively, thus accounting for a mean T1 to S1 and T1 to T12 spinal growth after surgery of 10.5 mm/year (SD 3.7) and 7.8 mm/year (SD 3.3), respectively. A total of six patients (five idiopathic EOS, one cerebral palsy EOS) had broken rods during their growth spurt but were uneventfully revised with a fusion procedure. No other complications were noted.

Conclusion

Our data show that SGR is a safe and effective technique for the treatment of EOS in nonambulatory hypotonic patients with a neuromuscular condition. Significant spinal growth can be expected after surgery and is comparable to other published techniques for EOS. While satisfactory correction of the deformity can be achieved and maintained with this technique, a high rate of rod breakage was seen in patients with an idiopathic or cerebral palsy EOS. Cite this article: Bone Joint J 2020;102-B(11):1560–1566.
Mortality after a proximal humeral fracture
Authors: Bergdahl Carl , Wennergren David , Ekelund Jan , Möller Michael
Published: November 2020

Aims

The aims of this study were to investigate the mortality following a proximal humeral fracture. Data from a large population-based fracture register were used to quantify 30-day, 90-day, and one-year mortality rates after a proximal humeral fracture. Associations between the risk of mortality and the type of fracture and its treatment were assessed, and mortality rates were compared between patients who sustained a fracture and the general population.

Methods

All patients with a proximal humeral fracture recorded in the Swedish Fracture Register between 2011 and 2017 were included in the study. Those who died during follow-up were identified via linkage with the Swedish Tax Agency population register. Age- and sex-adjusted controls were retrieved from Statistics Sweden and standardized mortality ratios (SMRs) were calculated.

Results

A total of 18,452 patients who sustained a proximal humeral fracture were included. Their mean age was 68.8 years (16 to 107) and the majority (13,729; 74.4%) were women. A total of 310 (1.68%) died within 30 days, 615 (3.33%) within 90 days, and 1,445 (7.83%) within one year after the injury. The mortality in patients sustaining a fracture and the general population was 1,680/100,000 and 326/100,000 at 30 days, 3,333/100,000 and 979/100,000 at 90 days, and 7,831/100,000 and 3,970/100,000 at one year, respectively. Increasing age, male sex, low-energy trauma, type A fracture, concomitant fractures, and non-surgical treatment were all independent factors associated with an increased risk of mortality.

Conclusion

Compared with the general population, patients sustaining a proximal humeral fracture have a significantly higher risk of mortality up to one year after the injury. The risk of mortality is five times higher during the first 30 days, diminishing to two times higher at one year, suggesting that these patients constitute a strikingly frail group, in whom appropriate immediate management and medical optimization are required. Cite this article: Bone Joint J 2020;102-B(11):1484–1490.
Does size of tendon gap affect patient-reported outcome following Achilles tendon rupture treated with functional rehabilitation?
Authors: Yassin Mohamed , Myatt Richard , Thomas William , Gupta Vatsal , Hoque Tagrit , Mahadevan Devendra
Published: November 2020

Aims

Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation.

Methods

Analysis of prospectively collected data on all 131 patients diagnosed with ATR at Royal Berkshire Hospital, UK, from August 2016 to January 2019 and managed non-operatively was performed. Diagnosis was confirmed on all patients by dynamic ultrasound scanning and gap size measured with ankle in full plantarflexion. Functional rehabilitation using an established protocol was the preferred treatment. All non-operatively treated patients with completed Achilles Tendon Rupture Scores (ATRS) at a minimum of 12 months following injury were included.

Results

In all, 82 patients with completed ATRS were included in the analysis. Their mean age was 51 years (standard deviation (SD) 14). The mean ATRS was 76 (SD 19) at a mean follow-up of 20 months (SD 11) following injury. Gap inversely affected ATRS with a Pearson’s correlation of -0.30 (p = 0.008). Mean ATRS was lower with gaps > 5 mm compared with ≤ 5 mm (73 (SD 21) vs 82 (SD 16); p = 0.031). Mean ATRS was lowest (70 (SD 23)) with gaps > 10 mm, with significant differences in perceived strength and pain. The overall re-rupture rate was two out of 131 (1.5%).

Conclusion

Increasing gap size predicts lower patient-reported outcome, as measured by ATRS. Tendon gap > 5 mm may be a useful predictor in physically demanding individuals, and tendon gap > 10 mm for those with low physical demand. Further studies that control for gap size when comparing non-operative and operative treatment are required to assess if these patients may benefit from surgery, particularly when balanced against the surgical risks. Cite this article: Bone Joint J 2020;102-B(11):1535–1541.
Fractures of the proximal- and middle-thirds of the humeral shaft should be considered as fragility fractures
Authors: Oliver William M. , Searle Henry K. C. , Ng Zhan Herr , Wickramasinghe Neil R. L. , Molyneux Samuel G. , White Tim O. , Clement Nicholas D. , Duckworth Andrew D.
Published: November 2020

Aims

The aim of this study was to determine the current incidence and epidemiology of humeral diaphyseal fractures. The secondary aim was to explore variation in patient and injury characteristics by fracture location within the humeral diaphysis.

Methods

Over ten years (2008 to 2017), all adult patients (aged ≥ 16 years) sustaining an acute fracture of the humeral diaphysis managed at the study centre were retrospectively identified from a trauma database. Patient age, sex, medical/social background, injury mechanism, fracture classification, and associated injuries were recorded and analyzed.

Results

A total of 900 fractures (typical 88.9%, n = 800/900; pathological 8.3%, n = 75/900; periprosthetic 2.8%, n = 25/900) were identified in 898 patients (mean age 57 years (16 to 97), 55.5% (n = 498/898) female). Overall fracture incidence was 12.6/100,000/year. For patients with a typical fracture (n = 798, mean age 56 years (16 to 96), 55.1% (n = 440/798) female), there was a bimodal distribution in men and unimodal distribution in older women (Type G). A fall from standing was the most common injury mechanism (72.6%, n = 581/800). The majority of fractures involved the middle-third of the diaphysis (47.6%, n = 381/800) followed by the proximal- (30.5%, n = 244/800) and distal-thirds (n = 175/800, 21.9%). In all, 18 injuries (2.3%) were open and a radial nerve palsy occurred in 6.7% (n = 53/795). Fractures involving the proximal- and middle-thirds were more likely to occur in older (p < 0.001), female patients (p < 0.001) with comorbidities (p < 0.001) after a fall from standing (p < 0.001). Proximal-third fractures were also more likely to occur in patients with alcohol excess (p = 0.003) and to be classified as AO-Orthopaedic Trauma Association type B or C injuries (p < 0.001).

Conclusion

This study updates the incidence and epidemiology of humeral diaphyseal fractures. Important differences in patient and injury characteristics were observed based upon fracture location. Injuries involving the proximal- and middle-thirds of the humeral diaphysis should be considered as fragility fractures. Cite this article: Bone Joint J 2020;102-B(11):1475–1483.
Is a split-dose intravenous dexamethasone regimen superior to a single high dose in reducing pain and improving function after total hip arthroplasty? A randomized blinded placebo-controlled trial
Authors: Lei Yiting , Huang Zeyu , Huang Qiang , Pei Fuxing , Huang Wei
Published: November 2020

Aims

Intravenous dexamethasone has been shown to reduce immediate postoperative pain after total hip arthroplasty (THA), though the effects are short-lived. We aimed to assess whether two equivalent perioperative split doses were more effective than a single preoperative dose.

Methods

A total of 165 patients were randomly assigned into three groups: two perioperative saline injections (Group A, placebo), a single preoperative dose of 20 mg dexamethasone and a postoperative saline injection (Group B), and two perioperative doses of 10 mg dexamethasone (Group C). Patients, surgeons, and staff collecting outcome data were blinded to allocation. The primary outcome was postoperative pain level reported on a ten-point Numerical Rating Scale (NRS) at rest and during activity. The use of analgesic and antiemetic rescue, incidence of postoperative nausea and vomiting (PONV), CRP and interleukin-6 (IL-6) levels, range of motion (ROM), length of stay (LOS), patient satisfaction, and the incidence of surgical site infection (SSI) and gastrointestinal bleeding (GIB) in the three months postoperatively, were also compared.

Results

The pain scores at rest were significantly lower in Groups B and C than in Group A on postoperative days 1 and 2. The dynamic pain scores and CRP and IL-6 levels were significantly lower for Groups B and C compared to Group A on postoperative days 1, 2, and 3. Patients in Groups B and C had a lower incidence of PONV, reduced use of analgesic and antiemetic rescue, improved ROM, shorter LOS, and reported higher satisfaction than in Group A. Patients in Group C had significantly lower dynamic pain scores and IL-6 and CRP levels on postoperative days 2 and 3, and higher ROM and satisfaction on postoperative day 3 than in Group B. No SSI or GIB occurred in any group.

Conclusion

Perioperative dexamethasone provides short-term advantages in reducing pain, PONV, and inflammation, and increasing range of motion in the early postoperative period after THA. A split-dose regimen was superior to a single high dose in reducing pain and inflammation, and increasing ROM, with better patient satisfaction. Level of evidence: I Cite this article: Bone Joint J 2020;102-B(11):1497–1504.
Robotic arm-assisted bi-unicompartmental knee arthroplasty maintains natural knee joint anatomy compared with total knee arthroplasty: a prospective randomized controlled trial
Authors: Banger Matthew S. , Johnston William D. , Razii Nima , Doonan James , Rowe Philip J. , Jones Bryn G. , MacLean Angus D. , Blyth Mark J. G.
Published: November 2020

Aims

The aim of this study was to compare robotic arm-assisted bi-unicompartmental knee arthroplasty (bi-UKA) with conventional mechanically aligned total knee arthroplasty (TKA) in order to determine the changes in the anatomy of the knee and alignment of the lower limb following surgery.

Methods

An analysis of 38 patients who underwent TKA and 32 who underwent bi-UKA was performed as a secondary study from a prospective, single-centre, randomized controlled trial. CT imaging was used to measure coronal, sagittal, and axial alignment of the knee preoperatively and at three months postoperatively to determine changes in anatomy that had occurred as a result of the surgery. The hip-knee-ankle angle (HKAA) was also measured to identify any differences between the two groups.

Results

The pre- to postoperative changes in joint anatomy were significantly less in patients undergoing bi-UKA in all three planes in both the femur and tibia, except for femoral sagittal component orientation in which there was no difference. Overall, for the six parameters of alignment (three femoral and three tibial), 47% of bi-UKAs and 24% TKAs had a change of < 2° (p = 0.045). The change in HKAA towards neutral in varus and valgus knees was significantly less in patients undergoing bi-UKA compared with those undergoing TKA (p < 0.001). Alignment was neutral in those undergoing TKA (mean 179.5° (SD 3.2°)) while those undergoing bi-UKA had mild residual varus or valgus alignment (mean 177.8° (SD 3.4°)) (p < 0.001).

Conclusion

Robotic-assisted, cruciate-sparing bi-UKA maintains the natural anatomy of the knee in the coronal, sagittal, and axial planes better, and may therefore preserve normal joint kinematics, compared with a mechanically aligned TKA. This includes preservation of coronal joint line obliquity. HKAA alignment was corrected towards neutral significantly less in patients undergoing bi-UKA, which may represent restoration of the pre-disease constitutional alignment (p < 0.001). Cite this article: Bone Joint J 2020;102-B(11):1511–1518.
Synovial fluid peptidase activity as a biomarker for knee osteoarthritis clinical progression
Authors: Seco-Calvo Jesús , Sánchez-Herráez Sergio , Casis Luis , Valdivia Asier , Perez-Urzelai Itxaro , Gil Javier , Echevarría Enrique
Published: November 2020

Aims

To analyze the potential role of synovial fluid peptidase activity as a measure of disease burden and predictive biomarker of progression in knee osteoarthritis (KOA).

Methods

A cross-sectional study of 39 patients (women 71.8%, men 28.2%; mean age of 72.03 years (SD 1.15) with advanced KOA (Ahlbäck grade ≥ 3 and clinical indications for arthrocentesis) recruited through the (Orthopaedic Department at the Complejo Asistencial Universitario de León, Spain (CAULE)), measuring synovial fluid levels of puromycin-sensitive aminopeptidase (PSA), neutral aminopeptidase (NAP), aminopeptidase B (APB), prolyl endopeptidase (PEP), aspartate aminopeptidase (ASP), glutamyl aminopeptidase (GLU) and pyroglutamyl aminopeptidase (PGAP).

Results

Synovial fluid peptidase activity varied significantly as a function of clinical signs, with differences in levels of PEP (p = 0.020), ASP (p < 0.001), and PGAP (p = 0. 003) associated with knee locking, PEP (p = 0.006), ASP (p = 0.001), GLU (p = 0.037), and PGAP (p = 0.000) with knee failure, and PEP (p = 0.006), ASP (p = 0.001), GLU (p = 0.037), and PGAP (p < 0.001) with knee effusion. Further, patients with the greatest functional impairment had significantly higher levels of APB (p = 0.005), PEP (p = 0.005), ASP (p = 0.006), GLU (p = 0.020), and PGAP (p < 0.001) activity, though not of NAP or PSA, indicating local alterations in the renin-angiotensin system. A binary logistic regression model showed that PSA was protective (p = 0.005; Exp (B) 0.949), whereas PEP (p = 0.005) and GLU were risk factors (p = 0.012).

Conclusion

These results suggest synovial fluid peptidase activity could play a role as a measure of disease burden and predictive biomarker of progression in KOA. Cite this article: Bone Joint Res 2020;9(11):789–797.
Treatment options in unresectable soft tissue and bone sarcoma of the extremities and pelvis – a systematic literature review
Authors: Smolle Maria Anna , Szkandera Joanna , Andreou Dimosthenis , Palmerini Emanuela , Bergovec Marko , Leithner Andreas
Published: November 2020

In patients with metastatic or unresectable soft tissue and bone sarcoma of extremities and pelvis, survival is generally poor. The aim of the current systematic review was to analyse recent publications on treatment approaches in patients with inoperable and/or metastatic sarcoma. Original articles published between 1st January 2011 and 2nd May 2020, using the search terms ‘unresectable sarcoma’, ‘inoperability AND sarcoma’, ‘inoperab* AND sarcoma’, and ‘treatment AND unresectable AND sarcoma’ in PubMed, were potentially eligible. Out of the 839 initial articles (containing 274 duplicates) obtained and 23 further articles identified by cross-reference checking, 588 were screened, of which 447 articles were removed not meeting the inclusion criteria. A further 54 articles were excluded following full-text assessment, resulting in 87 articles finally being analysed. Of the 87 articles, 38 were retrospective (43.7%), two prospective (2.3%), six phase I or I/II trials (6.9%), 22 phase II non-randomized trials (27.6%), nine phase II randomized trials (10.3%) and eight phase III randomized trials (9.2%). Besides radio/particle therapy, isolated limb perfusion and conventional chemotherapy, novel therapeutic approaches, including immune checkpoint inhibitors and tyrosine kinase inhibitors were also identified, with partially very promising effects in advanced sarcomas. Management of inoperable, advanced or metastatic sarcomas of the pelvis and extremities remains challenging, with the optimal treatment to be defined individually. Besides conventional chemotherapy, some novel therapeutic approaches have promising effects in both bone and soft tissue subtypes. Considering that only a small proportion of studies were randomized, the clinical evidence currently remains moderate and thus calls for further large, randomized clinical trials.

Cite this article: EFORT Open Rev 2020;5:799-814. DOI: 10.1302/2058-5241.5.200069
ESTIMATE OF THE INTENSITY-DURATION-FREQUENCY PARAMETERS OF INTENSE RAINFALL FOR THE STATE OF ALAGOAS, BRAZIL
Authors: Silva João Batista Lopes da , Bento Nicole Lopes , Gomes Gabriel Soares Lopes , Campos Alcinei Ribeiro , Silva Danilo Paulúcio da
Published: November 2020

The study of the rainfall characteristics is of fundamental importance since the frequency of floods has increased in several parts of Brazil due to anthropic impacts of climatic changes. Thus, this study aimed to determine the parameters of the intense rainfall equation (K, a, b, c) for 52 municipalities in the State of Alagoas using data from 164 rain gauges ta available from the National Water Agency (ANA). The data series were subjected to consistency analysis and further desegregation of maximum daily rainfall to durations of the 5; 10; 15; 20; 25; 30; 60; 360; 480; 600; 720 and 1,440 minutes and return period of 5; 10; 25; 50 and 100 years according to different probabilistic models. The adjustment of the parameters was carried out by means of non-linear regression, with R² greater than 0.949 for all the stations, considering for this purpose one station per municipality, totaling 51 municipalities of study. It was obtained that the maximum rainfall intensity predicted increases with the increase in the return period and decreases with the increase of the duration of the rain. The greater intensities were detected in the mesoregion of Eastern Alagoano and the lowest intensities in the mesoregion of Sertão Alagoano.
OCT-OCTA segmentation: combining structural and blood flow information to segment Bruch’s membrane
Authors: Schottenhamml Julia , Moult Eric M. , Ploner Stefan B. , Chen Siyu , Novais Eduardo , Husvogt Lennart , Duker Jay S. , Waheed Nadia K. , Fujimoto James G. , Maier Andreas K.
Published: November 2020

In this paper we present a fully automated graph-based segmentation algorithm that jointly uses optical coherence tomography (OCT) and OCT angiography (OCTA) data to segment Bruch’s membrane (BM). This is especially valuable in cases where the spatial correlation between BM, which is usually not visible on OCT scans, and the retinal pigment epithelium (RPE), which is often used as a surrogate for segmenting BM, is distorted by pathology. We validated the performance of our proposed algorithm against manual segmentation in a total of 18 eyes from healthy controls and patients with diabetic retinopathy (DR), non-exudative age-related macular degeneration (AMD) (early/intermediate AMD, nascent geographic atrophy (nGA) and drusen-associated geographic atrophy (DAGA) and geographic atrophy (GA)), and choroidal neovascularization (CNV) with a mean absolute error of ∼0.91 pixel (∼4.1 μm). This paper suggests that OCT-OCTA segmentation may be a useful framework to complement the growing usage of OCTA in ophthalmic research and clinical communities.
Efficient and high accuracy 3-D OCT angiography motion correction in pathology
Authors: Ploner Stefan B. , Kraus Martin F. , Moult Eric M. , Husvogt Lennart , Schottenhamml Julia , Yasin Alibhai A. , Waheed Nadia K. , Duker Jay S. , Fujimoto James G. , Maier Andreas K.
Published: November 2020

We describe a novel method for non-rigid 3-D motion correction of
orthogonally raster-scanned optical coherence tomography angiography
volumes. This is the first approach that aligns predominantly axial
structural features such as retinal layers as well as transverse
angiographic vascular features in a joint optimization. Combined with
orthogonal scanning and favorization of kinematically more plausible
displacements, subpixel alignment and micrometer-scale distortion
correction is achieved in all 3 dimensions. As no specific structures
are segmented, the method is by design robust to pathologic changes.
Furthermore, the method is designed for highly parallel implementation
and short runtime, allowing its integration into clinical workflow
even for high density or wide-field scans. We evaluated the algorithm
with metrics related to clinically relevant features in an extensive
quantitative evaluation based on 204 volumetric scans of 17 subjects,
including patients with diverse pathologies and healthy controls.
Using this method, we achieve state-of-the-art axial motion correction
and show significant advances in both transverse co-alignment and
distortion correction, especially in the subgroup with pathology.