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Purpose The clinical utility of echocardiography in the setting of a positive blood culture in paediatric patients presenting with osteomyelitis (OM) and/or septic arthritis (SA). Methods Retrospective review between 2013 and 2019: Patients < 18 years with OM, SA or combined infection (OM+SA) were included. Patients were excluded for immunodeficiency, loss of follow-up or penetrating infection. Charts with positive blood cultures were reviewed for echocardiography on that admission. Demographic variables were compared utilizing the Student's t-test and Fisher's exact test. A multivariable linear regression model was constructed to examine the association between echocardiography and length of stay, controlling for age, sex, fever, white blood cell (WBC) on admission, antibiotic administration and surgery performed. Results Of 157 patients with OM, SA or combined infection, 44 had a positive blood culture. In all, 26 had an echocardiogram, and none showed endocarditis. Echocardiography was independently associated with a 6.2-day length of stay increase. WBC count and surgical intervention demonstrated a trend toward significance in length of stay, with each WBC unit increase associated with a 0.53-day increase. Surgical intervention was associated with an average 6.3-day length of stay decrease. Conclusion No patient had a positive echocardiogram, and no changes in management were initiated. However, an echocardiogram increased stay by 6.2 days. In addition to costs associated with increased stay, patients were billed between $1460 and $1700 per echocardiogram. The utility of echocardiograms in the setting of bacteremia associated with musculoskeletal infections in the paediatric population should be re-examined, and guidelines should be updated to reflect the cost-benefit analysis. Level of Evidence III

Knee surgery, sports traumatology, arthroscopy 30(4), 1282-1291 (2022). doi:10.1007/s00167-021-06569-w, Published by Springer, Berlin ; Heidelberg

International journal of clinical pharmacy : IJCP 43(4), 825-838 (2021). doi:10.1007/s11096-021-01260-z, Published by Springer, Dordrecht [u.a.]

External Beam Radiotherapy (EBRT) allows remarkable pain control in patients with skeletal metastases. We performed a Bayesian network meta-analysis comparing the most commonly used radiotherapy regimens for palliative management in patients with skeletal metastases. The main online databases were accessed in October 2020. All randomized clinical trials evaluating the irradiation of painful bone metastases were considered. The following irradiation patterns were analysed and included in the present network meta-analysis: 8 Gy- and 10 Gy/single fraction, 20 Gy/5 fractions, 30 Gy/10 fractions. The Bayesian hierarchical random-effect model analysis was adopted in all comparisons. The Log Odds-Ratio (LOR) statistical method for dichotomic data was adopted for analysis. Data from 3595 patients were analysed. The mean follow-up was 9.5 (1 to 28) months. The cumulative mean age was 63.3 ± 2.9. 40.61% (1461 of 3595 patients) were female. The 8Gy/single fraction protocol detected reduced rate of “no pain response” (LOR 3.39), greater rate of “pain response” (LOR-5.88) and complete pain remission (LOR-7.05) compared to the other dose patterns. The 8Gy group detected a lower rate of pathological fractures (LOR 1.16), spinal cord compression (LOR 1.31) and re-irradiation (LOR 2.97) compared to the other dose patterns. Palliative 8Gy/single fraction radiotherapy for skeletal metastases shows outstanding results in terms of pain control, re-irradiations, pathological fractures and spinal cord compression, with no differences in terms of survivorship compared to the other multiple dose patterns.Level of evidence: I, Bayesian network meta-analysis of RCTs.

Background: Inferior pole patellar sleeve fractures (PSFs) are rare injuries that occur in skeletally immature patients that may be missed or falsely diagnosed as an inferior pole fracture (IPF) or Sinding-Larsen-Johansson syndrome (SLJS). Purpose: The objective of this study was to evaluate and compare clinical and radiographic features of patients with PSF, IPF, and SLJS. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Retrospective review of skeletally immature patients diagnosed with PSF, IPF, and SLJS between 2011 and 2019 at a single urban academic center was performed. Chart and radiographic review was completed. Between-group differences were assessed using analysis of variance, Kruskal-Wallis test, and Fisher exact test, as appropriate to variable distributions. Results: In total, 125 patients (82% male) were included, with a mean (SD) age of 10.7 (2) years (16 PSF, 51 IPF, 58 SLJS). There were no significant differences in patient characteristics between the 3 groups. One hundred percent of the patients with PSF ( P < .001) and IPF ( P < .001) had acute trauma, compared with 24% of patients with SLJS. Fewer patients with PSF had an intact straight leg raise (38%) compared with those with IPF (94%; P < .001) and SLJS (98%; P < .001). Fewer patients with SLJS had knee swelling (41%) compared with those with PSF (93%; P < .001) and IPF (94%; P < .001). More patients with PSF had knee effusion (81%) compared with those with IPF (37%; P = 0.011) and SLJS (3%; P < .001). More patients with SLJS were able to bear weight (88%) compared with those with IPF (12%; P < .001) and PSF (0; P < .001). Radiographically, compared with those with IPF and SLJS, patients with PSFs had increased mean prepatellar swelling (6.1 [ P < .001] and 6.5 [ P < .001] vs 12.9 mm), intra-articular effusion (6.1 [ P = .014] and 4.9 [ P = .001] vs 9.2 mm), maximum fragment size (26 [ P = .004] and 17.7 [ P < .001] vs 45.3 mm), and maximum fragment displacement (1.24 [ P = .002] and 1.45 [ P = .003] vs 13.30 mm), respectively. Compared with those with SLJS (1.10), patients with PSF (1.92; P < .001) and IPF (1.22; P < .001) had patella alta with higher mean Insall-Salvati ratios >1.2. Conclusion: Differences in clinical features such as ability to straight leg raise, knee swelling, knee effusion, ability to bear weight, and radiographic features, such as prepatellar swelling, intra-articular effusion, fragment displacement/size/shape/location, and patellar height, can all be helpful in recognizing rare pediatric inferior patellar pathology, thus increasing efficiency in indicating for higher-level imaging to reach a prompt diagnosis and provide appropriate treatment.

Introduction Femoroacetabular impingement (FAI) is a dynamic pathomechanical process of the femoral head–neck junction. Arthroscopic surgery for FAI has increased exponentially in the last decade, and this trend is expected to increase. Source of data Recent published literatures. Areas of agreement FAI promotes quick rehabilitation and low complication rates in the short-term follow-up. Areas of controversy Despite the growing interest on arthroscopic surgery for FAI, current evidence regarding the medium- and long-term role of arthroscopy are unsatisfactory. Growing points Systematically summarize current evidences, analyse the quantitative available data and investigate the medium- and long-term outcomes of arthroscopic surgery for FAI. Areas timely for developing research Arthroscopic surgery achieves very satisfactory outcomes for patients with FAI at a mean follow-up of 4 years.

Introduction The role of tourniquet during knee arthroplasty is controversial. The present study compares various tourniquet protocols using a Bayesian network meta-analysis of peri-operative data. Material and methods The present study was conducted in accordance with the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health interventions. The literature search was conducted in September 2020. All clinical trials investigating the role of tourniquet in knee arthroplasty were considered for inclusion. Methodological quality was assessed using Review Manager 5.3. A Bayesian hierarchical random-effects model analysis was used in all comparisons. Results Ultimately, pooled data from 68 studies (7413 procedures) were analysed. Significant inconsistency was found in the data relating to total estimated blood lost; no assumption could be made on this outcome. Full-time tourniquet resulted in the shortest surgical duration and lowest intra-operative blood lost, in both cases followed by incision-to-suture. The incision-to-suture protocol achieved the smallest drop in haemoglobin during the first 72 h post-operatively and the lowest rate of blood transfusion, both followed by full-time tourniquet. Hospitalisation was shortest in the absence (no-tourniquet) group, followed by the cementation-to-end group. Conclusion For knee arthroplasty, longer tourniquet use is associated with the shorter duration of surgery, lower intra-operative blood lost, lower drops in haemoglobin and fewer transfusion units. The shortest average hospitalisation was associated with no tourniquet use.

The role of tourniquet during knee arthroplasty is controversial. The present study compares various tourniquet protocols using a Bayesian network meta-analysis of peri-operative data.The present study was conducted in accordance with the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health interventions. The literature search was conducted in September 2020. All clinical trials investigating the role of tourniquet in knee arthroplasty were considered for inclusion. Methodological quality was assessed using Review Manager 5.3. A Bayesian hierarchical random-effects model analysis was used in all comparisons.Ultimately, pooled data from 68 studies (7413 procedures) were analysed. Significant inconsistency was found in the data relating to total estimated blood lost; no assumption could be made on this outcome. Full-time tourniquet resulted in the shortest surgical duration and lowest intra-operative blood lost, in both cases followed by incision-to-suture. The incision-to-suture protocol achieved the smallest drop in haemoglobin during the first 72 h post-operatively and the lowest rate of blood transfusion, both followed by full-time tourniquet. Hospitalisation was shortest in the absence (no-tourniquet) group, followed by the cementation-to-end group.For knee arthroplasty, longer tourniquet use is associated with the shorter duration of surgery, lower intra-operative blood lost, lower drops in haemoglobin and fewer transfusion units. The shortest average hospitalisation was associated with no tourniquet use.

Objectives: Inferior pole patellar sleeve fractures (PSF) are rare injuries that occur in skeletally immature patients with sparse literature on the diagnosis, management, and outcomes of this injury. Diagnosis of PSF can be difficult based on radiographs alone, as only a small bony fragment is often seen. Consequently, PSFs may be missed or falsely diagnosed as an inferior pole fracture (IPF) or Sinding-Larson-Johansson syndrome (SLJS) possibly leading to improper treatment and poor outcomes (Figure 1). The objective of this study was to evaluate and compare clinical and radiographic features of patients with PSF, IPF and SLJS to help improve diagnostic accuracy. Methods: This was a retrospective review of skeletally immature patients diagnosed with inferior pole patellar pathology between 2011-2019 at a single urban academic center. Patients were identified using both International Classification of Diseases 9th and 10th edition (ICD-9 and ICD-10) codes and Current Procedural Terminology (CPT) codes. Data from medical records (demographics, injury mechanism and physical exam) and lateral knee radiographs (fragment size, fragment displacement, number of fragments, Insall-Salvati, Caton-Deschamps, pre-patellar effusion, intra-articular effusion) was collected. ANOVA, Student’s t-test and Fisher’s exact test were used for comparisons between the three groups. Statistical significance was determined at pResults: A total of 125 patients were included: 82% male, average age 10.7 years (SD 2), 16 PSF, 51 IPF, 58 SLJS patients. There were no significant differences in patient demographics between the three groups (Table 1). Only 24% of SLJS patients presented with acute trauma compared to 100% of the PSF and IPF patients. Fewer PSF patients had an intact straight leg raise (37.5%) compared to IPF (94.1%) and SLJS (98.3%) (p 1.2 (Table 3). Conclusions: Differences in clinical features such as straight leg raise, knee swelling, knee effusion, ability to bear weight and radiographic features such as prepatellar swelling, intra-articular effusion, fragment displacement/size/shape/location can all be helpful in improving the accuracy of diagnosing inferior pole injuries in pediatric patients.

Archives of orthopaedic and trauma surgery 140(6), 769-776 (2020). doi:10.1007/s00402-020-03376-9, Published by Springer, Berlin ; Heidelberg

Non-steroidal anti-inflammatory drugs (NSAID) have been recommended to prevent of heterotopic ossification (HO) after total hip arthroplasty (THA), but debates are still ongoing. The present Bayesian network meta-analysis of randomized clinical trials (RCTs) compared all available pathways of NSAID treatment as prophylaxis for HO after THA. The present Bayesian network meta-analysis was conducted according to The PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions guidelines. All randomized clinical trials comparing two or more interventions to prevent HO after THA were considered for analysis. HO was classified according to Brooker. The quality of the methodological assessment was performed through the risk of bias summary tool of the Review Manager Software 5.3 (The Cochrane Collaboration, Copenhagen). The network meta-analysis was performed through a STATA routine for Bayesian hierarchical random-effects model analysis, with log odd ratio (LOR) effect measure. Data from 26 studies (6396 THAs; 58% females) were collected. The mean follow-up was 10.50 ± 5.7 months. ANOVA showed good comparability among mean age and gender (P > 0.5). Celecoxib demonstrated the highest rate of Brooker class 0 (LOR 6.96), followed by diclofenac (LOR 6.94). Naproxen demonstrated the lowest rate of Brooker I HO (LOR 2.82), followed by celecoxib (LOR 3.52). Celecoxib demonstrated lowest rate of Brooker class II HO (LOR 1.66), class III (LOR), and class IV (LOR 0.25). The equation for global linearity detected no statistically significant inconsistency (P > 0.5) in all the comparisons. The present Bayesian network meta-analysis encourages the use of celecoxib as a prophylaxis for HO. These conclusions must be interpreted in light of the limitations of the present study. Future investigations are required to establish more definitely the role of celecoxib.Level of Evidence: I, Bayesian network analysis of RCTs.

Introduction After the first patellar dislocation, most patients report damage of the medio-patellofemoral ligament (MPFL) and surgical reconstruction is required. The purpose of this study is to systematically review current evidence and to clarify the role of the gracilis and semitendinosus tendons as graft for isolated MPFL reconstruction. Materials and methods The present systematic review was conducted according to the PRISMA guidelines. The literature search was conducted in October 2019. All clinical trials using the semitendinosus and/or gracilis tendon grafts for isolated MPFL reconstruction in patients with patellofemoral instability were considered for inclusion. Only articles reporting a minimum of 12-month follow-up were considered. The PEDro score was used for the methodological quality assessment. Results Data from 1491 procedures were collected. The mean follow-up was 36.12 months. There was comparability among the patient baseline. All the scores of interests (Kujala, Tegner, Lysholm) and range of motion scored better in the semitendinosus group. Moreover, in favour of the semitendinosus group, a statistically significant reduction of the revision surgeries and re-dislocations were evidenced. Apprehension test and persistent instability sensation found any statistical correlations. Conclusion Isolated MPFL reconstruction through semitendinosus tendon graft performed better than the gracilis in selected patients suffering from recurrent patellofemoral instability.

The MPFL reconstruction is performed either via a single-bundle (SB) or double-bundle (DB) procedure. The purpose of this study is to perform a systematic review comparing SB versus DB graft for recurrent patellofemoral instability, to summarize current evidence, and to clarify the role of both techniques. We focused on clinical scores, physical examination, complications, revision surgeries, and failures.In May of 2019 the main online databases were accessed. All the clinical studies treating isolated MPFL reconstruction for patellofemoral instability through a single and/or double-bundle graft were enrolled in the present systematic review. Only articles reporting primary isolated MPFL reconstruction, reporting a minimum of 12-months follow-up were considered for inclusion.The scores of interest were in favour of the DB cohort: Kujala (+ 3.2, P = 0.03), Lysholm (+ 5.1, P = 0.001), Tegner (+ 0.3, P = 0.2), IKDC (+ 5.4, P = 0.01), VAS (+ 0.8, P = 0.3), ROM (+ 9.96, P = 0.04). In the DB graft, a reduction of overall complications (OR 0.59; P = 0.1), further surgeries (OR 0.64; P = 0.12) and re-dislocations (OR 0.61; P = 0.16) was observed. The SB group reported a reduction in the post-operative apprehension test (OR 2.42; P = 0.24).Current study support the use of double-bundle tendon graft for isolated MPFL reconstruction in selected patients with recurrent patellofemoral instability.

A correction to this paper has been published: https://doi.org/10.1007/s00590-021-02958-6

// Martha L. Slattery 1 , Andromahi Trivellas 2 , Andrew J. Pellatt 2 , Lila E. Mullany 1 , John R. Stevens 3 , Roger K. Wolff 1 , Jennifer S. Herrick 1 1 Department of Medicine, University of Utah, Salt Lake City, Utah, USA 2 Tulane Medical School, New Orleans, Louisiana, USA 3 Department of Mathematics and Statistics, Utah State University, Logan, Utah, USA Correspondence to: Martha L. Slattery, email: marty.slattery@hsc.utah.edu Keywords: colorectal cancer, miRNA, TGF-β, eIF4E, SMAD Received: October 13, 2016 Accepted: December 16, 2016 Published: January 05, 2017 ABSTRACT The TGF-β signaling pathway is involved in regulation of cell growth, angiogenesis, and metastasis. We test the hypothesis that genetic variation in the TGF-β signaling pathway alters miRNA expression. We use data from 1188 colorectal cancer cases to evaluate associations between 80 SNPs in 21 genes. Seven variants eIF4E rs12498533, NFκB1 rs230510, TGFB1 rs4803455, TGFBR1 rs1571590 and rs6478974, SMAD3 rs3743343, and RUNX1 rs8134179 were associated with expression level of miRNAs in normal colorectal mucosa. RUNX2 rs12333172 and BMPR1B rs13134042 were associated with miRNAs in normal colon mucosa; eIF4EBP3 rs250425, SMAD3 rs12904944, SMAD7 rs3736242, and PTEN rs532678 were associated with miRNA expression in normal rectal mucosa. Evaluation of the differential expression between carcinoma and normal mucosa showed that SMAD3 rs12708491 and rs2414937, NFκB1 rs230510 and rs3821958, and RUNX3 rs6672420 were associated with several miRNAs for colorectal carcinoma. Evaluation of site-specific differential miRNA expression showed that BMPR1B rs2120834, BMPR2 rs2228545, and eIF4EBP3 rs250425 were associated with differential miRNA expression in colon tissue and SMAD3 rs12901071, rs1498506, and rs2414937, BMPR2 rs2228545, and RUNX2 rs2819854, altered differential miRNA expression in rectal tissue. These data support the importance of the TGF-β signaling pathway to the carcinogenic process, possibly through their influence on miRNA expression levels.