Background: The purpose of this study was to assess the methodological quality of meta-analyses (MAs) and resolve evidence inconsistencies by quantifying overlap in primary studies, thereby providing enhanced evidence on the efficacy of extracorporeal shockwave therapy (ESWT) versus placebo, ultrasound therapy, and corticosteroid injections for lateral epicondylitis.
Methods: We conducted searches in four databases: PubMed, Embase, Cochrane Library, and Web of Science, until August 2024. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) graded the quality and reliability of the MAs, and the quality of outcomes was graded by Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Graphical Representation of Overlap for OVErviews (GROOVE) was applied to analyze overlap and classified the resulting evidence into four categories (I-IV) on the basis of evidence classification criteria.
Results: A total of nine MAs were included for analysis: five had a high AMSTAR 2 rating, three had a moderate AMSTAR 2 rating, and one had a low AMSTAR 2 rating. GROOVE analysis revealed substantial overlap, informing evidence classification. ESWT can effectively reduce the pain assessed by the visual analogue scale (VAS) compared with placebo (MD = -0.68; 95% CI -1.06, -0.3; P = 0.0004; I2 = 75%). Compared with ultrasound therapy, ESWT has a significantly large reduction in the level of pain after the treatment at 1-month follow-up (MD = -1.42; 95% CI -2.14, -0.7; P = 0.0001; I2 = 92%) and 3-month follow-up (MD = -1.65; 95% CI -1.81, -1.49; P < 0.00001; I2 = 98%). ESWT is better than corticosteroid injection when calculating the pooled effect size of VAS (SMD = 1.13, 95% Cl 0.72, 1.55; P < 0.00001; I2 = 0). ESWT also has a significant difference in the rate of 50% reduction in pain (RR = 1.38; 95% CI 1.09, 1.75; P = 0.008; I2 = 41%). However, compared with placebo, it has no clinically important difference of grip strength (MD = 3.33; 95% CI 0.93, 5.73; P = 0.007; I2 = 30%), and the pain score of Thomsen test (MD = -3.22; 95% CI -14.06, 7.62; P = 0.56; I2 = 69%).
Conclusions: ESWT has a significant difference in reducing pain evaluation and relief of pain symptoms, and the effect is better than ultrasound therapy and corticosteroid injections.
Level of evidence i:
This protocol has been registered in the prospero database: CRD42024586419.
Objective: This study aimed to evaluate the performance of five machine learning algorithms in predicting tibial intramedullary nail length using patient demographic data (gender, height, age, and weight), with the goal of developing a clinically relevant and accurate predictive model.
Methods: Retrospective data from 155 patients who underwent tibial intramedullary nailing at the Affiliated Jiangyin Hospital of Nantong University were analyzed. After data cleaning, outlier handling, and gender encoding, the dataset was divided into an 80% training set and 20% testing set. Models were trained and evaluated using root mean squared error (RMSE), mean absolute error (MAE), coefficient of determination (R2), and correlation analysis. Key variables included height (cm), weight (kg), age (years), and gender.
Results: The XGBoost model demonstrated superior clinical precision, achieving the lowest testing RMSE (9.15 mm) and MAE (7.56 mm), with an R2 of 0.871, explaining 87.1% of variance in nail length. While the random forest model had the highest R2 (0.874) and correlation coefficient (r = 0.935), XGBoost outperformed all models in error metrics, critical for minimizing surgical complications. Variable importance analysis identified height as the most influential factor, followed by weight and age. All models achieved acceptable accuracy (≥ 86.21%) within a ± 15 mm error margin, compatible with intraoperative adjustments.
Conclusions: Machine learning, particularly XGBoost, significantly improves preoperative prediction of tibial intramedullary nail length compared with traditional methods.
Level of evidence iv:
Background: Limited research exists on young patients with femoral head subchondral stress fractures (SSF), especially regarding how hip anatomy may contribute to this condition. Few studies have explored the potential correlation between its pathogenesis and developmental dysplasia of the hip (DDH). We aimed to determine hip morphology in patients with femoral head SSF and analyze the distribution of various parameters reflecting hip coverage and stability.
Materials and methods: Radiographic data of all patients with femoral head SSF who met the inclusion criteria between January 2019 and November 2023 were retrospectively reviewed. These data included the lateral center-edge angle (LCEA), Tönnis angle, anterior center-edge angle (ACEA), femoral head extrusion index, acetabular arc, femoral head lateralization, upsloping lateral sourcil, cliff sign, crossover sign, posterior wall sign, and ischial spine sign. We determined the proportion of borderline DDH (BDDH) and the distribution of each parameter on the affected side. Additionally, we compared differences between patients with LCEA < 25° and LCEA > 25°.
Results: In affected hips, 15 cases (57.7%) had BDDH, 3 cases (11.5%) had DDH, and only 8 cases (30.8%) had a normal LCEA. On the contralateral side, 8 cases (30.8%) had BDDH, 4 cases (15.4%) had DDH, and 14 cases (53.8%) had normal LCEA. Abnormalities were prominent in the extrusion index (50.0%), acetabular arc (65.4%), femoral head lateralization (46.2%), cliff sign (42.3%), and posterior wall sign (65.4%). Among patients with affected-side LCEA < 25°, more than 50% exhibited abnormalities in ACEA, extrusion index, acetabular arc, cliff sign, or posterior wall sign. Among patients with normal LCEA on the affected side, most had acetabular retroversion, with 75.0% showing a positive crossover sign and 75.0% showing a positive ischial spine sign.
Conclusions: This study revealed a notably high prevalence of BDDH in young patients with femoral head SSF. The various abnormalities observed in parameters reflecting coverage and stability in BDDH may explain the potential association between BDDH and femoral head SSF.
Level of evidence iv: Retrospective case series.
Background: The reverse sural artery flap (RSAF) has emerged as a versatile option for soft tissue reconstruction in the distal lower extremity, particularly when microsurgical expertise or resources are limited. Despite its increasing use, comprehensive multicenter data on its survival outcomes and anatomical site-specific performance remain limited.
Methods: This retrospective multicenter case series included all patients who underwent RSAF for distal lower extremity defects between 2015 and 2024 across military, governmental, private, and academic institutions. Data on patient demographics, defect characteristics, surgical technique, and postoperative outcomes were collected and analyzed using Jamovi. Kaplan-Meier survival analysis was used to assess flap survival over time, with subgroup comparisons based on defect site.
Results: A total of 60 patients were included. The overall flap survival rate was 96.7%, with a mean wound healing time of 21.5 days. Venous congestion occurred in 83.3% of cases. Persistent venous congestion occurred in 10% of cases, leading to partial flap necrosis. Flap width, pedicle length, prolonged operative time, and patient-specific factors such as body mass index (BMI) and smoking status were significantly associated with adverse outcomes. Site-specific analysis revealed that RSAFs used for ankle and lower leg defects had a 100% survival rate at 60 months, while heel-based flaps showed a decline in survival to 70.8% at 60 months.
Conclusions: RSAF is a highly successful and reliable option for lower extremity reconstruction, especially in resource-variable settings. However, anatomical site, flap design parameters, and modifiable patient risk factors significantly impact outcomes. Long-term surveillance highlights excellent durability in ankle and lower leg reconstructions, while heel-based reconstructions require closer follow-up. Level of Evidence Level III (Retrospective Comparative Study).
This editorial aims to guide prospective authors in effectively preparing and structuring a manuscript for submission to JOOT. Despite the increasing scientific quality of many submissions, the Editorial Board frequently receives manuscripts that fail to meet fundamental standards in structure, style or adherence to journal requirements, which may compromise their chances of acceptance. Scientific writing is a crucial skill, and tailoring a manuscript to the expectations and guidelines of the target journal is vital for successful publication. This article offers practical recommendations to enhance manuscript preparation, improve clarity and align submissions with the editorial standards of JOOT.
Introduction: Minimally invasive plate osteosynthesis (MIPO) has been reported to be superior to open reduction and internal fixation (ORIF) for the treatment of different long bone fractures. This retrospective study aimed to compare MIPO with the mini-open technique versus conventional ORIF for the treatment of displaced midshaft clavicular fractures. We hypothesized that this technique would improve supraclavicular nerve (SCN) injury-related numbness, decrease surgical incision, blood loss, thick scar, and overall patient satisfaction.
Methods: We retrospectively reviewed 45 cases of displaced midclavicular fractures that were treated surgically at our hospital between December 2020 and June 2022. There were 20 (44.4%) patients using mini-open with MIPO and 25 (55.6%) patients using conventional ORIF treated with anatomical locking plate guided by C-arm X-ray machine. Comparison of surgical indices (operative time, blood loss, incision length, and fluoroscopy exposure times) and postoperative complications (anterior chest wall numbness, area of numbness, superficial infection, hardware irritation, and scar satisfaction) were compared between the two groups. In addition, Disabilities of the Arm, Shoulder and Hand (DASH), Constant-Murley Score (CMS), and overall surgical satisfaction were compared between the two groups.
Results: The mini-open MIPO group had statistically significant benefits on the basis of surgical length, blood loss, visual analog scale (VAS) score on the first and third postoperative days, and length of hospital stay. Major complications, such as SCN-related numbness, area of numbness, and thick scarring, were greatly reduced. The cosmetic and overall surgical satisfaction was greater in MIPO. Conversely, hardware irritation, surgical infection, and numbness were more frequent in the ORIF group. There were no significant differences in DASH and CMS scores between the groups at the 12-month follow-up.
Conclusions: MIPO is a more effective and safer modern surgical method than ORIF for displaced midclavicle fractures. Improvements in operative indices, postoperative numbness owing to SCN injury, surgical incision, and cosmesis satisfaction were achieved.
Level of evidence: Level III, retrospective case-control study.
Background: Diaphyseal leg fractures are common in pediatric age, and the most used treatment is surgery using elastic stable intramedullary nailing (ESIN). In the past, a cutoff of 50 kg was the limit of weight indication for the use of ESIN. In literature, the concept of BMI has recently been introduced to evaluate the results owing to an increase in the incidence of obesity in children; up to now, it has only been used in one study for the femur but never in the tibia, although more than one author suggests doing so. The objective of this study was to research a correlation between weight, BMI, and the results of ESIN treatment.
Materials and methods: A total of 84 patients treated with ESIN from 2013 to 2021 were included; the inclusion criteria were clinical and radiographic data until complete healing and the presence of weight and height data collection; patients with an exposed fracture or neurovascular injury were excluded. The following were evaluated: clinical healing time in terms of load resumption (CHT), radiographic healing time (RHT), anteroposterior (APA) and lateral (LA) radiographic alignment, surgical time (CT), nonunion (NU), and delayed union (DC). Patients were divided into two weight groups (< 50; > 50). The statistical analysis was performed using STATA (Stata, College Station, TX, USA), and a p-value less than 0.05 was considered statistically significant. The Shapiro-Francia test was used to check the normality of each variable. Pearson's correlation coefficient was calculated for the correlation between variables.
Results: A total of 84 patients with an average weight of 41.53 kg (18-85 kg) were included. Patients were divided into two groups; 62 patients weighing < 50 kg (GR1) and 22 patients weighing > 50 kg (GR2). We found a statistically significant correlation between weight and CHT, RHT, and ST and between BMI and CHT, RHT, and ST. Average results: GR1: CHT 55.84 days; RHT 48.79 days; ST 61.68 min and GR2: CHT 63.27 days; RHT 55.77 days, ST 79.32. We found no significant difference in CHT and RHT between the two groups, while a significant difference for ST was observed.
Conclusions: We confirm that ESIN nails can also be used in patients weighing > 50 kg affected by tibial shaft fractures; in fact, we found no statistical differences between the two groups' clinical and radiographic healing times. Moreover, we found no difference in results between weight and BMI for tibial shaft fracture. The statistical difference correlation in ST between GR1 and GR2 does not imply an important difference in clinical practice.
Background: The impact of tantalum (Ta) versus titanium (Ti) acetabular components on reinfection risk in periprosthetic joint infection (PJI) remains controversial. While prior studies have focused on two-stage revisions, this is the first comparative analysis of Ta versus Ti in single-stage revisions. This study aimed to compare all-cause rerevision and infection recurrence rates between Ta and Ti acetabular components in single-stage revision for chronic PJI.
Materials and methods: In this study, all patients underwent single-stage revision combined with intra-articular (IA) antibiotic infusion, with 56 receiving Ta acetabular components and 79 receiving Ti components. Both the Ta and Ti groups utilized acetabular reconstruction methods (including cups with and without augments) and cementless prostheses for all femoral components. We compared implant survivorship between the two groups, using implant survivorship free from reinfection and all-cause revision as the endpoints. Multivariate logistic regression (MVLR) was used to determine the independent predictive factors for septic failure.
Results: The implant survivorship free from reinfection of the Ta group (92.9%; 95% confidence interval (CI) 85.7~98.2%) was comparable to that of the Ti group (88.6%; 95% CI 81.0~94.9%; P = 0.391; log-rank test). The implant survivorship free from all-cause rerevision of the Ta group (91.1%; 95% CI 84.1~100%) was comparable to that of the Ti group (87.3%; 95% CI 78.9~94.4%; P = 0.323; log-rank test). MVLR did not identify the Ta acetabular component (P = 0.414) as a protective factor against septic failure in acetabular reconstruction. However, previous revision (P = 0.048) was identified as a risk factor.
Conclusions: Ta acetabular components exhibited a risk of all-cause rerevision comparable to Ti components in single-stage revision, with no significant protective effect against reinfection. These findings suggest that the notion of Ta components preventing infections should be viewed with caution.
Background: Distal humeral fractures accounted for ~1% of all fractures; however, they were prone to complications, including nonunion if left untreated or inadequately managed. Nonunion, which predominantly occurred at the supracondylar level, resulted in mechanical instability, functional impairment, and persistent discomfort. The most commonly employed surgical options included open reduction and internal fixation (ORIF), total elbow arthroplasty (TEA), and external fixation. This article provides a comprehensive assessment of these surgical procedures and shared clinical experiences related to these challenging cases.
Methods: A systematic review of literature was conducted using the PubMed database up to October 2024, with a focus on cases involving extraarticular distal humeral nonunions that were treated with ORIF, TEA, or Ilizarov techniques.
Results: A total of 25 studies involving 448 patients were encompassed in the review, with a mean patient age of 50 years and an average follow-up period of 48 months. Reported success rates for ORIF and TEA were 90% and 74%, respectively. A higher rate of fracture healing was demonstrated by ORIF, although functional outcomes were found to be comparable between the techniques. Complications such as infections and reduced range of motion (ROM) were documented.
Conclusions: The highest success rate in treating aseptic nonunions was associated with ORIF, highlighting the importance of stable fixation, bone grafting, and meticulous preoperative planning. TEA was regarded as a viable option, particularly for patients with poor bone quality or complex, unreconstructible fractures. To optimize outcomes, surgical techniques were required to be customized on the basis of patient-specific factors and surgeon expertise. Further research is recommended to facilitate the comparison of long-term functional outcomes across different surgical approaches.
Level of evidence: IV.
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