This week, a series of four articles considers the place of the randomised controlled trial as we approach the second century of experience with the concept. Its basic principle is genuine uncertainty as to which treatment arm of the trial it would be in a patient's best interests to enter. This is not necessarily an easy concept to transmit, …

Randomised controlled trials

Controversy exists over whether the use of external fixation (EF) or unreamed tibial intramedullary nailing (UTN) is optimal for the treatment of open tibial fractures. The aim of this study was to compare clinical outcomes in terms of postoperative superficial and deep infection, malunion, delayed union, nonunion and hardware failure between these two treatment methods. So a systematic review and meta-analysis was performed. All available randomized controlled trials that compared the clinical results of EF to those of UTN were obtained and the reported numbers of citations for each observed item were extracted to perform data synthesis. Six published randomized controlled trials with a total of 407 cases fulfilled all inclusion criteria. Data analysis revealed that UTN reduced the incidence rates of superficial infection and malunion after fixation compared with EF. However, EF led to a significant reduction in hardware failure. For postoperative deep infection, delayed union and nonunion, the treatment effects were similar between these two groups. Therefore, we recommend UTN over EF for the management of open tibial fractures. However, patients’ postoperative weight bearing should be controlled to avoid hardware failure.

/pdf/external-fixation-versus-unreamed-tibial-intramedullary-ms4y0u8qe2.pdf

External Fixation versus Unreamed Tibial Intramedullary Nailing for Open Tibial Fractures: A Meta-analysis of Randomized Controlled Trials.

Tibial shaft fractures are the most common type of large long-bone fractures. Segmental tibial shaft fractures are severe injuries and its treatment can be followed by a high incidence of complications, nonunion, delayed union, malunion, infection or compartment syndrome. The most common treatment strategy is intramedullary fixation. Results of the unilateral external fixation treatment for segmental tibial shaft injuries are presented in this paper. Patients with segmental tibial shaft fractures, AO/OTA 42-C2 were treated as urgent cases by unilateral external fixation. Mitkovic-type external fixator was used in all of these fractures. There were 32 patients with segmental tibial shaft fractures (AO/OTA 42-C2), 20 males and 12 females, average age of 43.5 years. Average time of union was 5.9 (4.1–7.4) months for closed and 6.2 (5.1–7.9) months for open fractures. Average follow-up was 18 (26–60) months. Nine patients (28.12%) had open segmental tibial shaft fracture (2 Grade I, 2 Grade II, 1 Grade IIIA, 4 Grade IIIB). Union rate was 81.25% (26 cases). Nonunion rate was 18.75% (6 cases) and malunion 3.12% (1 case). Nonunion was higher in patients with open fractures (4). Compartment syndrome had been diagnosed in 6 cases (18.75%) with closed fracture and fasciotomy was performed when external fixator was applied. There were no deep infections. Pin tract infection was present in 7 cases (21.85%). Treatment of segmented tibial shaft fractures can be followed by a number of complications. Unilateral external fixation with convergent orientation of pins provides three-dimensional stability of the fracture and good biomechanical conditions for fracture healing, with lower complications rate.

External fixation of segmental tibial shaft fractures.

Background: To compare the clinical outcomes of external fixator (EF) and intramedullary nails (IN) in the treatment of open tibial fractures. Methods: We searched seven electronic databases (PubMed, MEDLINE, EMBASE, OVID, Cochrane library, CNKI, and CBM) for trials of tibial fracture fixation published from 1980 to 2013. The indicators including postoperative infection, malunion, nonunion, soft tissue injury, delayed healing, and healing time were used for quantitative outcome assessments. Results: A total of nine trials involving 532 patients (EF, n= 253; IN, n= 279) with open tibia fractures were included in this meta-analysis. The results indicated that the patients undergoing IN had lower incidence of postoperative infection (risk radio [RR] = 3.85; 95% confidence intervals [CI], 2.67–5.54; P < 0.0001), malunion (RR = 2.31; 95% CI, 1.40–3.81; P= 0.001), nonunion (RR = 1.41; 95% CI, 1.06–1.88; P = 0.02) and less healing time (weighted mean difference [WMD] = 6.19; 95% CI, 1.42–10.96; P = 0.01) compared with EF. However, regarding to the soft tissue injury (RR = 0.74; 95% CI, 0.34–1.62; P = 0.45) and delayed healing (RR = 1.38; 95% CI, 0.79–2.43; P = 0.26), there is no significantly difference between EF and IN approach. Conclusion: In conclusion, the use of IN is more effective than EF and may be considered as first-line approach in fixation of open tibial fractures.

/pdf/a-meta-analysis-of-external-fixator-versus-intramedullary-yzkpcstsyi.pdf

A meta-analysis of external fixator versus intramedullary nails for open tibial fracture fixation.

The aim of the present study is to evaluate the use of the Less Invasive Stabilization System (LISS) plate for distal femoral fractures, examining variables such as type of fracture and length of plate. A retrospective study of 30 patients with a distal femoral fracture, treated with a distal femur LISS plate (Synthes) was performed. Average age was 71 years old (20-101). According to the AO classification, 16 fractures were type A, 5 type B, and 9 type C. The consolidation index and clinical outcomes measured with Knee Society Score (KSS) questionnaire were evaluated. Fracture consolidation took an average time of 16 weeks (14-20). Mean KSS was 77,3 (50-97) at the 2-year follow-up visit, observing better outcomes on type C fractures (84,25). According to the KSS score, only two cases were described with bad functional outcomes (6%). Distal femur fractures treated with the LISS plate achieved 94% of good and acceptable outcomes. Unlike the previously published, the best results were obtained with AO type C fractures, probably associated to the lower age (mean 53 years old) and better functional recovery capacity of this group.

LISS plate for treatment of distal femur fracture. Clinical and functional outcomes.

Mixed fermentation improves the flavor quality of food. Untargeted metabolomics were used to evaluate the impact of mixed fermentation and single-strain fermentation on the volatile and non-volatile compound profiles of Kazak cheese. Lacticaseibacillus paracasei SMN-LBK and Kluyveromyces marxianus SMN-S7-LBK were used to make mixed-fermentation cheese (M), while L. paracasei SMN-LBK was applied in single-strain-fermentation cheese (S). A higher abundances of acids, alcohols, and esters were produced via mixed fermentation. Furthermore, 397 differentially expressed non-volatile metabolites were identified between S and M during ripening. The flavor compounds in mixed-fermentation cheese mainly resulted from ester production (ethyl butanoate, ethyl acetate, ethyl octanoate, and ethyl hexanoate) and amino acid biosynthesis (Asp, Glu, Gln, and Phe). The metabolites were differentially expressed in nitrogen metabolism, D-glutamine and D-glutamate metabolism, phenylalanine metabolism, D-alanine metabolism, and other metabolic pathways. The amount of flavor compounds was increased in M, indicating that L. paracasei SMN- LBK and K. marxianus SMN-S7-LBK had synergistic effects in the formation of flavor compounds. This study comprehensively demonstrated the difference in metabolites between mixed-fermentation and single-strain-fermentation cheese and provided a basis for the production of Kazak cheese with diverse flavor characteristics.

/pdf/differences-between-kazak-cheeses-fermented-by-single-and-23nea3es.pdf

Differences between Kazak Cheeses Fermented by Single and Mixed Strains Using Untargeted Metabolomics

BACKGROUND This prospective study aimed to compare clinical effects of intramedullary nailing guided by digital and conventional technologies in treatment of tibial fractures. MATERIAL AND METHODS Thirty-two patients (mean age 43 years, 18 males and 14 females) who were treated for tibial fractures from October 2010 to October 2012 were enrolled. They were sequentially randomized to receive intramedullary nailing guided by either digital technology (digital group, n=16) or conventional technology (conventional group, n=16). The operation time, fluoroscopy times, fracture healing time, distance between the actual and planned insertion point, postoperative lower limb alignment, and functional recovery were recorded for all patients. RESULTS The mean operation time in the digital group was 43.1±6.2 min compared with 48.7±8.3 min for the conventional technology (P=0.039). The fluoroscopy times and distance between the actual and planned insertion point were significantly lower in the digital group than in the conventional group (both P<0.001). The accuracy rate of the insertion point was 99.12% by digital technology. No difference was found in fracture healing time and good postoperative lower limb alignment between the digital and conventional groups (P=0.083 and P=0.310), as well as the effective rate (100% vs. 87.50%, P=0.144). CONCLUSIONS Intramedullary nailing guided by digital technology has many advantages in treatment of tibial fractures compared to conventional technology, including shorter operation time, reduced fluoroscopy times, and decreased distance between the actual and planned insertion point of the intramedullary nail.

Comparison of Tibial Intramedullary Nailing Guided by Digital Technology Versus Conventional Method: A Prospective Study.

To compare the clinical outcomes of external fixator (EF) and intramedullary nails (IN) in the treatment of open tibial fractures. We searched seven electronic databases (PubMed, MEDLINE, EMBASE, OVID, Cochrane library, CNKI, and CBM) for trials of tibial fracture fixation published from 1980 to 2013. The indicators including postoperative infection, malunion, nonunion, soft tissue injury, delayed healing, and healing time were used for quantitative outcome assessments. A total of nine trials involving 532 patients (EF, n = 253; IN, n = 279) with open tibia fractures were included in this meta-analysis. The results indicated that the patients undergoing IN had lower incidence of postoperative infection (risk radio [RR] = 3.85; 95% confidence intervals [CI], 2.67–5.54; P < 0.0001), malunion (RR = 2.31; 95% CI, 1.40–3.81; P = 0.001), nonunion (RR = 1.41; 95% CI, 1.06–1.88; P = 0.02) and less healing time (weighted mean difference [WMD] = 6.19; 95% CI, 1.42–10.96; P = 0.01) compared with EF. However, regarding to the soft tissue injury (RR = 0.74; 95% CI, 0.34–1.62; P = 0.45) and delayed healing (RR = 1.38; 95% CI, 0.79–2.43; P = 0.26), there is no significantly difference between EF and IN approach. In conclusion, the use of IN is more effective than EF and may be considered as first-line approach in fixation of open tibial fractures.

/pdf/retraction-note-a-meta-analysis-of-external-fixator-versus-3lbebe4btk.pdf

Retraction Note: A meta-analysis of external fixator versus intramedullary nails for open tibial fracture fixation

To evaluate the effectiveness of a replating technique having a less-invasive stabilization system (LISS) for femoral shaft fractures due to LISS failure in adults. There were 11 patients with hardware failure of LISS for femoral shaft fractures, on an average of 50 days after the primary operation. The failed implants were removed, and the fractures were replated with a LISS following the rationale of biological osteosynthesis. Radiological fracture union and incidence of postoperative complications were employed to evaluate the effectiveness of this replating technique for femoral shaft fractures. Operative duration including removing failed hardware and replating fractures averaged 81.5 min, with an average blood loss of 330 ml. Patients had an average follow-up of 25.7 months. Radiological evaluation indicated that fracture union occurred in an average of 4.4 months in all patients. The length and alignment of the affected limb were satisfactory, and hardware failure did not recur. The replating technique with LISS for femoral shaft fractures due to hardware failure of LISS can obtain satisfactory results when the appropriate rationale of biological osteosynthesis and functional exercise is followed.

Lin Liu

Papers

A meta-analysis of external fixator versus intramedullary nails for open tibial fracture fixation.

Differences between Kazak Cheeses Fermented by Single and Mixed Strains Using Untargeted Metabolomics

Comparison of Tibial Intramedullary Nailing Guided by Digital Technology Versus Conventional Method: A Prospective Study.

Retraction Note: A meta-analysis of external fixator versus intramedullary nails for open tibial fracture fixation

Repeat LISS treatment for femoral shaft fractures due to hardware failure: a retrospective analysis of eleven cases