Single versus double plate fixation of humeral shaft nonunion

INTRODUCTION

Humeral shaft fractures are common fractures of the diaphysis of the humerus. The aim of this study was to evaluate factors affecting the clinical outcomes of humeral nonunions surgically treated with open reduction and single- versus double-plate fixation with grafting.

MATERIALS AND METHODS

A total of 31 patients with nonunion treated with single- or double-plate screw fixation with bone grafting were retrospectively analysed. The patients were divided into two groups according to the treatment method as Group 1 (single-plate, n = 14) and Group 2 (double-plate, n = 17). Data including demographic and clinical characteristics of the patients, initial and final treatment, type of nonunion and localisation, graft use, shortening, follow-up, time to union, Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) scores, and patient-reported cosmetic outcomes were recorded.

RESULTS

Of the patients, eight were males, and 23 were females, with a mean age of 47.6 ± 15.8 (range, 20-86) years. Initial treatment was conservative treatment (Sarmiento brace) in seven patients, plate fixation in 22 patients, and intramedullary nailing in two patients. The mean follow-up was 31.0 ± 16.9 months in Group 1 and 25.4 ± 15.6 months in Group 2. There was one nonunion in Group 1 and three in Group 2. There were no significant differences in the union rate and time to union (p = 0.378 and p = 0.262, respectively). The mean Quick-DASH scores and cosmetic results were similar between the groups (p = 0.423 and p = 0.165, respectively). Radial nerve palsy developed in three patients in Group 2, and all these patients recovered completely during follow-up.

CONCLUSIONS

Although the double-plate fixation technique has similar clinical, radiological, and functional results to single-plate fixation, it is a more invasive and expensive technique with a longer operation time. Therefore, it should not be used as the first-line treatment option for all humeral shaft nonunion. Nevertheless, the double-plate technique may be preferred to achieve in cases requiring high stability, such as hypertrophic nonunion, osteopenia and comminuted fractures.

Effects of Gundelia tournefortii L. on biochemical parameters, antioxidant activities and DNA damage in a rat model of experimental obesity

The present study was designed to investigate the effects of Gundelia tournefortii L. plant extract on different tissues in terms of DNA damage, biochemical and antioxidant parameter values in rats with high-calorie diets. With this aim, Wistar albino male rats were divided into 4 groups containing 6 rats each and the study was completed over 12 weeks duration. At the end of the implementation process over the 12 weeks, rats were sacrificed and blood and tissue samples were obtained. Analyses were performed on blood and tissue samples. According to results for DNA damage (8-OHdG), in brain tissue the OG2 group was significantly reduced compared to the NC group. For MDA results in liver tissue, OG1 and OG2 groups were determined to increase by a significant degree compared to the control group, while the OG2 group was also increased significantly compared to the obese group. In terms of the other parameters, comparison between the groups linked to consumption of a high calorie diet (HCD) and administration of Gundelia tournefortii L. in terms of antioxidant activities and serum samples obtained statistically significant results. Gundelia tournefortii L. plant extracts had effects that may be counted as positive on antioxidant parameter activity and were especially identified to improve DNA damage and MDA levels in brain tissues. Additionally, consumption of Gundelia tournefortii L. plant extract in the diet may have antiobesity effects; thus, it should be evaluated for use as an effective weight-loss method and as a new therapeutic agent targeting obesity.

A rare cause of foot pain in an adolescent due to os paracuneiforme: a case report and review of the literature

Os paracuneiforme is an extremely rare accessory ossicle located at the medial aspect of the medial cuneiform bone. Although foot pain secondary to accessory ossicles is well known, symptomatic os paracuneiforme that requires surgical excision is rarely reported in the current literature. Herein, a 12-year-old boy with symptomatic os paracuneiforme is presented, and its clinical and imaging findings as well as the treatment are discussed.

Efecto de los daños causados por el insecto escudo verde (Palomena prasina L.) en las características cualitativas de la avellana

Este estudio se realizó en 2018 para determinar el efecto del daño del insecto escudo verde (DV) en las propiedades químicas del cultivar de avellana "Tombul". La composición proximal, proteína, lípidos totales (LT), carbohidratos, relación total de cenizas (CT), vitamina E (VE), fenólicos totales, valores de energía (E), color, composición de ácidos grasos, ácidos grasos totales, oxidación de lípidos e índice de calidad nutricional se determinaron en relación con los daños causados por el insecto. Se encontró que el nivel de LT, CT, VE, E, ácidos grasos monoinsaturados (MUFA) y ácidos grasos insaturados/saturados (UFA/SFA) fue menor en los granos de DV que en los granos buenos (GB). Aunque los granos de DV tienen niveles más altos de yodo, acidez, grasa libre y peróxidos, tienen niveles más bajos de la relación ácido oleico/linoleico y de los valores de rancimat. Además, los granos de DV tienen una relación más baja PUFA/SFA y de hipocolesterolémica/hipercolesterolémica, pero tienen valores de índice de aterogenicidad y trombogenicidad más altos.

Reliability of subluxation and articular involvement measurements during the assessment of bony mallet finger

The aim of this study was to investigate the reliability of distal interphalangeal joint (DIPJ) subluxation and articular surface involvement measurements during the assessment of bony mallet finger. Two observers measured articular involvement, subluxation ratio and rated joint congruency on 30 lateral radiographs of patients with bony mallet finger on two separate occasions. All measurements and ratings were done on magnified digital radiographs on a workstation. The intraclass correlation coefficient (ICC) and kappa statistics were used to establish relative agreement between observers. The intra-observer reliability for articular involvement and subluxation ratio were good for Observer A (ICCs 0.888 and 0.775) and excellent for Observer B (ICCs 0.958 and 0.910) on both occasions. However, the subluxation rating was moderate for both observers (kappa 0.772 and 0.780, respectively). Inter-observer reliability for articular involvement (ICC 0.884) and the subluxation ratio (ICC 0.818) was good on the first measurement. Although the subluxation rating was perfect for the first measurement (kappa 0.927), it was moderate for the second (kappa, 0.619). The reliability of articular involvement (%) and subluxation ratio (%) measurement was good and excellent. However, the decision on whether the DIPJ is congruent or incongruent was only moderately reproducible. These findings show us that surgeons should be cautious when assessing subluxation, which is the most important criterion for choosing the appropriate treatment.

Magnesium Bioabsorbable Screw Fixation of Radial Styloid Fractures: Case Report

Background  Several types of fixation materials may be used for the radial styloid fractures such as Kirschner wire fixation, screw fixation, volar plate fixation, and fragment-specific radial buttress plate fixation. However, each of these fixation techniques has certain complications usually related to either the surgical dissection or the application of fixation and symptomatic permanent hardware. Implant removal secondary to irritation of prominent screw heads or bulky plates is not uncommon after radial styloid fracture fixation. Case Description  Herein, two patients with an isolated radial styloid fracture who were treated with bioabsorbable magnesium (alloy: MgYREZr) screws are presented. In both patients, the fracture union was achieved without any complication and need for implant removal. Literature Review  This is the first report on the use of magnesium screws for this indication. Clinical Relevance  Magnesium bioabsorbable compression screw fixation may be an alternative solution that eliminates removal operations due to symptomatic hardware in radial styloid fractures.

Bilateral erector spinae plane block for scoliosis surgery: Case series

Spinal correction surgery is a very invasive surgical procedure and results in severe postoperative pain. We report six cases in which Bilateral Erector Spinae Plane Block was performed for scoliosis surgery. Our aim was to provide an effective perioperative pain management and to achieve intraoperative hemodynamic stability with no interference on neuromonitoring. The technical challenges are also highlighted. An ultrasound guided scout scan is necessarry to identify the bony prominences and determine the possible multiple injection points. Erector Spinae Plane Block in scoliosis surgery is an easier and safer technique compared to epidural anesthesia and can use instrumented complex spinal surgery. This block seems to have a role in perioperative pain pathway complementing the multimodal analgesic regimen and not have interference with evocated potentials in adults. However the diffusion mechanism of the this block is not well known hence it should be awake regarding local anesthetic toxicity.

Comparison of magnesium versus titanium screw fixation for biplane chevron medial malleolar osteotomy in the treatment of osteochondral lesions of the talus

PURPOSE

This retrospective study aimed to compare the clinical and radiological outcomes of patients who underwent biplane chevron medial malleolar osteotomy (MMO) for osteochondral lesions of the talus (OLT), fixed with either magnesium (Mg) or titanium (Ti) screws.

METHODS

A total of 22 patients (12 male and 10 female) with a mean age of 40.6 ± 12.5 years (range 18-56 years) who underwent MMO for OLT treatment were included in this retrospective study. Of the 22 patients, MMO was fixed with bioabsorbable Mg screws (Alloy: MgYREZr) in 11 patients, and in the remaining 11 patients (one bilateral) MMO was fixed with Ti screws. All patients were followed up for at least 1 year with a mean of 20.7 ± 8.9 months (range 12-49 months). The American Orthopedic Foot and Ankle Society (AOFAS) scale and the visual analog scale (VAS) were used to evaluate the clinical results. Union of the osteotomy, postoperative displacement and all other complications were followed and analyzed.

RESULTS

An improvement in the AOFAS scale and VAS points were recorded in both groups with no statistically significant difference between the groups (p 0.079 and 0.107, respectively). Complete union of the osteotomy was obtained in all patients. One patient in the Ti group required implant removal due to pain and irritation. There were no other significant complications in either group.

CONCLUSIONS

The results of this study showed that bioabsorbable Mg compression screws have similar therapeutic efficacy to Ti screws in respect of functional and radiological outcomes in MMO fixation. Bioabsorbable Mg screw is an alternative fixation material which can be safely used for MMO in ankle surgery.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Are perioperative therapeutic doses of statins associated with postoperative pain and opioid consumption after hip surgery under spinal anaesthesia?

Background

The anti-inflammatory effects of statins have been suggested to relieve postoperative pain. This retrospective study tested the association between the perioperative routine use of statins in therapeutic doses, and opioid requirements and pain scores, after hip replacement surgery.

Methods

With IRB approval, data was obtained for adult patients who had elective hip replacement surgery under spinal anaesthesia at Cleveland Clinic between 2005 and 2015. Patients were compared using a joint hypothesis framework. We used the inverse probability of treatment weighting method to control for observed confounding factors (a total of 26).

Results

We included 611 statin users and 780 non-statin users. Pain score during the initial 72 h after surgery was 0.07 higher (95% CI: -0.02, 0.17) in statin users (noninferiority test in both directions P<0.001). The estimated ratio of geometric means in the cumulative i.v. morphine equivalent opioid consumption was 1.01 (95% CI: 0.93, 1.10) for statin vs non-statin users (noninferiority test P=0.001 in the hypothesized direction and<0.001 in the other direction) during the initial 72 h after surgery. The statin and non-statin patients were deemed equivalent on postoperative opioid consumption and pain score.

Conclusions

This is the first large retrospective clinical study that investigates the effects of statin use on postoperative pain and opioid consumption. We observed no difference between statin users and non-users during the initial 72 h after hip surgery. Our findings do not support the routine use of statins as part of an analgesic regimen.

Avulsion fracture of anterior talofibular ligament from talus: A case report

Anterior talofibular ligament (ATFL) injuries can occur in three different distinct patterns; rupture of the ligament as a pure soft tissue injury, an avulsion fracture at the ATFL's attachment to either the fibula or the talus. Although fibular avulsion fractures are common, avulsion fracture of ATFL from talus is extremely rare with a single previously reported case in the current literature. A 34-year-old female with ATFL talar avulsion fracture associated with medial malleolar fracture was presented to the emergency department. Fixation of the fragment resulted with excellent functional outcome without a residual instability. Besides more common injury patterns such as mid-substance ATFL rupture and ATFL fibular avulsion fracture, talar avulsion fracture pattern should also be kept in mind in a patient presented with lateral ankle sprain. When a fragment is seen on the ankle radiographs at the tip of fibula, previously described special oblique views should be performed to reveal the correct origin of the fragment.

Scaphotrapeziotrapezoid Arthrodesis Using Limited Wrist Fusion Plates in Kienböck's Disease

PURPOSE

The purpose of this study was to evaluate the clinical and radiological results of scaphotrapeziotrapezoid (STT) arthrodesis with a limited wrist fusion plate in patients with Stage IIIB Kienböck's disease (KD).

MATERIALS AND METHODS

A retrospective review was performed on nine patients with Stage IIIB KD who underwent STT arthrodesis between 2014 and 2017 at our institution. Clinical evaluations of the patients were made using the shortened quick version of the Disabilities of the Arm, Shoulder, and Hand (Q-DASH) Outcome Measure score (Institute for Work and Health, Toronto, ON, Canada) and grip strength measurements before surgery and at the final follow-up examination. All patients underwent computed tomography (CT) scan to confirm the union of the arthrodesis.

RESULTS

A complete union was obtained in all patients. The Q-DASH score was changed from 57.8 ± 8.2 points (range: 47.7 - 70.5) to 32.3 ± 17.3 points (range: 13.6 - 54.5) (p = 0.008). Similarly, the grip strength was improved significantly (p = 0.007).

CONCLUSIONS

The use of limited wrist fusion plates for STT arthrodesis in KD is a safe and effective treatment method that provides a high rate union and acceptable functional results.

Effect of drying on the chemical composition of Çakıldak (cv) hazelnuts during storage

The hazelnut (Corylus avellana L.) is one of the most popular tree nuts in the world. The proper selection of drying methods is necessary to prevent oil oxidation which will influence the overall nut quality during storage. The aim of this study was to determine the effects of sun drying (SD) and artificial dryingied (AD) on the chemical traits of hazelnuts during long–term storage. Protein, lipid and moisture contents, water activity, fatty acid composition, sum of fatty acids, and oil oxidation properties were determined over 24 months’ storage (2015–2017) at 20–25 °C and 70–90% relative humidity. The results showed that monounsaturated fatty acids (MUFA) was the main fatty acid group (81.55–83.38%) followed by polyunsaturated (PUFA; 10.39–11.57%) and saturated fatty acids (SFA; 5.75–6.60%). The samples dried by AD had more SFA (5.86%) and MUFA (83.11%) than the SD samples. At the end of storage, the lowest free fatty acid, and peroxide value (0.52%–1.45 meqO2·kg-1, respectively), and the highest oleic/linoleic acidity ratio (7.76) were found from AD. Therefore, AD appears to be more promising for hazelnut drying.

Fixation of Small Osteochondral Fragments in a Comminuted Distal Humerus Fracture with Magnesium Bioabsorbable Screws: A Case Report

The treatment of comminuted distal humeral fractures with free osteochondral fragments is challenging. Osteochondral fragments should be retained whenever possible and secured with implants buried beneath the articular surface to obtain a uniform articular surface. Headless compression screws and K wires are commonly used for this purpose. However, certain complications have been reported with these fixation implants in case of the non-union and osteolysis of the fragments such as migration and cartilage damage. Fixation of osteochondral fractures in distal humeral fractures using bioabsorbable implants has been rarely reported in the current literature. Herein, a patient who sustained a comminuted distal humeral fracture with multi-fragmentary osteochondral fragments is presented, and treatment with magnesium bioabsorbable compression screws is discussed.

The association of hypotension during non-cardiac surgery, before and after skin incision, with postoperative acute kidney injury: a retrospective cohort analysis

Intra-operative hypotension is associated with acute postoperative kidney injury. It is unclear how much hypotension occurs before skin incision compared with after, or whether hypotension in these two periods is similarly associated with postoperative kidney injury. We analysed the association of mean arterial pressure < 65 mmHg with postoperative kidney injury in 42,825 patients who were anaesthetised for elective non-cardiac surgery. Intra-operative hypotension occurred in 30,423 (71%) patients: 22,569 (53%) patients before skin incision; and 24,102 (56%) patients after incision. Anaesthetised patients who were hypotensive had mean arterial pressures < 65 mmHg for a median (IQR [range]) of 5.5 (0.0-14.7 [0.0-60.0]) min.h^-1 before skin incision, compared with 1.7 [0.3-5.1 [0.0-57.5]) min.h^-1 after incision: a median (IQR [range]) of 36% (0%-84% [0%-100%]) of hypotensive readings were before incision. We diagnosed postoperative kidney injury in 2328 (5%) patients. The odds ratio (95%CI) for acute kidney injury was 1.05 (1.02-1.07) for each doubling of the duration of hypotension, p < 0.001. Postoperative kidney injury was associated with the product of hypotension duration and severity, that is, area under the curve, before skin incision and after, odds ratio (95%CI): 1.02 (1.01-1.04), p = 0.004; and 1.02 (1.00-1.04), p = 0.016, respectively. A substantial fraction of all hypotension happened before surgical incision and was thus completely due to anaesthetic management. We recommend that anaesthetists should avoid mean arterial pressure < 65 mmHg during surgery, especially after induction, assuming that its association with postoperative kidney injury is, at least in part, causal.

Fixation of medial malleolar fractures with magnesium bioabsorbable headless compression screws: short-term clinical and radiological outcomes in eleven patients

OBJECTIVE

The purpose of this retrospective study was to evaluate the outcome of medial malleolar fractures treated with magnesium (MgYREZr) bioabsorbable compression screw fixation.

MATERIALS AND METHODS

Eleven patients with a medial malleolar fracture (either isolated or accompanied by bimalleolar or trimalleolar ankle fractures) who were treated with magnesium bioabsorbable compression screws between 2015 and 2016 in our hospital were retrospectively evaluated. Patients were monitored with a mean follow-up of 17.3 ± 4.1 months (range 12-24 months). The mechanism of injury was ground level falls in all patients. All fractures were classified as closed fractures. American Orthopedic Foot and Ankle Society's (AOFAS) scale and the visual analog scale (VAS) were used to evaluate the clinical results during the final follow-up. Bone union and a possible loss of reduction were assessed with serial radiographs. Potential complications including revision surgery and infection were recorded and reported.

RESULTS

There were 11 patients (4 female, 7 male) with a mean age of 41 ± 21.9 years (range 20-78 years). Six patients had Herscovici type C and five patients had type B fractures. At the final follow-up the mean AOFAS score was 94.9 ± 5.7 points (range 85-100 points) and the mean VAS score was 0.4 ± 1.2 points (range 0-4 points). Radiographic solid union was achieved in all cases. No complications were seen during the follow-up. No patients required implant removal or revision surgery.

CONCLUSIONS

This is the first study that investigates the use of bioabsorbable magnesium compression screws in medial malleolar fractures. The results of this study revealed that fixation of medial malleolar fractures with bioabsorbable magnesium compression screws provides adequate fixation with good functional results.

LEVEL OF EVIDENCE

Level IV, therapeutic, retrospective case series.

The effect of gadolinium-based contrast agents on rat testis

Previous studies have reported that repeated administrations of linear gadolinium-based contrast agents lead to their accumulation in the brain and other tissues in individuals with normal renal functions. The purpose of this prospective animal study was to investigate the effect of multiple administrations of macrocyclic ionic (gadoteric acid) and linear nonionic (gadodiamide) gadolinium-based contrast agents (GBCAs) on rat testis tissue and to compare these molecules in terms of tissue damage. Thirty-two male Sprague-Dawley rats were kept without drugs for 5 weeks after administration of 0.1 mmol mg^-1 kg^-1 (0.2 ml/kg) gadodiamide and gadoteric acid for 4 days over 5 weeks. Biochemical, histopathological and immunohistochemical changes in testis tissue were evaluated at the end of 10 weeks. When used in repeated clinical doses, gadolinium was observed to increase apoptosis in the Leydig cells of the rat testis, and to increase serum Ca⁺² levels and reduce testosterone levels (p < .05). Although the difference was not statistically significant, a greater loss of spermatozoa and immature germinal cell accumulation were observed in the seminiferous tubule lumen in the GBCA groups compared with the control and saline groups (p > .05). Both linear and macrocyclic contrast agents have toxic effects on testis tissue, irrespective of the type of drug.

Isolated Lateral Malleolar Fracture Treated with a Bioabsorbable Magnesium Compression Screw

Magnesium (Mg) bioabsorbable screws are new biomaterials used in fracture fixation. In the current literature, there is only one case report on the use of magnesium bio-absorbable screws in ankle fractures. Within the present study, a 19-year-old female who sustained an isolated lateral malleolar fracture was treated with open reduction and intramedullary Mg screw fixation and then followed up for two years. Fracture union was achieved without any complication such as failure of fixation, loss of reduction, infection, or any other adverse reaction. Mg bioabsorbable screws are an alternative method of fracture fixation as compared to conventional metallic implants since they eliminate the need for implant removal.

Effects of Changing Size-Weight Parameters on the Temperature Dependent Exothermic Riser Sleeve Properties

Exothermic riser (feeder) sleeves are used to retain the heat in risers and to increase solidification duration. A riser should be enough hot to become the last solidified part in a mould cavity. Thus, risers can feed the other parts to result in sound casting products without cavity like defects. They are particularly preferred for steel and ductile iron casting operations which have high pouring temperatures. Exothermic riser sleeves are a mixture of metallothermic-based exothermic and insulating materials (Al, Fe2O3 and SiO2 etc.) that are manufactured in different sizes and shapes. In the present study, performances of some selected commercial sleeves were evaluated in terms of reaction duration, flammability and temperature change etc. Some thermochemical modelling studies were performed to understand the effect of reactant composition on sleeve performance prior to the performance tests.

A study of Staphylococcus aureusnasal carriage, antibacterial resistance and virulence factor encoding genes in a tertiary care hospital, Kayseri, Turkey

AIM

This study was to determine the virulence encoding genes, and the antibiotic resistance patterns of the Staphylococcus aureus isolates, which were isolated from the nasal samples of chest clinic patients.

MATERIALS AND METHODS

The nasal samples of the in-patients (431) and out-patients (1857) in Kayseri Training and Research Hospital's Chest Clinic, Kayseri, Turkey, were cultured on CHROMagar (Biolife, Italiana) S. aureus, and subcultured on sheep blood agar for the isolation of S. aureus. Disc diffusion method was used for antimicrobial susceptibility testing. The occurrence of the staphylococcal virulence encoding genes (enterotoksins [sea, seb, sec, see, seg, seh, sei, sej], fibronectin-binding proteins A, B [fnbA, fnbB], toxic shock syndrome toxin-1 [tst]) were detected by polymerase chain reaction.

RESULTS

Forty-five of the 55 (81.8%) S. aureus isolates from inpatients, and 319 (90.6%) isolates from tested 352 out-patient's isolates were suspected to all the antibiotics tested. methicillin-resistant S. aureus (MRSA) was detected in 1.2% of S. aureus isolates. Rifampin, trimethoprim-sulfamethoxazole, clindamycin, erythromycin, gentamicin resistance rates were 1.2%, 1.7%, 2.0%, 8.8%, and 1.2%, respectively. The isolates were susceptible to teicoplanin and vancomycin. The genes most frequently found were tst (92.7%), seg (85.8%), sea (83.6%), fnbA (70.9%). There was no statistical significance detected between MRSA and mecA-negative S. aureus isolates in encoding genes distribution (P > 0.05).

CONCLUSION

Our results show that virulence factor encoding genes were prevalent in patients with S. aureus carriage, whereas antibiotic resistance was low. These virulence determinants may increase the risk for subsequent invasive infections in carriers.

Steroid administration after anaesthetic induction with etomidate does not reduce in-hospital mortality or cardiovascular morbidity after non-cardiac surgery

BACKGROUND

We tested the primary hypothesis that corticosteroid administration after etomidate exposure reduces a composite of in-hospital mortality and cardiovascular morbidity after non-cardiac surgery.

METHODS

We evaluated ASA physical status III and IV patients who had non-cardiac surgery with general anaesthesia at the Cleveland Clinic. Amongst 4275 patients in whom anaesthesia was induced with etomidate, 804 were also given steroid intraoperatively, mostly dexamethasone at a median dose of 6 mg. We successfully matched 582 steroid patients with 1023 non-steroid patients. The matched groups were compared on composite of in-hospital mortality and cardiovascular morbidity using a generalized-estimating-equation model. Secondly, the matched groups were compared on length of hospital stay using a Cox proportional hazard model, and were descriptively compared on intraoperative blood pressures using a standardized difference.

RESULTS

There was no significant association between intraoperative steroid administration after anaesthetic induction with etomidate and the composite of in-hospital mortality or cardiovascular morbidity; the estimated common odds ratio across the two components of the composite was 0.86 [95% confidence interval (CI): 0.64, 1.16] for steroid vs non-steroid, P=0.33. The duration of postoperative hospitalisation was significantly shorter amongst steroid patients [median (Q1, Q3): 6 (3, 10) days] than non-steroid patients [7 (4, 11) days], with an estimated hazard ratio of 0.89 (0.80, 0.98) for steroid vs non-steroid, P=0.01. Intraoperative blood pressures were similar in steroid and non-steroid patients.

CONCLUSIONS

Steroid administration after induction of anaesthesia with etomidate did not reduce mortality or cardiovascular morbidity.

Accessory Ossicles of the Foot and Ankle: Disorders and a Review of the Literature

Accessory ossicles of the foot and ankle are normal variants of bone development that usually remain asymptomatic. However, they may be involved in various disorders and become a source of pain such as in fractures, dislocations, degenerative changes, osteonecrosis, osteoarthritis, osteochondral lesions, avascular necrosis, and irritation or impingement of adjacent soft tissues. Hence, during the assessment of the situations above, knowledge about these little-known ossicles could be very important to reach the correct diagnosis. Recent studies in the literature have mostly focused on the most frequent 9-12 accessory bones. In this review, 24 types of accessory ossicle are described. These ossicles are accessory navicular bone, os peroneum, os trigonum, os intermetatarseum, os vesalianum. os subfibulare, os subtibiale, os calcaneus secundarius, os calcanei accessorium, os supratalare, os sustentaculi, os talotibiale, os tali accessorium, talus secundarius, os subcalcis, os cuboideum secundarium, os supranaviculare, os infranaviculare, os paracuneiforme, os intercuneiforme, os cuneometatarsale I tibiale, os cuneometatarsale plantare, os cuneo–I metatarsale-II dorsale, and os aponeurosis plantaris. The clinical importance of these bones should be known thoroughly to reduce unnecessary orthopedic consultations and misdiagnosis. This article describes the clinical importance of the accessory ossicles and their possible pathological conditions. Understanding the possible disorders of the accessory ossicles of the foot and ankle can provide a more accurate diagnostic process.

Posterior tibial tendon impingement due to os subtibiale: a case report and up-to-date review

Os subtibiale is a rare accessory ossicle located at the tip of the medial malleolus. Although this small ossicle usually has no clinical significance, in some cases it may be a source of ankle pain. Symptomatic os subtibiale is an extremely rare diagnosis, and few cases have been reported to date. The case presented is of a 35-year-old female patient with symptomatic os subtibiale, with a discussion of the diagnosis, clinical findings, and treatment options.

Conversion of hip fusion to total hip arthroplasty: clinical, radiological outcomes and complications in 40 hips

OBJECTIVE

The purpose of this retrospective study is to report the clinical and radiological outcome of total hip arthroplasty in patients with previous hip arthrodesis.

PATIENTS AND METHODS

We retrospectively reviewed 28 (40 hips) prospectively followed patients in whom ankylosed hips were converted to total hip arthroplasty (THA) between 2010 and 2014 in our institution. The average age at the time of the conversion operation was 40.8 ± 9.8 years (range 24-62). The ankylosis had lasted 20.4 ± 13.0 years (range 3-56) before conversion surgery. The etiology of the ankylosis was septic arthritis in 10 (25%), post-traumatic hip osteoarthritis in 8 (20%), developmental hip dysplasia in 6 (15%), rheumatoid arthritis in 6 (15%), primary osteoarthritis in 5 (12.5%) and ankylosing spondylitis in 5 (12.5%) hips. The indications for arthroplasty were intractable low back pain in 14 (50%), hip pain in 24 (85.7%), and ipsilateral knee pain in 19 (67.8%) patients. Harris Hip Score (HHS) was used to rate the clinical results before and after the surgery. Radiographic evaluations included component malposition and loosening. All complications during the study period were recorded.

RESULTS

The mean follow-up period was 39.9 ± 10.6 months (range 24-60). The mean preoperative HHS was 33.3 ± 8.6 (range 18-50) and the mean HHS at the final follow-up was 74.9 ± 8.6 (range 52-97). There was a statistically significant increase in HHS (p = 0.0001). HHS was excellent in 1, good in 6, fair in 14 and poor in 7 patients. Increase in HHS was lower than 20 points in one patient (18 points), and one patient required two-staged exchange procedure due to deep infection. Thus, according to our success criteria (increase in HHS more than 20 points, radiographically stable implant, and no further surgical reconstruction), 92.8% (26/28) of patients had benefit from the surgery. Trendelenburg sign was positive in 12 hips. There was limb length inequality in 11 patients (mean 0.5 cm, range 1-3 cm). No patients had heterotopic ossification, sciatic nerve palsy or dislocation. There were five intra-operative fractures of the greater trochanter that were treated with cable wiring. One patient had trochanteric avulsion injury and was treated with trochanteric grip and cables. One patient (2.5%) had deep infection one year after the conversion THA and was treated with two-staged exchange procedure.

CONCLUSION

Conversion hip arthroplasty is an effective treatment method which provides functional recovery and patient satisfaction. However, a proper surgical technique and planning is necessary to minimize the complications.

Squamous cell carcinoma arising from teratoma of the ovary: magnetic resonance, computed tomography, and pathological findings

In the present case report, the authors investigated the clinicopathological characteristics of squamous cell carcinoma (SCC) arising from teratoma of the ovary and intended to report their clinical experience. Malignant transformation of ovarian teratoma is a quite rare condition with SCC observed to be the most common form of transformation. The present case was a 43-year-old female patient and her clinical presentation was abdominal pain, abdominal distension, and abdominal mass sensation. The patient underwent ultrasonography. After detection of a mass, magnetic resonance imaging (MRI) was performed. Surgery was performed on the patient and the pathological report revealed SCC arising from teratoma. The patient was evaluated retrospectively in terms of demographic characteristics, MRI, surgical findings, and prognosis.

Investigating the impact of non-Newtonian blood models within a heart pump

A detailed computational fluid dynamics (CFD) study of transient, turbulent blood flow through a positive displacement left ventricular assist device is performed. Two common models for non-Newtonian blood flow are compared to the Newtonian model to investigate their impact on predicted levels of shear rate and wall shear stress. Given that both parameters are directly relevant to the evaluation of risk from thrombus and haemolysis, there is a need to assess the sensitivity to modelling non-Newtonian flow effects within a pulsatile turbulent flow, in order to identify levels of uncertainly in CFD. To capture the effects of turbulence, the elliptic blending Reynolds stress model is used in the present study, on account of superior performance of second moment closure schemes previously identified by the present authors. The CFD configuration includes two cyclically rotating valves and a moving pusher plate to periodically vary the chamber volume. An overset mesh algorithm is used for each instance of mesh motion, and a zero gap technique was employed to ensure full valve closure. The left ventricular assist device was operated at a pumping rate of 86 BPM (beats per minute) and a systolic duration of 40% of the pumping cycle, in line with existing experimental data to which comparisons are made. The sensitivity of the variable viscosity models is investigated in terms of mean flow field, levels of turbulence and global shear rate, and a non-dimensional index is used to directly evaluate the impact of non-Newtonian effects. The clinical relevance of the results is reported along with a discussion of modelling uncertainties, observing that the turbulent kinetic energy is generally predicted to be higher in non-Newtonian flow than that observed in Newtonian flow. Copyright © 2016 John Wiley & Sons, Ltd.

Prevalence and distribution of the fabella: a radiographic study in Turkish subjects

BACKGROUND

The purpose of this study is to examine the plain knee radiographs in Turkish subjects in order to determine the prevalence of the fabella and analyse the differences between age, gender, laterality and its symmetry pattern.

MATERIALS AND METHODS

Bilateral antero-posterior and lateral knee radiographs of 500 patients (250 male and 250 female subjects, 1000 knee radiographs) were randomly selected from the clinical database and retrospectively evaluated. Data on patient age, gender, and knee laterality (right-left) were evaluated from hospital records. The differences between the sesamoid bones at a particular location and the side, sex and age groups were analysed.

RESULTS

The overall prevalence of the fabella (unilateral or bilateral) was 22.8% (114 subjects). The fabella was present unilaterally in 38 (7.6%) subjects, while it was present bilaterally in 76 (15.2%) subjects. The prevalence of the fabella was similar between the body sides. The prevalence of the fabella was also similar between genders (unilateral or bilateral cases) and age groups.

CONCLUSIONS

We examined the prevalence, symmetry pattern, age and gender differences in Turkish population. It is the first study performed on Turkish population with the largest sample in current literature. Prevalence of fabella is found to be 22.8% which is quite similar with other Caucasian ethnic populations.

Surface-Sensitive Microwear Texture Analysis of Attrition and Erosion

Scale-sensitive fractal analysis of high-resolution 3-dimensional surface reconstructions of wear patterns has advanced our knowledge in evolutionary biology, and has opened up opportunities for translatory applications in clinical practice. To elucidate the microwear characteristics of attrition and erosion in worn natural teeth, we scanned 50 extracted human teeth using a confocal profiler at a high optical resolution (X-Y, 0.17 µm; Z < 3 nm). Our hypothesis was that microwear complexity would be greater in erosion and that anisotropy would be greater in attrition. The teeth were divided into 4 groups, including 2 wear types (attrition and erosion) and 2 locations (anterior and posterior teeth; n = 12 for each anterior group, n = 13 for each posterior group) for 2 tissue types (enamel and dentine). The raw 3-dimensional data cloud was subjected to a newly developed rigorous standardization technique to reduce interscanner variability as well as to filter anomalous scanning data. Linear mixed effects (regression) analyses conducted separately for the dependent variables, complexity and anisotropy, showed the following effects of the independent variables: significant interactions between wear type and tissue type ( P = 0.0157 and P = 0.0003, respectively) and significant effects of location ( P < 0.0001 and P = 0.0035, respectively). There were significant associations between complexity and anisotropy when the dependent variable was either complexity ( P = 0.0003) or anisotropy ( P = 0.0014). Our findings of greater complexity in erosion and greater anisotropy in attrition confirm our hypothesis. The greatest geometric means were noted in dentine erosion for complexity and dentine attrition for anisotropy. Dentine also exhibited microwear characteristics that were more consistent with wear types than enamel. Overall, our findings could complement macrowear assessment in dental clinical practice and research and could assist in the early detection and management of pathologic tooth wear.

Fracture of biphalangeal fifth toe: A diagnostic pitfall in the emergency department

Biphalangeal toe is a normal anatomic variant where distal and middle phalanges fuse to each other. In the context of trauma, biphalangeal toes may pose a diagnostic challenge and fractures may be interpreted as normal which can lead to misdiagnosis and under treatment. Here, we present a rare case of fracture through a biphalangeal fifth toe with delayed diagnosis. This variation should be kept in mind during the evaluation of a patient with foot trauma and assessment of foot radiographs, particularly in the emergency department where the majority of initial cases are presented.

Reverse Segond fracture and associated knee injuries: A case report and review of 13 published cases

Reverse Segond fracture is originally described as an indirect radiographic clue for a specific injury complex of the knee joint that includes posterior cruciate ligament (PCL) rupture and medial meniscal tear. Herein, we describe a case with reverse Segond fracture associated with PCL avulsion fracture instead of PCL rupture. According to current literature review, reverse Segond fracture is not only associated with PCL and medial meniscal injuries, but also frequently associated with anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries. Furthermore, medial meniscus and PCL may remain intact.

A detailed analysis of messages posted on the 'Turk-Orthopod' mailing list over a 13-year period

OBJECTIVE

The objective of this study was to analyze the content of the 'Turk-Orthopod' mailing list between 2000 and 2013.

METHODS

All messages posted to the 'Turk-Orthopod' mailing list were documented and categorized by 4 orthopedic surgeons who were active members of the mailing list into 11 categories based on the content of the messages.

RESULTS

A total of 15,699 messages were evaluated and included in the analysis. The mean number of daily messages in 2000 was 0.98 messages/day and increased to 7.23 messages/day in 2013. The most common type of message was announcements (37.5%) about national or international congresses, conferences, symposia, meetings, and panels. The second most common type of message was condolence messages (11.7%). Case discussions and academic discussions comprised 6.3% and 4.5% of the messages, respectively.

CONCLUSION

The 'Turk-Orthopod' mailing list serves primarily as an information board and a powerful social media platform for communication among Turkish orthopedic surgeons. However, scientific case discussions and other professional issues comprise a minority of the messages.

Perioperative factors associated with acute kidney injury after partial nephrectomy

BACKGROUND

Partial nephrectomy is performed with the aim to preserve renal function. But the occurrence of postoperative acute kidney injury (AKI) can interfere with this goal. Our primary aim was to evaluate associations between pre-specified modifiable factors and estimated glomerular filtration rate after partial nephrectomy. Our secondary aims were to evaluate associations between pre-specified modifiable factors and both serum creatinine concentration and type of nephrectomy.

METHODS

The records of 1955 patients who underwent partial nephrectomy were collected. Postoperative estimated glomerular filtration rate (eGFR) was used as the primary outcome measure. Twenty modifiable risk factors were studied. A repeated-measures linear model with autoregressive within-subject correlation structure was used. The interaction between all the factors and type of nephrectomy was also studied.

RESULTS

A total of 1187 (61%) patients had no kidney injury, 647 (33%) had stage I, 80 (4%) had stage II, and 41 (2%) had stage III injury. The mean eGFR increased an estimated 0.83 (99.76% CI 0.79-0.88) ml min(-1) 1.73 m(-2) for a unit increase in baseline eGFR. Mean eGFR was 2.65 (99.76% CI: 0.13, 5.18) ml min(-1) 1.73 m(-2) lower in patients with hypertension. Mean eGFR decreased 0.42 (99.76% CI: 0.22, 0.62) ml min(-1) 1.73 m(-2) for a 10-minute longer in duration of procedure and decreased 2.09 (99.76% CI: 1.39, 2.80) ml min(-1) 1.73 m(-2) for a 10-minute longer in ischemia time. It was 3.53 (99.76% CI: 0.83, 6.23) ml min(-1) 1.73 m(-2) lower for patients who received warm ischemia as compared to cold ischemia.

CONCLUSION

Potentially modifiable factors associated with AKI in the postoperative period were identified as baseline renal function, preoperative hypertension, longer duration of surgical time and ischaemia time, and warm ischaemia.

Assessment of turbulence models for pulsatile flow inside a heart pump

Computational fluid dynamics (CFD) is applied to study the unsteady flow inside a pulsatile pump left ventricular assist device, in order to assess the sensitivity to a range of commonly used turbulence models. Levels of strain and wall shear stress are directly relevant to the evaluation of risk from haemolysis and thrombosis, and thus understanding the sensitivity to these turbulence models is important in the assessment of uncertainty in CFD predictions. The study focuses on a positive displacement or pulsatile pump, and the CFD model includes valves and moving pusher plate. An unstructured dynamic layering method was employed to capture this cyclic motion, and valves were simulated in their fully open position to mimic the natural scenario, with in/outflow triggered at control planes away from the valves. Six turbulence models have been used, comprising three relevant to the low Reynolds number nature of this flow and three more intended to investigate different transport effects. In the first group, we consider the shear stress transport (SST) [Formula: see text] model in both its standard and transition-sensitive forms, and the 'laminar' model in which no turbulence model is used. In the second group, we compare the one equation Spalart-Almaras model, the standard two equation [Formula: see text] and the full Reynolds stress model (RSM). Following evaluation of spatial and temporal resolution requirements, results are compared with available experimental data. The model was operated at a systolic duration of 40% of the pumping cycle and a pumping rate of 86 BPM (beats per minute). Contrary to reasonable preconception, the 'transition' model, calibrated to incorporate additional physical modelling specifically for these flow conditions, was not noticeably superior to the standard form of the model. Indeed, observations of turbulent viscosity ratio reveal that the transition model initiates a premature increase of turbulence in this flow, when compared with both experimental and higher order numerical results previously reported in the literature. Furthermore, the RSM is indicated to provide the most accurate prediction over much of the flow, due to its ability to more correctly account for three-dimensional effects. Finally, the clinical relevance of the results is reported along with a discussion on the impact of such modelling uncertainties.

Ultrasound elastographic evaluation of the median nerve in pregnant women with carpal tunnel syndrome

OBJECTIVE

To evaluate the median nerve (MN) in pregnant women with carpal tunnel syndrome (CTS) by using ultrasound elastography.

PATIENTS AND METHODS

30 wrists of 20 pregnant women with CTS and 25 wrists of 14 healthy control pregnant women were evaluated by ultrasound and ultrasound elastography (UE). The MN in the patients' wrist was imaged to measure the cross-sectional area and longitudinally to calculate the elasticity value (EV) at four different locations (proximal carpal tunnel (CT) at the level of the pisiform, distal CT at the level of the hamate, middle of the CT and forearm at one centimeter above the CT). Clinical classification was performed according to a historic and objective scale of CTS. In the healthy pregnant women and pregnant women with CTS, MN area and EV were analyzed statistically by comparing with parity and clinical grade.

RESULTS

There was a statistically significant difference for MN area between the patient and control groups (p = 0.001). A positive relationship was found between parity in pregnancy and clinical grade of the CTS (p = 0.035, Pearson's correlation coefficient = 0.386). Although MN elasticity for both groups was nearly the same in the proximal region of the CT, these values were decreased in the middle of the CT. MN elasticity values were smaller in the distal region of CT, and it was statistically significant in pregnant women with CTS (p = 0.02).

CONCLUSIONS

Ultrasound elastography, which is a non-invasive, inexpensive and a favorable diagnosis technique, may be useful in the diagnosis of CTS, especially in conditions in which an invasive procedure would be problem, as in pregnancy.

The expression of Forkhead transcription factors in decidua and placenta in patients with missed abortion

BACKGROUND

Forkhead transcription factors 3a (FOXO3a) has pleiotropic biological functions in the female reproductive tract. FOXO3a has a function in decidualization, in placental development, and also in inhibition of apoptosis. This study aims to investigate a possible role of FOXO3a in missed abortion.

MATERIALS AND METHODS

Decidual and placental tissue samples were obtained from the women with unwanted pregnancy as the control group and with missed abortion as the patient group. Immunohistochemistry technique was utilized to compare FOXO3a expression of the decidual cells in uterine decidual stroma and cytotrophoblast-syncytiotrophoblast cells in placental villous stroma. Immunohistochemistry was evaluated semiquantitatively utilizing the H-score technique. Results: It was demonstrated that H-Scores of FOXO3a expression in both uterine decidual stroma were increased in the missed abortion group (255.83 +/- 12.41) than in the normal pregnancy group (133.33 +/- 17.43). It was also shown that there was no difference between non-decidual area of the endometrium of the normal pregnancy and the missed abortion group (30.33 +/- 4.32; 39.66 +/- 14.30, respectively) and placental villous stroma (13.00 +/- 1.89; 13.00 +/- 1.67, respectively). However, the immunoreactivity of cytotrophoblast and syncytiotrophoblast cells significantly increased in the missed abortion group (18.83+1.47; 322.00 +/- 6.06, respectively) than in the normal pregnancy group (11.00 +/- 1.26; 254.00 +/- 8.17, respectively) (p < 0.05).

CONCLUSION

These data support the hypothesis that increased FOXO3a expression in missed abortion may prevent the discharge of dead fetus to maintain decidualization, prevention of oxidative stress, immunomodulation, and inhibition of apoptosis.

A diagnostic dilemma for solid ovarian masses: the clinical and radiological aspects with differential diagnosis of 23 cases

OBJECTIVE

This study aimed to analyze the clinical characteristics and diagnostic features of ovarian fibromatous masses.

MATERIALS AND METHODS

The authors reviewed the records of 23 women who underwent laparotomic surgeries and whose final histopathological diagnoses were ovarian fibroma, cellular fibroma, or fibrothecoma from January 2005 to January 2013. The clinical, ultrasonographic, magnetic resonance imaging, tumor marker, therapeutic, and histologic data were analyzed.

RESULTS

The mean age of the patients was 50.9 years. Sixteen patients were menopausal. The preoperative ultrasonography examination incorrectly diagnosed seven lesions as uterine fibromas, and the magnetic resonance imaging examination incorrectly labeled three lesions as pedunculated subserous uterine fibromas. The cancer antigen-125 levels of 17 cases were measured, with four being abnormal. Twenty-three patients underwent a laparotomy. Twenty patients underwent a total hysterectomy with bilateral salpingo-oophorectomy, and three underwent a tumorectomy. The histological diagnosis was fibrothecoma in 21 cases, fibroma in one case, and cellular fibroma in one case. Histopathologic examination of the endometrium of seven of the 20 patients who underwent hysterectomy revealed simple endometrial hyperplasia without atypia.

CONCLUSION

Ovarian fibromas and fibrothecomas are often misdiagnosed as uterine fibromas and occasionally mistaken for malignant tumors of the ovary preoperatively. As these tumors originate from ovarian stroma, they may be hormone-active tumors. Therefore, they may lead to premalignant changes in the endometrium. The preoperative evaluation of the endometrium is recommended.

Fatty degeneration and atrophy of the rotator cuff muscles after arthroscopic repair: does it improve, halt or deteriorate?

OBJECTIVE

The purpose of this study was to evaluate the changes in fatty degeneration and atrophy of rotator cuff muscles after arthroscopic repair. We further assessed the factors affecting the functional outcomes and integrity of the rotator cuff.

MATERIALS AND METHODS

One hundred and two prospectively followed patients who underwent single-row arthroscopic repair for full-thickness rotator cuff tears between 2008 and 2010 in our institution were included. All patients underwent shoulder MRI examination before the arthroscopic repair and at the final follow-up at least 2 years after the surgical repair. Supraspinatus muscle atrophy was measured and evaluated according to the Thomazeau classification. The fatty degeneration of the cuff muscles was graded according to the Goutallier classification. Functional outcomes were assessed with the Constant shoulder score. The changes in fatty degeneration and atrophy were analyzed during the treatment period. Correlation coefficients (Pearson r) and stepwise, multiple linear regression were used to determine the relationship between the outcome variables (final Constant score and integrity of the cuff), and the predictor variables, age, sex, follow-up duration, initial muscle atrophy, final muscle atrophy, initial fatty degeneration and final fatty degeneration.

RESULTS

Of the 102 patients reviewed, 87 patients responded and concluded the final clinical follow-up and MRI examination (85.2 % follow-up rate). There were 67 females and 20 males with a mean age of 62.5 ± 8.3 years (range 40-80 years). Mean follow-up period was 30.1 ± 5.8 months (range 24-43 months). At the final follow-up, the mean Constant shoulder score was 94.2 ± 8.2 (range 70-100), and 66 (75.9 %) patients rated as excellent, 14 (16.1 %) as good, and 7 (8.0 %) as fair. No patient had poor results. There was re-rupture in 26 (29.9 %) patients on final MRI examination. No patient had improvement in muscle atrophy and fatty degeneration. The atrophic changes between intact tendon and re-rupture cases were statistically similar (p = 0.300). The deterioration of fatty degeneration was significantly higher in the re-rupture group (p = 0.0001). The Constant shoulder score was significantly lower in patients with re-rupture (97.4 ± 5.0 versus 86.6 ± 9.3, p = 0.001).Multiple stepwise regression analysis showed that the Constant score was dependent on the final integrity of the tendon and the size of the tear (R (2) 0.420, p 0.001). The final integrity of the tendon was dependent on the age of the patient, initial and final fatty degeneration of the cuff muscles and the size of the tear (R (2) 0.669, p 0.001).

CONCLUSION

Initial muscle atrophy and fatty degeneration did not improve even after a successful rotator cuff repair where the tendon anatomic integrity was maintained for at least 2 years. It may continue to deteriorate, and the best possibility was preservation of the preoperative status. On the other hand, in cases of re-rupture, fatty degeneration and atrophy continued to worsen significantly. The factors affecting tendon integrity were found to be the age of the patient, the size of the tear and the severity of preoperative fatty degeneration in the rotator cuff.

Association between fibromyalgia and adverse perioperative outcomes

BACKGROUND

Fibromyalgia, the classic non-inflammatory pain syndrome, has been associated with chronic inflammatory makers which are linked with increased morbidity and mortality. We tested the primary hypothesis that patients with fibromyalgia undergoing hospital procedures have a high risk of cardiovascular complications. Our secondary goals were to evaluate the association of fibromyalgia with: (i) in-hospital thromboembolic events, (ii) in-hospital mortality, and (iii) in-hospital microvascular complications.

METHODS

We obtained 21.78 million discharge records from 2009 to 2010 from the US Agency for Healthcare Research and Quality censuses across the seven states. We matched fibromyalgia records and compared records with controls based on age, gender, state of discharge, principal procedure, and a propensity score developed from the set of diagnosis-related predictors. A multivariable logistic regression was used to compare matched fibromyalgia patients and controls on the primary and secondary outcomes.

RESULTS

We matched 89 589 pairs for a total sample size of 179 178 discharge records. The adjusted odds ratio for in-hospital cardiovascular complications was 1.04 [99% confidence interval (CI): 0.90-1.19, P=0.51], for thromboembolic events was 1.03 (99% CI: 0.93-1.15, P=0.46), for in-hospital mortality was 0.81 (99% CI: 0.73-0.89, P<0.001), and for microvascular complications was 0.96 (99% CI: 0.88, 1.04, P=0.18). Two separate sensitivity analyses produced results similar to that of the primary analysis for all three complication outcomes.

CONCLUSIONS

We found no evidence that the diagnosis of fibromyalgia increased the risk of in-hospital complications. Fibromyalgia seems to be associated with a reduction in in-hospital mortality, but this requires confirmation with a large prospective controlled study.