Hip fractures exceed 250,000 cases annually in the United States, with the worldwide incidence projected to increase by 240-310% by 2050. Hip fractures are predominantly diagnosed by radiologist ...review of radiographs. In this study, we developed a deep learning model by extending the VarifocalNet Feature Pyramid Network (FPN) for detection and localization of proximal femur fractures from plain radiography with clinically relevant metrics. We used a dataset of 823 hip radiographs of 150 subjects with proximal femur fractures and 362 controls to develop and evaluate the deep learning model. Our model attained 0.94 specificity and 0.95 sensitivity in fracture detection over the diverse imaging dataset. We compared the performance of our model against five benchmark FPN models, demonstrating 6-14% sensitivity and 1-9% accuracy improvement. In addition, we demonstrated that our model outperforms a state-of-the-art transformer model based on DINO network by 17% sensitivity and 5% accuracy, while taking half the time on average to process a radiograph. The developed model can aid radiologists and support on-premise integration with hospital cloud services to enable automatic, opportunistic screening for hip fractures.
The trabecular network is perceived as a collection of interconnected plate- (P) and rod-like (R) elements. Previous research has highlighted how these elements and their connectivity influence the ...mechanical properties of bone, yet further work is required to elucidate better the deeply interconnected nature of the trabecular network with distinct element formations conducting forces per their mechanical boundary conditions. Within this network, forces act through elements: a rod or plate with force applied to one end will transmit this force to a component connected to the other end, defining the boundary conditions for the loading of each element. To that end, this study has two aims: First, to investigate the connectivity of individually segmented elements of trabecular bone with respect to their local boundary conditions as defined by the surrounding trabecular network and linking them directly to the bone's overall mechanical response during loading using a mathematical graph model of the plate and rod (PR) Network. Second, we use this model to quantify side artifacts, a known artifact when testing an excised specimen of trabecular bone, where vertical trabeculae lose their load-bearing capacity due to a loss of connectivity, ultimately resulting in a change of the trabecular network topology.
Connected elements derived from our model predicted apparent elastic modulus by fitting a linear regression (
). In comparison, prediction using conventional bone volume fraction results in a lower accuracy (
), demonstrating the ability of the PR Network to estimate compressive elastic modulus independent of specimen size or loading boundary condition.
PR Network models are a novel approach to describing connectivity within the trabecular network and incorporating mechanical boundary conditions within the morphological analysis, thus enabling the study of intrinsic material properties of trabecular bone. Ultimately, PR Network models may be an early predictor or provide further insights into osteo-degenerative diseases.
Arthrofibrosis, or rigid contracture of major articular joints, is a significant morbidity of many neurodegenerative disorders. The pathogenesis depends on the mechanism and severity of the ...precipitating neuromuscular disorder. Most neuromuscular disorders, whether spastic or hypotonic, culminate in decreased joint range of motion. Limited range of motion precipitates a cascade of pathophysiological changes in the muscle-tendon unit, the joint capsule, and the articular cartilage. Resulting joint contractures limit functional mobility, posing both physical and psychosocial burdens to patients, economic burdens on the healthcare system, and lost productivity to society. This article reviews the pathophysiology of arthrofibrosis in the setting of neuromuscular disorders. We describe current non-surgical and surgical interventions for treating arthrofibrosis of commonly affected joints. In addition, we preview several promising modalities under development to ameliorate arthrofibrosis non-surgically and discuss limitations in the field of arthrofibrosis secondary to neuromuscular disorders.
Substance administration to laboratory animals necessitates careful consideration and planning in order to enhance agent distribution while reducing any harmful effects from the technique. There are ...numerous methods for administering cannabinoids; however, several parameters must be considered, including delivery frequency, volume of administration, vehicle, and the level of competence required for staff to use these routes properly. There is a scarcity of information about the appropriate delivery method for cannabinoids in animal research, particularly those that need the least amount of animal manipulation during the course of the investigation. This study aims to assess the feasibility and potential side effects of intraperitoneal and subcutaneous injection of CBD and THC using propylene glycol or Kolliphor in animal models. By evaluating the ease of use and histopathological side effects of these solvents, this study intends to help researchers better understand an accessible long-term delivery route of administration in animal experiments while minimizing the potential confounding effects of the delivery method on the animal.
Intraperitoneal and subcutaneous methods of systemic cannabis administration were tested in rat models. Subcutaneous delivery via needle injection and continuous osmotic pump release were evaluated using propylene glycol or Kolliphor solvents. In addition, the use of a needle injection and a propylene glycol solvent for intraperitoneal (IP) administration was investigated. Skin histopathological changes were evaluated following a trial of subcutaneous injections of cannabinoids utilizing propylene glycol solvent.
Although IP delivery of cannabinoids with propylene glycol as solvent is a viable method and is preferable to oral treatment in order to reduce gastrointestinal tract degradation, it has substantial feasibility limitations. We conclude that subcutaneous delivery utilizing osmotic pumps with Kolliphor as a solvent provides viable and consistent route of administration for long-term systemic cannabinoid delivery in the preclinical context.
Hip fractures inflict heightened morbidity and mortality upon older adults. Although previous studies have explored the impact of individual demographic factors on hip fracture risk, a comprehensive ...review can help reconcile disparities among these factors. This meta-analysis encompassed 69 studies involving 976,677 participants and 99,298 cases of hip fractures. We found that age ≥ 85 (OR = 1.75), BMI < 18.5 (OR 1.72), female sex (OR = 1.23), history of falls (OR = 1.88), previous fractures (OR = 3.16), menopause (OR 7.21), history of maternal hip fractures (OR = 1.61), single and unmarried status (OR = 1.70), divorced status (OR 1.38), residing in a residential care facility (OR = 5.30), and living alone (OR = 1.47) were significantly associated with an increased incidence of hip fracture. Conversely, BMI ranging from 25 to 30 (OR = 0.59), BMI > 30 (OR = 0.38), parity (OR = 0.79), non-Caucasian descent (overall OR = 0.4, Asian OR 0.36, Black OR = 0.39, and Hispanic OR = 0.45), and rural residence (OR = 0.95) were significantly associated with a diminished risk of hip fracture. Hip fracture patients exhibited significantly lower weight and BMI than the non-fracture group, while their age was significantly higher. However, age at menopause and height did not significantly differ between the two groups.
Tendinopathy is a degenerative condition resulting from tendons experiencing abnormal levels of multi-scale damage over time, impairing their ability to repair. However, the damage markers associated ...with the initiation of tendinopathy are poorly understood, as the disease is largely characterized by end-stage clinical phenotypes. Thus, this study aimed to evaluate the acute tendon responses to successive fatigue bouts of tendon overload using an in vivo passive ankle dorsiflexion system.
Sprague Dawley female rats underwent fatigue overloading to their Achilles tendons for 1, 2, or 3 loading bouts, with two days of rest in between each bout. Mechanical, structural, and biological assays were performed on tendon samples to evaluate the innate acute healing response to overload injuries.
Here, we show that fatigue overloading significantly reduces
functional and mechanical properties, with reductions in hysteresis, peak stress, and loading and unloading moduli. Multi-scale structural damage on cellular, fibril, and fiber levels demonstrated accumulated micro-damage that may have induced a reparative response to successive loading bouts. The acute healing response resulted in alterations in matrix turnover and early inflammatory upregulations associated with matrix remodeling and acute responses to injuries.
This work demonstrates accumulated damage and acute changes to the tendon healing response caused by successive bouts of
fatigue overloads. These results provide the avenue for future investigations of long-term evaluations of tendon overload in the context of tendinopathy.
To determine the overall incidence of venous thromboembolism (VTE) following shoulder arthroscopy and to define potential risk factors associated with its development that may help define guidelines ...for the use of thromboprophylaxis.
A systematic review was performed using PubMed, Embase, Web of Science, CINAHL, and Cochrane databases per PRISMA guidelines. The search terms consisted of variations of "Venous Thromboembolism" and "Shoulder Arthroscopy." Information regarding arthroscopy indication, risk factors, outcomes, and patient demographics was recorded and analyzed, and pooled odds ratios were reported for each variable.
Six hundred eighty-five articles were identified in the initial search, and 35 articles reported DVT, PE, or VTE incidence following shoulder arthroscopy. Seventeen nonoverlapping articles with a unique patient population incidence rates. Four articles were then used for subgroup meta-analysis. The incidence rate of VTE was 0.24%, ranging from 0.01% to 5.7%. BMI >30 (OR = 1.46; 95% CI = 1.22, 1.74; I2 = 0%) and hypertension (OR = 1.64; 95% CI = 1.03, 2.6; I2 = 75%) were significant risk factors (P < .05) for developing VTE following shoulder arthroscopy. Diabetes (OR = 1.2; 95% CI = 0.97, 1.48; I2 = 0%), insulin-dependent diabetes (OR = 5.58; 95% CI = 0.12, 260.19; I2 = 85%), smoking (OR = 1.04; 95% CI = 0.79, 1.37; I2 = 12%), male sex (OR = 0.95; 95% CI = 0.49, 1.85; I2 = 86%) and age over 65 (OR = 4.3; 95% CI = 0.25, 72.83; I2 = 85%) were not associated with higher VTE risk.
The VTE incidence following shoulder arthroscopy is low at 0.24%. Patients with BMI >30 and hypertension are at a higher risk for VTE after shoulder arthroscopy.
Level IV, systematic review and meta-analysis of Level I-IV studies.
With over 40,000 annual spine trauma admissions, the United States has one of the highest spine trauma incidences in the world. These patients are likely to experience long-term immobilization, and ...in addition to other risk factors, are at heightened risk of developing venous thromboembolic events. Many different classes of chemical anticoagulants are currently in use to prevent thromboembolic events, and while some guidelines and recommendations exist, these are mostly tailored towards elective spine procedures which are significantly different from acute traumatic spine injuries. Additionally, newer classes of chemical anticoagulants, the direct oral anticoagulants have recently emerged and have been suggested to have better efficacy than other existing classes of anticoagulants.
We conducted this meta-analysis to put together the available evidence regarding chemical anticoagulation in spine trauma patients. To the best of our knowledge, ours is one of the first meta-analyses to include both operative and nonoperative and both with and without accompanying spinal cord injury; and also include evidence about direct oral anticoagulants.
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Venous thromboembolic events, Deep Venous thrombosis, Pulmonary Embolism, Mortality, Major Bleeding.
We carried out a systematic search of Medline, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials from the inception of the journals/databases to March, 2023. Controlled vocabulary terms were identified as well as key terms and synonyms; and search results were limited to only English language papers. We developed a search for human studies examining efficacy of chemical anticoagulants for acute spinal trauma in adults. Terms included were spinal injuries, fractures, trauma, heparin, etc. We identified articles from our literature search that did a comparison between different chemical anticoagulant classes or between no anticoagulant use and any chemical anticoagulant in patients who had acute spine trauma as methods to prevent thromboembolic complications following operative and nonoperative acute spinal trauma with or without spinal cord injury. Three reviewers performed abstract screenings, full text review and data extraction; and all conflicts were resolved by consensus. Outcomes of interest were defined as deep venous thrombosis (DVT), pulmonary embolism (PE), major bleeding, and mortality.
Seven studies, comprising a total of 763 patients made a comparison of no chemical anticoagulant with any chemical anticoagulant. The included studies reported DVT as the sole outcome measure and results reveal a protective effect of chemical anticoagulant use compared to no anticoagulant use (odds ratio 0.40 (0.23 – 0.70)), p-value 0.0013. For a comparison of unfractionated heparin and low molecular weight heparin, 4 studies comprising 27,835 patients, reported VTE as an outcome. Five studies comprising 27,816 patients reported DVT and PE as outcomes while three studies reported major bleeding as an outcome. Results indicate that LMWH may be protective compared to UH for VTE, DVT and PE with odds ratios 0.77 (0.66 – 0.89) p-value 0.0005, 0.78 (0.66 – 0.93) p-value 0.0050 and 0.66 (0.51 – 0.85) p-value 0.0013 respectively. While there are lower odds of major bleeding for LMWH compared with UH (odds ratio 0.52 (0.22 – 1.24) p-value 0.1397), this association is not statistically significant. There were two studies that compared administration of DOACs compared with LMWH, with a total of about 1866 patients in the studies. There was an odds ratio of 0.31 (0.17 – 0.56), p-value 0.0001 for DVT outcome, indicating that DOACs may be more effective in preventing DVTs than LMWH. For other outcomes (PE, Major bleeding and mortality), the associations were nonsignificant.
The current available evidence suggests that spine trauma patients, both operative and nonoperative would benefit from chemical anticoagulant administration following trauma. Low molecular weight heparins have better efficacy compared to unfractionated heparin with no significant differences in their risk profiles. Lastly, emerging evidence indicates that direct oral anticoagulants may ultimately lower the odds of DVTs among this subset of patients compared to low molecular weight heparins without a significant increase in risk.
This abstract does not discuss or include any applicable devices or drugs.
The incidence of venous thromboembolic (VTE) events is significant among spine trauma patients, with those requiring surgical intervention at elevated risk. Chemical anticoagulation with ...unfractionated heparin, low molecular weight heparin and recently, direct oral anticoagulants have been used in acute settings to prevent the occurrence of VTE, however, this presents a therapeutic challenge to spine surgeons as bleeding complications in this subset of patients can have devastating consequences, highlighting the need to establish a balance. While clear guidelines exist for anticoagulation in elective spine surgery, recommendations regarding optimal timing of anticoagulation use in spine trauma is relatively scarce. A few individual studies exist, but results are mixed.
We conducted this meta-analysis to answer existing questions about optimal timing of anticoagulant administration, and provide recommendations for the spine surgeon.
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Deep Venous Thrombosis, Pulmonary Embolism, Major Bleeding, Mortality
We carried out a systematic search of Medline, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials from the inception of the journals/databases to February, 2023. Controlled vocabulary terms were identified as well as key terms and synonyms; and search results were limited to only English language papers. We developed a search for human studies examining optimal timing for acute spinal trauma in adults. Terms included were spinal injuries, fractures, trauma, heparin etc. We identified articles from our literature search that did a comparison between different timings of anticoagulant initiation in patients who had acute spine trauma as methods to prevent thromboembolic complications following operative and nonoperative acute spinal trauma with or without spinal cord injury. Three reviewers performed abstract screenings, full text review and data extraction; and all conflicts were resolved by consensus. Outcomes of interest were defined as deep venous thrombosis (DVT), pulmonary embolism (PE), major bleeding and mortality.
Five studies, making up a total of 13,110 patients, did a comparison between anticoagulant administration within 48hours of trauma and after 48hours; and reported DVT and PE as outcomes. The results show a significantly-lower odds of having a DVT or PE with early (within 48 hours) administration of chemical anticoagulants (odds ratios 0.20 (0.17 – 0.25) p-value 0.0001 and 0.46 (0.34 – 0.62) p-value 0.0001 respectively). Four studies had major bleeding as an outcome and reported slightly lower odds with early initiation but this association was not significant (0.85 (0.66 – 1.09) p-value 0.1964). Similarly, four studies reported mortality as an outcome measure with nonsignificant results.
The current available evidence suggests that early initiation of chemical anticoagulation within 48hours of injury in spine trauma patients boasts favorable outcomes with regards to prevention of thromboembolic complications, without putting these patients at risk of bleeding or mortality.
This abstract does not discuss or include any applicable devices or drugs.
The rising opioid epidemic is a public health crisis at the crossroads of orthopedic care and pain management. Medical marijuana is a potential non-opioid analgesic yet to be studied in the surgical ...setting and its effects on fracture repair are not fully understood. In addition to the analgesic effects of cannabinoids, studies have demonstrated potentially osteo-inductive properties, albeit controversial at the molecular level. Osteoblasts, osteoclasts and bone peripheral nerve terminals have been shown to have endocannabinoid receptors (CB1, CB2), comparably expressed to that of brain tissue.
This study aims to understand the molecular tissue and cell response to the administration of tetrahydrocannabinol (THC) and cannabidiol (CBD) compounds in a spinal fusion model.
Basic science animal model.
Quantitative PCR (qPCR) analysis.
Animal procedures were approved by the Institutional Animal Care and Use Committee (IACUC). 40 adult Sprague-Dawley rats were used for this study. Posterolateral lumbar spinal fusion was performed at the L4-L5 level utilizing allogenic bone graft. Four rats were used as donors for allografts, while 36 rats were divided among the 4 treatment groups. Treatment groups consisted of Saline control, 5mg/kg THC, 5mg/kg CBD, and 10mg/kg CBD+THC. Treatment was delivered through weekly 0.1 ml intraperitoneal injections. Newly formed bone and callus tissue were harvested 2- and 8-weeks postsurgery for assessment. qPCR analysis was performed to quantify changes in expression of osteogenic and cannabis receptor genes. Shapiro-Wilk normality test was performed. Based on the normality, One-way ANOVA or Kruskal-Wallis test followed by Tukey's or Dunn's multiple comparisons tests were performed using GraphPad Prism. Two-tailed values of p<0.05 were considered statistically significant.
qPCR data at 2 weeks indicated downregulated RANKL/OPG ratios skewing towards osteogenesis in the CBD and CBD+THC groups, when compared to Saline, with the THC group demonstrating a downward trend, though not reaching significance. ALPL, BMP4, SOST, CTNNB1 were all significantly higher in the CBD group compared to Saline, with CTNNB1 also showing an upregulating trend in the THC and CBD+THC groups. Data at 8 weeks shows no change in expression of CTNNB1, MMP13, Col1A1. Cannabis receptor CB1 was unchanged, while CB2 and GPR55 were upregulated for all treatment groups. TRPV1 receptor was downregulated for CBD and CBD+THC groups. Osteoblast activity markers ALPL and RUNX2 at 8 weeks were downregulated for all treatment groups, while SOST was downregulated for CBD and THC compared to Saline. In the CBD+THC group RANK, RANKL and OPG are downregulated compared to Saline. OPG was generally downregulated, but only significant for the CBD+THC group. Interestingly, RANKL/OPG ratio showed upregulation in the CBD and CBD+THC groups. RANKL showed upregulation in the CBD and THC groups.
Osteogenesis factors were upregulated (ALPL, BMP4, B-catenin pathway) in the cannabinoid treated groups at 2 weeks, which indicates potential bone regeneration enhancement. The RANKL/OPG ratio as an indicator for the metabolic state of bone showed downregulation at 2 weeks and upregulation at 8 weeks. Coincidentally, in the physiological setting, the ratio is lower in the early phases and increases at the later remodeling phases of healing and, thus, cannabinoids show enhanced effects. Overall, cannabinoids did not indicate any negative side effects on bone healing. On the contrary, there is the potential to enhance physiologic healing.
This abstract does not discuss or include any applicable devices or drugs.
