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Purpose The purpose of this meta-analysis is to analyse the literature on plate-assisted reduction during intramedullary nailing of tibial shaft fractures and to compare the rates of infection and nonunion. Methods The databases Medline, Embase, and Web of Science were searched from inception to February 2022 for literature comparing plate-assisted reduction during intramedullary nailing of extra-articular tibia fractures to standard, closed means of reduction. Data were extracted and pooled in a random effects meta-analysis for the primary outcomes of nonunion and infection risk. Results Five comparative studies were identified including 520 total patients, of which 151 underwent tibial nailing with the use of plate-assisted reduction with an average follow-up time of 17.9 months. Approximately two-thirds of patients retained the plate used to assist reduction during intramedullary nailing (102 of 151). Pooled analysis of the infection rates found no significant difference with plate-assisted intramedullary nailing (Risk Ratio [RR] 0.90, 95% CI 0.49–1.65, p  = 0.72), and for nonunion rates, there was also no significant difference with plate-assisted intramedullary nailing (Risk Ratio [RR] 0.80, 95% CI 0.40–1.60, p  = 0.53). Conclusions Plate-assisted reduction during intramedullary nailing of tibia shaft fractures was not associated with an increased risk for nonunion or infection, and can be safely applied as an adjunct for reduction in challenging fracture patterns, without the need for later removal. However, evidence is quite limited and further investigation into the use of provisional plating as a technique is needed as its use in intramedullary nailing continues to expand.

Background: The aim of this study was to synthesize accurate time-based estimates of meaningful neurologic decline in patients with degenerative cervical myelopathy (DCM) managed conservatively. Methods: Following the Cochrane Prognosis Methods Guidelines, we conducted a broad systematic search of Medline, Embase and CENTRAL. We included English-language studies reporting time-to-event analysis of neurologic deterioration in adult patients with DCM treated without surgery. Title, abstract and full-text screening was done in duplicate. On the basis of the best available evidence, we utilized a change in Modified Japanese Orthopaedic Association (mJOA) score of 2 to signify meaningful neurologic decline. Results: A total of 9570 studies were identified for title and abstract screening, ultimately yielding 6 studies for inclusion. Our final analysis included 2 level-1 prospective randomized control studies, 1 level-2 prospective cohort study, 2 level-3 retrospective cohort studies and 1 level-4 retrospective case series. Overall, 674 patients underwent conservative treatment for cervical myelopathy (range 35-247 per study) with an average mild-moderate initial modified Japanese Orthopaedic Association (mJOA) score of 14.23 (range 8.5-18) among the 5 studies where this was reported. The average reported age among the 6 included studies was 56.88 (range 28-80), with 50% males. Mean final follow-up was 24.5 months (range 5-208 mo). Our survival curves reveal a slow decline in neurologic function in a population of patients with mild-moderate mJOA scores. They show 86% survival at 1 year, 70% survival at 3 years and a slow decline to 48% survivorship with no meaningful neurologic deterioration at 20 years. Conclusion: To our knowledge, this systematic review and meta-analysis is the first synthesis of data on the natural history of DCM. Given the paucity of high-quality evidence supporting surgical intervention in mild-moderate DCM, with the relatively slow progression shown by our pooled survival estimates, longitudinal follow-up of conservatively managed moderate DCM patients is warranted to better understand the natural history of this pathology. Ultimately, a shared patient-centred approach should incorporate a careful review of possible prognostic factors for deterioration including nonremissible factors, and informed decision-making can be guided by the use of our proposed survivorship curves.

Background: The aim of this study was to synthesize available data on long-term survivorship for commonly performed cervical spine procedures using cutting-edge meta-analytic techniques. Methods: A systematic review of the Ovid Medline, Embase and CENTRAL databases was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Title, abstract and fulltext screening was done in duplicate with kappa scores used to measure agreement. Only articles with cohorts of greater than 20 patients followed for a minimum of 36 months and with available survival data were included. Procedures included were anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (CDA), laminoplasty and posterior laminectomy and fusion. Reconstructed individual patient data were pooled across studies using a Bayesian random-effects metaregression. Results: Our search identified a total of 1456 citations after exclusion of duplicates. After a full-text review of 156 titles, we included 20 studies including 8 randomized controlled trials. The total sample included 43 487 patients undergoing ACDF, 6800 patients undergoing laminoplasty, 2075 patients undergoing CDA and 32 871 patients undergoing posterior laminectomy and fusion. Our meta-regression of synthesized follow-up data with summary curves to 150 months for each of the aforementioned procedures. Posterior laminectomy and fusion was found to have significantly higher rates of secondary reoperation. At 60 months, implant survival was 94% (95% confidence interval 80%-95%) for laminoplasty, 87% (65%-96%) for laminectomy and fusion, 93% (83 %-97%) for CDA and 92% (80%-96 %) for ACDF. At 150 months, implant survival was 90% (68% -93 %) for laminoplasty, 82% (55%-92%) for laminectomy and fusion, 90% (70%-95%) for CDA and 89% (68%-93%) for ACDF. Conclusion: This is the first study to use rigorous statistical techniques to generate statistical models for time to failure of cervical spine procedures analyzing a total of over 85 000 patients. On the basis of long-term survival data from highquality publications, posterior laminectomy and fusion appears to have a significantly higher risk of secondary surgery when compared with ventral approaches or posterior laminoplasty. The granular survival curves produced by this study can be used to inform key decision-makers, counsel patients and aid in future trial design.

Purpose The purpose of this systematic review was to evaluate the rate at which patients return to sport following arthroscopic hip surgery. Methods The databases MEDLINE, EMBASE, and PubMed were searched by two reviewers, and titles, abstracts, and full-text articles screened in duplicate. English language studies investigating hip arthroscopy with reported return to sport outcomes were included. A meta-analysis of proportions was used to combine the rate of return to sports using a random effects model. Results Overall, 38 studies with 1773 patients (72% male), with a mean age of 27.6 years (range 11–65) and mean follow-up of 28.1 months (range 3–144) were included in this review. The pooled rate of return to sport was: 93% [95% confidence interval (CI) = 87–97%] at any level of participation; 82% (95% CI = 74–88%) at preoperative level of sporting activity; 89% (95% CI = 84–93%) for competitive athletes; 95% (95% CI = 89–98%) in pediatric patients; and 94% (95% CI 89.2–98.0%) in professional athletes. There was significant correlation between a shorter duration of preoperative symptoms and a higher rate of return to sports (Pearson correlation coefficient = − 0.711, p  = 0.021). Conclusion Hip arthroscopy yields a high rate of return to sport, in addition to marked improvement in pain and function in the majority of patients. The highest rates of return to sport were noted in pediatric patients, professional athletes, and those with a shorter duration of preoperative symptoms. This study provides clinicians with evidence-based data on athletes’ abilities to return to sport after arthroscopic hip surgery and identifies sub-populations with the highest rates of return to sport. Level of evidence IV, systematic review of Level II–IV studies.

We present the case of a 30-year-old pregnant woman who was found to have an aggressive-appearing osteolytic lesion of the left distal femur in the setting of hypercalcemia. Biopsy confirmed a brown tumor secondary to hyperparathyroidism. She underwent a successful parathyroidectomy followed by a Cesarean section. Postpartum, she sustained pathologic fractures of the ipsilateral femur and pelvis due to a fall, requiring operative fixation. She progressed to uncomplicated healing following surgical management. Although brown tumors can appear aggressive on imaging, they typically resolve following treatment of the underlying hyperparathyroidism. Pathologic fractures should be managed according to standard orthopedic principles. Clinicians should include brown tumors in the differential diagnosis when evaluating osteolytic lesions, particularly in the presence of hypercalcemia.

Study Design Systematic Review Objectives To conduct a meta-analysis on the survivorship of commonly performed cervical spine procedures to develop survival function curves for (i) second surgery at any cervical level, and (ii) adjacent level surgery. Methods A systematic review of was conducted following PRISMA guidelines. Articles with cohorts of greater than 20 patients followed for a minimum of 36 months and with available survival data were included. Procedures included were anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (ADR), laminoplasty (LAMP), and posterior laminectomy and fusion (PDIF). Reconstructed individual patient data were pooled across studies using parametric Bayesian survival meta-regression. Results Of 1829 initial titles, 16 citations were included for analysis. 73 811 patients were included in the second surgery analysis and 2858 patients in the adjacent level surgery analysis. We fit a Log normal accelerated failure time model to the second surgery data and a Gompertz proportional hazards model to the adjacent level surgery data. Relative to ACDF, the risk of second surgery was higher with ADR and PDIF with acceleration factors 1.73 (95% CrI: 1.04, 2.80) and 1.35 (95% CrI: 1.25, 1.46) respectively. Relative to ACDF, the risk of second surgery was lower with LAMP with deceleration factor .06 (95% CrI: .05, .07). ADR decreased the risk of adjacent level surgery with hazard ratio .43 (95% CrI: .33, .55). Conclusions In cases of clinical equipoise between fusion procedures, our analysis suggests superior survivorship with anterior procedures. For all procedures, laminoplasty demonstrated superior survivorship.

Background and Aims Initial reports on US COVID-19 showed different outcomes in different races. In this study we use a diverse large cohort of hospitalized COVID-19 patients to determine predictors of mortality. Methods We analyzed data from hospitalized COVID-19 patients (n = 5852) between March 2020- August 2020 from 8 hospitals across the US. Demographics, comorbidities, symptoms and laboratory data were collected. Results The cohort contained 3,662 (61.7%) African Americans (AA), 286 (5%) American Latinx (LAT), 1,407 (23.9%), European Americans (EA), and 93 (1.5%) American Asians (AS). Survivors and non-survivors mean ages in years were 58 and 68 for AA, 58 and 77 for EA, 44 and 61 for LAT, and 51 and 63 for AS. Mortality rates for AA, LAT, EA and AS were 14.8, 7.3, 16.3 and 2.2%. Mortality increased among patients with the following characteristics: age, male gender, New York region, cardiac disease, COPD, diabetes mellitus, hypertension, history of cancer, immunosuppression, elevated lymphocytes, CRP, ferritin, D-Dimer, creatinine, troponin, and procalcitonin. Use of mechanical ventilation (p = 0.001), shortness of breath (SOB) (p < 0.01), fatigue (p = 0.04), diarrhea (p = 0.02), and increased AST (p < 0.01), significantly correlated with death in multivariate analysis. Male sex and EA and AA race/ethnicity had higher frequency of death. Diarrhea was among the most common GI symptom amongst AAs (6.8%). When adjusting for comorbidities, significant variables among the demographics of study population were age (over 45 years old), male sex, EA, and patients hospitalized in New York. When adjusting for disease severity, significant variables were age over 65 years old, male sex, EA as well as having SOB, elevated CRP and D-dimer. Glucocorticoid usage was associated with an increased risk of COVID-19 death in our cohort. Conclusion Among this large cohort of hospitalized COVID-19 patients enriched for African Americans, our study findings may reflect the extent of systemic organ involvement by SARS-CoV-2 and subsequent progression to multi-system organ failure. High mortality in AA in comparison with LAT is likely related to high frequency of comorbidities and older age among AA. Glucocorticoids should be used carefully considering the poor outcomes associated with it. Special focus in treating patients with elevated liver enzymes and other inflammatory biomarkers such as CRP, troponin, ferritin, procalcitonin, and D-dimer are required to prevent poor outcomes.

Identifying the drivers of population declines in migratory species requires an understanding of how individuals are distributed between periods of the annual cycle. We built post- (fall) and pre-breeding (spring) migratory networks for the blackpoll warbler ( Setophaga striata ), a Neotropical-Nearctic songbird, using tracking data from 47 light-level geolocators deployed at 11 sites across its breeding range. During pre-breeding migration, two stopover nodes (regions) on the U.S. eastern seaboard received high scores in our network metrics (betweenness centrality and time-adjusted node weight), likely acting as key refuelling areas for most of the global blackpoll warbler population before their multi-day flights over the Atlantic Ocean. During post-breeding migration, highly ranked stopover nodes in the southeastern U.S. acted as a geographical bottleneck before birds dispersed to their boreal breeding destinations. Nodes located in northern Colombia and Venezuela were also ranked highly during both migrations and were likely used to prepare for (pre-breeding) and recover from (post-breeding) Atlantic flights. Blackpoll warblers showed a crosswise migration pattern, whereby individuals from western breeding populations tended to spend the nonbreeding season in the eastern part of the nonbreeding range and vice-versa. Despite this, the strength of migratory connectivity between the breeding and nonbreeding grounds ranged from moderate to low, largely because many individuals used more than one node during the ‘stationary’ nonbreeding period. Our results suggest that the number of breeding populations affected by a threat in the blackpoll warbler’s range will strongly depend on where and when this threat occurs. Consequently, our migratory network should be key to inform future conservation planning and population monitoring efforts.