Cross-sectional analysis. Ossification of the ligamentum flavum (OLF) is a pathological condition characterized by ectopic endochondral ossification and hypertrophy of the ligamentum flavum. It can lead to spinal canal stenosis and severe neurological deficits, with a high rate of clinical misdiagnosis, underscoring the need for improved early detection and intervention. This study aimed to explore the potential associations between serum calcium levels, both albumin-adjusted and unadjusted, as well as serum phosphate levels, and the presence of thoracolumbar OLF. This cross-sectional study included patients with radiologically confirmed lumbar intervertebral disc degeneration who were treated at the First Affiliated Hospital of Zhengzhou University between January 2021 and December 2024. Eligible participants were categorized into two groups based on the presence or absence of thoracolumbar ossification of the ligamentum flavum (OLF). Demographic characteristics and laboratory parameters were collected. Statistical analyses included univariate and multivariate logistic regression, restricted cubic spline (RCS) modeling, and stratified analyses to evaluate potential interactions and nonlinear associations. A total of 963 patients were initially screened for eligibility. After excluding those with incomplete clinical, imaging, or laboratory data, 691 patients were included in the final analysis, comprising 131 patients with radiologically confirmed OLF and 560 without OLF. Patients in the OLF group were older (median age: 56.0 vs. 48.0 years, p < 0.001), had a higher body mass index (BMI; 26.0 vs. 24.8, p = 0.001), and exhibited a significantly higher prevalence of hypertension (OR = 2.03, p = 0.001) and diabetes mellitus (OR = 1.84, p = 0.026). Serum calcium levels were inversely associated with OLF both before (OR = 0.50, p = 0.002) and after albumin correction (OR = 0.59, p = 0.015). Although serum phosphate levels also showed a negative association (OR = 0.61, p = 0.002), this significance was attenuated after multivariable adjustment (p = 0.064). RCS analysis revealed a nonlinear inverse relationship between albumin-corrected calcium and OLF risk (p for nonlinearity < 0.022). Stratified analyses further indicated that sex and diabetes status significantly modified the association between calcium levels and OLF (p for interaction < 0.05). Serum calcium levels, particularly when corrected for albumin, are independently and inversely associated with the risk of thoracolumbar OLF, suggesting that calcium metabolism dysregulation may play a critical role in its pathogenesis. The role of phosphate appears to be modulated by other confounding factors, warranting further investigation.
Finite element analysis (FEA) can translate tissue-level mechanical information into fabrication-ready designs. However, its use for spatially graded hydrogel meniscus constructs remains limited, and simulation-derived differences require cautious interpretation when the fabricated material does not reproduce the modeled tissue properties. One porcine knee was reconstructed from computed tomography and magnetic resonance imaging to build a whole-knee meniscus model. The paired medial and lateral menisci from the same knee were divided into 12 regions, and three technical compressive measurements per region were used to assign regional moduli to matched finite element zones. Homogeneous and heterogeneous meniscus models were compared under identical geometry, boundary conditions, and a 1000 N axial load at 0° flexion. The specimen-specific modulus ranking (1.83–118.57 MPa) was simplified into low-, intermediate-, and high-modulus zones and fabricated using 10
To evaluate the quality, readability, error patterns, and expert-rated response safety of large language model–generated information for patients with osteoporotic vertebral compression fractures (OVCFs), and to explore differences between a selected model and a spine surgeon in a simulated written consultation setting. This two-phase sequential benchmarking study evaluated ChatGPT-5.1, Gemini 2.5 Pro, DeepSeek-V3.2, and Qwen3-Max. In Phase 1, the four models answered 26 expert-developed OVCF questions. Three senior spine surgeons independently rated accuracy, comprehensiveness, and expert-rated response safety using predefined 5-point criteria. Response length, readability, aggregate model-ranking concordance, and predefined error categories were also assessed. In Phase 2, ChatGPT-5.1 and one spine surgeon independently answered 17 de-identified patient-derived questions using the same standardized instruction. Accuracy, comprehensiveness, and expert-rated response safety were evaluated by two senior spine surgeons through consensus, whereas empathy and usability were rated by one researcher. Friedman and paired Wilcoxon signed-rank tests were used, with Benjamini–Hochberg correction for multiple comparisons. In Phase 1, the four models differed in accuracy (Friedman χ2(3) = 12.64, P = 0.00548, Kendall’s W = 0.162), comprehensiveness (χ2(3) = 38.68, P = 2.03 × 10−8, W = 0.496), and expert-rated response safety (χ2(3) = 19.86, P = 0.000182, W = 0.255). After multiplicity correction, ChatGPT-5.1 and DeepSeek-V3.2 generally received higher ratings than Gemini 2.5 Pro, although several comparisons with Qwen3-Max were not statistically significant. Omission errors occurred across all four models. In Phase 2, no statistically significant difference was detected between ChatGPT-5.1 and the physician comparator in accuracy (paired mean difference, 0.24; 95
Ossification of the ligamentum flavum (OLF) is a degenerative spinal disorder characterized by aberrant endochondral ossification and is a major cause of thoracic spinal stenosis. Current treatment still relies mainly on surgical decompression, which relieves mechanical compression but does not halt the biological processes underlying ossification. Although growing evidence implicates metabolic reprogramming in ectopic ossification and osteochondral differentiation, the key metabolites driving OLF and their proximal upstream regulators remain unclear. Spatial metabolomics was performed on clinical thoracic ligamentum flavum specimens to identify lesion-associated metabolic alterations. Untargeted metabolomics and proteomics were then integrated with bioinformatic and machine-learning analyses to screen for key metabolites and upstream effectors. Public single-cell transcriptomic data were further incorporated to define the cell-state specificity of candidate molecules. Finally, human OLF tissues and an in vitro OLF model were used for functional validation through loss-of-function and rescue experiments, together with molecular assays. Spatial metabolomics clearly separated ossified, non-ossified, and control regions, and identified L-lactate as a core hub metabolite selectively enriched in ossified foci. Lactate-associated proteins and metabolites were enriched in translation, mRNA splicing, secretion, extracellular matrix remodeling, amino acid metabolism, glucose homeostasis, and lipid biosynthesis, indicating a metabolic state characterized by enhanced aerobic glycolysis, active anabolic-secretory programs, and accelerated tissue remodeling. Machine-learning analyses consistently identified HK3 as the glycolytic enzyme most strongly associated with tissue lactate abundance and significantly upregulated in OLF tissue. Single-cell analysis further showed that HK3 was mainly enriched in chondrocyte-like ligamentum flavum cells and closely linked to glycolytic activation and chondrogenic transition. Cross-omics integration highlighted HIF-1 signaling as a convergent upstream pathway activated in ossified lesions. Functionally, HK3 knockdown reduced lactate production and attenuated ossification marker expression, whereas exogenous lactate partially rescued these effects. In addition, HIF-1α inhibition reduced HK3 expression, whereas lactate supplementation partially restored HIF1A expression following HK3 silencing, suggesting a potential reciprocal relationship between HIF-1 signaling and HK3-dependent lactate production. Local lactate accumulation is a key metabolic feature of OLF. The HK3-lactate axis may contribute to OLF progression and may represent a potential metabolic target for future non-surgical strategies.
Surgical treatment of Sprengel deformity aims to improve shoulder symmetry and active shoulder motion while avoiding neurovascular injury. Whether clavicular osteotomy should be added to the modified Woodward procedure remains controversial, particularly because intraoperative neurophysiological monitoring (IONM) may independently influence neurological safety. This study compared clinical, radiographic, and safety outcomes after the modified Woodward procedure performed without adjuncts versus with a combined protocol of prophylactic clavicular osteotomy and IONM. We retrospectively reviewed 26 consecutive children with moderate-to-severe Sprengel deformity treated between January 2015 and July 2023. Group A included 16 patients who underwent the modified Woodward procedure without clavicular osteotomy or IONM. Group B included 10 patients who underwent prophylactic clavicular osteotomy and IONM before scapular descent. Outcomes included Cavendish cosmetic grade, Rigault radiographic grade, active shoulder abduction, perioperative variables, and complications over a minimum follow-up of 2 years. Ordinal outcomes were analyzed with Wilcoxon signed-rank and Mann–Whitney U tests. One transient postoperative brachial plexus palsy occurred in Group A (1/16, 6.3
This study designed a novel suspended patient-specific instrument (SPSI), described its design rationale and the surgical workflow of femur-first osteotomy based on this instrument, and explored its feasibility and early clinical outcomes in fixed-bearing unicompartmental knee arthroplasty (UKA). Ten patients with anteromedial osteoarthritis of the knee were included, all of whom underwent UKA with SPSI-assisted femur-first osteotomy. Operative time, blood loss, and postoperative complications were recorded. The resting pain VAS score and the objective knee component of the 2011 revised KSS were compared preoperatively and at 3 months postoperatively, and prosthetic positioning parameters were assessed via X-ray. All surgeries were completed successfully without abandonment of the SPSI or severe complications. The median operative time was 75.00 (70.00, 96.75) minutes, and the median blood loss was 50.00 (50.00, 62.50) ml. At 3 months postoperatively, the VAS score decreased significantly from 5.50 (5.00, 6.25) preoperatively to 0.50 (0.00, 1.00) (p = 0.005), while the KSS score improved significantly from 44.40 ± 4.67 preoperatively to 80.90 ± 5.45 (p < 0.001). Satisfactory prosthetic positioning parameters were achieved, with a femoral coronal angle of 89.70 ± 6.78°, a tibial coronal angle of 86.80 ± 2.20°, a femoral sagittal angle of 8.40 ± 1.89°, and a tibial sagittal angle of 82.00 ± 2.49°. The SPSI enables accurate localization of femoral prosthesis peg holes, and the femur-first osteotomy workflow optimizes the surgical field and simplifies intraoperative steps. Current preliminary data indicate this novel workflow may serve as a feasible alternative for fixed-bearing UKA, though comparative analysis and long-term survivorship data remain absent.
Manipulation under anesthesia can rapidly improve pain and motion in refractory frozen shoulder but usually requires operating-room and anesthesiology resources. This trial compared an ultrasound-guided wide-awake local anesthesia no tourniquet (WALANT)-based outpatient protocol with manipulation under general anesthesia. This single-center, prospective randomized controlled trial enrolled 72 adults with primary frozen shoulder persisting despite at least 6 months of conservative treatment. Participants were randomized 1:1 to ultrasound-guided WALANT-based manipulation in an outpatient setting or manipulation under general anesthesia in the operating room. The primary outcome was shoulder forward flexion at 4 weeks. Secondary outcomes included other range-of-motion measures, the visual analog scale (VAS), University of California Los Angeles (UCLA) Shoulder, Disabilities of the Arm, Shoulder and Hand (DASH), Constant–Murley, and six-item State-Trait Anxiety Inventory (STAI-6) scores, and early complications. Six participants in the general-anesthesia group did not complete follow-up; complete-case analyses included 36 WALANT and 30 general-anesthesia participants. At the prespecified 4 week primary endpoint, forward flexion was 170.56° ± 15.01° in the WALANT group and 159.60° ± 31.37° in the general-anesthesia group (between-group mean difference, 10.96°; 95
Glenohumeral corticosteroid injection has been a major treatment for adhesive capsulitis of the shoulder. Hydrodilatation is also a treatment option. However, few studies have considered the combined treatment of the two methods with heterogeneous protocols and results. The purpose of this study is to investigate the additional effect of hydrodilatation for glenohumeral corticosteroid injection in adhesive capsulitis of the shoulder involving a streamlined process. Sixty-two patients were randomized in this randomized controlled trial. Of these, 50 patients were included in the final per-protocol analysis: 24 in group CS and 26 in group CSHD. Group CS received a single ultrasound-guided glenohumeral injection with 1 mL (40 mg) triamcinolone and 4 mL lidocaine. Group CSHD received the same injection with an additional 15 mL of saline. Capsular distension without intended rupture was assessed using ultrasound, and the capsule-humeral head distance was measured. Pain visual analog scale, patient satisfaction, range of motion (ROM) in forward elevation and internal/external rotation, American Shoulder and Elbow Surgeons (ASES) score, and Constant score were assessed before injection and at 3 weeks, 7 weeks, 3 months, and 6 months after injection. The baseline data were similar between the groups. After injection, the CSHD group demonstrated a significantly greater capsule-humeral head distance on ultrasound (p < 0.001). Significant improvement was demonstrated within each group after 6 months (p < 0.001 in all parameters). However, compared to group CS, group CSHD showed a greater increase in the ASES score as early as week 3 (p < 0.001) and in ROM as early as week 7 (p < 0.050 in all directions). At the last follow-up at 6 months, group CSHD showed significantly better results in ROM (p < 0.005 in all directions), patient satisfaction (p = 0.004), ASES (p = 0.040), and Constant scores (p = 0.011) than group CS. In treating adhesive capsulitis, adding saline to a conventional corticosteroid injection to perform a single-shot, capsule-preserving hydrodilatation with a 20 mL solution may improve short- to mid-term functional recovery compared to an isolated corticosteroid injection. ClinicalTrials.gov identifier NCT06493656 (Retrospectively registered July 7, 2024).
Magnetic resonance imaging (MRI) reports for orthopedic conditions are filled with highly specialized terminology, leading to information asymmetry between clinicians and patients. Deficiencies persist in routine patient education regarding orthopedic imaging results, and a well-documented mismatch exists between physicians’ professional explanations and patients’ actual understanding of medical information. This study aimed to explore the feasibility of utilizing large language models (LLMs) to translate specialized orthopedic MRI reports into plain-language educational summaries, and to evaluate their impact on patients’ perceived comprehension and communication motivation. A prospective two-stage study design was adopted. In Stage I, two senior orthopedic surgeons evaluated 24 reports generated by six LLMs, assessing content accuracy via the Mika scale, reliability using the DISCERN tool, and objective readability. In Stage II, a total of 60 patients were randomly divided into three groups: conventional control group, Baichuan M3 group and Gemini 3.1 Pro group. We further compared changes in patients’ subjective comprehension and behavioral motivation after receiving AI-assisted interpretation. Stage I results showed that Baichuan M3 and Gemini 3.1 Pro delivered the best overall performance. Their accuracy (median Mika score = 1.0) and reliability were significantly superior to other models (P < 0.001). Stage II demonstrated that baseline characteristics were comparable across the three groups (P > 0.05). Following the AI intervention, both the Baichuan M3 and Gemini 3.1 Pro groups exhibited significant within-subject improvements compared to their respective baselines (all P < 0.001). No statistically significant difference was observed in the overall utility between the two AI models (P > 0.05). Among all assessed domains, the dimension of action guidance and motivation demonstrated the most pronounced enhancement, with mean scores increasing by 2.5–2.8 points. LLMs show promise as auxiliary communication aids for patient-oriented orthopedic education. AI-assisted plain-language transformation is associated with higher patient-rated clarity and strengthened subjective motivation to engage in clinical dialogue. Given that imaging reports alone cannot replace comprehensive clinical reasoning, such tools should be deployed under strict safety guardrails to assist—not replace—physician-patient communication. This study adopts a prospective two-stage design to establish a standardized evaluation framework for LLM-assisted orthopedic MRI report rewording, providing a reliable evidence-based pathway for auxiliary patient education in orthopedic settings. Traditional automated Chinese readability tools show evident limitations in assessing medical texts, verifying that high-quality clinical patient education relies on complete semantic logic and empathetic narration, rather than superficial vocabulary simplification. Real-patient randomized controlled exploratory evaluation reveals that AI-assisted interpretation of professional MRI reports helps narrow doctor-patient communication gaps and yields favorable outcomes in patient-rated clarity and subjective consultation experience. Optimized LLM medical interpretation prominently boosts patients’ action guidance awareness and health motivation, laying a solid psychological foundation for constructive physician-patient dialogue. When deployed under strict safety guardrails as educational supplements, standardized LLMs exhibit stable patient empowerment effects in localized Chinese orthopedic outpatient settings, supporting their safe integration into clinical communication.
To evaluate the clinical and radiographic outcomes of anterior intervertebral osteotomy and fusion (AIOF), guided by the inflection point of the uncinate process (IPUP), for the treatment of multilevel cervical spondylotic myelopathy (MCSM), and to compare these outcomes with those of laminoplasty. We retrospectively reviewed 118 patients with MCSM who underwent surgery between January 2017 and December 2022 and had a minimum follow-up of 24 months. Of these, 57 patients underwent AIOF and 61 underwent laminoplasty. Perioperative outcomes, radiographic parameters, clinical outcomes, and complications were compared between the two groups. Repeated-measures outcomes were analyzed using linear mixed-effects models with adjustment for the corresponding baseline values and prespecified clinical covariates. Intraoperative blood loss was significantly lower in the AIOF group than in the laminoplasty group (P < 0.05). After adjustment, at the final follow-up, the AIOF group had a greater C2–C7 Cobb angle (adjusted mean difference, 9.12°; 95
The poor correlation between structural damage and pain severity in osteoarthritis remains a major clinical paradox, suggesting that purely structural or inflammatory explanations are insufficient. In this review, we propose the Pain Convergence Model, a hypothesis-generating framework in which biomechanical stress, cellular senescence, and metabolic inflammation converge at the neuro-immune interface to amplify pain signals. This model supports three therapeutic strategies: targeting systemic pathological drivers, modulating the neuro-immune interface, and addressing central sensitization. Translating this framework into clinical practice will require validated biomarkers for patient stratification and mechanism-oriented trial designs, although the model currently awaits experimental validation.
Osteoarthritis (OA) has traditionally been regarded as a mechanically driven degenerative joint disorder. However, recent advances in single-cell sequencing, spatial omics, and immunohistochemical analyses have revealed that OA is also characterized by persistent low-grade inflammation and complex immune dysregulation involving multiple joint-resident and infiltrating cell populations. Among these, T cells, synovial macrophages, and mesenchymal stromal cells (MSCs) form a dynamic regulatory network. Within the T-cell compartment, two distinct immunoregulatory axes are dysregulated in OA: the Th1/Th2 axis (skewed toward a Th1-dominant pro-inflammatory state) and the Th17/Treg axis (characterized by excessive Th17 activity and impaired Treg function). B cells, although less studied, may also contribute to synovial inflammation through antibody production and cytokine secretion. Among different MSC populations, human adipose-derived stem cells (hADSCs), a readily accessible MSC source with potent immunomodulatory, anti-inflammatory, and tissue-reparative properties, have emerged as promising therapeutic candidates for OA. Their ability to regulate both innate and adaptive immune responses positions them as key modulators of the osteoarthritic immune microenvironment. Here, we synthesize current evidence on the role of T-cell infiltration in OA, the mechanisms governing macrophage polarization, and the bidirectional crosstalk between hADSCs and immune cells through cytokines, chemokines, exosomal microRNAs, and metabolic reprogramming. We further propose an integrated model of a T cell–macrophage–hADSC tripartite immune communication axis, in which macrophages serve as intermediary hubs, T cells act as upstream drivers of imbalance, and hADSCs function as microenvironment remodelers. This conceptual framework provides a mechanistic basis for understanding OA progression and may support the rational design of hADSC-based interventions.
Intervertebral disc degeneration (IDD) is a major contributor to low back pain. In women, postmenopausal status is associated with greater lumbar disc degeneration, estradiol decline, and systemic iron accumulation. We investigated the associations among estradiol, iron metabolism biomarkers, and lumbar disc degeneration, focusing on potential indirect associations involving iron metabolism. This retrospective cross-sectional study included 150 women with lumbar MRI, clinical data, and previously stored residual serum samples, contributing 750 disc-level observations. After ethics approval and study-specific written informed consent, estradiol and iron metabolism biomarkers were measured in the stored samples. Lumbar discs from L1/L2 to L5/S1 were graded using the modified Pfirrmann system. Estradiol was specified as the exposure, and serum iron, ferritin, soluble transferrin receptor, and total iron-binding capacity were evaluated as candidate mediators. Mediation analyses combined a two-step modeling strategy with g-computation, with 95
Previous studies have demonstrated inferior medium- and long-term PROMs in patients with multijoint arthritis, the influence of concomitant painful joints on short-term postoperative outcomes remains unclear. A retrospective comparative analysis was performed on prospectively collected PROMs from 110 consecutive patients undergoing primary unilateral TKA between November 2024 and September 2025 at a tertiary academic center. Patients were divided into a single arthritic joint group (SAJ; n = 59) and a multiple arthritic/painful joint group (MAJ; n = 51). PROMs included the Oxford Knee Score (OKS), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), EQ-5D, overall health score, general health score, and single-item back pain severity score. Outcomes were assessed preoperatively and at 6 weeks postoperatively. There were no significant differences in baseline demographic characteristics between groups. Preoperative PROMs were comparable between the SAJ and MAJ cohorts. Postoperatively, patients in the MAJ group reported significantly greater pain in other joints (2.12 vs. 0.84, p < 0.001) and higher back pain severity scores (1.39 vs. 0.56, p = 0.018). Despite this increased pain burden, no significant differences were observed in postoperative OKS (33.9 vs. 34.0, p = 0.75), KOOS-JR (7.1 vs. 7.3, p = 0.40, raw unconverted scores), EQ-5D (9.4 vs. 8.4, p = 0.13), overall health score (79.6 vs. 74.0, p = 0.31), or general health score (2.4 vs. 2.7, p = 0.08). All observed differences remained below established minimal clinically important difference thresholds. Patients with multijoint arthritis and concomitant back pain demonstrated a greater overall pain burden but achieved comparable early postoperative PROMs following primary TKA compared to patients with isolated knee osteoarthritis. Concurrent painful joints did not appear to adversely influence short-term knee-specific or global postoperative outcomes at 6 weeks. These findings suggest that early perceived recovery after TKA may be primarily driven by improvement in the operated knee rather than total body pain burden.
Deep vein thrombosis (DVT) poses a common and critical risk for mortality in elderly hip fracture (HF) patients. Venous angiography and ultrasound examinations serve as crucial diagnostic tools but pose challenges in cases with prevalent complications. The extensive training period for technical personnel, coupled with the rapid advancements in machine learning, prompts our research to harness the potential of the random forest algorithm. Our aim is to construct a predictive model that evaluates the risk of thrombosis formation in elderly HF patients upon admission. We conducted a retrospective evaluation of 448 elderly HF patients who received surgical treatment between May 2021 and November 2023. The division of our study cohort ensued, randomly allocating participants into training and test datasets with a meticulous 70:30 ratio. The employment of the Random Forest algorithm in this process led to the creation of a refined and optimized predictive model. Eleven important variables, namely ALB, A/G, PLT, Fib, D-dimer, CREA, Pi, GFR, FDP, fracture onset to surgery time, and cardiopulmonary diseases, were screened based on Random Forest features. In the training set, AUC, the 95
Abstract Background Postoperative pain following total hip arthroplasty (THA) and total knee arthroplasty (TKA) drives opioid dependence. Perioperative duloxetine is an option as a multimodal analgesic adjunct, yet its efficacy and safety in this population are not fully defined. Methods This systematic review and meta-analysis compared perioperative duloxetine to placebo in THA and TKA patients, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD420261294277). The search strategy spanned PubMed, Web of Science, and Scopus. The Cochrane Library was also queried from inception to March 2, 2026. The primary outcomes were Visual Analog Scale (VAS) pain scores at rest and during ambulation; secondary outcomes included postoperative opioid consumption and the incidence of adverse effects. VAS and Numeric Rating Scale (NRS) pain scores were converted to a common 0–100 mm scale for pooling and expressed as mean differences (MD) with 95% confidence intervals (CI); opioid consumption was standardized to morphine milligram equivalents (MME) and expressed as MD in MME. Dichotomous data were expressed as risk ratios (RR). Results Thirteen randomized controlled trials (RCTs) (n = 1176) were included. Duloxetine significantly reduced pain at rest (MD − 5.09 mm, 95% CI − 8.76 to − 1.43, P = 0.006) and during ambulation (MD − 4.55 mm, 95% CI − 8.71 to −0.40, P = 0.03) at 24 h. Analgesic benefits persisted at 2 weeks (rest pain: MD − 6.48 mm, 95% CI − 11.14 to − 1.82, P = 0.006; ambulatory pain: MD − 8.93 mm, 95% CI − 13.16 to − 4.69, P < 0.0001) and ≥3 months (rest pain: MD − 2.79 mm, 95% CI − 4.93 to − 0.64, P = 0.01; ambulatory pain: MD − 3.76 mm, 95% CI − 6.62 to − 0.89, P = 0.01). After standardization to morphine milligram equivalents (MME), statistically significant opioid-sparing effects were observed at 48 h (MD − 22.74 MME, 95% CI − 44.17 to − 1.31, P = 0.04, I 2 = 100%) and 72 h (MD − 10.58 MME, 95% CI − 18.67 to − 2.49, P = 0.01); both estimates were subject to extreme heterogeneity, and the 48-h estimate in particular should be interpreted with substantial caution given its very wide interval. Duloxetine significantly reduced the risk of nausea/vomiting (RR 0.73, 95% CI 0.55–0.97, P = 0.03); a borderline reduction in fatigue was also observed (RR 0.87, 95% CI 0.76–0.996, P = 0.04). Duloxetine increased the risk of drowsiness/somnolence (RR 1.88, P = 0.001). Conclusions Perioperative duloxetine produces statistically significant, though sub-threshold, analgesic effects across all assessed timepoints and a selective opioid-sparing effect spanning 48 to 72 h postoperatively when incorporated into multimodal analgesia for THA and TKA. All findings are subject to substantial heterogeneity and should be interpreted with caution. Duloxetine significantly reduced the incidence of nausea/vomiting and increased the risk of drowsiness/somnolence, the latter warranting preoperative patient counseling; a borderline reduction in fatigue was also observed. However, on leave-one-out sensitivity analysis, the long-term (≥ 3-month) reduction in pain at rest, the nausea/vomiting reduction, and the fatigue reduction each lost statistical significance upon exclusion of a single high-risk trial (Inamullah 2023) and should be interpreted with corresponding caution.
Thoracic ossification of the ligamentum flavum complicated by dural ossification carries a high risk of cerebrospinal fluid leakage during decompression. Whether the ossified dura should be resected or left as a floating island remains contested, and the choice is more consequential in unilateral biportal endoscopy, where watertight dural repair is technically difficult. We compared the two strategies in this setting. We retrospectively reviewed 131 consecutive patients treated for thoracic ossification of the ligamentum flavum at a single mini-invasive spinal surgery centre between January 2020 and December 2025. Thirty-nine patients with intraoperatively confirmed dural ossification treated by unilateral biportal endoscopy were identified (21 resection, 18 floating). 1:1 propensity score matching (caliper 0.2) on age, ossification area, spinal canal area, canal occupation ratio, and preoperative neurological score yielded 12 matched pairs. Perioperative metrics, intraoperative neuromonitoring, dural sac cross-sectional area on magnetic resonance imaging, modified Japanese Orthopaedic Association score, and Oswestry Disability Index were compared by t-test, Mann–Whitney U test, or Fisher’s exact test. Baseline characteristics were balanced after matching. The floating group had shorter operative time (2.57 ± 0.64 vs. 3.26 ± 0.69 h, P = 0.02) and a trend toward lower blood loss (30 vs. 55 mL, P = 0.07). No cerebrospinal fluid leakage occurred with the floating technique, compared with two cases (16.67
Impairment of localized angiogenic and osteogenic signaling networks significantly delays the healing of osteoporotic fractures. Systemic administration of sclerostin monoclonal antibody (Scl-Ab) encounters clinical restrictions due to potential cardiovascular risks highlighted by FDA black box warnings, and fails to ensure adequate local drug concentrations. This study aimed to develop an injectable localized drug delivery system for the sustained co-delivery of Scl-Ab and vascular endothelial growth factor (VEGF), evaluating its potential translational applicability in treating osteoporotic fractures. An injectable non-covalent hydrogel matrix (A-ND) capable of loading Scl-Ab and VEGF was synthesized through physical crosslinking of acrylamide, sodium p-styrene sulfonate, and acryloyloxyethyltrimethylammonium chloride.In vitro experiments evaluated the effects of the system on bone marrow mesenchymal stem cell (BMSC) migration and osteogenic differentiation. In vivo, randomized cohorts of ovariectomized (OVX) rats with stabilized femoral fractures were treated locally with the hydrogel formulations (n = 6 rats per group). Local bone repair and systemic biosafety were evaluated at 12 weeks using radiography, micro-CT analysis, biomechanical testing, localized tissue molecular biological assays, and histological examination. The A-ND hydrogel exhibited a highly porous microstructure ( 3 μm) and enabled stable sustained release of Scl-Ab and VEGF over 28 days. In vitro, the combined dual-drug group (D1) significantly enhanced BMSC migration and mineralized matrix deposition (OD: 1.639 ± 0.016), associated with the upregulation of downstream markers linked to Wnt and AKT signaling. In vivo, compared with single-agent and control cohorts, the D1 group achieved advanced fracture bridging and remodeling, demonstrating the highest radiographic scores (4.00 ± 0.000) and maximum biomechanical load-bearing capacity (187.80 ± 17.29 N). Histological and hematological examinations confirmed that major organs maintained intact architecture and systemic parameters remained within normal ranges. Localized injection of the Scl-Ab/VEGF@A-ND delivery system effectively accelerates osteoporotic fracture repair by concurrently supporting local osteogenic and angiogenic pathways. This platform proposes a safe, minimally invasive, and precision-targeted translational strategy for the treatment of fragile fractures.
The surgical management of chronic Achilles tendon ruptures (CATR) with significant tissue defects (Myerson Type II/III) presents a clinical challenge. Traditional reconstructive methods relying on free hamstring autografts or flexor hallucis longus transfers are often limited by donor-site morbidity, infection risks, or are unavailable in patients with a history of anterior cruciate ligament (ACL) reconstruction. This technical note describes a refined, tissue-preserving surgical technique utilising a doubled free autologous peroneus longus (PL) tendon graft. Under regional anaesthesia and thigh tourniquet control, a targeted 4 cm mini-open lateral incision is performed. The PL tendon is identified, harvested proximally using a tendon stripper, and a concomitant distal side-to-side tenodesis of the PL to the PB is performed to minimise eversion weakness. On the back table, the free PL autograft is doubled to achieve a 10 mm diameter construct. A calcaneal tunnel is drilled using progressive reaming. The free graft is routed through the proximal Achilles stump, passed subcutaneously, and drawn through the calcaneus. Final rigid stabilisation is secured with a 10 × 30 mm Bio-Interference Screw (Arthrex®) with the ankle held in maximum forced equinus to ensure optimal tensioning. Postoperatively, a 4-phase accelerated protocol begins with 3 weeks in a short-leg fibreglass cast under protected weight-bearing. This technique achieves reliable primary mechanical stability, allowing for early protected loading while minimising soft-tissue stripping in the hypovascular distal Achilles watershed area. The free PL autograft provides an adequate structural match, and complements the translational framework of the Soft Tissue Healing Diamond (ST-Diamond) concept. Furthermore, this approach serves as a potential alternative for middle-aged patients who have a history of prior ACL reconstruction using hamstring autografts, avoiding contralateral donor-site morbidity or the use of allografts. The described mini-open free peroneus longus autograft reconstruction with interference screw fixation represents a cautious, reproducible, and biologically sound salvage option for large chronic Achilles tendon defects, balancing mechanical stability with minimal surgical morbidity.
To investigate whether bilateral gait biomechanical characteristics differ among individuals with varying levels of kinesiophobia after anterior cruciate ligament reconstruction (ACLR) and healthy controls. This cross-sectional observational study included 36 individuals who were ≥ 12 months post-ACLR and 18 healthy controls. Individuals after ACLR were classified into high- and low-kinesiophobia groups using a predefined TSK-17 cutoff score of 40. A three-dimensional motion capture system synchronized with force platforms was used to quantify bilateral gait biomechanics during self-selected walking, including spatiotemporal, kinematic, and kinetic parameters. Limb symmetry indices (LSIs) were calculated for prespecified bilateral gait variables, and exploratory analyses examined associations between continuous TSK-17 scores and biomechanical outcomes. Compared with healthy controls, individuals after ACLR demonstrated reduced knee flexion–extension range of motion (ROM), with greater reductions in the high-kinesiophobia group than in the low-kinesiophobia group. Specifically, the involved limb had a 10.0° lower knee flexion–extension ROM in the high-kinesiophobia group than in the low-kinesiophobia group (95
