Comparative Interrupted Time Series Analysis of Long-term Direct Medical Costs in Patients With Hip Fractures and a Matched Cohort: A Large-database Study.

BACKGROUND: Previous studies on medical costs in patients with hip fractures have focused on medical costs incurred for a short period after the injury. However, patients often had comorbidities before their hip fractures that would have affected medical costs even had they not sustained a fracture. Consequently, these studies may have overestimated the costs associated with hip fractures and did not characterize the duration of increased medical costs adequately. Without knowing this crucial information, it is difficult to craft thoughtful health policy to support these patients' needs. QUESTIONS/PURPOSES: (1) To compare the direct medical costs for 5 years before fracture and up to 5 years after injury in a group of patients who underwent hip fracture surgery with a matched group of patients who did not experience a hip fracture, (2) to analyze the duration over which the increased direct medical costs associated with a hip fracture continues, and (3) to analyze whether there is a difference in direct medical costs according to age group using a nationwide claims database in South Korea. METHODS: The National Health Insurance Service Sample cohort in South Korea consisted of 1 million patients who were selected using a systematic, stratified, random sampling method from 48,222,537 individuals on December 31, 2006. Under a compulsory social insurance system established by the National Health Insurance Act, all patients were followed until 2015. Patients with hip fractures and matched controls were selected from the National Health Insurance Service sample of South Korea. Patients with hip fractures were defined as those who were hospitalized with a diagnosis of femoral neck fracture or intertrochanteric fracture and who underwent surgical treatment. We excluded patients with hip fractures before January 1, 2007 to ensure a minimum 5-year period that was free of hip fractures. Patients with hip fractures were matched with patients of the same age and gender at the date of admission to an acute care hospital for surgery (time zero). If patients with hip fractures died during the follow-up period, we performed matching among patients whose difference from the time of death was within 1 month. This method of risk-set matching was repeated sequentially for the next patient until the last patient with a hip fracture was matched. We then sequentially performed 1:5 random sampling for each risk set. A total of 3583 patients in the hip fracture cohort (patients with hip fractures) and 17,915 patients in the matched cohort (those without hip fractures) were included in this study. The mean age was 76 ± 9 years, and 70% were women in both groups. Based on the Charlson comorbidity index score, medication, and medical history, the patients with hip fractures had more comorbidities. Person-level direct medical costs per quarter were calculated for 5 years before time zero and up to 5 years after time zero. Direct medical costs were defined as the sum of that insurer's payments (that is, the National Health Insurance Service's payments), and that patient's copayments, excluding uncovered payments. We compared direct medical costs between patients with hip fractures and the patients in the matched cohort using a comparative interrupted time series analysis. The difference-in-difference estimate is the ratio of the differences in direct medical costs before and after time zero in the hip fracture cohort to the difference in direct medical costs before and after time zero in the matched cohort; the difference in difference estimates were calculated each year after injury. To identify changes in direct medical cost trends in patients with hip fractures and all subgroups, joinpoint regression was estimated using statistical software. RESULTS: The direct medical costs for the patients with hip fractures were higher than those for patients in the matched cohort at every year during the observation period. The difference in direct medical costs between the groups before time zero has increased every year. The direct medical costs in patients with hip fractures was the highest in the first quarter after time zero. Considering the differential changes in direct medical costs before and after time zero, hip fractures incurred additional direct medical costs of USD 2514 (95% CI 2423 to 2606; p < 0.01) per patient and USD 264 (95% CI 166 to 361; p < 0.01) per patient in the first and second years, respectively. The increase in direct medical costs attributable to hip fracture was observed for 1.5 to 2 years (difference-in-difference estimate at 1 year 3.0 [95% CI 2.8 to 3.2]; p < 0.01) (difference-in-difference estimate at 2 years 1.2 [95% CI 1.1 to 1.3]; p < 0.01; joinpoint 1.5 year). In the subgroups of patients younger than 65, patients between 65 and 85, and patients older than 85 years of age, the increase in direct medical costs attributable to hip fracture continued up to 1 year (difference-in-difference estimate ratio at 1 year 2.7 [95% CI 2.1 to 3.4]; p < 0.01; joinpoint 1 year), 1.5 to 2 years (difference-in-difference estimate ratio at 1 year 2.8 [95% CI 2.6 to 3.1]; p < 0.01; difference-in-difference estimate ratio at 2 years 1.2 [95% CI 1.1 to 1.3]; p < 0.01; joinpoint 1.5 years), and 39 months to 5 years (difference-in-difference estimate ratio at 1 year 5.2 [95% CI 4.4 to 6.2]; p < 0.01; difference-in-difference estimate ratio at 5 years 2.1 [95% CI 1.4 to 3.1]; p < 0.01; joinpoint 39 months) from time zero, respectively. CONCLUSION: The direct medical costs in patients with hip fractures were higher than those in the matched cohort every year during the 5 years before and after hip fracture. The increase in direct medical costs because of hip fractures was maintained for 1.5 to 2 years and was greater in older patients. Based on this, we suggest that health policies should focus on patients' financial and social needs, with particular emphasis on the first 2 years after hip fracture with stratification based on patients' ages. LEVEL OF EVIDENCE: Level II, economic analysis.

What Is the Difference in the Risk of Suicide Death Between Spine Fracture in Patients Older Than 65 Years and Matched Controls? A Large-database Study from South Korea.

BACKGROUND: Pain and kyphotic deformity after spinal fractures can result in a decrease in a patient's physical function and quality of life. Furthermore, physical illness, such as respiratory compromise, or mental illness, including depression, may be exacerbated by a spinal fracture. Complications caused by spinal fractures and old age are risk factors for suicide, but studies on these patients are rare. QUESTIONS/PURPOSES: (1) What is the incidence rate of death by suicide after a spinal fracture in patients older than 65 years? (2) How much does the risk of death by suicide increase in patients older than 65 years who have spine fractures compared with well-matched controls? (3) How does this risk change as a function of increasing time after injury? METHODS: Spinal fractures in patients older than 65 years and matched controls were selected from the National Health Insurance Service-Senior cohort (NHIS-Senior) of South Korea. The NHIS-Senior consists of 558,147 people selected by 10% simple random sampling method from a total of 5.5 million people 60 and older in 2002; all people were followed through 2015. A total of 31,357 patients with spine fractures and their 62,714 matched controls remained in the study. The mean follow-up time was 4.3 ± 3.0 years (135,229 person-years) in the spine fracture group and 4.6 ± 3.0 years (290,096 person-years) in the matched control group. We matched the groups for demographic factors such as age, gender, Charlson Comorbidity Index score, medication history, medical history, preoperative disability, number of hospital admissions, as well as socioeconomic factors such as household income level, residential district, and type of national health insurance using a 1:2 risk set propensity score matching by a nearest-neighbor matching algorithm with a maximum caliber of 0.1 of the hazard components. The incidence rate of suicide and the 95% confidence interval were calculated based on a generalized linear model with a Poisson distribution. The effect size was presented as a hazard ratio (HR) using Cox's proportional hazard model with robust variance estimator that accounts for clustering within matched pairs. RESULTS: The overall risk of death by suicide throughout the surveillance period, expressed as an incidence rate, was 116 per 100,000 person-years in spinal fracture (157 deaths by suicide over 135,229 person-years). Throughout the entire surveillance period, the risk of death by suicide was greater among patients with spinal fractures than it was in the control group (HR 1.8 [95% CI 1.5 to 2.2]; p < 0.01). This difference was greatest in the first 365 days after the fracture (HR 2.5 [95% CI 1.6 to 3.8]; p < 0.01) (45 deaths by suicide, incidence rate: 156 per 100,000 person-years in spinal fracture). The risk of suicide death in patients with spine fracture from 365 days to the last follow-up was also higher than that of matched controls (HR 1.6 [95% CI 1.3 to 2.1]; p < 0.01). CONCLUSIONS: Considering the substantially increased risk of death by suicide in patients with spine fractures who are older than 65 years, surgeons should consider offering psychiatric evaluation and management more frequently, particularly in patients with chronic pain, functional disability, and depressive mood. Future studies should investigate the underlying causes of suicide, such as deteriorating socioeconomic support or depression, and whether early initiation of psychological support after injury can reduce the suicide rate. LEVEL OF EVIDENCE: Level III, prognostic study.

Gait analysis after total hip arthroplasty using direct anterior approach versus anterolateral approach: a systematic review and meta-analysis.

BACKGROUND: Comparative studies of total hip arthroplasty using the direct anterior approach (DAA) compared with the anterolateral approach (ALA) by gait analysis compared the results of the two groups, the damage to the abductor muscle, with objective and detailed kinematic as well as kinetic data of actual gait. The purpose of this systematic review was to analyze the differences in gait such as time-dependent parameters, kinetics, and kinematics after THA using the DAA compared with ALA. METHODS: PubMed Central, OVID Medline, Cochrane Collaboration Library, Web of Science, EMBASE and AHRQ carried out a comprehensive search for all relevant randomized controlled trials and comparative studies, up to December 2018. Based on the following criteria, studies were selected: 1) study design: randomized controlled trials or non-randomized comparative studies; 2) study population: patients with primary osteoarthritis or avascular necrosis; 3) intervention: total hip arthroplasty by DAA or ALA; 4) Kinetic and kinematic data after gait analysis in the plains during postoperative follow-up. RESULTS: Of the 148 studies, 7 randomized controlled trials and 5 comparative studies were finally included in this systematic review. The peak hip flexion within 3 months after surgery was described in two studies and was significantly higher in the DAA group. (OR = 1.90; 95% CI [1.67,2.13]; P < 0.01, Z = 16.18). The gait speed within 3 months after surgery was reported in 3 studies and was significantly higher in the DAA group than in the ALA group. (SMD = 0.17; 95% CI [0.12,0.22]; P < 0.01, Z = 6.62) There was no difference between the two groups in stride length, step length, and hip range of motion in sagittal plane. CONCLUSIONS: In this meta-analysis, gait speed and peak hip flexion within 3 months after surgery were significantly higher in the DAA group than in the ALA group. Despite a few significant differences between two approaches, determining whether the reported differences in terms of postoperative gait values are clinically meaningful remains a substantial challenge.

Acute Cholecystitis in Elderly Patients after Hip Fracture: a Nationwide Cohort Study.

BACKGROUND: Because acute cholecystitis in elderly hip fracture is not easily distinguishable from other gastrointestinal symptoms and involves atypical clinical behaviors, it may not be diagnosed in the early stage. However, the exact incidences could not be reported. We utilized data from a nationwide claims database and attempted to assess the incidence of acute cholecystitis in elderly hip fracture patients and how cholecystitis affects mortality rates after hip fracture. METHODS: Study subjects were from the Korean National Health Insurance Service-Senior cohort. From a population of approximately 5.5 million Korean enrollees > 60 years of age in 2002, a total of 588,147 participants were randomly selected using 10% simple random sampling. The subjects included in this study were those who were over 65 years old and underwent surgery for hip fractures. RESULTS: A total of 15,210 patients were enrolled in the cohort as hip fracture patients. There were 7,888 cases (51.9%) of femoral neck fracture and 7,443 (48.9%) cases of hemiarthroplasty. Thirty-six patients developed acute cholecystitis within 30 days after the index date (30-day cumulative incidence, 0.24%). Four of the 36 acute cholecystitis patients (11.1%) died within 30 days versus 2.92% of patients without acute cholecystitis. In the multivariate-adjusted Poisson regression model, hip fracture patients with incident acute cholecystitis were 4.35 (adjusted risk ratio 4.35; 95% confidence interval, 1.66-11.37; P = 0.003) times more likely to die within 30 days than those without acute cholecystitis. CONCLUSION: Incidence of acute cholecystitis in elderly patients after hip fracture within 30 days after the index date was 0.24%. Acute cholecystitis in elderly hip fracture patients dramatically increases the 30-day mortality rate by 4.35-fold. Therefore, early disease detection and management are crucial for patients.

A Minimum Ten Years of Follow-Up of Alumina Head on Delta Liner Total Hip Arthroplasty.

BACKGROUND: In the early days when delta ceramics were developed, there was a period of using delta ceramic liner and alumina ceramic head. Therefore, the purpose of this study is to investigate the clinical and radiological outcomes of total hip arthroplasty using delta ceramic liner on alumina ceramic head after a minimum of 10 years of follow-up and to evaluate problems of early delta ceramic liner. METHODS: Alumina on delta cementless total hip arthroplasty was performed in 92 hips (85 patients) from August 2005 to March 2007 at our hospital. Bilateral total hip arthroplasty were performed in 7 patients, 30 patients on the left side and 48 patients on the right side. Preoperative diagnosis was osteonecrosis of the femoral head in 34 hips (37%), degenerative arthritis in 31 hips (33.7%), femur neck fracture in 21 hips (22.8%), and rheumatoid arthritis in 6 hips (6.5%). All surgeries were carried out with anterolateral approach. For the clinical evaluation, Harris hip score (HHS), pain, and range of motion were assessed. Radiographs were reviewed by the authors to search for any signs of osteolysis, loosening of implants, and heterotopic ossification. RESULTS: HHS was compared between preoperative and final follow-ups. The mean HHS improved from preoperative 58.3 points (range 27-76) to 92.7 points (range 78-98) on the final follow-up (P = .02). The mean range of hip motion at the final follow-up was flexion 116.9°, adduction 23.8°, abduction 34.6°, internal rotation 16.3°, and external rotation 39.2°. As for the postoperative pain, 1 patient complained of inguinal pain and 4 patients complained of thigh pain. Because of trauma, 3 cases of dislocation were observed in all cases. There are 3 cases with dislocation and 2 cases were treated with conservative treatment without recurrence, but 1 case was required for surgical treatment due to eccentric rim wear of delta liner. The aseptic loosening of acetabular cup and femoral stem was each 1 hip. CONCLUSION: Alumina head-on-delta liner cementless THA, using a large femoral head 32-36 mm in diameter, demonstrated satisfactory clinical and radiological results in the minimum 10 years of follow-up. Eccentric rim wear can occur even in delta ceramic liners that are known to have high strength, and this can lead to dislocation which can, in turn, increase the possibility of linear fracture.

Comprehensive genetic exploration of skeletal dysplasia using targeted exome sequencing.

PURPOSE: The purpose of this study was to evaluate the clinical utility of targeted exome sequencing (TES) as a molecular diagnostic tool for patients with skeletal dysplasia. METHODS: A total of 185 patients either diagnosed with or suspected to have skeletal dysplasia were recruited over a period of 3 years. TES was performed for 255 genes associated with the pathogenesis of skeletal dysplasia, and candidate variants were selected using a bioinformatics analysis. All candidate variants were confirmed by Sanger sequencing, correlation with the phenotype, and a cosegregation study in the family. RESULTS: TES detected "confirmed" or "highly likely" pathogenic sequence variants in 74% (71 of 96) of cases in the assured clinical diagnosis category and 20.3% (13 of 64 cases) of cases in the uncertain clinical diagnosis category. TES successfully detected pathogenic variants in all 25 cases of previously known genotypes. The data also suggested a copy-number variation that led to a molecular diagnosis. CONCLUSION: This study demonstrates the feasibility of TES for the molecular diagnosis of skeletal dysplasia. However, further confirmation is needed for a final molecular diagnosis, including Sanger sequencing of candidate variants with suspected, poorly captured exons.Genet Med 18 6, 563-569.

Clinical Feasibility of a Markerless Gait Analysis System.

Background: The gait analysis method that has been used in clinical practice to date is an optical tracking system (OTS) using a marker, but a markerless gait analysis (MGA) system is being developed because of the expensive cost and complicated examination of the OTS. To apply this MGA clinically, a comparative study of the MGA and OTS methods is necessary. The purpose of this study was to evaluate the compatibility between the OTS and the MGA methods and to evaluate the usefulness of the MGA system in actual clinical settings. Methods: From March 2021 to August 2021, 14 patients underwent gait analysis using the OTS and MGA system, and the spatiotemporal parameters and kinematic results obtained by the 2 methods were compared. To evaluate the practicality of the MGA system in an actual clinical setting, MGA was performed on 14 symptomatic children with idiopathic toe walking, who had been treated with a corrective cast, and the pre-cast and post-cast results were compared. For the OTS, the Motion Analysis Eagle system was used, and for MGA, DH Walk was used. Results: The spatiotemporal parameters showed no significant difference between the OTS and MGA system. The joint angle graphs of the kinematics along the sagittal plane showed similar shapes as a whole, with particularly high correlations in the hip and knee (pelvis: 29.4%, hip joint: 96.7%, knee joint: 94.9%, and ankle joint: 68.5%). A quantified comparison using the CORrelation and Analysis (CORA) score also showed high similarity between the 2 methods. The MGA results of pre-cast application and post-cast removal for children with idiopathic toe walking showed a statistically significant improvement in ankle dorsiflexion after treatment (p < 0.001). Conclusions: MGA showed a good correlation with the conventional OTS in terms of spatiotemporal parameters and kinematics. We demonstrated that ankle sagittal kinematics improved after treatment by corrective cast in children with idiopathic toe walking using the MGA method. Thus, after the improvement of a few limitations, the MGA system may soon be able to be clinically applied.

Assessment of arthrogenic quadriceps muscle inhibition by physical examination in the supine position during isometric contraction is feasible as demonstrated by electromyography: a cross-sectional study.

BACKGROUND: Preventing severe arthrogenic muscle inhibition (AMI) after knee injury is critical for better prognosis. The novel Sonnery-Cottet classification of AMI enables the evaluation of AMI severity but requires validation. This study aimed to investigate the electromyography (EMG) patterns of leg muscles in the examination position from the classification during isometric contraction to confirm its validity. We hypothesised that the AMI pattern, which is characterised by quadriceps inhibition and hamstring hypercontraction, would be detectable in the supine position during isometric contraction. METHODS: Patients with meniscal or knee ligament injuries were enrolled between August 2023 and May 2024. Surface EMG was assessed during submaximal voluntary isometric contractions (sMVIC) at 0° extension in the supine position for the vastus medialis (VM) and vastus lateralis (VL) muscles and at 20° flexion in the prone position for the semitendinosus (ST) and biceps femoris (BF) muscles. Reference values for normalisation were obtained from the EMG activity during the gait of the uninjured leg. The Kruskal-Wallis test was used to compare the activation patterns of the muscle groups within the same leg, and the post-hoc tests were conducted using the Mann-Whitney U test and Bonferroni correction. RESULTS: Electromyographic data of 40 patients with knee injuries were analyzed. During sMVIC, the extensor and flexor muscles of the injured leg showed distinct behaviours (P < 0.001), whereas the uninjured side did not (P = 0.144). In the injured leg, the VM differed significantly from the ST (P = 0.018), and the VL differed significantly from the ST and BF (P = 0.001 and P = 0.026, respectively). However, there were no statistically significant differences within the extensor muscle groups (VM and VL, P = 0.487) or flexor muscle groups (ST and BF, P = 0.377). CONCLUSION: AMI was detectable in the examination position suggested by the Sonnery-Cottet classification. The flexor and extensor muscles of the injured leg exhibited distinct activation behaviours, with inhibition predominantly occurring in the quadriceps muscles, whereas the hamstrings showed excitation.

Nested Case Control Study on the Risk of Suicide Death in Elderly Patients with Pelvic Fractures Using a Nationwide Cohort.

Background: The aim of this study was to investigate the incidence rate of suicide deaths in elderly patients with pelvic fractures using a nationwide database and to analyze change in the risk of suicide death overtime after pelvic fractures compared to controls. Methods: We used the National Health Insurance Service-Senior cohort (NHIS-Senior) of South Korea. Cases and controls were matched for sex, age, history of hospital admission within 1 year, and presence of depression on the date of suicide death. Controls were collected by random selection at a 1 : 5 ratio from patients at risk of becoming cases when suicide cases were collected. Incident pelvic fractures were identified from the NHIS-Senior as follows: first admission during the observational period (2002-2015) to an acute care hospital with a diagnostic code of International Statistical Classification of Diseases and Related Health Problems, 10th revision S321, S322, S323, S324, S325, or S328 and age 65-99 years. Conditional logistic regression analysis was performed to evaluate the association between pelvic fractures and the risk of suicide death. Results: A total of 2,863 suicide cases and 14,315 controls were identified. Suicide case patients had been more frequently exposed to steroids (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.21-1.45), benzodiazepines (OR, 1.76; 95% CI, 1.61-1.93), and non-steroidal anti-inflammatory drugs (OR, 1.18; 95% CI, 1.07-1.29). Pelvic fractures within 1 year from the date of suicide death were statistically significantly associated with increased risk of suicide (adjusted OR [AOR], 2.65; 95% CI, 1.29-5.45; p = 0.008) compared to controls. The risk of suicide death declined as the incidence date of pelvic fracture was more remote from the date of suicide death: AORs of 2.59 (95% CI, 1.33-5.04; p = 0.005) within 2 years and 2.13 (95% CI, 1.15-3.95; p = 0.017) within 3 years. However, there was no statistical significance in the increased risk of suicide death for pelvic fractures that had occurred ≥ 4 years ago (p > 0.05). Conclusions: Pelvic fractures in the elderly population increased the risk of suicide death within 3 years, suggesting the need for psychiatric support among elderly patients with pelvic fractures.

Operative treatment for ganglion cysts of the foot and ankle.

The authors analyzed the clinical results of surgical excision for symptomatic or recurrent ganglion cysts of the foot and ankle, and tried to elucidate the prognostic factors. Fifty-three cases of ganglions in the foot and ankle were followed for more than 24 months after excision. The mean duration of follow-up was 3.7 years. As a preceding treatment, 17 cases received a mean of 1.3 aspirations, and 16 cases recurred after a mean of 1.7 operations. The cyst was most common in the dorsum of the foot and ankle, where 35 cases were found. Thirty cases originated from the tendon sheath, 19 cases from the joint, and 4 cases from others. Preoperative mean AOFAS foot scores were low in the cysts associated with the tarsal tunnel syndrome, and in the cysts of the plantar aspect of the first toe. Postoperative mean AOFAS foot scores were significantly increased in the preceding 2 groups. There were 3 (5.7%) cases of recurrence, all of which originated from the tendon sheath. In the case of ganglion cysts originating from the tendon sheath, careful attention should be paid to locate satellite masses to avoid recurrence.

Review on Basicervical Femoral Neck Fracture: Definition, Treatments, and Failures.

Basicervical femoral neck fracture is an uncommon fracture that accounts for only 1.8% of all proximal femoral fractures. Previous studies have recommended that the choice of implant to treat this fracture should be similar to that of intertrochanteric fracture. However, in previous studies on basicervical fractures, the definition and treatment results of these fractures were different, and there were also debates on the implant that had to be used. Therefore, the purpose of this study was to review the studies that performed surgical treatment of basicervical femoral fractures and to assess the definition of basicervical fracture, the use of implants, and failure rates and clinical results. Study selection was based on the following inclusion criteria: (1) treatment outcome for basicervical femoral neck fracture was reported; and (2) dynamic hip screw, proximal femoral nail, or multiple screw fixation was used as treatment. PubMed Central, OVID MEDLINE, Cochrane Collaboration Library, Web of Science, EMBASE, and AHRQ databases were searched to identify relevant studies published up to March, 2020 with English language restriction. A total of 15 studies were included in this study. Differences were found in the definition of basicervical fracture, treatment results, rehabilitation protocol, and fixation failure rate. Definitions and treatment methods for basicervical fractures varied, and treatment outcomes also differed among the enrolled studies. Further research is needed that would be restricted to those fractures that conform to the definition of basicervical fracture.

The effect of surgery type on mortality in elderly patients with pertrochanteric femoral fracture: A Korean nationwide cohort study.

BACKGROUND/OBJECTIVE: The purpose of this study is to analyze the effect of surgical methods on mortality and the relative risk of patients who underwent internal fixation (IF) or hemiarthroplasty (HA) after being diagnosed as a pertrochanteric fracture over 65 years old in a Korean nationwide cohort with a single insurance medical system. METHODS: The Korean National Health Insurance Service-Senior cohort (NHIS-Senior, NHIS-2018-2-111) was used in this study. The eligibility criteria for incident hip fracture patients were the following: (1) first-time admission to acute care hospitals (index admission) with pertrochanteric fracture (ICD-10 S721), (2) three years of hip fracture-free period, (3) recipients of typical surgeries including IF, HA, (4) age between 65 and 99. RESULTS: a total of 7223 patients were enrolled in the cohort. There were 1662 patients (23%) in the HA group and 5561 patients (77%) in the IF group. Mortality rates of the IF group and HA group were 13.46 and 17.94 cases per 100 person-years, respectively. In the multivariable-adjusted Cox proportional hazard model, the HA group had 1.22 times more hazard of all-cause mortality than IF group (aHR 1.22, 95% CI 1.13-1.32). In subgroup analysis, aged 65-79 and female patients showed a prominent association between surgery type and mortality (aHR 1.52, 95% CI 1.29-1.79). CONCLUSIONS: In patients with pertrochanter fracture over 65 years, 1.22-fold mortality rate was observed when HA was performed compared to that of IF, and the difference in mortality was particularly prominent within 1-year after surgery.

Clinical and Radiological Outcomes after Various Treatments of Midshaft Clavicle Fractures in Adolescents.

BACKGROUD: Controversy exists about the optimal treatment of midshaft clavicle fractures in the presence of significant displacement, comminution, or shortening of the fracture in adolescents. The purpose of this study was to compare the clinical and radiological outcomes of 4 different treatments for midshaft clavicle fractures in adolescents: conservative treatment with a figure-of-8 (FO8) brace, open reduction and internal fixation with a plate (OPL), minimally invasive plate osteosynthesis (MIPO), and intramedullary nail fixation with a threaded Steinmann pin (TSP). METHODS: A total of 94 teenagers with midshaft clavicle fractures were divided into the FO8, OPL, MIPO, and TSP groups (n = 24, 33, 16, and 21, respectively). We analyzed clinical and radiological outcomes and complications in each group and compared the results among the groups. RESULTS: All groups showed satisfactory clinical and radiological outcomes, but each group showed different results for the assessment items. The Constant-Murley scores were higher in the operated groups than in the FO8 group. Recovery of joint motion was faster in the operated groups. The TSP group had the highest cosmetic satisfaction with respect to the satisfaction score and measured scar length. Fracture union was achieved in all patients. At the final follow-up, the bone length was closer to normal in the OPL and TSP groups than in the FO8 and MIPO groups, and angulation was less in the OPL and TSP groups than in the MIPO and FO8 groups. The TSP and MIPO groups obtained faster bone healing than the OPL and FO8 groups. In the operated groups, 9 patients had metal-induced irritating symptoms; 1, supraclavicular nerve injury symptoms; and 4, refractures after plate removal. CONCLUSIONS: The nonoperatively treated group had no iatrogenic complications. The operated groups complained of various disadvantages induced by surgery; however, these groups achieved faster functional recovery and slightly better radiological and functional results than the nonoperative group.

Changes in Gait and Radiographic and Clinical Results of Calcaneal Lengthening Osteotomy in Children with Idiopathic Flexible Flatfoot.

BACKGROUD: In this study, we aimed to analyze kinematic and kinetic changes in gait and to assess radiographic and clinical improvement after calcaneal lengthening osteotomy (CLO) in children with idiopathic symptomatic flexible flatfoot deformities. METHODS: The study group consisted of 22 children (28 feet) with idiopathic symptomatic flexible flatfoot, which was treated by CLO as an index operation. We excluded patients with flatfoot that developed secondary to neuromuscular diseases. There were 18 boys (22 feet) and 4 girls (6 feet). The average age of the patients was 10.8 ± 1.51 years. Surgical results were assessed by radiologic imaging, clinical evaluation, and gait analysis, which were performed before surgery and 1 year after surgery. Medical records were reviewed to check postoperative complications. RESULTS: Talonavicular coverage was recovered to 16.7° from 32.7° (p < 0.01). Lateral talo-first metatarsal angle and calcaneal pitch angle increased by 20.1° and 9.9°, respectively (p < 0.01). Weight-bearing radiographs demonstrated a decrease in the anteroposterior angle and lateral talocalcaneal angle by 6.9° and 10°, respectively (p < 0.01). Hindfoot valgus was corrected to near neutral position after CLO. Kinematic results showed that the ankle valgus angle in the coronal plane was reduced from 35.48° preoperatively to 16.64° postoperatively during gait (p < 0.05). The preoperative out-toeing gait (preoperative foot progression angle, 20.31°) was also normalized to 14.21° postoperatively. The kinetics results showed that the push-off moment (maximum ankle plantar flexion) on the sagittal plane increased from 0.66 Nm/kg preoperatively to 0.83 Nm/kg postoperatively (p < 0.01). The mean Yoo score was 9.2 ± 1.05 postoperatively: satisfactory in 24 cases (86%) and unsatisfactory in 4 cases. Of the 4 unsatisfactory cases, 2 cases were overcorrection and 2 cases were undercorrection, and 3 of them were well managed by wedge foot insoles. CONCLUSIONS: The 3-dimensional deformities of the flexible flatfoot were effectively corrected by CLO, based on the morphological assessment using radiologic imaging. The correction was well maintained during gait at 1 year after the operation.

Biomechanical Evaluation of Internal Fixation of Pauwels Type III Femoral Neck Fractures: A Systematic Review of Various Fixation Methods.

BACKGROUND: The purpose of this systematic review was to investigate various fixation methods or implants used in the treatment of Pauwels type III femoral neck fractures. METHODS: PubMed Central, OVID Medline, Cochrane Collaboration Library, Web of Science, Embase, and AHRQ databases were searched to identify relevant studies published until August 2017 with English language restriction. Studies were selected on the basis of the following inclusion criteria: biomechanical study of Pauwels type III femoral neck fractures and the use of dynamic hip screw (DHS) or multiple screw fixation or other devices for fixation of the fracture. RESULTS: A total of 15 studies were included in the systematic review. Eight studies were conducted using cadavers, six studies using sawbones, and one using a finite element model. During the mechanical testing, each study measured mechanical stiffness, failure to cyclic loading, failure to vertical loading of each fixation device. DHS was included in 11 studies, multiple screw fixation in 10 studies, and other devices in six studies. Baitner et al. and Samsami et al. reported that the mechanical stiffness of DHS was superior to three inverted triangular screw fixation. Hawks et al. and Gumustas et al. reported that using a transverse calcar screw can withstand vertical loading better than three inverted triangular screw fixation. In addition, there were some studies where instruments such as Intertan nail, locking plate or other devices showed excellent biomechanical properties. CONCLUSIONS: There are a variety of methods and instruments for fixation of the Pauwels type III fractures. However, it is difficult to conclude that any method is more desirable because there are advantages and disadvantages to each method. Therefore, we should pay attention to the implant choice and consider adequate weight bearing affecting the stiffness of the implant.

Changes in gait parameters after femoral derotational osteotomy in cerebral palsy patients with medial femoral torsion.

Medial femoral torsion (MFT) is a common pathologic gait in cerebral palsy (CP) children that can be corrected by femoral derotational osteotomy (FDO). It is not clearly known as to how much various gait parameters change after FDO. The aim of this study was to quantify changes in gait parameters after FDO. The study group included 19 young CP patients (28 limbs, age<20 years, average age: 13.2 years) with symptomatic MFT, treated with distal FDO. The study group was divided into two groups: the unilateral FDO group (UG) and the bilateral FDO group (BG). The mean degree of derotation was 24.6° (25.0° for UG, 24.4° for BG). Pre-FDO and post-FDO values of Staheli's rotational profiles and kinematic data were compared. A paired t-test and Pearson's correlation were used for statistical analysis. The mean internal hip rotation was 71.4±6.9° before surgery and 48.6±10.7° after surgery in the UG (P<0.05) and it was 63.8±15.8° before surgery and 40.9±9.2° after FDO in the BG (P<0.05). The change in the foot progression angle (FPA) was 12.9° in the UG group (P<0.05) and 12.6° in the BG group (P<0.05). The degree of FPA had changed by about a half of the surgical derotation angle. Changes in the mean hip rotation during gait were 14.8° in the UG (P<0.05) and 6.7° in the BG (P<0.05) groups. The overall pelvic rotation was not changed after surgery. However, in patients with preoperative compensatory pelvic rotation of more than 5°, there was a change of 5.3±4.8° in the UG and 6.6±1.54° in the BG after surgery (P<0.05). There was also a trend showing that the younger the patient, the more the pelvic rotation changed (P=0.069). In-toeing gait because of MFT improved with FDO in CP patients. The expected degree of postoperative correction of FPA and hip rotation is about a half of the FDO degree. The degree of compensatory pelvic rotation should be considered to determine the correction angle of FDO, especially in young patients with preoperative pelvic rotation of more than 5°.

Comparison between Cementless and Cemented Bipolar Hemiarthroplasty for Treatment of Unstable Intertrochanteric Fractures: Systematic Review and Meta-analysis.

PURPOSE: This study was conducted to compare cemented and cementless bipolar hemiarthroplasty in elderly patients with unstable intertrochanteric fractures via meta-analysis and systematic review of relevant studies. MATERIALS AND METHODS: Systematic review and meta-analysis were performed on 31 available clinical studies; 19 of these studies used cemented stems, 12 used cementless stems, one used both types of stems, and two studies involved a comparative analysis of both stem types. RESULTS: There were statistically significant differences in rates of leg length discrepancy (LLD) greater than 1 cm between the cemented (event rate, 0.089) and cementless groups (event rate, 0.015 and 0.047; P=0.03). CONCLUSION: Cemented bipolar hemiarthroplasty and cementless bipolar hemiarthroplasty performed on elderly patients with unstable intertrochanteric fracture revealed similar mortality and complication rates; however, the rate of LLD greater than 1 cm was significantly higher in the cemented group compared with the cementless group.

Femoral head wedge resection for the treatment of avascular necrosis of the femoral head after pediatric femoral neck fracture: a case report.

This research focuses on femoral head wedge resection for the treatment of avascular necrosis (AVN) of the femoral head. A 9-year-old girl presented to the emergency room complaining of right hip pain that occurred after a pedestrian car accident. After 8 months of internal fixation using cannulated screws for Delbet-type 2 fracture of the femoral neck, AVN of the femoral head developed in the patient. Even though valgus-derotation-extension intertrochanteric osteotomy was performed for the treatment of AVN, it progressed further and femoral head wedge resection was performed to recover the femoral head sphericity. After 3 years of follow-up, radiograph results showed appropriate and satisfactory congruency and containment. This research shows that the treatment of AVN of the femoral head using femoral head wedge resection is an effective method that can yield excellent results.

Spinal Cord Injury During Ultrasound-Guided C7 Cervical Medial Branch Block.

Ultrasound-guided cervical medial branch block (CMBB) is commonly performed to diagnose and treat head, neck, and shoulder pain. However, its use at the C7 level has been shown to be less accurate than at other levels, which may increase the chance of injury owing to the imprecision of needle site provided by the ultrasound guide. We report the first case of iatrogenic spinal cord injury from an ultrasound-guided C7 CMBB. The patient, upon receiving this procedure, had fainted shortly after experiencing an electrical sensation that ran from the neck to the toe. The patient complained of weakness and tingling sensation in the left upper extremity. Cervical magnetic resonance imaging revealed a hematoma in the cervical spinal cord, and an electrophysiological study, which was performed at 3 weeks after the incident, revealed an injury at the left C3-T2 anterior horn. After 2 months of rehabilitation, the patient showed moderate improvement in the strength of the left proximal upper extremity; however, there was no improvement in the strength of the left distal upper extremity. Therefore, we recommend caution when performing ultrasound-guided CMBB at the C7 level, as the guide particularly at this level is relatively inaccurate, posing a risk of spinal cord injury.

Correlation of the torsion values measured by rotational profile, kinematics, and CT study in CP patients.

BACKGROUND: The purpose of study was to analyze correlations between bony torsions measured by Staheli's rotation profile, computed tomography (CT) torsional study, and gait analysis in patients with cerebral palsy (CP). MATERIALS & METHOD: The study group comprised of 26 children with CP (spastic diplegia, Gross Motor Function Classification System (GMFCS) 1-2, mean age 12.6 years) with torsional deformities. All subjects were assessed by examining: 1) rotational profile [internal rotation (IR) and external rotation (ER)], 2) CT torsional profile [femoral anteversion (FAV) and tibial torsion (TT)], and 3) gait analysis [mean hip rotation (HR) and mean knee rotation (KR)]. Statistical analysis was performed using the Pearson correlation test. RESULTS: In the femur, there was good correlation between FAV and Staheli's rotational profile of IR and ER (Pearson correlation coefficient (PC=0.69, 0.52, p<0.05)). ER correlated very strongly with mean HR during gait (PC=0.8, p<0.05). There was, however, poor correlation between HR and IR (p>0.05), and between HR and FAV (p>0.05). In the tibia, mean KR correlated well with thigh-foot angle (TFA) (PC=0.72) and CT tibia torsion (TT) (PC=0.62). TT also correlated with TFA (PC=0.62). CONCLUSION: Gait analysis and Staheli's rotational profile reflect both static and dynamic factors of gait abnormalities. However, CT study reflect static factor primarily. Dynamic factors tend to influence the measurements of the femoral torsion only due to large rotational arc of hip joint. In surgical planning, it must be considered that HR sometimes does not correlate with CT anteversion angle. Similarly, it must also be considered that KR correlates well with TFA and CT TT angle.