Functional alignment maximises advantages of robotic arm-assisted total knee arthroplasty with better patient-reported outcomes compared to mechanical alignment.

PURPOSE: Robotic arm-assisted total knee arthroplasty (RTKA) enables adjustment of implant position to achieve the surgeon's preferred alignment. However, the alignment concept that most effectively enhances patient satisfaction remains unclear. This study compares the clinical outcomes of patients who underwent functionally aligned RTKA (FA-RTKA), mechanically aligned conventional TKA (MA-CTKA) and mechanically aligned RTKA (MA-RTKA). METHODS: A prospectively collected database was retrospectively reviewed for patients who underwent primary TKA for knee osteoarthritis. One hundred and forty-seven knees were performed with MA-CTKA, followed by 72 consecutive knees performed with MA-RTKA, and subsequently, 70 consecutive knees performed with FA-RTKA were enrolled. After 1:1 propensity score matching of patient demographics, 70 knees were finally included in each group. The extent of additional soft tissue release during surgery was identified, and the Coronal Plane Alignment of the Knee classification was utilised to categorise the alignment. At the 1-year follow-up, patient-reported outcomes, including the pain Visual Analogue Scale, Knee Society Score, Western Ontario and McMaster Universities Arthritis Index and Forgotten Joint Score-12, were also compared among the groups. RESULTS: The FA-RTKA group showed significantly less additional soft tissue release than the MA-CTKA and MA-RTKA groups (15.7%, 38.6% and 35.7%, respectively; p = 0.006). Statistically significant differences in functional scores were observed in the postoperative 1-year clinical outcomes in favour of the FA-RTKA group, which had a significantly larger percentage of knees that maintained constitutional alignment and joint line obliquity than those of the other groups. CONCLUSIONS: Functionally aligned TKA showed superior 1-year postoperative patient-reported outcomes compared with those of conventional and robotic arm-assisted mechanically aligned TKA. Therefore, the advantage of RTKA is maximised when the implant positioning is based on functional alignment. The application of RTKA with mechanical alignment has been proven ineffective in improving the clinical outcomes of patients. LEVEL OF EVIDENCE: Level III.

Robotic-assisted medial unicompartmental knee arthroplasty restored prearthritic alignment and led to superior functional outcomes compared with conventional techniques.

PURPOSE: Robotic-assisted medial unicompartmental knee arthroplasty (UKA) can ensure precise preoperative planning, minimise soft tissue damage and restore native coronal alignment. However, few studies have investigated how these advantages translate into differences in early postoperative outcomes. This study aimed to compare differences in early outcomes between conventional UKA (C-UKA) and robotic-assisted UKA (R-UKA). METHODS: This retrospective study investigated two groups of patients who underwent medial UKA: C-UKA group (n = 35) and R-UKA group (n = 35). We assessed (1) serum indicators (hemoglobin, creatine kinase and C-reactive protein) and pain visual analogue scale (VAS) at postoperative days (PODs) 1, 2, 4 and 6; (2) radiologic parameters including joint line height change and arithmetic and mechanical hip-knee-ankle angle (aHKA and mHKA); (3) patient-reported outcomes including Knee Society Scores, Western Ontario and Mcmaster Universities Arthritis Index (WOMAC) and Forgotten Joint Score-12 (FJS-12) at 1-year follow-up. RESULTS: Despite similar serum indicator results, pain VAS was lower in the R-UKA group than in the C-UKA group at PODs 2 (2.5 ± 1.3 vs. 3.6 ± 1.2, p = 0.02), 4 (2.4 ± 0.9 vs. 3.3 ± 1.0, p = 0.03) and 6 (1.9 ± 1.1 vs. 3.1 ± 1.1, p < 0.01). The joint line height change was significantly lower in the R-UKA group than in the C-UKA group (0.9 mm ± 0.6 mm vs. 2.0 mm ± 1.3 mm, p = 0.02). The equivalence test for preoperative aHKA and postoperative mHKA revealed equivalence in only the R-UKA group (p < 0.01). The R-UKA group showed better WOMAC and FJS-12 compared to C-UKA group at 1-year follow-up. CONCLUSION: R-UKA led to lower pain VAS in the early postoperative period compared with C-UKA. Additionally, R-UKA effectively restored the joint line and prearthritic lower limb alignment, resulting in superior functional outcomes at 1-year follow-up compared with C-UKA. LEVEL OF EVIDENCE: Level III.

Perioperative antiplatelet in elderly patients aged over 70 years treated with proximal femur fracture: continue or discontinue?

BACKGROUND: Antiplatelet medication has been frequently performed in elderly patients with hip fracture, because of comorbidities. This observational cohort study was to evaluate the effect of continuous perioperative antiplatelet medication on the outcomes after cephalomedullary nailing (CMN) in elderly patients with a proximal femur fracture. METHODS: One hundred and sixty-two consecutive patients aged ≥70 years undergoing CMN for proximal femur fracture between January 2015 and January 2017 were recruited. Of the 162 patients, 47 (study group) taking antiplatelets preoperatively due to comorbidities were compared with 107 (control group) who were not on antiplatelets. 8 patients taking anticoagulant medication were excluded. Postoperative hemoglobin (Hb) and hematocrit (Hct) levels, transfusion amount and estimated blood loss (EBL), occurrence of venous thromboembolism (VTE) and delirium, intensive care unit (ICU) admission, complications, length of hospital stay, readmission, and in-hospital and 1-year mortalities were measured and compared between the two groups. RESULTS: A higher number of patients in the study group had concomitant cardiovascular (p = 0.006) and endocrinologic (p = 0.004) diseases, received perioperative transfusion (p = 0.003), and were admitted to ICU postoperatively (p = 0.014). However, there were no significant differences in postoperative Hb and Hct levels, EBL, length of hospital stay, and the incidences of VTE and delirium between the two groups. In addition, in-hospital and 1-year mortalities as well as postoperative complications showed no significant differences between both groups. CONCLUSIONS: CMN can be performed without delay in elderly patients with proximal femoral fracture receiving antiplatelet therapy prior to admission without discontinuing antiplatelets, and is as safe as in patients who are not on antiplatelet medication. However, more caution is required with respect to transfusions and ICU care after surgery in these patients.

Topical tranexamic acid in elderly patients with femoral neck fractures treated with hemiarthroplasty: efficacy and safety? - a case-control study.

BACKGROUND: Perioperative blood management is an important issue in the treatment of elderly patients at an increased risk of postoperative complications. Accordingly, tranexamic acid (TXA) is widely administered to reduce blood loss and transfusion requirements. In this case-control study, the effect of topical TXA on the outcomes of elderly patients with femoral neck fractures after hemiarthroplasty was evaluated. METHODS: This study enrolled elderly patients (age ≥ 70 years) who underwent cementless bipolar hemiarthroplasty for femoral neck fractures between January 2015 and January 2017. The study group comprised 72 patients who received TXA via topical administration during surgery. After propensity matching, the control group comprised 72 patients who did not receive topical TXA. The perioperative and postoperative parameters of the two groups were compared. RESULTS: The estimated blood loss, vacuum tube drainage, and total transfusion volume were significantly lower in the study group than the control (p = 0.024, 0.003, and 0.019, respectively). Despite a lack of significant intergroup differences in the lengths of ICU and hospital stays; rates of ICU admission, venous thromboembolism, delirium, and readmission; and rates of in-hospital and 1-year mortality, the incidence of postoperative medical complications was significantly lower in the study group (p = 0.003). CONCLUSION: Topical TXA administration appears to be a simple and effective option for reducing blood loss, transfusion requirements, and medical complications after hemiarthroplasty in elderly patients with femoral neck fractures.

Dislocations after use of dual-mobility cups in cementless primary total hip arthroplasty: prospective multicentre series.

BACKGROUND: The purpose of this study was to investigate the incidence of dislocation and specific complications of the dual-mobility cup. METHODS: The arthroplasties involved 167 hips in 165 patients; 51 hips (30.5%) were in men and 116 (69.4%) were in women. The active articulation E1® dual-mobility cup (Biomet, Warsaw, IN, USA) was used, and the surgical approach was posterolateral in 120 hips and anterolateral in 47 hips. RESULTS: Four (2.3%) dislocations were observed. Mean time of dislocation was 30.5 days post-operatively. Three incomplete reductions occurred during closed reduction. When comparing parameters between dislocation and no-dislocation groups, there were no differences in patient and surgical parameters. However, all dislocations occurred in patients with femoral neck fractures and in the posterolateral approach group. CONCLUSION: The incidence of dislocation in total hip arthroplasty (THA) using a dual-mobility cup was acceptable, and cup diameter of the dislocation group was substantially larger than that of no-dislocation group. Based on clinical outcomes of our study, we conclude that the dual-mobility cup is a reliable option in THA, and further studies are necessary.

Lateral locked plating for distal femur fractures by low-energy trauma: what makes a difference in healing?

PURPOSE: The objective of this study is to investigate healing outcome of lateral locked plating for distal femoral fractures caused by low-energy trauma. In addition, we sought to determine predictable factors associated with fracture healing time. METHODS: Seventy-three patients (73 fractures) with distal femur fractures (AO/OTA type 33) caused by low-energy trauma were recruited. The mean age of patients was 69.8 years (range, 43-87 years). All fractures were stabilized by less invasive osteosynthesis with anatomical periarticular locking system. Patients were followed up for mean 17.3 months (range, 6-44 months). RESULTS: Of the 73 fractures, 52 (71.2%) fractures showed bony union within 6 months after the index surgery while the remaining 21 (28.8%) fractures showed delayed union or received revision surgery prior to complete healing. Although overall healing rate from the initial surgery was 93.2% (68/73), which seems to be satisfactory, the rate of surgical complications was 11.0% (8/73). Of all 73 fractures, seven received further surgery including three re-osteosynthesis. On multivariable analysis, plate-screw density at the fracture site was an independent predictable factor associated with the problematic healing. CONCLUSIONS: Our findings suggest that complications related to increased healing time and fixation construct are not infrequent and ongoing problems in managing low-energy distal femur fractures. Specifically, plate-screw density at the fracture site has a significant influence on healing time in these fractures.

Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon.

PURPOSE: The purpose of this study was to assess the results of a novel surgical technique for the treatment of chronic lateral ankle instability with attenuated or deficient ligamentous tissue that the modified Broström procedure could not be performed. A lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon has been performed. METHODS: Thirty-four consecutive patients treated with lateral ankle ligament reconstruction using anterior half of the peroneus longus tendon were enrolled. Median age at surgery was 24 years (range 19-46 years). The clinical and radiologic outcomes were evaluated preoperatively and at a median of 21 months (range 12-51 months) follow-up. RESULTS: The Karlsson-Peterson ankle score significantly improved from 58.2 ± 10.9 points preoperatively to 83.9 ± 7.0 points at the last follow-up. Mechanical stability was achieved. The mean talar tilt angle significantly improved from 15.7° ± 3.5° preoperatively to 4.6° ± 1.7° at the last follow-up, and the mean anterior talar translation significantly improved from 7.3 ± 2.6 mm preoperatively to 4.1 ± 1.7 mm at the last follow-up. Fifteen patients (52%) were very satisfied with the results, nine patients (31%) were satisfied, four patients (14%) were fair, and one patient (3%) was dissatisfied with the results. CONCLUSIONS: Lateral ankle ligament reconstruction using the anterior half of the peroneus longus tendon can be a surgical option for chronic lateral ankle instability with attenuated or deficient ligaments. LEVEL OF EVIDENCE: Case-series, Level IV.

Large Osteophytes over 10 mm at Posterior Medial Femoral Condyle Can Lead to Asymmetric Extension Gap Following Bony Resection in Robotic Arm-Assisted Total Knee Arthroplasty with Pre-Resection Gap Balancing.

Robotic arm-assisted total knee arthroplasty (TKA) involves a pre-resection gap balancing technique to obtain the desired gap. However, the expected gap may change owing to the soft-tissue release effect of unreachable osteophytes. This study evaluated the effect of unreachable osteophytes of the posterior medial femoral condyle on gap changes following bony resection. We retrospectively analysed 129 robotic arm-assisted TKAs performed for varus knee osteoarthritis. Knees were classified according to the size of osteophytes on the posterior medial femoral condyle using preoperative computed tomography measurement. After the removal of reachable osteophytes, the robotic system measured pre- and post-resection medial extension (ME), lateral extension (LE), medial flexion (MF), and lateral flexion (LF) gaps. No extension gap changes were observed for 25 (19.4%), and no flexion gap changes were observed 41 (31.8%) knees, following bone cuts. ME, LE, MF, and LF gaps increased with the osteophyte size (p < 0.05). For osteophytes <10 mm, all the gaps increased symmetrically. However, for osteophytes >10 mm, the ME gap increased asymmetrically more than LE, MF, and LF gaps (p < 0.05). The gap changes due to bony resection were correlated to the osteophyte sizes of the posterior medial femoral condyle. Surgeons should plan a slightly tight medial extension gap to attain the desired gaps for >10 mm osteophytes.

Simultaneous reduction and fixation using an anatomical suprapectineal quadrilateral surface plate through modified Stoppa approach in superomedially displaced acetabular fractures.

Treatment of superomedially displaced acetabular fractures including a quadrilateral surface (QLS) is challenging. We present a surgical technique using an anatomical suprapectineal QLS plate through the modified Stoppa approach and report the availability of this plate to treat this fracture type along with the surgical outcomes. Sixteen consecutive patients (14 men and 2 women) who underwent surgical treatment using an anatomical suprapectineal QLS plate through a modified Stoppa approach for superomedially displaced acetabular fractures between June 2018 and June 2020, were enrolled retrospectively. These fractures included 11 both-column fractures and 5 anterior-column and posterior hemitransverse fractures, which were confirmed on preoperative 3-dimensional computed tomography. Surgical outcomes were clinically assessed using the Postel Merle d'Aubigné (PMA) score and visual analog scale (VAS) score at the final follow-up, and radiological evaluations were performed immediately after the operation and at the final follow-up. For comparative analysis, 23 patients who underwent internal fixation with the conventional reconstruction plate through modified ilioinguinal approach between February 2010 and May 2018, were selected. This control group was composed of 18 both-column fractures and 5 anterior-column and posterior hemitransverse fractures. The follow-up period was at least 1 year in all patients. The mean operation time and blood loss was 109 min, and 853 ml, respectively, whereas 236 min, and 1843 ml in control group. Anatomical reduction was achieved in 14 (87.5%) patients, while imperfect reduction was achieved in the remaining 2 patients. At the final follow-up, radiographic grades were excellent, fair, and poor in 14 patients (87.5%), one, and one, respectively. The mean PMA score was 16.1 (range 13-18) and the mean VAS score was 1.0 (range 0-3). No secondary reduction loss or implant loosening was observed. However, 2 patients underwent conversion to total hip arthroplasty (THA) due to post-traumatic arthritis and subsequent joint pain. No other complications were observed. In the comparative analysis, radiological outcome showed a significant relationship with the conversion to THA (p = 0.013). Shorter operation time and less blood loss were significantly observed in the QLS plate fixation group through the modified Stoppa approach compared with the conventional reconstruction plate fixation group through modified ilioinguinal approach (p < 0.001, respectively). Simultaneous reduction and fixation using an anatomical suprapectineal QLS plate through the modified Stoppa approach may be a viable technique in superomedially displaced acetabular fractures along with shorter operation time and less blood loss.

Impact of coronal plane fragments and anterior big neck fragments on the occurrence of perioperative lateral wall fractures in AO/OTA 31-A1,2 intertrochanteric fractures treated with cephalomedullary nailing.

PURPOSE: Cephalomedullary nails are used widely today for pertrochanteric fractures, and intraoperative lateral wall fractures can cause adverse effects. Recently, a high incidence of coronal fragments in pertrochanteric fractures was reported when analyzed with 3D CT reconstructions. In this study, we analyzed the association between the type of coronal fragments and perioperative lateral wall fractures. METHODS: Patients diagnosed with pertrochanteric fractures and treated by cephalomedullary nails at three university hospitals from September 2016 to December 2020 were examined. A total of 463 patients were included. We examined the coronal fragments and divided the patients into two groups according to the involvement of the posteromedial cortex. Postoperative X-rays were scanned for fracture lines at the blade entry site. RESULTS: Twenty-two patients among 463 patients had perioperative lateral wall fractures. The AO type A2 fractures, use of provisional pins, existence of coronal fragments, involvement of the posteromedial cortex, and the existence of anterior big neck fragments were significantly relevant to perioperative lateral wall fractures. 11 of 22 lateral wall fracture patients were delayed fracture patients, identified 4 weeks after surgery. A coronal fragment combined by anterior big neck fragments had a 9.24 times higher risk of lateral wall fractures compared to fractures with only coronal fragments. CONCLUSION: Pertrochanteric fractures with large coronal fragments and anterior big neck fragments have a high risk of perioperative lateral wall fractures when treated by cephalomedullary nails. Surgeons should examine the width of the intact lateral wall, and take caution to preserve its integrity.

Dual mobility articulation total hip arthroplasty for displaced neck fracture in elderly with neuromuscular disorder.

PURPOSE: Neuromuscular disease is well known to be at increased risk of complications following hip replacement surgeries. This study is prospectively conducted to investigate clinical performance and survivorship of total hip arthroplasty (THA) using dual mobility articulation in femoral neck fractures of elderly with neuromuscular disease. MATERIALS AND METHODS: We prospectively enrolled 162 patients (162 hips) with displaced femoral neck fracture who gave informed consent for dual mobility articulation THA. Of the 162 patients, 35 patients had neuromuscular disease including cerebral palsy, poliomyelitis, hemiplegia, and Parkinson disease (NM group). The other 127 patients had no history of neuromuscular disease (non-NM group). The mean age was 76.5 years (range, 60 - 95) and female ratio was 71.0% (115/162). Clinical outcomes including Harris hip score (HHS), University of California Los Angles activity (UCLA) score were compared between the two groups. Computed tomography and serial radiographs were obtained after surgery. Postoperative complications and reoperation including revision were recorded. RESULTS: Pain-VAS and all clinical scores of the NM group were comparable to those of the non-NM group. The incidence of dislocation in the NM group did not differ from that in Non-NM group (2/35, 5.7% versus 5/127, 3.9%, p = 0.645). Reoperation was performed in 3 hips (3/35, 8.6%) of the NM group and in 4 hips (4/127, 3.1%) of the non-NM group (p = 0.173). Kaplan-Meier survivorship with an end point of revision for any reason was 97.1% (95% confidence interval [CI], 0.92 to 1.03) in the NM group and 98.4% (95% CI, 0.96 to 1.01) in the non-NM group at 7.3 years after surgery. CONCLUSIONS: In elderly with neuromuscular disease, THA with dual mobility articulation is a reasonable option as a treatment for femoral neck fractures.

Angiomyxolipoma (vascular myxolipoma) of the knee in a 9-year-old boy.

Angiomyxolipoma (vascular myxolipoma) is a very rare variant of lipoma. This tumor is characterized by mature adipose tissue mixed with myxoid stroma and vascular vessels. To date, nine cases have been reported, all of them occurring in adults. Herein, we report a unique case of a 9-year-old boy presenting with a solitary painful mass on the right medial thigh and illustrate the imaging characteristics of this rare tumor.

Management of anteromedially displaced acetabular fractures using a collinear reduction clamp through modified ilioinguinal approach.

The authors present a surgical technique using a collinear reduction clamp through the modified ilioinguinal approach (MIA) for anteromedially displaced acetabular fractures along with the surgical outcomes. Between October 2010 and June 2015, 15 patients underwent surgical treatment for anteromedially displaced acetabular fractures; 10 both-column fractures and 5 anterior column and posterior hemitransverse fractures. Anteriorly displaced anterior column fragment and medially displaced quadrilateral plate fragment were simultaneously reduced using a collinear clamp and fixed with a 3.5mm-reconstruction plate through MIA. Postoperatively, anatomical reduction was achieved in 12 patients, while imperfect reduction was achieved in 3. At a mean follow-up of 49.0 months (range, 24-93 months), the mean Postel Merle d'Aubigné score were 16.3 and the mean VAS score was 0.9. Final radiographic grades according to Matta system were excellent in 13 patients and good in 2. Surgical technique using a collinear reduction clamp through the MIA can provide satisfactory outcomes in anteromedially displaced acetabular fractures.

Signaling pathway of glutamate in the vestibular nuclei following acute hypotension in rats.

Acute hypotension induces excitation of electrical activity and expression of c-Fos protein and phosphorylated extracellular signal-regulated kinase (pERK) in the vestibular nuclei. Expression of c-Fos protein and pERK is mediated by the excitatory neurotransmitter, glutamate. In this study, in order to investigate the signaling pathway of glutamate in the vestibular nuclei following acute hypotension, expression of the NR2B subunit of glutamate N-methyl-D-aspartate (NMDA) receptors and the GluR1 subunit of glutamate alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA) receptors was measured by Western blotting in the medial vestibular nucleus (MVN) following acute hypotension in bilateral labyrinthectomized (BL) rats. In intact labyrinthine animals, acute hypotension increased expression of pGluR1 and pNR2B in the MVN. Expression of pGluR1 Ser831 and Ser845 peaked at 5 and 30 min after acute hypotension and expression of pNR2B peaked at 60 min after acute hypotension, respectively. In BL animals, expression of pGluR1 Ser831, pGluR1 Ser845, and pNR2B was decreased significantly compared to intact labyrinthine animals following acute hypotension. These results suggest that excitatory afferent signals from the peripheral vestibular receptors, resulting from acute hypotension, release glutamate into postsynaptic neurons in the vestibular nuclei and the excitatory signals are transmitted through the GluR1 subunit of the AMPA receptors and the NR2B subunits of the NMDA receptors in the vestibular system.

Postoperative fever after hemiarthroplasty in elderly patients over 70 years of age with displaced femoral neck fracture: Necessity of routine workup?

OBJECTIVES: Displaced femoral neck fracture in elderly patients has been treated with hemiarthroplasty as the treatment of choice. Fever following HA is common in these elderly patients. The aim of this study was to determine which post-HA fever workup could be beneficial in this group of patients. METHODS: A total of 272 consecutive patients aged ≥70 years undergoing HA for displaced femoral neck fracture were retrospectively investigated. Postoperative fever (POF) was defined as any recorded body temperature ≥38°C in the early postoperative period. POF in each patient was characterized by the maximum temperature, the day of the first fever, and frequency of fever, stratified as either single or multiple fever spikes. Medical records were reviewed to identify positive fever workups and febrile complications. RESULTS: Of 272 patients, 135 (49.6%) developed POF. A total of 428 routine diagnostic tests were performed in all patients with POF, of which only 57 tests (13.3%) were positive. Urinalysis showed the highest positive rate (21.9%), followed by urine culture (14.3%), chest x-ray (12.6%), and blood culture (1.1%). The most common febrile complication was pneumonia (12.6%), followed by urinary tract infection (8.1%). On multivariate logistic regression for positive workups, only fever after postoperative day (POD) 2 was a risk factor for positive chest x-ray (OR 3.86, p=0.016) and urine culture (OR 5.04, p=0.019). Moreover, fever after POD 2 (OR 6.93, p<0.0001) and multiple fever spikes (OR 2.92, p=0.026) were independent predictors of infectious febrile complications. CONCLUSIONS: Routine workup for POF following hemiarthroplasty in elderly patients with displaced femoral neck fracture is not warranted. However, for fever after POD 2 and multiple fever spikes, chest x-ray and urinalysis would be necessary to rule out the two most common febrile complications such as pneumonia and urinary tract infection.

Does preoperative mechanical prophylaxis have additional effectiveness in preventing postoperative venous thromboembolism in elderly patients with hip fracture?-Retrospective case-control study.

BACKGROUND: Elderly patients undergoing hip fracture surgery (HFS) are at increased risk of postoperative venous thromboembolism (VTE). To reduce this risk, combined postoperative mechanical and chemical thromboprophylaxis has been routinely performed after HFS in these patients. This retrospective case-control study was conducted to evaluate the additional effectiveness of preoperative mechanical thromboprophylaxis for the prevention of VTE following HFS in elderly patients. METHODS: Of 539 consecutive patients aged 70 years or older undergoing HFS, 404 (control group) did not receive preoperative mechanical thromboprophylaxis, while 135 (study group) received mechanical thromboprophylaxis using an intermittent pneumatic compression device and graduated compression stockings from the time of admission until surgery. All patients received combined postoperative mechanical and chemical thromboprophylaxis following HFS in accordance with the same protocol. The incidence of symptomatic VTE confirmed based on clinical symptoms and 3-dimensional CT angiography within one month of surgery was investigated in both groups. RESULTS: The American Society of Anesthesiologists grade was higher (p = 0.016) in the study group and more patients in this group had concomitant cardiovascular and neurologic diseases (p = 0.005 and p = 0.009, respectively). In addition, more patients in the study group had received anticoagulant medication preinjury owing to comorbidities (39% vs 28%, p = 0.025). The overall incidences of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) were 7.4% and 3.7%, and 2.2% and 1.5% in the control and study groups, respectively. According to multiple logistic regression, symptomatic DVT significantly reduced in the study group (OR 0.28, p = 0.042), while there was no significant difference in the incidence of symptomatic PE between the two groups (p = 0.223). CONCLUSIONS: Preoperative mechanical thromboprophylaxis may confer an additional benefit by preventing postoperative VTE without adding more risk of perioperative bleeding in elderly patients with hip fracture.

The natural course of prevertebral soft tissue swelling after anterior cervical spine surgery: how long will it last?

BACKGROUND CONTEXT: Prevertebral soft tissue swelling (PSTS) after anterior cervical spine surgery (ACSS) has been regarded as one of the critical complications that cause airway obstruction. Still, however, no research has dealt with how PSTS returns to presurgery status after ACSS; most recommendations are being performed without information about its natural course, focusing on acute-phase swelling after surgery. PURPOSE: The study aimed to examine how long postsurgery PSTS lasts and when it returns to its presurgery state, and to analyze the actual influence of a number of factors to observe the natural progress of postsurgery PSTS. STUDY DESIGN/SETTING: This is a prospective observational study. PATIENT SAMPLE: The sample included a total of 160 patients who underwent ACSS, including anterior cervical discectomy and fusion (ACDF) and cervical total disc replacement (TDR). OUTCOME MEASURES: The diameter of PSTS measured at each set time point after surgeries was compared with PSTS measurements before surgery, and analyzed with factors influencing PSTS. METHODS: Anterior and posterior diameters of the anterior soft tissue of C3 (pharyngeal airway) and C6 (laryngeal airway) were measured using simple lateral radiography before surgery, immediately after surgery, at 2 weeks, 1, 3, 6, and 12 months after surgery. The progress of postsurgery PSTS was analyzed according to patients' individual characteristics, such as age, gender, weight, body mass index (BMI), smoking status, use of antiplatelet therapy, hypertension and diabetes mellitus, complaints of dysphagia, along with surgical factors such as anesthesia time, operation time, numbers of involved operation segments, transfusion, estimated blood loss , and operation method. Multivariable analysis by generalized linear mixed model was used to perform additional univariable analysis on variables found to be related to PSTS. In addition, to find the postsurgery interval at which PSTS naturally stabilizes, repeated measures analysis of variance and Bonferroni method were used to perform post-hoc tests. There were no sources of funding and no conflicts of interest associated with this study. RESULTS: For ACDF, the mean values (95% confidence interval [CI]) of PSTS in C3 were 4.38 (4.04~4.71), 10.40 (9.64~11.17), 7.72 (7.10~8.35), 6.24 (5.74~6.69), 5.43 (5.03~5.82), 5.14 (4.77~5.50), and 4.96 (4.59~5.33) mm at each follow-up time, respectively. In C6, the average values (95% CI) of PSTS were 14.43 (13.96~14.91), 19.18 (18.59~19.77), 17.92 (17.37~18.47), 16.98 (16.45~17.51), 16.18 (15.67~16.69), 15.95 (15.50~16.40), and 15.49 (15.50~16.40) mm. For cervical TDR, the mean values (95% CI) of PSTS in C3 were 3.67 (3.45~3.89), 8.05 (7.17~8.93), 5.42 (4.92~5.91), 4.57 (4.21~4.92), 4.12 (3.99~4.36), 4.10 (3.87~4.34), and 3.90 (3.66~4.14) mm at each follow-up time, respectively. In C6, the average values (95% CI) of PSTS were 13.61 (12.96~14.25), 16.51 (15.80~17.21), 15.77 (15.13~16.42), 15.24 (14.61~15.87), 14.62 (14.01~15.22), 14.52 (13.88~15.17), and 13.94 (13.20~14.68) mm. It is discovered that PSTS after surgery returned to presurgery status within 1 to 3 months in the pharyngeal airway (C3) and within 3 to 6 months in the laryngeal airway (C6), and gender, BMI, and surgery method (ACDF) were determined to be the factors having influence on PSTS after surgery. CONCLUSIONS: It is necessary to pay attention to PSTS and patient conditions after ACSS for at least 1 to 6 months postsurgery, depending on surgical method and operation levels.

Torsional malalignment, how much significant in the trochanteric fractures?

OBJECTIVES: The rotational alignment is definitely important in the long bones such as tibias and femurs. We also predict the importance of rotational alignment in the trochanteric fractures. So we measured torsional malalignment in trochanteric fracture and anlaysed their risk factors and their clinical significance. METHODS: A total of 109 inpatients who had undergone internal fixation following trochanteric fracture and a postoperative pelvic CT scan between 2008 and 2013, with at least one year follow-up, were selected. Factors that affect torsional malalignment, such as age, gender, fracture stability, injured area, operative time, time of surgery after admission, and ASA status, were investigated. Factors that affect the patients' clinical results in malrotation, including ambulation time after surgery, postoperative complication rates, pain assessment of VAS one year postoperatively and Koval score, were also investigated. RESULTS: Of the 109 subjects, torsional malalignment was observed in 28 (25.7%) subjects with a mean torsional malalignment angle of 20.7° (range: -31.2° to 27.1°). Torsional malalignment risk factors were fracture stability (p=0.021) and operative time (p=0.043). In terms of the time to ambulation after surgery, the postoperative complication rates, and the VAS and Koval scores at one year postoperatively, no statistically significant difference was observed between the torsional malalignment patients and the non-deformity patients. CONCLUSIONS: In this study, 25.7% of the patients who had undergone internal fixation following trochanteric fracture experienced torsional malalignment. Major factors of the torsional malalignment were an unstable fracture and the consequent delay in the operative time. But the torsional malalignment was deemed to have no effect on clinical results.

Risk factors for contra-lateral hip fracture in elderly patients with previous hip fracture.

INTRODUCTION: Contra-lateral hip fractures in elderly patients with a previous hip fracture increase the incidence of complications and socioeconomic burden. The purpose of this study was to identify the risk factors that contribute to the occurrence of contra-lateral hip fracture in elderly patients. MATERIALS AND METHODS: Among 1093 patients treated for a hip fracture, 47 patients sustained a contra-lateral hip fracture. These patients were compared with 141 patients with a unilateral hip fracture (controls). RESULTS: The incidence of contra-lateral hip fracture was 4.3% among the 1093 patients treated for a hip fracture at our institute. A contra-lateral hip fracture occurred within 2 years of initial fracture in 66%, and subsequently, the annual incidence rate decreased. A similar fracture pattern was noted in 70% of patients who sustained an intertrochanteric fracture. In terms of preoperative factors, respiratory disease (OR 2.57, P=0.032) and visual impairment (OR 2.51, P=0.012) were higher in patients with a contra-lateral hip fracture than in controls, and for postoperative factors, the proportions of patients with postoperative delirium (OR 2.91, P=0.022), late onset of rehabilitation (OR 1.05, P=0.023), and poor ambulatory status at 3 months (OR 1.34, P=0.002) were also significantly higher in patients than in controls. CONCLUSIONS: Postoperative delirium and underlying visual impairment and respiratory disease could be risk factors of contra-lateral fracture in elderly patients. Early and active rehabilitation after surgery is important to prevent the occurrence of contra-lateral hip fracture in the elderly.