Outcomes of total hip arthroplasty after failed free vascularized fibular grafting for osteonecrosis of the femoral head.

PURPOSE: Total hip arthroplasty (THA) after vascularized fibular grafting (VFG) is technically demanding with poorer outcomes compared to primary THA in patients with osteonecrosis of the femoral head (ONFH). The purpose of this study was to compare the outcomes of THA after VFG after removal of the graft with that of primary THA. METHODS: ONFH patients treated by VFG at a single institution were studied retrospectively. THAs after VFG performed by single arthroplasty surgeon with a single type of THA prosthesis were enrolled in the study. A control cohort of patients was created by 1:1 matching with the THA after VFG cohort according to age, gender, and American Society of Anesthesiology (ASA) score from ONFH patients treated by primary THA. Early and long-term outcomes were compared between the two groups. RESULTS: A total of 24 hips were included in the THA after VFG group and compared with 24 primary THA hips. No significant difference was noted in stem position. The THA after VFG group had increased blood loss and longer duration of operation time. There were two cases of intraoperative femur fractures in the THA after VFG group. The femoral stem of both groups were stable, with no cases of revision, and similar HHS scores at the last follow-up. CONCLUSION: THA after VFG may have similar short to midterm outcomes with primary THA after removal of the residual abutting bone graft and correct positioning of the femoral stem.

ARCO Consensus on the Pathogenesis of Non-traumatic Osteonecrosis of the Femoral Head.

Osteonecrosis of the femoral head (ONFH) is a devastating disease frequently leading to femoral head collapse and hip arthritis. Specifically, non-traumatic ONFH primarily affects young and middle-aged adults. Although compromised local circulation of the femoral head seems to be pathognomonic for the disease, the pathogenesis is perplexing and continues to be an area of scrutiny and research. Comprehension of the pathogenesis is of crucial importance for developing and guiding treatments for the disease. Therefore, we provide an up-to-date consensus on the pathogenesis of non-traumatic ONFH.

Osteonecrosis of the Femoral Head: an Updated Review of ARCO on Pathogenesis, Staging and Treatment.

Non-traumatic osteonecrosis of the femoral head (ONFH) usually affects adults younger than 50 years and frequently leads to femoral head collapse and subsequent arthritis of the hip. It is becoming more prevalent along with increasing use of corticosteroids for the adjuvant therapy of leukemia and other myelogenous diseases as well as management of organ transplantation. This review updated knowledge on the pathogenesis, classification criteria, staging system, and treatment of ONFH.

Long-Term Results of Total Hip Arthroplasty in Young Patients With Osteonecrosis After Allogeneic Bone Marrow Transplantation for Hematological Disease: A Multicenter, Propensity-Matched Cohort Study With a Mean 11-Year Follow-Up.

BACKGROUND: The number of young patients with hematological disease requiring total hip arthroplasty (THA) is expected to increase. We aimed to investigate the long-term THA outcomes in patients with osteonecrosis of the femoral head (ONFH) following allogeneic bone marrow transplantation (BMT) for hematological disease. METHODS: All patients who underwent THA for osteonecrosis after BMT from 1997 to 2012 were identified at 2 institutions. Using propensity scores, 75 THAs in 45 patients were matched for age, gender, body mass index, American Society of Anesthesiologists score, and year of surgery with 75 THAs in 58 patients with idiopathic ONFH without a history of hematological disease (1:1 ratio). The mean age at surgery was 36.7 years and 52% were men. Clinical and radiographic evaluations were performed and clinical scores were obtained at last follow-up. Kaplan-Meier analyses were used to compare survivorship. RESULTS: At a mean follow-up of 10.6 ± 3.5 years, clinical, radiographic, and survivorship outcomes, and the Harris hip scores were similar between both groups. The 13-year survivorship for all-cause revision was 93.4% for the BMT group and 95% for the control group (P = .928). No significant differences were observed between groups in the rates of reoperation (4% vs 5.3%, P = 1.000), 90-day readmission (all 5.3%), or overall mortality (4.4% vs 1.7%, P = .681). No hips had periprosthetic joint infection or septic loosening in either group. Osteolysis occurred in none of the BMT patients and in 2 hips (2.7%) of the control patients (P = .497). CONCLUSION: This large cohort multicenter survey at 11-year follow-up shows that contemporary cementless THA in young hematological disease patients after allogeneic BMT is not associated with a higher risk for surgical complications, revision, reoperation, readmission, and mortality compared to a matched cohort of idiopathic ONFH.

The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head.

BACKGROUND: The Association Research Circulation Osseous (ARCO) presents the 2019 revised staging system of osteonecrosis of the femoral head (ONFH) based on the 1994 ARCO classification. METHODS: In October 2018, ARCO established a task force to revise the staging system of ONFH. The task force involved 29 experts who used a web-based survey for international collaboration. Content validity ratios for each answer were calculated to identify the levels of agreement. For the rating queries, a consensus was defined when more than 70% of the panel members scored a 4 or 5 rating on a 5-point scale. RESULTS: Response rates were 93.1%-100%, and through the 4-round Delphi study, the 1994 ARCO classification for ONFH was successfully revised. The final consensus resulted in the following 4-staged system: stage I-X-ray is normal, but either magnetic resonance imaging or bone scan is positive; stage II-X-ray is abnormal (subtle signs of osteosclerosis, focal osteoporosis, or cystic change in the femoral head) but without any evidence of subchondral fracture, fracture in the necrotic portion, or flattening of the femoral head; stage III-fracture in the subchondral or necrotic zone as seen on X-ray or computed tomography scans. This stage is further divided into stage IIIA (early, femoral head depression ≤2 mm) and stage IIIB (late, femoral head depression >2 mm); and stage IV-X-ray evidence of osteoarthritis with accompanying joint space narrowing, acetabular changes, and/or joint destruction. This revised staging system does not incorporate the previous subclassification or quantitation parameters, but the panels agreed on the future development of a separate grading system for predicting disease progression. CONCLUSION: A staging system has been developed to revise the 1994 ARCO classification for ONFH by an expert panel-based Delphi survey. ARCO approved and recommends this revised system as a universal staging of ONFH.

Fourth-generation ceramic-on-ceramic THA results in improvements in midterm outcomes compared to third-generation THA but does not resolve noise problems: a cohort study of a single-hip system.

BACKGROUND: Using data from the Korean Hip Registry, we aimed to investigate mid-term clinical and radiographic outcomes, including the prevalence of periprosthetic joint infection (PJI), osteolysis, and component loosening or dislocation, and to analyze the incidence of bearing-related complications following modern ceramic-on-ceramic (COC) total hip arthroplasty (THA) using a single cementless hip system. METHODS: Four hundred eighty-two patients (602 hips) who underwent Forte or Delta COC THAs with a single hip system and had a minimum 5-year follow-up were identified. The sample included 243 (50.4%) women and 239 (49.6%) men with a mean age of 50.6 years (range: 18-83 years). The Forte group comprised 310 hips, and the Delta group comprised 292 hips. The mean follow-up was 6.1 years (range: 5-10.2 years). RESULTS: Cup orientation did not differ between groups. No hip had a PJI or osteolysis in either group. All acetabular components and all but two femoral components (in the Delta group) were well fixed. Dislocations occurred in six (1.9%) hips in the Forte group and one (0.3%) hip in the Delta group (p = 0.124). A total of nine (1.5%) revisions were performed. The 5-year survival rates for all-cause revisions were 98.4 and 98.6%, respectively. One (0.3%) ceramic head fracture occurred in the Forte group. Sixteen (5%) hips exhibited clicking and 6 (2%) hips had squeaking in the Forte group; 16 (6%) hips exhibited clicking and 5 (2%) hips had squeaking in the Delta group. Multiple regression analysis revealed that noise generation was unassociated with any factor. CONCLUSIONS: From the Korean Hip Registry data, THA with modern ceramic bearings showed encouraging results, with lower risks of PJI, osteolysis, and component loosening. In particular, Delta COC THA resulted in no PJI or ceramic fracture and had a reduced dislocation risk. However, associated noise remains a concern.

Etiologic Classification Criteria of ARCO on Femoral Head Osteonecrosis Part 1: Glucocorticoid-Associated Osteonecrosis.

BACKGROUND: Glucocorticoid usage, a leading cause of osteonecrosis of the femoral head (ONFH), and its prevalence was reported in 25%-50% of non-traumatic ONFH patients. Nevertheless, there have been no unified criteria to classify glucocorticoid-associated ONFH (GA-ONFH). In 2015, the Association Research Circulation Osseous addressed the issue of developing a classification scheme. METHODS: In June 2017, a task force was set up to conduct a Delphi survey concerning ONFH. The task force invited 28 experts in osteonecrosis/bone circulation from 8 countries. Each round of the Delphi survey consists of questionnaires, analysis of replies, and feedback reports to the panel. After 3 rounds of the survey, the panel reached a consensus on the classification criteria. The response rates were 100% (Round 1), 96% (Round 2), and 100% (Round 3), respectively. RESULTS: The consensus on the classification criteria of GA-ONFH included the following: (1) patients should have a history of glucocorticoid use >2 g of prednisolone or its equivalent within a 3-month period; (2) osteonecrosis should be diagnosed within 2 years after glucocorticoid usage, and (3) patients should not have other risk factor(s) besides glucocorticoids. CONCLUSION: Association Research Circulation Osseous established classification criteria to standardize clinical studies concerning GA-ONFH.

Etiologic Classification Criteria of ARCO on Femoral Head Osteonecrosis Part 2: Alcohol-Associated Osteonecrosis.

BACKGROUND: Although alcohol is a leading risk factor for osteonecrosis of the femoral head (ONFH) and its prevalence reportedly ranges from 20% to 45%, there are no unified classification criteria for this subpopulation. In 2015, Association Research Circulation Osseous decided to develop classification criteria for alcohol-associated ONFH. METHODS: In June of 2017, Association Research Circulation Osseous formed a task force to conduct a Delphi survey. The task force invited 28 experts in osteonecrosis/bone circulation from 8 countries. Each round of the Delphi survey included questionnaires, analysis of replies, and feedback reports to the panel. After 3 rounds of the survey, consensus was reached on the classification criteria. The response rates for the 3 Delphi rounds were 100% (round 1), 96% (round 2), and 100% (round 3). RESULTS: The consensus on the classification criteria of alcohol-associated ONFH included the following: (1) patients should have a history of alcohol intake >400 mL/wk (320 g/wk, any type of alcoholic beverage) of pure ethanol for more than 6 months; (2) ONFH should be diagnosed within 1 year after alcohol intake of this dose; and (3) patients should not have other risk factor(s). CONCLUSION: ARCO-established classification criteria to standardize clinical studies concerning AA-ONFH.

Delay of total hip arthroplasty to advanced stage worsens post-operative hip motion in patients with femoral head osteonecrosis.

PURPOSE: Osteonecrosis of the femoral head (ONFH) is commonly detected in young patients and most surgeons tend to delay total hip arthroplasty (THA) until the end stage of the disease. We hypothesised that post-operative range of motion (ROM) of the hip as well as baseline ROM at the time of surgery decreases with the disease progression. The purpose of this study was to determine whether patients, who were operated at an advanced stage, have pre- and post-operative hip ROM similar to ROM of patients, who were operated at earlier stages. METHODS: Eight hundred and fifty patients (850 hips) treated with THA for ONFH were classified according to pre-operative stages of Association Research Circulation Osseous (ARCO). Fifty-six patients were operated at stage 2, 458 at stage 3, and 336 at stage 4. Pre-operative and one year post-operative ROM was compared among the stages. RESULTS: Pre-operative sum of hip ROM decreased with the progression of ARCO stage (P < 0.001) and correlated with the post-operative sum of hip ROM (correlation coefficient 0.661). Although hip ROM improved after THA in all stages, post-operative ROM in patients with lower pre-operative ROM did not improve to the same level as in those with a higher pre-operative ROM (P < 0.001). CONCLUSIONS: The progression of ONFH negatively affected post-operative hip ROM as well as baseline hip ROM at the time of THA. Surgeons should consider a delay of THA negatively affects the hip ROM after the arthroplasty, when they determine the treatment modality for ONFH patients.

Surgical accuracy, function, and quality of life of simultaneous versus staged bilateral Total hip Arthroplasty in patients with Osteonecrosis of the femoral head.

BACKGROUND: The optimal surgical option for patients requiring bilateral hip replacement remains controversial. The purpose of this study was to compare surgical accuracy; functional outcome and health-related quality of life; and prosthetic-related complications and revision surgery of a simultaneous bilateral total hip arthroplasty (THA) with those of a staged bilateral THA with an interval between procedures <12 months. METHODS: A total of 123 unselected consecutive patients (mean age, 43.3 years) who underwent bilateral THAs for osteonecrosis of the femoral head (ONFH) with a minimum follow-up of two years (mean, 60.2 months) were studied retrospectively; 63 simultaneous procedures served as a test group and 60 staged procedures served as a control group. RESULTS: The mean postoperative leg-length discrepancy (LLD) and the percentage of patients who had an LLD >3 mm were significantly lower in the simultaneous group (P < 0.001 and P = 0.001, respectively). A higher number of cups within the safe zones, a higher correction rate, and a lower failure rate for the cup placement in the second-operated hip were also identified in the simultaneous group. The mean Harris hip score, EuroQol-5D index, and EuroQol-visual analogue scale score were all better in the simultaneous group at the latest follow-up (P < 0.001, in all comparisons). We found that the simultaneous procedure was associated with a lower incidence of postoperative prosthetic-related complications and revision surgery. CONCLUSIONS: We suggest that bilateral ONFH could be treated with a simultaneous THA rather than a staged THA to achieve a better surgical outcome.

Effect of Inner Taper Angle of Acetabular Metal Shell on the Malseating and Dissociation Force of Ceramic Liner.

BACKGROUND: Malseating of ceramic liner appeared as a matter of concern in multibearing metal, although multibearing cup can be coupled with hard liners as well as polyethylene liner. In this metal shell, the inner taper angle should be 10° for the modularity, while standard metal shells for ceramic liner have an inner taper angle of 18°. However, there has been no study in the effect of taper angle to the risk of malseating. We evaluated whether the taper angle of metal shell might affect the malseating of ceramic liner, and dissociation force of ceramic liner from metal shell. METHODS: Three surgeons manually inserted ceramic liners into two designs of metal shell with different tapers angles (10° and 18°). We compared malseating rates of ceramic liners and push-out strengths, which means dissociation force of the ceramic liner from the metal shell, between these two metal shell designs. RESULTS: The malseating rates in 10° metal shell were higher than those in 18° metal shell (23.3% vs 0%, P < .05). The mean dissociation force (1148.8 ± 46.7 N) in 10° taper cup was higher than that (389.7 ± 108.3 N) in 18° taper cup (P < .01). CONCLUSION: Our results suggest that surgeon should be cautious about malseating of ceramic liner when using multi-bearing metal shell with inner taper angle of 10°. CLINICAL RELEVANCE: When surgeon use multi-bearing metal shell with inner taper angle of 10°, our results suggest that surgeon should be cautious about malseating of ceramic liner.

Decreased Lumbar Lordosis and Deficient Acetabular Coverage Are Risk Factors for Subchondral Insufficiency Fracture.

Subchondral insufficiency fracture (SIF) of the femoral head occurs in the elderly and recipients of organ transplantation. Osteoporosis and deficient lateral coverage of the acetabulum are known risk factors for SIF. There has been no study about relation between spinopelvic alignment and anterior acetabular coverage with SIF. We therefore asked whether a decrease of lumbar lordosis and a deficiency in the anterior acetabular coverage are risk factors. We investigated 37 patients with SIF. There were 33 women and 4 men, and their mean age was 71.5 years (59-85 years). These 37 patients were matched with 37 controls for gender, age, height, weight, body mass index and bone mineral density. We compared the lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope, acetabular index, acetabular roof angle, acetabular head index, anterior center-edge angle and lateral center-edge angle. Lumbar lordosis, pelvic tilt, sacral slope, lateral center edge angle, anterior center edge angle, acetabular index and acetabular head index were significantly different between SIF group and control group. Lumbar lordosis (OR = 1.11), lateral center edge angle (OR = 1.30) and anterior center edge angle (OR = 1.27) had significant associations in multivariate analysis. Decreased lumbar lordosis and deficient anterior coverage of the acetabulum are risk factors for SIF as well as decreased lateral coverage of the acetabulum.

Preventing Venous Thromboembolism with Use of Intermittent Pneumatic Compression after Total Hip Arthroplasty in Korean Patients.

Intermittent Pneumatic Compression (IPC) device has been used to prevent venous thromboembolism (VTE). This study investigated the effectiveness of IPC device. We evaluated incidences of deep vein thrombosis (DVT) and pulmonary embolism (PE) in total hip arthroplasty (THA) patients after use of IPC device, and compared with historical incidences from our institution. We applied IPC device in 741 patients who underwent 870 elective primary THAs from January 2010 to December 2013, DVT was detected in 3 patients (0.3%) by sonography, and one (0.1%) of them was symptomatic. Symptomatic PE occurred in 1 patient (0.1%) and there were no cases of fatal PE. The incidence of symptomatic DVT was significantly lower than the historical control (P = 0.042). The IPC is a safe and effective prophylaxis of VTE after primary THA in Korea.

Metal on Metal or Ceramic on Ceramic for Cementless Total Hip Arthroplasty: A Meta-Analysis.

BACKGROUND: Hard bearings, metal on metal (MOM) and ceramic on ceramic (COC), have been developed to overcome polyethylene wear-related osteolysis, but comparisons between these 2 hard bearings are limited. We performed a meta-analysis to determine revision rates for (1) any reason, (2) aseptic loosening, (3) periprosthetic joint infection (PJI), and (4) recurrent dislocation between MOM and COC bearings in cementless total hip arthroplasty. METHODS: This analysis included 3 studies comparing COC and MOM bearings and 56 studies reporting outcomes of MOM or COC bearings. We conducted a comparison meta-analysis (with a fixed-effects model) on the 3 comparative studies and a proportional meta-analysis on the data from the 59 articles to determine a consensus. RESULTS: In the comparison meta-analysis, MOM showed higher revision rate than COC for any reason (odds ratio = 2.39, P = .046) and PJI (odds ratio = 6.21, P = .015). In the proportion meta-analysis, the MOM group showed significantly higher revision rate than COC group for any reason, aseptic loosening, and PJI. CONCLUSION: MOM bearings were associated with a higher risk of revision for any reason and PJI than COC bearings after cementless total hip arthroplasty.

Frequency, Developing Time, Intensity, Duration, and Functional Score of Thigh Pain After Cementless Total Hip Arthroplasty.

BACKGROUND: Although thigh pain is an annoying problem after total hip arthroplasty (THA), little information has been known about its natural course. METHODS: To determine the frequency, time of onset, and duration of thigh pain after cementless THA, we evaluated 240 patients (240 hips) who underwent primary THA because of femoral head osteonecrosis with the use of a single tapered stem. RESULTS: Twenty-seven patients (11.3%) experienced thigh pain during the follow-up of 3-11 years (mean, 84 months). The pain developed 2-78 months (median, 25 months) after THA. The 75% of pain developed within 36 months. In 25 patients, the pain disappeared postoperatively 1 month-64 months (mean, 17.4 months), and 2 patients (7.4%, 2/27) had persistent thigh pain. There were no differences in the latest Harris Hip Score between the thigh pain group and no thigh pain group. CONCLUSION: Our results provided basic information about the natural history of thigh pain after cementless THA with a tapered stem design.

Incidence and Risk Period of Periprosthetic Femoral Fracture After Cementless Bipolar Hemiarthroplasty in Elderly Patients.

BACKGROUND: The purpose of this study was to investigate the periprosthetic femoral fracture (PFF) after cementless bipolar hemiarthroplasty incidence, noting fracture types and the results of treatment in elderly patients. METHODS: We retrospectively reviewed 1563 elderly patients (1177 women and 386 men) who underwent cementless bipolar hemiarthroplasty for femoral neck fracture (1061 patients) or intertrochanteric fracture (502 patients). The type of fracture was classified according to the Vancouver classification. The average age was 79.6 years (range, 65-103 years). Clinical and radiologic evaluations were performed and Kaplan-Meier survivorship was analyzed. RESULTS: Thirty-seven PFFs (2.4%) occurred during a mean follow-up of 44.4 months. Two-thirds of PFFs (67%) occurred within 1 year. Most PFFs (22/27), which occurred within 2 years, were Vancouver type B fractures. After that, type A fractures were predominant (7/9). Based on Kaplan-Meier survivorship with PFF as the end point, the incidence rate was 1.7% (95% confidence interval [CI] = 1.6%-1.8%) at 12 months, 2.2% (95% CI = 2.1%-2.3%) at 36 months, and 3.8 % (95% CI = 3.6%-4.0%) at 144 months postoperatively. CONCLUSION: After cementless bipolar hemiarthroplasty in elderly patients, a caution should be paid to prevent PFF particularly during 1-year postoperatively.

Could larger diameter of 4th generation ceramic bearing decrease the rate of dislocation after THA?

BACKGROUND: Fourth generation (Delta) ceramic bearing was developed to reduce dislocation after total hip arthroplasty (THA) by increasing the head diameter. We tested a hypothesis that 32/36 mm Delta ceramic bearing decreases the dislocation rate. We also evaluated ceramic-related complications and early outcome of this thin liner-on-large head ceramic bearing. METHODS: We performed a prospective study on patients who underwent THA with use of 32/36 mm Delta ceramic bearing. The dislocation rate was compared with the historical dislocation rate of third generation 28 mm ceramic bearing. We also evaluated ceramic fracture, squeak, short-term results and survival. Follow-up period was minimum 2 years. RESULTS: Between April 2010 and February 2012, we enrolled 250 consecutive patients (278 hips). All patients received cementless prostheses. Four patients (4 hips) who received metal shells ≤ 46 mm and 28 mm heads were excluded. Three patients died and 2 patients were lost within 2 years. The remaining 241 patients (269 hips) were followed for 24-46 months. There were 142 men (161 hips) and 99 women (108 hips) with a mean age of 53.7 years (range, 17-75 years) at the index operation. Dislocation occurred in three hips (1.1%). An old age was a risk factor for dislocation. Ceramic fracture and squeaking did not occur in any patient. Mean Harris hip score was 90.3 points at the latest follow-up. All acetabular and femoral components had bone-ingrowth stability. No hip had detectable wear or osteolysis. The survival was 99.3% in the best case scenario and 97.8% in the worst at 48 months. CONCLUSIONS: Total hip arthroplasty with use of 32/36 mm Delta ceramic bearing showed lower incidence of hip dislocation compared with 28 mm third generation ceramic bearing. A caution should be paid to prevent a fall in senile patients even though a large head is used. The short-term results of THA with this type of ceramic articulation are encouraging and we did not find any ceramic-related complications.

Is transverse acetabular ligament a reliable guide for aligning cup anteversion in total hip arthroplasty?: A measurement by CT arthrography in 90 hips.

BACKGROUND: Transverse acetabular ligament (TAL) has been used as a landmark for aligning cup anteversion. The use of TAL as a guide is based on the assumption that TAL version is distributed within the safe zone of acetabular cup. However, there was rarely reported to compare anteversion between TAL and acetabulum using direct measurement methods. The purpose of this study was to measure the anteversion of TAL in computed tomography arthrography (CTA) and compare it with Lewinnek's safe zone and anteversion of bony acetabulum. METHODS: 81 patients (90 hips) were selected among 204 patients (228 hips) who received CTA for hip pathology evaluation between March 2010 and June 2013. The anteversion of TAL measured at the lowest level of the acetabular notch and the anteversion of the acetabulum was measured at the level of femoral head center. RESULTS: The mean TAL anteversion was 11.8° (SD 4.5, range 0-22.2). In eight hips (8.8%), TAL anteversion was outside the safe zone (15° ± 10°) as defined by Lewinnek. The mean acetabular anteversion was 13.3° ± 4.4° (range -1.0° to 22.6°). There was a strong correlation between TAL anteversion and acetabular anteversion (Pearson's correlation coefficient; 0.908, p < 0.001). CONCLUSIONS: TAL anteversion has a large individual variation, and considerable portion of hips have TAL anteversion outside the safety zone of cup anteversion. TAL anteversion is influenced by acetabular anteversion. In hips with retroverted or pauci-anteverted acetabulum, TAL should be used cautiously because there is a risk of cup malposition.

Prevalence of Venous Thromboembolism after Immediate Screening in Hip Fracture Patients.

Purpose: Venous thromboembolism (VTE) is a major complication for hip fracture patients, and may exist preoperatively. This study aimed to examine the prevalence of VTE after immediate screening in hip fracture patients. Materials and Methods: Hip fracture patients with an elevated level of D-dimer underwent screening for VTE using computed tomography (CT) angiography. Anticoagulation treatments were administered preoperatively to patients diagnosed with VTE, followed by administration of additional anticoagulation postoperatively. Medical records were reviewed to identify risk factors for preoperative VTE and determine the prognosis of the patients. Results: Among 524 hip fracture patients, 66 patients (12.6%) were diagnosed with VTE, including 42 patients with deep vein thrombosis (DVT), 17 patients with pulmonary thromboembolism (PTE), and 7 patients with both DVT and PTE. Of the patients with VTE, 68.2% were diagnosed within 24 hours of injury, and 33.3% of these patients had PTE. VTE patients showed a tendency toward being overweight (P<0.01) and not on anticoagulant medication (P=0.02) compared to patients without VTE. The risk of VTE was higher for femur shaft fractures (odds ratio [OR] 4.83, 95% confidence interval [CI] 2.18-10.69) and overweight patients (OR 2.12, 95% CI 1.17-3.85), and lower for patients who were previously on anticoagulants (OR 0.36, 95% CI 0.18-0.74). Patients with preoperatively diagnosed VTE were asymptomatic before and after surgery. Conclusion: Clinicians should be aware that VTE may be present within 24 hours of injury, and screening for VTE or prophylactic measures should be considered for high-risk patients.

Impaired binding affinity of YTHDC1 with METTL3/METTL14 results in R-loop accumulation in myelodysplastic neoplasms with DDX41 mutation.

DEAD box helicase 41 (DDX41) mutations are the most prevalent predisposition to familial myelodysplastic syndrome (MDS). However, the precise roles of these variants in the pathogenesis of MDS have yet to be elucidated. Here, we discovered a novel mechanism by which DDX41 contributes to R-loop-induced DNA damage responses (DDR) in cooperation with the m6A-METTL complex (MAC) and YTHDC1 using DDX41 knockout (KO) and DDX41 knock-in (KI, R525H, Y259C) cell lines as well as primary samples from MDS patients. Compared to wild type (WT), DDX41 KO and KI led to increased levels of m6A RNA methylated R-loop. Interestingly, we found that DDX41 regulates m6A/R-loop levels by interacting with MAC components. Further, DDX41 promoted the recruitment of YTHDC1 to R-loops by promoting the binding between METTL3 and YTHDC1, which was dysregulated in DDX41-deficient cells, contributing to genomic instability. Collectively, we demonstrated that DDX41 plays a key role in the physiological control of R-loops in cooperation with MAC and YTHDC1. These findings provide novel insights into how defects in DDX41 influence MDS pathogenesis and suggest potential therapeutic targets for the treatment of MDS.