The effectiveness of low-dose and high-dose tranexamic acid in posterior lumbar interbody fusion: a double-blinded, placebo-controlled randomized study.

PURPOSE: Tranexamic acid is a proven drug used for reduction of intraoperative blood loss in spinal surgery. However, optimal dosing considering risk/benefits is not well established owing to the heterogeneity in patient selection and surgical procedures of previous studies. This study aimed to evaluate the effectiveness and safety of various tranexamic acid regimens in reducing perioperative blood loss in single-level posterior lumbar interbody fusion (PLIF). METHODS: Patients were randomly grouped into three different interventions: low-dose tranexamic acid (LD), high-dose tranexamic acid (HD), and placebo-controlled (PC) groups. The HD and LD groups received 10 and 5 mg/kg of bolus loading dose and 2 and 1 mg/kg of continuous infusion until 5 h after surgery, respectively. Data on patient demographics and preoperative and 24-h postoperative laboratory values were collected. Outcome parameters include intraoperative blood loss, 24-h postoperative blood loss, and blood loss during removal of the last drain. RESULTS: Seventy-two patients (mean age 63.3 ± 7.6 years) showed similar baseline characteristics. Intraoperatively, blood loss was reduced by the administration of tranexamic acid (P = 0.04), contributed predominantly by a difference between the LD and HD groups (123 mL; P < 0.01). The 24-h postoperative blood loss was reduced (P < 0.01), contributed predominantly by a difference between the PC and LD groups (144 mL; P = 0.02). During the removal of the last drain, statistical difference was found between the PC and HD groups (125 mL; P = 0.00). No complications or side effects from tranexamic acid use were noted. CONCLUSION: Tranexamic acid administration for single-level PLIF was effective and safe in reducing perioperative blood loss in a dose-dependent manner. An HD regimen comprising 10 mg/kg of bolus loading dose and 2 mg/kg/h of continuous infusion is recommended. LEVEL OF EVIDENCE: Level 1 study according to Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence.

Clinical outcome of autologous bone marrow aspirates concentrate (BMAC) injection in degenerative arthritis of the knee.

PURPOSE: As a treatment method of degenerative arthritis of knee, this study evaluated the clinical efficacy of the intra-articular injection of autologous bone marrow aspirates concentrate (BMAC) with adipose tissue. MATERIALS AND METHODS: Between April 2011 and May 2012, 41 patients (75 knees) who were diagnosed as a degenerative knee arthritis and underwent the BMAC injection with adipose tissue were included in this study. Mean age was 60.7 years old (ranged 53-80). Kellgren-Lawrence grade was used for assessing radiologic degree of osteoarthritis; there were each 12, 24, 33, and 6 cases of grade I, II, III, and IV. At preoperative and postoperative 3, 6, and 12 months, pain score using visual analogue scale (VAS) and functional scales were used for evaluation. RESULTS: After the procedure, mean VAS score was decreased from 7.0 preoperatively to 4.1, 3.5, and 3.3 postoperatively 3, 6, and 12 months. And functional scores were also improved; International Knee Documentation Committee score (from 37.7 preoperatively to 59.3, 66.3, 69.3 postoperatively), SF-36 health score (from 31.5 to 43.5, 45.6, 47.7), knee and osteoarthritis outcome score (from 43.1 to 64.9, 68.5, 70.6), Lysholm Knee Questionnaire (from 37.3 to 65.4, 68.6, 71.0) were all increased after the procedure. When classified according to K-L grade, the improvement of VAS score in grade IV group was 8.2 preoperatively to 5.5, 5.3, and 5.7 postoperatively, which was significantly poorer than those of grade I-III groups. In the knee functional scales, similar pattern was checked. CONCLUSIONS: BMAC injection significantly improved both knee pain and functions in the patients with degenerative arthritis of knee. Also, the injection would be more effective in early to moderate phases.

Outcomes of Non-Operative Management for Pseudarthrosis after Pedicle Subtraction Osteotomies at Minimum 5 Years Follow-Up.

OBJECTIVE: Minimal data exist regarding non-operative management of suspected pseudarthrosis after pedicle subtraction osteotomy (PSO). This study reports radiographic and clinical outcomes of non-operative management for post-PSO pseudarthrosis at a minimum 5 years post-detection. METHODS: Nineteen consecutive patients with implant breakage indicating probable pseudarthrosis after PSO surgery (13 women/ six men; mean age at surgery, 58 years) without severe pain and disability were treated with non-operative management (mean follow-up, 5.8 years; range, 5-10 years). Non-operative management included medication, intermittent brace wearing and avoidance of excessive back strain. Radiographic and clinical outcomes analysis was performed. RESULTS: Sagittal vertical axis (SVA), proximal junctional angle, thoracic kyphosis achieved by a PSO were maintained after detection of pseudarthrosis through ultimate follow-up. Lumbar lordosis and PSO angle decreased at final follow-up. There was no significant change in Oswestry Disability Index (ODI) scores and Scoliosis Research Society (SRS) total score, or subscales of pain, self-image, function, satisfaction and mental health between detection of pseudarthrosis and ultimate follow-up. SVA greater than 11 cm showed poorer ODI and SRS total score, as well as the pain, self-image, and function subscales (p<0.05). CONCLUSION: Non-operative management of implant failure of probable pseudarthrosis after PSO offers acceptable outcomes even at 5 years after detection of implant breakage, provided SVA is maintained. As SVA increased, outcome scores decreased in this patient population.

Correlation of IGF1R expression with ABCG2 and CD44 expressions in human osteosarcoma.

Osteosarcoma is the most common type of malignant bone tumors. Insulin Growth Factor 1 receptor (IGFR1) has been known as a prognostic factor for metastasis of osteosarcoma. ABC subfamily G member2 (ABCG2) is related to resistance to anti-cancer drug, and CD44 has a role in tumor growth and metastasis. The purpose of this study is to investigate the relationship among expression patterns of IGF1R, ABCG2, and CD44 in osteosarcoma. The expression levels of IGF1R, ABCG2, and CD44 proteins were determined in tissue arrays containing osteosarcoma tissues from 59 osteosarcoma patients. The expression pattern of IGF1R was highly correlated with the expression pattern of ABCG2 (r = 0.88) in overall osteosarcoma patients. According to pathological types, the expression pattern of IGF1R showed the higher correlation with ABGC2 (r = 0.90) and CD44 (r = 0.61) in osteoblatic type than in chondroblastic type. According to gender with pathologic type, the correlation between the expression patterns of IGF1R and CD44 was higher in male with osteoblatic type than in female with osteoblatic type. Among different age groups, the 1-10 years age group showed higher correlation in IGF1R versus CD44 (r = 0.90) and ABCG2 versus CD44 (0.80) than in other age groups. These results showed that the expression of IGF1R appears to be highly correlated with the expression of ABCG2 in osteosarcoma and with the expression of CD44 in osteosarcoma patients under age of 10, which suggests that ABCG2 and CD44 can be used as prognostic factors with IGF1R for specific prognosis and efficient treatment of osteosarcoma.

Supra-acetabular line is better than supra-iliac line for coronal balance referencing-a study of perioperative whole spine X-rays in degenerative lumbar scoliosis and ankylosing spondylitis patients.

BACKGROUND CONTEXT: The aim of spinal deformity correction is to restore the spine's functional alignment by balancing it in both the sagittal and coronal planes. Regardless of posture, the ideal coronal profile is straight, and therefore readily assessable. PURPOSE: This study compares two radiological methods to determine which better predicts postoperative standing coronal balance. STUDY DESIGN/SETTING: We conducted a single-center, radiographic comparative study between 2011 and 2015. PATIENT SAMPLE: A total of 199 patients with a mean age of 55.1 years were studied. Ninety patients with degenerative lumbar scoliosis (DLS) and 109 ankylosing spondylitis (AS) were treated with posterior surgery during this period. OUTCOME MEASURES: Baseline clinical and radiographic parameters (sagittal and coronal) were recorded. Comparison was performed between the new supra-acetabular line (central sacral vertical line [CSVL1]) and conventional supra-iliac line (CSVL2) perpendicular methods of coronal balance assessment. These methods were also compared with the gold standard standing C7 plumb line. METHODS: Each patient underwent standardized operative procedures and had perioperative spine X-rays obtained for assessment of spinal balance. Adjusted multivariate analysis was used to determine predictors of coronal balance. RESULTS: Significant differences in baseline characteristics (age, gender, and radiographic parameters) were found between patients with DLS and AS. CSVL1, CSVL2, and C7 plumb line differed in all the perioperative measurements. These three radiological methods showed a mean right coronal imbalance for both diagnoses in all pre-, intra-, and postoperative radiographs. The magnitude of imbalance was the greatest for CSVL2 followed by CSVL1 and subsequently the C7 plumb line. A larger discrepancy between CSVL and C7 plumb line measurements intraoperatively than those postoperatively suggests a postural effect on these parameters, which is greater for CSVL2. Multivariate analysis identified that in DLS, the preoperative C7 plumb line was predictive of its postoperative value. CSVL1, but not CSVL2, was predictive of the postoperative C7 plumb line in patients with AS. CONCLUSIONS: The supra-acetabular line (CSVL1) is better, although not ideal, as compared with the supra-iliac line (CSVL2) in determining coronal balance. Because CSVL1 still cannot be relied on with a high predictive value, it is imperative that future studies continue to identify better intraoperative markers for achieving coronal balance.