Predictive factors for neurological deterioration after surgical decompression for thoracic ossified yellow ligament.

PURPOSE: To investigate the rate and predictive factors of post-operative neurological deterioration in ossified yellow ligament (OYL) surgery. METHODS: A retrospective review was conducted for all patients with thoracic OYL causing myelopathy requiring surgical decompression from January 1998 to December 2012. Clinical parameters under study included clinical presentation, distribution of OYL, pre-operative walking score, pre- and post-operative neurological status, status of intra-operative neurophysiological monitoring, and modified Japanese Orthopaedic Association (mJOA) score. Any complications were also recorded. All outcomes were measured at post-operative 1 week and at 2 years. RESULTS: A total of 26 patients were included in this study. Most patients (92.3%) had Frankel grade D pre-operatively. The rate of neurological deterioration was 15.4% and was correlated with the presence of dural tear, extra-dural hematoma and spinal cord injury. Pre-operative walking score was prognostic of patients' walking ability in the post-operative period. Intra-operative monitoring of Somatosensory Evoked Potentials (SSEP) was found to be useful for monitoring spinal cord injury in OYL surgery, with a positive predictive value of 100% and a negative predictive value of 92.3%. The false negative rate of a SSEP signal drop was only 7.7% CONCLUSIONS: This is the first study exploring risk factors for post-operative neurological deterioration after surgery for thoracic OYL. The rate of neurological deficit is not small and prognostic factors for poor outcome include poor pre-operative walking score, presence of intra-operative dural tear, extra-dural hematoma and spinal cord injury, and intra-operative drop of SSEP signal.

Recommendations on the post-acute management of the osteoporotic fracture - Patients with "very-high" Re-fracture risk.

Osteoporosis is a systemic skeletal disease where there is low bone mass and deterioration of bone microarchitecture, leading to an increased risk of a fragility fracture. The aim of this clinical guideline from Fragility Fracture Network Hong Kong SAR, is to provide evidence-based recommendations on the post-acute treatment of the osteoporotic fracture patient that presents for clinical care at the Fracture Liaison Service (FLS). It is now well established that the incidence of a second fracture is especially high after the first 2 years of the initial osteoporotic fracture. Therefore, the recent osteoporotic fracture should be categorized as "very-high" re-fracture risk. Due to the significant number of silent vertebral fractures in the elderly population, it is also recommended that vertebral fracture assessment (VFA) should be incorporated into FLS. This would have diagnostic and treatment implications for the osteoporotic fracture patient. The use of a potent anti-osteoporotic agent, and preferably an anabolic followed by an anti-resorptive agent should be considered, as larger improvements in BMD is strongly associated with a reduction in fractures. Managing other risk factors including falls and sarcopenia are imperative during rehabilitation and prevention of another fracture. Although of low incidence, one should remain vigilant of the atypical femoral fracture. The aging population is increasing worldwide, and it is expected that the treatment of osteoporotic fractures will be routine. The recommendations are anticipated to aid in the daily clinical practice for clinicians. The Translational potential of this article: Fragility fractures have become a common encounter in clinical practise in the hospital setting. This article provides recommendations on the post-acute management of fragility fracture patients at the FLS.

Giant cell tumor of the humeral head treated by denosumab: Implication to shoulder surgeons.

Giant cell tumor is a benign bone tumor that is commonly encountered. The optimal treatment of a giant cell tumor which causes extensive bony destruction is controversial. Recent studies on the receptor activator of nuclear factor κB ligand antagonist denosumab may offer a new treatment option for these patients. We presented a patient with giant cell tumor of the humeral head. He was initially treated with denosumab and subsequently with the operation. The shoulder joint was successfully salvaged. But there are potential difficulties that surgeons may face in patients treated with denosumab.

The distal radius and ulna classification in assessing skeletal maturity: a simplified scheme and reliability analysis.

The aim of this study is to simplify the distal radius and ulna classification for practical use and to test its reliability. This was a prospective single-center study of patients with juvenile and adolescent idiopathic scoliosis. Left-hand radiographs were retrieved for measurements by three examiners. Reliability analysis was carried out by intraclass correlation. 34 females and 16 males were recruited, mean age 12.7 years (±SD 1.7). The grades varied from R4-R11 to U1-U9. There was strong to near-perfect intraclass correlation. This study concludes that the simplified distal radius and ulna classification is a reliable tool for assessment of skeletal maturity.

Notching of the femoral stem neck in metal-on-metal total hip replacement: a case report.

We report a case of impingement in a metal-on-metal total hip replacement causing both notching of the femoral stem neck and aseptic loosening of the acetabular component. The acetabular component was inserted in excessive anteversion. The femoral stem and acetabular components were retrieved. A larger femoral head was used, and an acetabular component was placed in a less anteverted position. Intra-operative testing through different ranges of movement is recommended to identify potential impingement.