Therapeutic advantage of teriparatide in very elderly patients with proximal femoral fractures: a functional and BMD analysis.

BACKGROUND: Teriparatide, a recombinant parathyroid hormone, is pivotal in osteoporosis treatment, particularly in post-surgical recovery for hip fractures. This study investigates its efficacy in functional recovery post-hip fracture surgery in elderly patients, a demographic particularly susceptible to osteoporotic fractures. METHODS: In this retrospective cohort study, 150 elderly patients with proximal femoral fractures undergoing open reduction and internal fixation were enrolled. They were categorized into two groups: receiving 20 µg of daily teriparatide injections for 18 months and receiving standard antiresorptive medications during a 24-month follow-up. Detailed records of patient demographics, Fracture Risk Assessment Tool scores, and comorbidities were kept. Key outcomes, including bone mineral density (BMD) and functional scores (Barthel Index and Visual Analog Scale for hip pain), were evaluated at 3 and 24 months post-surgery. RESULTS: Out of the original cohort, 126 patients (20 men and 106 women with an average age of 85.5 ± 9.3 years) completed the study. The teriparatide group exhibited significant enhancements in both functional scores and BMD when compared to the control group. Notably, functional improvements were less pronounced in male patients compared to female patients. Additionally, the incidence of new fractures was markedly lower in the teriparatide group. CONCLUSION: Administering teriparatide daily for 18 months post-surgery for proximal femoral fractures significantly benefits very elderly patients by improving functionality and bone density, with observed differences in recovery between genders. These results reinforce the efficacy of teriparatide as a potent option for treating osteoporosis-related fractures in the elderly and highlight the importance of considering gender-specific treatment and rehabilitation strategies.

Effect of Osteoporosis Treatments on Osteoarthritis Progression in Postmenopausal Women: A Review of the Literature.

PURPOSE OF REVIEW: The purpose of this literature review was to determine if medications used to treat osteoporosis are also effective for treating osteoarthritis (OA). RECENT FINDINGS: A total of 40 relevant articles were identified. Studies were categorized into those (1) discussing estrogen and selective estrogen receptor modulators (SERMs), (2) bisphosphonates, (3) parathyroid hormone (PTH) analogs, and (4) denosumab, and (5) prior review articles. A large amount of evidence suggests that estrogen and SERMs are effective at reducing OA symptoms and disease progression. Evidence suggests that bisphosphonates, the most common medications used to treat osteoporosis, can reduce OA symptoms and disease progression. In vivo studies suggest that PTH analogs may improve the cartilage destruction associated with OA; however, few human trials have examined its use for OA. Denosumab is approved to treat osteoporosis, bone metastases, and certain types of breast cancer, but little study has been done with respect to its effect on OA. The current evidence indicates that medications used to treat osteoporosis are also effective for treating OA. Estrogen, SERMs, and bisphosphonates have the most potential as OA therapies. Less is known regarding the effectiveness of PTH analogs and denosumab in OA, and more research is needed.

Femoral neck system versus multiple cannulated screws for the fixation of Pauwels classification type II femoral neck fractures in older female patients with low bone mass.

BACKGROUND: Femoral neck fractures in older adult patients are a major concern and often necessitate surgical intervention. This study compared the clinical outcomes of 2 surgical techniques: the femoral neck system (FNS) and cannulated compression screws (CCSs). METHODS: A total of 40 female patients (mean age 73.50 ± 11.55 years) with femoral neck fractures of Pauwels classification type II and receiving surgical fixation between 2020 and 2022 were enrolled. The patients were categorized into an FNS group (n = 12) or a CCS group (n = 28), and surgical duration, intraoperative blood loss, length of hospital stay, and incidence of postoperative adverse events were analyzed. RESULTS: No significant intergroup differences in demographic characteristics were discovered. The mean surgical duration for all patients was 52.88 ± 22.19 min, with no significant difference between the groups. However, the FNS group experienced significantly higher intraoperative blood loss (P = 0.002) and longer hospital stay (P = 0.023) than did the CCS group. The incidence of osteonecrosis was higher in the CCS group, whereas the incidence of nonunion or malunion was higher in the FNS group. The surgical method did not appear to be a significant risk factor. The main risk factor for revision surgery was longer duration until the first adverse event (P = 0.015). CONCLUSION: The FNS does not appear to provide superior surgical outcomes compared with CCSs in older adult women with Pauwels classification type II femoral neck fractures. A longer duration between surgical fixation and the first adverse event before stabilization of the fracture site may be a risk factor for revision surgery.

COVID-19 Infection Was Associated with the Functional Outcomes of Hip Fracture among Older Adults during the COVID-19 Pandemic Apex.

Background and Objectives: Hip fractures are associated with mortality and poor functional outcomes. The COVID-19 pandemic has affected patterns of care and health outcomes among fracture patients. This study aimed to determine the influence of COVID-19 infection on hip fracture recovery. Materials and Methods: We prospectively collected data on patients with hip fractures who presented at Hualien Tzu Chi Hospital between 9 March 2022 and 9 September 2022. The data included demographic information and functional scores taken before, during, and after surgery. The patients were divided into two groups: COVID-19 (+) and COVID-19 (-). Results: This study recruited 85 patients, 12 of whom (14.12%) were COVID-19 (+). No significant differences in preoperative or perioperative parameters between the two groups were observed. The postoperative Barthel index score was significantly impacted by COVID-19 infection (p = 0.001). The incidence of postoperative complications was significantly correlated with general anesthesia (p = 0.026) and the length of stay (p = 0.004) in hospital. Poor postoperative functional scores were associated with lower preoperative Barthel index scores (p < 0.001). Male sex (p = 0.049), old age (p = 0.012), a high American Society of Anesthesiologists grade (p = 0.029), and a high Charlson comorbidity index score (p = 0.028) were associated with mortality. Conclusions: Hip fracture surgeries were not unduly delayed in our hospital during the COVID-19 pandemic, but the patients' postoperative Barthel index scores were significantly influenced by COVID-19 (+). The preoperative Barthel index score may be a good predictive tool for the postoperative functional recovery of these patients.

Zebrafish models for glucocorticoid-induced osteoporosis.

Glucocorticoid-induced osteoporosis (GIOP) is the most common form of secondary osteoporosis due to excessive or long-term glucocorticoid administration, disturbing the homeostasis between bone formation and bone resorption. The bone biology of zebrafish shares a high degree of similarities with mammals. In terms of molecular level, genes and signaling pathways related to skeletogenesis are also highly correlated between zebrafish and humans. Therefore, zebrafish have been utilized to develop multiple GIOP models. Taking advantage of the transparency of zebrafish larvae, their skeletal development and bone mineralization can be readily visualized through in vivo staining without invasive experimental handlings. Moreover, the feasibility of using scales or fin rays to study bone remodeling makes adult zebrafish an ideal model for GIOP research. Here, we reviewed current zebrafish models for GIOP research, focused on the tools and methods established for examining bone homeostasis. As an in vivo, convenient, and robust model, zebrafish have an advantage in performing high-throughput drug screening and could be used to investigate the action mechanisms of therapeutic drugs.

Gu Sui Bu (Drynaria fortunei J. Sm.) antagonizes glucocorticoid-induced mineralization reduction in zebrafish larvae by modulating the activity of osteoblasts and osteoclasts.

ETHNOPHARMACOLOGICAL RELEVANCE: Gu Sui Bu (GSB), the dried rhizome of Drynaria fortunei J. Sm., is widely used in traditional Chinese medicine for treating fractures and osteoporosis. Although glucocorticoids are widely prescribed in modern medicine, the efficacy of GSB in treating glucocorticoid-induced osteoporosis (GIOP) remains unclear. AIM OF THE STUDY: GIOP is one of the most prevalent forms of osteoporosis and increases the risk of fracture, which can cause severe complications in elderly people. Safe, efficacious, and cost-effective treatment options for GIOP are thus warranted. The present study investigated the efficacy and mechanism of GSB for treating GIOP. MATERIALS AND METHODS: We established an efficient and robust in vivo GIOP model by optimizing zebrafish larvae rearing conditions and the dose and duration of dexamethasone treatment. Bone calcification was evaluated through calcein staining. To quantify the degree of vertebral mineralization in the larvae, we developed a scoring system based on the rate of vertebral calcification; this system reduced quantification errors among individual zebrafish caused by inconsistencies in staining or imaging parameters. Quantitative real-time polymerase chain reaction was used to access the expression levels of genes essential to the differentiation and function of bone cells. High-performance liquid chromatography was employed to identify naringin in the GSB extract. RESULTS: GSB significantly reversed the dexamethasone-induced calcification delay in zebrafish larvae. GSB enhanced osteoblast activity by increasing the expression of collagen I, osteopontin, and osteonectin and repressed bone resorption by decreasing the expression of matrix metalloproteinases (mmps), including mmp9 and mmp13a. We also identified naringin as one of the constituents of GSB responsible for the herbal extract's anti-GIOP activity. CONCLUSIONS: Using the in vivo zebrafish GIOP model that we established, the efficacy of traditional Chinese medicines in treating GIOP could be systematically investigated. GSB has an osteogenic effect and may thus be an efficacious and cost-effective treatment option for GIOP. Notably, bone resorption activity was found to be retained after GSB treatment, which would be beneficial for maintaining normal bone remodeling.

The Short-Term Changes of the Sagittal Spinal Alignments After Acute Vertebral Compression Fracture Receiving Vertebroplasty and Their Relationship With the Change of Bathel Index in the Elderly.

Introduction: Fragility vertebral compression fractures (VCFs) are of major concern due to aging populations worldwide, which may occur after a fall from standing or due to severe osteoporosis, impacting greatly the life quality of the elderly. This study thus determined the factors independently associated with poor functional recovery from a new VCF and changes in sagittal spinal alignment after vertebroplasty in elderly patients with osteoporosis. Materials and Methods: The data were collected from patients older than 70 years and diagnosed with a new VCF. Logistic regression analysis was performed to determine factors independently associated with function and radiographic status. Results: We enrolled 8 male and 34 female patients with a mean age of 80.74 ± 8.31 years between January and July 2020. Compared with preoperative data, post-vertebroplasty lumbar sagittal alignments and functional scores improved significantly, and function recovered gradually over 12 weeks. Climbing stairs was the most influential performance indicator at the beginning of the recovery process. At each postoperative follow-up, changes in the C7-sacrum sagittal vertical axis exhibited an influence on functional recovery. Male patients were better able to move from a chair to a bed at the 2-week postoperative follow-up, and positive changes in the spino-sacral angle led to improved function in terms of stair climbing at the 6-week postoperative follow-up. Conclusions: Vertebroplasty seemed to be effective for functional recovery related to sagittal spinal alignment improvement of the elderly with VCFs during postoperative 12 weeks, which may be a critical stage for the recovery for their life activities. The recovery rate for stair climbing after vertebroplasty was slower than for the other functional performance indicators in our study. In addition, if a patient was unable to demonstrate a marked improvement in sagittal alignment, they were likely to have ongoing impaired function and a poor prognosis after surgery.

Use of an Intramedullary Allogenic Fibular Strut Bone and Lateral Locking Plate for Distal Femoral Fracture with Supracondylar Comminution in Patients over 50 Years of Age.

Background and Objectives: Distal femoral fracture is a severe injury that makes surgery challenging, particularly comminuted fractures in the supracondylar region. This study aimed to evaluate the outcomes of distal femoral fracture treated with the application of an intramedullary fibular allogenic bone strut in open reduction and internal fixation (ORIF) with precontoured locking plates in patients over 50 years of age. Materials and Methods: The study retrospectively enrolled 202 patients over 50 years of age with traumatic comminuted distal femoral fracture (AO/OTA 33-A3, 33-C2 and 33-C3) treated with ORIF with a locking plate from January 2016 to December 2019. The two groups were divided into patients who received an intramedullary allogenic bone strut and those who did not. Patients were followed for at least 1 year, with their function scores and radiographic data recorded. Results: A total of 124 patients were recruited, comprising 60 men and 64 women with an average age of 62.4 ± 8.5 years. The 36 patients who had received an intramedullary allogenic fibular bone strut reported lower postoperative pain scores at 1 month and lower postoperative Knee Society Scores (KSS) at 3 months than the control group. The application of an intramedullary allogenic fibular bone strut appeared to be significantly correlated with better 3-month postoperative KSS. Conclusions: The ORIF of distal femoral comminuted fracture with an intramedullary allogenic fibular bone strut can reduce pain and improve knee function in the early stages of postoperative rehabilitation and may reduce the time to union in patients over 50 years of age.

The molecular etiology and treatment of glucocorticoid-induced osteoporosis.

Glucocorticoid-induced osteoporosis (GIOP) is the most common form of secondary osteoporosis, accounting for 20% of osteoporosis diagnoses. Using glucocorticoids for >6 months leads to osteoporosis in 50% of patients, resulting in an increased risk of fracture and death. Osteoblasts, osteocytes, and osteoclasts work together to maintain bone homeostasis. When bone formation and resorption are out of balance, abnormalities in bone structure or function may occur. Excess glucocorticoids disrupt the bone homeostasis by promoting osteoclast formation and prolonging osteoclasts' lifespan, leading to an increase in bone resorption. On the other hand, glucocorticoids inhibit osteoblasts' formation and facilitate apoptosis of osteoblasts and osteocytes, resulting in a reduction of bone formation. Several signaling pathways, signaling modulators, endocrines, and cytokines are involved in the molecular etiology of GIOP. Clinically, adults ≥40 years of age using glucocorticoids chronically with a high fracture risk are considered to have medical intervention. In addition to vitamin D and calcium tablet supplementations, the major therapeutic options approved for GIOP treatment include antiresorption drug bisphosphonates, parathyroid hormone N-terminal fragment teriparatide, and the monoclonal antibody denosumab. The selective estrogen receptor modulator can only be used under specific condition for postmenopausal women who have GIOP but fail to the regular GIOP treatment or have specific therapeutic contraindications. In this review, we focus on the molecular etiology of GIOP and the molecular pharmacology of the therapeutic drugs used for GIOP treatment.

The incidence of mental disorder increases after hip fracture in older people: a nationwide cohort study.

BACKGROUND: People living with dementia seem to be more likely to experience delirium following hip fracture. The association between mental disorders (MD) and hip fracture remains controversial. We conducted a nationwide study to examine the prevalence of MD in geriatric patients with hip fractures undergoing surgery and conducted a related risk factor analysis. MATERIAL AND METHODS: This retrospective cohort study used data from Taiwan's National Health Insurance Research Database between 2000 and 2012 and focused on people who were older than 60 years. Patients with hip fracture undergoing surgical intervention and without hip fracture were matched at a ratio of 1:1 for age, sex, comorbidities, and index year. The incidence and hazard ratios of age, sex, and multiple comorbidities related to MD and its subgroups were calculated using Cox proportional hazards regression models. RESULTS: A total of 1408 patients in the hip fracture group and a total of 1408 patients in the control group (no fracture) were included. The overall incidence of MD for the hip fracture and control groups per 100 person-years were 0.8 and 0.5, respectively. Among MD, the incidences of transient MD, depression, and dementia were significantly higher in the hip fracture group than in the control group. CONCLUSIONS: The prevalence of newly developed MD, especially transient MD, depression, and dementia, was higher in the geriatric patients with hip fracture undergoing surgery than that in the control group. Prompt and aggressive prevention protocols and persistent follow-up of MD development is highly necessary in this aged society.

The incidence of severe urinary tract infection increases after hip fracture in the elderly: a nationwide cohort study.

Although urinary tract infection (UTI) is a common perioperative complication among elderly patients with hip fracture, its incidence and effects are often underestimated. This study investigated the effects of severe UTI (S-UTI) on elderly patients with hip fracture and the risk factors for this condition. In this retrospective nationwide cohort study, we searched Taiwan's National Health Insurance Research Database from 2000 to 2012 for data on patients aged ≥ 50 years with hip fracture who underwent open reduction and internal fixation or hemiarthroplasty for comparison with healthy controls (i.e. individuals without hip fracture). The study and comparison cohorts were matched for age, sex, and index year at a 1:4 ratio. The incidence and hazard ratios of age, sex, and multiple comorbidities associated with S-UTI were calculated using Cox proportional hazard regression models. Among the 5774 and 23,096 patients in the study and comparison cohorts, the overall incidence of S-UTI per 100 person-years was 8.5 and 5.3, respectively. The risk of S-UTI was cumulative over time and higher in the study cohort than in the comparison cohort, particularly in those who were older, were female, or had comorbidities of cerebrovascular accident or chronic renal failure.

Hepatic encephalopathy increases the risk of hip fracture: a nationwide cohort study.

BACKGROUND: Osteoporotic hip fracture is a common general health problem with a significant impact on human life because it debilitates the patients and largely decreases their quality of life. Early prevention of fractures has become essential in recent decades. This can be achieved by evaluating the related risk factors, as a reference for further intervention. This is especially useful for the vulnerable patient group with comorbidities. Hepatic encephalopathy (HE), a major complication of liver cirrhosis, may increase the rate of falls and weaken the bone. This study evaluated the correlation between hepatic encephalopathy and osteoporotic hip fracture in the aged population using a national database. METHODS: This retrospective cohort study used data from Taiwan's National Health Insurance Research Database between 2000 and 2012. We included people who were older than 50 years with hepatic encephalopathy or other common chronic illnesses. Patients with and without hepatic encephalopathy were matched at a ratio of 1:4 for age, sex, and index year. The incidence and hazard ratios of osteoporotic hip fracture between the both cohorts were calculated using Cox proportional hazard regression models. RESULTS: The mean age of the enrolled patients was 66.5 years. The incidence ratio of osteoporotic hip fracture in the HE group was significantly higher than that in the non-HE group (68/2496 [2.7%] vs 98/9984 [0.98%]). Patients with HE were 2.15-times more likely to develop osteoporotic hip fractures than patients without HE in the whole group. The risk ratio was also significantly higher in female and older individuals. The results were also similar in the comorbidity subgroups of hypertension, diabetes mellitus, hyperlipidemia, senile cataract, gastric ulcer, and depression. Alcohol-related illnesses seemed to not confound the results of this study. CONCLUSIONS: HE is significantly associated with an increased risk of osteoporotic hip fractures, and the significance is not affected by the comorbidities in people aged more than 50 years. The cumulative risk of fracture increases with age.

Two surgical strategies for treating multilevel cervical spondylotic myelopathy combined with kyphotic deformity.

This study compared the surgical outcomes of two surgical methods for treating multilevel cervical spondylotic myelopathy (MCSM) combined with cervical kyphotic deformity (CKD): (1) the ELTA method consisted of expansive open-door laminoplasty (EOLP) followed by three-segment anterior cervical discectomy fusion (ACDF), and (2) the LAPI method consisted of long-segment ACDF followed by long-level posterior instrumented fusion (PIF). Surgical treatment of CKD combined with MCSM remains challenging. Surgical considerations should include adequate spinal cord decompression and restoration of satisfactory cervical sagittal alignment (CSA). In certain situations, a solid PIF structure is vital to prevent failure.We included 105 patients who underwent the aforementioned surgical methods for MCSM combined with CKD from January 2013 to December 2017. The minimum follow-up period was 1 year. Comparative analysis was performed to compare the two surgical strategies' preoperative and postoperative functional outcomes, including a visual analog scale for neck pain, neck disability index, the Japanese Orthopedic Association cervical myelopathy score, and the Nurick score, as well as the CSA radiographic outcomes, including C2-7 Cobb angle, C2-7 sagittal vertical axis, and C7 slope. The risk factors related to reduced improvement in functional status were analyzed.A total of 63 patients underwent ELTA and 42 patients underwent LAPI. Improvements in functional outcomes were considerable in both groups. The mean C2-7 Cobb angle was restored from 7.4°â€Š±â€Š2.1° kyphosis to 8.8°â€Š±â€Š4.7° lordosis in the ELTA group and from 15.3°â€Š±â€Š4.2° kyphosis to 15.8°â€Š±â€Š8.1° lordosis in the LAPI group. The maximal correction angle was 22.6° in the ELTA group and 42.6° in the LAPI group.Although changes in CSA seemed to be significantly correlated with improvements of functional status, the ELTA and LAPI methods were both effective for treating MCSM combined with CKD, when appropriately selected. The ELTA method was indicated for MCSM patients who had a low degree of CKD, whereas the LAPI method was indicated for MCSM patients who had poor function scores and a high degree of CKD.

Risk factors for carpal tunnel syndrome or trigger finger following distal radius fracture: a nationwide study.

New-onset carpal tunnel syndrome (CTS) and trigger finger after distal radius fractures (DRFs) with or without open reduction and internal fixation (ORIF) have been reported inconsistently across different studies. This study assessed the incidence of CTS and trigger finger after DRFs using Taiwan National Health Insurance Research Database. In total, 1454 patients in the case (ORIF) cohort and 1454 patients in the control (non-ORIF) cohort were included in this retrospective study. The mean age was approximately 55 years old, and the female to male ratio was approximately 3/2. Nine patients underwent carpal tunnel release (CTR) surgery after diagnosis of CTS in the case group, and no patients did in the control group; whereas 19 cases of CTS were diagnosed without CTR in the case group, and 4 such cases were observed in the control group. Five cases of trigger finger were diagnosed in the case group, and 3 cases were diagnosed in the control group. CTS were significantly associated with ORIF for DRFs within 9 months after the fracture, whereas trigger finger was not significantly different between groups. Diabetes mellitus was a significant risk factor for CTS and trigger finger within 9 months after the incidence of DRFs.

The risk factors of nonunion after intramedullary nailing fixation of femur shaft fracture in middle age patients.

Although the optimal treatment for femur shaft fracture is intramedullary nailing fixation, nonunion still occurs. We determined the oligotrophic nonunion rate among femur fractures managed operatively and identified risk factors for reoperation. This was a retrospective clinical study. The data of the patients between 40 and 70 years old with diaphyseal femur fracture who have received reamed and interlocked intramedullary nailing fixation in our hospital from February 2014 to April 2018 were collected. They were followed at regular intervals for at least 1 year after the operation. The primary outcome was nonunion of the fracture site that required reoperation in accordance with the radiographic union scale for tibial shaft fracture (RUST), which is a reasonable score system for lower limb diaphyseal fracture. Three of them were hypertrophic nonunion (1.9%) and the other 13 cases were oligotrophic nonunion (8.6%) at postoperative 12 months follow-up. All of the postoperative plain films showed adequate reduction quality. The three hypertrophic nonunion cases were all obese male with fracture site comminution. Fracture at the proximal third junction, hypertension (HTN) and diabetes mellitus (DM) was significantly associated with oligotrophic nonunion of the fracture site from logistic regression analysis. The mean RUST score 3 months after the operation was not significantly different between the union group and nonunion group but was significantly lower 6 months after the operation in the nonunion group. In conclusion, intramedullary nailing of the femur shaft fractures was associated with a low risk of nonunion at the 1-year follow-up in the middle age group. Those with comorbidity such as obese, HTN, and DM, with fracture site at the proximal third junction or comminution should be followed up closely and rehabilitation with cause aggressively. Radiographic scale as the RUST score at postoperative 6 months could be used to predict this complication.

The adductor tubercle can be a radiographic landmark for joint line position determination: an anatomic-radiographic correlation study.

BACKGROUND: The adductor tubercle (AT) has been used intraoperatively as a landmark to evaluate the joint line position in knee arthroplasty. The purpose of this study was to determine whether the AT could be clearly identified on radiographic imaging as well as if the AT to joint line distance could be accurately measured for use as a radiographic landmark. METHODS: The distance from the AT to the joint line was measured on each of 78 knees during total knee arthroplasty. Next, the AT was marked with a metal marker for radiographic analysis. On the postoperative radiograph, the location of the AT was determined by tracing the metal marker. Subsequently, the radiographic joint line distance (RJLD) was measured and compared with the intraoperative joint line distance (IJLD) to test the agreement of the measurements. RESULTS: Location analysis indicated that the inflection point on the radiographic contour of the distal femur was the predicted location for the AT. The mean IJLD was 45 ± 3 mm and the RJLD was 45 ± 4 mm. The intraclass correlation coefficient was used to evaluate the inter-rater reliability between the two methods; that coefficient was 0.751, indicating good agreement between them. Measurements on the radiograph were comparable to the intraoperative measurements of the operated knees. CONCLUSIONS: In addition to being an intraoperative landmark, the AT may also be an eligible radiographic landmark for analyzing joint line level. The RJLD measurement may be obtained to plan the joint line position in knees with significant bone loss preoperatively and to follow up the results of surgery postoperatively.

Medium-term clinical outcomes of laminoplasty with adjunct short anterior fusion in multilevel cervical myelopathy.

OBJECTIVES: Expansive open-door laminoplasty (EOLP) is effective for multilevel cervical spondylotic myelopathy (MCSM). When MCSM is combined with one- or two-level segmental kyphosis, instability, or major anterior foci, EOLP with short-segment anterior cervical fusion (ACF) results in good short-term neurological recovery and can preserve postoperative range of motion (ROM). The objective of this study was to evaluate the medium-term clinical outcomes of this procedure and to analyze the risk factors affecting the neurological function at the last follow-up. MATERIALS AND METHODS: A total of 87 patients were enrolled in this retrospective study conducted from January 2007 to May 2011. These patients exhibited MCSM with combined short segmental kyphosis, instability, or major anterior pathology, and received EOLP and short-segment anterior fusion. The follow-up period lasted at least 60 months. The radiographic outcomes were collected from plain radiographs with dynamic views checked preoperatively and at the last follow-up. Neurological status and visual analog scale scores for neck pain were evaluated. Logistic regression analysis was then applied to determine the correlation between radiographic parameters and rates of neurological recovery. RESULTS: The mean Japanese Orthopedics Association recovery rate at the last follow-up was 77.8%. The improvement in functional scores and reduction in neck pain were statistically significant. The most influential risk factor affecting neurologic recovery was preoperative functional status. CONCLUSIONS: EOLP followed by short-segment ACF is a favorable treatment for patients with MCSM with concomitant short-segment kyphosis, instability, or major anterior pathology.

Open reduction and internal fixation with plating is beneficial in the early recovery stage for displaced midshaft clavicular fractures in patients aged 30-65 years old.

OBJECTIVES: Midshaft clavicular fractures are increasingly treated operatively rather than nonoperatively. Studies have shown mixed results for both types of treatment. The aim of this study was to compare the early-stage functional status associated with open reduction and internal fixation (ORIF) with plating and that associated with conservative treatment for displaced midshaft clavicular fractures. MATERIALS AND METHODS: A single-center retrospective review of the results of 120 cases of displaced midshaft clavicular fractures in patients aged 30-65 years old was conducted. The primary outcome was fracture union status at 6 months. Other outcomes were subjective shoulder value (SSV) scores, visual analog scale (VAS) scores, and radiographic shortening at 6 weeks, 3 months, and 6 months. The complication rates in the operative and nonoperative groups were recorded. RESULTS: The delayed union rate at 6-month postoperatively and VAS scores at 6 weeks, 3 months, and 6 months postinjury were significantly higher in the conservative treatment group than in the ORIF group. SSV scores were significantly improved at 6-month postinjury in the ORIF group. CONCLUSIONS: This is the first study to discuss the importance of early-stage functional restoration after ORIF with plating for displaced midshaft clavicular fractures. This surgery leads to lower pain complications in the earlier stages of bone healing and lower delayed union rates compared with conservative treatment, in patients aged 30-65 years old.

Surgical results of a one-stage combined anterior lumbosacral fusion and posterior percutaneous pedicle screw fixation.

OBJECTIVES: Lumbosacral fusion through either an anterior or a posterior approach to achieve good lordosis and stability is always a challenging surgical operation and is often accompanied by a higher rate of pseudarthrosis than when other lumbar segments are involved. This study evaluated the clinical and radiological results of lumbosacral fusions achieved through a combined anterior and posterior approach. MATERIALS AND METHODS: From June 2008 to 2012, 20 patients who had L5-S1 instability and stenosis were consecutively treated, first by anterior interbody fusion using an allogenous strut bone graft through the pararectus approach and then by posterior pedicle screw fixation. A minimum of 1-year of clinical and radiological follow-up was conducted. Intraoperative blood loss, surgical time, and any surgery-related complications were recorded. Clinical outcomes were assessed using a visual analog scale (VAS) and the patient's Oswestry Disability Index (ODI) score. After 1 year, radiological outcomes were assessed by analyzing pelvic incidence, lumbar lordosis, and segmental lordosis using static plain films, while fusion stability was assessed using dynamic plain films. RESULTS: The mean operative time and blood loss were 215 min and 325 cc, respectively. After 1 year, the VAS and ODI scores had significantly improved, and stable fusion with good lordotic curvature was obtained in all cases. CONCLUSION: The surgical results of the combined procedure are satisfactory in terms of the functional and radiological outcomes. Our method offers advantages regarding both anterior fusion and posterior fixation.

Are There Age- and Sex-related Differences in Spinal Sagittal Alignment and Balance Among Taiwanese Asymptomatic Adults?

BACKGROUND: Sagittal spinopelvic balance and proper sagittal alignment are important when planning corrective or reconstructive spinal surgery. Prior research suggests that people from different races and countries have moderate divergence; to the best of our knowledge, the population of Taiwan has not been studied with respect to this parameter. QUESTIONS/PURPOSES: To investigate normal age- and sex-related differences in whole-spine sagittal alignment and balance of asymptomatic adults without spinal disorders. METHODS: In this prospective study, we used convenience sampling to recruit asymptomatic volunteers who accompanied patients in the outpatient orthopaedic department. One hundred forty males with a mean age of 48 ± 19 years and 252 females with a mean age of 53 ± 17 years underwent standing lateral radiographs of the whole spine. For analysis, participants were divided in three groups by age (20 to 40 years, 41 to 60 years, and 61 to 80 years) and analyzed by sex (male and female). The following eight radiologic parameters were measured: sacral slope, pelvic tilt, pelvic incidence, thoracic kyphosis, lumbar lordosis, cervical lordosis, C2-C7 sagittal vertical axis, and C7-S1 sagittal vertical axis. Three observers performed estimations of the sagittal parameters twice, and the intraclass correlation coefficients for inter- and intraobserver variability were 0.81 and 0.83. RESULTS: The mean pelvic incidence was 49° ± 12°; lumbar lordosis was smaller in the group that was 61 to 80 years old than in the groups that were 20 to 40 years and 41 to 60 years (95% CI of the difference, 4.50-13.64 and 1.00- 9.60; p < 0.001), while cervical lordosis was greater in the 61 to 80 years age group than the other two groups (95% CI of the difference, -14.64 to -6.57 and -11.57 to -3.45; p < 0.001). The mean C7-S1 sagittal vertical axis was 30 ± 29 mm, and there was no difference among the three groups and between males and females. Pelvic tilt was greater in the group 61 to 80 years old than the 20 to 40 years and 41 to 60 years age groups (95% CI of the difference, -10.81 to -5.42 and -7.15 to -2.08; p < 0.001), while sacral slope was larger in 61 to 80 years age group than in the 41 to 60 years group (95% CI of the difference, 0.79-6.25; p = 0.006). C7 slope was greater in 61 to 80 years age group than in the 20 to 40 years group (95% CI of the difference, -7.49 to -1.26; p = 0.002) and larger in 41 to 60 years age group than in 20 to 40 years group (95% CI of the difference, -6.31 to -0.05; p = 0.045). C2-C7 sagittal vertical axis was greater in males than in females (95% CI of the difference, 2.84-7.74; p < 0.001). C7 slope was negatively correlated with thoracic kyphosis (95% CI of the difference, -0.619 to 0.468; p < 0.001) and lumbar lordosis (95% CI of the difference, -0.356 to -0.223; p < 0.001), and positively correlated with pelvic incidence (95% CI of the difference, 0.058- 0.215; p < 0.001) and cervical lordosis (95% CI of the difference, 0.228 - 0.334; p < 0.001). CONCLUSIONS: Normal values of the spinopelvic sagittal parameters vary by age and sex in Taiwanese individuals. CLINICAL RELEVANCE: Pelvic incidence and sacral slope observed in this population seemed smaller than those reported in other studies of white populations; this seems important when considering spine surgery in Taiwanese patients. Future studies should include collection of whole body sagittal parameters of larger and more-diverse populations, and assessments of patients with symptomatic spinal disorders.