Human primary myoblasts derived from paraspinal muscle reflect donor age as an experimental model of sarcopenia.

BACKGROUND: Low back pain is a general phenomenon of aging, and surgery is an unavoidable choice to relieve severe back pain. The discarded surgical site during surgery is of high value for muscle and muscle-related research. This study investigated the age-dependent properties of patients' paraspinal muscles at the cellular level. METHODS: To define an association of paraspinal muscle degeneration with sarcopenia, we analyzed lumbar paraspinal muscle and myoblasts isolated from donors of various ages (25-77 years). Preoperative evaluations were performed by bioimpedance analysis using the InBody 720, magnetic resonance (MR) imaging of the lumbar spine, and lumbar extension strength using a lumbar extension dynamometer. In addition, the growth and differentiation capacity of myoblasts obtained from the donor was determined using proliferation assay and western blotting. RESULTS: The cross-sectional area of the lumbar paraspinal muscle decreased with age and was also correlated with the appendicular skeletal muscle index (ASM/height2). Human primary myoblasts isolated from paraspinal muscle preserved their proliferative capacity in vitro, which tended to decrease with donor age. The age-dependent decline in myoblast proliferation was correlated with levels of cell cycle inhibitory proteins (p16INK4a, p21CIP1, and p27KIP1) associated with cellular senescence. Primary myoblasts isolated from younger donors differentiated into multinucleate myotubes earlier and at a higher rate than those from older donors in vitro. Age-dependent decline in myogenic potential of the isolated primary myoblasts was likely correlated with the inactivation of myogenic transcription factors such as MyoD, myogenin, and MEF2c. CONCLUSIONS: Myoblasts isolated from human paraspinal muscle preserve myogenic potential that correlates with donor age, providing an in vitro model of sarcopenia.

Nested Case Control Study on the Risk of Suicide Death in Elderly Patients with Pelvic Fractures Using a Nationwide Cohort.

Background: The aim of this study was to investigate the incidence rate of suicide deaths in elderly patients with pelvic fractures using a nationwide database and to analyze change in the risk of suicide death overtime after pelvic fractures compared to controls. Methods: We used the National Health Insurance Service-Senior cohort (NHIS-Senior) of South Korea. Cases and controls were matched for sex, age, history of hospital admission within 1 year, and presence of depression on the date of suicide death. Controls were collected by random selection at a 1 : 5 ratio from patients at risk of becoming cases when suicide cases were collected. Incident pelvic fractures were identified from the NHIS-Senior as follows: first admission during the observational period (2002-2015) to an acute care hospital with a diagnostic code of International Statistical Classification of Diseases and Related Health Problems, 10th revision S321, S322, S323, S324, S325, or S328 and age 65-99 years. Conditional logistic regression analysis was performed to evaluate the association between pelvic fractures and the risk of suicide death. Results: A total of 2,863 suicide cases and 14,315 controls were identified. Suicide case patients had been more frequently exposed to steroids (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.21-1.45), benzodiazepines (OR, 1.76; 95% CI, 1.61-1.93), and non-steroidal anti-inflammatory drugs (OR, 1.18; 95% CI, 1.07-1.29). Pelvic fractures within 1 year from the date of suicide death were statistically significantly associated with increased risk of suicide (adjusted OR [AOR], 2.65; 95% CI, 1.29-5.45; p = 0.008) compared to controls. The risk of suicide death declined as the incidence date of pelvic fracture was more remote from the date of suicide death: AORs of 2.59 (95% CI, 1.33-5.04; p = 0.005) within 2 years and 2.13 (95% CI, 1.15-3.95; p = 0.017) within 3 years. However, there was no statistical significance in the increased risk of suicide death for pelvic fractures that had occurred ≥ 4 years ago (p > 0.05). Conclusions: Pelvic fractures in the elderly population increased the risk of suicide death within 3 years, suggesting the need for psychiatric support among elderly patients with pelvic fractures.

Comparative Interrupted Time Series Analysis of Long-term Direct Medical Costs in Patients With Hip Fractures and a Matched Cohort: A Large-database Study.

BACKGROUND: Previous studies on medical costs in patients with hip fractures have focused on medical costs incurred for a short period after the injury. However, patients often had comorbidities before their hip fractures that would have affected medical costs even had they not sustained a fracture. Consequently, these studies may have overestimated the costs associated with hip fractures and did not characterize the duration of increased medical costs adequately. Without knowing this crucial information, it is difficult to craft thoughtful health policy to support these patients' needs. QUESTIONS/PURPOSES: (1) To compare the direct medical costs for 5 years before fracture and up to 5 years after injury in a group of patients who underwent hip fracture surgery with a matched group of patients who did not experience a hip fracture, (2) to analyze the duration over which the increased direct medical costs associated with a hip fracture continues, and (3) to analyze whether there is a difference in direct medical costs according to age group using a nationwide claims database in South Korea. METHODS: The National Health Insurance Service Sample cohort in South Korea consisted of 1 million patients who were selected using a systematic, stratified, random sampling method from 48,222,537 individuals on December 31, 2006. Under a compulsory social insurance system established by the National Health Insurance Act, all patients were followed until 2015. Patients with hip fractures and matched controls were selected from the National Health Insurance Service sample of South Korea. Patients with hip fractures were defined as those who were hospitalized with a diagnosis of femoral neck fracture or intertrochanteric fracture and who underwent surgical treatment. We excluded patients with hip fractures before January 1, 2007 to ensure a minimum 5-year period that was free of hip fractures. Patients with hip fractures were matched with patients of the same age and gender at the date of admission to an acute care hospital for surgery (time zero). If patients with hip fractures died during the follow-up period, we performed matching among patients whose difference from the time of death was within 1 month. This method of risk-set matching was repeated sequentially for the next patient until the last patient with a hip fracture was matched. We then sequentially performed 1:5 random sampling for each risk set. A total of 3583 patients in the hip fracture cohort (patients with hip fractures) and 17,915 patients in the matched cohort (those without hip fractures) were included in this study. The mean age was 76 ± 9 years, and 70% were women in both groups. Based on the Charlson comorbidity index score, medication, and medical history, the patients with hip fractures had more comorbidities. Person-level direct medical costs per quarter were calculated for 5 years before time zero and up to 5 years after time zero. Direct medical costs were defined as the sum of that insurer's payments (that is, the National Health Insurance Service's payments), and that patient's copayments, excluding uncovered payments. We compared direct medical costs between patients with hip fractures and the patients in the matched cohort using a comparative interrupted time series analysis. The difference-in-difference estimate is the ratio of the differences in direct medical costs before and after time zero in the hip fracture cohort to the difference in direct medical costs before and after time zero in the matched cohort; the difference in difference estimates were calculated each year after injury. To identify changes in direct medical cost trends in patients with hip fractures and all subgroups, joinpoint regression was estimated using statistical software. RESULTS: The direct medical costs for the patients with hip fractures were higher than those for patients in the matched cohort at every year during the observation period. The difference in direct medical costs between the groups before time zero has increased every year. The direct medical costs in patients with hip fractures was the highest in the first quarter after time zero. Considering the differential changes in direct medical costs before and after time zero, hip fractures incurred additional direct medical costs of USD 2514 (95% CI 2423 to 2606; p < 0.01) per patient and USD 264 (95% CI 166 to 361; p < 0.01) per patient in the first and second years, respectively. The increase in direct medical costs attributable to hip fracture was observed for 1.5 to 2 years (difference-in-difference estimate at 1 year 3.0 [95% CI 2.8 to 3.2]; p < 0.01) (difference-in-difference estimate at 2 years 1.2 [95% CI 1.1 to 1.3]; p < 0.01; joinpoint 1.5 year). In the subgroups of patients younger than 65, patients between 65 and 85, and patients older than 85 years of age, the increase in direct medical costs attributable to hip fracture continued up to 1 year (difference-in-difference estimate ratio at 1 year 2.7 [95% CI 2.1 to 3.4]; p < 0.01; joinpoint 1 year), 1.5 to 2 years (difference-in-difference estimate ratio at 1 year 2.8 [95% CI 2.6 to 3.1]; p < 0.01; difference-in-difference estimate ratio at 2 years 1.2 [95% CI 1.1 to 1.3]; p < 0.01; joinpoint 1.5 years), and 39 months to 5 years (difference-in-difference estimate ratio at 1 year 5.2 [95% CI 4.4 to 6.2]; p < 0.01; difference-in-difference estimate ratio at 5 years 2.1 [95% CI 1.4 to 3.1]; p < 0.01; joinpoint 39 months) from time zero, respectively. CONCLUSION: The direct medical costs in patients with hip fractures were higher than those in the matched cohort every year during the 5 years before and after hip fracture. The increase in direct medical costs because of hip fractures was maintained for 1.5 to 2 years and was greater in older patients. Based on this, we suggest that health policies should focus on patients' financial and social needs, with particular emphasis on the first 2 years after hip fracture with stratification based on patients' ages. LEVEL OF EVIDENCE: Level II, economic analysis.

Suicide in Elderly Patients with Hip Fracture: A South Korean Nationwide Cohort Study.

BACKGROUND: The purpose of the present study was to evaluate the incidence rate (IR) of suicide in elderly patients with hip fracture on the basis of a nationwide cohort and to analyze the change in the hazard ratio for suicide after hip fracture over time in comparison with a control group. METHODS: Patients with hip fracture and their matched controls were selected from the National Health Insurance Service-Senior cohort (NHIS-Senior) of the Republic of Korea. The NHIS-Senior consists of 558,147 people selected by a 10% simple random-sampling method from a total of 5.5 million subjects ≥60 years of age in 2002. Risk-set matching (1:2) on the propensity score was performed with use of a nearest neighbor matching algorithm with a maximum caliper of 0.1 for the hazard components. The IR of suicide and 95% confidence interval (CI) were calculated on the basis of a generalized linear model with a Poisson distribution. The effect size was presented as a hazard ratio (HR) with use of the Cox proportional-hazard model with a robust variance estimator that accounts for clustering within matched pairs. RESULTS: A total of 11,477 patients with hip fracture and 22,954 matched controls were included. The mean duration of follow-up was 4.59 years, generating 158,139 person-years. During follow-up, a total of 170 suicides were identified. Comparisons at up to 180 days and 365 days showed that patients with hip fracture were at higher risk for suicide than matched controls (p = 0.009 and 0.004, respectively; stratified log-rank test). During the first 180 days of follow-up, 14 suicides were identified in patients with hip fracture during 11,152 person-years (IR, 266.1 per 100,000 person-years; 95% CI, 157.6 to 449.4). Patients with hip fracture were 2.97 times more likely to kill themselves than their matched controls during the same period (HR = 2.97; 95% CI, 1.32 to 6.69). CONCLUSIONS: Hip fracture in elderly patients increased suicide risk within a year. A new approach to psychiatric evaluation and management is needed in elderly patients with hip fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The effect of surgery type on mortality in elderly patients with pertrochanteric femoral fracture: A Korean nationwide cohort study.

BACKGROUND/OBJECTIVE: The purpose of this study is to analyze the effect of surgical methods on mortality and the relative risk of patients who underwent internal fixation (IF) or hemiarthroplasty (HA) after being diagnosed as a pertrochanteric fracture over 65 years old in a Korean nationwide cohort with a single insurance medical system. METHODS: The Korean National Health Insurance Service-Senior cohort (NHIS-Senior, NHIS-2018-2-111) was used in this study. The eligibility criteria for incident hip fracture patients were the following: (1) first-time admission to acute care hospitals (index admission) with pertrochanteric fracture (ICD-10 S721), (2) three years of hip fracture-free period, (3) recipients of typical surgeries including IF, HA, (4) age between 65 and 99. RESULTS: a total of 7223 patients were enrolled in the cohort. There were 1662 patients (23%) in the HA group and 5561 patients (77%) in the IF group. Mortality rates of the IF group and HA group were 13.46 and 17.94 cases per 100 person-years, respectively. In the multivariable-adjusted Cox proportional hazard model, the HA group had 1.22 times more hazard of all-cause mortality than IF group (aHR 1.22, 95% CI 1.13-1.32). In subgroup analysis, aged 65-79 and female patients showed a prominent association between surgery type and mortality (aHR 1.52, 95% CI 1.29-1.79). CONCLUSIONS: In patients with pertrochanter fracture over 65 years, 1.22-fold mortality rate was observed when HA was performed compared to that of IF, and the difference in mortality was particularly prominent within 1-year after surgery.

Arthroscopic Assessment of Cartilage Healing Status after Treatment of Tibial Plateau Fracture.

BACKGROUND: There are a few reports on the healing status of the cartilage after the treatment of tibial plateau fracture. In this study, we analyzed the healing status of articular cartilage using second-look arthroscopy with clinical and radiological results from patient's in schatzker Type I, II, and III tibial plateau fracture. MATERIALS AND METHODS: 43 patients operated between January 2011 and December 2013 were included in this retrospective study. Radiological evaluation was performed by comparing simple radiographs from the preoperative, postoperative, and final followup period. Clinical evaluations were performed using the Knee Society Knee Score (KSKS) and the Knee Society Functional Score (KSFS). Moreover, second-look arthroscopic evaluation was performed during implant removal, and cartilage healing status was classified according to the International Cartilage Repair Society grading system (ICRS). RESULTS: In all 43 patients, bony union was achieved with a mean duration of 13.7 weeks. The degree of cartilage healing was poor when the step-off was high (P = 0.016). Furthermore, even in cases with satisfactory step-off <2 mm, there was no case with complete cartilage healing. Between ICRS grade and clinical results, the respective Pearson coefficient for KSKS and KSFS were r = -0.62 and r = -0.59 indicating mean statistically significant negative correlations (P = 0.001). CONCLUSION: Even though step off was reduced anatomically and clinical outcome was excellent or good, there was not always complete cartilage healing in a followup on second-look arthroscopy. Therefore, we focused on not only radiologic and clinical outcome but also the actual status of cartilage with second-look arthroscopy.

Biomechanical Evaluation of Internal Fixation of Pauwels Type III Femoral Neck Fractures: A Systematic Review of Various Fixation Methods.

BACKGROUND: The purpose of this systematic review was to investigate various fixation methods or implants used in the treatment of Pauwels type III femoral neck fractures. METHODS: PubMed Central, OVID Medline, Cochrane Collaboration Library, Web of Science, Embase, and AHRQ databases were searched to identify relevant studies published until August 2017 with English language restriction. Studies were selected on the basis of the following inclusion criteria: biomechanical study of Pauwels type III femoral neck fractures and the use of dynamic hip screw (DHS) or multiple screw fixation or other devices for fixation of the fracture. RESULTS: A total of 15 studies were included in the systematic review. Eight studies were conducted using cadavers, six studies using sawbones, and one using a finite element model. During the mechanical testing, each study measured mechanical stiffness, failure to cyclic loading, failure to vertical loading of each fixation device. DHS was included in 11 studies, multiple screw fixation in 10 studies, and other devices in six studies. Baitner et al. and Samsami et al. reported that the mechanical stiffness of DHS was superior to three inverted triangular screw fixation. Hawks et al. and Gumustas et al. reported that using a transverse calcar screw can withstand vertical loading better than three inverted triangular screw fixation. In addition, there were some studies where instruments such as Intertan nail, locking plate or other devices showed excellent biomechanical properties. CONCLUSIONS: There are a variety of methods and instruments for fixation of the Pauwels type III fractures. However, it is difficult to conclude that any method is more desirable because there are advantages and disadvantages to each method. Therefore, we should pay attention to the implant choice and consider adequate weight bearing affecting the stiffness of the implant.

Gait analysis after total hip arthroplasty using direct anterior approach versus anterolateral approach: a systematic review and meta-analysis.

BACKGROUND: Comparative studies of total hip arthroplasty using the direct anterior approach (DAA) compared with the anterolateral approach (ALA) by gait analysis compared the results of the two groups, the damage to the abductor muscle, with objective and detailed kinematic as well as kinetic data of actual gait. The purpose of this systematic review was to analyze the differences in gait such as time-dependent parameters, kinetics, and kinematics after THA using the DAA compared with ALA. METHODS: PubMed Central, OVID Medline, Cochrane Collaboration Library, Web of Science, EMBASE and AHRQ carried out a comprehensive search for all relevant randomized controlled trials and comparative studies, up to December 2018. Based on the following criteria, studies were selected: 1) study design: randomized controlled trials or non-randomized comparative studies; 2) study population: patients with primary osteoarthritis or avascular necrosis; 3) intervention: total hip arthroplasty by DAA or ALA; 4) Kinetic and kinematic data after gait analysis in the plains during postoperative follow-up. RESULTS: Of the 148 studies, 7 randomized controlled trials and 5 comparative studies were finally included in this systematic review. The peak hip flexion within 3 months after surgery was described in two studies and was significantly higher in the DAA group. (OR = 1.90; 95% CI [1.67,2.13]; P < 0.01, Z = 16.18). The gait speed within 3 months after surgery was reported in 3 studies and was significantly higher in the DAA group than in the ALA group. (SMD = 0.17; 95% CI [0.12,0.22]; P < 0.01, Z = 6.62) There was no difference between the two groups in stride length, step length, and hip range of motion in sagittal plane. CONCLUSIONS: In this meta-analysis, gait speed and peak hip flexion within 3 months after surgery were significantly higher in the DAA group than in the ALA group. Despite a few significant differences between two approaches, determining whether the reported differences in terms of postoperative gait values are clinically meaningful remains a substantial challenge.

Mobile bearing medial unicompartmental knee arthroplasty in patients whose lifestyles involve high degrees of knee flexion: A 10-14year follow-up study.

BACKGROUND: Because Asian populations have different lifestyles, such as squatting and sitting on the floor, from those of Western populations, it is possible that the clinical results and survival rate of unicompartmental knee arthroplasty (UKA) for Asian patients may be different. This study described outcomes of mobile bearing medial UKA for Korean patients. METHODS: A total of the 164 knees treated with mobile bearing UKAs in 147 patients (14 males and 133 females) were reviewed. The mean follow-up period was 12.1years (range 10.1-14). RESULTS: The clinical outcomes, such as the Hospital for Special Surgery Knee score, the Oxford Knee Score and the Knee Society rating system, showed statistically significant improvement from pre-operative to final follow-up (P<0.05). A total of 26 UKAs (15.8%) required revision; the most common reason was bearing dislocation. The 95% confidence interval of survival rate at 12years was 84.1%, with revision for any reason as the end point. CONCLUSIONS: Minimally invasive mobile bearing UKA in Asian patients who required high degrees of knee flexion showed rapid recovery and good clinical outcome. However, they also showed relatively high rates of bearing dislocation and aseptic loosening. Therefore, mobile bearing UKA should only be performed in patients whose lifestyle involves high flexions after carefully considering these risks and benefits.

Treatment of Advanced Kienböck Disease With a Vascularized Radial Bone Flap Wrapped in the Pronator Quadratus.

PURPOSE: In the present study, we aimed to assess the radiologic and clinical outcomes after excision of the lunate, insertion of a vascularized radial bone flap wrapped in the pronator quadratus, and distraction with an external fixator of the joint, for the treatment of avascular necrosis of the lunate with carpal height collapse, fragmentation, and perilunar osteoarthritic changes. MATERIALS AND METHODS: From May 2006 to July 2014, a total of 25 patients (13 men and 12 women; mean age, 38.7 years; age range, 28-52 years) with advanced Kienböck disease were treated with excision of the lunate and insertion of a vascularized radial bone flap wrapped in the pronator quadratus, followed by distraction with an external fixator of the joint; all these patients met our inclusion criteria, including symptomatic avascular necrosis of the lunate with carpal collapse and osteoarthritis of the wrist. We evaluated the scaphocapitate angle for radiologic assessment. Moreover, the overall clinical results were graded by using the wrist range of motion, modified Mayo wrist score, and disabilities of the arm, shoulder, and hand score. RESULTS: All the patients exhibited improved symptoms, and subsequently returned to their work and recreational activities. The mean scaphocapitate angles and carpal height ratio improved from 33.7 degrees (range, 32.1-35.7 degrees) and 0.46 degrees (range, 0.42-0.51 degrees) preoperatively to 56.3 degrees (range, 54.7-59.8 degrees) and 0.50 degrees (range, 0.46-0.56 degrees) at the follow-up, respectively. The final average range of motion was as follows: wrist flexion, 73 degrees (range, 62-81 degrees); and extension, 76 degrees (range, 69-88 degrees). The average postoperative modified Mayo wrist score and disabilities of the arm, shoulder, and hand score were 91 points (range, 80-100 points) and 11 points (range, 2-24 points), respectively. CONCLUSION: We suggest that the excision of the lunate and insertion of a vascularized radial bone flap wrapped in the pronator quadratus, followed by distraction with an external fixator of the joint, is a reliable method for the treatment of Kienböck disease with collapse or fragmentation of the lunate, and achieves high functional scores, increased range of movement, and relief of pain, without any complications.

Conservative Treatment Is Sufficient for Acute Distal Radioulnar Joint Instability With Distal Radius Fracture.

Treatments for acute distal radioulnar joint (DRUJ) instability with distal radius fracture vary from conservative to operative treatment, although it seems to be no consensus regarding which treatment is optimal. This prospective randomized study was designed to compare the clinical outcomes for operative and conservative treatment of acute DRUJ instability with distal radius fracture, according to the presence or absence and type of ulnar styloid process fracture and the degree of its displacement. Between July 2008 and February 2013, we enrolled 157 patients who exhibited an unstable DRUJ during intraoperative manual stress testing (via the ballottement test) after fixation of the distal radius. Patients were classified according to the type of the ulnar styloid process fracture, using preoperative wrist radiography, and each group was divided into subgroups, according to their treatment method. We then compared the clinical outcomes between the conservative and operative treatments, using their range of motion; Disabilities of the Arm, Shoulder, and Hand score; modified Mayo wrist score; and grip strength. At 3 months after surgery, among patients without ulnar styloid process fracture, the flexion-extension range was 79 ± 15° after supination sugar-tong splinting (group A-1), 91 ± 14° after DRUJ transfixation (group A-2), and 89 ± 10° after arthroscopic triangular fibrocartilage complex repair (group A-3); the operative treatments provided greater joint motion ranges than conservative treatment. The groups with ulnar styloid process fractures at the tip (group B) or base (group C) also exhibited better clinical outcomes after the operative treatments, compared with after the conservative treatment. However, at the final follow-up, groups A-1, A-2, and A-3 exhibited similar flexion-extension ranges (122 ± 25°, 119° ± 18°, and 120° ± 16°, respectively) and modified Mayo wrist scores (87 ± 7, 89 ± 8, and 85 ± 9). Thus, the conservative and operative treatments provided similar long-term outcomes, and similar results were observed for patients with ulnar styloid process fracture at the tip or base. The average splint application period for patients who underwent conservative treatment was 6.6 weeks (range, 4-9 weeks). In our practice, conservative treatment (supination sugar-tong splinting) and surgical treatments provided similar long-term outcomes for acute DRUJ instability with distal radius fracture.

Screw-Home Movement of the Tibiofemoral Joint during Normal Gait: Three-Dimensional Analysis.

BACKGROUND: The purpose of this study was to evaluate the screw-home movement at the tibiofemoral joint during normal gait by utilizing the 3-dimensional motion capture technique. METHODS: Fifteen young males and fifteen young females (total 60 knee joints) who had no history of musculoskeletal disease or a particular gait problem were included in this study. Two more markers were attached to the subject in addition to the Helen-Hayes marker set. Thus, two virtual planes, femoral coronal plane (P f ) and tibial coronal plane (P t ), were created by Skeletal Builder software. This study measured the 3-dimensional knee joint movement in the sagittal, coronal, and transverse planes of these two virtual planes (P f and P t ) during normal gait. RESULTS: With respect to kinematics and kinetics, both males and females showed normal adult gait patterns, and the mean difference in the temporal gait parameters was not statistically significant (p > 0.05). In the transverse plane, the screw-home movement occurred as expected during the pre-swing phase and the late-swing phase at an angle of about 17°. However, the tibia rotated externally with respect to the femur, rather than internally, while the knee joint started to flex during the loading response (paradoxical screw-home movement), and the angle was 6°. CONCLUSIONS: Paradoxical screw-home movement may be an important mechanism that provides stability to the knee joint during the remaining stance phase. Obtaining the kinematic values of the knee joint during gait can be useful in diagnosing and treating the pathological knee joints.

Surgical treatment of pathological fractures occurring at the proximal femur.

PURPOSE: To analyze the results of surgical treatment for pathological fractures at the proximal femur. MATERIALS AND METHODS: Nineteen patients with a pathological fracture were included. The mean age was 65.7 years old. The patients comprised 8 males and 11 females. Primary tumors, types of pathological fractures, surgical procedures, and postoperative complications were recorded. Musculoskeletal Tumor Society (MSTS) functional score was used for functional evaluation. A Kaplan-Meier survival analysis was used to determine survival rate. RESULTS: The primary malignancies were 6 cases of breast cancer, 3 cases of lung cancer, 3 cases of renal cell carcinoma, 2 cases of cholangiocarcinoma, 2 cases of hepatocellular carcinoma, 1 case of esophageal cancer, 1 case of colon cancer, and 1 case of ovarian cancer. Pathological fractures included 8 cases of pertrochanteric fractures and 11 cases of subtrochanteric fractures. Intramedullary nailing was performed in 10 cases, and joint replacement surgery was performed in 9 cases. Postoperative complications included local recurrence in 1 case, infection in 1 case, and nail breakage in 1 case. The mean postoperative MSTS score was 21. The mean survival period was 10.6 months. Patient survival rates were 42.1% after 6 months, 26.3% after 12 months, and 10.5% after 24 months. CONCLUSION: Surgical treatment of pathological fractures at the proximal femur provided early ambulation, and excellent pain relief. The surgery was well tolerated emotionally. Surgery is necessary for improving the quality of life in such patients; however, more cases of pathological fractures in these regions should be subjected to detailed analysis.

Modified hemihamate arthroplasty technique for treatment of acute proximal interphalangeal joint fracture-dislocations.

We retrospectively reviewed 11 patients who underwent modified hemihamate arthroplasty for the treatment of comminuted dorsal fracture-dislocation of the proximal interphalangeal (PIP) joint. This technique was used to minimize the potential risk of complications at the recipient site by volarly oblique osteotomy in the coronal plane at graft harvesting and anatomical repair of the detached flexor sheath. The average joint involvement of the fracture was 58.4%, and the mean duration of follow-up was 38 months. The active range of motion of the distal interphalangeal, PIP, and metacarpophalangeal joint was 80.4, 85.4, and 91.8 degrees, respectively. The mean disabilities of the arm, shoulder, and hand score was 4.8, and all patients achieved bony union at final follow-up. One patient showed radiographic signs of graft absorption, but this did not limit their daily activities. The modified hemihamate arthroplasty technique is safe and reliable and reduces the risk of iatrogenic damage when used to treat comminuted dorsal fracture-dislocations of the PIP joint.

Plate osteosynthesis versus intramedullary nailing for both forearm bones fractures.

PURPOSE: Given the continuing improvements in nail implants, intramedullary nailing could become an alternative treatment option to osteosynthesis for the treatment of fractures in both forearm bones, with the proper indication. The aim of this prospective study was to evaluate and compare the results of plate osteosynthesis and intramedullary nailing for the treatment of diaphyseal fractures in both forearm bones. METHODS: Sixty-seven patients (mean age, 41 years; range, 22-76 years) of this prospective study were divided into two groups according to treatment randomly: ORIF group (plate osteosynthesis) and IMN group (intramedullary nail). The results were assessed on the basis of the time to union, functional recovery (range of motion and functional outcomes [Grace and Eversmann rating system and DASH]), restoration of the ulna and the radial bow, operating time, exposure time to fluoroscopy, complications, and patient satisfaction. The ratio of the magnitude of the maximum radial bow on the injured side to that on the contralateral side (i.e., "the ratio of the contralateral side") was determined to evaluate the effectiveness of radial bow restoration between groups. RESULTS: The time to union and the exposure time to fluoroscopy were significantly shorter in ORIF group than in IMN group. The presence of butterfly segment and severe displacement were factors leading to the increase in the time of union in IMN group. No intergroup differences were observed in the restoration and magnitude of the maximum radial bow on the injured side. However, ORIF group showed a significantly improved ratio of the contralateral side compared to IMN group. In terms of the location of maximum radial bow and ratio of the contralateral side, significant differences were found between groups. The functional outcomes did not significantly differ between the two groups, irrespective of the time of assessment. All patients achieved union in both groups, with the exception of a single case of nonunion in IMN group and one case of refracture after implant removal in ORIF group. CONCLUSION: Based on the significant differences in the ratio of the contralateral side, plate osteosynthesis resulted in a more excellent extent of restoration to the conditions prior to the injury. Nevertheless, such significant differences in the restoration of the bow had no effect on the final clinical outcome. If the indication is properly selected, our results suggested intramedullary nailing can be acceptable and effective treatment options for fractures in both forearm bones.

A comparison between orthogonal and parallel plating methods for distal humerus fractures: a prospective randomized trial.

With the continuing improvements in implants for distal humerus fractures, it is expected that newer types of plates, which are anatomically precontoured, thinner and less irritating to soft tissue, would have comparable outcomes when used in a clinical study. The purpose of this study was to compare the clinical and radiographic outcomes in patients with distal humerus fractures who were treated with orthogonal and parallel plating methods using precontoured distal humerus plates. Sixty-seven patients with a mean age of 55.4 years (range 22-90 years) were included in this prospective study. The subjects were randomly assigned to receive 1 of 2 treatments: orthogonal or parallel plating. The following results were assessed: operating time, time to fracture union, presence of a step or gap at the articular margin, varus-valgus angulation, functional recovery, and complications. No intergroup differences were observed based on radiological and clinical results between the groups. In our practice, no significant differences were found between the orthogonal and parallel plating methods in terms of clinical outcomes, mean operation time, union time, or complication rates. There were no cases of fracture nonunion in either group; heterotrophic ossification was found 3 patients in orthogonal plating group and 2 patients in parallel plating group. In our practice, no significant differences were found between the orthogonal and parallel plating methods in terms of clinical outcomes or complication rates. However, orthogonal plating method may be preferred in cases of coronal shear fractures, where posterior to anterior fixation may provide additional stability to the intraarticular fractures. Additionally, parallel plating method may be the preferred technique used for fractures that occur at the most distal end of the humerus.

Ceramic-on-ceramic total hip arthroplasty: minimum of six-year follow-up study.

BACKGROUND: This study examines the clinical and radiologic results of ceramic-on-ceramic total hip arthroplasties with regard to wear, osteolysis, and fracture of the ceramic after a minimum follow-up of six years. METHODS: We evaluated the results of a consecutive series of 148 primary ceramic-on-ceramic total hip arthroplasties that had been performed between May 2001 and October 2005 in 142 patients. The mean age was 57.2 years (range, 23 to 81 years). The mean follow-up period was 7.8 years (range, 6.1 to 10.1 years). Preoperative diagnosis was avascular necrosis in 77 hips (52%), degenerative arthritis in 36 hips (24.3%), femur neck fracture in 18 hips (12.2%), rheumatoid arthritis in 15 hips (10.1%), and septic hip sequelae in 2 hips (1.4%). Clinical results were evaluated with the Harris hip score, and the presence of postoperative groin or thigh pain. Radiologic analysis was done with special attention in terms of wear, periprosthetic osteolysis, and ceramic failures. RESULTS: The mean Harris hip score improved from 58.3 (range, 10 to 73) to 92.5 (range, 79 to 100) on the latest follow-up evaluation. At final follow-up, groin pain was found in 4 hips (2.7%), and thigh pain was found in 6 hips (4.1%). Radiologically, all femoral stems demonstrated stable fixations without loosening. Radiolucent lines were observed around the stem in 25 hips (16.9%), and around the cup in 4 hips (2.7%). Endosteal new bone formation was observed around the stem in 95 hips (64.2%) and around the cup in 88 hips (59.5%). No osteolysis was observed around the stem and cup. There were 2 hips (1.4%) of inclination changes of acetabular cup, 2 hips (1.4%) of hip dislocation, 1 hip (0.7%) of ceramic head fracture, and 1 hip (0.7%) of squeaking. The Kaplan-Meier survival rate of the prostheses was 98.1% at postoperative 7.8 years. CONCLUSIONS: The ceramic-on-ceramic total hip arthroplasty produced excellent clinical results and implant survival rates with no detectable osteolysis on a minimum six-year follow-up study. The ceramic-on-ceramic couplings could be a reasonable option of primary total hip arthroplasty for variable indications.

Modified retrograde percutaneous intramedullary multiple Kirschner wire fixation for treatment of unstable displaced metacarpal neck and shaft fractures.

The purpose of this prospective study was to evaluate the functional and radiographic outcomes of our new surgical technique, retrograde percutaneous intramedullary multiple Kirschner wire (K-wire) fixation, for the treatment of unstable displaced metacarpal neck or shaft fractures. Between March 2005 and April 2010, 56 consecutive patients with 65 metacarpal fractures were treated with closed reduction and retrograde intramedullary fixation with at least 2 K-wires. The average follow-up duration was 13 months. The clinical outcome was assessed by the total active motion (TAM) of the digit, presence of rotational deformity, grip strength, patient satisfaction, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. The radiographic outcome was assessed by the time to union, dorsal angulation, and shortening. The average operating time was 11 min (range, 6-17 min) for isolated single metacarpal fractures and 18 min (range, 13-25 min) for isolated simultaneous 2-metacarpal fractures. There was no significant difference in the average TAM of the digit between the injured and uninjured hands in both neck and shaft fractures. Four patients developed extensor tendon irritation during follow-up, but the irritations disappeared completely after removal of the wires, and there was no need to perform tenolysis. The average DASH score was 8.7 (range, 0-21). Radiographic union was achieved in all patients at a mean of 5.2 weeks. Radiographic assessment revealed a significant reduction in the average dorsal angulation to 8° (SD, 2) in neck fractures and to 4° (SD, 2) in shaft fractures postoperatively. The average shortening was corrected significantly to 1 mm (SD, 2) in neck fractures and to -1 mm (SD, 2) in shaft fractures postoperatively. Based on our experience, our retrograde intramedullary K-wire fixation technique is an acceptable alternative modality for the treatment of unstable displaced metacarpal fractures. This straightforward technique can facilitate early hand mobilization, correct the deformity, and provide good clinical and radiographic outcomes.

Volar long locking compression plate fixation for distal radius fractures with metaphyseal and diaphyseal extension.

Comminuted distal radial fractures with metaphyseal and diaphyseal extension are uncommon and remain a challenge to treat. The purpose of this study was to assess the radiographic and functional outcomes of treatment with the volar long locking compression plate (LCP) system for distal radius fractures with metaphyseal and diaphyseal extension. This retrospective study was performed on 22 consecutive patients who were treated with open reduction and internal fixation with the application of a 2.4-mm-extra-long LCP volar distal radius plate. Patients were evaluated based on clinical signs and radiography studies. The average time to fracture union was 16 weeks. The volar tilt was restored to a mean of 10.1°. The radial length and radial inclination were restored to a mean of 12.8 mm and 23.6° at final follow-up, respectively. The mean loss of radial length was -1.0 mm at final follow-up as compared with the contralateral extremity. The average ulnar variance was positive 0.1 mm at final follow-up with a congruent distal radioulnar joint. The degree of collapse after fixation between immediate postoperative and final follow-up visit was -0.1 mm. Using the demerit-point system of the Gartland and Werley rating system, 14 results were rated as excellent, 5 as good and 1 as fair. DASH scores averaged 10.1 points. Based on our experience, the volar long LCP is useful in the management of comminuted fractures of the distal radius, in which there is proximal extension into the diaphysis and can avoid or minimize the complications of external fixation or dorsal bridging distraction plate.

Flavokawain B, a kava chalcone, induces apoptosis in synovial sarcoma cell lines.

Synovial sarcomas (SS) are soft tissue sarcomas with poor prognosis, displaying a lack of response to conventional cytotoxic chemotherapy. Although SS cell lines have moderate chemosensitivity to isofamide and doxorubicin therapy, the clinical prognosis is still poor. In this article, we showed that flavokawain B (FKB), a novel chalcone from kava extract, potently inhibits the growth of SS cell lines SYO-I and HS-SY-II through induction of apoptosis. Treatment with FKB increased caspase 8, 9, and 3/7 activity compared to vehicle-treated controls, indicating that both extrinsic and intrinsic apoptotic pathways were activated. Furthermore, FKB treatment of both cell lines resulted in increased mRNA and protein expression of death receptor-5 and the mitochondrial pro-apoptotic proteins Bim and Puma, while down-regulating the expression of an inhibitor of apoptosis, survivin in a dose-dependent manner. Our results suggest the natural compound FKB has a pro-apoptotic effect on SS cell lines. FKB may be a new chemotherapeutic strategy for patients with SS and deserves further investigation as a potential agent in the treatment of this malignancy.