Risk factors for reoperation after discectomy of lumbar herniated intervertebral disc disease.

Objectives: Discectomy is the most common surgery for lumbar herniated intervertebral disc (HIVD) disease. However, 5%-24% of patients undergo a second surgery due to recurrent disc herniation. Materials and Methods: This study was aimed to identify the risk factors for reoperation after discectomy of lumbar HIVD and recommend treatment for patients with a high risk of reoperation. We recruited patients diagnosed as having single-level lumbar HIVD who underwent open discectomy from January 1, 2000, to December 31, 2012 in our hospital. We used a survival curve to inspect the survival time and reoperation rate after surgery. We discussed the correlation of reoperation rate with discectomy level, body mass index, heavy lifting after surgery, sex, and age. Furthermore, we investigated the correlation between the experience of a surgeon and the reoperation rate. Results: A total of 619 patients were enrolled in our study. Most patients were 40-60 years old (48.8%), and most of them had herniation at L4/5 level (48.9%). The 8-year survival rate was 92%. Weight lifting after surgery may increase the reoperation rate by 115 and 18 times for those >60 years and <40 years, respectively. In addition, less experience of the surgeon and female sex had a high reoperation rate. Conclusion: Postoperative working modification may be very important for preventing patients from recurrent HIVD. For elderly people with HIVD, a more conservative therapy could be selected. If patients with lumbar spine hypermobility or severe degeneration require wide laminectomy, primary fusion should be considered.

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.

Incidence of Acute Upper Gastrointestinal Bleeding and Related Risk Factors among Elderly Patients Undergoing Surgery for Major Limb Fractures: An Analytical Cohort Study.

(1) Background: Upper gastrointestinal bleeding (UGIB), a major postoperative complication after surgical fixation of major limb fractures, can be fatal but is often neglected. This study determined the incidence rates of and related risk factors for perioperative UGIB among older patients with major upper limb fractures but without a history of peptic ulcer disease (PUD). (2) Methods: We collected the data of patients aged more than 65 years who underwent surgery for major limb fracture between 1 January 2001 and 31 December 2017, from Taiwan's National Health Insurance Research Database and excluded those with a history of UGIB and PUD before the date of surgery. The primary outcome was the incidence of UGIB requiring panendoscopy during hospitalization. A multiple logistic regression model was used to identify the independent predictors of UGIB, with adjustment for confounding factors. The final model included variables that were either statistically significant in univariate analyses or deemed clinically important. (3) Results: The incidence of UGIB was 2.8% among patients with major limb fractures. Male sex, older age, major lower limb fracture, and a history of chronic renal disease were significant risk factors for the increased incidence of perioperative UGIB. (4) Conclusions: Patients with major limb fractures who underwent surgery exhibited a higher rate of stress ulceration with UGIB, even when they had no history of PUD. Perioperative preventive protocols (e.g., protocols for the administration of proton-pump inhibitors) may be necessary for patients with these major risk factors.

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.

Tramadol May Increase Risk of Hip Fracture in Older Adults with Post-Traumatic Osteoarthritis.

Tramadol, an analgesic widely used for arthritic pain, is known to have adverse effects. This study investigated the association between the long-term use of tramadol for pain control and subsequent hip fractures in patients aged 60 years or older with posttraumatic osteoarthritis. This population-based retrospective cohort study included patients with posttraumatic osteoarthritis who received tramadol for pain control for more than 90 days within a 1-year period. A control cohort was enrolled using propensity score matching. The primary outcome was a new diagnosis of hip fracture requiring surgery. In total, 3093 patients were classified into each cohort. Tramadol use was identified as a risk factor for hip fracture (adjusted hazard ratio (aHR): 1.41; 95% confidence interval (CI): 1.09-1.82; p = 0.008), especially among patients aged 60-70 years (aHR: 2.11; 95% CI: 1.29-3.47; p = 0.003) and among male patients (aHR: 1.83; 95% CI: 1.24-2.70; p = 0.002). This is the first cohort study focusing on the association between long-term tramadol use and hip fracture among older adults with posttraumatic osteoarthritis. Tramadol, as a long-term pain control analgesic for older adults with posttraumatic osteoarthritis, may increase the risk of hip fracture, especially among male patients and those aged 60-70 years.

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 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.

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.

Comparison of Mid-term Survivorship and Clinical Outcomes between Bipolar Hemiarthroplasty and Total Hip Arthroplasty with Cementless Stem: A Multicenter Retrospective Study.

OBJECTIVES: To compare the clinical outcome between bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) using a U2 HA cementless hip stem, and the results of elderly femoral neck fracture patients who underwent BHA with a cementless hip stem. METHODS: A multicenter retrospective study enrolled 96 BHA and 115 THA cases using U2 HA cementless hip stems with mean age (BHA: 67.9 years; THA: 64.1 years), body height (BHA: 160.4 cm; THA: 160.7 cm) and weight (BHA: 62.7 kg; THA: 64.5 kg) recorded. Mean follow-up durations were, respectively, 7.1 (BHA) and 7.8 (THA) years. Survivorship analyses and Oxford hip scores were compared. RESULTS: Both the BHA and the THA groups revealed high survival rates at 5-year (100%) and 10-year (100.0% and 90.1%) follow-up. The THA group achieved better joint performance and pain relief. The cementless HA stems had survived perfectly for 10 years for elderly femoral neck fracture patients following BHA. CONCLUSIONS: The U2 HA cementless hip stem provides an effective solution for both BHA and THA surgeries, and for elderly femoral neck fracture patients undergoing BHA. According to the findings of the current study, THA may be inadequate for addressing avascular necrosis, and pain control is a considerable concern for patients who have undergone BHA.

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.

Clinical Outcome of Minimally Invasive Decompression Without Discectomy in Contained Foraminal Disc Herniation: A Single-Center Study.

BACKGROUND: Foraminal disc herniation is rare. When conservative treatment fails, it is often treated with discectomy via a paraspinal or Wiltse approach. In contained foraminal disc herniation, more symptoms arise from the foraminal compression of the exiting nerve root, including the dorsal root ganglion, than from the herniation itself. We aimed to evaluate the benefits of stand-alone decompression without discectomy for patients with contained foraminal disc herniation. METHODS: This study included 17 patients with unilateral single-level foraminal disc herniation (14 women and 3 men; mean age, 62.8 ± 14.6 years, range, 37-86 years). Disc herniation was confirmed as contained by preoperative magnetic resonance imaging and/or computed tomography and by intraoperative exploration. All patients underwent thorough decompression without discectomy, via a paraspinal approach. Pain was evaluated preoperatively and at 3 and 12 months postoperatively using a visual analog scale (VAS). The Oswestry Disability Index (ODI) and Macnab criteria were used to evaluate final outcomes. RESULTS: The most commonly affected level was L5-S1. All 17 patients showed significant improvements in VAS and ODI scores at 3 and 12 months postoperatively. According to the Macnab criteria, outcome results were excellent in 13 patients and good in 4. The mean duration of follow-up was 18.4 ± 2.4 months, with no recurrences or lumbar instability at the final follow-up. CONCLUSIONS: Stand-alone decompression without discectomy is an effective method for relieving symptoms and preserving the disc in contained foraminal disc herniation. A minimally invasive approach with thorough decompression techniques yields good results.

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.

Fresh frozen cortical strut allograft in two-level anterior cervical corpectomy and fusion.

Anterior cervical corpectomy and fusion (ACCF) is one of the main surgical strategies for the management of multilevel cervical spondylotic myelopathy (MCSM). High complication rates of graft bone fracture, resorption, displacement, and fusion collapse or pseudarthrosis have been previously reported. The strategies to prevent the aforementioned complications include using fresh frozen cortical strut allograft (FFCSA) to keep most of the original bone quality and using additional anterior plate fixation to improve the fusion stability and union rate. In this study, we evaluated 4-year follow-ups for surgical outcomes and analyzed the risk factors of MCSM patients who received 2-level ACCF with FFCSA and titanium dynamic plate fixation. We retrospectively collected preoperative and postoperative radiographic and clinical data of patients from 2005 to 2009; the inclusion criteria were having been diagnosed as MCSM and having received 2-level ACCF with an FFCSA fibular shaft and an anterior dynamic plate. The cervical curvature lordosis improved and the neurogenic function recovered well postoperatively. Visual analog scale for neck pain and neck disability index scores both decreased after 12 and 48 months following surgery. The Japanese Orthopaedic Association score recovery rate at postoperative 4 years was 87.5%. Fusion rates achieved 100% at 12 months. The preoperative Nurick score seemed to be the only significant risk factor correlated with the functional recovery rate at 4 years after the surgery. In conclusion, based on a minimum 4-year follow-up of 2-level ACCF with FFCSA and dynamic titanium plates for patients with MCSM, the surgical results were satisfying and the complication rates were low.

The Midterm Surgical Outcome of Modified Expansive Open-Door Laminoplasty.

Laminoplasty is a standard technique for treating patients with multilevel cervical spondylotic myelopathy. Modified expansive open-door laminoplasty (MEOLP) preserves the unilateral paraspinal musculature and nuchal ligament and prevents facet joint violation. The purpose of this study was to elucidate the midterm surgical outcomes of this less invasive technique. We retrospectively recruited 65 consecutive patients who underwent MEOLP at our institution in 2011 with at least 4 years of follow-up. Clinical conditions were evaluated by examining neck disability index, Japanese Orthopaedic Association (JOA), Nurick scale, and axial neck pain visual analog scale scores. Sagittal alignment of the cervical spine was assessed using serial lateral static and dynamic radiographs. Clinical and radiographic outcomes revealed significant recovery at the first postoperative year and still exhibited gradual improvement 1-4 years after surgery. The mean JOA recovery rate was 82.3% and 85% range of motion was observed at the final follow-up. None of the patients experienced aggravated or severe neck pain 1 year after surgery or showed complications of temporary C5 nerve palsy and lamina reclosure by the final follow-up. As a less invasive method for reducing surgical dissection by using various modifications, MEOLP yielded satisfactory midterm outcomes.

Modified fixations for distal femur fractures following total knee arthroplasty: a biomechanical and clinical relevance study.

PURPOSE: Distal femur fractures adjacent to total knee arthroplasty are a rare yet complex problem. Recently, extramedullary locking plate and retrograde intramedullary nail fixations have become popular options, but the complication rates associated with these procedures are 15-20 %. Modified fixations were assessed in an effort to reduce complications from unstable periprosthetic fractures. METHODS: Using experimental and finite element methods, this study compared the construct behaviours of a locking plate, a retrograde intramedullary nail, and their modifications (a spiral-blade supplemented in an intramedullary nail or a locking plate/allograft hybrid) when subjected to various fracture types, locations, loading conditions, and bony strength. The implanted models were used to assess construct stiffness, fracture micromotion, and implant stress under different osteoporotic conditions. Finally, we collected 40 cases for radiological analysis to indicate the appropriate procedure for treating periprosthetic fractures following total knee arthroplasty. RESULTS: Regardless of the fracture type, femoral constructs fixed with a conventional or spiral-blade supplemented intramedullary nail exhibited higher axial but lower torsional stiffness than those fixed with a locking plate. Torsional deformation occurred if the lower-positioned fracture had no medial support. The locking plate/allograft construct exhibited the highest stiffness and the least micromotion. A review of 40 clinical cases confirmed the above findings regarding the locking plate/allograft construct. CONCLUSION: The spiral-blade supplement of retrograde intramedullary nail and locking plate/allograft modified constructs significantly stabilizes the unstable fractured gaps. The locking plate/allograft is recommended for the periprosthetic fractures with deficient bone stock and severe osteoporosis to improve alignment and healing potentials.

When and how do prosthetic hips fail after total hip arthroplasties?-A retrospective study.

BACKGROUND/PURPOSE: Understanding failure modes, time to revision, and vulnerable components in revision hips could help reduce the risk of revision surgeries. Our aim was to investigate the association between the index diagnosis and the failure mode in patients undergoing revision surgeries. METHODS: A total of 402 patients who underwent a first revision surgery in a single hospital between 2000 and 2012 were recruited in a retrospective study. Multiple logistic regression analysis was used to evaluate the association of the index diagnosis of the primary total hip arthroplasty and short-term failure, as well as specific failure mode that occurred early, while controlling for sex, age, and the type of prosthesis. RESULTS: The mean time to revision due to all failure modes was 9.48 (standard deviation = 6.08) years. Defining short-term failure as a time to revision <5 years after total hip arthroplasty, the primary failure mode was infection (32.4%), followed by loosening (25.7%) and instability (17.1%). In multivariate analysis, as compared to osteonecrosis, patients with index diagnosis as infection was significantly associated with revision due to infection (odds ratio = 9.69, p = 0.013). In addition, osteoarthritis increased the odds of loosening (odds ratio = 4.18, p = 0.012). In contrast to studies in the United States and Europe, acetabular component revisions were the most common type found in our study. CONCLUSION: This study demonstrates that, compared with patients with osteonecrosis, patients with infection and osteoarthritis had higher odds of revision due to infection and loosening, respectively. Further studies are needed to examine the cause-effect relationship between index diagnosis and mode of failure.