Risk factors for postoperative urinary retention in fragility hip fracture patients: a prospective study.

BACKGROUND: Postoperative urinary retention (POUR) among older patients with hip fractures is common and may result in delayed ambulation, prolonged hospital stays, and urinary tract infections. Although preoperative urinary catheter indwelling and early postoperative removal can prevent perioperative urinary retention, this condition may occur in some patients after catheter removal, which requires urinary catheter re-indwelling or intermittent catheterization. Therefore, this study aims to identify risk factors and develop a screening tool for postoperative urinary retention in patients who have undergone operative treatment for fragility hip fractures subsequent to urinary catheter removal. METHODS: A prospective cohort study of 145 fragility hip fracture in older patients who were operatively treated between September 2020 and May 2022 was conducted. All patients were evaluated for urine retention after urinary catheter removal using a bladder scan. In addition, factors related to urinary retention were collected and utilized for screening tool development. RESULTS: Of the included patients, 22 (15.2%) were diagnosed with POUR. A multivariable logistic regression model using a stepwise backward elimination algorithm identified the current use of drugs with anticholinergic effect (OR = 11.9, p = 0.012), international prostate symptom score (IPSS) ≥ 8 (OR = 9.3, p < 0.001), and inability to independently get out of bed within 24 h postoperatively (OR = 6.5, p = 0.051) as risk factors of POUR. The screening tool that has been developed revealed an excellent performance (AuROC = 0.85, 95%CI 0.75 to 0.91) with good calibration and minimal optimism. CONCLUSIONS: Current use of drugs with anticholinergic effects, IPSS ≥ 8, and inability to independently get out of bed within 24 h postoperatively are significant variables of POUR. For additional external validation, a proposed scoring system for POUR screening was developed. TRIAL REGISTRATION: The study protocol was retrospectively registered in The Thai Clinical Trials Registry (TCTR20220502001: 2 May 2022).

Long-term outcome of nonunion of the lateral humeral condyle fracture in children: a multicentre retrospective study.

PURPOSE: Lateral humeral condyle nonunion in children is a rare condition. The treatment protocol for nonunion of lateral humeral condyle remains controversial due to the potential complication. This study reports long-term functional outcomes of the nonunion of the lateral humeral condyle fracture. In addition, we identified the prognostic factors for nonunion of the lateral humeral condyle fracture. METHODS: We conducted a multicentre retrospective cohort study of nonunion of lateral humeral condyle between January 1995 and December 2022. The patient's preoperative demographic information was reviewed. Potential risk factors of poor functional outcome, such as age, duration from initial injury, and fracture displacement, were retrieved. Functional outcomes at the latest follow-up visit were evaluated using the Mayo Elbow Performance Score (MEPS). Multivariable linear regression was deployed to evaluate the association of potential risk factors with the functional outcome. RESULTS: A total of 63 patients from eight medical centers were included, of which 60 were surgically treated. Patients' average age was 7.3 years old, with a mean follow-up duration of seven years. All nonunion cases were successfully treated, resulting in a normalized humeroulnar angle. The rate of AVN was 16.7%. All patients reported excellent range of motion and MEPS at the latest follow-up. Multivariable linear regression demonstrated that Fracture displacement (ß = -0.88, 95% CI -1.55 to -0.22, p = 0.010) and duration from initial injury (ß = -0.09, 95% CI -0.17 to -0.02, p = 0.010) were statistically significant factors influencing functional outcome of lateral humeral condyle nonunion. CONCLUSIONS: Initial fracture displacement and duration from the initial injury are statistically significantly associated with elbow function in lateral humeral condyle nonunion. However, the effect size for these factors is relatively small and does not reach clinical significance. Despite this, the functional outcome is excellent in all patients, with an average follow-up duration of seven years.

Prevalence of osteoporosis, sarcopenia, and high falls risk in healthy community-dwelling Thai older adults: a nationwide cross-sectional study.

Thailand has transitioned from an aging society to an aged society, which implies that the prevalence of age-related disorders will increase; however, epidemiological data specific to the prevalence of age-related degenerative musculoskeletal disorders among Thai older adults remain limited. Accordingly, the aim of this study was to investigate the prevalence of age-related musculoskeletal diseases, including osteoporosis, sarcopenia, and high falls risk among healthy community-dwelling Thai older adults. This cross-sectional nationwide study enrolled Thai adults aged ≥60 yr from 2 randomly selected provinces from each of the 6 regions of Thailand via stratified multistage sampling during March 2021 to August 2022. All enrolled participants were evaluated for BMD, skeletal muscle mass, grip strength, and gait speed. Osteoporosis was diagnosed according to the World Health Organization definition, and sarcopenia was diagnosed according to the Asian Working Group for Sarcopenia (AWGS) 2019 criteria. Falls risk was determined using the self-rated Fall Risk Questionnaire. A total of 2991 eligible participants were recruited. The mean age of participants was 69.2 ± 6.5 yr (range: 60-107), and 63.1% were female. The prevalence of osteoporosis, sarcopenia, and high falls risk was 29.7%, 18.1%, and 38.5%, respectively. Approximately one-fifth of subjects (19.1%) had at least 2 of 3 risk factors (ie, osteoporosis, sarcopenia, and high falls risk) for sustaining a fragility fracture, and 3.4% had all 3 risk factors. In conclusion, the results of this study revealed a high and increasing prevalence of osteoporosis, sarcopenia, and high falls risk in healthy community-dwelling Thai older adults. Since these conditions are all major risk factors for fragility fracture, modification of Thailand's national health care policy is urgently needed to address the increasing prevalence of these conditions among healthy community-dwelling older adults living in Thailand.

Establishing Normative Values for Performance-Based Tests in Older Thai Adults: A Nationwide Cross-Sectional Study.

OBJECTIVE: To determine normative values and identify contributing factors for physical performance tests in older, Thai, community-dwelling adults. DESIGN: Nationwide cross-sectional study. SETTING: Thai older community-dwelling adults. PARTICIPANTS: Thai older community-dwelling adults aged ≥60 years who had no major health problems (N=1430) between March 2021 and August 2022. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Normative values for the timed Up and Go (TUG) test, gait speed test, and 5-times sit-to-stand (5TSTS) test were determined for sex and age groups. Multivariable quantile regression analysis was employed to evaluate the participants, considering factors that may influence physical performance, such as height, and Charlson comorbidity index (CCI). RESULTS: The study included 1430 eligible participants. Their mean age was 68.4±5.8 years, and 58.5% were women. Men demonstrated superior physical performance in the medians (p50) of the TUG (10.0 s vs 11.0 s), gait speed (0.98 m/s vs 0.91 m/s), and 5TSTS (14.0 s vs 16.1 s) tests compared with women. These differences were consistently observed across age groups. Moreover, age, sex, and height were significantly associated with poor physical performance. CONCLUSION: This study observed variations in the normative values of TUG, gait speed, and 5TSTS tests among different age groups of older, Thai, community-dwelling adults. Additionally, our findings identified age, sex, and height as significant contributing factors to physical performance in this population.

Sarcopenia in Thai community-dwelling older adults: a national, cross-sectional, epidemiological study of prevalence and risk factors.

BACKGROUND: Sarcopenia is an age-related condition characterized by a progressive loss of skeletal muscle mass. It leads to declining physical performance, potentially culminating in a diminished quality of life or death. This study investigated the prevalence of sarcopenia and its associated risk factors among Thai community-dwelling individuals of advanced age. METHODS: Between March 2021 and August 2022, we conducted a nationwide community-based epidemiological survey across all six major regions of Thailand. Participants with sarcopenia were identified according to the 2019 criteria of the Asian Working Group for Sarcopenia (AWGS). The risk factors were examined using multivariable logistic regression. RESULTS: Of the 2456 participants, the overall prevalence of sarcopenia was 18.1%, with nearly two-thirds (66.9%) classified as having severe sarcopenia. Multivariate analysis identified six associated risk factors for sarcopenia. They are a lower body mass index (odds ratio [OR] = 11.7, 95% confidence interval [CI] = 7.8-17.4), suboptimal leg calf circumference (OR = 6.3, 95% CI = 4.3-9.5), male sex (OR = 2.8, 95% CI = 2.2-3.7), a history of chronic obstructive pulmonary disease (OR = 2.3, 95% CI = 2.3-5.0), advanced age (OR = 2.1, 95% CI = 1.3-3.3), and an increasing time in the timed up-and-go test (OR = 1.1, 95% CI = 1.0-1.1). CONCLUSIONS: This is the first large-scale national study to represent the prevalence and risk factors for sarcopenia in Thai community-dwelling individuals of advanced age using the AWGS 2019 criteria. Interventions such as lifestyle modifications and appropriate nutrition should be promoted throughout adulthood to maintain muscle strength and delay the onset of sarcopenia, particularly in males. TRIAL REGISTRATION: The Central Research Ethics Committee of the National Research Council of Thailand authorized the study protocol (approval number COA-CREC023/2021).

Single Buried Intramedullary K-Wire Fixation in Nonthumb Metacarpal Shaft Fractures with Immediate Postoperative Mobilization without Any Immobilization.

Objective: This study aims to evaluate the outcomes of single intramedullary K-wire fixation in nonthumb, metacarpal shaft fractures with immediate postoperative hand mobilization without any immobilization. Method: This is a retrospective case series conducted from January 2019 to December 2022. We included patients with closed, simple transverse, or short oblique metacarpal shaft fracture treated with single, 1.4 mm, intramedullary K-wire fixation. Gentle postoperative range of motion exercise was encouraged in every patient without any hand, finger, or wrist motion restriction material. Clinical outcomes were evaluated with total active flexion; grip strength; disability of arm, shoulder, and hand (DASH) score; and the American Society for Surgery of the Hand Total Active Flexion (ASSH TAF) score. Results: This study included 34 patients, 25 males and 9 females with a mean age of 33.14 years (ranging 18-59). A total of 43 metacarpal shafts were treated. The mean DASH score at two and 6 weeks postoperative was 41.5 (ranging 19.16-60.34) and 9.58 (ranging 0.83-23.27). The mean final DASH score at last follow-up was 3.48 (ranging 0-8.33). Mean TAF at 2 weeks postoperative, 6 weeks postoperative, and at final follow-up was 203.8 (ranging 185-240), 238.2 (ranging 220-270), and 259.25 (ranging 240-270) degrees, respectively. The mean grip strength of the injured hand was 66.14 and 86.1% of the uninjured hand at 6 weeks and 3 months postoperative. There was no nonunion, malrotation, or infection. In conclusion, single intramedullary K-wire fixation gives excellent outcomes in the treatment of single or multiple, simple, metacarpal shaft fractures without the need of postoperative immobilization.

A diagnostic predictive model for secondary osteoporosis in patients with fragility fracture: a retrospective cohort study in a tertiary care hospital.

Identifying secondary causes among osteoporotic patients is crucial. However, there is no simple tool for screening secondary osteoporosis. A predictive model for screening secondary osteoporosis was constructed using simple clinical and biochemical parameters. This predictive model may provide clinicians with guidance to perform further investigations for specific causes of osteoporosis. PURPOSE: Establishing whether a fragility fracture is secondary to a specific cause of osteoporosis is crucial for treatment outcomes. Therefore, this study aimed to develop a simple screening tool for secondary osteoporosis in the elderly initially presented with fragility fractures. METHODS: A retrospective cohort study including 456 patients with fragility hip and vertebral fractures that occurred between January 2017 and July 2022 was conducted. Demographic, clinical, biochemical, and final diagnostic data were retrieved. Potential predictors for secondary osteoporosis were determined by multivariable logistic regression analysis, and a predictive model for secondary osteoporosis was subsequently developed using identified potential predictors. RESULTS: This study included 343 females and 113 males with a mean age of 76.9 ± 11.0 years. One hundred and twenty-one patients (26.5%) were diagnosed with secondary osteoporosis. Vitamin D deficiency (71.9%) was the most common cause of secondary osteoporosis, followed by glucocorticoid-induced osteoporosis (23.9%) and primary hyperparathyroidism (9.9%). The potential predictors for secondary osteoporosis included in the predictive model were age, body mass index (BMI), corrected calcium, phosphate, thyroid stimulating hormone, and a 10-year probability of hip fractures calculated by BMI-based FRAX®. With a cut-off level of 0.22, the proposed predictive model has an AuROC of 0.75 (95% CI 0.69 to 0.81) with a sensitivity of 77%, a specificity of 66%, and an accuracy of 68.9%. CONCLUSION: A predictive model for screening secondary osteoporosis was constructed using simple clinical and biochemical parameters. This newly developed predictive model may provide clinicians with guidance to perform further advanced investigations for secondary causes of osteoporosis.

Perioperative blood loss reduction using a sterile exsanguination tourniquet for orthopedic femoral-related surgeries in children: a randomized controlled study.

OBJECTIVES: The sterile exsanguination tourniquet (SET) could be an alternative for providing bloodless surgeries in orthopedic femoral-related surgeries in pediatric patients where the standard pneumatic tourniquet would not be feasible. This randomized-controlled study aimed to evaluate the efficacy of SET in decreasing total perioperative blood loss and blood transfusion. METHODS: We conducted an unplanned interim analysis of data from a randomized-controlled trial. At the time of the analysis, 31 pediatric patients had been randomly assigned to undergo surgery with the SET application (the SET group, 15 patients) and without the SET application (the control group, 16 patients). An intention-to-treat analysis was performed to evaluate the total perioperative blood loss, postoperative blood transfusion, estimated intraoperative blood loss, total drainage volume, postoperative hemoglobin level, and operative time according to the significance level adjusted for multiplicity (p < 0.029). RESULTS: There was a borderline statistically significant lower body weight-adjusted TBL in the SET group (SET = 14.1 (7.7, 16.9) ml/kg vs. control 18.3 (14.8, 37.2) ml/kg, p-value = 0.027). The body weight-adjusted transfusion volume was statistically significantly greater in the control group (SET = 0.0 (0.0, 0.0) ml/kg vs. control = 2.1 (0.0, 9.7) ml/kg, p = 0.017). Body weight-adjusted estimated intraoperative blood loss was significantly lower in the SET group (SET = 0.8 (0.2, 3.5) ml/kg vs. control = 5.6 (3.4, 21.5) ml/kg, p < 0.001). In addition, the operative time was lower in the SET group with borderline statistical significance (SET = 105 (85.0, 125.0) vs. control = 130 (101.3, 167.5), p = 0.039). CONCLUSION: Utilization of a sterile exsanguination tourniquet (SET) significantly reduced an estimated intraoperative blood loss while preventing the need for blood transfusion after pediatric orthopedic femoral-related surgeries. Trial registration TCTR20220412003.

Predictive factors for recurrence after lower limb deformity correction in hypophosphatemic rickets.

BACKGROUND: Surgical treatment for severe lower limb deformities in patients with hypophosphatemic rickets has shown satisfactory outcomes. However, the rates of recurrence of deformities after surgical correction were high, and studies on predictive factors of recurrence were limited. This study aimed to determine the predictive factors for the recurrence of lower limb deformities after surgical correction in patients with hypophosphatemic rickets, and the effects of each predictor on the recurrence of deformities. METHODS: We retrospectively reviewed the medical records of 16 patients with hypophosphatemic rickets aged 5-20 years and who had undergone corrective osteotomies between January 2005 and March 2019. Demographic data from the patients, biochemical profiles, and radiographic parameters were collected. Univariable Cox proportional hazard analyses of recurrence were performed. Kaplan-Meier failure estimation curves for deformity recurrences of potential predictors were created. RESULTS: A total of 38 bone segments were divided into 2 groups: 8 segments with recurrent deformities and 30 segments without recurrent. The average follow-up time was 5.5 ± 4.6 years. Univariable Cox proportional hazard analyses of recurrence found that an age < 10 years (hazard ratio [HR], 5.5; 95% CI, 1.1-27.1; p = 0.04), and gradual correction by hemiepiphysiodesis (HR, 7.0; 95% CI, 1.2-42.7; p = 0.03) were associated with recurrence after surgery. The Kaplan-Meier failure estimation for deformity recurrences by age at the time of surgery also achieved a statistically significant difference between ages < 10 years and those > 10 years (p = 0.02). CONCLUSIONS: Identifying predictive factors for the recurrence of lower limb deformities after surgical correction in hypophosphatemic rickets can assist in early recognition, proper intervention, and prevention. We found that an age < 10 years at the time of surgery was associated with recurrence after deformity correction and gradual correction with hemiepiphysiodesis may also be a potential factor affecting the recurrence.

A long-term outcome (up to 29 years) of bilateral iliac wings "bayonet osteotomies" for closure of bladder exstrophy.

BACKGROUND: Several types of pelvic osteotomy techniques have been reported and employed by orthopedic surgeons to enhance the approximation of symphyseal diastasis in bladder exstrophy patients. However, there is limited evidence on a long-term follow-up to confirm which osteotomy techniques provide the most suitable and effective outcomes for correcting pelvic deformities. This study aimed to describe the surgical technique of bilateral iliac bayonet osteotomies for correcting pelvic bone without using fixation in bladder exstrophy and to report on the long-term clinical and radiographic outcomes following the bayonet osteotomies. METHODS: We retrospectively reviewed patients with bladder exstrophy who underwent bilateral iliac bayonet osteotomies with the closure of bladder exstrophy between 1993 and 2022. Clinical outcomes and radiographic pubic symphyseal diastasis measurements were evaluated. From a total of 28 operated cases, eleven were able to attend a special follow-up clinic or were interviewed by telephone by one of the authors with completed charts and recorded data. RESULTS: A total of 11 patients (9 female and 2 male) with an average age at operation of 9.14 ± 11.57 months. The average followed-up time was 14.67 ± 9.24 years (0.75-29), with the average modified Harris Hip score being 90.45 ± 1.21. All patients demonstrated decreased pubic symphyseal diastasis distance (2.05 ± 1.13 cm) compared to preoperative (4.58 ± 1.37 cm) without any evidence of nonunion. At the latest follow-up, the average foot progression angle was externally rotated 6.25° ± 4.79° with full hips ROM, and no patients reported abnormal gait, hip pain, limping, or leg length discrepancy. CONCLUSIONS: Bilateral iliac wings bayonet osteotomies technique demonstrated a safe and successful pubic symphyseal diastasis closure with an improvement both clinically and radiographically. Moreover, it showed good long-term results and excellent patient's reported outcome scores. Therefore, it would be another effective option for pelvic osteotomy in treating bladder exstrophy patients.

Comparative effectiveness of different pedicle screw density patterns in spinal deformity correction of small and flexible operative adolescent idiopathic scoliosis: inverse probability of treatment weighting analysis.

PURPOSES: An optimal pedicle screw density for spinal deformity correction in adolescent idiopathic scoliosis (AIS) remains poorly defined. We compared radiographic correction, operative time, estimated blood loss, and implant cost among different screw density patterns in operatively treated AIS patients. METHODS: A retrospective observational cohort study of AIS patients who underwent posterior spinal fusion using all-pedicle screw instrumentation was conducted from January 2012 to December 2018. All patients were categorized into three different pedicle screw density groups: the very low density (VLD), the low density (LD), and the high density (HD) group. The comparative effectiveness between each pairwise comparison was performed under the inverse probability of the treatment weighting method to minimize the possible confounders imbalance among treatment groups. The primary endpoints in this study were the degrees of correction and deformity progression at 2 years postoperatively. RESULTS: A total of 174 AIS patients were included in this study. The adjusted treatment effects demonstrated similar degrees of deformity correction after 2 years in the three treatment groups. However, the VLD and LD group slightly increased the curve progression at 2 years compared to the HD group by 3.9° (p = 0.005) and 3.2° (p = 0.044), respectively. Nevertheless, the limited screw density patterns (VLD and LD) significantly reduced the operative time, estimated blood loss, and implant cost per operated level. CONCLUSION: The limited pedicle screw pattern (VLD and LD) in relatively flexible AIS spinal deformity correction results in similar coronal and sagittal radiological outcomes while reducing operative time, estimated blood loss, and implant cost compared to the high-density pedicle screw instrumentation.

Comparative evaluation of radiographic morphologic parameters for predicting subsequent contralateral fragility hip fracture.

PURPOSE: Subsequent contralateral fragility hip fracture (SCHF) is one of the most serious conditions in osteoporotic patients due to high morbidity and mortality. This study aimed to investigate the predictive ability of radiographic morphologic parameters for SCHF in patients diagnosed with unilateral fragility hip fractures. METHODS: We conducted a retrospective observational study of unilateral fragility hip fracture patients between April 2016 and December 2021. Radiographic morphologic parameters, including canal-calcar ratio (CCR), cortical thickness index (CTI), canal-flare index (CFI), and morphological cortical index (MCI), were measured from patients' contralateral proximal femur anteroposterior radiographic study to evaluate the risk of SCHF. Multivariable logistic regression analysis was employed to determine the adjusted predictive ability of the radiographic morphologic parameters. RESULTS: Of the included 459 patients, 49 (10.7%) experienced SCHF. All radiographic morphologic parameters demonstrated excellent performance in predicting SCHF. After being adjusted by patients' age, BMI, visual impairment status, and dementia, CTI revealed the greatest adjusted odds ratio for SCHF of 35.05 (95% CI 7.34 to 167.39, p < 0.001) followed by CFI (OR = 13.32; 95% CI 6.50 to 27.32, p < 0.001), MCI (OR = 5.60; 95% CI 2.84 to 11.04, p < 0.001), and CCR (OR = 4.50; 95% CI 2.32 to 8.72, p < 0.001). CONCLUSION: CTI demonstrated the greatest odds ratio for SCHF, followed by CFI, MCI, and CCR. These radiographic morphologic parameters could provide a preliminary prediction for SCHF in elderly patients presenting with unilateral fragility hip fractures.

A Predictive Score for Infantile Blount Disease Recurrence After Tibial Osteotomy.

INTRODUCTION AND OBJECTIVE: Several predictive factors for infantile Blount disease recurrence after tibial osteotomy were discovered. This study aimed to examine and utilize various predictors to develop a prediction score for infantile Blount disease recurrence after tibial osteotomy. METHODS: We conducted a retrospective cohort study of infantile Blount disease patients who underwent tibial osteotomy between January 1998 and December 2020. Potential predictors, including clinical and radiographic parameters, were examined for their association with the disease recurrence after receiving tibial osteotomy. A predictive score was subsequently developed based on those potential predictors through multivariable logistic regression modeling. RESULTS: A total of 101 extremities diagnosed with infantile Blount disease from 58 patients who underwent tibial osteotomy were included. Of those, 15 extremities (14.9%) recurred. Univariable logistic regression analysis identified age older than 42 months [odds ratio (OR)=4.28; P =0.026], Langenskiöld classification stage III (OR=9.70; P <0.001), LaMont classification type C (OR=15.44; P <0.001), preoperative femorotibial angle <-14 degrees (OR=4.21, P =0.021), preoperative metaphyseal-diaphyseal angle >16 degrees (OR=8.61, P =0.006), preoperative medial metaphyseal slope angle >70 degrees (OR=7.56, P =0.001), and preoperative medial metaphyseal beak angle >128.5 degrees (OR=13.46, P =0.001) as potential predictors of infantile Blount disease recurrence after tibial osteotomy. A predictive score comprised of age younger than 42 months, LaMont classification type C, and medial metaphyseal beak angle >128 degrees demonstrated an excellent predictive performance (area under the receiver operating characteristic curve =0.87), good calibration, and high internal validity. CONCLUSIONS: Our developed predictive score accurately predicted infantile Blount disease recurrence after tibial osteotomy. The results from our developed prediction tool allow physicians to inform prognosis, increase awareness during the follow-up period, and consider additional interventions to prevent disease recurrence. LEVEL OF EVIDENCE: Level II.

Is subclassification of Gartland extension-type pediatric supracondylar fracture into types IIA and IIB necessary for treatment decision? A result of pediatric orthopedist's survey and review of literature.

Extension-type pediatric supracondylar humeral fractures are very common. The Gartland classification is typically used to guide treatment. However, there is still no consensus on what factors should be used to subclassify the type II fractures and whether subclassification is needed to guide treatment. Therefore, we aim to explore the opinions of pediatric orthopedists on the treatment method of the Gartland type II supracondylar fracture. Specifically, we ask what factors are considered for their treatment decisions and whether subclassification is needed to guide treatment. An online questionnaire was developed and sent to the Thai Paediatric Orthopedics Society and Asia-Pacific Paediatric Orthopaedic Society members. The results were analyzed to explore the relationship between respondents' demographic factors and treatment decisions. Out of 113 participants reached, 57 (50.4%) responded to the questionnaire. Factors chosen by respondents are stability testing intraoperatively (73.7%), the relationship of the anterior humeral line and capitellum (66.7%), the presence of rotation (50.9%), the presence of translation (47.4%), the presence of medial comminution 42.1%), soft tissue condition(38.6%), the shaft - condylar angle (31.6%), and the Bauman angle (21.1%). Thirty-three of 57 respondents (57.9%) deemed subclassification for Gartland type II necessary for guiding treatment. About half of respondents in our study deemed the current Gartland type II subclassification necessary to guide treatment, which may indicate that the subclassification might not be sufficiently comprehensive and reliable. Therefore, better criteria for a subclassification and a prospective evaluating study might be needed.

Surgical outcome of scoliosis in patients with Marfan syndrome.

PURPOSE: To evaluate clinical and radiographic outcomes after surgical scoliosis correction and posterior instrumented fusion in SMF patients. METHODS: A single-center medical database was reviewed to identify MF patients who presented with scoliosis from 2000 to 2015. Patients who underwent spinal fusion surgery were included. Demographic, operative and clinical data were reviewed, and the preoperative, postoperative, and latest follow-up radiographic parameters were compared. RESULTS: Twelve patients were identified (2 males, 10 females) with an average age at surgery of 14.4 ± 2.6 years. Comorbidities were found in 84.6%. Most patients (90.9%) presented with a right thoracic curve. The average preoperative Cobb angle was 75.6 ± 15.5 degrees. Posterior instrumented spinal fusion was performed in all patients (1 hook/pedicular screw and 11 pedicle screws only). The average follow-up period was 6.8 ± 3.1 years. The mean postoperative Cobb angle after surgery and at the final follow-up was 33.4 ± 18.0 degrees and 35.5 ± 18.4 degrees, respectively. There was a statistically significant difference among the preoperative and postoperative Cobb angles (p < 0.001), but no significant difference among the sagittal angles. Two perioperative complications including superficial wound infection and broken rods were observed. CONCLUSIONS: Posterior scoliosis correction and instrumented spinal fusion resulted in a satisfactory outcome in MF patients. Perioperative complications are not uncommon; however, no neurological complication or spinal decompensation was observed in this study. LEVEL OF EVIDENCE: IV.

Comparative effectiveness of treatment modalities in severe Legg­Calvé­Perthes disease: Systematic review and network meta­analysis of observational studies.

PURPOSE: There are several treatment modalities for Legg-Calvé-Perthes disease (LCPD), self-limiting, avascular osteonecrosis of the femoral head in children. Most treatments focus on containment of the weakened femoral head, but there is no consensus on the best modality for severe LCPD. Therefore, we compared the effectiveness of all treatment modalities for severe LCPD. MATERIALS AND METHODS: We searched the PubMed, Embase, and Scopus up until July 2021 for studies that investigated LCPD treatment effectiveness. A network meta-analysis was performed to examine the comparative effectiveness in terms of the ability to achieve radiographic spherical congruity of the hip joint after skeletal maturity. The risk ratio (RR) and 95% confidence interval (CI) of each treatment modality were estimated from both direct and indirect evidence. Treatment ranking was based on Surface Under the Cumulative Ranking curve (SUCRA). RESULTS: A total of 857 studies were identified and 34 comparative studies with 3718 affected hips comparing seven different LCPD treatment modalities were included. Compared with symptomatic treatment, combined osteotomy was the most effective modality (RR = 1.47, 95% CI 0.90 to 2.42, SUCRA = 0.8), followed by femoral varus osteotomy (RR = 1.31, 95% CI 1.06 to 1.60, SUCRA = 0.7), and Salter innominate osteotomy (RR = 1.25, 95% CI 0.95 to 1.65, SUCRA = 0.6). CONCLUSIONS: Combined osteotomy is the most effective procedure in terms of improving the spherical congruity of the hip joint in severe LCPD patients. However, the superiority of operative treatments seems to be limited to patients older than eight years old.

Using Combinations of Both Clinical and Radiographic Parameters to Develop a Diagnostic Prediction Model Demonstrated an Excellent Performance in Early Detection of Patients with Blount's Disease.

Early identification of pathological causes for pediatric genu varum (bowlegs) is crucial for preventing a progressive, irreversible knee deformity of the child. This study aims to develop and validate a diagnostic clinical prediction algorithm for assisting physicians in distinguishing an early stage of Blount's disease from the physiologic bowlegs to provide an early treatment that could prevent the progressive, irreversible deformity. The diagnostic prediction model for differentiating an early stage of Blount's disease from the physiologic bowlegs was developed under a retrospective case-control study from 2000 to 2017. Stepwise backward elimination of multivariable logistic regression modeling was used to derive a diagnostic model. A total of 158 limbs from 79 patients were included. Of those, 84 limbs (53.2%) were diagnosed as Blount's disease. The final model that included age, BMI, MDA, and MMB showed excellent performance (area under the receiver operating characteristic (AuROC) curve: 0.85, 95% confidence interval 0.79 to 0.91) with good calibration. The proposed diagnostic prediction model for discriminating an early stage of Blount's disease from physiologic bowlegs showed high discriminative ability with minimal optimism.

Prognostic Factors of 1-Year Postoperative Functional Outcomes of Older Patients with Intertrochanteric Fractures in Thailand: A Retrospective Cohort Study.

Restoration of ambulatory status is considered a primary treatment goal for older patients with intertrochanteric fractures. Several surgical-related parameters were reported to be associated with mechanical failure without focusing on the functional outcomes. Our study examines the roles of both clinical and surgical parameters as prognostic factors on 1-year postoperative ambulatory outcomes, reaching a good functional outcome (the New Mobility Score: NMS ≥ 5) and returning to preinjury functional status at one year, of older patients with intertrochanteric fracture. Intertrochanteric fractures patients age ≥65 years who underwent surgical treatment at our institute between January 2017 and February 2020 were included. Of 209 patients included, 149 (71.3%) showed a good functional outcome at one year. The pre-injury ambulatory status (OR 52.72, 95%CI 5.19-535.77, p = 0.001), BMI <23 kg/m2 (OR 3.14, 95%CI 1.21-8.13, p = 0.018), Hb ≥10 g/dL (OR 3.26, 95%CI 1.11-9.57, p = 0.031), and NMS at discharge ≥2 (OR 8.50, 95%CI 3.33-21.70, p < 0.001) were identified as independent predictors for reaching a good postoperative functional outcome. Only aged ≤80 (OR 2.34, 95%CI 1.11-4.93, p = 0.025) and NMS at discharge ≥2 (OR 6.27, 95%CI 2.75-14.32, p < 0.001) were significantly associated with an ability to return to preinjury function. To improve postoperative ambulatory status, orthopedic surgeons should focus more on modifying factors, such as maintaining the preoperative hemoglobin ≥10 g/dL and providing adequate postoperative ambulation training to maximize the patients' capability upon discharge. While surgical parameters were not identified as predictors, they can still be used as guidance to optimize the operation quality.

Development of Clinical Prediction Rules for One-Year Postoperative Functional Outcome in Patients with Intertrochanteric Fractures: The Intertrochanteric Fracture Ambulatory Prediction (IT-AP) Tool.

Individualized prediction of postoperative ambulatory status for patients with intertrochanteric fractures is clinically relevant, during both preoperative and intraoperative periods. This study intended to develop clinical prediction rules (CPR) to predict one-year postoperative functional outcomes in patients with intertrochanteric fractures. CPR development was based on a secondary analysis of a retrospective cohort of patients with intertrochanteric fractures aged ≥50 years who underwent a surgical fixation. Good ambulatory status was defined as a New Mobility Score ≥ 5. Two CPR for preoperative and intraoperative predictions were derived using clinical profiles and surgical-related parameters using logistic regression with the multivariable fractional polynomial procedure. In this study, 221 patients with intertrochanteric fractures were included. Of these, 160 (72.4%) had good functional status at one year. The preoperative model showed an acceptable AuROC of 0.77 (95% CI 0.70 to 0.85). After surgical-related parameters were incorporated into the preoperative model, the model discriminative ability was significantly improved to an AuROC of 0.83 (95% CI 0.77 to 0.88) (p = 0.021). The newly-derived CPR enable physicians to provide patients with intertrochanteric fractures with their individualized predictions of functional outcome one year after surgery, which could be used for risk communication, surgical optimization and tailoring postoperative care that fits patients' expectations.