Minimally Invasive Spine Surgery versus Open Posterior Instrumentation Surgery for Unstable Thoracolumbar Burst Fracture.

STUDY DESIGN: Retrospective study. PURPOSE: To compare the clinical and radiological results of minimally invasive spine surgery (MISS) and open posterior instrumentation surgery for the treatment of unstable burst fractures. OVERVIEW OF LITERATURE: MISS has exhibited postoperative outcomes similar to those obtained using open posterior instrumentation in various spine diseases. There remains no consensus regarding the use of MISS in the treatment of unstable burst fracture. METHODS: We enrolled 40 patients who underwent either MISS (M group, 20 patients) or open posterior instrumentation surgery (O group, 20 patients) for the treatment of traumatic unstable burst fractures. Clinical outcomes were evaluated based on postoperative back pain, operation time, blood loss, hospital stay duration, and perioperative complications. For radiologic evaluation, preoperative magnetic resonance imaging and plain radiography were performed before and after the surgery to evaluate the changes in the kyphotic angle and fracture union. RESULTS: The change in the kyphotic angle was -8.2°±5.8° in the M group and -8.0°±7.8° in the O group. No significant difference was noted in terms of the change in the kyphotic angle (p=0.94, t-test) after 12 months of surgery. The Visual Analog Scale score was 1.5±0.7 points in the M group, while it was 5.2±1.4 points in the O group. In the M group, back pain has significantly decreased (p<0.01, t-test). The estimated blood loss was 195.5 mL in the M group and 1,077.5 mL in the O group; the operation time was significantly decreased in the O group from 290.7 to 120.7 minutes in the M group (p<0.05, t-test) (p=0.36, t-test). The average duration of hospital stay was 36.0 days in the M group and 41.9 days in the O group (p=0.36, t-test). CONCLUSIONS: For the treatment of unstable burst fractures, MISS showed significant differences in terms of postoperative back pain, operation time, and blood loss as compared to open posterior instrumentation surgery.

Risk of Osteoporotic Fracture in Patients with Breast Cancer: Meta-Analysis.

BACKGROUND: The fracture risk induced by anti-estrogen therapy in patients with breast cancer remains controversial. The aim of this study was to perform a meta-analysis and systematic review to evaluate the risk of osteoporotic fracture in patients with breast cancer. METHODS: A systematic search was performed to identify studies that included any osteoporotic fracture (hip fracture and vertebral fracture) in patients breast cancer. Main outcome measures were occurrence and risk of osteoporotic fractures including hip and vertebral fractures in patients and controls. RESULTS: A systematic search yielded a total of 4 studies that included osteoporotic fracture outcomes in patients with breast cancer. Meta-analysis showed a higher risk of osteoporotic fracture in patients with breast cancer. Analysis of these 4 studies involving a total of 127,722 (23,821 cases and 103,901 controls) patients showed that the incidence of osteoporotic fractures was higher in the breast cancer group than in the control group. The pooled estimate of crude relative risk for osteoporotic fracture was 1.35 (95% confidence interval, 1.29-1.42; P<0.001). CONCLUSIONS: Although studies were limited by a small number, results suggested a possible association between anti-estrogen therapy and increased risk of osteoporotic fractures in patients with breast cancer.

Anterior Cortical Window Technique Instead of Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty: A Minimum 10-Year Follow-up.

BACKGROUND: The anterior cortical window technique was developed to facilitate stem removal in revision total hip arthroplasty (THA). In this technique, only the anterior cortex of the proximal femur is osteomized; the trochanter, lateral cortex, and medial cortex remain intact. Therefore, a new stem can be press-fitted into the femur and mediolateral stability can be obtained. However, the long-term results of revision THA using this technique are unknown. We report the outcome and survivorship at a minimum of 10-year follow-up. METHODS: From May 2003 to April 2006, 69 patients (75 hips) underwent revision THA using an anterior cortical window and a cementless distal interlocking stem. Of these, 50 patients (56 hips) were followed up for 10 to 13 years (mean, 11.5 years). There were 26 men (29 hips) and 24 women (27 hips) with a mean age of 51.2 years (range, 29 to 82 years) at the time of revision arthroplasty. We evaluated radiographs, Harris hip score, University of California at Los Angeles (UCLA) activity score, Koval category, and survivorship. RESULTS: Nonunion of the osteotomy occurred in one hip (2%). Five stems (8.9%) subsided 5 mm or more. At the final evaluation, the mean Harris hip score, UCLA activity score, and the Koval category were 82.5, 4.6, and 1.5, respectively. Survivorship with any operations as the end point was 80.4% and that with stem-revision as the end point was 91.1%. CONCLUSIONS: With use of an anterior cortical window, a well-fixed stem can be easily removed, and a new stem can be inserted with firm mediolateral stability in the proximal femur in revision THA. We recommend using this technique instead of the extended trochanteric osteotomy in revision THA.

Concomitant Septic Arthritis of the Hip in Patients with Osteonecrosis of the Femoral Head.

INTRODUCTION: Septic hip is a rare condition and is known to occur in immune-compromised patients. In general, surgeons are not concerned about the superimposed septic hip when they operate on patients with osteonecrosis of the femoral head (ONFH) if the patient is not immune compromised. We evaluated 1) the proportion of septic arthritis among patients with ONFH, 2) the clinical and laboratory features, and 3) the outcomes of two-stage THA in those patients. MATERIALS AND METHODS: We identified patients who were diagnosed as having concomitant septic arthritis of the hip among 1,226 patients who underwent THA due to ONFH from 2011 to 2018 at our institution. A diagnosis of septic arthritis was made by aspirated joint fluid; white blood cell (WBC) count >15,000/ml and neutrophils >75%, microbiological culture, and/or the findings of septic arthritis on magnetic resonance imaging (MRI) scan. Osteonecrotic patients with infection were treated with two-stage THA. RESULTS: Among the 1,226 osteonecrotic patients, 14 (1.1%) had concomitant septic arthritis of the hip. There were nine men and five women. None of them were immune compromised or had a remote septic focus. In the preoperative evaluation, all 14 patients had elevated serum erythrocyte sedimentation rate (ESR) (>20mm/hr) and/or C-reactive protein (CRP) (>0.5mg/dL), and three patients had a fever (>37.5°C). Findings of septic hip were seen in all 12 patients who had preoperative MRI. The neutrophil count in the high-power field was >5 in all 12 patients who had intraoperative frozen section histology. The 14 patients were followed for one to seven years after the arthroplasty, and no patient had evidence of infection at the final follow up. CONCLUSION: When a patient with ONFH has an unexplained elevation of ESR and/or CRP, concomitant septic arthritis of the hip should be suspected.

Reliability of measuring lateral bowing angle of the femur in patients with atypical femur fractures.

BACKGROUND: Lateral femoral bowing causes a higher tensile mechanical load on the lateral side of the femur, which plays a critical role in the pathogenesis of atypical femoral fractures (AFFs). There are many ways to measure lateral femoral bowing on plain radiographs, and there are difficulties in finding a correspondence point between measurements among multiple measurers. The purpose of this study is to prove the best method of correspondence between the investigators by analyzing the reliability of various methods for measuring lateral femoral bowing. MATERIALS AND METHODS: We retrospectively collected data from 85 patients (87 femurs) diagnosed with AFF who had plain radiographs of entire femur from October 2013 to March 2018. The femoral bowing was measured in coronal view of femur plain radiographs using five methods (Sasaki, Morin, Jang, Kim, and Yau) by three examiners, respectively. The intra- and interobserver reliability of each method was assessed using intraclass correlation coefficient (ICC) for continuous variables. RESULTS: All methods showed excellent intra- and interobserver reliability with ICC of >0.8. Among five methods, the Yau's method was the highest reliable method (ICC = 0.980, 95% confidence interval = 0.971-0.986). CONCLUSIONS: All methods of measuring lateral femoral bowing in the coronal plane of plain radiographs are reliable. And, we recommend Yau's method, which has a clear reference point for measuring femoral bowing and is highest reproducible.

Medial Meniscal Root Repair Using Curved Guide and Soft Suture Anchor.

Medial meniscal root tears have been repaired using various methods. Arthroscopic all-inside repair using a suture anchor is one of the popular methods. However, insertion of the suture anchor into the proper position at the posterior root of the medial meniscus is technically difficult. Some methods have been reported to facilitate suture anchor insertion through a high posteromedial portal, a posterior trans-septal portal, or a medial quadriceptal portal. Nevertheless, many surgeons still have difficulty during anchor insertion. We introduce a technical tip for easy suture anchor insertion using a 25° curved guide and a soft suture anchor through a routine posteromedial portal.