Risk factors for recurrent lumbar disc herniation after discectomy.

PURPOSE: There are many reports about the risk factors for recurrence after lumbar disc surgery. However, there are none about whether lumbosacral transitional vertebrae (LSTV) are associated with recurrent lumbar disc herniation (LDH). We investigated various risk factors for recurrent LDH after discectomy including LSTV. METHODS: A total of 119 patients who had undergone a discectomy for L4-5 disc herniation were evaluated with a minimum follow-up of two years. Clinical parameters including age, gender, body mass index (BMI), and smoking status, and radiological parameters including type of herniated disc, degree of disc degeneration, LSTV, and sagittal range of motion (SROM) in flexion-extension radiography were evaluated. SROM was measured by the difference of the lordotic angle between the flexion and extension view. RESULTS: Recurrent disc herniation at L4-5 developed in 21 (17.6%) of the 119 patients. The mean period between primary surgery and recurrence was 17.6 ± 21.1 months. LSTV was found in 11 (52.4%) of the 21 patients who had recurrence and seven (7.1%) of the 98 patients in the non-recurrent group. SROM at L4-5 was 11.68 ± 4.24° in the recurrent group and 9.04 ± 3.65° in the non-recurrent group with a significant difference (p = 0.004). Multiple logistic regression analyses confirmed that LSTV and a larger SROM were significant risk factors for recurrent disc herniation at L4-5. CONCLUSIONS: Lumbosacral transitional vertebrae and a hypermobile disc in flexion-extension radiography were found to be risk factors for recurrent lumbar disc herniation.

Long-Term Results of Hip Arthroplasty Using Extensive Porous-Coated Stem-A Minimum Follow-Up of 15 Years.

INTRODUCTION: We report the clinical and radiographic results of hip arthroplasty using extensive porous-coated stems over 15 years in Korea. METHODS: This retrospective study included 210 patients (268 hips) who underwent total hip arthroplasties (232 hips) and bipolar hemiarthroplasties (36 hips) between June 1996 and December 2002 for avascular necrosis of the femoral head, hip fracture, or osteoarthritis, after excluding those who died or were lost to follow-up. One senior author (K.H.M.) evaluated Harris Hip Score (HHS); limping gait; and leg length discrepancy, and 3 independent reviewers assessed the radiographic findings, including the level of stress shielding, Dorr classification, subsidence and loosening of femoral stem, heterotopic ossification (Brooker classification), osteolysis of acetabulum, wear rate of the polyethylene liner, component loosening, and revision rate. RESULTS: The mean follow-up duration was 16.9 years and average age at operation was 50.9 years. The HHS improved at the last follow-up. Stress shielding was grade 1 in 185 hips, grade 2 in 35 hips, grade 3 in 37 hips, and grade 4 in 11 hips. Femoral stem subsidence was <3 mm in 4 hips and >3 mm in 6 hips. Femoral stems with stable bony ingrowth were observed in 258 hips, fibrous stable femoral stems in 4 hips, and unstable femoral stems in 6 hips. Heterotopic ossification was class 1 in12 and class 2 in 4 hips. Revision surgery was performed for periprosthetic osteolysis of cup (45 hips), recurrent dislocation (1), unstable femoral stem (1), and infection (1). The Kaplan-Meier survivorship at the 15-year follow-up was 86.2%. The survivorship of femoral stem at 15 years was 99.3%, and if including impending revision due to unstable femoral stem was 97.1%. DISSCUSSION: This study has all the limitations inherent with a retrospective design. However, a large number of patients in this cohort operated on by a single surgeon and a long-term follow-up are some of the potential advantages of the current study. CONCLUSIONS: At the 15-year follow-up, extensive porous-coated stem showed relatively good survivorship even in geriatric patients (Dorr type C).

Clinical efficiency of bone marrow mesenchymal stem cell implantation for osteonecrosis of the femoral head: a matched pair control study with simple core decompression.

BACKGROUND: To date, several trials have reported the use of mesenchymal stem cell (MSC) implantation for osteonecrosis of the femoral head (ONFH). However, the clinical outcomes have not been conclusive. This study compared the clinical and radiological results of bone marrow mesenchymal stem cell (BMMSC) implantation with traditional simple core decompression (CD) using a matched pair case-control design. METHODS: We retrospectively reviewed 100 patients with ONFH (106 hips) who had been treated by CD alone (50 patients, 53 hips) and CD + BMMSC implantation (50 patients, 53 hips) between February 2004 and October 2014. We assessed the total hip replacement arthroplasty (THA) conversion rate and ARCO (Association Research Circulation Osseous) stage progression. Survivor rate analysis was performed using the Kaplan-Meier method, and an additional THA was defined as the primary endpoints. RESULTS: The mean follow-up period was 4.28 years. There was a difference in the THA conversion rate between the CD (49%) and CD + BMMSC groups (28.3%) (p = 0.028). ARCO stage progression was noted in 20 of 53 hips (37.7%) in the CD group and 19 of 53 hips (35.8%) in the CD + BMMSC group. Among collapsed cases (ARCO stages III and IV), there was no difference in clinical failure rate between the two groups. Conversely, in the pre-collapse cases (ARCO stages I and II), only 6 of 30 hips (20%) progressed to clinical failure in the CD + BMMSC group, whereas 15 of 30 hips (50%) progressed to clinical failure in the CD group (p = 0.014). Kaplan-Meier survival analysis showed a significant difference in the time to failure between the two groups up to 10-year follow-up (log-rank test p = 0.031). There was no significant difference in terms of age (p = 0.87) and gender (p = 0.51) when comparing THA conversion rates between groups. No complication was noted. CONCLUSIONS: These results suggest that implantation of MSCs into the femoral head at an early stage of ONFH lowers the THA conversion rate. However, ARCO stage progression is not affected by this treatment. TRIAL REGISTRATION: Retrospectively registered.

The optimal protocol to reduce blood loss and blood transfusion after unilateral total knee replacement: Low-dose IA-TXA plus 30-min drain clamping versus drainage clamping for the first 3 h without IA-TXA.

INTRODUCTION: Although intraarticular tranexamic acid (IA-TXA) administration or drainage clamping are popular methods used to reduce blood loss after total knee replacement (TKR), the protocol remains controversial. We aimed (1) to establish new protocols through investigating whether two methods, that is, low-dose (500 mg) IA-TXA plus 30-min drain clamping and drainage clamping for the first 3 h without IA-TXA, can reduce blood loss and blood transfusion after unilateral TKR and (2) to make recommendations related to clinical application. MATERIALS AND METHODS: This study, conducted from September 2014 to June 2016 related to enrolled 95 patients with primary osteoarthritis who were to have a unilateral cemented TKR, was nonrandomized and retrospective. In group A, the drain was released following tourniquet deflation. In group B, 500-mg TXA was injected into the knee joint via a drain tube after fascia closure and the drain was clamped for the first 30 min to prevent leakage. In group C, the drain was clamped for the first 3-h postoperation. Demographic characteristics and clinical data were collected, including the levels of hematocrit (Hct), the total blood loss (TBL), drained blood volume (BV), the amount of blood transfused, and any complications that developed. RESULTS: We found a significantly lower postoperative TBL, drained BV, decreasing Hct level, and less transfused BV in the IA-TXA injection group (group B) and the 3-h drainage clamping group (group C) compared to the conventional negative drainage group (group A; p < 0.001). There was no significant difference between groups B and C ( p = 0.99). CONCLUSIONS: The drainage clamping method can be safer than IA-TXA administration in patients with risk factor of venous thromboembolic complication. Furthermore, the IA-TXA administration can be more optimal than drainage clamping in patients with high bleeding tendency or lateral retinacular release during TKR, who would be concerned about postoperative wound complication.