Fragility Fracture Network-Japan: The challenge of establishment of a national hip fracture database and successful achievement of nationwide health system change for hip fracture care in Japan.

BACKGROUND: In April 2022, a new reimbursement scheme for hip fracture was implemented by the Japanese health ministry. Japan is one of the world's most aged societies, facing a significant, rapidly growing burden of osteoporosis and fragility fractures. The incidence of hip fractures is projected to increase from 240,000 in 2020 to 320,000 by 2040. In 2015, Fragility Fracture Network-Japan (FFN-Japan) was formally established as a nonprofit organization in order to create the optimal fragility fracture care system in Japan. METHODS: FFN-Japan launched the Japan National Hip Fracture Database (JNHFD) in 2017, initially with only eight participating hospitals across Japan. The number of patients enrolled from May 2017 to the end of 2020 in the JNHFD from the 16 hospitals registered the patients during this period with amounting to 4271 patients in total. FFN-Japan invited officials from the Ministry of Health, Labor and Welfare (MHLW) to participate in round table meetings to discuss the data collected in the JNHFD and to consider opportunities for nationwide improvement in hip fracture care. RESULTS: The proportion of patients who underwent surgery within 36 h of arrival at hospital was 48.1% in 2018, 58.6% in 2019, and 44.9% in 2020 indicating the delay of surgery. Regarding secondary fracture prevention, initiation of osteoporosis treatment during the in-patients was 60.2% in 2018, 54.0% in 2019, and 64.5% in 2020 indicating the inadequate post fracture care. In April 2022, the Central Social Insurance Medical Council of the Japanese MHLW announced a new reimbursement scheme for hip fracture care including two key components: Early surgery (within 48 h from injury) and Secondary fracture prevention immediately after fracture. DISCUSSION: The new reimbursement scheme of hip fracture care in Japan will catalyze and underpin major improvements on acute multidisciplinary care and post-fracture care with secondary fracture prevention. FFN-Japan played a key role on these policy changes to the health system by means the close collaboration and ongoing communication with the government. CONCLUSION: Within five years of establishment of the JNHFD, FFN-Japan in collaboration with visionary leaders from the Japanese government have successfully achieved a major reform of the Japanese health system's reimbursement of hip fracture care. This reform has laid the foundation for transformation of management of this debilitating and life-threatening injury that currently afflicts almost a quarter of a million older Japanese citizens each year.

Patellofemoral Osteoarthritis Progression After Open-Wedge High Tibial Osteotomy Does Not Affect the Clinical Outcomes or Survivorship at Minimum 7 Years' Follow-Up.

PURPOSE: To evaluate the clinical and radiologic outcomes of open-wedge high tibial osteotomy (OWHTO) with respect to the patellofemoral joint and to assess the effects of patellofemoral osteoarthritis (OA) progression after OWHTO on clinical outcomes at minimum 7 years' follow-up. METHODS: We retrospectively reviewed 95 knees that underwent OWHTO and at least 7 years of follow-up. Clinical parameters including anterior knee pain, Japanese Orthopedic Association score, Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score, Hospital for Special Surgery patella score, and Knee Injury and Osteoarthritis Outcome Score-patellofemoral subscale were evaluated. Radiologic outcomes were evaluated preoperatively and at final follow-up. Patellofemoral OA progressions were evaluated using Kellgren-Lawrence grade, and we divided the patients into 2 groups (progression group and non-progression group) to evaluate the effect of patellofemoral OA progression after OWHTO on long-term clinical outcomes. RESULTS: The mean follow-up period was 10.8 ± 2.6 years (range: 7.6-17.3 years). The mean Japanese Orthopedic Association score significantly improved (from 64.4 ± 11.6 to 90.9 ± 9.3, P < .001), and the mean Oxford Knee Score at final follow-up was 40.4 ± 8.3. Due to medial OA progression, 5 cases were converted to total knee arthroplasty, and the survival rate was 94.7% at 10.8 years of follow-up. Radiologically, patellofemoral OA progression was observed at final follow-up in 48 knees (50.5%). However, there were no significant differences in all clinical outcomes at final follow-up between the progression and non-progression groups. CONCLUSIONS: Patellofemoral OA progression may progress over long-term follow-up after OWHTO. Related symptoms are minimal and this does not affect the clinical outcomes or survivorships at minimum 7 years follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Influence of lateral hinge fractures on biplanar medial closing-wedge distal femoral osteotomy for valgus knee: a new classification of lateral hinge fracture.

BACKGROUND: The purpose of this study was to examine the influence of lateral hinge fractures in medial closing-wedge distal femoral osteotomy (MCWDFO) on bone union. METHODS: Twenty-one patients were followed-up for more than 1 year after MCWDFO. The incidence and type of hinge fracture, as well as the course of bone healing, were investigated. Slow healing was defined as bone union was not obtained until 3 months after surgery. RESULTS: Hinge fractures were observed in 12 cases (57%). There were three types of hinge fractures. Type 1: the lateral cortex was completely cut through (4 cases), type 2: the osteotomy line was too proximal (6 cases), and type 3: the hinge point was significantly medial (2 cases). There was a significant difference in the mean correction angles between hinge fracture and no-fracture cases, with the mean angles being 13.8 ± 4.0° and 9.6 ± 3.1°, respectively. Sixty-seven percent (8/12) of cases with hinge fractures developed slow healing. Among the hinge fracture cases, when there was no displacement of the hinge fracture and good contact with the anterior flange, 40% (2/5) of cases developed slow healing. If there was displacement of the hinge or no contact of the anterior flange, 86% (6/7) of cases developed slow healing. In contrast, only 11% (1/9) of subjects who did not have a hinge fracture, developed slow healing. In 67% (6/9) of cases with slow healing, a correction loss of 2° or greater (average: 4.3 degrees valgus) was observed. There were no cases of non-union. Clinical outcomes at 1 year showed no significant difference between the groups with and without hinge fractures. CONCLUSIONS: There is a very high risk of hinge fracture in patients undergoing MCWDFO. Hinge fractures often lead to slow healing and a loss of correction. We recommend the endpoint of the distal lateral cortex of the femur as the ideal hinge point for the prevention of hinge fractures. Bone union is obtained slowly in even all hinge fracture cases without revision surgery. Consequently, surgical results are not affected by the occurrence of hinge fracture at 1 year.

Differences in age-related characteristics among elderly patients with hip fractures.

BACKGROUND: Incidence of hip fracture among aging patients has been increasing annually in Japan; patients aged ≤74 years may be inappropriately classified as elderly. This study aimed to identify differences in the incidence of serious perioperative complications and in-hospital, 90-day, 6-month, and 1-year mortality rates according to three age groups among patients with hip fractures. METHODS: Patients aged ≥65 years treated for hip fracture by our multidisciplinary treatment system were included in this study. They were divided into the pre-old age (65-74 years), old age (75-89 years), and super-old age (≥90 years) groups. The baseline characteristics and outcomes of the three groups were compared, and variables associated with in-hospital, 30-day, 6-month, and 1-year mortality were analyzed. RESULTS: In the older population, there was a higher proportion of female participants; those with trochanteric fractures, low bone mineral density, dementia, decreased walking ability and independence in performing activities of daily living; and those not living at home. Moreover, the proportion of patients with hypertension, diabetes mellitus, and circulatory disorders, American Society of Anesthesiologists Physical Status scores, and serum albumin levels significantly differed. Further, there was a significant difference in the incidence of serious complications among males and the 6-month and 1-year mortality rates among females. In addition, female patients in the pre-old age group had a higher mortality rate at any period compared with those in the old age group. CONCLUSIONS: Patients with hip fracture who were aged 65-74, 75-89, and ≥90 years differ in terms of baseline characteristics, incidence of complications, and mortality rates. Female patients aged<75 who had fragility hip fractures potentially had worse prognosis. Our findings may be useful in preoperative explanation, postoperative management, and prognostic prediction.

Orthogeriatric co-management at a regional core hospital as a new multidisciplinary approach in Japanese hip fracture operation.

BACKGROUND: This study aimed to evaluate the effects of orthogeriatric co-management of hip fractures at a regional core hospital. METHODS: This study included patients with proximal hip fracture. Patients were divided into two groups, conventional multidisciplinary group I including patients attending the hospital between April 2015 and March 2016 and orthogeriatric group II including patients attending the hospital between April 2016 and March 2017, which were compared etrospectively. In the control group, the conventional multidisciplinary team treated patients as whole-body controls. In the intervention group, the newly recruited geriatricians performed physical examinations, laboratory tests, radioactive imaging, and physiological tests. Furthermore, they consulted ward pharmacists, rigorously conducted positive polypharmacy interventions , and evaluated the type and number of mediated drugs on admission. RESULTS: The number of medicated drugs significantly decreased from 6.03 ± 4.3 on admission to 5.50 ± 3.59 on discharge in group II, whereas group I did not show a significant decrease. Despite the more number of hospitalized patients in group II (166 patients) than in group I (126 patients), the recovery rate from postoperative urinary retention increased significantly from 57.8% (19/30) in group I to 84.3% (32/59) in group II (p = 0.049), while the incidence of aspiration pneumonia decreased from 7.1% (9/126) in group I to 2.49% (4/166) in group II (p = 0.08). The patients received six or more prescribed drugs on admission, and the number remained constant. However, the number of medicated drugs on discharge showed a marginally significant decrease from 6.03 ± 4.3 in group I to 5.50 ± 3.59 in group II (p < 0.05). CONCLUSIONS: Compared to the conventional multidisciplinary group, the orthogeriatric team contributed to reducing the number of multi-effect drugs and perioperative complications without negatively affecting mortality despite the increased number of patients. The in-hospital mortality rate did not change between the groups. The orthogeriatric program succeeded in preventing and treating perioperative complications.

Low-intensity pulsed ultrasound does not promote bone healing and functional recovery after open wedge high tibial osteotomy.

AIMS: To evaluate whether low-intensity pulsed ultrasound (LIPUS) accelerates bone healing at osteotomy sites and promotes functional recovery after open-wedge high tibial osteotomy (OWHTO). METHODS: Overall, 90 patients who underwent OWHTO without bone grafting were enrolled in this nonrandomized retrospective study, and 45 patients treated with LIPUS were compared with 45 patients without LIPUS treatment in terms of bone healing and functional recovery postoperatively. Clinical evaluations, including the pain visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) score, were performed preoperatively as well as six weeks and three, six, and 12 months postoperatively. The progression rate of gap filling was evaluated using anteroposterior radiographs at six weeks and three, six, and 12 months postoperatively. RESULTS: The pain VAS and JOA scores significantly improved after OWHTO in both groups. Although the LIPUS group had better pain scores at six weeks and three months postoperatively, there were no significant differences in JOA score between the groups. The lateral hinge united at six weeks postoperatively in 34 (75.6%) knees in the control group and in 33 (73.3%) knees in the LIPUS group. The progression rates of gap filling in the LIPUS group were 8.0%, 15.0%, 27.2%, and 46.0% at six weeks and three, six, and 12 months postoperatively, respectively, whereas in the control group at the same time points they were 7.7%, 15.2%, 26.3%, and 44.0%, respectively. There were no significant differences in the progression rate of gap filling between the groups. CONCLUSION: The present study demonstrated that LIPUS did not promote bone healing and functional recovery after OWHTO with a locking plate. The routine use of LIPUS after OWHTO was not recommended from the results of our study. Cite this article: Bone Jt Open 2022;3(11):885-893.

Postoperative Urinary Retention in Japanese Elderly Males with a Femoral Neck or Trochanteric Fracture.

We assessed risk factors for postoperative urinary retention (UR) in elderly males with femoral bone fractures: 169 Japanese males (mean age 81.95 ± 1.19 years) who had undergone hip surgery at a municipal hospital (Toyama, Japan). A multiple logistic regression analysis was used to test possible risk factors for UR: age, body mass index, serum albumin, cognitive impairment, activities of daily living (ADL), and history of diabetes mellitus (DM). UR occurred in 24 (14.2%) of the 169 patients. A multivariate logistic regression analysis with age adjustment showed that ADL (odds ratio [OR] 3.88; 95% confidence interval [CI]: 1.2-12.5, p=0.023) was significantly associated with the development of UR, and a history of DM showed marginal significance for UR occurrence (OR 0.36, 95%CI: 0.11-10, p=0.064). These results suggests that ADL is a risk factor for UR development in elderly males who have undergone surgery for femoral neck or trochanter fractures.

Multidisciplinary care model for geriatric patients with hip fracture in Japan: 5-year experience.

INTRODUCTION: Japan is a super-aging society, the geriatric care system establishment for hip fractures is at an urgent task. This report described our concept of multidisciplinary care model for geriatric hip fractures and 5-year outcomes at the Toyama City Hospital, Japan. METHODS: In this retrospective cohort study, a multidisciplinary treatment approach was applied for elderly patients with hip fracture since 2014. These patients (n = 678, males: n = 143, mean age: 84.6 ± 7.5 years), were treated per the multidisciplinary care model. Time to surgery, length of hospital stays, complications, osteoporosis treatment, mortality, and medical costs were evaluated. RESULTS: The mean time to surgery was 1.7 days. Overall, 78.0% patients underwent surgery within 2 days. The mean duration of hospital stay was 21.0 ± 12.4 days. The most frequent complication was deep venous thrombosis (19.0%) followed by dysuria (14.5%). Severe complications were pneumonia 3.4%, heart failure 0.8% and pulmonary embolism 0.4%. The in-hospital mortality rate was 1.2%. The 90-day, 6-month, and 1-year mortality rates were 2.5%, 6.7%, and 12.6%, respectively. The pharmacotherapy rate for osteoporosis at discharge was 90.7%, and the continuation pharmacotherapy rate was 84.7% at 1-year follow-up. The total hospitalization medical cost per person was lower than about 400 other hospitals' average costs every year, totaled 14% less during the 5-year study period. CONCLUSION: We have organized a multidisciplinary team approach for geriatric hip fracture. This approach resulted in a shorter time to surgery and hospital stay than the national average. The incidence of severe complications and mortality was low. The multidisciplinary treatment has maintained a high rate of osteoporosis treatment after discharge and at follow-up. Furthermore, the total medical cost per person was less than the national average. Thus, the multidisciplinary treatment approach for geriatric hip fractures was effective and feasible to conduct in Japan.

Asymmetry of the pelvic ring evaluated by CT-based 3D statistical modeling.

The human pelvis is a complex anatomical structure that consists of the innominate bones, sacrum and coccyx to form the pelvic ring. Even though considered to be a symmetric entity, asymmetry of the pelvic ring (APR) might occur to alter its anatomy, function, or biomechanics or to impact assessment and treatment of clinical cases. APR and its assessment is complicated by the intricate anatomy of the pelvic ring. There is only limited information and understanding about APR with no established evaluation methods existing. The objective of the present study was to adopt CT-based 3D statistical modeling and analysis to assess APR within the complex anatomy of the pelvic ring. We were interested to establish a better understanding of APR with knowledge and applications transferred to human anatomy, related research, and development subjects and to clinical settings. A series of 150 routine, clinical, pelvic CT protocols of European and Asian males and females (64 ± 15 (20-90) years old) were post-processed to compute gender- and ancestry-specific 3D statistical models of the pelvic ring. Evaluations comprised principal component analysis (PCA) that included size, shape, and asymmetry patterns and their variations to be assessed. Four different CT-based 3D statistical models of the entire pelvic ring were computed according to the gender and ancestry specific groups. PCA mainly displayed size and shape variations. Examination of additional PCA modes permitted six distinct asymmetry patterns to be identified. They were located at the sacrum, iliac crest, pelvic brim, pubic symphysis, inferior pubic ramus, and near to the acetabulum. Accordingly, the pelvic ring demonstrated not to be entirely symmetric. Assessment of its asymmetry proved to be a challenging task. Using CT-based 3D statistical modeling and PCA, we identified six distinct APRs that were located at different anatomical regions. These regions are more prone to APRs than other sites. Minor asymmetry patterns have to be distinguished from the distinct APRs. Side differences with regard to size, shape, and/or position require to be taken into account. APRs may be due different load mechanisms applied via spine or lower extremity or locally. There is a need for simpler and efficient, yet reliable methods to be routinely transferred to human anatomy, related research, and development subjects and to clinical settings.

Factors Associated With Patient Satisfaction After Opening-Wedge High Tibial Osteotomy.

BACKGROUND: Opening-wedge high tibial osteotomy (OWHTO) is expected to result in higher patient satisfaction compared with knee arthroplasty due to joint preservation. However, patient satisfaction rates as well as factors associated with satisfaction after OWHTO remain unclear. PURPOSE: To evaluate patient subjective satisfaction after OWHTO and determine factors associated with patient satisfaction after OWHTO. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This study enrolled 123 patients (123 knees) who underwent unilateral OWHTO. Clinical parameters, including range of motion (ROM), visual analog scale (VAS) score for pain, Knee injury and Osteoarthritis Outcome Score (KOOS), weightbearing line ratio (WBLR), and medial proximal tibial angle (MPTA), were assessed before surgery and at the final follow-up at a minimum of 2 years. Patient satisfaction was evaluated using a 5-point scale regarding (1) surgery, (2) pain relief, (3) knee mobility, (4) daily living function, and (5) lower extremity alignment. The mean overall satisfaction scores for the 5 questions were calculated, and the sample was divided into 2 main groups (satisfied or unsatisfied). Preoperative characteristics, physical activity level, patient expectations for surgery, ROM, and KOOS were compared between the groups. Cartilage regeneration was assessed at the time of plate removal, and WBLR and MPTA were also assessed. Factors associated with patient satisfaction were analyzed using multivariable logistic regression analysis. RESULTS: The mean ± SD follow-up was 54.6 ± 20.6 months. The mean WBLR significantly changed from 20.7% ± 11.8% preoperatively to 66.9% ± 10.2% at the final follow-up, and all KOOS subscale scores significantly improved after surgery. Of the 123 patients, 109 (88.6%) were graded as satisfied. Factors associated with patient satisfaction were expectations met (odds ratio, 17.4; P = .026), better postoperative KOOS Pain score (odds ratio, 1.30; P = .001), and better postoperative KOOS Activities of Daily Living score (odds ratio, 1.36; P = .002). CONCLUSION: OWHTO is an effective treatment in terms of subjective satisfactory outcomes. Patient expectations for surgery have a significant effect on patient satisfaction. Surgeons should consider patient expectations before OWHTO and provide patient education to improve patient satisfaction.

Mortality and the Risk Factors in Elderly Female Patients With Femoral Neck and Trochanteric Fractures.

BACKGROUND: The main purpose of this study is to exhaustively explore risk factors, including age, gender, and several clinical indices, for mortality in elderly patients with femoral neck fracture and to evaluate some of them using survival analyses. METHODS: This was a retrospective study tracking 1 year for vital prognosis. Data were collected at post-operation from medical records of the cases. Survival analysis was conducted to investigate the risk factors for death, including albumin, urinary retention, activity of daily living (ADL), and cognitive disorder. RESULTS: We recruited 318 patients with a history of hip surgery carried out at Toyama Municipal Hospital, in which 39 patients died for 1 year after discharge. The results showed a significant decrease in survival rate in low albumin, positive urinary retention, and low ADL (P < 0.01, by log-rank test). The hazard ratios (95% confidence interval) of albumin, urinary retention, ADL, and cognitive disorder were 0.36 (0.19 - 0.69), 0.4 (0.2 - 0.8), 0.29 (0.15 - 0.58) and 0.65 (0.32 - 1.29), respectively. CONCLUSIONS: This study demonstrated that albumin, urinary retention and ADL were the important risk factors for mortality, and suggested that the postoperative management of albumin, urinary retention and ADL is important, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.

Open-wedge high tibial osteotomy for spontaneous osteonecrosis of the medial tibial plateau shows excellent clinical outcomes.

PurposeThere have been few reports on medial tibial plateau osteonecrosis, and treatment options remain controversial. This study aimed to evaluate the clinical outcomes of open-wedge high tibial osteotomy (OWHTO) for osteonecrosis of the medal tibial plateau.MethodsPatients who underwent OWHTO for spontaneous osteonecrosis of the medial tibial plateau from November 2013 to September 2017 at our institution and followed up for at least 2 years after surgery were included in this study. Patients with history of alcohol abuse and corticosteroid therapy were excluded. Clinical evaluations, including the Japanese Orthopedic Association (JOA) score and the Oxford Knee Score (OKS), were measured preoperatively and at the final followup. Radiological evaluations included the weight-bearing line ratio (WBLR) and the lesion stage of the osteonecrosis according to Carpintero, Lotke, and the modified Ficat and Arlet classification. The area and size of the necrosis and the type of meniscus tear were also evaluated using preoperative magnetic resonance imaging (MRI). Additionally, cartilage regeneration was evaluated at plate removal.ResultsTwelve cases that underwent OWHTO for spontaneous osteonecrosis of the medial tibial plateau were enrolled. Eleven cases had isolated medial tibial osteonecrosis, and one case had both femoral and tibial osteonecrosis. The mean age was 59.6 ± 9.0 years, and the mean follow-up period was 41.8 ± 17.6 months.The WBLR significantly changed after OWHTO (24.0% ± 10.7% to 66.3% ± 6.7%, P < 0.001), and all clinical scores significantly improved after surgery: JOA score 63.3 ±12.3 to 95.0 ± 4.8, OKS 27.4 ± 7.8 to 42.6 ± 4.1, both 0.001. There were no adverse complications requiring additional surgery. The MRI findings revealed that all cases had meniscal lesions in addition to a necrotic lesion. Second-look arthroscopy was performed at plate removal in 11 cases, and cartilage regeneration was observed in 9/11 cases (81.8%).ConclusionsThis study's results demonstrated that OWHTO is an effective procedure for spontaneous osteonecrosis of the medial tibial plateau with respect to subjective and objective clinical outcomes.

Risk factors for the development of aspiration pneumonia in elderly patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort.

Aspiration pneumonia (AP) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of AP in elderly patients with femoral neck fractures.We recruited 426 patients (age 84.9 ±â€Š7.4 years) with a history of hip surgery carried out at Toyama Municipal Hospital. AP occurred in 18 out of 426 cases (4.23%). Statistical test has found significant differences in age, gender, serum albumin level, and cognitive impairment, between AP and non-AP groups. Subsequently multiple logistic regression analysis was conducted to investigate the risk factors for AP, including age, gender, serum albumin, cognitive impairment, and activities of daily living (ADL). Adjusted odds ratio showed significant differences in age, gender, and serum albumin, whereas no significant differences were found in cognitive impairment and ADL.This study suggested that serum albumin seemed to be a risk factor for AP but were necessary to assess under adjustment of confounding factors, including age and gender. Monitoring serum albumin level seemed to be important for the postoperative management of AP, especially in elderly patients receiving surgery of femoral neck and trochanteric fractures.

Plate removal without loss of correction after open-wedge high tibial osteotomy is possible when posterior cortex bone union reaches osteotomy gap center even in incompletely filled gaps.

PURPOSE: The study aimed to evaluate the optimal timing for plate removal after open-wedge high tibial osteotomy (OWHTO) without loss of correction and to investigate risk factors for loss of correction after plate removal. The study presents the hypothesis that plate removal without loss of correction was possible when gap filling reached zone 2 (25-50%) on anteroposterior radiographs. METHODS: Ninety-one patients (101 knees) who underwent OWHTO using the TomoFix® plate were enrolled. Plate removal was performed at an average 16.4 ± 5.4 months after OWHTO. Clinical evaluation included plate-related symptoms, the Japanese Orthopedic Association Knee Score (JOA score), and Oxford Knee Score (OKS). Radiological outcomes, including the hip-knee-ankle angle (HKA), weight-bearing line ratio (WBLR), medial proximal tibial angle (MPTA), and posterior tibial slope (PTS), were evaluated preoperatively, at plate removal and at 1 year after plate removal. Computed tomography (CT) was performed at plate removal to evaluate the flange bone union, progression rates of gap filling, and posterior cortex bone union. In addition, the risk factors for loss of correction after plate removal were evaluated. RESULTS: At plate removal, 63 (62.4%) knees had plate-related symptoms (mild, 56 knees; moderate, 7 knees; severe, 0). After plate removal, the JOA score did not change, whereas OKS further improved; six knees developed loss of correction. On CT evaluation at plate removal, the flange bone union was achieved in all cases; the progression rates of gap filling and posterior cortex bone union were 47.0% ± 16.6% and 62.8% ± 16.5%, respectively. A posterior cortex union rate of < 43.3% was the only predictor for loss of correction after plate removal (odds ratio: 1.38, P < 0.01). CONCLUSIONS: Plate removal without loss of correction after OWHTO was possible when bone union of the posterior cortex reached the center of the osteotomy gap even in incompletely filled gaps. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

Outcome after treatment of osteoarthritis with open-wedge high-tibial osteotomy with a plate: 2-year results of a Japanese cohort study.

PURPOSE: This prospective multicenter study evaluated patient reported outcomes (PROs) in individuals undergoing medial open-wedge high-tibial osteotomy (OWHTO) with plate stabilization compared to conservative care or no treatment. METHODS: One hundred eighteen of 148 patients older than 40 years were elected for OWHTO with plate treatment. Thirty patients declined surgery and were followed as a conservative group. The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 2 years. Secondary measures included Oxford knee score, Western Ontario and McMaster Universities osteoarthritis index, range of motion (ROM), joint space width (JSW), femorotibial angle (FTA), and weight-bearing line ratio (WBLR). RESULTS: Patient enrollment and baseline characteristics were heterogeneously distributed and led to group characteristics that were not comparable. Therefore, the comparison of the KOOS between the groups showing no differences must be treated with caution. In the OWHTO plate group, all PROs and the ROM significantly improved between baseline and 2-year follow-up. JSW remained stable in the OWHTO group. The FTA and WBLR significantly changed from a mean of 179.3 (95% confidence interval (CI): 178.7, 179.9) to 169.8 (95% CI: 169.2, 170.5) and from 23.1 (95% CI: 20.7, 25.5) to 62.4 (95% CI 59.0, 65.8), respectively. Treatment failure with conversion to total knee arthroplasty occurred in 1% of the OWHTO group; and in the conservative group, 10% converted to HTO or knee arthroplasty. CONCLUSIONS: OWHTO with plate leads to significant improvement of PROs and function 2 years after intervention and demonstrates reliable mechanical axis correction with subsequent shift of weight-bearing.

Comparison of Clinical and Radiologic Outcomes Between Normal and Overcorrected Medial Proximal Tibial Angle Groups After Open-Wedge High Tibial Osteotomy.

PURPOSE: To evaluate whether the overcorrected medial proximal tibial angle (MPTA) affects the clinical outcomes after open-wedge high tibial osteotomy (OWHTO) and to assess the correlation between knee joint line obliquity (KJLO) changes and the compensatory changes in the hip and ankle joints. METHODS: Consecutive patients who underwent OWHTO from July 2006 to August 2015 were included. Exclusion criteria were bilateral OWHTO and follow-up of <2 years. The patients were retrospectively divided into 2 groups according to postoperative MPTA; a normal group (MPTA <95°) and an overcorrected MPTA group (MPTA ≥95°). The groups were compared with respect to the clinical and radiologic outcomes after OWHTO. Clinical parameters, including Japanese Orthopedic Association (JOA) score, Oxford Knee Score (OKS), and Knee Injury and Osteoarthritis Outcome Score (KOOS), were evaluated. Radiologic outcomes, including the hip-knee-ankle angle (HKA), joint line convergence angle (JLCA), MPTA, KJLO, ankle joint line obliquity (AJLO), and hip abduction angle (HAA), were evaluated preoperatively and at the final follow-up. RESULTS: Ninety-four patients (normal group; n = 52, overcorrected group; n = 42) were included in this study. After OWTHO, the mean increases in HKA and MPTA were 11.0° ± 3.2° and 10.4° ± 2.7°, respectively, whereas the change in KJLO was only 3.7° ± 2.9°. The mean AJLO (4.3 ± 3.9 to -1.3 ± 3.3, P < .001) and HAA (3.7 ± 2.5 to -1.1 ± 2.3, P < .001) significantly decreased after OWHTO. The mean postoperative MPTA in the overcorrected group was 96.9° ± 1.5°, whereas the mean postoperative KJLO was only 3.1° ± 2.0°. No significant differences were noted in all clinical scores between the groups at the final follow-up. CONCLUSIONS: A certain degree of overcorrected MPTA (≥95°) did not affect the clinical outcomes after OWHTO because of compensatory changes in the hip and ankle joints. LEVEL OF EVIDENCE: Level Ⅲ, retrospective comparative study.

Treatment of a sacral fracture associated with an intrasacral meningocele: A case report.

We report a case of sacral fracture complicated by an intrasacral meningocele in a 37-year-old male. The patient had a left sacral fracture with bilateral fractures of the superior and inferior pubic rami. The sacrum was fixed with a posterior plate and both superior pubic rami were fixed with an intramedullary screw. However, computed tomography myelogram and magnetic resonance imaging showed the intrasacral meningocele with the leakage of the cerebrospinal fluid into the buttocks and developed delayed union. Reoperation utilizing a strong anterior and posterior internal fixation combined with posterior bone grafting was undertaken and bone union was obtained.

Urinary retention as a postoperative complication associated with functional decline in elderly female patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort.

Urinary retention (UR) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of UR in elderly female patients with femoral neck fractures.We recruited 221 female patients (age 85.3 ±â€Š7.0 years) with a history of hip surgery carried out at Toyama Municipal Hospital. UR occurred in 34 out of 221 cases (15.4%). Multiple logistic regression analysis was conducted to investigate the risk factors for UR, including age, body mass index (BMI), serum albumin, cognitive impairment, and activities of daily living (ADL).The results showed significant association of UR with cognitive impairment (P = .005, odds ratio [OR] 4.11, 95% confidence interval [CI] 1.53-11.03), and ADL (P = .029, OR 2.61, 95% CI 1.11-6.18), under adjustment with age and BMI.This study demonstrated that cognitive function and ADL were the important risk factors for UR, suggested that the postoperative management of UR is important with taking account of neurofunctional assistance and nursing care in daily living, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.

Space available for trans-sacral implants to treat fractures of the pelvis assessed by virtual implant positioning.

INTRODUCTION: The use of trans-sacral implants to treat fractures of the sacrum is limited by the variable pelvic anatomy. We were interested in how many trans-sacral implants can be placed per pelvis? If a trans-sacral implant cannot be placed in S1, where is the cortex perforated, and is the use of sacroiliac screws safe in these pelves? MATERIALS AND METHODS: 3D pelvic models were created from CT scans of 156 individuals without fractures (92 European and 64 Japanese, 79 male and 77 female, mean age 66.7 ± 13.7 years). Trans-sacral implants with a diameter of 7.3 mm were positioned virtually with and without a surrounding safe zone of 12 mm diameter. RESULTS: Fifty-one percent of pelves accommodated trans-sacral implants in S1 with a safe zone. Twenty-two percent did not offer enough space in S1 for an implant even when ignoring the safe zone. Every pelvis had sufficient space for a trans-sacral implant in S2, in 78% including a safe zone as well. In S1, implant perforation was observed in the sacral ala and iliac fossa in 69%, isolated iliac fossa perforation in 23% and perforation of the sacral ala in 8%. Bilateral sacroiliac screw placement was always possible in S1. CONCLUSIONS: The use of trans-sacral implants in S1 requires meticulous preoperative planning to avoid injury of neurovascular structures. S2 more consistently offers space for trans-sacral implants.