Association of the joint line orientation angle of the contralateral limb with the alignment change of the unilateral and bilateral opening-wedge high tibial osteotomy.

PURPOSE: This study aimed to evaluate and compare unilateral and bilateral open-wedge high tibial osteotomy (OWHTO) using mid-term serial assessment of clinical and radiological outcomes, especially focussing on coronal lower extremity alignment. METHODS: Serial radiological assessments were performed in 40 patients (80 knees) with bilateral OWHTO and 49 patients (49 knees) with unilateral OWHTO. Both groups were further divided into four subgroups to compare each limb (unilateral involved and non-involved limbs and bilateral primarily and secondarily treated limbs). Radiological and clinical outcomes were evaluated and compared among the four groups. For the alignment change assessment, the pelvic tilt angle (PTA), weight-bearing line ratio (WBLR), joint line orientation angle (JLOA), medial proximal tibia angle (MPTA), joint line convergence angle (JLCA), distal tibia articular angle (DTAA), and talar inclination (TI) were measured pre- and postoperatively at 3, 6, and 12 months and annually thereafter. Student's t-test, one-way repeated-measures analysis of variance, and correlation analysis were used to compare the groups. RESULTS: Patients in the unilateral and bilateral OWHTO groups had similar postoperative radiological and clinical outcomes. Each unilaterally involved limb and primarily treated bilaterally involved limb were negatively affected by the contralateral limb with respect to increased JLOA during the postoperative period (unilateral OWHTO group: r = -0.350, p = 0.023; bilateral OWHTO group: r = -0.520, p = 0.005). The correction change of the ankle parameters in the secondarily treated limb showed greater varus alignment than the primarily treated limb after bilateral OWHTO (DTAA (0.1 ± 3.0 vs. -0.5 ± 3.8°, p = 0.014) and TI (0.9 ± 3.2° vs. -0.3 ± 2.9, p = 0.001)). CONCLUSION: Unilateral and bilateral OWHTOs shared similar postoperative radiological and clinical outcomes. Alignment changes of the unilateral OWHTO and the primarily treated limb of the bilateral OWHTO were associated with the JLOA of the contralateral limb. LEVEL OF EVIDENCE: Cohort study; Level III.

Medially and distally inserted tuberosity screw fixation of the osteotomized tubercle is safe and effective in retro-tubercular bi-planar opening-wedge high tibial osteotomy.

PURPOSE: The purpose of this study was to develop a safe and effective method of inserting one tuberosity screw and to determine whether retro-tubercular (RT)-Open-wedge high tibial osteotomy (OWHTO) with tuberosity screw fixation can be conducted to overcome the problem of osteotomized tubercle and produce favorable outcomes compared to RT-OWHTO without tuberosity screw fixation. METHODS: From 2018 to 2020, patients who underwent bi-planar RT-OWHTO were allocated as two groups (RT-OWHTO without tuberosity screw fixation as group I and with screw fixation as group II). Computed tomography (CT) was used to analyze osteotomy configurations such as RT gap and tip distance, and union of the main and second plane osteotomy sites. The RT gap distance was measured as the length of the osteotomy gap. The RT tip distance was measured as the length of the gap at the tip of the tibial tubercle. Post-operative complications were analyzed also. To evaluate the neurovascular (NV) approximity of screw fixation group, the pre-operative magnetic resonance imaging (MRI) images were referenced on the post-operative CT for the assessment of the safe zone. RESULTS: In total, 44 knees in group I and 46 knees in group II were enrolled. The RT gap distance (2.58 ± 0.69 mm vs. 0.57 ± 0.57 mm; p < .001) and RT tip distance (4.31 ± 1.60 mm vs. 1.48 ± 1.42 mm; p < .001) were significantly larger in group I than in group II. The sum of union grade in the second plane osteotomy site (17.93 ± 2.18 points vs. 22.24 ± 2.57 points; p < .001) was statistically different between two groups at three months post operatively. Post-operative tuberosity prominence occurred in five knees only in group I (p = 0.025), although tibial tuberosity fracture developed in seven cases in group II compared with two cases in group I with no statistical significance. NV was safe when the screw was inserted medially. CONCLUSION: RT-OWTHO with one-screw fixation for the tuberosity was effective in terms of tuberosity prominence and the union of the second plane osteotomy site. However, it also produced another problem, such as tuberosity fracture. In addition, a tuberosity screw was safe when it was inserted in the medial-distal direction. LEVEL OF EVIDENCE: Cohort study; level III.

Is there any benefit in the combined ligament reconstruction with osteotomy compared to ligament reconstruction or osteotomy alone?: Comparative outcome analysis according to the degree of medial compartment osteoarthritis with anterior or posterior cruciate ligament insufficiency.

INTRODUCTION: The purpose of this study was to compare the outcomes of middle-aged patients with anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) insufficiency by assessing different groups: high tibial osteotomy (HTO), HTO with combined ligament reconstruction, and isolated ligament reconstruction according to the alignment change and medial compartment osteoarthritis (OA). MATERIALS AND METHODS: From 2014 to 2019, middle-aged (40-65 years) patients with knee instability were enrolled in this retrospective study. They were categorized into three groups: group I, HTO; group II, HTO with combined ACL or PCL reconstruction; and group III, isolated ligament reconstruction. Radiological outcomes, including Kellgren-Lawrence grade, mechanical femorotibial angle (mFTA), weight-bearing line (WBL) ratio, and posterior tibial slope were compared. Knee stability and clinical outcomes were also compared. RESULTS: Seventy-nine patients completed the final assessment. Group I was older than other two groups (p = 0.006). Groups I and II had a higher body mass index (p = 0.043) and more preoperative varus alignment than group III (p < 0.001). OA severity was ranked in the order of group I, II, and III (p < 0.001). Group I showed more valgus alignment than group II after HTO (p = 0.024 for mFTA and 0.044 for WBL ratio, respectively). Compared to their preoperative status, all three groups showed significant improvement in knee stability (p < 0.001); however, group I showed inferior knee stability regardless of ACL or PCL reconstruction (p < 0.001 and 0.043, respectively). All clinical scores significantly improved in the three groups (p < 0.001), and they showed comparable clinical outcomes in the final assessment. CONCLUSIONS: Our strategy in managing middle-aged patients with knee instability according to the varus alignment and medial degeneration showed favorable stability and clinical outcomes. Middle-aged patients with knee instability should be managed with different strategies depending on their status. LEVEL OF EVIDENCE: Case-control study; Level-III.

Clinical relevance of roll-back replacement of ultra congruent total knee arthroplasty: comparison of mid-term outcomes with posterior stabilizing design.

INTRODUCTION: The outcomes of total knee arthroplasty (TKA) remain controversial, and we do not know which factors are important for successful outcomes. This study aimed to compare the mid-term outcomes of different conceptual designs by evaluating the radiological and clinical outcomes. MATERIALS AND METHODS: A total of 478 total knee arthroplasties (TKAs) were enrolled and allocated into groups I [posterior stabilizing (PS) with anterior referencing (AR)], II [PS with posterior referencing (PR), and III [ultra-congruent (UC) TKA)]. Preoperative findings, last follow-up clinical outcomes, and final follow-up radiological and indirect assessments of the femoral rollback were compared between the groups. RESULTS: The mean follow-up period was 72.6 ± 12.9 months. The tourniquet was used samely applied to every group. Flexion contracture was significantly larger in group III than in groups I and II (3.3 ± 2.7, p < 0.001), and further flexion was significantly smaller in group III (130.0° ± 2.7°, p < 0.001). Among the radiological parameters, posterior osteophyte formation was the most common in group III (67.8%). The rollback distance was significantly smaller in group III than in groups I and II (p < 0.001). The active deep flexion angle was affected by the posterior condylar offset (PCO) ratio, and the contact point changed the distance (p < 0.05). CONCLUSION: PS TKAs showed better ROMs than UC TKAs; however, no differences were noted in the clinical outcome scales. The flexion angle was affected by the PCOR and rollback at both PS and UC TKAs. However, rollback negatively affected the flexion angle during UC TKAs. An inappropriate femoral rollback was identified, and femoral osteophyte formation was determined to be the most prominent in UC TKAs. Level of evidence Level III comparative study.

Excessively Increased Joint-Line Obliquity After Medial Opening-Wedge High Tibial Osteotomy Is Associated With Inferior Radiologic and Clinical Outcomes: What Is Permissible Joint-Line Obliquity.

PURPOSE: This study aimed to evaluate the permissible joint-line obliquity (JLO) based on radiologic and clinical outcomes with midterm follow-up after medial open-wedge high tibial osteotomy (MOWHTO). METHODS: Patients who had undergone MOWHTO from March 2014 to May 2016 were retrospectively evaluated. They were divided into 4 groups based on JLO as represented by postoperative medial proximal tibial angle (MPTA). Radiologic parameters including MPTA, joint-line orientation angle (JLOA), joint-line convergence angle (JLCA), posterior tibial slope, weightbearing line ratio (WBLR), and coronal translation were analyzed. Clinical outcomes were evaluated with American Knee Society Score (AKSS), Western Ontario and McMaster University Index, and short-form 36 health survey (SF-36). The changes between preoperation and final follow-up in JLOA and MPTA were defined as ΔJLOA and ΔMPTA. RESULTS: A total of 135 knees were finally included (MPTA ≤90.32° as group I; 90.33° to 92.62° as group II; 92.74° to 95.22° as group III; and ≥95.23° as group IV). The last follow-up MPTA, JLOA, and JLCA values were different between the groups (P < .001, P < .001, and P = .015, respectively). WBLR and JLOA positively correlated with MPTA; however, WBLR showed an abrupt increase at MPTA >96.5°, and the JLOA distribution tended to be greater than the regression line at MPTA >96°. Moreover, ΔJLOA was not as large as ΔMPTA. The percentage of patients attaining a minimal clinically important difference was significantly lower in the AKSS-functional score and SF-36 physical component summary in group IV (P = .008 and 0.021, respectively). CONCLUSION: The JLOA did not change as much as the MPTA, but an MPTA >95.2° abruptly increased the JLOA and valgus overcorrection after MOWHTO. Poor clinical outcomes were more evident in excessive MPTA (>95.2°) than in mildly undercorrected or properly corrected MPTA (<95.2°). LEVEL OF EVIDENCE: III, retrospective cohort study.

Additional tying on the adjustable-loop device improves the outcomes of anterior cruciate ligament reconstruction using hamstring autograft.

PURPOSE: The purpose of this study was to verify the efficacy of a novel technique for additional tying on the adjustable-loop device to prevent stress concentration on the graft loop end and gradual loop lengthening. METHODS: A total of 124 patients who underwent anterior cruciate ligament reconstruction using hamstring autografts from 2014 to 2017 were included in this retrospective study. After 1:1 propensity score matching, two groups were formed (group I: 50 patients without tying vs. group II: 50 patients with tying). Anterior laxity was evaluated using side-to-side differences. Tunnel length, loop length, and graft-tunnel gap were measured using follow-up magnetic resonance imaging. The signal-to-noise ratio was calculated at the loop end, loop inner side, tunnel entrance, and graft mid-substance. The clinical outcomes were assessed using the International Knee Documentation Committee score, Lysholm score, pivot shift test, and Lachman test. RESULTS: The average follow-up period was 63.2 ± 4.8 and 53.8 ± 11.9 months in groups I and II, respectively. Anterior laxity showed that side-to-side differences improved significantly 6 months postoperatively in both the groups. Although the anterior laxity improved in group II (2.9 ± 1.0 to 1.6 ± 0.8, p < 0.001), it deteriorated in group I (2.5 ± 1.5 to 3.3 ± 1.3 mm, p < 0.001) at the final follow-up. The graft-tunnel gap was significantly larger in group I (p < 0.001). The signal-to-noise ratios of the loop end and loop inner side were significantly higher in group I (p < 0.001 and p = 0.020, respectively). The clinical outcomes at the final follow-up were not significantly different between the groups. CONCLUSION: The additional tying on the adjustable-loop device was not superior to the control group in clinical stability examination or outcome. However, it was effective in anterior laxity measured by stress radiographs, preventing stress on the adjustable-loop device, and gradual graft loop lengthening. LEVEL OF EVIDENCE: Level III.

Increased Bone Mineral Density in Cervical or Thoracic Diffuse Idiopathic Skeletal Hyperostosis (DISH): A Case-Control Study.

We aim to compare the bone mineral density (BMD) in a group of patients with cervical or thoracic diffuse idiopathic skeletal hyperostosis (DISH) with that in a matched control group. We also investigated the prevalence of osteoporosis in the two groups and determined the correlation between BMD and the extent of spinal DISH. From 1999 to July 2015, 65 patients with DISH underwent dual-energy X-ray absorptiometry at our institute. The control group was matched with regard to age, sex, and body mass index to the patient group on a 1:1 basis. BMD was measured at the lumbar spine (L1-L4), femur neck, and femur total areas using dual-energy X-ray absorptiometry. The BMDs of the DISH and control groups were significantly different at the lumbar spine (L1-L4) and the femur neck (p = 0.005, 0.001). The rates of patients with osteopenia and osteoporosis were lower in the DISH than in the control group for the lumbar spine (L1-L4) (p = 0.05). A positive correlation was observed between the lumbar spine (L1-L4) BMD and the number of spine levels affected by DISH (p = 0.04). The BMDs of the lumbar spine and femur neck were found to be higher in the DISH group than in a matched control group, when patients with lumbar DISH involvement were excluded. The rates of osteopenia and osteoporosis tended to be lower in the DISH group than in the control group. Lumbar spine BMD is significantly correlated with the number of spine levels affected by DISH.

Survivorship Analysis and Clinical Outcomes of Transtibial Pullout Repair for Medial Meniscus Posterior Root Tears: A 5- to 10-Year Follow-up Study.

PURPOSE: This study investigated the clinical outcomes and mid- to long-term survival rates in patients undergoing transtibial pullout repair of medial meniscus posterior root tears (MMPRTs) after a minimum follow-up of 5 years. METHODS: Between 2005 and 2011, patients with MMPRTs who had been followed for at least 5 years after undergoing transtibial pullout repair were recruited. Participants were identified using medical records and information in a prospectively collected database. Clinical outcomes were assessed based on a comparison of patient preoperative Lysholm scores and their scores at the final follow-up. A Kaplan-Meier survival analysis was used to investigate the survival rates of repair procedures. Clinical failures were defined as cases requiring conversion to total knee arthroplasty (TKA) or having final Lysholm score <65 or less than their preoperative scores. RESULTS: Overall, 91 patients (mean age, 58.7 ± 9.7 years) were included: the mean follow-up duration was 84.8 ± 13.8 months. Among these patients, the mean Lysholm score improved significantly from 51.8 ± 7.9 preoperatively to 83.0 ± 11.1 at the final follow-up (P < .001). Overall, 4 patients failed due to conversion to TKA (n = 1) or having final Lysholm scores <65 or less than the preoperative scores (n = 3). The overall Kaplan-Meier probabilities of survival after repair were 99% at 5 years, 98% at 6 years, 95% at 7 years, and 92% at 8 years. CONCLUSIONS: Among patients with MMPRTs, transtibial pullout repair demonstrated a high clinical survival rate and the patients demonstrated clinical improvement, based on mid- and long-term follow-up examinations. LEVEL OF EVIDENCE: Level IV, retrospective uncontrolled case series.

Feasibility of Modified FOLFOX in Elderly Patients Aged ≥80 Years with Metastatic Gastric Cancer or Colorectal Cancer.

OBJECTIVE: The aim of this study was to assess the feasibility of a modified FOLFOX regimen as first-line treatment in elderly patients with metastatic gastric cancer (GC) or colorectal cancer (CRC). METHODS: We included chemotherapy-naïve patients over 80 years old with metastatic GC or CRC in our study. From September 2008 to November 2014, 28 consecutive patients were enrolled and treated with modified FOLFOX. RESULTS: The study population consisted of an equal number of GC and CRC patients. The median age was 82.2 years in the GC group and 81.1 years in the CRC group. The total number of administered cycles was 89 (with a median of 6 per patient) in the GC group and 112 (with a median of 8 per patient) in the CRC group. Median progression-free survival (PFS) and overall survival (OS) were 5.4 and 6.6 months in the GC group and 7.3 and 8.1 months in the CRC group, respectively. There was no significant difference in PFS (p = 0.941) and OS (p = 0.238) between the GC and the CRC group. The 1-year survival rates were 35.7% with GC and 42.9% with CRC. Common grade 3/4 hematology toxicities were neutropenia (10.7%) and anemia (14.3%). Salvage chemotherapy was administered to 1 patient with GC and 7 patients with CRC. CONCLUSIONS: The modified FOLFOX regimen can be cautiously considered as a first-line treatment option in extremely elderly patients with metastatic GC or CRC.

The clinicopathological relevance of pretransplant anti-angiotensin II type 1 receptor antibodies in renal transplantation.

BACKGROUND: Anti-angiotensin II type 1 receptor antibodies (AT1R-Abs) have been suggested as a risk factor for graft failure and acute rejection (AR). However, the prevalence and clinical significance of pretransplant AT1R-Abs have seldom been evaluated in Asia. METHODS: In this multicenter, observational cohort study, we tested the AT1R-Abs in pretransplant serum samples obtained from 166 kidney transplant recipients. Statistical analysis was used to set a threshold AT1R-Abs level at 9.05 U/mL. RESULTS: Pretransplant AT1R-Abs were detected in 98/166 (59.0%) of the analyzed recipients. No graft loss or patient death was reported during the study period. AT1R-Abs (+) patients had a significantly higher incidence of biopsy-proven AR than AT1R-Abs (-) patients (27.6 versus 10.3%, P = 0.007). Recipients with pretransplant AT1R-Abs had a 3.2-fold higher risk of AR within a year of transplantation (P = 0.006). Five study subjects developed microcirculation inflammation (score ≥2). Four of them were presensitized to AT1R-Abs. In particular, three patients had a high titer of anti-AT1R-Abs (>22.7 U/mL). CONCLUSIONS: Pretransplant AT1R-Abs is an independent risk factor for AR, especially acute cellular rejection, and is possibly associated with the risk of antibody-mediated injury. Pretransplant assessment of AT1R-Abs may be useful for stratifying immunologic risks.

Optic disc and peripapillary retinal nerve fiber layer characteristics associated with glaucomatous optic disc in young myopia.

PURPOSE: To explore optic disc and peripapillary retinal nerve fiber layer (RNFL) features associated with glaucomatous optic disc (GOD) in young myopia. METHODS: Presence of GOD, optic disc tilt, and disc torsion were determined using fundus photographs. If the measured disc tilt ratio was >1.3, the optic disc was classified as tilted. Optic disc torsion was defined as a >15° deviation in the long axis of the optic disc from the vertical meridian. The average and four quadrants RNFL thicknesses were assessed using spectral domain optical coherence tomography (SD-OCT). Logistic regression analyses were performed to identify factors associated with the presence of GOD. RESULTS: Nine hundred and sixty myopic subjects were recruited from four refractive surgery clinic databases. The mean age was 26.6 ± 5.7 years and spherical equivalent (SE) was -5.5 ± 2.5 diopters. Among 960 eyes, 26 (2.7%) received GOD group classification. Among 934 normal eyes, 290 (31.0%) had titled optic discs. Eighteen eyes (69.2%) in the GOD group had tilted optic discs. When compared to normal eyes, the GOD group had significantly higher tilt ratios (1.4 ± 0.2 vs. 1.2 ± 0.1, p < 0.001) and less SE (-7.8 ± 2.7 vs. -5.4 ± 2.5 diopters, p < 0.001). Greater tilt ratio (odds ratio (OR) = 4.9, p < 0.001), less SE (OR = 0.708, p < 0.001), and thinner average RNFL (OR = 0.910, p = 0.001) were significantly associated with GOD. Among 934 normal eyes, 366 (39.2%) displayed disc torsion, while among 26 glaucomatous eyes, eight (30.8%) displayed disc torsion. CONCLUSIONS: Optic disc tilt was found in approximately one-third of young myopic eyes and was independently associated with the presence of GOD.

Dynamic stabilization using the Dynesys system versus posterior lumbar interbody fusion for the treatment of degenerative lumbar spinal disease: a clinical and radiological outcomes-based meta-analysis.

OBJECTIVE The Dynesys, a pedicle-based dynamic stabilization (PDS) system, was introduced to overcome the drawbacks of fusion procedures. Nevertheless, the theoretical advantages of PDS over fusion have not been clearly confirmed. The aim of this study was to compare clinical and radiological outcomes of patients who underwent PDS using the Dynesys system with those who underwent posterior lumbar interbody fusion (PLIF). METHODS The authors searched PubMed, Embase, Web of Science, and the Cochrane Database. Studies that reported outcomes of patients who underwent PDS or PLIF for the treatment of degenerative lumbar spinal disease were included. The primary efficacy end points were perioperative outcomes. The secondary efficacy end points were changes in the Oswestry Disability Index (ODI) and back and leg pain visual analog scale (VAS) scores and in range of motion (ROM) at the treated and adjacent segments. A meta-analysis was performed to calculate weighted mean differences (WMDs), 95% confidence intervals, Q statistics, and I(2) values. Forest plots were constructed for each analysis group. RESULTS Of the 274 retrieved articles, 7 (which involved 506 participants [Dynesys, 250; PLIF, 256]) met the inclusion criteria. The Dynesys group showed a competitive advantage in mean surgery duration (20.73 minutes, 95% CI 8.76-32.70 minutes), blood loss (81.87 ml, 95% CI 45.11-118.63 ml), and length of hospital stay (1.32 days, 95% CI 0.23-2.41 days). Both the Dynesys and PLIF groups experienced improved ODI and VAS scores after 2 years of follow-up. Regarding the ODI and VAS scores, no statistically significant difference was noted according to surgical procedure (ODI: WMD 0.12, 95% CI -3.48 to 3.72; back pain VAS score: WMD -0.15; 95% CI -0.56 to 0.26; leg pain VAS score: WMD -0.07; 95% CI -0.47 to 0.32). The mean ROM at the adjacent segment increased in both groups, and there was no substantial difference between them (WMD 1.13; 95% CI -0.33 to 2.59). Although the United States is the biggest market for Dynesys, no eligible study from the United States was found, and 4 of 8 enrolled studies were performed in China. The results must be interpreted with caution because of publication bias. During Dynesys implantation, surgeons have to decide the length of the spacer and cord pretension. These values are debatable and can vary according to the surgeon's experience and the patient's condition. Differences between the surgical procedures were not considered in this study. CONCLUSIONS Fusion still remains the method of choice for advanced degeneration and gross instability. However, spinal degenerative disease with or without Grade I spondylolisthesis, particularly in patients who require a quicker recovery, will likely constitute the main indication for PDS using the Dynesys system.

Modified iliac screw fixation: technique and clinical application.

BACKGROUND: A conventional iliac bolt and the S2 alar iliac screw fixation technique (S2AI) are commonly used sacropelvic fixation techniques. However, conventional iliac bolt technique requires a lateral connector and commonly has prominent screw head problems. S2AI reportedly has a high instrument failure rate. We aim to introduce a modified iliac screw fixation technique and to investigate its clinical application in adult patients. METHODS: The entrance site of the modified iliac screw fixation technique was 1 cm medial and 1 cm caudal from the posterosuperior iliac spine. From 2009 to 2015, ten adult patients underwent sacropelvic fixation with the modified iliac screw fixation technique in our spine clinic. A minimum 12-month clinical and radiographic follow-up was adopted. The mean follow-up period was 30.7 months (12-74 months). Mean number of fixation levels was 7.7 segments (5-10 segments). RESULTS: Postoperatively, the C7 plumb line (SVA) was significantly decreased (P = 0.04). Upon the last X-ray, SVA did not differ between postoperative and the last X-ray (P = 0.1). There was no breakage during our follow-up period. There was no prominent screw head. There were no cases requiring implant removal. CONCLUSIONS: The modified iliac screw fixation technique does not cause prominence in the sacral region, and does not require a lateral connector, both of which are necessary when using the classical iliac bolt technique. This technique also avoids the acute angle between the screw head and the shaft of the screw commonly seen in S2AI. The modified iliac screw fixation technique can be an effective alternative for sacropelvic fixation.

Minimally invasive cervical foraminotomy and diskectomy for laterally located soft disk herniation.

PURPOSE: The posterior cervical foraminotomy and diskectomy (PCD) is a traditional surgical technique for patients with laterally located soft-disk herniation. Recently, tubular retractor-assisted posterior foraminotomy and diskectomy (MTPF) and posterior percutaneous endoscopic cervical foraminotomy and diskectomy (P-PECD) have been introduced, but a comparative study has not yet been performed. METHODS: Patients with foraminal soft-disk herniation and a follow-up period of >2 years were retrospectively reviewed; 22 patients underwent a MTPF and 22 patients underwent a P-PECD. The primary end-point was an improvement of arm pain more than 4.3. The clinical parameters (age, sex, disability index, neck and arm pain), radiological parameters (cervical curvature, segmental angle, anterior-/posterior-disk height and amount of facet joint removal) preoperatively and at postoperative month 24 and the surgical methods were considered as co-variates. RESULTS: Successful outcome was achieved in 19/22 (87%) of the patients after both MTPF and a P-PECD. Preoperative SA showed trend (P = 0.08; OR 1.2; 95% CI 0.98-1.4) and the cut-off SA was 1.45° (sensitivity 80%, specificity 73%). The length of the facet joint's removal was 0.02-2.49 mm (0.1-15.2%) with no difference between the MTPF and P-PECD. The surgical method was not a significant factor. CONCLUSIONS: For patients with foraminal soft-disk herniation, either MTPF or P-PECD, may be regarded as an alternative options to open surgery. Preoperative kyphotic SA (cut-off value 1.45°) seemed to be associated with poor outcome and this may be considered in selecting surgical methods.

Segmental kyphosis after cervical interbody fusion with stand-alone polyetheretherketone (PEEK) cages: a comparative study on 2 different PEEK cages.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: Two polyetheretherketone (PEEK) cages of different designs were compared in terms of the postoperative segmental kyphosis after anterior cervical discectomy and fusion. SUMMARY OF BACKGROUND DATA: Segmental kyphosis occasionally occurs after the use of a stand-alone cage for anterior cervical discectomy and fusion. Although PEEK material seems to have less risk of segmental kyphosis compared with other materials, the occurrence of segmental kyphosis for PEEK cages has been reported to be from 0% to 29%. There have been a few reports that addressed the issue of PEEK cage design. METHOD: A total of 41 consecutive patients who underwent single-level anterior discectomy and fusion with a stand-alone cage were included. Either a round tube-type (Solis; 18 patients, S-group) or a trapezoidal tube-type (MC+; 23 patients, M-group) cage was used. The contact area between the cage and the vertebral body is larger in MC+ than in Solis, and anchoring pins were present in the Solis cage. The effect of the cage type on the segmental angle (SA) (lordosis vs. kyphosis) at postoperative month 24 was analyzed. RESULTS: Preoperatively, segmental lordosis was present in 12/18 S-group and 16/23 M-group patients (P=0.84). The SA was more lordotic than the preoperative angle in both groups just after surgery, with no difference between groups (P=0.39). At 24 months, segmental lordosis was observed in 9/18 S-group and 20/23 M-group patients (P=0.01). The patients in M-group were 7.83 times more likely than patients in S-group (P=0.04; odds ratio, 7.83; 95% confidence interval, 1.09-56.28) not to develop segmental kyphosis. CONCLUSIONS: The design of the PEEK cage used may influence the SA, and this association needs to be considered when using stand-alone PEEK cages.

Is Hemiresurfacing Arthroplasty for Osteonecrosis of the Hip a Viable Solution?

We conducted a systematic review of published studies that evaluated the outcomes of hemiresurfacing arthroplasty (HRA) in patients with osteonecrosis (ON). A structured literature review of multiple databases referenced articles from 1950 to 2014. A total of 430 patients from 14 published studies were identified. The mean duration of follow-up after the HRA was 69 months. At the final follow-up, the mean postoperative Harris hip score was 85. Overall clinical success rate was 74%. A total of 102 (21%) revision surgeries were required after the index procedure. Our study has helped to further elucidate the outcomes of HRA in patients with ON. We believe that HRA in young, active patients is a viable option providing symptomatic relief and functional improvement.

KNOW-KT (KoreaN cohort study for outcome in patients with kidney transplantation: a 9-year longitudinal cohort study): study rationale and methodology.

BACKGROUND: Asian patients undergoing kidney transplantation (KT) generally have better renal allograft survival and a lower burden of cardiovascular disease than those of other racial groups. The KNOW-KT aims to explore allograft survival rate, cardiovascular events, and metabolic profiles and to elucidate the risk factors in Korean KT patients. METHODS: KNOW-KT is a multicenter, observational cohort study encompassing 8 transplant centers in the Republic of Korea. KNOW-KT will enroll 1,000 KT recipients between 2012 and 2015 and follow them up to 9 years. At the time of KT and at pre-specified intervals, clinical information, laboratory test results, and functional and imaging studies on cardiovascular disease and metabolic complications will be recorded. Comorbid status will be assessed by the age-adjusted Charlson co-morbidity index. Medication adherence and information on quality of life (QoL) will be monitored periodically. The QoL will be assessed by the Kidney Disease Quality of Life Short Form. Donors will include both living donors and deceased donors whose status will be assessed by the Kidney Donor Risk Index. Primary endpoints include graft loss and patient mortality. Secondary endpoints include renal functional deterioration (a decrease in eGFR to <30 mL/min/1.73 m2), acute rejection, cardiovascular event, albuminuria, new-onset diabetes after transplant, and QoL. Data on other adverse outcomes including episodes of infection, malignancy, recurrence of original renal disease, fracture, and hospitalization will also be collected. A bio-bank has been established for the acquisition of DNA, RNA, and protein from serum and urine samples of recipients at regular intervals. Bio-samples from donors will also be collected at the time of KT. KNOW-KT was registered in an international clinical trial registry (NCT02042963 at http://www.clinicaltrials.gov) on January 20th, 2014. CONCLUSION: The KNOW-KT, the first large-scale cohort study in Asian KT patients, is expected to represent the Asian KT population and provide information on their natural course, complications, and risk factors for complications.

Cervical extension magnetic resonance imaging in evaluating cervical spondylotic myelopathy.

BACKGROUND: Cervical spondylotic myelopathy (CSM) may be caused by static and dynamic spinal cord compression, particularly during neck extension. Dynamic compression may be better evaluated with dynamic magnetic resonance (MR) images. We performed a retrospective study to determine the clinical indication for dynamic MR imaging, and conducted a survey regarding image interpretation by clinicians. METHOD: A total of 32 patients (M:F = 20:12, 60.1 ± 10.7 years) who had undergone neutral/extension cervical MR imaging were included. The study population consisted of 22 patients with signs of cervical myelopathy (M group) and 10 patients without signs of myelopathy (NM group). The number of compression levels (complete obliteration of the anterior and posterior subarachnoid space) was assessed at each level in mid-sagittal, T2-weighted, neutral and extension MR images. Reproduced images from 22 patients in the M group were randomly arranged, and four experienced spine surgeons at four different institutes interpreted them to reach a clinicians' agreement. The agreements were then assessed with inter-rater correlation coefficients (ICC). RESULTS: Analysis with extension MR images found an increased number of compression levels in 23/32 (72 %) of patients; 20/22 in the M group and 3/10 in the NM group (p < 0.01, chi-squared test), as compared to findings of the neutral MR images. Clinical factors for increased compression levels in extension MR images were age (p < 0.01, 63.3 ± 10.0 years vs. 51.9 ± 8.1) and signs of myelopathy (p < 0.01, odds ratio, 23.33). Clinician agreement was improved with extension MR images; ICC was 0.67 with neutral and 0.81 with extension MR images. CONCLUSIONS: The evaluation of CSM may be improved with dynamic MR images. Dynamic MR scanning may be considered for elderly patients with signs of myelopathy, but an interpretation for asymptomatic spinal compression based exclusively on extension MR image should be made with caution.

The surgical outcome and the surgical strategy of percutaneous endoscopic discectomy for recurrent disk herniation.

STUDY DESIGN: A retrospective analysis. OBJECTIVE: To present the surgical outcome of percutaneous endoscopic discectomy (PED) for recurrent herniated intervertebral disk disease (HIVD) and to suggest a surgical strategy. SUMMARY OF BACKGROUND DATA: Revision discectomy is technically demanding because of the scar tissue, unclear anatomic planes, and retraumatization to the posterior structures. Although open microdiscectomy is a standard method, endoscopic techniques have emerged as a surgical alternative with comparable results. PED was performed with either the transforaminal (PETD) or the interlaminar approach (PEID). Previous reports have shown the surgical outcomes of PETD or PEID for recurrent HIVD, but the application of each approach was not addressed clearly. METHODS: Consecutive 26 patients (M:F=16:10, mean age 53.1±12.4 y), who underwent PED for recurrent HIVD, were enrolled. The previous operation was an open discectomy in 22, a PETD in 2, and a PEID in 2 patients. PETD was considered preferentially, if it was feasible (n=11), because of the scar tissue formed by the previous operation. PEID was chosen (n=15) because of a high iliac crest (8), high canal compromise (3), high-grade inferior migration (2), and narrow neural foramen (2). All patients were followed up for 19.3±11.3 months. RESULTS: In all patients, the recurrent disk material was removed successfully, and conversion to an open surgery was not necessary. Postoperative magnetic resonance imaging revealed that the ruptured disk was removed successfully in all cases. A favorable outcome (excellent or good outcome by MacNab's criteria) was achieved in 21 patients (81%). Re-recurrence occurred in 2 patients at 6 and 12 months postoperatively. Risk factors for an unfavorable outcome were not found in the present study (P>0.05). CONCLUSIONS: The relevant utilization of updated surgical techniques may be helpful in overcoming the difficulty of revision surgery.

Comparison of the Clinical Efficacy of Anabolic Agents and Bisphosphonates in the Patients With Osteoporotic Vertebral Fracture: Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: We investigated the clinical efficacy of anabolic agents compared with bisphosphonates (BPs) for the incidence of new osteoporotic vertebral fracture (OVF) and fracture healing of OVF in the patients with OVF via meta-analyses of randomized controlled trials (RCTs). METHODS: Electronic databases, including PubMed, Embase, and Cochrane Library were searched for published RCTs till December 2022. The RCTs that recruited participants with osteoporosis at high-/very high-risk of fracture (a history of osteoporotic vertebral or hip fracture) or fresh OVF were included in this study. We assessed the risk of bias on every included RCTs, estimated relative risk (RR) for the incidence of new OVF and fracture healing of OVF, and overall certainty of evidence. Meta-analyses were performed by Cochrane review manager (RevMan) ver. 5.3. Cochrane risk of bias 2.0 and GRADEpro/GDT were applied for evaluating methodological quality and overall certainty of evidence, respectively. RESULTS: Five hundred eighteen studies were screened, and finally 6 eligible RCTs were included in the analysis. In the patients with prevalent OVF, anabolic agents significantly reduced the incidence of new OVF (teriparatide and romosozumab vs. alendronate and risedronate [RR, 0.57; 95% confidence interval, 0.45-0.71; p < 0.00001; high-certainty of evidence]; teriparatide vs. risedronate [RR, 0.50; 95% confidence interval, 0.37-0.68; p < 0.0001; high-certainty of evidence]). However, there was no evidence of teriparatide compared to alendronate in fracture healing of OVF (RR, 1.23; 95% confidence interval, 0.95-1.60; p = 0.12; low-certainty of evidence). CONCLUSION: In the patients with prevalent OVF, anabolic agents showed a significant superiority for preventing new OVF than BPs, with no significant evidence for promoting fracture healing of OVF. However, considering small number of RCTs in this study, additional studies with large-scale data are required to obtain more robust evidences.