Unstable intertrochanteric fractures are associated with a greater hemoglobin drop during the perioperative period: a retrospective case control study.

BACKGROUND: With an increase in the elderly population, the occurrence of hip fractures, femoral neck fractures, and intertrochanteric fractures (ITFs) is also increasing. It is important to establish effective perioperative methods that would help reduce the morbidity and mortality rates associated with ITFs. The purpose of this study was to determine the effects of ITFs according to the AO classification for perioperative hemoglobin drop. METHODS: Seventy-six patients with ITFs classified as AO 31-A1 or A2 and fixated with intramedullary nails participated in this retrospective cohort study. Medical records of these patients were retrospectively reviewed from September 2016 to August 2018. The perioperative hemoglobin drop was chosen as the main outcome measure and calculated as the difference between pre- and postoperative hemoglobin levels. Multivariate linear regression analysis was performed and included the following variables: AO classification (A1.1-A2.1 [stable] vs. A2.2-A2.3 [unstable]), time interval between injury and surgery, age, body mass index, and the use of anticoagulants. RESULTS: Among the 76 patients who met the inclusion criteria, a significantly higher hemoglobin drop was observed in the AO 31 A2.2-A2.3 (unstable) group than in the AO 31 A1.1-A2.1 (stable) group (p = 0.04). The multivariate analysis also showed a greater hemoglobin drop in the unstable group (p < 0.05). CONCLUSIONS: Patients with unstable ITFs exhibited a greater hemoglobin drop and a hidden blood loss was suspected around the fracture site. We believe that this should be taken into consideration when presurgical blood transfusion is being planned for patients with unstable ITFs, to reduce associated postoperative complications, especially in patients with severe anemia or high risk of mortality.

Outcomes of FETD versus UBE in the treatment of L5S1 foraminal stenosis: A comparative study.

Background: The L5S1 level exhibits unique anatomical features compared with other levels. This makes minimally invasive surgery for L5S1 foraminal stenosis (FS) challenging. This study compared the surgical outcomes of full endoscopic transforaminal decompression (FETD) and unilateral biportal endoscopy with the far-lateral approach (UBEFLA) in patients with L5S1FS. Methods: In this retrospective study, 49 patients with L5S1FS were divided into two groups. Of these, 24 patients underwent FETD, 25 patients underwent UBEFLA. The study assessed demographic data, leg pain visual analog scale (VAS) score, back pain VAS score, Oswestry Disability Index (ODI), modified MacNab outcome scale, and radiographic parameters including postoperative lateral facet preservation (POLFP). Results: The Mann-Whitney U test revealed that the UBEFLA group exhibited a higher VAS score for back pain at one week after the operation, whereas the FETD group exhibited a higher leg pain VAS score 6 weeks after the operation. All four undesired MacNab outcomes in the FETD group were attributed to residual leg pain, whereas all five undesired MacNab outcomes in the UBEFLA group were due to recurrent symptoms. Radiographically, the FETD group exhibited greater POLFP. Conclusions: When L5S1FS is performed, there may be challenges in adequately clearing the foraminal space in FETD. On the other hand, UBEFLA allowed for a more comprehensive clearance. However, this advantage of UBEFLA was associated with spinal instability as a future outcome.

Nail-stem construct method for periprosthetic humeral fractures with recalcitrant nonunion after total elbow arthroplasty: A surgical technique.

Objectives: The objective of this study was to describe the surgical technique using an innovative nail-stem construct in treatment of periprosthetic humeral fractures with recalcitrant nonunion after total elbow arthroplasty (TEA). Materials and Methods: Patients diagnosed with humeral recalcitrant nonunion in periprosthetic fractures and stem loosening after TEA were retrospectively recruited between 2018 and 2019. The demographic data and related clinical outcomes were recorded. We use a cutting length of the nail pushing into the humeral canal and then pull back distally to dock the tip of the humeral stem. The cement was packed into the humeral canal, and the periprosthetic bone defect was impacting with harvested allograft chip. Results: Patient age, gender, lesion site, number of previous surgeries, and the time period from the primary TEA to the nail-stem reconstruction were allocated. Moreover, the range of motion, degree of elbow stability, and level of pain were evaluated for each patient following this procedure. All the four patients achieved an optimal range of motion and secure stability with painless elbow at final follow-up. Conclusion: Our proposed nail-stem construct with double allogenous bone plate is a feasible alternative for revisional TEA in patients with implant loosening, periprosthetic humeral fractures, and recalcitrant nonunion.

Teriparatide treatment shows faster healing than sacroplasty for postmenopausal women with sacral insufficiency fracture.

Objectives: Sacral insufficiency fracture (SIF) is not an uncommon osteoporosis fracture among the elderly. Aside from traditional treatments, sacroplasty and teriparatide (TPTD) injection have been introduced. This report aims to compare the effects of sacroplasty and teriparatide on clinical outcomes of SIF. Methods: Thirty-one elderly patients with SIF were enrolled in this retrospective observational study. Four male patients were excluded. Fourteen patients who received TPTD for 6 months were classified into the TPTD group (TT), and 13 who underwent sacroplasty were classified into the sacroplasty group (SS). All patients in both groups were instructed to take calcium and vitamin D supplements daily. Their symptoms and signs, visual analog score (VAS), Oswestry disability index (ODI), and radiographic studies were retrospectively reviewed. Results: The TT group showed significantly lower VAS than SS group after 3 (P < 0.001) and 6 months of treatment (P < 0.001). The TT group also has significant lower ODI than SS group after 1 (P = 0.010), 3 (P = 0.005) and 6 months (P < 0.001) of treatment. Upon generalized estimating equations (GEE) analysis, the TT group showed significantly more reduction in both VAS and ODI compared to the SS group at 1 month (P = 0.022, P = 0.001), 3 months (P < 0.001, P < 0.001), and 6 months (P < 0.001, P < 0.001) post-treatment. Conclusions: Postmenoposal woman with SIF who received TPTD healed better than those who underwent sacroplasty after 1 month treatment.

Anterior Cervical Discectomy and Fusion Versus Conservative Treatment for Cervical Angina Conservative Treatment.

STUDY DESIGN: This study employed a retrospective study design. OBJECTIVE: This retrospective cohort study aimed to compare the outcomes of anterior cervical discectomy and fusion (ACDF), and those of conservative treatment for patients with cervical angina. SUMMARY OF BACKGROUND DATA: Cervical angina is typically characterized by intolerable and paroxysmal angina-like precordial pain, which is caused by cervical disk degeneration in patients without definitive cardiovascular abnormalities. Diagnosis is either delayed or neglected because of its various clinical manifestations. Whether conservative or surgical treatment is appropriate remains controversial because of the lack of comparative studies. MATERIALS AND METHODS: From 2009 to 2016, 163 patients with cervical angina with advanced chest pain, tightness, or palpitation were retrospectively studied. Twenty-three patients underwent ACDF, and the other 140 patients were treated nonsurgically by medication, physical therapy, collar immobilization, or stellate ganglion block. Japanese Orthopedic Association (JOA) score and 20-point autonomic nervous system (ANS) score were assessed pretreatment and posttreatment. Patients' satisfaction was assessed using the Odom criteria. RESULTS: The average age of the patients was 50 years, and most of them were females. The average follow-up was 25.5 months. The pretreatment JOA and 20-point ANS scores in the conservative and ACDF groups were 13.3 versus 11.7 (P=0.110) and 13.0 versus 13.3 (P=0.928), respectively. Generalized estimating equation analysis showed that posttreatment JOA and ANS scores at each observation interval improved significantly in the ACDF group (P<0.001). Angina-like symptoms also improved significantly in the ACDF group (P<0.001). During an average 2-year follow-up, good or excellent results were obtained in 78.2% of surgical patients and 35% of nonsurgical patients. CONCLUSIONS: Compared with conservative therapy, surgical treatment with ACDF for cervical angina provided better and more consistent relief from angina-like symptoms and overall sympathetic symptoms. LEVEL OF EVIDENCE: Level III.

Ameliorated Full-Endoscopic Transforaminal Decompression for L5-S1 Foraminal and Extraforaminal Stenosis.

STUDY DESIGN: This is a retrospective review. OBJECTIVE: To describe a modified surgical technique, full-endoscopic transforaminal decompression (FETD) in patients with L5-S1 foraminal stenosis or extraforaminal stenosis (EFS) and to detail the short-term results. SUMMARY OF BACKGROUND DATA: Performing FETD surgery for L5-S1 FS and EFS is challenging because of high iliac crests in most cases and the difficulty in accurately differentiating between FS and EFS by images preoperatively. MATERIAL AND METHODS: Patients who had solitary unilateral L5-S1 FS or EFS and had undergone FETD between October 2014 and December 2017 were included. In total, 22 patients underwent FETD for L5 root compressions at the L5-S1 levels. All patients were followed up for more than 1 year. RESULTS: The mean visual analog scale score for back and leg pain, assessed preoperatively and at 12 months postoperatively, improved from 6.3±1.7 to 1.59±1.30 and from 7.29±0.78 to 1.41±1.20, respectively. The mean Oswestry Disability Index improved from 61.53% preoperatively to 15.8% at 12 months postoperatively. Neurovascular injury-related complications were absent in all these cases. CONCLUSION: Successful short-term clinical outcome is achievable using the ameliorated FETD technique for treating L5-S1 FS and EFS.

Early Percutaneous Vertebroplasty Improves Bone-Cement Integration and Reduces Adjacent Fractures.

BACKGROUND: Percutaneous vertebroplasty (PVP) is widely used for treatment of osteoporotic vertebral compression fractures (VCFs). However, the influence of PVP timing (early vs. late) on development of adjacent vertebral fractures has rarely been discussed. This retrospective cohort study aimed to evaluate bone-cement binding for thoracolumbar fractures (T8-L3) using a new assessment method to predict risk for adjacent vertebral fractures. METHODS: Patients with a single-level T-score ≤ -1.0 of lumbar bone mineral density and a primary osteoporotic VCF in the thoracolumbar region (T8-L3) who underwent PVP from October 2016 to February 2018 at our medical university-affiliated hospital were included. Patients were divided into refracture and non-refracture groups. All patients underwent computed tomography after vertebroplasty. Bone-cement distribution patterns were evaluated using standardized axial computed tomography images of each cemented vertebra by 4 independent observers with ImageJ software. The smoothness index was calculated as a percentage of smooth margins. RESULTS: Of 51 VCFs, 15 (29.4%) and 36 (70.6%) were refracture and non-refracture VCFs, respectively. The mean smoothness index (MSI) was higher in the refracture group than in the non-refracture group (P < 0.01), with an increased refracture risk that corresponded to increased MSI values (P = 0.004). Spearman correlation coefficient (0.375) showed a positive correlation between the fracture-vertebroplasty interval and MSI (P = 0.01). CONCLUSIONS: Axial computed tomography images were used to characterize bone-cement binding properties. Patients who underwent early PVP had a lower MSI, better bone-cement integration, and fewer adjacent fractures.

Full endoscopic interlaminar discectomy (FEID) for recurrent lumbar disc herniation: surgical technique, clinical outcome, and prognostic factors.

BACKGROUND: The objective of this study is to determine the effectiveness and prognostic factors of revisional full endoscopic interlaminar discectomy (FEID) for recurrent herniation after conventional open disc surgery. The major concerns of the repeated discectomy for recurrent lumbar disc herniation (RLDH) are the epidural scar and postoperative segmental instability. Compared to open discectomy, endoscopic method has advantages of less tissue traumatization, clearer visualization and better tissue identification. With the improvement of endoscopic technique and instrument, the problems related to adhesive scar tissues or postoperative instability could be overcome. METHODS: From June 2014 to December 2016, FEID was performed in consecutive 24 patients for RLDH. The age ranged from 25 to 60 years (mean 44.6 years). The level operated was L5-S1 in 16 cases and L4-5 in 8 cases. To avoid injury to the neural tissue, we started with the bony structure. A small part of facet or lamina might be resected in severe stenotic or adhesive condition. Aggressive separation of the scar from the neural tissue might lead to dural tear and should be avoided. The herniated disc material was removed after neural tissue had been clearly identified and protected. RESULTS: The follow-up period was at least 24 months. The visual analog scale (VAS) for leg pain and back pain, and Oswestry disability index (ODI) showed significant improvement after treatment. Excellent or good outcome by the modified Macnab's criteria was obtained in 22 of 24 patients at two years follow-up. Excellent outcome was noted in 100 percent patients younger than 50 years. Small durotomy occurred in 2 patients and no visible cerebrospinal fluid (CSF) leakage was detected despite repair was not performed. Two additional surgery was performed including one repeated FEID for re-recurrence of disc herniation and one fusion surgery for postoperative back pain. CONCLUSIONS: FEID is a safe and effective alternative for recurrent disc herniation. The successful rate was greater than 90 percent, especially in the younger patients with the advantages of early recovery and no need for fusion.

Comparison of Mid-term Survivorship and Clinical Outcomes between Bipolar Hemiarthroplasty and Total Hip Arthroplasty with Cementless Stem: A Multicenter Retrospective Study.

OBJECTIVES: To compare the clinical outcome between bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) using a U2 HA cementless hip stem, and the results of elderly femoral neck fracture patients who underwent BHA with a cementless hip stem. METHODS: A multicenter retrospective study enrolled 96 BHA and 115 THA cases using U2 HA cementless hip stems with mean age (BHA: 67.9 years; THA: 64.1 years), body height (BHA: 160.4 cm; THA: 160.7 cm) and weight (BHA: 62.7 kg; THA: 64.5 kg) recorded. Mean follow-up durations were, respectively, 7.1 (BHA) and 7.8 (THA) years. Survivorship analyses and Oxford hip scores were compared. RESULTS: Both the BHA and the THA groups revealed high survival rates at 5-year (100%) and 10-year (100.0% and 90.1%) follow-up. The THA group achieved better joint performance and pain relief. The cementless HA stems had survived perfectly for 10 years for elderly femoral neck fracture patients following BHA. CONCLUSIONS: The U2 HA cementless hip stem provides an effective solution for both BHA and THA surgeries, and for elderly femoral neck fracture patients undergoing BHA. According to the findings of the current study, THA may be inadequate for addressing avascular necrosis, and pain control is a considerable concern for patients who have undergone BHA.

Earlier Vertebroplasty for Osteoporotic Thoracolumbar Compression Fracture May Minimize the Subsequent Development of Adjacent Fractures: A Retrospective Study.

BACKGROUND: Percutaneous vertebroplasty (PVP) is widely used to treat osteoporotic vertebral compression fractures (OVCFs). The influence of timing (early vs. late) of PVP on the development of adjacent vertebral fractures (AVF) has rarely been discussed. OBJECTIVE: This study aimed to compare the incidence of AVF among patients who received early PVP (= 30 days after symptom onset, EPVP) or late PVP (> 30 days after symptom onset, LPVP) in the thoracolumbar region (T10 to L2) after a 1-year follow up. STUDY DESIGN: A retrospective cohort study. SETTING: Department of Orthopedic, an affiliated hospital of a medical university. METHODS: Patients who had single-level, T-score = -2.5 of lumbar bone mineral density (BMD), primary OVCF in the thoracolumbar region (T10 to L2) and who received PVP between July 2012 and June 2014 were included in the study. They were divided into early PVP and late PVP groups according to the interval between symptom onset and treatment. The risk factors associated with subsequent AVFs were analyzed. RESULTS: Of the 225 patients reviewed, 124 met the criteria and were followed for a minimum of 1 year. Eleven patients (14.1%) in the EPVP group (n = 78) and 18 patients (39.1%) in the LPVP group (n = 46) experienced an AVF during the first year following vertebroplasty. Outcomes were significantly better in patients with higher bone mineral density, lower cement volume, and without cement leakage (P < 0.01). Cox regression indicated an increase risk for AVF for LPVP, with an adjusted hazard ratio of 6.08 (95% confidence interval: 2.50-14.81). LIMITATION: The incidence of AVFs could be over estimated due to this being a retrospective study with a small case number and lack of either biomechanical study of intra-vertebral cement distribution by times to support the result. CONCLUSIONS: Compared with later interventions, PVP performed within 30 days after fracture development may be associated with a lower risk of adjacent fractures in the thoracolumbar region. KEY WORDS: Percutaneous vertebroplasty, osteoporosis, osteoporotic vertebral compression fracture, adjacent vertebral fracture.

Incident osteoarthritis and osteoarthritis-related joint replacement surgery in patients with ankylosing spondylitis: A secondary cohort analysis of a nationwide, population-based health claims database.

BACKGROUND: Ankylosing spondylitis (AS) might be associated with an increased risk of secondary osteoarthritis. However, there is a lack of studies assessing its impact on osteoarthritis-related surgery. The aim of this secondary cohort study was to investigate the risk of symptomatic osteoarthritis and osteoarthritis-related surgery, including total hip replacement surgery (THRS) and total knee replacement surgery (TKRS) in patients with AS. METHODS: Using the Taiwan's National Health Insurance Research Database, we identified 3,462 patients with AS between 2000 and 2012. A comparison cohort was assembled consisting of five patients without AS, based on frequency matching for sex, 10-year age interval, and index year, for each patient with AS. Both groups were followed until diagnosis of the study outcomes or the end of the follow-up period. RESULTS: Male patients with AS exhibited a significantly higher incidence of osteoarthritis (adjusted incidence rate ratio [IRR] 1.43; P < 0.001), THRS (adjusted IRR 12.59; P < 0.001), and TKRS (adjusted IRR 1.89; P = 0.036). Moreover, analyses stratified by age group (20-39 years versus 40-80 years) indicated a high IRR (adjusted IRR 27.66; P <0.001) for THRS among younger patients with AS. CONCLUSIONS: Male patients with AS had a significant higher risk of developing osteoarthritis, and receiving THRS and TKRS. Young patients with AS also showed a significant higher risk of receiving THRS.