Revision Extension of Fusion Surgery in Thoracolumbar Spine Using a Newly Designed Revision Rod - Comparative Matched Cohort Study Versus Implant-Replacement Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the results of revision extension of fusion surgery using the newly designed revision rod and implant-replacement surgery in thoracolumbar spine. METHODS: Thirty-one patients who underwent extension of fusion surgery using the revision rod for adjacent segment disease were included in this study. Thirty-one patients who underwent implant-replacement revision surgery were selected as a control group by matching age, sex, preoperative diagnosis, and number of revision segments. RESULTS: The mean age was 70.7 ± 8.0 years in the revision rod (RR) group and 69.0 ± 8.4 years in the control group. Preoperative diagnoses, underlying diseases, and mean number of revision segments (2.2 ± 1.1) were similar in both groups. The change of hemoglobin (1.0 ± 1.9 vs 2.5 ± 1.5 g/dl; P < .01), hematocrit (4.1 ± 4.9 vs 7.2 ± 4.4 % P < .01) and albumin (.8 ± .9 vs 1.3 ± .4 g/dl; P < .01) levels before and after surgery showed significant differences between the two groups. Hemovac drainage was significantly less in the RR group (P = .01). The mean operative time was shorter in the RR group (203.5 ± 9.5 min vs 233.5 ± 8.7 min; P = .12) with no statistical difference. Radiological results showed that the average lumbar lordosis 2 years after surgery was lower in the RR group compared to the control group (25.1 ± 9.9° vs 32.9 ± 9.8°; P = .02). Union rates and clinical outcomes were not different between the two groups. CONCLUSION: Revision extension of fusion surgery using a newly designed revision rod had less hemovac drainage and superior laboratory findings compared to implant-replacement revision surgery.

Global Sagittal Alignment and Clinical Outcomes after 1-3 Short-Segment Lumbar Fusion in Degenerative Spinal Diseases.

STUDY DESIGN: Level III retrospective study. PURPOSE: We investigated the impact of short-segment lumbar fusion on the restoration of global sagittal alignment and the correlations between spino-pelvic parameters and clinical outcomes. OVERVIEW OF LITERATURE: Sagittal imbalance leads to energy consumption and pain in maintaining a standing position. For adult spinal deformity, it is critical to create optimal lumbar lordosis (LL) in order to achieve restoration of sagittal imbalance. However, surgeons do not pay attention to correcting LL in short-segment lumbar fusion. METHODS: A total of 69 patients with transforaminal lumbar interbody fusion (TLIF) for degenerative spinal disease were evaluated with a minimum 2-year follow-up. All patients underwent TLIF with hyper-lordotic angle cages to achieve higher LL. Radiological spino-pelvic parameters including sagittal vertical axis (SVA) and clinical outcomes using the Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) were evaluated. RESULTS: The average LL was 35.8°±9.9° before surgery, 42.3°±9.3° 1 year after surgery, and 40.3°±10.2° 2 years after surgery (p <0.01). The average SVA was 43.1±6.2 mm before surgery, 21.2±4.9 mm 1 year after surgery, and 34.0±4.7 mm 2 years after surgery (p <0.01). The average LL and SVA improved in two- or three-segment fusion, but not in one-segment fusion. The correlation between ΔLL and ΔSVA was significant in all segment fusions. The correlation between ΔLL and ΔSVA was more significant at the L4-5 and L5-S1 segments than at L3-4. ODI was significantly correlated with SVA (p <0.05). NRS showed no correlation with the radiological parameters. CONCLUSIONS: Two- or three-segment lumbar fusion using hyper-lordotic angle cages improved LL and SVA. A significant correlation between the correction of LL and SVA was found. Higher correction of LL using hyper-lordotic angle cages is thus recommended in short-segment lumbar fusion, since postoperative improvements of SVA significantly affect clinical outcomes.

Pedicle Subtraction Osteotomy in Adult Spinal Deformity: Comparing Fixed Versus Flexible Sagittal Imbalance.

STUDY DESIGN/SETTING: Level III-retrospective radiologic and clinical comparative study. OBJECTIVE: This study compares the results of pedicle subtraction osteotomy (PSO) for fixed versus flexible sagittal imbalance in adult spinal deformity. SUMMARY OF BACKGROUND DATA: The result of PSO may be different according to the flexibility of the deformity. METHODS: Sixty-one patients who underwent PSO were enrolled with a minimum 2-year follow-up. Twenty-one patients had fixed imbalance resulting from ankylosing spondylitis and iatrogenic flatback deformity, and 40 patients had flexible imbalance resulting from degenerative spinal deformity and posttraumatic kyphosis. RESULTS: The mean age was 54.9±9.2 years in the fixed group and 65.9±10.5 years in the flexible group (P<0.01). PSO achieved about 35 degrees of correction of kyphotic angle in both groups, but the loss of correction (LOC) was higher in the flexible group. The correction of Lumbar Lordosis was similar in both groups, at 31.7±15.4 degrees in the fixed group and 32.3±20.8 degrees in the flexible group, although the LOC was also higher in the flexible group than in the fixed group, at 9.8±12.4 and 2.7±3.5 degrees, respectively (P<0.01). The sagittal vertical axis was much more restored in the fixed group than in the flexible group (P=0.002). Postoperative complications were identified in 4 patients in the fixed group, consisting of neurological deficit and screw loosening, and in 15 patients in the flexible group, consisting of proximal junctional kyphosis, screw pullout, rod fracture, and pseudarthrosis. CONCLUSIONS: PSO for flexible sagittal imbalance resulted in a higher LOC of the osteotomy angle, Lumbar Lordosis, and sagittal vertical axis relative to the fixed deformity. Furthermore, more complications such as implant failure developed in the flexible group.

Factors associated with postoperative acute kidney injury after hip fractures in elderly patients.

OBJECTIVES: Acute kidney injury (AKI) is a rare but serious complication after hip fractures. The aim of this study was to evaluate the incidence and the risk factors of postoperative AKI after hip fractures. METHODS: From January 2011 to December 2016, 550 patients who underwent surgery of hip fractures at our institution were retrospectively reviewed. AKI was defined and classified by AKI Network (AKIN) Classification/Staging System. The incidence, mortality, and risk factors of postoperative AKI were investigated. Receiver operating characteristic curve analysis was conducted to evaluate the ability of markers in predicting AKI. RESULTS: The incidence of postoperative AKI was 4.4% (25 cases). The mean onset of postoperative AKI was 8.0 ± 5.3 days and recovered after 7.0 ± 4.2 days after the occurrence of AKI. Of 25 patients with AKI, 6 patients (24.0%) died within 1 year after surgery. The independent risk factors for postoperative AKI are the estimated blood loss (EBL) (odds ratio (OR) 1.64; 95% confidence interval (CI) 1.33-2.58; p < 0.01) and postoperative level of albumin (OR 1.77; 95% CI 1.52-2.74; p < 0.01). The cutoff value of the serum albumin was <2.8 g/dL with a sensitivity of 88.0% and a specificity of 77.1%. The cutoff value of EBL was <766.5 mL with a sensitivity of 84.0% and a specificity of 66.3%. CONCLUSION: Postoperative AKI after hip fractures had low incidences (4.4%) but high mortality (24.0%). The postoperative AKI was correlated with blood loss and low postoperative albumin levels.

Is the Oral Chemical Prophylaxis Necessary for the Prevention of Venous Thromboembolism after Joint Arthroplasty in a Korean Population?

PURPOSE: Venous thromboembolism (VTE) is a serious complication that may occur after a major orthopedic surgery. The aim of the present study was to determine the necessity of a chemical thromboprophylactic agent (rivaroxaban [RXB]) by analyzing the prevalence of VTE in Korean arthroplasty patients who received RXB for prophylaxis compared with those who did not receive RXB. MATERIALS AND METHODS: A total of 2,603 patients who underwent knee or hip arthroplasty between 1996 and 2017 were prospectively evaluated. Of these, 1,608 patients underwent surgery before January 2010 and were not administered any type of prophylaxis after surgery; the remaining 995 underwent surgery after 2010 and received oral RXB once daily for 5-13 days from the day after hemovac drain removal to postoperative day 14. RESULTS: The primary study outcome was the prevalence of VTE, pulmonary embolism or death during follow up. The overall incidence of VTE was 1.69% (n=44); of these, 12 occurred in the RXB group and 32 in the non-prophylactic group. The odds ratio of VTE in the RXB group was 0.61. However, the statistical power of the study was 0.313 due to the low incidence of VTE. CONCLUSION: Treatment with oral chemical prophylaxis decreased the incidence of VTE after knee or hip arthroplasty in a Korean population. Furthermore, no serious complications occurred after administering oral RXB, which, coupled with its convenience, suggests oral RXB offers an attractive alternative to other agents. However, we recommend that further studies, including a multicenter study, be conducted to achieve adequate statistical power.

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

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

Clinical and Radiological Outcomes of Rectangular Tapered Cementless Stem According to Proximal Femoral Geometry in Elderly Asian Patients.

PURPOSE: A retrospective analysis of mid- to long-term clinical and radiological outcomes of Korean patients over 60 years of age who underwent hip arthroplasty using a cementless rectangular tapered stem according to Dorr proximal femur geography. MATERIALS AND METHODS: From January 2007 to December 2013, 107 patients (112 hips) underwent hip arthroplasty using the C2 stem. The mean age of patients was 77.4 years (range, 60-91 years) and the mean follow-up duration was 91.1 months (range, 60-116 months). All patients were evaluated clinically and radiologically with special attention to Dorr femoral bone classification, implant fixation, radiolucent line (RLL), and thigh pain. RESULTS: All implants demonstrated radiographic evidence of stable fixation by bone ingrowth without any change in position. The mean Harris hip score improved from 65.5±16.0 (preoperative) to 90.5±15.9 (final follow-up) (P<0.001). Incidence of RLLs, stress shielding, and thigh pain was highest in patients with Dorr type A (RLL, P=0.021; stress shielding, P=0.030; thigh pain, P<0.001). One stem revision was performed due to deep infection. The Kaplan-Meier survival rate of the femoral stem was 97.6%. CONCLUSION: The overall survival rate of the C2 stems was greater than 97%; there were no significant differences in survival of the C2 stem according to the Dorr classification. The incidences of RLL of thigh pain and RLL were significantly different among Dorr classifications and (highest in patients with Dorr type A).

Prognostic Factors and Clinical Outcomes after Treatment of Periprosthetic Femoral Fractures Using a Cable-plate.

PURPOSE: To analyze prognostic factors for the treatment of periprosthetic femoral fractures (PFFs) using the cable-plate construct. MATERIALS AND METHODS: A retrospective review of a consecutive series of 41 PFFs treated by osteosynthesis using the cable-plate system. The mean age of patients was 67.3±12.1 years (range, 42-86 years) and the mean follow-up period was 31.5±11.6 months (range, 12-58 months). Fresh frozen cortical strut allografts were leveraged in three cases for additional stability. Prognostic factors that may potentially affect clinical outcomes were analyzed. RESULTS: At the time of final follow-up, fracture union was obtained in 29 hips (70.7%; Group I) after an average of 13.5 weeks (range, 12-24 weeks). Healing failure after surgical treatment was observed in 12 cases (29.3%; Group II), including delayed union (n=10) cases and nonunion (n=2). Factors significantly associated with fracture union included fracture pattern (P=0.040), plate overlap percentage to stem length (P<0.001) and T-score at the preoperative bone mineral density (P=0.011). Transverse-type fractures around or just distal to a well-fixed femoral stem were observed in six cases (50.0%) of Group II. CONCLUSION: The cable-plate osteosynthesis of PFFs should be performed with caution in transverse-type fractures or in cases with severe osteoporosis. Fixation with sufficient plate overlap to stem length may be critical to prevent healing failure.