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.

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 retrospectively. 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.

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.

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.

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.

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.

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.

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.

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.

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.

Long-term clinical results of the crosse de hockey procedure for recurrent patellar dislocation

BACKGROUND

A gold standard procedure has not been established for recurrent patellar dislocation because of multifactorial etiologies. We have been performing crosse de hockey procedure, which is a combination of medial and anterior transfer of the tibial tuberosity, in our institution since 1993. This study aimed to investigate the long-term clinical results of this procedure.

MATERIALS AND METHODS

A total of 19 patients (21 knees) underwent the crosse de hockey procedure for recurrent patellar dislocation. Of these patients, four were lost to follow-up. The remaining 17 knees in 15 patients (5 male and 10 female) were included in this study. The mean follow-up period was 13.2 years (range: 5-22.6 years). Clinical evaluation was performed using the Kujala score. Radiographic indicators, such as modified Insall-Salvati ratio, sulcus angle, congruence angle, tilting angle, lateral shift ratio, and the progression of patellofemoral osteoarthritis (OA), were measured.

RESULTS

Positive apprehension sign and redislocation were not observed in any of the patients. The mean Kujala score was significantly improved from 36.5 ± 18.0 preoperatively to 92.6 ± 9.9 at the final follow-up. Definite OA (a grade 2 or more using the Iwano grading system) was not observed in the patellofemoral joint at the final follow-up.

CONCLUSIONS

The crosse de hockey procedure showed satisfactory long-term clinical results for recurrent patellar dislocation. This procedure could prevent the progression of patellofemoral OA because of the unloading effect of the patellofemoral joint by anteromedial transfer of the tibial tuberosity.

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 ± 7.4 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.

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.

The influence of pre-operative antiplatelet and anticoagulant agents on the outcomes in elderly patients undergoing early surgery for hip fracture

BACKGROUND

Early surgery improves the prognosis of elderly patients with hip fractures. However, many patients take antiplatelet and anticoagulant therapies for comorbidities. This study compared perioperative outcomes and 1-year mortality rates with early surgery in elderly patients with hip fractures taking or not taking these agents preoperatively.

METHODS

Among 418 patients undergoing surgery for hip fractures at our institution from 2014 to 2016, 266 patients over 65 years who had surgery within 48 hours of admission were enrolled. We excluded patients with high-energy injuries, multiple or pathological fractures, and patients undergoing osteosynthesis for femoral neck fractures. The study population was divided into those who underwent hemiarthroplasty for neck fractures and those who underwent osteosynthesis for trochanteric fractures. We also divided the population into patients receiving chronic anticoagulation therapy (medicated group: 19 hemiarthroplasty, 70 osteosynthesis) and patients not receiving anticoagulation therapy (non-medicated group: 47 hemiarthroplasty, 130 osteosynthesis). Comorbidities, intraoperative blood loss, estimated blood loss from admission to the first and seventh day after surgery, transfusions, length of stay, complications, and 1-year mortality rates were evaluated.

RESULTS

Diabetes mellitus and cerebrovascular disorders were significantly more common in the medicated group for both surgery types. In the osteosynthesis group, estimated blood loss on the first day was 710 ml in the medicated group and 572 ml in the non-medicated group (P = 0.015). In the hemiarthroplasty group, corresponding values were 668 and 480 ml, respectively (P = 0.016). Estimated blood loss on the seventh day, complications, length of stay and 1-year mortality rate were not increased significantly.

CONCLUSIONS

The medicated group had an increase in estimated blood loss on the first day. However, there was no significant increase in transfusions, complications and 1-year mortality rates. Early surgery for elderly patients with hip fractures is recommended, even for those taking antiplatelet and anticoagulant agents.

Assessment of unloading effects after open wedge high tibial osteotomy using quantitative bone scintigraphy

INTRODUCTION

We evaluated changes in bone tracer uptake (BTU) in open wedge high tibial osteotomy (OWHTO) and determined if BTU correlates with clinical symptoms, postoperative alignment, or cartilage regeneration after OWHTO.

MATERIALS AND METHODS

Seventy-five knees in 64 patients who underwent OWHTO for medial compartment osteoarthritis were enrolled in this retrospective study. All cases were assessed preoperatively and at plate removal using bone scintigraphy. Visual analog scale (VAS), Japanese Orthopedic Association (JOA) score, Oxford Knee Score (OKS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and the weight-bearing line ratio (WBLR) were assessed preoperatively and at plate removal. In addition, cartilage regeneration was evaluated at plate removal. We assessed changes in BTU for the medial and lateral compartment after OWHTO and the correlations between BTU of the medial compartment and all other parameters were analyzed.

RESULTS

Postoperatively, all outcome measures significantly improved: mean VAS 61.4 ± 18.3 to 9.5 ± 8.2, mean JOA score 65.1 ± 11.5 to 94.7 ± 6.0, mean OKS 29.4 ± 8.1 to 42.3 ± 4.1, mean KOOS 57.0 ± 14.3 to 83.7 ± 9.6, mean WBLR 22.8 ± 10.9 to 70.0 ± 9.4. Cartilage regeneration was observed in 53 knees (70.7%). BTU of the medial compartment significantly decreased after OWTHO, whereas no increased postoperative BTU was found in the lateral compartment. Postoperative BTU of the medial compartment significantly correlated with VAS, KOOS, and WBLR. No statistically significant associations were found between BTU and cartilage regeneration.

CONCLUSIONS

OWHTO significantly decreased BTU of the medial compartment, which correlated with knee pain and postoperative mechanical alignment. Unloading effects of OWHTO led to pain relief after surgery, regardless of cartilage regeneration.

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 ± 7.0 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.

Large opening gaps, unstable hinge fractures, and osteotomy line below the safe zone cause delayed bone healing after open-wedge high tibial osteotomy

PURPOSE

To evaluate bone formation in the osteotomy gap after open-wedge high tibial osteotomy (OWHTO), including after plate removal, and to investigate risk factors for delayed bone healing.

METHODS

Ninety-three patients (102 knees) who underwent OWHTO without bone grafting were enrolled. The osteotomy gap was divided into the lateral hinge and the four zones on anteroposterior radiographs, and we defined the zone in which trabecular bone continuity could be observed as gap filling. Bone formation in the osteotomy gap was evaluated according to this definition at 3, 6, and 12 months postoperatively; at plate removal; and at the final follow-up (mean, 62.3 ± 30.2 months). We also investigated the risk factors for delayed bone healing.

RESULTS

The lateral hinge united at 3 months postoperatively in 92 knees (90.2%). At 1 year postoperatively, 98 knees (96.1%) reached zone 1 and 92 knees (90.2%) reached zone 2. At plate removal, gap filling reached zone 2 in all cases and progressed further without loss of correction after plate removal. Opening width over 13.0 mm [odds ratio (OR): 1.61, P = 0.02], Takeuchi's classification type II lateral hinge fracture (OR: 20.4, P < 0.01), and osteotomy line below the safe zone (OR: 8.98, P < 0.01) significantly delayed bone formation after OWHTO.

CONCLUSIONS

Gap filling progressed from lateral to medial after OWHTO without bone grafting and progressed further after plate removal. Large opening gaps, unstable hinge fractures, and osteotomy line below the safe zone cause delayed bone healing after OWHTO.

The effect of a multidisciplinary approach on geriatric hip fractures in Japan

BACKGROUND

This study aimed to report results of the multidisciplinary treatment approach for geriatric hip fractures and evaluate its effectiveness compared with conventional treatment. Patients aged 65 years and older who presented with a hip fracture at our hospital on or after 2014 were treated according to a multidisciplinary approach.

METHOD

Two groups of patients with hip fracture were compared. Group I (n = 364) was treated according to the new multidisciplinary approach in 2014-2016, and Group II (n = 105) which received conventional treatment in 2012. Time to surgery, length of hospital stay, postoperative complications, osteoporosis treatment, functional recovery, in-hospital mortality, 90-day mortality, and 1-year mortality were evaluated. The medical costs of multidisciplinary treatment were compared with those in other hospitals every year.

RESULTS

There were no significant differences in the time to surgery between Group I and Group II, but each was considerably shorter than the average time in other Japanese hospitals. The length of hospital stay was longer in Group I. The overall postoperative complication rate was lower in Group I, but there was no significant difference for each individual complication. The rate of anti-osteoporosis pharmacotherapy administration at the time of discharge was significantly higher in Group I. Moreover, the proportion of patients who recovered to their pre-injury functional level was significantly higher in Group I. The mortality rates did not significantly differ year on year. The total hospitalization medical cost per patient for the multidisciplinary treatment was lower than other hospital costs every year.

CONCLUSIONS

Multidisciplinary treatment produced no significant improvement in time to surgery, length of hospital stay, or postoperative complications. However, the use of the multidisciplinary treatment approach led to a significant increase in osteoporosis treatment rate and better functional recovery. Furthermore, the total medical costs for multidisciplinary treatment were lower than the acute care hospital costs.

3D statistical model of the pelvic ring - a CT-based statistical evaluation of anatomical variation

The pelvic ring is a highly complex construct with a central role for human stability and mobility. The observable interindividual differences in skeletal anatomy are caused by anatomical variation in the innominate bones as well as the sacrum, further to differences in the spatial arrangement of these bones to each other. The aim of this study was to generate a 3D statistical model of the entire pelvic ring in order to analyse the observed interindividual differences and anatomical variation. A series of 50 anonymized pelvic CT scans of uninjured Japanese adults [30 males, 20 females, average age of 74.9 years, standard deviation (SD) 16.9 years] were processed and analysed, resulting in a 3D statistical overall mean model and separate male and female mean models. Principal component analysis (PCA) of the overall statistical model predominantly showed size variation (20.39%) followed by shape variation (14.13%), and a variation of the spatial arrangement of the sacrum to the innominate bones in different anatomical peculiarities (11.39 and 8.85%). In addition, selected internal and external pelvic parameters were manually measured with the objective of further evaluating and quantifying the observed interindividual as well as the known sex-specific differences. A separate statistical model of the grey value distribution based on the given Hounsfield unit (HU) values was calculated for assessing bone mass distribution, thus an indication of bone quality utilizing grey values as a quantitative description of radiodensity was obtained. A consistent pattern of grey value distribution was shown, with the highest grey values observed between the sacro-iliac joint and the acetabulum along the pelvic brim. Low values were present in the sacral ala, in the area of the iliac fossa as well as in the pubic rami next to the symphysis. The present model allows a differentiated analysis of the observed interindividual variation of the pelvic ring and an evaluation of the grey value distribution therein. Besides providing a better understanding of anatomical variation, this model could be also used as a helpful tool for educational purposes, preoperative planning and implant design.

Femoral Periprosthetic Fractures after Total Knee Arthroplasty: New Surgically Oriented Classification with a Review of Current Treatments

Purpose

As the number of total knee arthroplasties (TKAs) increases, the incidence of femoral periprosthetic fractures after TKA is also increasing. This review aimed to suggest a new surgically oriented classification system for femoral periprosthetic fractures.

Methods

We investigated the classifications, and current treatment trends for femoral periprosthetic fractures after TKA by means of a thorough review of the relevant literature.

Results

Numerous studies reported good results of surgical treatment with modern fixatives including locking compression plates and retrograde intramedullary nails. However, few classifications of femoral periprosthetic fractures reflect the recent developments in surgical treatment.

Conclusions

We recommend that surgical management be considered the first-line treatment for femoral periprosthetic fractures after TKA. Our new classification will help in deciding the surgical treatment option for femoral periprosthetic fractures after TKA.

Fragility fractures of the sacrum occur in elderly patients with severe loss of sacral bone mass

INTRODUCTION

Patients suffering from osteoporosis-associated fragility fractures of the sacrum (FFS; also termed sacral insufficiency fractures) are increasingly observed. They have typical fracture patterns with fracture lines located in the sacral ala. When treating these patients operatively, iliosacral screw loosening is not uncommon. We aimed to study the sacral bone mass in patients presenting with a FFS using 3D statistical models.

MATERIALS AND METHODS

3D models of averaged Hounsfield units (HU) were generated based on CT scans from 13 patients with a unilateral FFS (mean age 79.6 years; 11 females, 2 males). The control group without fractures consisted of 28 males and 32 females (mean age of 68.3 years). A virtual bone probe along the trans-sacral corridors S1 and S2 was taken.

RESULTS

The bone mass distribution in the fractured sacra was similar to the control group, however, with overall lower HU. Large zones of negative HU were located in the sacral ala. In the fractured sacra, the HU in the sacral ala was significantly lower on the non-injured side when comparing to the fractured side (p < 0.001) as well as compared to the non-fractured group (p < 0.001). Low bone mass was observed in sacral body S1 (40 HU) and S2 (20 HU).

CONCLUSIONS

The extensive area of negative HU may explain the fracture location in the sacral ala. The low HU in the sacral bodies advocates the use of trans-sacral implants or augmented iliosacral screws to enhance the strength of fracture fixation. The increased HU in the fractured ala could be explained by fracture-asssociated hemorrhage and can be used as a diagnostic tool.

Critical dimensions of trans-sacral corridors assessed by 3D CT models: Relevance for implant positioning in fractures of the sacrum

Trans-sacral implants can be used alternatively to sacro-iliac screws in the treatment of osteoporosis-associated fragility fractures of the pelvis and the sacrum. We investigated trans-sacral corridor dimensions, the number of individuals amenable to trans-sacral fixation, as well as the osseous boundaries and shape of the S1 corridor. 3D models were reconstructed from pelvic CT scans from 92 Europeans and 64 Japanese. A corridor of <12 mm was considered critical for trans-sacral implant positioning, and <8 mm as impossible. A statistical model of trans-sacral corridor S1 was computed. The limiting cranio-caudal diameter was 11.6 mm (±5.4) for S1 and 14 mm (±2.4) for S2. Trans-sacral implant positioning was critical in 52% of cases for S1, and in 21% for S2. The S1 corridor was impossible in 26%, with no impossible corridor in S2. Antero-superiorly, the S1 corridor was limited not only by the sacrum but in 40% by the iliac fossa. The statistical model demonstrated a consistent oval shape of the trans-section of corridor S1. Considering the variable in size and shape of trans-sacral corridors in S1, a thorough anatomical knowledge and preoperative planning are mandatory using trans-sacral implants. In critical cases, S2 is a veritable alternative. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2577-2584, 2017.

Patellofemoral Osteoarthritis Progression and Alignment Changes after Open-Wedge High Tibial Osteotomy Do Not Affect Clinical Outcomes at Mid-term Follow-up

PURPOSE

To evaluate the clinical and radiological outcomes of open-wedge high tibial osteotomy (OWHTO) with respect to the patellofemoral joint and to assess whether patellofemoral osteoarthritis (OA) progression and alignment changes after OWHTO affect clinical outcomes.

METHODS

Inclusion criteria were consecutive patients who underwent OWHTO from March 2005 to September 2013. Exclusion criteria were loss to follow-up within 2 years and absence of second-look arthroscopy findings at the time of plate removal. The clinical parameters, including anterior knee pain while climbing stairs, Japanese Orthopedic Association score, and Oxford Knee Score, were evaluated. Radiological outcomes, including weight-bearing line ratio, modified Blackburne-Peel ratio, posterior tibial slope, tilting angle, lateral shift ratio, and patellofemoral OA (Kellgren-Lawrence grade), were evaluated preoperatively and at the final follow-up. Cartilage status (International Cartilage Repair Society grade) was evaluated at the initial HTO and at plate removal.

RESULTS

Fifty-three patients (60 knees) were included in this study. The mean follow-up was 58.2 ± 22.4 months. Two knees (3%) presented with mild anterior knee pain after OWHTO. The mean Japanese Orthopedic Association score (66.9 ± 11.2 to 91.2 ± 9.7) significantly improved (P < .001), and the mean Oxford Knee Score at the final follow-up was 42.0 ± 5.3. The mean modified Blackburne-Peel ratio (0.9 ± 0.1 to 0.7 ± 0.1, P < .001) and tilting angle (6.8 ± 3.7 to 5.6 ± 3.4, P = .033) significantly decreased after OWHTO, whereas no significant changes in posterior tibial slope (P = .511) and lateral shift ratio (P = .522) were observed. Radiologically, patellofemoral OA had progressed in 15 knees (27%), and arthroscopically patellofemoral cartilage degeneration had progressed in 27 knees (45%). However, there was no significant correlation between changes in patellofemoral alignment and clinical outcomes.

CONCLUSIONS

Changes in patellofemoral alignment and patellofemoral OA progression did not affect the clinical outcomes of OWHTO at mid-term follow-up.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Responsiveness of the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Oxford Knee Score (OKS) in Japanese patients with high tibial osteotomy

BACKGROUND

To assess responsiveness of the Japanese Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Oxford Knee Score (OKS) in patients undergoing open-wedge HTO to treat knee osteoarthritis and/or osteonecrosis.

METHODS

Patients completed a set of questionnaires before HTO surgery (baseline) and 1 year after surgery. The questionnaires comprised the validated Japanese versions of the KOOS, the OKS, and the SF-36v2 and a visual analogue scale (VAS) for local knee pain and general pain. The treating surgeon completed the Japanese Orthopedic Association (JOA) score for osteoarthritic knees. The study included 119 patients aged 64.7 ± 8.3, 116 were followed at 1 year. 90 patients had knee osteoarthritis (OA) solely. 28 patients suffered from both OA and osteonecrosis (ON); one patient had ON only. Responsiveness to change was assessed using the effect size (ES) between the baseline and the 1-year postoperative assessment and standardized response mean. A distribution-based approach was used to determine the minimally detectable change (MDC95) for the KOOS subscales, and the OKS.

RESULTS

All instruments demonstrated statistically significant changes between the preoperative assessments and one year after surgery. All changes showed an improvement in score, but the condition-specific measures revealed higher responsiveness than the generic measures. All KOOS subscales, the OKS, the local pain VAS, and the JOA score showed large ESs (ES > 1.24) and SRMs (SRM>1.04). At a 95% confidence level, the respective MDCs were 15.83, 18.94, 15.22, 18.99 and 17.23 for the KOOS-Pain, KOOS-Symptoms, KOOS-ADL, KOOS-Sport/Rec, and KOOS-QOL subscales, respectively. The MDC95 for the OKS was 8.29.

CONCLUSIONS

Both, the KOOS and OKS are responsive for use in Japanese-speaking patients with knee osteoarthritis and/or osteonecrosis who are undergoing HTO.

Morphometry of the sacrum and its implication on trans-sacral corridors using a computed tomography data-based three-dimensional statistical model

BACKGROUND CONTEXT

Trans-sacral implants are increasingly used to treat fractures of the sacrum, especially for osteoporosis-associated fragility fractures. However, the complex and highly variable sacral anatomy limits their use. It is still not clear which morphologic characteristics are critical to determine the availability and dimensions of trans-sacral corridors.

PURPOSE

This study aims to assess sacral anatomy and its influence on trans-sacral corridors.

STUDY DESIGN

This study used a computed tomography (CT)-based three-dimensional (3D) statistical size and shape model of the sacrum with multiple morphometric measurements.

MATERIALS AND METHODS

A 3D statistical model was computed using clinical CT data of 92 intact pelvises (mean age 61.5 years). Multiple measurements of the sacrum and the trans-sacral corridors were taken. Descriptive statistics and linear regression were calculated. Shape and size were analyzed using principal component analysis.

RESULTS

The limiting craniocaudal diameter of the trans-sacral corridor was 13.1 mm (±5 mm) in S1 and 13.8 mm (±2.4 mm) in S2. In S1, the craniocaudal diameter correlated with larger sacral curvature (SC), pelvic incidence (PI), and cranially located auricular surfaces. The presence of an accessory articulation with L5 was associated with a larger trans-sacral corridor S1. In contrast, the craniocaudal diameter of the S2 corridor correlated with more caudally situated auricular surfaces and lower PI. The sacral shape, as demonstrated by the statistical model, was highly variable, which affected the size and availability of trans-sacral corridor S1. Important determinants of trans-sacral corridor S1 were the craniocaudal position of the auricular surfaces and the shape of the sacral ala, which were influenced by SC, sacral height, and PI.

CONCLUSIONS

The human sacrum is highly variable in size and shape. The dimensions of trans-sacral corridors depend on the sacral shape and specific morphologic characteristics. Understanding of morphologic variants helps with preoperative assessments of the trans-sacral corridors. When planning to use trans-sacral implants, because of variable sacral anatomy and dimensions of the trans-sacral corridors, thorough preoperative planning is mandatory.

Age does not affect the clinical and radiological outcomes after open-wedge high tibial osteotomy

PURPOSE

Open-wedge high tibial osteotomy (OWHTO) is a well-established procedure in the management of medial compartment osteoarthritis and osteonecrosis of the medial femoral condyle. Several studies have evaluated factors that negatively influence outcomes. However, few reports have investigated the effect of age on HTO outcome. We evaluated the influence of the age on the outcome after HTO.

METHODS

The TomoFix^® plate was used to perform 60 consecutive OWHTOs. Twenty-six knees in 23 patients >65 years old (mean age at surgery 68.7 ± 2.9 years; range 65-75 years, group A) were compared with 34 knees in 27 patients <65 years old (mean age at surgery 56.2 ± 7.5 years; range 38-64 years, group B) with respect to the clinical and radiological outcomes after HTO. The clinical evaluation included the Japanese Orthopedic Association Knee Score (JOA score), Oxford Knee Score (OKS) and complications after surgery.

RESULTS

There were no statistical differences in the background factors between the two groups. Postoperatively, the mean JOA score showed a significant improvement in both groups. The mean OKS after surgery was 41.6 ± 5.9 in group A and 41.4 ± 5.9 in group B. There were no statistical differences in the postoperative knee alignment and clinical outcomes between the two groups.

CONCLUSION

OWHTO using the rigid long plate was an effective procedure independent of patient's age. The results showed that age did not influence the clinical and radiological outcomes after OWHTO.

A refined definition improves the measurement reliability of the tip-apex distance

BACKGROUND

Tip-apex distance (TAD) is reported as a good predictor for cut-outs of lag screws and spiral blades in the treatment of intertrochanteric fractures, and surgeons are advised to strive for TAD within 20 mm. However, the femoral neck axis and the position of the lower limb in the lateral radiograph are not clearly defined and can lead to measurement errors. We propose a refined TAD by defining these factors. The objective of this study was to analyze the reliability of this refined TAD.

METHODS

The radiographs of 130 prospective cases with unstable trochanteric fractures were used for the analysis of the refined TAD. The refined TAD was independently measured by 2 raters with clinical experience of more than 10 years (rater 1, 2) and 2 raters with much less clinical experience (rater 3, 4) after they received a training about the new measurement method. Intraclass correlation coefficient (ICC [2,4]) was calculated to assess the interrater reliability.

RESULTS

The mean refined TADs were 18.2:18.4:18.2:18.2 mm for rater 1:2:3:4. There was a strong correlation among all four raters (ICC 0.998, (95% CI: 0.998, 0.999).

CONCLUSIONS

Regardless of the clinical experience of raters, the refined TAD is a reliable tool and can be used to develop new TAD recommendations for predicting failure of fixation. Future studies with larger samples are needed to evaluate the predictive value of the refined TAD.

Sacral Bone Mass Distribution Assessed by Averaged Three-Dimensional CT Models: Implications for Pathogenesis and Treatment of Fragility Fractures of the Sacrum

BACKGROUND

Fragility fractures of the sacrum are increasing in prevalence due to osteoporosis and epidemiological changes and are challenging in their treatment. They exhibit specific fracture patterns with unilateral or bilateral fractures lateral to the sacral foramina, and sometimes an additional transverse fracture leads to spinopelvic dissociation. The goal of this study was to assess sacral bone mass distribution and corresponding changes with decreased general bone mass.

METHODS

Clinical computed tomography (CT) scans of intact pelves in ninety-one individuals (mean age and standard deviation, 61.5 ± 11.3 years) were used to generate three-dimensional (3D) models of the sacrum averaging bone mass in Hounsfield units (HU). Individuals with decreased general bone mass were identified by measuring bone mass in L5 (group 1 with <100 HU; in contrast to group 2 with ≥100 HU).

RESULTS

In group 1, a large zone of negative Hounsfield units was located in the paraforaminal lateral region from S1 to S3. Along the trans-sacral corridors, a Hounsfield unit peak was observed laterally, corresponding to cortical bone of the auricular surface. The lowest Hounsfield unit values were found in the paraforaminal lateral region in the sacral ala. An intermediate level of bone mass was observed in the area of the vertebral bodies, which also demonstrated the largest difference between groups 1 and 2. Overall, the Hounsfield units were lower at S2 than S1.

CONCLUSIONS

The models of averaged bone mass in the sacrum revealed a distinct 3D distribution pattern.

CLINICAL RELEVANCE

The negative values in the paraforaminal lateral region may explain the specific fracture patterns in fragility fractures of the sacrum involving the lateral areas of the sacrum. Transverse fractures located between S1 and S2 leading to spinopelvic dissociation may occur because of decreased bone mass in S2. The largest difference between the studied groups was found in the vertebral bodies and might support the use of transsacral or cement-augmented implants.

Geriatric tibial plateau fractures: Clinical features and surgical outcomes

BACKGROUND

Operative treatment of geriatric tibial plateau fractures is challenging and controversial. There are few studies focusing on the clinical features and operative outcomes of tibial plateau fractures in the elderly. Hence, this study aimed to investigate the clinical features and operative results of these fractures.

METHODS

Thirty-three displaced tibial plateau fractures in patients >65 years old (mean age: 72.1 years, range: 65-94 years) were treated operatively. We investigated the mechanisms of injury, fracture types according to the Schatzker classification, incidences of soft tissue injury, and postoperative complications. Clinical and radiographic data were analyzed in 23 patients at the last follow-up. The mean follow-up period was 4.0 years (range: 1-13 years). Twenty-one patients were treated with open reduction and internal fixation and evaluated using the Rasmussen clinical and radiologic scores. Two patients with advanced osteoarthritis were treated primarily with total knee arthroplasty and assessed using the Japanese Orthopaedic Association score for the knee osteoarthritis.

RESULTS

Twenty-four patients (72.7%) were injured by low-energy trauma such as a simple fall. Four patients had compartment syndrome and required fasciotomies. Rasmussen clinical and radiologic scores were satisfactory in 85.7% and 81.0% of patients, respectively. Two patients treated primarily with total knee arthroplasty showed no radiologic abnormality, and their Japanese Orthopaedic Association scores were both 70 points.

CONCLUSIONS

Geriatric tibial plateau fractures, although mostly due to low-energy trauma, were often accompanied with severe comminution and compartment syndrome. Postoperative results of open reduction and internal fixation for this population were relatively good. Therefore, primary total knee arthroplasty should only be considered for well-selected patients.

Inadequate management for secondary fracture prevention in patients with distal radius fracture by trauma surgeons

We evaluated the secondary fracture prevention in 1445 patients with distal radius fracture by trauma surgeons. The rate of patients with distal radius fracture who underwent bone mineral density (BMD) examination was low, suggesting that appropriate treatment for osteoporosis by trauma surgeons is not performed at present.

INTRODUCTION

To clarify the status of osteoporosis interventions after distal radial fractures by trauma surgeons who play the main role in treatment for these fractures, we performed a survey involving multiple institutions in Japan.

METHODS

We asked 155 board members of the Japanese Society for Fracture Repair for their cooperation and performed a survey in 48 institutions with which members who gave cooperation were affiliated. The subjects consisted of consecutive patients with distal radial fractures occurring between January and December 2012. The presence or absence of a diagnosis of osteoporosis and bone mineral density examination after fracture was investigated.

RESULTS

A total of 1445 patients with distal radial fractures were evaluated in this study. BMD examination for diagnosis and treatment for osteoporosis after fracture was performed respectively in 126 (8.7 %) and 193 (13.4 %) of 1445 patients. Treatment for osteoporosis was performed in 93 (73.8 %) of 126 patients who underwent BMD examination after fracture and 100 (8.2 %) of 1219 who did not undergo BMD examination. Of the 126 patients who underwent BMD examination after fracture, 89 showed a BMD <80 % of the young adult mean as a criterion for the initiation of drug treatment for osteoporosis in Japan and 77 (86.5 %) of the 89 patients were treated with drugs.

CONCLUSIONS

The rate of patients with distal radial fractures who underwent BMD examination was low, suggesting that appropriate treatment for osteoporosis by trauma surgeons is not performed at present.

[Hip Fracture--Epidemiology, Management and Liaison Service. Multidisciplinary approach for the treatment of proximal femoral fractures]

Multidisciplinary approach for proximal femoral fracture was organized in the hospital. Inter and intra division obstacles were discussed. After general consensus of the team was obtained, manuals and guidelines of the each division were prepared. In addition to this, the electrical chart specific for the proximal femoral fracture was made which enables to eliminate in-hospital reference letters. As the results, all patients were examined by internal medicine doctors at the time of admission. Average interval from the time of admission to surgery became 1.3 days. Closer relationship with psychiatrist made early detection and treatment of delirium possible. After changing the system to check the antiosteoporosis medication at the time of discharge by the ward pharmacist dramatically increased the prescription rate form 39 percent to 95 percent.

3D statistical modeling techniques to investigate the anatomy of the sacrum, its bone mass distribution, and the trans-sacral corridors

The complex anatomy of the sacrum makes surgical fracture fixation challenging. We developed statistical models to investigate sacral anatomy with special regard to trans-sacral implant fixation. We used computed tomographies of 20 intact adult pelves to establish 3D statistical models: a surface model of the sacrum and the trans-sacral corridor S1, including principal component analysis (PCA), and an averaged gray value model of the sacrum given in Hounsfield Units. PCA demonstrated large variability in sacral anatomy markedly affecting the diameters of the trans-sacral corridors. The configuration of the sacral alae and the vertical position of the auricular surfaces were important determinants of the trans-sacral corridor dimension on level S1. The statistical model of trans-sacral corridor S1 including the adjacent parts of the iliac bones showed main variation in length; however, the diameter was the main criterion for the surgically available corridor. The averaged gray value model revealed a distinct pattern of bone mass distribution with lower density particularly in the sacral alae. These advanced 3D statistical models provide a thorough anatomical understanding demonstrating the impact of sacral anatomy on positioning trans-sacral implants.

Do design adaptations of a trochanteric nail make sense for Asian patients? Results of a multicenter study of the PFNA-II in Japan

PURPOSE

Asian patients with osteoporosis suffer from an increased incidence of hip fracture and a potentially increased risk of fixation failure due to anatomical differences compared to Caucasians. To cope with these differences, an Asian size- and geometry-adapted Proximal Femoral Nail Antirotation (PFNA-II) was developed. The objective of this prospective multicenter study was to assess the risk of fracture fixation complications (FFCs), the occurrence of mismatch and the quality of life status of patients treated with the PFNA-II.

PATIENTS AND METHODS

176 Japanese patients with an isolated, unstable, closed trochanteric fracture were treated with the PFNA-II. Patients were prospectively screened for anticipated complications and classified accordingly; complications were centrally reviewed by a complication review board to avoid bias by the treating surgeon, and categorized using a standardized reporting system. Outcome measurements included the occurrence and evaluation of FFCs, the radiological assessment of mismatch and quality of life measured with the EQ-5D score.

RESULTS

3 Intraoperative and 15 postoperative complications were found in 16/176 patients. The risk of sustaining any intraoperative or postoperative FFC was 1.7% (3/176; 95% CI: 0.35-4.9) and 8% (14/176; 95% CI: 4.4-13), respectively. The most likely cause for FFCs was the "bone/fracture" factor (9/14 patients). Radiologically detectable contact of the implant with the inner cortex ("mismatch") was reported for 17/173 patients (10%).

CONCLUSIONS

The reported complication risks and mismatches are reasonable for this patient cohort. The geometry- and size-adapted PFNA-II is relatively safe but requires standardized assessment in a larger target cohort.

Retroperitoneoscopic drainage of bilateral psoas abscesses under intraoperative laparoscopic ultrasound guidance

Despite improved diagnostic modalities for psoas abscesses, the optimum management strategy is not uniform. A 67-year-old man presented with bilateral psoas abscesses secondary to L1-L2 pyogenic discitis. On contrast-enhanced CT, the largest of these abscesses measured 13 × 14 × 33 mm on the right. The patient developed sepsis caused by Klebsiella pneumonia. There were no signs of improvement after 3 weeks of systematic antibiotic administration. We performed surgical drainage of bilateral psoas abscesses by retroperitoneoscopy. Intraoperative laparoscopic ultrasound was useful to determine abscess location in the muscles prior to drainage and confirm no residual abscesses after drainage. The patient was afebrile 3 days later, and his clinical symptoms resolved. Retroperitoneoscopic drainage may represent a feasible minimally invasive therapeutic option for psoas abscess, and intraoperative laparoscopic ultrasound has the potential to increase the safety and efficacy of this surgical procedure.

Justification criteria for vertebral fractures: year 2012 revision

Justification Criteria for Vertebral Fractures 2012 version was made based on new clinical findings. Major differences in this version compared to the 1996 version are inclusion of the semiquantitative method (SQ), statements to improve considerations during radiographic analysis, and the need for more detailed evaluation by MRI.

Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ): a patient-based evaluation tool for hip-joint disease. The Subcommittee on Hip Disease Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association

BACKGROUND

The Japanese Orthopaedic Association Hip Score is widely used in Japan, but this tool is designed to reflect the viewpoint of health-care providers rather than that of patients. In gauging the effect of medical therapies in addition to clinical results, it is necessary to assess quality of life (QOL) from the viewpoint of patients. However, there is no tool evaluating QOL for Japanese patients with hip-joint disease.

METHODS

With the aim of more accurately classifying QOL for Japanese patients with hip-joint disease, we prepared a questionnaire with 58 items for the survey derived from 464 opinions obtained from approximately 100 Japanese patients with hip-joint disease and previously devised evaluation criteria. In the survey, we collected information on 501 cases, and 402 were subjected to factor analysis. From this, we formulated three categories-movement, mental, and pain-each comprising 7 items, for a total of 21 items to be used as evaluation criteria for hip-joint function.

RESULTS

The Cronbach's α coefficients for the three categories were 0.93, 0.93, and 0.95, respectively, indicating the high reliability of the evaluation criteria. The 21 items included some related to the Asian lifestyle, such as use of a Japanese-style toilet and rising from the floor, which are not included in other evaluation tools.

CONCLUSIONS

This self-administered questionnaire may become a useful tool in the evaluation of not only Japanese patients, but also of members of other ethnic groups who engage in deep flexion of the hip joint during daily activities.

The risk of a second hip fracture in patients after their first hip fracture

We investigated the incidence of additional fractures and the rate of prescription of osteoporotic pharmacotherapy after an initial hip fracture. We surveyed female patients aged 65 and over who sustained their first hip fracture between January 1, 2006, and December 31, 2007, treated at 25 hospitals in five geographic areas in Japan. Data for 1 year after the first hip fracture were collected from medical records, and questionnaires were mailed to all patients. In total, 2,663 patients were enrolled, and 335 patients were excluded based on exclusion criteria. The analysis was performed on 2,328 patients. During the 1-year follow-up period 160 fractures occurred in 153 patients and 77 subsequent hip fractures occurred in 77 patients. The incidence of all additional fractures among patients who sustained their first hip fracture was 70 (per 1,000 person-year) and that for second hip fracture was 34. In comparison to the general population, women ≥65 years of age who sustained an initial hip fracture were four times as likely to sustain an additional hip fracture. Antiosteoporosis pharmacotherapy was prescribed for 436 patients (18.7%), while 1,240 patients (53.3%) did not receive any treatment during the 1-year period. Patients who have sustained one hip fracture have a higher risk of a second hip fracture compared to the general population, and most of these women receive no pharmaceutical treatment for osteoporosis.

Cross-cultural adaptation and validation of the Oxford 12-item knee score in Japanese

INTRODUCTION

With the high incidence of knee osteoarthritis (OA) in Japan, there is a strong need not only for surgical therapies, but also for validated outcome measures. For this study, we completed cross-cultural adaptation, testing and validation of the Oxford knee score (OKS) for prospective use in national and international clinical studies involving Japanese patients.

MATERIALS AND METHODS

The Japanese version of the OKS was developed according to the standard cross-cultural adaptation guidelines. For validation, the OKS was tested on 54 patients diagnosed with OA, osteonecrosis, ligament or meniscus injury. Reliability was tested using the intraclass correlation coefficient (ICC). Internal consistency or homogeneity was assessed using Cronbach's alpha. The correlation between the Japanese OKS, WOMAC and SF-36 questionnaires was used to assess construct validity.

RESULTS

No major difficulties were encountered with the translation and pre-testing stages. For reliability and validity, the Japanese OKS was completed without any missed responses by 53 (98.15%) and 52 (96.30%) patients at the first and second distribution, respectively. The total OKS showed good reliability with an ICC of 0.85. Internal consistency was strong (Cronbach's alpha = 0.90). Strong construct validity (ICC values of 0.51-0.84) was obtained against the WOMAC and SF-36 (physical functioning, role-physical, bodily pain, and social functioning subscales) scores. Notable "ceiling" effects of the OKS were reported for 11 of the 12 questionnaire items.

CONCLUSION

The Japanese OKS has proven to be a reliable and valid instrument for the self-assessment of knee pain and function in Japanese speaking patients with knee OA and other knee complaints.

Complication reporting in orthopaedic trials. A systematic review of randomized controlled trials

BACKGROUND

The nature and frequency of complications during or after orthopaedic interventions represent critical clinical information for safety evaluations, which are required for the development or improvement of orthopaedic care. The goal of this systematic review was to check whether essential data regarding the assessment of the prevalence, severity, and characteristics of complications related to orthopaedic interventions are consistently provided by the authors of papers on randomized controlled trials.

METHODS

Five major peer-reviewed orthopaedic journals were screened for randomized controlled trials published between January 2006 and July 2007. All relevant papers were obtained, anonymized, and evaluated by two external reviewers. A checklist consisting of three main parts (definition, evaluation, and reporting) was developed and applied for the assessment of complication reporting. The results were stratified into surgical and nonsurgical categories.

RESULTS

One hundred and twelve randomized controlled trials were identified. Although complications were included as trial outcomes in two-thirds of the studies, clear definitions of anticipated complications were provided in only eight trials. In 83% of the trials, the person or group assessing the complications was not identified. No trial involved a data safety review board for assessment and classification of complications.

CONCLUSIONS

The lack of homogeneity among the published studies that we reviewed indicates that improvement in the reporting of complications in orthopaedic clinical trials is necessary. A standardized protocol for assessing and reporting complications should be developed and endorsed by professional organizations and, most importantly, by clinical investigators.

Apnea, glial apoptosis and neuronal plasticity in the arousal pathway of victims of SIDS

Of 27,000 infants whose sleep-wake characteristics were studied under the age of 6 months, 38 died unexpectedly 2-12 weeks after the sleep recording in a pediatric sleep laboratory. Of these infants, 26 died of sudden infant death syndrome (SIDS), and 12 of definitely identified causes. The frequency and duration of sleep apneas were analysed. Sleep recordings and brainstem histopathology were studied to elucidate the possible relationship between sleep apnea and neuropathological changes within the arousal system. Immunohistochemical analyses were conducted using tryptophan hydroxylase (TrypH), a serotonin synthesizing enzyme, and growth-associated phosphoprotein 43 (GAP43), a marker of synaptic plasticity. The terminal-deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) method was used for apoptosis. The pathological and physiological data were correlated for each infant. In the SIDS victims, statistically significant positive correlations were seen between the number of TrypH-positive neurons in the dorsal raphe nucleus of the midbrain and the duration of central apneas (p = 0.03), between the number of TUNEL-positive glial cells in the pedunculopontine tegmental nucleus (PPTN) and the average number of spines in GAP43-positive neurons in the PPTN (p = 0.04). These findings in the dorsal raphe nucleus of the midbrain and PPTN, that play important roles in the arousal pathway suggest a possible link between changes in arousal and SIDS.

Sudden infant deaths: stress, arousal and SIDS

The prevalence of the Sudden Infant Death Syndrome (SIDS) has dropped in most countries following the development of education campaigns on the avoidance of preventable risk factors for SIDS. These include factors in the infant's micro environment, such as prenatal passive smoking, administration of sedative drugs, prone sleep, high ambient temperature or sleeping with the face covered. Sleep laboratory studies have shown that these risk conditions contribute to the development of respiratory and autonomic disorders and reduce the child's arousability. The opposite effects were seen when studying factors protective from SIDS, such as breastfeeding or the use of a pacifier. In victims of SIDS, similar breathing, autonomic and arousal characteristics were recorded days or weeks before their death. It is concluded that in some infants, already immature control mechanisms can be aggravated by environmental factors.

[Surgical treatment for fractures]

The aims of fracture treatment are the rapid recovery of the injured limbs without muscle and bone atrophy or joint contracture and the early return of the patients to their social life. The decision making for surgery is multifactorial. However, one should not choose conservative treatment for a case with absolute surgical indication and should not operate on a case with ideal indication for conservative treatment. In order to obtain good results, meticulous preoperative planning, careful surgery and appropriate postoperative management are mandatory.

Sudden infant deaths: from epidemiology to physiology

The incidence of sudden infant death syndrome (SIDS) has dropped significantly in most countries following the development of education campaigns on the avoidance of risk factors for SIDS. However, questions have been raised about the physiological mechanism responsible for the effects of these environmental risk factors. Since 1985, a series of prospective, multicentric studies have been developed to address these questions; over 20,000 infants were recorded during one night in a sleep laboratory and among these, 40 infants eventually died of SIDS. In this review, the following methods were employed: sleep recordings and analysis, monitoring procedure, data analysis of sleep stages, cardiorespiratory and oxygen saturation, scoring of arousals, spectral analysis of the heart rate and the determination of arousal thresholds, and statistical analysis and the results including sleep apneas, arousals and heart rate and autonomic controls in both future SIDS victims and normal infants were introduced separately. In addition, the physiological effect of prenatal risk factors (maternal smoking during gestation) and postnatal risk factors (administration of sedative drugs, prone sleeping position, ambient temperature, sleeping with the face covered by a bed sheet, pacifiers and breastfeeding) in normal infants were analyzed. In conclusion, the physiological studies undertaken on the basis of epidemiological findings provide some clues about the physiological mechanisms linked with SIDS. Although the description of the mechanisms responsible for SIDS is still far from complete, it appears to involve both arousal responses and cardiac autonomic controls during sleep-wake processes.