Comparison of Denosumab and Zoledronic Acid in Postmenopausal Women With Osteoporosis: Bone Mineral Density (BMD) and Trabecular Bone Score (TBS).

BACKGROUND: Denosumab (DEN) and zoledronic acid (ZOL) currently represent the most potent antiresorptive agents for the treatment of osteoporosis. Despite similar effects on bone resorption, these agents have distinct mechanisms of action. The objective of this study was to compare the effect of DEN and ZOL after two-year administration on bone mineral density (BMD), trabecular bone score (TBS), bone turnover markers, and persistence. METHODS: A total of 585 postmenopausal women with osteoporosis who did not use osteoporosis medications were retrospectively reviewed. 290 patients were administered 60 mg DEN subcutaneously every 6 months from 2017 to 2018, and 295 patients were treated with 5 mg ZOL intravenously yearly from 2015 to 2017. BMD, TBS, and C-terminal cross-linking telopeptide of type 1 collagen (CTX) measurements were obtained at baseline and two-year after DEN injection or ZOL infusion. RESULTS: After two-year follow-up, 188 patients in the DEN group and 183 patients in the ZOL group were compared. BMD change from baseline at two years was significantly greater in the DEN group compared with the ZOL group (P < 0.001). The changes of TBS in the DEN group were statistically significant compared with baseline (P < 0.001) and the ZOL group (P < 0.001). The DEN group led to significantly greater reduction of CTX compared with ZOL group (P = 0.041). CONCLUSION: In postmenopausal women with osteoporosis, DEN was associated with greater BMD increase at all measured skeletal sites, greater increase of TBS, and greater inhibition of bone remodeling compared with ZOL.

Difference between bone age at the hand and elbow at the onset of puberty.

ABSTRACT: In the pubertal period, bone age advances rapidly in conjunction with growth spurts. Precise bone-age assessments in this period are important, but results from the hand and elbow can be different. We aimed to compare the bone age between the hand and elbow around puberty onset and to elucidate the chronological age confirming puberty onset according to elbow-based bone age.A total of 211 peripubertal subjects (127 boys and 84 girls) who underwent hand and elbow radiographs within 2 months was enrolled. Two radiologists and a pediatric orthopedic surgeon assessed bone age. Hand bone age was graded using the Greulich-Pyle (GP) method, and elbow bone age was determined using the Sauvegrain method. The correlation of 2 methods was evaluated by Demining regression analysis, and the mean absolute difference (MAD) with chronological age was compared between pre-pubertal and pubertal subjects. Receiver-operating characteristic curve analysis was performed to determine the chronological age confirming puberty onset.There was a statistically significant difference in bone age revealed by the GP and Sauvegrain methods in the pubertal group. In the pubertal group, the MAD was 1.26 ±â€Š0.90 years with the GP method and 0.61 ±â€Š0.47 years with the Sauvegrain method in boys (P < .001), while in girls, the MAD was 0.84 ±â€Š0.60 years and 0.53 ±â€Š0.36 years with the same 2 methods (P = .033). The chronological age for confirming puberty onset using the elbow was 12.2 years in boys and 10.3 years in girls.The bone ages of hand and elbow were different at puberty, and the elbow was a more reliable location for bone-age assessment at puberty. Puberty onset according to elbow occurred slightly earlier than expected.

The limbus in developmental dysplasia of the hip: An obstacle to reduction and its images changed by the femoral head position.

ABSTRACT: This study aimed to describe the shape of the limbus arthroscopically and via arthrogram and magnetic resonance imaging (MRI), and to determine whether it prevents concentric reduction of the femoral head in developmental dysplasia of the hip (DDH).Twelve patients (mean age, 10.2 months; range, 3-31 months) who underwent arthroscopic-assisted reduction for DDH were retrospectively reviewed. Limbus shapes were captured on arthrogram before reduction, after closed reduction, and after arthroscopic-assisted reduction and categorized according to the Miyake classification.On arthrogram, the superior limbus was blocked in 2 hips, inverted in 2, intermediate in 5, and everted in 3 after attempted closed reduction. After arthroscopic-assisted reduction, the limbus was everted in 7 hips and normal in 5. On arthroscopy, in all cases, the limbus appeared as a whitish, cartilage-like ring with a variably blunted edge before reduction, without inversion or eversion. On postoperative MRI, 10 of 12 superior limbi showed hypertrophy or globular compression by the femoral head with intermediate or mixed MRI signal intensities and blunted edges. The remaining 2 hips had hypertrophied superior limbi with sharp edges. On transverse plane MRI, the posterior limbus of all hips showed sharp margins with low MRI signal intensity. Residual subluxation was observed in 7 of the 12 hips with interposition of the anteroinferior limbus.The appearance of the limbus varied according to the femoral head position, and it was neither inverted nor everted. Interposed anteroinferior limbi with residual subluxation suggest impeded concentric reduction in DDH.

Risk of reoperation and infection after percutaneous endoscopic lumbar discectomy and open lumbar discectomy : a nationwide population-based study.

AIMS: Open discectomy (OD) is the standard operation for lumbar disc herniation (LDH). Percutaneous endoscopic lumbar discectomy (PELD), however, has shown similar outcomes to OD and there is increasing interest in this procedure. However despite improved surgical techniques and instrumentation, reoperation and infection rates continue and are reported to be between 6% and 24% and 0.7% and 16%, respectively. The objective of this study was to compare the rate of reoperation and infection within six months of patients being treated for LDH either by OD or PELD. METHODS: In this retrospective, nationwide cohort study, the Korean National Health Insurance database from 1 January 2007 to 31 December 2018 was reviewed. Data were extracted for patients who underwent OD or PELD for LDH without a history of having undergone either procedure during the preceding year. Individual patients were followed for six months through their encrypted unique resident registration number. The primary endpoints were rates of reoperation and infection during the follow-up period. Other risk factors for reoperation and infection were also evalulated. RESULTS: Out of 549,531 patients, 522,640 had undergone OD (95.11%) and 26,891 patients had undergone PELD (4.89%). Reoperation rates within six months were 2.28% in the OD group, and 5.38% in the PELD group. Infection rates were 1.18% in OD group and 0.83% in PELD group. The risk of reoperation was lower for patients with OD than for patients with PELD (adjusted hazard ratio (HR) 0.38). The risk of infection was higher for patients with OD than for patients undergoing PELD (HR, 1.325). CONCLUSION: Compared with the OD group, the PELD group showed higher reoperation rates and lower infection rates. Cite this article: Bone Joint J 2021;103-B(8):1392-1399.

Assessment of rapidly advancing bone age during puberty on elbow radiographs using a deep neural network model.

OBJECTIVES: Bone age is considered an indicator for the diagnosis of precocious or delayed puberty and a predictor of adult height. We aimed to evaluate the performance of a deep neural network model in assessing rapidly advancing bone age during puberty using elbow radiographs. METHODS: In all, 4437 anteroposterior and lateral pairs of elbow radiographs were obtained from pubertal individuals from two institutions to implement and validate a deep neural network model. The reference standard bone age was established by five trained researchers using the Sauvegrain method, a scoring system based on the shapes of the lateral condyle, trochlea, olecranon apophysis, and proximal radial epiphysis. A test set (n = 141) was obtained from an external institution. The differences between the assessment of the model and that of reviewers were compared. RESULTS: The mean absolute difference (MAD) in bone age estimation between the model and reviewers was 0.15 years on internal validation. In the test set, the MAD between the model and the five experts ranged from 0.19 to 0.30 years. Compared with the reference standard, the MAD was 0.22 years. Interobserver agreement was excellent among reviewers (ICC: 0.99) and between the model and the reviewers (ICC: 0.98). In the subpart analysis, the olecranon apophysis exhibited the highest accuracy (74.5%), followed by the trochlea (73.7%), lateral condyle (73.7%), and radial epiphysis (63.1%). CONCLUSIONS: Assessment of rapidly advancing bone age during puberty on elbow radiographs using our deep neural network model was similar to that of experts. KEY POINTS: • Bone age during puberty is particularly important for patients with scoliosis or limb-length discrepancy to determine the phase of the disease, which influences the timing and method of surgery. • The commonly used hand radiographs-based methods have limitations in assessing bone age during puberty due to the less prominent morphological changes of the hand and wrist bones in this period. • A deep neural network model trained with elbow radiographs exhibited similar performance to human experts on estimating rapidly advancing bone age during puberty.

Association of Ankle Dorsiflexion With Plantar Fasciitis.

This study aimed to compare the mean ankle dorsiflexion range between individuals with and without plantar fasciitis using passive ankle dorsiflexion with consistent pressure, and to identify the prevalence of an isolated gastrocnemius and gastrocnemius soleus complex contracture in 2 groups. 91 participants were prospectively classified into the plantar fasciitis group (45 subjects) and the control group (46 subjects). Ankle dorsiflexion was measured with the knee extended and with the knee flexed 90° using a standard orthopedic goniometer while a consistent force of 2 kg was applied under the plantar surface of the forefoot using a custom-made scale. Intraclass correlation coefficients (ICC) were calculated to determine the interobserver and intraobserver reliability of the current ankle dorsiflexion measurement. The current ankle dorsiflexion measurement revealed excellent interobserver and intraobserver reliability. The mean ankle dorsiflexion in the knee extended was -9.6° ± 8.1° and -11.2° ± 8.2° in the study and control groups, respectively (p = .353). The mean ankle dorsiflexion in the knee flexed was 7.8° ± 6.5° and 5.1° ± 7.4° in the study and control groups, respectively (p = .068). In the study and control groups, 68.9% and 65.2%, respectively, had an isolated gastrocnemius contracture and 24.4% and 30.4%, respectively, had a gastrocnemius-soleus complex contracture (p = .768). The present study demonstrated that there were no significant differences in passive ankle dorsiflexion and in the prevalence of an isolated gastrocnemius or gastrocnemius soleus complex contracture between individuals with and without plantar fasciitis.

False-negative joint aspiration of septic arthritis of the hip in neonates.

In neonates, timely detection of septic arthritis of the hip can be challenging. Joint aspiration can be a useful diagnostic procedure, but scanty fluid in a septic joint has been reported, leading false-negative results. This study aimed to investigate clinical course of neonates with septic arthritis of the hip despite initial negative findings on joint aspiration. The neonates who surgically treated for septic arthritis of the hip between 2003 and 2013 for septic arthritis of the hip despite initial negative joint aspiration were retrospectively reviewed. Clinical presentations, MRI, intraoperative findings, functional and radiographic outcomes were evaluated. Six neonates were included with a mean follow-up of 12 years (range 5-15 years). All patients showed negative results on joint aspirations performed with ultrasound guidance or fluoroscopy. The mean duration between the onset of symptoms and initial surgery was 15.2 days (range 4-25 days). Four patients (67%) had extracapsular abscesses that were connected to perforated joint capsules on MRI. Intraoperatively, all patients were found to have hip joint instability with a ruptured capsule. Five (83%) patients experienced a complicated recovery. Four patients required reconstructive hip surgery, or further procedures to correct leg length discrepancy. Neonates with false-negative aspiration typically had a delay in appropriate surgical treatment. These cases suggest that the absence of aspirable fluid contents in the hip joint does not rule out septic arthritis in neonates. Our findings highlight the importance of considering spontaneous hip joint capsular perforation as the cause of extra-articular drainage of pus and instability.

Predicting postoperative complications in patients undergoing lumbar spinal fusion by using the modified five-item frailty index and nutritional status.

AIMS: As the population ages and the surgical complexity of lumbar spinal surgery increases, the preoperative stratification of risk becomes increasingly important. Understanding the risks is an important factor in decision-making and optimizing the preoperative condition of the patient. Our aim was to determine whether the modified five-item frailty index (mFI-5) and nutritional parameters could be used to predict postoperative complications in patients undergoing simple or complex lumbar spinal fusion. METHODS: We retrospectively reviewed 584 patients who had undergone lumbar spinal fusion for degenerative lumbar spinal disease. The 'simple' group (SG) consisted of patients who had undergone one- or two-level posterior lumbar fusion. The 'complex' group (CG) consisted of patients who had undergone fusion over three or more levels, or combined anterior and posterior surgery. On admission, the mFI-5 was calculated and nutritional parameters collected. RESULTS: Complications occurred in 9.3% (37/396) of patients in the SG, and 10.1% (19/167) of patients in the CG. In the SG, the important predictors of complications were age (odds ratio (OR) 1.036; p = 0.002); mFI-5 (OR 1.026 to 2.411, as score increased to 1 ≥ 2 respectively; p = 0.023); albumin (OR 11.348; p < 0.001); vitamin D (OR 2.185; p = 0.032); and total lymphocyte count (OR 1.433; p = 0.011) . In the CG, the predictors of complications were albumin (OR 9.532; p = 0.002) and vitamin D (OR 3.815; p = 0.022). CONCLUSION: The mFI-5 and nutritional status were effective predictors of postoperative complications in the SG, but only nutritional status was successful in predicting postoperative complications in the CG. The complexity of the surgery, as well as the preoperative frailty and nutritional status of patients, should be considered when determining if it is safe to proceed with lumbar spinal fusion. Cite this article: Bone Joint J 2020;102-B(12):1717-1722.

Antibacterial infection and immune-evasive coating for orthopedic implants.

Bacterial infection and infection-induced immune response have been a life-threatening risk for patients having orthopedic implant surgeries. Conventional biomaterials are vulnerable to biocontamination, which causes bacterial invasion in wounded areas, leading to postoperative infection. Therefore, development of anti-infection and immune-evasive coating for orthopedic implants is urgently needed. Here, we developed an advanced surface modification technique for orthopedic implants termed lubricated orthopedic implant surface (LOIS), which was inspired by slippery surface of Nepenthes pitcher plant. LOIS presents a long-lasting, extreme liquid repellency against diverse liquids and biosubstances including cells, proteins, calcium, and bacteria. In addition, we confirmed mechanical durability against scratches and fixation force by simulating inevitable damages during surgical procedure ex vivo. The antibiofouling and anti-infection capability of LOIS were thoroughly investigated using an osteomyelitis femoral fracture model of rabbits. We envision that the LOIS with antibiofouling properties and mechanical durability is a step forward in infection-free orthopedic surgeries.

Assessing changes in cervical epidural pressure during biportal endoscopic lumbar discectomy.

OBJECTIVE: Biportal endoscopic spinal surgery has been performed for several years, and its effectiveness is well known; however, no studies on its safety, specifically intracranial pressure, have been conducted to date. The authors sought to evaluate the effect of biportal endoscopic lumbar discectomy on intracranial pressure by monitoring cervical epidural pressure (CEP) changes throughout the procedure. METHODS: Twenty patients undergoing single-level biportal endoscopic lumbar discectomy were enrolled in this study. CEPs were monitored throughout the procedure, consisting of phase 1, establishing the surgical portal and working space; phase 2, performing decompression and discectomy; and phase 3, turning off the fluid irrigation system. After discectomy was completed, the authors evaluated changes in CEP as the irrigation pressure increased serially by adding phase 4, increasing irrigation pressure with outflow open; and phase 5, increasing irrigation pressure with outflow closed. RESULTS: The mean baseline CEP was measured as 16.65 mm Hg. In phase 1, the mean CEP was 17.3 mm Hg, which was not significantly different from the baseline CEP. In phase 2, the mean CEP abruptly increased up to 35.1 mm Hg when the epidural space was first connected with the working space, followed by stabilization of the CEP at 31.65 mm Hg. In phase 4, the CEP increased as the inflow pressure increased, showing a linear correlation, but not in phase 5. No patients experienced neurological complications. CONCLUSIONS: It is important to ensure that irrigation fluid is not stagnant and is maintained continuously. More attention must be paid to keeping pressures low when opening the epidural space.

Incidence & Risk Factors of Postoperative Delirium After Spinal Surgery in Older Patients.

Although postoperative delirium is a common complication in older patients, few papers have described risk factors after of spinal surgery. The purpose of this study was to analyze various perioperative risk factors for delirium after spinal surgery in older patients. This study was performed on retrospective data collection with prospective design. We analyzed 138 patients over 65 years of age who underwent spinal surgery. Preoperative factors were cognitive function (Mini-Mental State Examination-Korean (MMSE-K) and the Korean version of the Delirium Rating Scale-Revised-98 (K-DRS 98)), age, sex, type of admission, American Society of Anesthesiologist classification, metabolic equivalents, laboratory findings, visual analog scale, and Oswestry Disability Index. Intraoperative factors were operation time, blood loss, and type of procedure. Postoperative factors were blood transfusion and type of postoperative pain control. Postoperative delirium developed in 25 patients (18.16%). Patients were divided into two groups: Group with delirium (group A) and group without delirium (group B). MMSE-K scores in Group A were significantly lower than in Group B (p < 0.001). K-DRS 98 scores were significantly higher in Group A than Group B (p < 0.001). The operation time was longer in Group A than Group B (p = 0.059). On multivariate regression analysis, the odds ratio of K-DRS 98 was 2.43 (p = 0.010). After correction for the interaction between age and MMSE-K, patients younger than 73 years old had a significantly lower incidence of delirium with higher MMSE-K score (p = 0.0014). Older age, low level of preoperative cognitive function, long duration of surgery, and transfusion were important risk factors of postoperative delirium after spinal surgery. It is important to recognize perioperative risk factors and manage appropriately.

Biportal endoscopic discectomy for high-grade migrated lumbar disc herniation.

OBJECTIVE: Although endoscopic procedures for lumbar disc herniation have improved greatly and offer many advantages, the indications are limited mostly to nonmigrated or low-grade migrated disc herniation. Endoscopic application in migrated disc herniation cases is still challenging and technically demanding. The goal in this study was to determine the feasibility of biportal endoscopic discectomy for removal of high-grade migrated disc herniation. METHODS: A retrospective review was performed in 262 patients who had undergone biportal endoscopic discectomy after the diagnosis of lumbar herniated disc. According to preoperative MRI findings, disc herniation was classified into 5 zones based on the direction and distance from the disc space. Patients were divided into 2 groups-a high-grade migration group and a low-grade migration group. Clinical outcomes were evaluated using the Oswestry Disability Index (ODI), visual analog scale (VAS), and modified Macnab criteria, and those outcomes and operation time were compared between the 2 groups. RESULTS: There were 10 patients with "high-grade up," 8 with "low-grade up," 98 with disc-level, 102 with "low-grade down," and 44 with "high-grade down" herniation, thereby yielding 54 patients in the high-grade group and 208 in the low-grade group. Demographic data for the 2 groups showed no significant difference. There was no significant difference between the 2 groups in ODI, VAS, and modified Macnab criteria. Operation time between the 2 groups was not significantly different (60.74 vs 65.63 minutes, p > 0.05). CONCLUSIONS: Biportal endoscopic discectomy can be effective for high-grade migrated lumbar disc herniation with no prolonged operation time and satisfactory clinical outcomes.

Modified Broström procedure in patients with chronic ankle instability is superior to conservative treatment in terms of muscle endurance and postural stability.

PURPOSE: To compare muscle strength, muscle endurance, and postural stability in both the affected and unaffected ankles between patients with chronic ankle instability (CAI) who underwent conservative treatment and those who underwent the modified Broström procedure (MBP). METHODS: A total of 67 patients (37, conservative treatment; 30, MBP) participated. Muscle strength and muscle endurance were measured using an isokinetic device, and postural stability was tested using a postural stabilometry system. We used the independent t test for continuous variables with a normal distribution and Fisher's exact test for categorical variables. RESULTS: There was no difference in the muscle strengths of the affected and unaffected ankles between the groups. The muscle endurance of plantarflexion and inversion muscles was significantly lower in the affected ankles of the conservative treatment group than in those of the MBP group (plantarflexion: 209 ± 103.1 vs. 318 ± 162.2, p = 0.001; inversion: 93 ± 58.7 vs. 154 ± 65.9, p < 0.001). Static postural stability testing showed no significant differences between the affected and unaffected ankles of the two groups. In the dynamic postural stability test, the overall, anterior-posterior, and medial-lateral stability indices were all significantly higher in the affected ankles of the conservative treatment group than in those of the MBP group (p < 0.001, p = 0.004, p = 0.004, respectively), with no differences observed in the unaffected ankles. CONCLUSION: The MBP may significantly improve muscle endurance and dynamic postural stability in CAI patients in whom conservative treatment has failed. Therefore, clinicians should consider using MBP instead of conservative treatment when patients show severe muscle weakness or dynamic postural instability. LEVEL OF EVIDENCE: Case-control study, Level III.

Individuals with recurrent ankle sprain demonstrate postural instability and neuromuscular control deficits in unaffected side.

PURPOSE: To compare proprioception, postural stability, and neuromuscular control between patients with mechanical laxity and recurrent ankle sprain. METHODS: Among 86 patients with ankle instability, 45 patients had mechanical laxity (mean age 27.2 ± 7.0 years) and 41 had recurrent ankle sprain (mean age 25.1 ± 9.2 years). Both the affected and unaffected ankles of each patient were evaluated. Proprioception and neuromuscular control tests were conducted using an isokinetic machine, and postural stability was tested using a postural stabilometry system. RESULTS: Proprioception was not significantly different between the unaffected or affected ankles of the mechanical laxity group compared with those of the recurrent ankle sprain group (n.s). Static and dynamic postural stability and neuromuscular control were similar in the affected ankles between the two groups (n.s). However, postural stability (static, overall: p = 0.009, anterior-posterior: p = 0.028, medial-lateral: p = 0.022; dynamic, overall: p = 0.012, anterior-posterior: p = 0.004, medial-lateral: p = 0.001) and neuromuscular control (inversion: p = 0.031, eversion: p = 0.039, dorsiflexion: p = 0.029, plantarflexion: p = 0.035) were significantly decreased in the unaffected ankles of the recurrent ankle sprain group compared with those of the mechanical laxity group. CONCLUSION: The unaffected ankles of the recurrent ankle sprain group showed significant decreases in both postural stability and neuromuscular control compared with the mechanical laxity group. Clinicians and therapists should consider unaffected ankle rehabilitation in patients with recurrent ankle sprain to prevent future sprain events. LEVEL OF EVIDENCE: Case-control study, III.

Chronic Ulnohumeral Subluxation After Surgical Treatment of Lateral Condylar Fracture Dislocation of the Elbow in a Child: A Case Report.

CASE: A 10-year-old boy presented with chronic ulnohumeral subluxation 6 months after an open reduction of a Milch type II lateral condyle fracture subluxation performed at another hospital. The patient had persistent elbow pain and limited range of motion (ROM) between 20° and 50°. After the open reduction for chronic ulnohumeral subluxation and corrective osteotomy for articular surface reconstruction, he had an uneventful recovery with improved ROM of the affected elbow and no pain. CONCLUSIONS: Intra-articular corrective osteotomy for articular surface reconstruction may be feasible to improve mobility and relieve pain in pediatric patients with lateral condylar malunion and elbow subluxation.

Spinal epidural abscess successfully treated with biportal endoscopic spinal surgery.

Surgical decompression and antibiotic therapy are the treatments of choice for patients with spinal epidural abscess (SEA). Surgical treatment included decompression, evacuation of abscess, and debridement. Recently, minimal invasive surgery has been introduced more widely, and biportal endoscopic spinal surgery have shown satisfactory clinical outcomes compared with traditional open surgery. The purpose of this study was to evaluate the efficacy of biportal endoscopic spinal surgery for the treatment of SEA .From January 2016 to June 2017, 13 patients who underwent biportal endoscopic spinal surgery under the diagnosis of SEA were retrospectively enrolled in this study. The surgical indications of the enrolled patients included SEA with or without early stage spondylodiscitis who had neurological symptoms. Periopertaive data and clinical outcomes were assessed by regular serologic testing, imaging studies, physical examination, visual analog scale, Oswestry Disability Index and modified Macnab criteria.Offending pathogens were identified in seven (54%) of 13 biopsy specimens. Appropriate intravenous antibiotics for the identified pathogens isolated from infected tissue biopsy cultures were administrated to patients for at least 30 days. All patients reported satisfactory relief of pain and neurological symptoms after surgery. No surgery-related complications and recurrences were found after 2 years follow up.Biportal endoscopic spinal surgery may be an effective alternative to traditional open surgical decompression for the treatment of SEA.

Bone union after spinal fusion surgery using local bone in long-term bisphosphonate users: a prospective comparative study.

Bisphosphonates are the most commonly used drugs for osteoporosis and long-term use of bisphosphonates may affect fusion rate after spinal fusion surgery. There was significant delayed union after 6 months in long-term bisphosphonates users; however, there were no significant difference in fusion rate of long-term bisphosphonate users. Therefore, spinal fusion surgery should not be hesitated in long-term bisphosphonates users. PURPOSE: Bisphosphonates (BPs) are the most popular class of drugs for treatment of postmenopausal osteoporosis. Long-term use of BPs may also inhibit the spinal fusion process after posterior lumbar interbody fusion (PLIF). We compared bone fusion rates of long-term BPs users and non-users after undergoing spinal fusion surgery. METHODS: A total of 97 postmenopausal women who were candidates for single-level PLIF were recruited from 2015 to 2016. Participants were divided into two groups, with 63 patients in a long-term BPs user group and 34 patients in a non-user group. Serum C-terminal cross-linking telopeptide (CTX) levels were checked for bone resorption markers. Bone fusion rates were calculated at 6 months and 1 and 2 years after the surgery. Clinical outcomes were measured using the Oswestry Disability Index (ODI) and visual analog scale (VAS). RESULTS: Serum CTX level was dramatically decreased in the long-term BPs user group (p < 0.05). Fusion rates at 6 months after surgery were 42% in the non-user group and 26% in the long-term BPs user group (p = 0.035). However, fusion rates were 82% in the long-term BPs user group and 87% in the non-user group at 2 years after surgery (p > 0.05). There was no significant difference between the two groups in ODI or VAS. CONCLUSIONS: Even though there was significant delayed union after 6 months in long-term BPs users, at the 2-year postoperative follow-up, there was no significant difference in bone fusion rate between the two groups. Long-term BPs users showed fusion rates greater than 80% and clinical outcome improvements that were comparable to those in non-users. No significant effect on fusion rate after PLIF was found in long-term BPs users.

Patient Blood Management During Lumbar Spinal Fusion Surgery.

OBJECTIVE: Patient blood management (PBM) is defined as treatment of a patient who is at risk of transfusion to minimize the need for transfusion and improve the probability of an optimal clinical outcome. We performed the present study to examine the effects of PBM in spinal fusion surgery. METHODS: A total of 154 patients who had undergone 1- and 2-level posterior lumbar interbody fusion for degenerative lumbar disease were included. We retrospectively reviewed the data from 101 patients from 2012 to 2016 as the pre-PBM group. We recruited 53 patients from 2017 to 2018 for the post-PBM group. Intravenous iron was administered 2-4 weeks before surgery, and intravenous tranexamic acid was administered intraoperatively in the post-PBM group. The primary outcome was the reduction of hemoglobin (Hb). The secondary outcomes included perioperative blood loss, Hemovac drain output, postoperative transfusion, complications, and length of hospital stay. RESULTS: Intravenous iron was administered 17.4 days before surgery in the post-PBM group. The reduction in Hb was not significantly different statistically between the 2 groups (3.06 vs. 3.33 g/dL; P > 0.05). Of the 101 patients in the pre-PBM group, 24 (24%) underwent transfusion. In contrast, no patient in the post-PBM group had required a transfusion (P < 0.001). The average hospital stay was 10.15 days in the pre-PBM group and 8.33 days in the post-PBM group (P = 0.02). The average operative time was 146 minutes in the pre-PBM group and 133 minutes in the post-PBM group (P = 0.03). The Hb decrease and total Hemovac drain output did not differ significantly between the 2 groups. CONCLUSIONS: Implementation of PBM is an effective strategy for reducing the rate of transfusion in patients undergoing lumbar spinal fusion surgery without significant complications.

Is biportal technique/endoscopic spinal surgery satisfactory for lumbar spinal stenosis patients?: A prospective randomized comparative study.

BACKGROUND: Lumbar decompressive surgery is a standard surgical technique for lumbar spinal stenosis. Many new surgical techniques have been introduced, ranging from open surgery to minimally invasive procedures. Minimally invasive surgical techniques are preferred because patients experience less postoperative pain and shorter hospital stays. However, the success rate of minimally invasive techniques have been controversial. The object of this study was to assess the feasibility of spinal decompression using biportal technique/endoscopic surgery compared with microscopic surgery. METHODS: Seventy lumbar spinal stenosis patients undergoing laminectomy were included in this study. A number table was used to randomize the patients into two groups: a biportal technique/endoscopic surgery group (BG-36) and a microscopic surgery group (OG-34). One surgeon performed either biportal technique/endoscopic decompression or microscopic decompression using a tubular retractor, depending on the group to which the patient was randomized. Perioperative data and clinical outcomes at postoperative 6 months were collected and analyzed. RESULTS: The demographic data and level of surgery were comparable between the two groups. A shorter operation time (36 ±â€Š11 vs 54 ±â€Š9 min), less hemovac drain output (25.5 ±â€Š15.8 vs 53.2 ±â€Š32.1 ml), less opioid usage (2.3 ±â€Š0.6 vs 6.5 ±â€Š2.5 T) and shorter hospital stay (1.2 ±â€Š0.3 vs 3.5 ±â€Š0.8 days) were shown in BG. The BG experienced no significant differences in clinical outcomes compared with OG. Favorable clinical outcomes were shown at 6 months after surgery in both groups. CONCLUSION: Lumbar decompressive surgery using biportal technique/endoscopy showed favorable clinical outcomes, less pain and a shorter hospital stay compared to microscopic surgery in patients with lumbar spinal stenosis.