Factors Affecting Incomplete L5/S Posterior Lumbar Interbody Fusion, Including Spinopelvic Sagittal Parameters.

STUDY DESIGN: Retrospective observational study. PURPOSE: In this study we identify risk factors, including patient demographics, sagittal parameters, and clinical examinations, affecting incomplete L5/S posterior lumbar interbody fusion (PLIF). OVERVIEW OF LITERATURE: The lumbosacral spine is considered to have an interbody fusion rate lower than that of the lumbar spine, but few studies have investigated the cause, including investigating the pelvis. We believe that pelvic morphology can affect L5/S interbody fusion of the lumbosacral spine. METHODS: We observed 141 patients (61 men, 80 women; average age, 65.8 years) who had undergone PLIF and checked for the presence of L5/S interbody fusion. We investigated factors such as age, gender, the presence of diffuse idiopathic skeletal hyperostosis (DISH), fusion level, and grade 2 osteotomy, as well as pre-, post-, and post-preoperative L5/S disk height and angle, lumbar lordosis, Visual Analog Scale (VAS) score, Japanese Orthopaedic Association (JOA) score, and pelvic incidence (PI), comparing those with and without L5/S interbody fusion. In addition, we analyzed the patients classified into short-level (n=111) and multi-level fusion groups (n=30). RESULTS: Overall, the L5/S interbody fusion rate was 70% (short-level, 78%; multi-level, 40%). Age and pre- and post-preoperative L5/S disk angle were significantly different in each fusion level group. DISH presence, grade 2 osteotomy, and postoperative VAS and JOA scores were significantly different in the short-level fusion group, whereas PI was significantly different in the multi-level fusion group. CONCLUSIONS: Incomplete union after L5/S PLIF correlates with advanced age, many fusion levels, and a large value of preoperative and a small value of post-preoperative L5/S disk angles.

Risk Factors Affecting Cage Retropulsion into the Spinal Canal Following Posterior Lumbar Interbody Fusion: Association with Diffuse Idiopathic Skeletal Hyperostosis.

STUDY DESIGN: This was a retrospective observational study. PURPOSE: We identify risk factors, including physical and surgical factors, and comorbidities affecting cage retropulsion following posterior lumbar interbody fusion (PLIF). OVERVIEW OF LITERATURE: Diffuse idiopathic skeletal hyperostosis (DISH) is considered a risk factor for reoperation after PLIF. We evaluated the effect of DISH on cage retropulsion into the spinal canal, which may require surgical revision for severe neurological disorders. METHODS: A total of 400 patients (175 men, 225 women) who underwent PLIF were observed for >1 year. Factors investigated included the frequency of cage retropulsion and surgical revision. In addition, physical (age, sex, disease), surgical (fusion and PLIF levels, cage number, grade 2 osteotomy), and comorbid (DISH, existing vertebral fracture) factors were compared between patients with and without cage retropulsion. Factors related to surgical revision during the observation period were also considered. RESULTS: Cage retropulsion occurred in 15 patients and surgical revision was performed in 11. Revisions included the replacement of pedicle screws (PSs) with larger screws in all patients and supplementary implants in 10. Among the patients with cage retropulsion, the average PLIF level was 2.7, with DISH present in nine patients and existing vertebral fractures in six. Factors affecting cage retropulsion were diagnoses of osteoporotic vertebral fracture, multilevel fusion, single-cage insertion, grade 2 osteotomy, presence of DISH, and existing vertebral fracture. Multivariable analysis indicated that retropulsion of a fusion cage occurred significantly more frequently in patients with DISH and multilevel PLIF. CONCLUSIONS: DISH and multilevel PLIF were significant risk factors affecting cage retropulsion. Revision surgery for cage retropulsion revealed PS loosening, suggesting that implant replacement was necessary to prevent repeat cage retropulsion after revision.

Early functional recovery after two-stage surgery with an allogenic bone graft for baseplate loosening in reverse shoulder arthroplasty: a case report.

OBJECTIVES: Reverse shoulder arthroplasty (RSA) for cuff tear arthropathy results in good shoulder function. However, RSA is associated with several complications, including infection, dislocation of the shoulder joint, implant loosening, and axillary nerve palsy. Several problems may also occur on the glenoid side, including bone defects of the glenoid, baseplate loosening, and displacement of the sphere. Herein, we report a 79-year-old man who obtained early functional recovery following a two-stage operation with an allogenic bone graft to treat baseplate loosening and a glenoid bone defect after RSA. CASE REPORT: The patient presented with pain during motion and limited active shoulder joint movement 5 weeks after undergoing RSA for cuff tear arthropathy. CT revealed baseplate loosening and a glenoid bone defect; these complications were treated via a two-stage operation. The first stage comprised the removal of all implants and the grafting of allogenic bone from the femoral head into the glenoid defect. Six months later, CT confirmed complete union of the grafted bone and glenoid. The second stage comprised the re-insertion of all implants. Two months after the last operation, the active shoulder range of motion of the affected side was almost identical to that of the contralateral side. CONCLUSION: Good early functional recovery was obtained using a two-stage operation for baseplate loosening after RSA. Allogenic bone grafting was effective in the reconstruction of the glenoid defect.

Activities of Daily Living after Surgical Treatment for Osteoporotic Vertebral Fracture with or without Diffuse Idiopathic Skeletal Hyperostosis: A Retrospective Single-Institutional Study.

STUDY DESIGN: This investigation was a retrospective observational study. PURPOSE: The aim of this study was to evaluate whether having diffuse idiopathic skeletal hyperostosis (DISH) as a comorbidity affects the patient's ability to perform activities of daily living (ADL) after surgical treatment for osteoporotic vertebral fracture (OVF). OVERVIEW OF LITERATURE: A few studies have extensively evaluated elderly patients with comorbidities such as DISH and OVFinduced persistent back pain and their ability to perform ADL postoperatively. METHODS: In this study, 63 patients (21 men and 42 women) who underwent surgical treatment for OVF were enrolled. Of these patients, 26 had DISH (D+) and 37 did not have DISH (D-). Patient demographic characteristics and surgical, clinical, and radiological findings were compared between those with and without DISH. The change in their ability to perform ADL after surgery was also evaluated. RESULTS: Age, number of comorbidities, and 1-year mortality rate were significantly higher in the D+ group (p<0.05). Postoperative Visual Analog Scale (VAS) scores were significantly higher in patients with impaired (n=6, p=0.04) abilities to perform ADL, and improvements in VAS scores were significantly higher in patients with unchanged abilities to perform ADL (n=54, p=0.03) after surgery. The average postoperative VAS scores were 2.2 for the D+ group and 2.3 for the D- group, which were not significantly different. CONCLUSIONS: The frequency of OVF with DISH was higher in elderly men with multiple comorbidities and contributed to a higher 1-year mortality rate than those in patients without DISH. However, preoperative and postoperative VAS scores and improvements in VAS scores were similar between those with and without DISH. Postoperative impaired ability to perform ADL was associated with old age, high postoperative VAS scores, and little improvements in VAS scores, which were limitedly influenced by DISH. Surgical treatment of OVF combined with DISH is effective and appropriate for elderly patients.

Surgical Treatment of Osteoporotic Vertebral Fracture Associated with Diffuse Idiopathic Skeletal Hyperostosis along with Comparative Assessment of the Levels of Affected Vertebra or Anterior Column Reconstruction.

INTRODUCTION: Surgical treatment of osteoporotic vertebral fracture (OVF) often involves older patients with various comorbidities; thus, attending physicians must pay special attention to the invasiveness of surgical procedures and possible perioperative complications. In this retrospective observational study, we investigated the relationship between OVF and diffuse idiopathic skeletal hyperostosis (DISH) by examining the clinical characteristics and surgical outcomes. METHODS: Subjects comprised 26 patients (14 men, 12 women) who underwent surgical treatment for OVF complicated by DISH. Vertebral injuries affected the thoracolumbar transitional vertebrae in 18 patients and the middle and lower lumbar vertebrae in eight patients. The clinical characteristics, surgical results, radiological assessments, and outcomes were evaluated on the basis of the levels of affected vertebrae and whether anterior column reconstruction (ACR) was performed. RESULTS: Visual Analog Scale (VAS) measurements improved from an average of 69.7 mm before surgery to 21.3 mm after surgery. 14 patients had neurological deficits, who exhibited improvements by one or more steps on the Frankel scale after surgery. Activities of daily living (ADLs) were maintained during the six-month period following surgery in 23 patients. Comorbidity was observed in 22 patients. 14 patients had perioperative complications, and six required additional surgery. Both operating time and blood loss volume were significantly higher in patients in the middle and lower lumbar vertebrae and ACR groups. Postoperative correction loss was also significantly lower in the ACR group. CONCLUSIONS: Favorable degrees of improvement in neurological deficits and VAS were observed following surgery in patients with OVF complicated by DISH, and postoperative ADLs were maintained in 92% of the patients. Elderly men frequently presented with comorbidities, and the frequencies of patients with perioperative complications and those requiring additional surgery were high.

Correlation between ultrasonographic findings and symptoms of knee osteoarthritis.

OBJECTIVES: Knee osteoarthritis (OA) is mainly diagnosed by clinical and radiographic findings. The aim of this study was to evaluate the correlation between ultrasonography (US) findings during flexion and knee loading and symptoms of knee OA. METHODS: We studied 33 knees with OA in 21 patients. Using US, the medial meniscal protrusion was measured at the midpoint of the medial joint space with the patient standing and the knee in maximum extension and flexion. With the knee in extension, the thickness of the synovial membrane at the suprapatellar area and the size of the osteophytes at the medial joint space were measured. Radiography was performed to determine the Kellgren-Lawrence (K-L) scores. The correlations between US findings and the visual analog scale (VAS) score, Japanese Knee Osteoarthritis Measure (JKOM) score, K-L score, and range of motion (ROM) were analyzed. RESULTS: Medial meniscal protrusion was significantly correlated with K-L score and ROM limitation. Synovial membrane thickness was also significantly correlated with the total JKOM and usual activity scores. There was no correlation between the VAS scores and US findings. Multigroup comparisons of the patients' positions during US did not reveal significant intergroup differences. CONCLUSIONS: US was able to detect a change in medial meniscal protrusion during knee flexion and loading. Although medial meniscal protrusion was not correlated with pain, it was related to structural changes of the knee, similar to radiographic findings. Synovial membrane thickness detected by US correlated with pain and a disturbance in the usual activity of patients with OA.

Mechanical simulation study of postoperative displacement of trochanteric fractures using the finite element method.

BACKGROUND: Femoral trochanteric fractures are common among older adults. In the reduction of trochanteric fractures, acquiring the support of the anterior cortex at the fracture site on lateral view immediately after surgery is important. However, even if the cortical support is acquired, postoperative displacement due to the loss of this support often occurs. This study aimed to investigate local stress distribution in several trochanteric fracture models and to evaluate risk factors for postoperative displacement using the finite element (FE) method. METHODS: Displaced two-fragment fracture models with an angulation deformity at the fracture site and a non-displaced two-fragment fracture model were constructed. The models with an angulation deformity were of two types, one with the proximal fragment directed backward (type A) and the other with the proximal fragment rotated forward from the femoral neck axis (type B). Thereafter, FE models of the femur and a sliding hip screw mounted on a 135° three-hole side-plate were constructed. A 2010-N load was applied to the femoral head, and a 1086-N load was applied to the greater trochanter. Under this condition, the maximum value of the von Mises stress distribution and the amount of displacement of the femoral head vertex in the distal direction were investigated. RESULTS: A larger maximum stress value at the medial femoral neck cortex and a higher amount of displacement in the distal direction were particularly recognized in type A models. These results indicate that microstructural damage was larger in type A models and that type A fracture alignment may be particularly related to fracture collapse and subsequent postoperative displacement. CONCLUSION: Even if support of the anterior cortex at the fracture site on lateral view is acquired immediately after surgery, caution is necessary for cases in which the proximal fragment is directed backward in the postoperative displacement from the viewpoint of the biomechanics of the FE method.

Cine MRI of the Triangular Fibrocartilage Complex during Radial-Ulnar Deviation.

Purpose Changes in the shape of the triangular fibrocartilage complex (TFCC) during radial-ulnar deviation were studied using "cine-mode" magnetic resonance imaging (MRI) in 10 right wrists of healthy volunteers, 5 wrists of TFCC tear, and 5 wrists of ulnar styloid nonunion. Subjects and Methods The wrist was fixed in a custom acrylic device, which only allows radial and ulnar deviation. Coronal MR images of nine radial-ulnar deviated positions (every 5 degree from 15 degrees radial deviation to 25 degrees ulnar deviation) were obtained in volunteers and patients. Cine-mode MRI was assembled and was output to MPEG video to observe. Results Cine MRI demonstrated the ulnar side of the TFCC was elongated by average 15 mm in 15 degrees of radial deviation and shortened by average 8 mm in 25 degrees of ulnar deviation in all normal TFCC subjects. Distal portion of the triangular fibrocartilage (TFC) was compressed during radial-ulnar deviation in 10 healthy volunteers and in 3 patients, but proximal portion of the TFC was stable throughout the motion. In contrast, the wavy deformities on the disc in ulnar deviation were observed in three patients with horizontal tear inside the TFCC. In nonunion of the ulnar styloid process, the fragment was snapped in maximum ulnar deviated position or elongation of the space between the styloid fragment and ulna was seen. Conclusion This study indicated normal and abnormal changes in the shape of the TFCC during radial-ulnar deviation motion on cine MRI. The abnormal dynamic changes of the TFCC may be seen in ulnar deviated position in patients, which are related to positive ulnocarpal stress test with the wrist forced ulnar deviated.

Analysis of the Postoperative Displacement of Trochanteric Fractures on Lateral View Radiographs.

Achieving sufficient support of the anterior cortex of the femoral neck is a fundamental goal of the reduction of trochanteric fractures. However, anterior-cortex support is often lost after the fracture reduction. Our aim was to analyze factors contributing to the postoperative displacement of an acceptably reduced trochanteric fracture. The cases of 40 patients with a post-reduction Ikuta subtype N fracture alignment were reviewed. All fractures were fixed with 135° free-sliding plates. On postoperative day 14, patients were classified into two groups: those with retention of the Ikuta subtype N alignment, and those with progression to Ikuta subtype P alignment. The clinical and radiological factors were evaluated between the groups. In addition, to define one of the factors, i.e., the postoperative rotational displacement between the proximal and distal fragments, the relationship between radiographic findings and computed tomography image measurements was assessed in 15 of the 40 patients. Angulation at the fracture site on lateral view radiographs was defined as postoperative rotational displacement, and unstable trochanteric fractures and postoperative rotational displacement were identified as significant risk factors for the postoperative displacement. Therefore, cautious and careful follow-up is warranted for patients with unstable trochanteric fractures or fractures having rotational displacement.

Entrapment of the Flexor Hallucis Longus Tendon by Direct Impalement in the Osseofibrous Tunnel Under the Sustentaculum Tali: An Extremely Rare Complication of a Calcaneal Fracture: A Case Report.

CASE: This article presents a case of entrapment of the flexor hallucis longus tendon in the osseofibrous tunnel under the sustentaculum tali due to a bone fragment from a calcaneal fracture. Despite good visualization with computed tomography, we did not recognize this complication preoperatively. Limited motion of the hallux was the key to recognition of this rare pathogenic situation. CONCLUSION: We emphasize the importance of careful physical examination of the forefoot when there is a hindfoot injury.

Intraarticular injection of high molecular weight hyaluronan for osteoarthritis of the knee - prediction of effectiveness with biological markers.

OBJECTIVE: The possibility of predicting the effectiveness of intraarticular injection of high molecular weight hyaluronan (HA) was investigated using biological markers. METHODS: In 32 patients with osteoarthritis (OA) of the knee, 38 knees were treated with HA injection, and the clinical symptoms were evaluated using the Japanese Orthopaedic Association (JOA) score and pain visual analog scale (VAS). The concentrations of chondroitin 6-sulfate, 4-sulfate (C6S, C4S), and aggrecan were measured in synovial fluid collected at the time of initiation of injection. The relationship between the biological markers and the improvement of clinical symptoms after injection for 1 month was investigated. RESULTS: C6S/C4S and concentration of aggrecan decreased after injection, although these decreases were not significant. Positive correlations were noted between the concentrations of C6S and aggrecan before HA injection and the improvement of the JOA score after injection; however, radiological OA stage had no significant relation with improvement both of the JOA score and VAS. CONCLUSION: It has been reported that the concentration of aggrecan-derived fragments in synovial fluid decreases with advancement of the OA stage, reflecting decreases in the amount of residual cartilage and suppression of chondrocyte metabolism. Our findings suggested that HA injection exhibits a greater clinical effect in cases with a high intraarticular aggrecan fragment concentration, i.e., cases in which a high amount of residual cartilage and chondrocyte metabolic activity remain. The biological markers were useful in predicting the effectiveness of HA injection for OA of the knee.

Joint biomarkers in idiopathic femoral head osteonecrosis: comparison with hip osteoarthritis.

OBJECTIVE: To compare concentrations of joint biomarkers in synovial fluid (SF) between idiopathic osteonecrosis of the femoral head (ION) and osteoarthritis (OA) of the hip joint. METHODS: Levels of the joint biomarkers cartilage oligomeric matrix protein (COMP), antigenic keratan sulfate (AgKS), and hyaluronan (HA) in SF samples from 21 cases of ION and their relationship to disease stage and history of steroid use were assessed and compared to the result of 29 cases of hip OA. RESULTS: In both the ION and hip OA groups, levels of COMP and AgKS in SF showed a significant positive correlation. The ION group had significantly higher levels of AgKS in SF than the hip OA group. In the ION group, stage II patients had significantly higher SF levels of both COMP and AgKS than those in stage III patients. No difference in level of HA in hip joint SF was found between steroid and non-steroid treated ION patients or between the stage II and III subgroups. CONCLUSION: SF levels of COMP and AgKS may serve as useful joint biomarkers that reflect cartilage metabolism not only in hip OA but also in ION.

The appearance of the lateral ulnar collateral ligament on magnetic resonance imaging.

The lateral ulnar collateral ligament is an important element of the elbow's lateral capsuloligamentous complex, and loss of integrity contributes to posterolateral rotatory instability. However, the normal appearance on magnetic resonance imaging is poorly defined. The purpose of this study was to assess the appearance of the lateral ulnar collateral ligament of asymptomatic elbows on magnetic resonance imaging. We performed magnetic resonance imaging on 20 asymptomatic elbows. The lateral ulnar collateral ligament was identified as a hypointense structure originating from the lateral epicondyle and inserting on the proximal ulna in 10 cases (50%) and was ambiguous in the other 10 elbows. The identified lateral ulnar collateral ligament images included areas of high signal intensity, which was confusing because it suggested ligamentous disruption within the ligament. These results indicate that magnetic resonance imaging is not reliable for diagnosing lateral ulnar collateral ligament injuries at the present time. Further progress in magnetic resonance imaging will be clinically useful for diagnosing abnormalities of the lateral ulnar collateral ligament.

Femoral shaft fracture callus formation after intramedullary nailing: a comparison of interlocking and Ender nailing.

Intramedullary nailing is widely used for the operative treatment of femoral fractures. Recently, the biologic healing of fractures has become better understood from fundamental investigations. However, there has been no clinical comparison between the fracture healing process with these two fixation methods. The purpose of this study was to use radiographs to compare callus formation with two types of intramedullary nailing for femoral shaft fractures: reamed interlocking (IL) nails and Ender nails. Femoral shaft type A fractures (AO classification) were studied. Twenty-seven fractures were treated with reamed IL nailing, and 81 fractures were treated with Ender nailing. The callus area was calculated from the maximum cross-sectional area on the anteroposterior and lateral radiographs. The callus appeared at a mean of 3.9 weeks after surgery in the IL group, and at a mean of 2.8 weeks in the Ender group ( P < 0.05). In the IL and Ender groups, fracture healing was noted at a mean of 3.4 and 2.0 months, respectively. The mean area of callus formation in the IL and Ender nailing groups was 439.5 mm(2) and 699.4 mm(2), respectively ( P < 0.02). Ender nailing results in abundant callus, which forms at an earlier stage after the procedure than in patients treated with IL nailing. Dynamization at the fracture site is reported to increase external callus formation. Our results indicate that the elasticity of the fixation obtained with Ender nailing promotes callus formation.