Prevention of Adjacent Segmental Disease after Fusion in Degenerative Spinal Disorder: Correlation between Segmental Lumbar Lordosis Ratio and Pelvic Incidence-Lumbar Lordosis Mismatch for a Minimum 5-Year Follow-up.

Study Design: Retrospective study. Purpose: Associations among risk factors related to adjacent segmental disease (ASD) remain unclear. We evaluated the risk factors and segmental lordosis ratio to prevent ASD developing after lumbar spinal fusion. Overview of Literature: Risk factors related to ASD development are age, sex, obesity, pre-existing degeneration, number of fusion segments, and decreased postoperative lumbar lordosis (LL). However, the associations among these factors are still unclear and should be clearly identified. Methods: We retrospectively reviewed data on 274 patients who underwent lumbar spinal fusion of three segments or below for lumbar degenerative disease from January 2010 to December 2012, with over 5 years of follow-up. Patients with preoperative sagittal vertical axis (SVA) >5 cm were excluded due to sagittal imbalance. A total of 37 patients with ASD and 40 control patients (CTRL) were randomly selected in a similar distribution of matching variables: age, sex, and preoperative degenerative changes. Sex, age, number of fusion segments, radiologic measurements, L4-5-S1/L1-S1 LL ratio, and spinopelvic parameters (pelvic incidence [PI], pelvic tilt [PT], sacral slope [SS], and SVA) were analyzed. Logistic regression was used to analyze the correlation between PI-LL mismatch and L4-5-S1 segmental lordosis rate. Results: No significant difference was found between ASDs and CTRL groups regarding age, sex, number of fusion segments, fusion method, and preoperative and postoperative spinopelvic parameters (PI, SS, PT, and LL). However, regarding the L4-5-S1/L1-S1 lordosis ratio, 50% (p=0.045), 60% (p=0.031), 70% (p=0.042), 80% (p=0.023), and 90% (p=0.023) were statistically significant; <20% (p=0.478), 30% (p=0.223), and 40% (p=0.089) were not statistically significant. In the postoperative PI-LL <10 group, ASD occurred less frequently than in the PI-LL >10 group, and the difference was statistically significant (p=0.048). Conclusions: Patients with a postoperative L4-5-S1/L1-S1 lordosis ratio >50% had less occurrence of ASD. Correcting LL according to PI and physiologic segmental lordosis ratio is important in preventing ASD.

Femoral head wedge resection for the treatment of avascular necrosis of the femoral head after pediatric femoral neck fracture: a case report.

This research focuses on femoral head wedge resection for the treatment of avascular necrosis (AVN) of the femoral head. A 9-year-old girl presented to the emergency room complaining of right hip pain that occurred after a pedestrian car accident. After 8 months of internal fixation using cannulated screws for Delbet-type 2 fracture of the femoral neck, AVN of the femoral head developed in the patient. Even though valgus-derotation-extension intertrochanteric osteotomy was performed for the treatment of AVN, it progressed further and femoral head wedge resection was performed to recover the femoral head sphericity. After 3 years of follow-up, radiograph results showed appropriate and satisfactory congruency and containment. This research shows that the treatment of AVN of the femoral head using femoral head wedge resection is an effective method that can yield excellent results.

Effect of causes of surgical delay on early and late mortality in patients with proximal hip fracture.

INTRODUCTION: The purpose of this study was to investigate the reasons for delayed surgery in patients with proximal hip fracture and to compare differences in mortality between delayed surgery cases and non-delayed surgery cases. In addition, we evaluated causal factors for delayed surgery that affected differences in mortality. METHODS: From 2003 to 2013, 1290 patients (1290 hips) with unilateral femoral neck or intertrochanteric fractures who underwent surgery were categorized into Group Ia (402 patients, early surgery group) and Group Ib (888 patients, delayed surgery group). The delayed surgery group was categorized as Group IIa (270 patients, pre-hospital delay group) and Group IIb (618 patients, post-hospital delay group). Among 618 patients with post-hospital delay, 165 patients in Group IIIa were defined as delayed surgery cases due to patient factors, and 453 patients in Group IIIB were defined as delayed surgery cases due to hospital factors. Early and late mortality was compared between each group. RESULTS: Of 1290 patients, 888 patients underwent delayed surgery (mean 7.5 days, range 3-167 days) after hip fracture. The cumulative mortality rate at 30, 60 days, 3, and 12 months was 0.7, 2.0, 3.0, and 9.5% in Group Ia, respectively, and 2.4, 4.5, 5.2, and 14.5% in Group Ib, respectively (p = 0.047, p = 0.027, p = 0.078, and p = 0.012, respectively). Of 618 patients with post-hospital surgery delay, the cumulative mortality rate at 30 days and 12 months was 4.8 and 21.2% in Group IIIa, respectively, and 1.8, and 12.6% in Group IIIb, respectively (p = 0.033 and p = 0.008, respectively). After adjustments, patient factors for delayed surgery (HR 2.780; 95% CI 1.012-7.640, p = 0.047) were significantly associated with death after hip fracture. CONCLUSIONS: This study demonstrated that delayed surgery was significantly related to 30-day and 1-year mortality. Surgery delay due to drugs' hold and medical comorbidity was related to 30-day mortality after adjustment.