A novel surgical approach using the "lateral corridor" for minimally invasive oblique lumbar interbody fusion at L5-S1: a clinical series and technical note.

PURPOSE: The minimally invasive oblique lumbar interbody fusion (MI-OLIF) L5-S1 was introduced to overcome the limitations of conventional fusion techniques, however, MI-OLIF is not possible using the standard method due to vascular structures in some cases. We aimed to introduce the "lateral corridor" and report the details of the surgical technique with a clinical case series. METHODS: We utilized the lateral access route of the left common iliac vein and named it the "lateral corridor", to distinguish the technique from the standard technique (central corridor). The type and frequency of branch vessels that required additional manipulations were reviewed, and the frequency of intraoperative vascular injury was investigated. RESULTS: Among the 107 patients who underwent MI-OLIF L5-S1, 26 patients (24.3%) who received the "lateral corridor" technique were included. Branch vessel ligation was required in 42.3% of the patients. The types of branch vessels that required ligation were seven cases (26.9%) of the iliolumbar vein (ILV) and six cases (23.1%) of ascending lumbar vein (ALV). The ILV and ALV were ligated in two cases. None of the patients developed intraoperative vascular injuries. CONCLUSION: We introduced the "lateral corridor" as an alternative approach for MI-OLIF L5-S1, implemented it in 24.3% of the patient cohort, and reported favorable outcomes devoid of vascular complications. The "lateral corridor" necessitated ligation of the ILV or ALV in 42.3% of cases. The "lateral corridor" approach appears to be a promising surgical technique, offering feasibility even in instances where the vascular anatomy precludes the employment of the conventional approach.

Hip Fractures in Centenarians: Functional Outcomes, Mortality, and Risk Factors from a Multicenter Cohort Study.

Background: Increasing longevity has caused the very old population to become the fastest-growing segment. The number of centenarians (over 100 years old) is increasing rapidly. Fractures in the elderly lead to excessive medical costs and decreased quality of life with socioeconomic burdens. However, little research has thoroughly examined the functional outcomes and mortality of hip fractures in centenarians. Methods: This is a retrospective observational study. Sixty-eight centenarian hip fracture patients were admitted to the 10 institutions from February 2004 to December 2019. Fifty-six patients with 1-year follow-up were finally included. The following data were obtained: sex, age, body mass index, Charlson comorbidity index value on the operation day, Koval's classification for ambulatory ability, type of fracture, the time interval from trauma to surgery, American Society of Anesthesiologists grade, surgery-related complications, and duration of hospital stay. Postoperative Koval's classification (at 1 year after surgery) and information about death were also collected. Multivariate analysis was performed to analyze the risk factors affecting mortality 1 year after surgery. Results: Mortality rates were 26.8% at 6 months and 39.3% at 1 year. The 90-day mortality was 19.6%, and one of them (2.1%) died in the hospital. The 1-year mortality rates for the community ambulatory and non-community ambulatory groups were 29% and 52%, respectively. Only 9 (16.1%) were able to walk outdoors 1 year after surgery. The remaining 47 patients (83.9%) had to stay indoors after surgery. Multivariate analysis demonstrated that the pre-injury ambulatory level (adjusted hazard ratio, 2.884; p = 0.034) was associated with the risk of mortality. Conclusions: We report a 1-year mortality rate of 39.3% in centenarian patients with hip fractures. The risk factor for mortality was the pre-injury ambulatory status. This could be an important consideration in the planning of treatment for centenarian hip fracture patients.

Bipolar Hemiarthroplasty in Unstable Intertrochanteric Fractures with an Effective Wiring Technique.

Purpose: Bipolar hemiarthroplasty has recently been acknowledged as an effective option for treatment of unstable intertrochanteric fracture. Trochanteric fragment nonunion can cause postoperative weakness of the abductor muscle and dislocation; therefore, reduction and fixation of the fragment is essential. The purpose of this study was to perform an evaluation and analysis of the outcomes of bipolar hemiarthroplasty using a useful wiring technique for management of unstable intertrochanteric fractures. Materials and Methods: A total of 217 patients who underwent bipolar hemiarthroplasty using a cementless stem and a wiring technique for management of unstable intertrochanteric femoral fractures (AO/OTA classification 31-A2) at our hospital from January 2017 to December 2020 were included in this study. Evaluation of clinical outcomes was performed using the Harris hip score (HHS) and the ambulatory capacity reported by patients was classified according to Koval stage at six months postoperatively. Evaluation of radiologic outcomes for subsidence, breakage of wiring, and loosening was also performed using plain radiographs at six months postoperatively. Results: Among 217 patients, five patients died during the follow-up period as a result of problems unrelated to the operation. The mean HHS was 75±12 and the mean Koval category before the injury was 2.5±1.8. A broken wire was detected around the greater trochanter and lesser trochanter in 25 patients (11.5%). The mean distance of stem subsidence was 2.2±1.7 mm. Conclusion: Our wiring fixation technique can be regarded as an effective additional surgical option for fixation of trochanteric fracture fragments during performance of bipolar hemiarthroplasty.

Midterm Outcomes of Intramedullary Fixation of Intertrochanteric Femoral Fractures Using Compression Hip Nails: Radiologic and Clinical Results.

Background: Various implants are used to treat intertrochanteric fractures. However, the optimal implant to stabilize intertrochanteric femoral fractures is still a matter of debate. The purpose of the present study was to evaluate the midterm outcomes of patients treated using compression hip nails (CHNs). Methods: Between March 2013 and April 2018, 164 patients with intertrochanteric femoral fractures who were treated with internal fixation using CHNs were enrolled in this study. The mean age of the patients was 79.6 years. We retrospectively collected and estimated information such as reduction state, implant position, operation time, blood loss, hospital stay, time to achieve union, clinical scores (Harris hip score [HHS] and EuroQol five-dimensional [EQ-5D]), intraoperative complications (such as lag jamming and drill bit breakage), failure of fixation, avascular necrosis, and surgical site infection. Results: The mean follow-up period was 39.69 months. Eight percent of the patients required an open reduction. The mean operation time was 131 minutes, the mean blood loss was 221.19 mL, the mean hospital stay was 20.66 days, and the average time to union was 18 weeks. Intraoperative complications included 8 cases of breakage of the drill bit while making distal holes. The failure rate was 3.7% and revision surgery was performed in 6 cases (for cut-out in 5 and pull-out of the lag screw in 1). Asymptomatic venous thromboembolism occurred in 2 cases and hematoma requiring intervention occurred in 1 case. There were no other complications such as avascular necrosis, infection, and lateral irritation. At the 2-year follow-up, the averages of HHS and EQ-5D were 71.54 and 0.68, respectively. Conclusions: Among the implants used to treat intertrochanteric femoral fractures, CHNs had a surgical failure of 3.7% and showed good radiologic and clinical results.

Transfusion Trends of Knee Arthroplasty in Korea: A Nationwide Study Using the Korean National Health Insurance Service Sample Data.

Knee arthroplasties are strongly associated with blood transfusion to compensate for perioperative bleeding. The purpose of this study was to evaluate trends of transfusion associated with knee arthroplasties using nationwide data of the National Health Insurance Service-National Sample Cohort (NHIS-NSC). Using data from the nationwide claims database of the Health Insurance Review Assessment Service managed by the NHIS, 50,553 knee arthroplasties under three categories (total knee replacement arthroplasty, uni-knee replacement arthroplasty, and revision arthroplasty) from 2012 to 2018 were identified. Overall transfusion rate, transfusion count, proportion of each type of transfusion, and cost associated with each type of operation were investigated. Overall transfusion rate was 83.4% (5897/7066) in 2012, 82.7% (5793/7001) in 2013, 79.6% (5557/6978) in 2014, 75.9% (5742/7557) in 2015, 73.1% (6095/8337) in 2016, 68.2% (4187/6139) in 2017, and 64.6% (4271/6613) in 2018. The proportion of each type of transfusion was 1.8% for fresh frozen plasma, 0.5% for platelets, and 97.7% for red blood cells. The average cost of transfusion was $109.1 ($123 in 2012, $124 in 2013, $123.3 in 2014, $110.6 in 2015, $100 in 2016, $92.9 in 2017, and $90.1 in 2018). In this nationally representative study of trends in transfusion associated with knee arthroplasty, we observed significantly high rates of blood transfusion among patients undergoing knee arthroplasties. Although the overall rate of transfusion had declined, the allogeneic transfusion rate was still high from 2012 to 2018 in Korea. Thus, surgeons need to develop various patient blood management plans and minimize the use of allogeneic transfusion when performing knee arthroplasties.

Hip Fracture Surgery without Transfusion in Patients with Hemoglobin Less Than 10 g/dL.

BACKGROUD: Hip fracture surgery is associated with blood loss, which may lead to adverse patient outcomes. The hemoglobin level declines gradually in most hip fracture cases involving femoral neck fractures and intertrochanteric fractures. It decreases further after hip fracture surgery due to perioperative bleeding. We developed a protocol, which avoids transfusion in hip fracture surgery, and reviewed the hemodynamic outcomes of patients with hemoglobin less than 10 g/dL without transfusion. METHODS: From 2014 to 2019, we retrospectively recruited 34 patients with hip fractures and a hemoglobin level less than 10 g/dL, who refused to undergo transfusion. There were 19 patients with femoral neck fractures and 15 patients with intertrochanteric fractures. Our patient blood management (PBM) protocol involving 4,000 U erythropoietin (3 times a week) and 100 mg iron supplement (every day) was applied to all included patients. Intraoperatively, a cell saver and tranexamic acid were used. Postoperatively, the protocol was maintained until the patients' hemoglobin level reached 10 g/dL. We evaluated the feasibility of our protocol, perioperative complications, and hemodynamic changes. RESULTS: Nineteen patients with femoral neck fractures underwent bipolar hemiarthroplasty and 15 patients with intertrochanteric fractures underwent internal fixation with a cephalomedullary nail. The mean hemoglobin level was 8.9 g/dL (range, 7.3-9.9 g/dL) preoperatively, 7.9 g/dL (range, 6.5-9.3 g/dL) immediately postoperatively, 7.7 g/dL (range, 4.3-9.5 g/dL) on postoperative day 1, 7.4 g/dL (range, 4.2-9.4 g/dL) on postoperative day 3, 8.1 g/dL (range, 4.4-9.7 g/dL) on postoperative day 5, 8.5 g/dL (range, 4.5-9.9 g/dL) on postoperative day 7, and 9.9 g/dL (range, 5.7-11.1 g/dL) on postoperative day 14. The average intraoperative bleeding was 206.2 ± 78.7 mL. There was no case associated with complications of anemia. CONCLUSIONS: Hip fracture surgery in patients with hemoglobin less than 10 g/dL was feasible without the need for transfusion using our PBM protocol in 34 patients. Using this protocol, the operation was conducted safely despite the anemic condition of patients with fractures whose hemoglobin was less than 10 g/dL.

The impact of sequential therapy from short-term teriparatide to denosumab compared with denosumab alone in patients with osteoporotic hip fracture: a 1-year follow-up study.

BACKGROUND: Sequential therapy from bone-forming medication to resorptive agents is reportedly effective for patients with severe osteoporosis. The objective of this study is to determine the impact of implementing short-term teriparatide (TPTD) intervention before denosumab (DMab) therapy compared with DMab therapy alone for 1 year after hip fracture. METHODS: We retrospectively reviewed the medical records and radiographs of patients who were treated due to osteoporotic hip fracture. TPTD was administered to 22 patients for an average of 12.1 weeks after which the intervention was switched to DMab therapy for 12 months (group 1). DMab alone was administered to 16 patients for 12 months (group 2). Bone mineral density (BMD) was evaluated before and after treatment at the 1-year follow-up. The improvement of BMD in hip and spine was compared with the levels of bone turnover marker. RESULTS: The difference in femoral neck BMD was 0.005 ± 0.04 in group 1 and - 0.014 ± 0.10 in group 2 (p = 0.442). The difference of spine BMD was 0.043 ± 0.05 in group 1 and 0.052 ± 0.06 in group 2 (p = 0.640). BMD of the spine improved significantly in groups 1 and 2 (p < 0.001, p = 0.002). There was no statistical difference in C-terminal telopeptide and osteocalcin level. CONCLUSION: Short-term TPTD administration followed by DMab alone was effective only in improving spine BMD. Short-term treatment with TPTD caused mild improvement in femur neck BMD compared with DMab alone. However, further research with a longer duration of TPTD treatment is warranted, as our findings lack statistical significance.

Removal of bent intramedullary nail: Two case reports.

INTRODUCTION: The removal of bent intramedullary (IM) nail can become a challenge. Therefore, various methods have been reported for the extraction of nails after femoral refracture. We want to share our successful treatment. PATIENT CONCERNS: Case 1. A 44-year-old man was admitted to our clinic after falling while playing soccer. He complained severe right thigh pain with a visible deformity of the femur. His medical history revealed a right femoral shaft fracture caused in a traffic accident which had been treated with intramedullary nailing. Case 2. A 27-year-old man, who had suffered a right femur fracture after a motorcycle accident and been treated with an IM nail, presented after falling down the stairs. He had severe right thigh pain without any open wound or neurologic deficit. DIAGNOSIS: Case 1. Plain radiographs revealed a refracture of the right femoral shaft and a bent IM nail. The initial varus deformity of the nail was 60.1° in the coronal plane. Case 2. The valgus deformity of the nail was 16.1° with an apex-posterior angulation of 34.8° in the sagittal image of plain radiographs. INTERVENTIONS: Case 1. Initial manual reduction was tried in emergency room. Then, under general anesthesia closed reduction of the fracture and bent IM nail was done. After closed reduction, the nail was straightened and extracted smoothly. Case 2. Closed manipulation was attempted initially. But no difference in the deformity was achieved. Therefore, via skin incision, the bent nail was progressively sectioned with high-speed cutting burr until the nail could be straightened. OUTCOMES: Case 1. The patient was mobilized with partial-weight bearing assisted with a crutch on postoperative day two. One year after surgery, the fracture union was complete and the patient was pain-free. Case 2. Six months after surgery, the fracture union was complete with sufficient callus formation around the fracture site. CONCLUSION: There is no gold standard method to remove a bent IM nail. However, since manual reduction to straighten the bent nail causes minimal soft tissue damage, it should be considered first. If it fails, other methods should be attempted, progressing from the minimally invasive technique to more invasive methods.

Reliability of measuring lateral bowing angle of the femur in patients with atypical femur fractures.

BACKGROUND: Lateral femoral bowing causes a higher tensile mechanical load on the lateral side of the femur, which plays a critical role in the pathogenesis of atypical femoral fractures (AFFs). There are many ways to measure lateral femoral bowing on plain radiographs, and there are difficulties in finding a correspondence point between measurements among multiple measurers. The purpose of this study is to prove the best method of correspondence between the investigators by analyzing the reliability of various methods for measuring lateral femoral bowing. MATERIALS AND METHODS: We retrospectively collected data from 85 patients (87 femurs) diagnosed with AFF who had plain radiographs of entire femur from October 2013 to March 2018. The femoral bowing was measured in coronal view of femur plain radiographs using five methods (Sasaki, Morin, Jang, Kim, and Yau) by three examiners, respectively. The intra- and interobserver reliability of each method was assessed using intraclass correlation coefficient (ICC) for continuous variables. RESULTS: All methods showed excellent intra- and interobserver reliability with ICC of >0.8. Among five methods, the Yau's method was the highest reliable method (ICC = 0.980, 95% confidence interval = 0.971-0.986). CONCLUSIONS: All methods of measuring lateral femoral bowing in the coronal plane of plain radiographs are reliable. And, we recommend Yau's method, which has a clear reference point for measuring femoral bowing and is highest reproducible.

Transfusion trends in hip arthroplasty in Korea: a nationwide study by the Korean National Health Insurance Service.

BACKGROUND: Hip arthroplasties are strongly associated with blood transfusion to compensate for perioperative bleeding. The purpose of this study was to evaluate the trends in transfusion associated with hip arthroplasties, using nationwide data supplied by the National Health Insurance Service. STUDY DESIGN AND METHODS: We used data from nationwide claims database of the Health Insurance Review Assessment Service. The data managed by the National Health Insurance Service were used to identify 161,934 hip arthroplasties under three categories, including bipolar hemiarthroplasty, total hip arthroplasty, and revision arthroplasty, from 2007 to 2015. The transfusion rates, transfusion amounts, the proportion of transfusion, and cost associated with each type of operation were investigated and stratified according to age, sex, hospital type, and region. RESULTS: The proportion of patients receiving any allogeneic transfusion was 81.1% in 9 years. The overall proportion of transfusion was 7% fresh frozen plasma, 12% platelets, and 77% RBCs. The average count of transfusions was 4.1 in bipolar hemiarthroplasty (343,815/83,729), 4.3 in total hip arthroplasty (196,869/46,097), and 8.7 in revision arthroplasty (35,044/4,024) from 2007 to 2015. CONCLUSION: In this nationally representative study of trends in transfusion associated with hip arthroplasty, we observed significantly high rates of blood transfusion among patients undergoing hip arthroplasties. Although the overall amount of transfusion declined, the allogeneic transfusion rate was still high from 2007 to 2015 in Korea, and higher than other countries are reporting.

Atypical incomplete femoral neck fracture in patients taking long-term bisphosphonate: Case report, a report of 2 cases.

RATIONALE: We present 2 cases of lateral incomplete impending fracture of the femoral neck without trauma in elderly patients taking long-term bisphosphonate (BP) treatment, and we defined it as atypical femoral neck fracture (AFNF). To the best of our knowledge, this is the first report on the follow-up results of AFNF. PATIENT CONCERNS: Patients in both cases had been taking BP drugs for a long time with osteoporosis. The duration of BP treatment was 6 years, and there was no history of repeated stresses. DIAGNOSES: All fractures were linear at the lateral aspect of the mid portion of the femoral neck, and the BMD of the femoral neck was -0.9, and -1.8, respectively. INTERVENTIONS: Internal fixation was performed in both cases (73 years, 68 years) using cannulated screws. OUTCOMES: In both patients who underwent screw fixation, the fracture line started to extend distally at 4 weeks and 2 weeks following surgery. In the 3-month follow-up image, the length of the fracture increased by 20.1 mm and 9.9 mm, respectively. There was a problem with active rehabilitation, and the possibility of revision was also found to be a burden in terms of mortality and cost in older patients. LESSONS: In the case of AFNF, guidelines for treatment should be set in consideration of the decreased bone healing, even when the fracture pattern is simple. Arthroplasty based on a wider indication may be worth considering.

Radiologic outcomes of open reduction and internal fixation for cementless stems in Vancouver B2 periprosthetic fractures.

OBJECTIVE: The aim of this study was to evaluate the radiologic outcomes of open reduction and lateral plating with wiring in the treatment of Vancouver B2 periprosthetic femoral fractures. METHODS: We retrospectively recruited 37 patients treated with ORIF with lateral plating and wiring for Vancouver B2 fractures. The 27 patients (15 men and 12 women; mean age: 70.8 ± 8.3 years) without follow-up loss had achieved complete bony union without notable complications. The average union period was checked after operation with radiologic findings. Radiologic outcomes were evaluated by ipsilateral limb length discrepancy (LLD) and subsidence between immediate postoperative length and length at postoperative 1 year after adjusting for magnification differences. The average distance to which the retained stem sunk down was investigated between immediate postoperative radiographs and final radiographs showing union. RESULTS: Ten patients could not be evaluated, because of mortality or failure to follow up. The average time to union was 18.3 weeks, and the average distance of stem sinking was 2.5 ± 1.7 mm (range: 0-7.2 mm), which was significantly different between immediate postoperative radiographs and final radiographs. There was no case with loss of reduction or loss of fixation, requiring revision surgery. CONCLUSION: Open reduction and lateral plating with wiring as a treatment for Vancouver B2 periprosthetic femoral fractures produced good radiologic outcomes with successful bony union. ORIF can be considered the alternative option for treating patients with Vancouver B2 PPF, instead of stem revision surgery. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Characteristics of and Factors Contributing to Immediate Postoperative Pain After Ankle Fracture Surgery.

To build an appropriate strategy of pain management after ankle fracture surgery, surgeons need to know the characteristics of postoperative ankle pain and its contributing factors. The aim of the present study was to investigate the maximum pain period after ankle fracture surgery and the factors affecting postoperative pain using a linear mixed model when patient-controlled analgesia (PCA) was used as a basic modality. A total of 219 adult patients (108 males and 111 females; mean age 51.2 ± 15.9 years) who had undergone operative treatment for ankle fractures were included. Data on fracture severity, causes of injury, interval between injury and surgery, anesthesia method, American Society of Anesthesiologists classification, and operative time were collected. Pain intensity was measured using an 11-point pain intensity numerical rating scale preoperatively and postoperatively every 8 hours. Intravenous PCA was prescribed to all patients. The chronologic pattern of postoperative pain and factors affecting it were statistically analyzed using a linear mixed model. Maximum postoperative pain was observed at 8 hours postoperatively, and the maximum pain numerical rating scale score was 3.92, measured at 8-hour intervals. The severity of fracture (p = .01) was the only significant factor contributing to postoperative pain after ankle fracture surgery on multivariate analysis. Clinicians should consider the chronologic pattern of postoperative pain after ankle fracture surgery during postoperative pain management. Interventions for pain control, in addition to PCA, might be needed at ~8 hours postoperatively, especially for those with severe ankle fractures.

Pathologic femoral fracture due to tenofovir-induced Fanconi syndrome in patient with chronic hepatitis B: A case report.

RATIONALE: We report a case of a hepatitis B virus (HBV)-positive patient with preexisting bone disease who developed tenofovir-induced Fanconi syndrome and subsequently sustained pathologic fracture. To our best knowledge, this is the first report in the English literature about pathologic femoral fracture due to tenofovir-induced Fanconi syndrome in patient with chronic hepatitis B (CHB). The present report describes detailed our experience with the diagnosis of pathologic femoral fracture due to tenofovir-induced Fanconi syndrome and treatment. PATIENT CONCERNS: A 45-year-old man visited our hospital with pain in the right thigh region and gait disturbance which had started 3 months ago and worsened 1 week before admission. The patient was diagnosed with CHB in 2004. He was on lamivudine medication for 2 years. Medication for the patient was subsequently changed to adefovir in 2009 and tenofovir disoproxil fumarate (TDF) in 2013. He was on TDF since 2013. DIAGNOSIS: His hip joint magnetic resonance imaging (MRI) revealed hypointensity lesions and cortical bone destruction in fat-saturated MR image at the iliopsoas muscle attachment site of the lesser trochanter of both femur. On blood test showed 25-OH vitamin D level at 6.42 ng/mL (normal range, >20 ng/mL) and U-deoxypyridinoline level at 7.60 nM/mMcr (normal range, 2.30-5.40 nM mMcr). However, osteocalcin and parathyroid hormone levels were within normal range. Based on these findings, the present case was concluded as tenoforvir-induced Fanconi syndrome. INTERVENTIONS: TDF treatment was discontinued. After cooperation with internal medicine department, in order to prevent further fractures of the right lesser trochanter, internal fixation was performed under spinal anesthesia using compression hip nails (APIS, TDM, Korea). OUTCOMES: Positive outcome by medication and operation demonstrates that his phosphorus and serum calcium levels were maintained within normal range and pain in the right thigh region was improved from visual analogue pain score (VAS) 7 before surgery to VAS 2 after surgery. LESSONS: Physicians need to regularly monitor bone metabolism in patients with take in tenofovir for early diagnosis before its progression to pathologic fractures.

Survivorship and Complications after Hip Fracture Surgery in Patients with Chronic Kidney Disease.

The aim of this study was to investigate survival rate, complications and associated risk factors after hip fracture surgery in patients with chronic kidney disease (CKD) by comparing to non-CKD patients. A total of 119 patients (130 hips, 63 hips CKD group, 67 hips non-CKD) who underwent hip fracture surgery were included. We assessed variables including age, gender, CKD, comorbidities, operation delay and operation time as risk factors for survival and complications after hip fracture surgery. The survival rate was 55.8% at 1-year, 45.8% at 3-year, and 31.4% at 5-year in CKD group, whereas 82.1%, 60.7%, and 36.8%, respectively in non-CKD. Age (more than 85) (hazard ratio [HR], 3.238; 95% confidence interval [CI], 1.736-6.042; P < 0.001), stages 4, 5 of CKD (HR, 2.004; 95% CI, 1.170-3.433; P = 0.001), cerebrovascular disease (HR, 2.213; 95% CI, 1.196-4.095; P = 0.001), and malignancy (HR, 3.086; 95% CI, 1.553-6.129; P = 0.001) were significant risk factors. Complications occurred in 17 hips of CKD group and 8 hips of non-CKD. Stage 4-5 of CKD (odds ratio [OR], 3.401; 95% CI, 1.354-8.540; P = 0.001), malignancy (OR, 3.184; 95% CI, 0.984-10.301; P = 0.050) were significant risk factor. When performing hip fracture surgery in patients with CKD, surgeons should consider age, severity of CKD, and presence of other comorbid disease, such as cerebrovascular disease and malignancy, as patients with these risk factors will need more intensive preoperative and postoperative care.

Revision Arthroplasty Using a MUTARS® Prosthesis in Comminuted Periprosthetic Fracture of the Distal Femur.

Periprosthetic fractures after total knee arthroplasty (TKA) are gradually increasing, reflecting extended lifespan, osteoporosis, and the increasing proportion of the elderly during the past decade. Supracondylar periprosthetic femoral fracture is a potential complication after TKA. Generally, open reduction and internal fixation are the conventional option for periprosthetic fracture after TKA. However, the presence of severe comminution with component loosening can cause failure of internal fixation. Although the current concept for periprosthetic fracture is open reduction and internal fixation, we introduce an unusual case of revision arthroplasty using a MUTARS® prosthesis for a comminuted periprosthetic fracture in the distal femur after TKA, with technical tips.

A protocol avoiding allogeneic transfusion in joint arthroplasties.

INTRODUCTION: Arthroplasties of hip and knee are associated with blood loss, which may lead to adverse patient outcome. Performing arthroplasties in Jehovah's Witness patients who do not accept transfusion has been a matter of concern. We developed a protocol, which avoids transfusion in arthroplasties of Jehovah's Witness patients, and evaluated the feasibility and safety of the protocol. MATERIALS AND METHODS: The target of preoperative hemoglobin was more than 10 g/dL. When preoperative hemoglobin was lower than 10 g/dL, 4000 U erythropoietin (3 times a week) and 100 mg iron supplement (every day) were administered until the hemoglobin reached 10 g/dL. When the preoperative hemoglobin was higher than 10 g/dL, 4000 U erythropoietin and 100 mg iron supplement were administered once, before operation. During the operation, cell saver was used. Postoperatively, erythropoietin and iron supplements were administered until the hemoglobin reached 10 g/dL, similar to the preoperative protocol. We evaluated the feasibility of our protocol, perioperative complications and hematologic changes. RESULTS: From 2002 to 2014, 186 Witness patients visited our department. In 179 patients (96.2 %), 77 total knee arthroplasties, 69 bipolar hemiarthroplasties and 33 total hip arthroplasties were performed. The mean hemoglobin level was 12.3 g/dL preoperatively, 9.4 g/dL on postoperative day 3 and 10.3 g/dL on postoperative day 7. One patient died immediately after the arthroplasty and the remaining 178 patients survived. CONCLUSIONS: Total joint arthroplasty could be done without transfusion using this protocol in most of our patients. The rates of infection and mortality were similar with known infection and mortality rates of arthroplasties. In patients who do not want allogeneic transfusions, our protocol is a safe alternative to perform joint arthroplasties.

Can Alarming Improve Compliance with Weekly Bisphosphonate in Patients with Osteoporosis?

BACKGROUND: Although bisphosphonate is effective for the prevention and treatment of osteoporosis, poor medication compliance is a key-limiting factor. We determined whether alarm clock could improve compliance with weekly bisphosphonate in patients with osteoporosis, by comparing with age- and gender-matched control group. METHODS: Fifty patients with osteoporosis were recruited and participated in alarm clock group. Patients were asked to take orally weekly risedronate for 1 year, and received alarm clock to inform the time of taking oral bisphosphonate weekly. Using the propensity score matching with age and gender, 50 patients were identified from patients with osteoporosis medication. We compared the compliance with bisphosphonate using medication possession ratio (MPR) between two groups. RESULTS: Although there was no significant difference of baseline characteristics between both groups, the mean MPR (0.80±0.33) of alarm clock group was higher than that (0.56±0.34) of control group (P<0.001). CONCLUSIONS: Alarming could improve the compliance with weekly oral bisphosphonate in patients with osteoporosis.

Clinical and Radiologic Outcomes among Bipolar Hemiarthroplasty, Compression Hip Screw and Proximal Femur Nail Antirotation in Treating Comminuted Intertrochanteric Fractures.

PURPOSE: In comminuted intertrochanteric fractures, various operative options have been introduced. The purpose of this study was to determine whether there were differences in clinical and radiologic outcomes among bipolar hemiarthroplasty (BH), compression hip screw (CHS) and proximal femur nail antirotation (PFNA) in treating comminuted intertrochanteric fractures (AO/OTA classification, A2 [22, 23]). MATERIALS AND METHODS: We retrospectively evaluated total 150 patients (BH, 50; CHS, 50; PFNA, 50) who were operated due to intertrochanteric fractures from March 2010 to December 2012 and were older than 65 years at the time of surgery. We compared these three groups for radiologic and clinical outcomes at 12 months postoperatively, including Harris Hip Score, mobility (Koval stage), visual analogue scale and radiologic limb length discrepancy (shortening). RESULTS: There was no statistical significance among three groups in clinical outcomes including Harris Hip Score, mobility (Koval stage), visual analogue scale. However, there was significant differences in radiologic limb discrepancy in plain radiographs at 12 months postoperatively (radiologic shortening: BH, 2.3 mm; CHS, 5.1 mm; PFNA, 3.0 mm; P=0.000). CONCLUSION: There were no clinical differences among BH, PFNA, and CHS in this study. However, notable limb length shortening could be originated during fracture healing in osteosynthesis, compared to arthroplasty (BH

Sciatic Nerve Palsy Caused by Ruptured and Contracted Short External Rotator Muscles after Primary Total Hip Arthroplasty.

Although the incidence of sciatic nerve palsy following total hip arthroplasty is low, this complication can cause devastating permanent nerve palsy. The authors experienced a case of sciatic nerve palsy caused by ruptured and contracted external rotator muscles following total hip arthroplasty in a patient suffering from osteonecrosis of the femoral head. We report this unusual case of sciatic nerve palsy with a review of the literature.