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Herpes zoster is caused by reactivated varicella-zoster virus (VZV) and characterized by a painful skin rash with vesicles that affects the adjacent dermatomes. Transverse myelitis is a rare complication of VZV infection that may even occur in immunocompetent patients. Here, we report a 60-year-old male patient admitted with right lower-extremity weakness and hypesthesia. Spine magnetic resonance imaging (MRI) revealed transverse myelitis at the C3–C4 and T6 levels. A month prior to admission, the patient was diagnosed with herpes zoster involving the right T2-T4 dermatome. Considering his history of VZV infection, he was treated with intravenous steroids and acyclovir. Eleven days after hospitalization, paraplegia developed to Medical Research Council grade 0/5 despite performing plasmapheresis. MRI confirmed the aggravation of the cord lesion between T4 and T7. Acute transverse myelitis after VZV infection is a rare disease that can cause serious sequelae in immunocompetent patients. Therefore, clinicians should be cautious of this situation.

Femoral neck fracture is a common osteoporotic fracture in elderly patients and is effectively managed with arthroplasty. However, the benefits and risks of surgical drain after arthroplasty in these patients are still debatable. Hence, we conducted this case-control study to investigate the necessity of surgical drain in elderly patients with femoral neck fractures treated with cementless bipolar hemiarthroplasty. This study enrolled elderly patients (aged ≥ 70 years) who underwent cementless bipolar hemiarthroplasty for femoral neck fractures between April 2016 and December 2021. The patients were classified into the control group comprising 199 patients with surgical drain after surgery performed between April 2016 and June 2020, and the study group, which comprised 134 patients with no surgical drain between July 2020 and December 2021. Demographics, perioperative data and postoperative complications were compared between the two groups. Estimated blood loss, perioperative transfusion volume and rate, and length of hospital stay were significantly lower in the study group than in the control group (p

In cases of hyponatremia induced by brain damage, it is important to distinguish between the syndrome of inappropriate anti-diuretic hormone secretion (SIADH) and cerebral salt wasting syndrome. A ventriculoperitoneal (VP) shunt is the standard treatment for hydrocephalus, and external lumbar drainage (ELD) is an option to evaluate the effect of a VP shunt. However, ELD has potential complications, such as subarachnoid hemorrhage, meningitis, and rarely hyponatremia. Therefore, we report a case of a patient with cerebral salt-wasting syndrome resulting from ELD to treat normal-pressure hydrocephalus during the rehabilitation of acute ischemic stroke.

To investigate the surgical outcomes of anatomical anterior cruciate ligament (ACL) reconstruction according to the graft isometry measured during surgery. Electrical medical records of patients who underwent an arthroscopic ACL reconstruction through the transportal technique using hamstring tendon autograft between 2012 and 2016 were retrospectively reviewed. The patients were classified into two groups based on the graft length change throughout the knee range of motion measured just before graft fixation (Group 1, graft length change ≤ 2 mm; Group 2, graft length change > 2 mm). Comparative analyses, including a non-inferiority trial, were performed regarding the clinical scores, knee laxity, and radiographic parameters between the groups. A total of 67 patients were included in the study. The total change in the length of ACL graft throughout the knee range of motion was 1.4 ± 0.4 mm in Group 1 (range, 0.2–2.0 mm), and 3.0 ± 0.7 mm in Group 2 (range, 2.2–5.0 mm). Group 1 showed a relatively high (proximal) femoral tunnel and shallow (anterior) tibial tunnel compared to Group 2 (P

Background: Increased varus alignment of the lower extremity is known to be a poor prognostic factor for the surgical repair for a medial meniscus root tear (MMRT). However, given the concept of constitutional varus, which is present in a substantial portion of the normal population, the generally accepted surgical indication for MMRT concerning a varus alignment of 5° may be unnecessarily narrow. Purpose: To compare the surgical outcomes of arthroscopic transtibial pullout repair of MMRT according to the degree of varus alignment of the lower extremity. Study Design: Cohort study; Level of evidence, 3 Methods: Patients who underwent isolated arthroscopic transtibial pullout repair of MMRT between January 2010 and July 2017 at one institution and had a minimum follow-up of 2 years were included in this study. Patients were classified into 1 of 2 groups: the experimental group (n = 22) included patients with a preoperative hip-knee-ankle angle between 5° and 10° varus (mild to moderate varus alignment) and the control group (n = 51) included those with a preoperative hip-knee-ankle angle Results: There were no statistically significant differences in surgical outcomes between the groups in subjective and objective aspects, which were consistent before and after inverse probability of treatment weighting. Apart from the clinical improvement observed in both groups, overall degenerative changes in the knee were found, although progression rates did not differ between the groups. In terms of the noninferiority trial, the overall surgical outcomes in the experimental group were not inferior to those in the control group. Conclusion: The short-term surgical outcomes of arthroscopic transtibial pullout repair for MMRT of patients with mild to moderate varus alignment were not inferior to but rather comparable with those with neutral alignment in terms of subjective and objective aspects. Therefore, it would be inappropriate to exclude patients with a diagnosis of MMRT from being indicated for the surgery simply because of mild to moderate varus alignment.

The objective of this retrospective study was to investigate the surgical outcomes of AO/OTA 31 A1-3 trochanteric fractures treated with the new-generation Gamma3 nail with U-Blade (RC) lag screw and to analyze the risk factors related to fixation failure. A total of 318 consecutive patients who underwent cephalomedullary nailing using Gamma3 nail with U-Blade lag screw for trochanteric hip fractures between September 2015 and June 2018 were enrolled. The average age was 80 years and most patients (69%) were women. The mean follow-up was 12.2 months with a minimum of 6 months. 309 (97.2%) showed bony union with a mean time to union of 13.5 ± 8.7 weeks. Cut-out occurred in 2 patients (0.6%) and 7 patients showed excessive collapse (≥15 mm) of the proximal fragment. These 9 patients were assigned to the failure group. The presence of a basicervical fracture component and comminution of the anterior cortex on preoperative 3-D CT showed a significant association with fixation failure, including cut-out, although comminution of the anterior cortex was the only independent risk factor for fixation failure on multivariate logistic regression analysis. Gamma3 nail with U-Blade lag screw showed favorable results for trochanteric hip fractures, with low cut-out rate (0.6%). However, more caution is required in treating trochanteric fractures with a basicervical fracture component and anterior cortex comminution even with this nail.

Treatment of superomedially displaced acetabular fractures including a quadrilateral surface (QLS) is challenging. We present a surgical technique using an anatomical suprapectineal QLS plate through the modified Stoppa approach and report the availability of this plate to treat this fracture type along with the surgical outcomes. Thirteen consecutive patients (11 men and 2 women) who underwent surgical treatment using an anatomical suprapectineal QLS plate through a modified Stoppa approach for superomedially displaced acetabular fractures between June 2018 and June 2020, were enrolled retrospectively. These fractures included 10 both-column fractures and 3 anterior-column and posterior hemitransverse fractures, which were confirmed on preoperative 3-dimensional computed tomography. Surgical outcomes were clinically assessed using the Postel Merle d’Aubigné (PMA) score and visual analog scale (VAS) score at the final follow-up, and radiological evaluations were performed immediately after the operation and at the final follow-up. The follow-up period was longer than 1 year in all patients with a mean 22.9 months. The mean operation time was 103 min. Anatomical reduction was achieved in 11 (84.6%) patients, while imperfect reduction was achieved in the remaining two (15.3%) patients. At the final follow-up, radiographic grades were excellent, fair, and poor in 11 (84.6%), one (7.6%), and one patient, respectively. The mean PMA score was 16.3 (range, 13-18) and the mean VAS score was 1.0 (range, 0-3). No secondary reduction loss or implant loosening was observed. However, two patients underwent conversion to total hip arthroplasty due to post-traumatic arthritis and subsequent joint pain. No other complications were observed. Simultaneous reduction and fixation using an anatomical suprapectineal QLS plate through the modified Stoppa approach can provide satisfactory outcomes in superomedially displaced acetabular fractures, resulting in shorter operation times and fewer complications.

Treatment of superomedially displaced acetabular fractures including a quadrilateral surface (QLS) is challenging. We present a surgical technique using an anatomical suprapectineal QLS plate through the modified Stoppa approach and report the availability of this plate to treat this fracture type along with the surgical outcomes. Sixteen consecutive patients (14 men and 2 women) who underwent surgical treatment using an anatomical suprapectineal QLS plate through a modified Stoppa approach for superomedially displaced acetabular fractures between June 2018 and June 2020, were enrolled retrospectively. These fractures included 11 both-column fractures and 5 anterior-column and posterior hemitransverse fractures, which were confirmed on preoperative 3-dimensional computed tomography. Surgical outcomes were clinically assessed using the Postel Merle d’Aubigné (PMA) score and visual analog scale (VAS) score at the final follow-up, and radiological evaluations were performed immediately after the operation and at the final follow-up. For comparative analysis, 23 patients who underwent internal fixation with the conventional reconstruction plate through modified ilioinguinal approach between February 2010 and May 2018, were selected. This control group was composed of 18 both-column fractures and 5 anterior-column and posterior hemitransverse fractures. The follow-up period was at least 1 year in all patients. The mean operation time and blood loss was 109 min, and 853 ml, respectively, whereas 236 min, and 1843 ml in control group. Anatomical reduction was achieved in 14 (87.5%) patients, while imperfect reduction was achieved in the remaining 2 patients. At the final follow-up, radiographic grades were excellent, fair, and poor in 14 patients (87.5%), one, and one, respectively. The mean PMA score was 16.1 (range 13–18) and the mean VAS score was 1.0 (range 0–3). No secondary reduction loss or implant loosening was observed. However, 2 patients underwent conversion to total hip arthroplasty (THA) due to post-traumatic arthritis and subsequent joint pain. No other complications were observed. In the comparative analysis, radiological outcome showed a significant relationship with the conversion to THA (p = 0.013). Shorter operation time and less blood loss were significantly observed in the QLS plate fixation group through the modified Stoppa approach compared with the conventional reconstruction plate fixation group through modified ilioinguinal approach (p

Even though the dislocation rate is lower in the hemiarthroplasty (HA) than total hip arthroplasty, it has still developed as one of serious complications in elderly patients. We have used short external rotators (SER) preserving posterolateral approach to reduce dislocation after hip arthroplasty, especially in elderly patients. The present study was conducted to introduce SER preserving posterolateral approach and report the dislocation rate after HA via this approach in elderly patients with femoral neck fractures.Between January 2015 and July 2019, 307 consecutive elderly patients aged over 70 years who underwent cementless bipolar HA for femoral neck fractures and were followed up for at least one year, were enrolled in this study. All surgeries were performed using the SER preserving posterolateral approach. The demographic and perioperative data were examined and the complications including dislocation were investigated.Mean operation time was 54.3 min, and mean estimated blood loss was 252.4 cc. The mean follow-up time was 22.1 months, HHS was 67.5 points at the final examination Dislocation following HA developed in only one patient (0.3%) with dementia during hospital stay, which was reduced closely with no subsequent recurrence. Periprosthetic femoral fracture occurred in two patients, which was treated with internal fixation in one patient and with stem revision in the other patient. There was no surgical site infection or periprosthetic infection as complications.The SER preserving technique in posterolateral approach effectively can be effective for reducing the dislocation after HA in elderly patients with femoral neck fracture. It can be encouraged in posterolateral approach for HA, especially in elderly patients under the risk of dislocation.

This study aimed to (1) evaluate the short-term clinical outcomes of patients who underwent non-operative treatment for partial anterior cruciate ligament (ACL) tears diagnosed using the outpatient-based diagnostic criteria and (2) investigate the radiographic predictors distinguishing patients at risk of non-operative treatment failure.From 2010 to 2019, patients diagnosed with partial ACL tears and treated with non-operative treatment were reviewed retrospectively. Patients were then classified into two groups: those who successfully responded to non-operative treatment (group S) and those who failed to respond to non-operative treatment and required surgical reconstruction within 6 months after injury (group F). ACL laxity, patient-reported outcomes (PROs), and several radiographic parameters were analyzed. To identify radiographic predictors related to clinical outcomes, radiographic parameters were compared between the groups, which were statistically matched for potential confounders (age and activity level) using inverse probability of treatment weighting.A total of 44 patients were analyzed (mean age, 28.7 ± 8.7 years; 31 men), and classified into two groups (group S, 23 patients; group F, 21 patients). There were no significant differences in ACL laxity and PROs between the groups at 1 year after either non-operative treatment or surgical reconstruction. A comparison of radiographic parameters between the groups revealed significant differences in several parameters related to secondary signs of ACL injury. Subsequent regression analyses revealed that anterior tibial translation and extent of bone bruises were radiographic predictors related to clinical outcomes.Non-operative treatment for partial ACL tears diagnosed using the outpatient-based diagnostic criteria can provide successful short-term clinical outcomes in selective patients. Secondary signs of ACL injuries, particularly the amount of anterior tibial translation and the extent of bone bruises, are radiographic predictors that could differentiate patients at risk of non-operative treatment failure.Retrospective cohort study, III.

Objectives This study was conducted to investigate the stress around nails and cortical bones in subtrochanteric (ST) fractures fixed using short cephalomedullary nails (CMNs) in finite element models (FEMs) and to determine the appropriate short CMN type for different fracture levels. Methods The following three types of short CMNs were used: type A, which is 170 mm in length and has 1 distal locking screw; type B, 200 mm in length and 1 distal screw; and type C, 200 mm in length and 2 distal screws. A total of 24 FEMs were tested on a transverse ST fracture at 8 levels [0, 10, 20, 25, 30, 35, 40 and 50 mm below the lower margin of lesser trochanter (LT)], and were fixed using 3 different CMN types. Finite element analysis was then performed to evaluate the stress around the cortical bones and the CMNs under the assumption of anatomical reduction and fracture gap of 1 mm. Results Peak von Mises stress (PVMS) was greatest on the cortical bone around the distal screw hole and was greater than the yield strength at fracture levels ≥ 35 mm below the LT in FEMs fixed with type A and B. In contrast, FEMs fixed with type C showed PVMS less than the yield strength at all fracture levels. The PVMS within the implant was greater than the yield strength at the junction of the nail with the distal screw and distal screw itself at fracture levels ≥ 35 mm below the LT in FEMs fixed using type A. Conversely, in FEMs fixed using type B and C, all PVMSs within the implant were less than the yield strength, regardless of the fracture level. Conclusion Short CMNs 170 or 200 mm in length with 1 distal screw may be used in a limited manner in high ST transverse fractures under the assumptions of anatomical reduction and fracture gap ≤ 1 mm. Meanwhile, short CMN 200 mm in length with 2 distal screws may be an available treatment option in most of ST transverse fractures regardless of the fracture level under the same set of assumptions.

The authors present a surgical technique using a collinear reduction clamp through the modified ilioinguinal approach (MIA) for anteromedially displaced acetabular fractures along with the surgical outcomes. Between October 2010 and June 2015, 15 patients underwent surgical treatment for anteromedially displaced acetabular fractures; 10 both-column fractures and 5 anterior column and posterior hemitransverse fractures. Anteriorly displaced anterior column fragment and medially displaced quadrilateral plate fragment were simultaneously reduced using a collinear clamp and fixed with a 3.5mm-reconstruction plate through MIA. Postoperatively, anatomical reduction was achieved in 12 patients, while imperfect reduction was achieved in 3. At a mean follow-up of 49.0 months (range, 24-93 months), the mean Postel Merle d'Aubigné score were 16.3 and the mean VAS score was 0.9. Final radiographic grades according to Matta system were excellent in 13 patients and good in 2. Surgical technique using a collinear reduction clamp through the MIA can provide satisfactory outcomes in anteromedially displaced acetabular fractures.

Background This study aimed to investigate the incidence and risk factors of postoperative urinary retention (POUR) among elderly patients who underwent hip fracture surgery and to evaluate the effect of indwelling catheterization on the occurrence of POUR. Materials and methods From January 2012 to January 2015, consecutive patients aged over 70 years who underwent hip fracture surgery were enrolled in this study. All patients underwent indwelling catheterization due to voiding difficulty upon admission. Demographic data, perioperative variables, and postoperative duration of patient-controlled analgesia and indwelling catheterization, postoperative complications, and mortality were collected. The incidence of POUR was investigated, and the risk factors related to POUR were analyzed using a logistic regression analysis. The cutoff value for the timing of catheter removal was determined using receiver operating characteristic (ROC) curve analysis. Results POUR developed in 68 patients (31.8%) of the 214 patients. Of these, 24 (35.3%) were male. The indwelling catheter was left in place for an average of 3.4 days (range, 0–7 days) postoperatively. A significant difference was noted in gender and duration of indwelling catheterization between patients with POUR and without. The cutoff value for the timing of catheter removal as determined by ROC curve analysis was 3.5 postoperative day with 51.4% sensitivity and 71.5% specificity. Multiple logistic regression revealed that the duration of the indwelling catheter [odds ratios (OR), 0.31; p = 0.016)] and male gender (OR, 2.22; p = 0.014) were independent risk factors related to the occurrence of POUR. Conclusions The significant risk factors of POUR among elderly patients undergoing hip fracture surgery were early indwelling catheter removal and male gender. Therefore, early removal of indwelling catheter in elderly patients following hip fracture surgery may increase the risk of POUR, especially in male patients.

This study aimed to evaluate (1) the overall reasons for first revision in CoC THAs; (2) whether the reasons for revision differ between third-generation and fourth-generation CoC THAs; and (3) the specific factors associated with bearing-related problems as the reason for revision. We retrospectively reviewed 2045 patients (2194 hips) who underwent first revision THA between 2004 and 2013, among which 146 hips with CoC bearings underwent revision. There were 92 hips with third-generation ceramic bearings and 54 hips with fourth-generation ceramic bearings. The major reasons for CoC THA revisions were ceramic fracture and loosening of the cup or stem. When ceramic fracture, squeaking, incorrect ceramic insertion, and unexplained pain were defined as directly related or potentially related to ceramic use, 28.8% (42/146) of CoC revisions were associated with bearing-related problems. Among the third-generation ceramic bearings, revision was performed in 41.3% (38/92) of cases owing to bearing-related problems whereas revisions were performed for only 7.4% (4/54) of cases with fourth-generation ceramic bearings owing to bearing-related problems (p

High tibial osteotomy (HTO) is an effective alternative for medial compartmental knee osteoarthritis (OA). Circulating microRNAs (miRNAs) are known to serve as OA-related biomarkers. The present study investigated the differential expression of serum miRNAs before and after HTO to identify potential miRNAs as prognostic biomarkers. miRNA-polymerase chain reaction (PCR) arrays were used to screen for miRNAs in the serum at preoperative and 6-month postoperative time points from six patients, and the differentially expressed miRNAs identified in the profiling stage were validated using real-time PCR at post-operative months 6 and 18 in 27 other HTO-treated patients. Among 84 miRNAs involved in the inflammatory process, three (miR-19b-3p, miR-29c-3p, and miR-424-5p) showed differential expression patterns in the profiling stage (p = 0.011, 0.015, and 0.021, respectively). Levels of these three and four other miRNAs (miR-140-3p, miR-454-3p, miR-let-7e-5p, and miR-885-5p) known to be related to OA progression were evaluated in the serum of 27 patients. Only four miRNAs (miR-19b-3p, miR-140-3p, miR-454-3p, and miR-let-7e-5p) were significantly upregulated at postoperative month 6 (p = 0.003, 0.005, 0.004, and 0.004, respectively), and only miR-140-3p was significantly upregulated up to 18 months after operation (p = 0.003). Together, this study reveals the significantly upregulated serum miRNAs after HTO as potential prognostic biomarkers, however, further studies are warranted to elucidate their clinical implications.

A finite element analysis was performed to evaluate the stresses around nails and cortical bones in subtrochanteric (ST) fracture models fixed using short cephalomedullary nails (CMNs). A total 96 finite element models (FEMs) were simulated on a transverse ST fracture at eight levels with three different fracture gaps and two different distal locking screw configurations in both normal and osteoporotic bone. All FEMs were fixed using CMNs 200 mm in length. Two distal locking screws showed a wider safe range than 1 distal screw in both normal and osteoporotic bone at fracture gaps ≤ 3 mm. In normal bone FEMs fixed even with two distal locking screws, peak von Mises stresses (PVMSs) in cortical bone and nail constructs reached or exceeded 90% of the yield strength at fracture levels 50 mm and 0 and 50 mm, respectively, at all fracture gaps. In osteoporotic bone FEMs, PVMSs in cortical bone and nail constructs reached or exceeded 90% of the yield strength at fracture levels 50 mm and 0 and 50 mm, respectively, at a 1-mm fracture gap. However, at fracture gaps ≥ 2 mm, PVMSs in cortical bone reached or exceeded 90% of the yield strength at fracture levels ≥ 35 mm. PVMSs in nail showed the same results as 1-mm fracture gaps. PVMSs increased and safe range reduced, as the fracture gap increased. Short CMNs (200 mm in length) with two distal screws may be considered suitable for the fixation of ST transverse fractures at fracture levels 10 to 40 mm below the lesser trochanter in normal bone and 10 to 30 mm in osteoporotic bone, respectively, under the assumptions of anatomical reduction at fracture gap ≤ 3 mm. However, the fracture gap should be shortened to the minimum to reduce the risk of refracture and fixation failure, especially in osteoporotic fractures.

To investigate the surgical outcomes of anatomical anterior cruciate ligament (ACL) reconstruction according to the graft isometry measured during surgery.Electrical medical records of patients who underwent an arthroscopic ACL reconstruction through the transportal technique using hamstring tendon autograft between 2012 and 2016 were retrospectively reviewed. The patients were classified into two groups based on the graft length change throughout the knee range of motion measured just before graft fixation (Group 1, graft length change ≤ 2 mm; Group 2, graft length change 2 mm). Comparative analyses, including a non-inferiority trial, were performed regarding the clinical scores, knee laxity, and radiographic parameters between the groups.A total of 67 patients were included in the study. The total change in the length of ACL graft throughout the knee range of motion was 1.4 ± 0.4 mm in Group 1 (range, 0.2-2.0 mm), and 3.0 ± 0.7 mm in Group 2 (range, 2.2-5.0 mm). Group 1 showed a relatively high (proximal) femoral tunnel and shallow (anterior) tibial tunnel compared to Group 2 (P 0.001 and P = 0.028, respectively), but there were no apparent differences in the macroscopic view. There were no statistically significant differences in the clinical outcomes between groups at 2 years after surgery, which satisfied the non-inferiority criterion of Group 1 in terms of clinical scores and knee laxity compared to Group 2.The surgical outcomes of anatomical ACL reconstruction in patients with non-isometric ACL graft were not inferior in terms of clinical scores and knee laxity, compared to those with nearly-isometric ACL graft. The graft tunnel placement in the isometric position during anatomical ACL reconstruction, which is technically challenging in the clinical setting, is not a crucial factor in terms of clinical outcomes.Level IV.

To investigate the surgical outcomes of anterior cruciate ligament (ACL) reconstruction using a low-dose irradiated tibialis anterior allograft with a fixed-loop cortical suspension device for the femur based on the graft insertion length (GIL) in the femoral tunnel.Between January 2010 and January 2018, the medical records of consecutive patients who underwent arthroscopic ACL reconstruction with a tibialis anterior allograft fixed with the EndoButton CL for the femur and who had at least 2 years of follow-up were retrospectively evaluated. Patients were classified into 3 groups based on the GIL in the femoral tunnel (group 1, GIL15 mm; group 2, GIL of 15-20 mm; and group 3, GIL20 mm), and their functional scores, knee laxity, and radiographic parameters were evaluated.A total of 91 patients were analyzed. There were no statistically significant differences in the functional scores and knee laxity between the 3 groups at 2 years postoperatively. However, significant differences were observed in tunnel widening at 1 year postoperatively in the femur (P = .045 for absolute value and P = .004 for relative value) and the tibia (P = .014 for absolute value and P = .012 for relative value), revealing that both the femoral and tibial tunnels widened as the GIL decreased. Additional linear regression analyses were performed to identify whether the GIL independently affects tunnel widening. Consequently, the femoral tunnel depth, tunnel diameter, and GIL were found to independently influence femoral tunnel widening (P = .008, P = .019, and P.001, respectively), whereas the tunnel diameter and GIL affected tibial tunnel widening (P.001 and P = .004, respectively).The GIL in the femoral tunnel during ACL reconstruction using a tibialis anterior allograft with a fixed-loop cortical suspension device for the femur has no significant association with the postoperative functional outcomes and knee laxity, but it has a negative correlation with tunnel widening in the femur and the tibia.Level III, retrospective cohort study.

Purpose To investigate relevant factors influencing increases in medial joint space width (JSW) after medial open-wedge high tibial osteotomy (MOWHTO). Methods Between January 2010 and December 2018, the electronic medical records of consecutive patients who underwent MOWHTO and subsequent second-look arthroscopic assessment at least 12 months after MOWHTO were retrospectively evaluated. The patients were classified into 2 groups according to changes in the medial JSW of the knee at the time of the second-look operation compared with that at baseline before the initial surgical procedure. Various radiographic parameters, arthroscopic findings, and clinical scores were compared between the groups, and regression analysis was performed to identify factors related to increases in medial JSW. Results A total of 114 patients were analyzed. In a bivariate analysis, patients who experienced an increase in medial JSW showed a significantly higher postoperative weight-bearing line ratio (WBLR) (P = .008) and a greater proportion of severe preoperative cartilage lesions in the medial compartment of the knee compared with patients with a maintained or reduced medial JSW (P = .035). In terms of clinical scores, patients with an increased medial JSW showed relatively favorable clinical outcomes at the time of the second-look operation. Regression analysis indicated only postoperative WBLR as a relevant factor associated with an increase in medial JSW after MOWHTO (odds ratio, 1.057; P = .01). Additional analysis with patients reclassified according to the postoperative WBLR showed that as the postoperative WBLR increased, the medial JSW increased, without a significant change in the lateral JSW. Conclusions An increase in the medial JSW of the knee joint after MOWHTO appears to be associated with an increase in the postoperative WBLR, not with cartilage regeneration. Obtaining adequate correction so that the postoperative WBLR is within 60% to 70% would be desirable in terms of postoperative changes in the medial JSW, as well as clinical outcomes. Level of Evidence Level III, retrospective cohort study.

High tibial osteotomy (HTO) is a well-established treatment for medial compartmental knee osteoarthritis. Several microRNAs (miRNAs) are involved in osteoarthritis progression and are useful as osteoarthritis-related biomarkers. In this prospective study, we investigated differentially expressed microRNAs in the synovial fluid (SF) before and after HTO in patients with medial compartmental knee osteoarthritis to identify microRNAs that can be used as prognostic biomarkers. We used miRNA-PCR arrays to screen for miRNAs in SF samples obtained preoperatively and 6 months postoperatively from 6 patients with medial compartmental knee osteoarthritis who were treated with medial open wedge HTO. Differentially expressed miRNAs identified in the profiling stage were validated by real-time quantitative PCR in 22 other patients who had also been treated with HTO. All patients radiographically corresponded to Kellgren-Lawrence grade II or III with medial compartmental osteoarthritis. These patients were clinically assessed using a visual analogue scale and Western Ontario McMaster Universities scores. Mechanical axis changes were measured on standing anteroposterior radiographs of the lower limbs assessed preoperatively and at 6 months postoperatively. Among 84 miRNAs known to be involved in the inflammatory process, 14 were expressed in all SF specimens and 3 (miR-30a-5p, miR-29a-3p, and miR-30c-5p) were differentially expressed in the profiling stage. These 3 miRNAs, as well as 4 other miRNAs (miR-378a-5p, miR-140-3p, miR-23a-3p, miR-27b-3p), are related to osteoarthritis progression. These results were validated in the SF from 22 patients. Clinical and radiological outcomes improved after HTO in all patients, and only 2 miRNAs (miR-30c-5p and miR-23a-3p) were significantly differentially expressed between preoperative and postoperative 6-month SF samples (p = 0.006 and 0.007, respectively). Of these two miRNAs, miR-30c-5p correlated with postoperative pain relief. This study provides potential prognostic miRNAs after HTO and further investigations should be considered to determine clinical implications of these miRNAs.

Yi-Hwa Choi,1 Dae-Hwan Kim,2 Tae-Young Kim,2 Tae-Wan Lim,1 Seok-Woo Kim,2 Je-Hyun Yoo2 1Department of Anesthesiology and Pain Medicine, Hallym Sacred Heart Hospital, Hallym University College of Medicine, 2Department of Orthopaedic Surgery, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea Purpose: Postoperative delirium is a risk factor for worse outcome after hip fracture surgery in elderly patients. Postoperative delirium is associated with anesthesia, postoperative pain, and patient factors. We investigated the incidence, predictors, and prognostic implications of postoperative delirium after hemiarthroplasty (HA) in elderly patients with femoral neck fracture.Patients and methods: A total of 356 consecutive patients aged >70 years who underwent HA for femoral neck fracture were enrolled. Diagnosis of delirium was made by a psychiatrist based on patient status and an objective scoring system. The patients were divided into 2 categories according to the HA onset time (immediate [≤24 h after surgery] vs delayed delirium [>24h after surgery]) and its incidence, predictors and mortality were evaluated.Results: Postoperative delirium was diagnosed in 110 patients (30.9%) during hospitalization. Immediate and delayed delirium occurred in 59 (53.6%), and 51 (46.4%) patients, respectively. The independent predictors of immediate delirium included age (odds ratio [OR] 1.47, 95% CI 0.98–2.23, p=0.066), and general anesthesia (OR 2.25, 95% CI 1.17–4.43, p=0.015). The independent predictors of delayed delirium were parkinsonism (OR 5.75, 95% CI 1.66–19.96, p=0.006), intensive care unit stay (OR 1.85, 95% CI 0.97–3.56, p=0.064), and higher American Society of Anesthesiologists grade (OR 2.33, 95% CI 0.90–6.07, p=0.083). On Kaplan–Meier survival analysis, the 2-year survival rate was significantly lower in the immediate delirium group than those in the delayed and control groups (71.0% vs 83.6% vs 87.8%, respectively; p=0.031).Conclusion: Immediate and delayed delirium after HA for femoral neck fracture had different predictors and immediate delirium was associated with worse prognosis. Keywords: delirium, elderly patients, femoral neck fracture, hemiarthroplasty

Background Context Prevertebral soft tissue swelling (PSTS) after anterior cervical spine surgery (ACSS) has been regarded as one of the critical complications that cause airway obstruction. Still, however, no research has dealt with how PSTS returns to presurgery status after ACSS; most recommendations are being performed without information about its natural course, focusing on acute-phase swelling after surgery. Purpose The study aimed to examine how long postsurgery PSTS lasts and when it returns to its presurgery state, and to analyze the actual influence of a number of factors to observe the natural progress of postsurgery PSTS. Study Design/Setting This is a prospective observational study. Patient Sample The sample included a total of 160 patients who underwent ACSS, including anterior cervical discectomy and fusion (ACDF) and cervical total disc replacement (TDR). Outcome Measures The diameter of PSTS measured at each set time point after surgeries was compared with PSTS measurements before surgery, and analyzed with factors influencing PSTS. Methods Anterior and posterior diameters of the anterior soft tissue of C3 (pharyngeal airway) and C6 (laryngeal airway) were measured using simple lateral radiography before surgery, immediately after surgery, at 2 weeks, 1, 3, 6, and 12 months after surgery. The progress of postsurgery PSTS was analyzed according to patients' individual characteristics, such as age, gender, weight, body mass index (BMI), smoking status, use of antiplatelet therapy, hypertension and diabetes mellitus, complaints of dysphagia, along with surgical factors such as anesthesia time, operation time, numbers of involved operation segments, transfusion, estimated blood loss , and operation method. Multivariable analysis by generalized linear mixed model was used to perform additional univariable analysis on variables found to be related to PSTS. In addition, to find the postsurgery interval at which PSTS naturally stabilizes, repeated measures analysis of variance and Bonferroni method were used to perform post-hoc tests. There were no sources of funding and no conflicts of interest associated with this study. Results For ACDF, the mean values (95% confidence interval [CI]) of PSTS in C3 were 4.38 (4.04~4.71), 10.40 (9.64~11.17), 7.72 (7.10~8.35), 6.24 (5.74~6.69), 5.43 (5.03~5.82), 5.14 (4.77~5.50), and 4.96 (4.59~5.33) mm at each follow-up time, respectively. In C6, the average values (95% CI) of PSTS were 14.43 (13.96~14.91), 19.18 (18.59~19.77), 17.92 (17.37~18.47), 16.98 (16.45~17.51), 16.18 (15.67~16.69), 15.95 (15.50~16.40), and 15.49 (15.50~16.40) mm. For cervical TDR, the mean values (95% CI) of PSTS in C3 were 3.67 (3.45~3.89), 8.05 (7.17~8.93), 5.42 (4.92~5.91), 4.57 (4.21~4.92), 4.12 (3.99~4.36), 4.10 (3.87~4.34), and 3.90 (3.66~4.14) mm at each follow-up time, respectively. In C6, the average values (95% CI) of PSTS were 13.61 (12.96~14.25), 16.51 (15.80~17.21), 15.77 (15.13~16.42), 15.24 (14.61~15.87), 14.62 (14.01~15.22), 14.52 (13.88~15.17), and 13.94 (13.20~14.68) mm. It is discovered that PSTS after surgery returned to presurgery status within 1 to 3 months in the pharyngeal airway (C3) and within 3 to 6 months in the laryngeal airway (C6), and gender, BMI, and surgery method (ACDF) were determined to be the factors having influence on PSTS after surgery. Conclusions It is necessary to pay attention to PSTS and patient conditions after ACSS for at least 1 to 6 months postsurgery, depending on surgical method and operation levels.

To determine the functional relevance of diffusion tensor imaging (DTI) metrics and conventional MRI (signal intensity change in T2, compression ratio) by measuring the correlation of these parameters with clinical outcome measured by the modified Japanese Orthopedic Association (mJOA) score. A total of 20 cervical myelopathy (CM) patients participated in this prospective cohort study. The severities of CM were assessed using the mJOA score. Conventional MRIs (T2-weighted images) measuring the signal changes of spinal cords and the degree of compression at the lesion level and DTI metrics [fractional anisotropy (FA), apparent diffusion coefficient (ADC)] at each lesion and below each lesion (C7/T1) level were acquired using a 3-T Achieva MRI. These parameters were correlated with the mJOA scores to determine the functional relevance. Ninety percent of CM patients showed signal changes and 30 % of patients noted a more than 40% canal compression ratio in conventional MRIs at the lesion level; however, these findings were not correlated with the mJOA score (p

Background Management of atypical femoral fracture on bisphosphonate therapy still remains controversy and is reported high rate of complications. The aim of this study was to evaluate the outcome of intramedullary nailing in patients with atypical femoral fracture who took bisphosphonate more than one year through the multicenter retrospective study. Methods We gathered 75 atypical femoral fractures from seven institutions between 2009 and 2014. Among them 46 atypical femoral fractures which met the inclusion criteria was evaluated in this study. The average age was 70.1 years (53–80) and the average duration of bisphosphonate use was 5.1 years (1–15 years). Medical records and radiographs were reviewed to determine time to union, union rate, need for revision surgery, restoration of ambulatory function, and complications. Results Twenty-nine (63%) fractures healed within 6 months without complications. The average time to union except two non-union was 24.9 weeks (11–48 weeks). Two patients (4.3%) underwent revision surgery for non-union and there was no implant failure. Thirty-seven (80.4%) patients achieved their pre-fracture ambulatory function at the final follow up. Conclusions Although the incidence of delayed bone healing is high in atypical femoral fracture on bisphosphonate therapy even treated with intramedullary nailing, the incidence of revision surgery and implant failure was relatively lower than those of extramedullary devices.

Displaced femoral neck fracture in elderly patients has been treated with hemiarthroplasty as the treatment of choice. Fever following HA is common in these elderly patients. The aim of this study was to determine which post-HA fever workup could be beneficial in this group of patients.A total of 272 consecutive patients aged ≥70 years undergoing HA for displaced femoral neck fracture were retrospectively investigated. Postoperative fever (POF) was defined as any recorded body temperature ≥38°C in the early postoperative period. POF in each patient was characterized by the maximum temperature, the day of the first fever, and frequency of fever, stratified as either single or multiple fever spikes. Medical records were reviewed to identify positive fever workups and febrile complications.Of 272 patients, 135 (49.6%) developed POF. A total of 428 routine diagnostic tests were performed in all patients with POF, of which only 57 tests (13.3%) were positive. Urinalysis showed the highest positive rate (21.9%), followed by urine culture (14.3%), chest x-ray (12.6%), and blood culture (1.1%). The most common febrile complication was pneumonia (12.6%), followed by urinary tract infection (8.1%). On multivariate logistic regression for positive workups, only fever after postoperative day (POD) 2 was a risk factor for positive chest x-ray (OR 3.86, p=0.016) and urine culture (OR 5.04, p=0.019). Moreover, fever after POD 2 (OR 6.93, p0.0001) and multiple fever spikes (OR 2.92, p=0.026) were independent predictors of infectious febrile complications.Routine workup for POF following hemiarthroplasty in elderly patients with displaced femoral neck fracture is not warranted. However, for fever after POD 2 and multiple fever spikes, chest x-ray and urinalysis would be necessary to rule out the two most common febrile complications such as pneumonia and urinary tract infection.