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Background: Intrapelvic hemorrhage following pelvic fractures, including pelvic ring and acetabular fractures, originates from the venous system and the fracture. Arterial injury often causes significant bleeding and hemodynamic instability. The superior gluteal artery (SGA) is a frequently injured artery in patients with pelvic fractures. This study investigated the incidence and pattern of SGA injuries associated with pelvic fractures., Methods: We retrospectively reviewed the medical records of patients with pelvic fractures who visited our institution between January 2016 and April 2022. Patients who underwent angiography for suspected arterial injury and SGA embolization were identified. Furthermore, the demographics and patterns of pelvic fractures were evaluated., Results: In total, 2042 patients with pelvic fractures visited our trauma emergency department and 498 patients (24.4%) underwent embolization for arterial injuries. Of these, 30 patients (1.5% of the total and 6.0% of the patients who underwent procedures) received embolization therapy of the main trunk of the SGA. The mean age of patients was 51.2 (23-85 years), and the injury mechanisms were all high-energy injuries. There were 19 pelvic ring injuries, eight acetabular fractures, and three combined injuries. Acetabular fractures involved mostly both columns. The three combined injuries were lateral compression involving both columns, vertical shear involving both columns, and lateral compression with T-type fractures. Twelve (40.0%) occurred through the sciatic notch of different patterns., Conclusions: SGA injury occurred in 1.5% of all pelvic fractures and was identified in 6% of patients receiving embolization. SGA injury occurs through various injury mechanisms and fracture patterns, even in the absence of a fracture in the sciatic notch. However, no conclusions could be drawn in this study on the association between SGA injuries, injury mechanisms, and fracture patterns. Since the prediction of SGA injury by fracture pattern is limited, angiography should be performed regardless of fracture pattern when an injury is suspected., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Medial opening-wedge high tibial osteotomy (MOWHTO) is performed to treat young adults with medial compartment knee osteoarthritis associated with varus deformity. However, factors influencing joint space width (JSW) vary according to the type of medial meniscal tear and have not yet been completely elucidated., Purpose: To examine changes in JSW according to the type of medial meniscal tear after MOWHTO and analyze the influencing factors., Study Design: Cohort study; Level of evidence, 3., Methods: This study was conducted on 134 patients who underwent MOWHTO for medial osteoarthritis and were followed up for >2 years. The patients were classified into 3 groups based on medial meniscal status: intact, nonroot tear, and root tear. The authors then measured the JSW preoperatively and at 3 months, 6 months, 1 year, and >2 years postoperatively; analyzed whether the change in JSW varied according to meniscal status; and determined the association of these changes with the preoperative cartilage grade of the medial femoral condyle (MFC) and medial tibial plateau (MTP). International Knee Documentation Committee (IKDC) scores were used to evaluate clinical function., Results: Of the 134 patients, the medial meniscus was intact in 29 patients, a nonroot tear was observed in 58 patients, and a root tear was observed in 47 patients. Postoperatively, JSW increased for all groups, but the timing of the increase varied between the groups ( P < .001). JSW increased the most 6 months postoperatively in the intact group and 3 months postoperatively in the nonroot tear and root tear groups ( P < .001). Additionally, the increase in JSW was the greatest in the root tear group. Preoperatively, MFC and MTP cartilage status differed among the groups; MTP status did not affect the JSW, but MFC status did ( P < .001). The IKDC score increased from the preoperative to postoperative time point in all groups, but there was no significant difference between groups., Conclusion: The authors observed that the amount and timing of increase in JSW were dependent on the pattern of medial meniscal tear observed when MOWHTO was performed. In addition, the cartilage grade of MFC before surgery was associated with changes in JSW. The IKDC score was not significantly different between groups. However, a longer follow-up period is needed to analyze the correlation with the meniscal tear pattern and JSW., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI19C1085) and by a 2023 research grant from Pusan National University Yangsan Hospital. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

The use of a large femoral head in total hip arthroplasty (THA) to stabilize and reduce the incidence of dislocation is on the increase, but concerns arise when combining them with small acetabular components due to potential mechanical failures in thin polyethylene (PE) liners. A single-institution, retrospective cohort study was conducted on 116 patients with minimum 2-year follow-up who received 36-mm femoral heads and acetabular components ≤ 52 mm, using either remelted highly cross-linked polyethylene (remelted HXLPE) or vitamin E-infused HXLPE (VEPE). Osteolysis and implant loosening were not observed in either group. Although a fracture of the PE liner was observed in each group (1.7%), the clinical outcomes were excellent, as the mean modified Harris Hip Score (mHHS) at the last follow-up was 93.5. Moreover, the mean linear wear rates measured by digital imaging software in both groups were low, with 0.035 mm/y in remelted HXLPE and 0.030 mm/y in VEPE. In conclusion, The use of a large femoral head on a thin PE liner can be a viable treatment option in patients who need to prioritize stability; however, careful attention should be paid to mechanical fractures of the PE liner., (© 2023. The Author(s).)

Total hip replacement arthroplasty (THA) in hip dysplasia patients has a higher dislocation rate than in patients with simple hip osteoarthritis due to anatomical deformation. Therefore, to reduce postoperative THA dislocation is the challenge for arthroplasty surgeons. From 2015 to 2020, 1525 patients underwent THA performed by two surgeons at a single institution. A total of 152 patients involving 172 THAs were included. The patients were classified into dual-mobility (DM) and fixed-bearing (FB) acetabular cup groups. The occurrence of postoperative dislocation and functional evaluation of the hip joint, was analyzed before and after surgery using the modified Harris hip score(mHHS). There was no difference in the preoperative demographics and radiographic parameters between the groups. The incidence of postoperative hip dislocation was significantly lower in the DM group (DM 0% vs. FB 9.0%) (P value = 0.003). The mHHS showed no difference before surgery and after surgery (DM 91.80 vs FB 92.03). Treating hip dysplasia patients with THA using a dual-mobility acetabular cup can reduce postoperative dislocations, and could be used for the better management of these patients., (© 2023. The Author(s).)

This meta-analysis demonstrated that a greater prevalence of delayed union and nonunion and a longer time to fracture healing in the group that did not receive TPTD treatment after AFFs than in the group that received TPTD treatment., Purpose: To date, there is no hard evidence for medical management after atypical femoral fracture (AFF), even though weak data indicate faster healing with teriparatide (TPTD). Herein, we aimed to investigate the effect of postfracture TPTD treatment on AFF healing using a pairwise meta-analysis focusing on delayed union, nonunion, and fracture healing time., Methods: A systematic search of the MEDLINE (PUBMED), Embase, and Cochrane Library databases was performed for studies investigating the effect of TPTD after AFF up to October 11, 2022. We compared the incidence of delayed union and nonunion and the time of fracture healing between the TPTD ( +) and TPTD (-) groups., Results: The 6 studies analyzed a total of 214 AFF patients, including 93 who received TPTD therapy after AFF and 121 who did not. The pooled analysis showed a significantly higher rate of delayed union in the TPTD (-) group than in the TPTD ( +) group (OR, 0.24; 95% CI, 0.11-0.52; P < 0.01; I 2  = 0%), and a higher nonunion rate was observed in the TPTD (-) group than in the TPTD ( +) group with low heterogeneity (OR, 0.21; 95% CI, 0.06-0.78; P = 0.02; I 2  = 0%). The TPTD (-) group required 1.69 months longer to achieve fracture union than the TPTD ( +) group, with statistical significance (MD =  - 1.69, 95% CI: - 2.44 to - 0.95, P < 0.01; I 2  = 13%). Subgroup analysis for patients with complete AFF showed that the TPTD (-) group had a higher rate of delayed union with low heterogeneity (OR, 0.22; 95% CI, 0.10-0.51; P < 0.01; I 2  = 0%), but there was no significant difference in the nonunion rate between TPTD ( +) and TPTD (-) groups (OR, 0.35; 95% CI, 0.06-2.21; P = 0.25; I 2  = 0%). Fracture healing took significantly longer in the TPTD (-) group (MD =  - 1.81, 95% CI: - 2.55 to - 1.08; P < 0.01; I 2  = 48%). The reoperation rate showed no significant difference between the two groups (OR, 0.29; 95% CI, 0.07-1.20; P = 0.09; I 2  = 0%)., Conclusions: The current meta-analysis supported the hypothesis that TPTD treatment following AFF might benefit fracture healing, lowering the rate of delayed union and nonunion and shortening the fracture healing time., (© 2023. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

One of the key aspects of the diagnosis and treatment of atypical femoral fractures is the early detection of incomplete fractures and the prevention of their progression to complete fractures. However, an incomplete atypical femoral fracture can be misdiagnosed as a normal lesion by both primary care physicians and orthopedic surgeons; expert consultation is needed for accurate diagnosis. To overcome this limitation, we developed a transfer learning-based ensemble model to detect and localize fractures. A total of 1050 radiographs, including 100 incomplete fractures, were preprocessed by applying a Sobel filter. Six models (EfficientNet B5, B6, B7, DenseNet 121, MobileNet V1, and V2) were selected for transfer learning. We then composed two ensemble models; the first was based on the three models having the highest accuracy, and the second was based on the five models having the highest accuracy. The area under the curve (AUC) of the case that used the three most accurate models was the highest at 0.998. This study demonstrates that an ensemble of transfer-learning-based models can accurately classify and detect fractures, even in an imbalanced dataset. This artificial intelligence (AI)-assisted diagnostic application could support decision-making and reduce the workload of clinicians with its high speed and accuracy., (© 2023. The Author(s).)

Background: Outcomes for patients with femoroacetabular impingement (FAI) treated with hip arthroscopy can differ depending on whether there is underlying intra-articular pathology., Purpose: To evaluate the outcomes of patients after undergoing hip arthroscopy depending on their underlying pathology (isolated FAI, isolated labral tear, or combined FAI and a labral tear) using the 12-Item International Hip Outcome Tool (iHOT-12)., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 75 patients diagnosed with FAI with or without labral tears and isolated labral tears who underwent hip arthroscopy performed by the same surgeon at a single institution from January 2014 to December 2019 were included in this study. All patients had at least 2 years of follow-up data. Patients were divided into 3 groups as follows: patients with FAI and an intact labrum; patients with an isolated labral tear; and patients with combined FAI and a labral tear. The iHOT-12 scores at 1.5, 3, 6, 12, 18, and >24 months postoperatively were compared and analyzed. Outcome scores were also evaluated in terms of the substantial clinical benefit (SCB) and the patient-acceptable symptomatic state (PASS)., Results: Of 75 patients who underwent hip arthroscopy, 14 had FAI, 23 had labral tears, and 38 had both. All groups showed significant improvements on the iHOT-12 from preoperative to the final follow-up (FAI, from 37.64 ± 3.77 to 93.64 ± 1.50; labral tear, from 33.70 ± 3.55 to 93 ± 1.24; combined, from 28.55 ± 3.15 to 93.03 ± 0.88) ( P < .001 for all). However, compared with other groups, the patients with FAI and a labral tear had lower scores at 1.5, 3, 6, and 12 months postoperatively ( P < .001), highlighting a slower rate of recovery. For all groups, recovery to normal function according to the SCB was 100% at 12 months, and satisfaction according to the PASS was 100% at 18 months postoperatively., Conclusion: The final iHOT-12 scores were similar at 18 months regardless of the pathology treated; however, patients with FAI and a labral tear took longer to reach their plateau., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This study was supported by the Research Institute for Convergence of Biomedical Science and Technology (30-2022-011), Pusan National University Yangsan Hospital. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

The aim of this study was to conduct a meta-analysis of randomized controlled trials (RCTs) for comparison of the effectiveness of pericapsular nerve group (PENG) block with that of other analgesic techniques for reduction of postoperative pain and consumption of opioids after total hip arthroplasty (THA). A search of records in the PubMed, Embase, and Cochrane Library, and ClinicalTrials.gov databases was conducted in order to identify studies comparing the effect of the PENG block with that of other analgesics on reduction of postoperative pain and consumption of opioids after THA. Determination of eligibility was based on the PICOS (participants, intervention, comparator, outcomes, and study design) criteria as follows: (1) Participants: patients who underwent THA. (2) Intervention: patients who received a PENG block for management of postoperative pain. (3) Comparator: patients who received other analgesics. (4) Outcomes: numerical rating scale (NRS) score and opioid consumption during different periods. (5) Study design: clinical RCTs. Five RCTs were finally included in the current meta-analysis. Significantly lower postoperative opioid consumption at 24 hours after THA was observed in the group of patients who received the PENG block compared with the control group (standard mean difference=-0.36, 95% confidence interval -0.64 to -0.08). However, no significant reduction in NRS score at 12, 24, and 48 hours after surgery and opioid consumption at 48 hours after THA was observed. The PENG block showed better results for opioid consumption at 24 hours after THA compared with other analgesics., Competing Interests: CONFLICT OF INTEREST: The authors declare that there is no potential conflict of interest relevant to this article., (Copyright © 2023 by Korean Hip Society.)

Background: The primary objective of the present study was to compare surgical failures of intertrochanteric fractures of the femur through a meta-analysis of randomized controlled trials and to assess the change in surgical outcomes over time in a cumulative meta-analysis., Methods: To identify studies evaluating the surgical outcomes of internal fixation using sliding hip screws (SHS) or cephalomedullary (CM) nails for the treatment of intertrochanteric fractures of the femur, all records until August 2021 in the PubMed, Embase, and Cochrane Library databases were searched. Studies with the following characteristics were considered eligible: patients who had an intertrochanteric fracture of the femur (population); patients who received surgical treatment using a CM nail (intervention); patients who received surgical treatment using SHS (comparator); surgical failures that required reoperation, including cut-out or cut-through of lag screws, varus collapse or posterior angulation of proximal fragments, loosening of lag screws or helical blades, and fracture nonunion (outcomes); and two reviewers independently reviewed the titles and abstracts of the randomized controlled trials and selected relevant studies for a full-text review (study design)., Results: Twenty-one studies were included in the final analysis consisting of 1,777 cases in the SHS group and 1,804 cases in the CM nail group. The cumulative standard mean difference was 0.87, indicating that CM nails had no significant effect in improving the surgical outcomes. There was no significant difference in surgical failure between SHS and CM nails for all intertrochanteric fractures (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.76-1.49). Pooled data showed no significant difference between the two groups in terms of surgical failure in unstable intertrochanteric fractures (OR, 0.80; 95% CI, 0.42-1.54)., Conclusions: Although the use of CM nails has become a current trend in the treatment of intertrochanteric fractures, there is no literature supporting their clinical superiority when compared with SHS., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported., (Copyright © 2023 by The Korean Orthopaedic Association.)

Background: This study investigated the results of component asymmetry (CA) in bilateral cementless total hip arthroplasty (THA)., Methods: This study included 300 patients, who underwent bilateral cementless THA between April 2000 and December 2017. They were divided into the component symmetry (CS) and CA groups; CA group was sub-classified into acetabular component asymmetry (ACA) and femoral component asymmetry (FCA). Radiologic and clinical outcomes of the CA group were compared with those of the CS group., Results: The incidence of CA was 25.7% (77/300 patients), including 55 patients with ACA, 34 patients with FCA, and 12 with both components asymmetric. The mean time interval between operations in the CA group was significantly longer than that in the CS group ( p < 0.001). The mean differences in horizontal and vertical distances from teardrop to the center of rotation of the acetabular component between both hips in the ACA group were significantly larger than those in the CS group ( p = 0.033 and p < 0.001, respectively). The mean femoral component alignment angle difference between both hips was significantly larger in the FCA group than in the CS group ( p < 0.001). The mean Harris Hip Score at last follow-up of the CA group was similar to that of the CS group., Conclusions: CA in patients undergoing bilateral cementless THA was not rare, especially with a longer time interval between operations. Regardless of CA, when stable fixation of the components was achieved, satisfactory radiologic and clinical outcomes were obtained., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported., (Copyright © 2023 by The Korean Orthopaedic Association.)

Osteoporosis and osteoporotic fractures cause socioeconomic concerns, and medical system and policies appear insufficient to prepare for these issues in Korea, where the older adult population is rapidly increasing. Many countries around the world are already responding to osteoporosis and osteoporotic fractures by adopting fracture liaison service (FLS), and such an attempt has only begun in Korea. In this article, we introduce the operation methods for institutions implementing FLS and characteristics of services, and activities of the FLS Committee for FLS implementation in the Korean Society for Bone and Mineral Research. In addition, we hope that the current position statement will contribute to the implementation of FLS in Korea and impel policy changes to enable a multidisciplinary and integrated FLS operated under the medical system.

The aim of this study was to provide helpful information for use in selection of an appropriate medication after osteoporotic fractures through conduct of a literature review. In addition, a review of the recommendations of several societies for prevention of subsequent fractures was performed and the appropriate choice of medication for treatment of atypical femur fractures was examined. Clinical perspective was obtained and an updated search of literature was conducted across PubMed and MEDLINE and relevant articles were selected. The articles were selected manually according to relevance, and the references for identified articles and reviews were also evaluated for relevance. The following areas are reviewed: Commonly prescribed osteoporosis medications: BPs (bisphosphonates), denosumab, and SERMs (selective estrogen receptor modulators) in antiresorptive medications and recombinant human parathyroid hormone teriparatide, recently approved Romosuzumab in anabolic agents, clinical practice guidelines for the management of osteoporosis, osteoporotic fracture, and atypical femur fracture. Most medications for treatment of osteoporosis do not delay fracture healing and the positive effect of teriparatide on fracture healing has been confirmed. In cases where an osteoporotic fracture is diagnosed, risk assessment should be performed for selection of very high-risk patients in order to prevent subsequent fractures, and administration of anabolic agents is recommended., Competing Interests: CONFLICT OF INTEREST: The authors declare that there is no potential conflict of interest relevant to this article., (Copyright © 2022 by Korean Hip Society.)

Introduction: The aim of the present study was to introduce surgical technique using long PFNA for the treatment of ipsilateral intertrochanteric and femoral shaft fractures, and evaluate the characteristics of this fracture by comparing its surgical outcomes with those of isolated intertrochanteric and femoral shaft fractures., Materials and Methods: Between March 2013 and December 2018, 38 patients with ipsilateral intertrochanteric and femoral shaft fracture were identified at two institutions. Twenty-eight patients with ipsilateral intertrochanteric and femoral shaft fractures were enrolled in the present study. After propensity score matching, fifty-six patients with isolated intertrochanteric (group B) and femoral shaft (group C) fractures were finally enrolled in the present study for 1:2 matching to compare surgical outcomes to that of ipsilateral intertrochanteric and femoral shaft fractures (Group A)., Results: All 28 patients achieved union of intertrochanteric fractures, while two experienced non-union of femoral shaft fractures. The union time of intertrochanteric fractures in group A was significantly shorter than that in group B. The union time of femoral shaft fractures in group A was significantly longer than that in group C., Conclusions: The surgical treatment of ipsilateral intertrochanteric and femoral shaft fractures using long PFNA was advantageous as it allowed both fractures on the same femur to be fixed in one go and showed good surgical outcomes. However, fixation of femoral shaft fractures might be insufficient depending on the fracture level and configuration, and can be a cause of hypertrophic non-union., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: This study aimed to report the surgical outcomes in patients with high-energy induced subtrochanteric fracture and determine the risk factors for nonunion using statistical analysis., Methods: This study evaluated 88 patients with high-energy induced subtrochanteric fractures who underwent surgeries with indirect reduction technique and intramedullary nailing between March 2015 and December 2020. Outcome measures, including union time and nonunion incidence, were assessed by radiologic evaluation. Multiple logistic regression analyses were performed to identify the risk factors for nonunion, using age, sex, injury severity score, body mass index, preoperative mobility score, implant, and isthmic fixation as covariates., Results: Five nonunions and two delayed unions were identified. The average union time was 17.4 weeks. Multiple logistic regression analyses showed that poor isthmic fixation was the only risk factor for nonunion (odds ratio 15.294, 95% confidence interval 1.603-145.894, P value 0.018). Out of five nonunion cases, four were confirmed as hypertrophic, and one was confirmed as atrophic., Conclusion: Although surgical treatment using an indirect reduction technique and intramedullary nailing showed good outcomes, hypertrophic nonunion due to distal instability could occur if a firm fixation at the level of the isthmus cannot be achieved., Level of Evidence: Level III, retrospective cohort study., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To evaluate the efficacy of peripheral nerve block on reduction in opioid consumption and pain control after hip arthroscopy., Method: To identify studies evaluating the effects of peripheral nerve block on pain control and reduction in opioid consumption in hip arthroscopy, we searched all records in the PubMed, Embase, and Cochrane Library databases until May 2021. Studies with the following characteristics were considered eligible: 1) patients who underwent a hip arthroscopy (population); 2) patients who received peripheral nerve block (intervention); 3) patients who did not receive peripheral nerve block (comparator); 4) record of total opioid consumption as a primary outcome and pain level at 1, 3 to 6, and 24 hours after surgery, patient satisfaction, and incidence of nausea and vomiting as secondary outcomes (outcomes); and 5) randomized controlled trial (study design). Data were independently extracted by two reviewers and synthesized using a random or fixed-effects model, according to the heterogeneity., Results: Eight RCTs were finally included in the meta-analysis. There were no significant differences in postoperative opioid consumption at 24 hours (standardized mean difference [SMD] = -0.091, 95% confidence interval [CI] [-0.270, 0.089]) or in visual analog scale (VAS) score at 1 (SMD = 0.299, 95% CI [-0.758, 0.160]), 3 to 6 (SMD = -0.304, 95% CI [-0.655, 0.047]), and 24 (SMD = -0.230, 95% CI [-0.520, 0.060]) hours postoperatively between the peripheral nerve block and control groups. Moreover, no significant differences were observed in patient satisfaction (SMD < 0.001, 95% CI [-0.284, 0.284]) or the incidence of nausea and vomiting (SMD = 0.808, 95% CI [0.311, 2.104]) between the two groups., Conclusion: Peripheral nerve block for hip arthroscopy has no clinical advantage regarding pain management after surgery when compared with the group that received the local infiltration of analgesics without peripheral nerve block., Level of Evidence: Level II, meta-analysis of level I and II randomized controlled trials (RCTs)., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

This study aimed to evaluate the early results of primary total hip arthroplasty (THA) using dual mobility (DM) cups in patients at a risk of dislocation and compare them with that of fixed bearing (FB) THA. This retrospective study included patients who had undergone primary THA between January 2016 and December 2018 and were at a risk of dislocation. A propensity score-matched analysis was conducted for 63 THA procedures with vitamin-E infused highly cross-linked polyethylene (VEPE) DM bearing and 63 THA procedures performed with FB from the same manufacturer for a mean follow-up period of 3.1 and 3.5 years, respectively. The radiologic outcomes at the last follow-up and incidence of postoperative complications were evaluated and compared statistically between the two groups. The modified Harris hip score (mHHS) was used to assess patient-reported outcomes. Postoperative dislocation occurred in 4 cases (6.3%) in the FB group, but did not occur in the DM group (p = 0.042). There was no difference in the radiologic outcomes and postoperative complications between the two groups. The mHHS at the last follow-up showed satisfactory outcomes in both the groups (DM group, 90.5; FB group, 88.1), without a statistical difference between the groups. The early results of THA using VEPE DM bearing showed better outcomes than that of THA with FB for patients at a risk of dislocation. A longer follow-up period is recommended to assess the stability and overall outcomes., (© 2022. The Author(s).)

Hypothesis: The purpose of this study was to determine the incidence of osseous lesions and the recurrence rate after arthroscopic surgery in shoulder septic arthritis patients and evaluate the influencing factors., Materials and Methods: We retrospectively reviewed 44 patients who underwent arthroscopic surgery for septic arthritis of the shoulder between January 2012 and September 2019. The average age of the patients was 65.57 ± 14.2 years, and 56.8% were female patients. The minimum follow-up period was 12 months (average, 32.8 ± 14.2 months; range, 12-72 months). We assessed variables including sex, age, underlying diseases, duration from symptom onset to magnetic resonance imaging (MRI), duration from symptom onset to surgery, radiologic results (radiography and MRI), history of injection therapy, and postoperative infection. The incidence of osseous lesions and the recurrence rate were calculated according to independent variables. In addition, multivariate logistic regression was performed to identify the risk factors for osseous lesions and recurrent infection after adjustment for other variables., Results: Twenty-one patients had an osseous lesion on MRI, and 12 patients had evidence of bone erosion on radiographs. In univariate analyses, significant (P < .05) risk factors for the presence of osseous lesions were female sex, lower C-reactive protein level, and longer duration from symptom onset to MRI. The overall infection recurrence rate was 22.7% (10 of 44 patients). Culture results and the duration from symptom onset to surgery were significant risk factors for recurrent infection (P < .05). As the duration from symptom onset to MRI increased by 1 day, the probability of osseous lesions increased 1.31-fold (95% confidence interval, 1.08- to 1.59-fold; P = .007), and this probability was significantly higher after correction for other risk factors., Conclusions: To reduce the severity of septic shoulder infection, timely diagnosis and treatment are essential. Even if osseous lesions are present, good results can be obtained if meticulous débridement is performed through arthroscopic surgery. However, functional and radiologic long-term follow-up studies are needed in patients with osseous lesions., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: -Establishing the ideal indications for conservative treatment for elderly patients with valgus impacted femoral neck fractures is difficult because few studies have identified predictive factors for the failure of this treatment method. This study aimed to report the outcomes of conservative treatment for elderly patients with valgus impacted femoral neck fractures and determine risk factors that lead to treatment failure., Methods: -From January 2009 to December 2018, 206 patients with valgus impacted femoral neck fracture were identified at two institutions. Elderly patients with valgus impacted femoral neck fractures corresponding to an Orthopedic Trauma Association/AO Foundation (OTA/AO) classification of 31-B1.1 or 31-B1.2 who were treated conservatively were included in the study. The following data was collected to compare the preoperative characteristics of patients with valgus impacted femoral neck fractures: age, sex, bone mineral density, medical comorbidities (hypertension, diabetes mellitus, ischemic heart disease, arrhythmia, chronic kidney disease [CKD], and stroke), medial cortex displacement, valgus angle, posterior tilt, and retroversion. These data were used to assess the independent predictors for failure of conservative treatment using multiple logistic regression analysis., Results: -The failure rate after conservative treatment for valgus impacted femoral neck fracture in the enrolled patient group was 27.3% (15 of 55). CKD, presence of medial cortex displacement, high posterior tilt, and high retroversion were all identified as independent predictors for failure. The cut-off values for retroversion and posterior tilt that predicted treatment failure were 12.5° (area under curve [AUC] 0.768, p = 0.002, 95% confidence interval [CI] 0.632-0.903, sensitivity 0.733, 1-specificity 0.300) and 7.5° (AUC 0.712, p = 0.016, 95% CI 0.542- 0.881, sensitivity 0.667, 1-specificity 0.325), respectively., Conclusions: -The present study showed that a high union rate could be obtained if the indications for conservative treatment in for elderly patients with valgus impacted femoral neck fractures are well-defined. Thus, we believe that conservative treatment can be a viable option for valgus impacted femoral neck fractures when elderly patients with high-risk comorbidities have acceptable fracture angulation, no medial cortex displacement, and no CKD., Level of Evidence: -Level III, retrospective cohort study., Competing Interests: Conflict of interest There is no conflict of interest in this study., (Copyright © 2021. Published by Elsevier Ltd.)

Rationale: Total hip arthroplasty (THA) with a polyethylene (PE) liner is 1 of the most effective and successful treatment strategies for end-stage hip disorders. Vitamin E-infused highly cross-linked polyethylene is theoretically known to prevent failure due to oxidative degradation in the body, and is resistant to wear; therefore, successful long-term survival of THA is expected., Patient Concerns: In June 2019, approximately 1.5 years after THA, the patient sat down and stood up without any specific issue; however, an unusual bullet sound occurred around the left hip joint. Since then, his discomfort persisted, and he was admitted to the emergency department., Diagnosis: Plain radiography and metal artifact reduction computed tomography performed in the emergency department revealed eccentric elevation of the prosthetic femoral head and suspected PE liner failure., Intervention: Revision surgery was performed for modular component exchange. To reduce the dislocation risk without performing cup exchange, conversion to dual-mobility articulation was performed., Outcomes: During the regular follow-up post-surgery, the patient could perform daily life activities without any discomfort, and dislocation was not observed. At 2 years postoperatively, no significant changes were observed in the radiographic images., Lessons: This case report presents an unexpected failure of THA due to superior rim fracture and excessive wear at the locking mechanism of the vitamin E-infused highly cross-linked polyethylene liner. This is an interesting case, as early PE liner failure occurred without strong labor intensity or trauma. A modular component exchange was performed with a dual-mobility bearing, and no issues were observed approximately 2 years after the reoperation. Therefore, third-generation highly cross-linked polyethylene liners can also cause early failure without a clear cause, and this case report highlights the necessity of considering several strategies for reoperation., Study Design: Case report., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Aims: The prognosis of patients with chronic kidney disease (CKD) and intertrochanteric fractures is unclear. This study was aimed to analyze the mortality and complication rates among CKD patients with intertrochanteric femoral fractures and the risk factors of one-year mortality after surgery., Patients and Methods: This retrospective cohort study included 49 patients diagnosed with grades III, IV, or V CKD who were surgically treated for an intertrochanteric fracture between January 2011 and February 2019 at a tertiary university hospital. Preoperative parameters, including age, gender, bone mineral density, follow-up period (mean: 8.6 months range: 1~82 months), underlying disease, American Society of Anesthesiologists classification, fracture classification, and grade of CKD were identified, and complications and mortality rates after surgery were examined. The patients were divided into two groups according to whether one-year mortality after surgery had occurred or not, and a logistic regression analysis was performed to analyze the risk factors of mortality., Results: Of the 49 total patients, 16 died <1 year postoperatively. Pneumonia (n = 11) was the most common postoperative complication. Twenty-one patients died during the follow-up period. Significant differences in gender (p = 0.006) and grade of CKD (p = 0.022) distributions were found between the two groups, divided according to whether one-year mortality had occurred or not. In a univariate analysis, CKD grade and postoperative septic shock were highly associated with one-year mortality. In a multivariate analysis, septic shock, acute kidney injury, and CKD grade were identified as the risk factors of one-year mortality., Conclusion: The mortality and complication rates were high among the CKD patients with intertrochanteric fractures. Grades of CKD significantly correlated with one-year mortality after surgery; therefore, they and an important factor that must be considered when developing a strategy to improve the postoperative survival rate of patients with CKD., Competing Interests: Declarations of Competing Interest None., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Although highly positive results for wear reduction of highly cross-linked polyethylene (HXLPE) have been reported around the 10-year follow-up, the long-term result related to reoperation and wear-related survival is still an issue. Therefore, this study aimed to compare the follow-up results of a single manufacture's polyethylene liner for >15 years in terms of survival and wear rate., Methods: This retrospective cohort study included 134 primary total hip arthroplasties (THAs) who were followed up for at least 15 years. The mean age at the time of surgery was 50.7 years (conventional polyethylene [CPE] group = 22; HXLPE group = 112). Linear and volumetric wear rates of polyethylene were measured, and the reoperation rate and radiographic osteolysis were evaluated and Kaplan-Meier survival analysis was performed in both groups. Implant-related complications were also examined., Results: HXLPE group showed a significantly lower wear rate in both linear and volumetric wear. None of the hip radiographs showed evidence of loosening or osteolysis in the HXLPE group. The survival rates at 15- to 18-year follow-up were 90.9% and 95.5% in the CPE and HXLPE groups when all-cause reoperation was the endpoint, and 90.9% and 100.0% when the wear-related reoperation was the endpoint, respectively. Implant-related complications were not different between the 2 groups., Conclusions: Wear reduction and osteolysis showed a great advantage in HXLPE after a 15-year follow-up. Although the CPE and HXLPE showed excellent survival, wear and osteolysis were more frequent in the CPE; therefore, the high risk of reoperation in the future should be considered.

Background: This study aimed to evaluate the follow-up results of bipolar hemiarthroplasty (BHA) for more than 10 years in patients aged < 60 years and to analyze the risk factors for acetabular erosion after BHA., Methods: This retrospective study included 114 patients who underwent BHA were followed-up for at least 10 years. The mean age was 54.1 years, and the mean follow-up duration was 13.8 years. The patients were divided into two groups according to the presence of acetabular erosion, and the preoperative parameters were compared between the two groups. Moreover, the risk factors related to acetabular erosion after BHA were analyzed using statistical comparisons., Results: Reoperation was performed in 44 of the 114 patients (38.6 %). The survival rate when the end point was reoperation related to acetabular erosion was found to be significantly time-dependent: 73.2 % at 5 years, 48.8 % at 10 years, and 25.9 % at 15 years. The acetabular erosion group showed significantly younger age at the time of surgery, higher body mass index (BMI), more avascular necrosis of the femoral head, and smaller prosthetic femoral head. The final multivariate logistic regression analysis showed that young age at the time of surgery were independent risk factors for acetabular erosion after BHA in patients aged < 60 years., Conclusions: The minimum 10-year follow-up outcomes of BHA in patients aged < 60 years showed a relatively high conversion rate to total hip arthroplasty. When considering BHA in younger patients, more careful decisions should be made with respect to patient's choice, keeping in mind that long-term survival cannot be guaranteed.

Background: Transverse acetabular fractures, although classified as elementary, have worse outcomes than other types of acetabular fractures. Prognostic factors for this fracture type are not clearly established. This study aimed to assess the surgical outcomes of transverse acetabular fractures and subtypes thereof and to investigate the prognostic factors., Methods: Between 2014 and 2019, 39 patients (39 hips) had transverse fractures or subtypes thereof. We reviewed the surgical outcomes and evaluated patient factors, injury factors, and surgical factors in relation to osteoarthritis (OA) and conversion to total hip arthroplasty (THA). Additionally, we analyzed the cutoff values for postoperative residual gaps and steps., Results: Twenty-three male patients and sixteen female with a mean age of 41.7 years (range, 18-78 years) were included. There were 29 satisfactory reductions (74.4%). Eleven hips (28.2%) developed OA, and five (12.8%) of them underwent THA. Dome impaction (odds ratio [OR], 41.173; 95% confidence interval [CI], 1.804-939.814; p = 0.020) and residual gaps (OR, 4.251; 95% CI, 1.248-14.479; p = 0.021) were correlated with poor outcomes. Residual gaps (≥3 mm) and residual steps (≥1 mm) were significantly associated with OA., Conclusions: Relatively poor reduction was found for transverse acetabular fractures and subtypes thereof. However, the rates of OA and conversion to THA were not high. Dome impaction and wide residual gaps were identified as risk factors for poor outcomes. The development of OA significantly increased if residual gap and step were more than 3 mm and 1 mm, respectively.

Background: This study aimed to compare the radiological results between closed nailing without bone graft (BG) and open nailing with BG for aseptic subtrochanteric nonunion and to determine when an open procedure with BG should be considered., Methods: In this retrospective study, we investigated patients who underwent surgical intervention for subtrochanteric nonunion between January 2008 and March 2018 in two institutions. Patients with infection, large bone defect, pathologic fracture, open fracture, previous surgery using plate, and follow-up of less than 1 year were excluded. We compared the demographic details and radiological results between patients who underwent the open procedure with BG (BG group) and the closed procedure without BG (non-BG group) as a historical control, and risk factors for the failure of revision surgery were evaluated., Results: Thirty-seven patients met the criteria and were divided into the following two groups: the BG group (n=19) who underwent open nailing with BG and the non-BG group (n=18) who underwent closed reamed nailing without BG. The mean degrees of correction of varus and flexion deformity were significantly different (p=0.001, respectively), 6.2° and 2.9° in the BG group and 4.1° and 0.6° in the non-BG group, respectively. Bony union was observed in 17 cases (89.5%) in an average of 7.4 months in the BG group and in 16 cases (88.9%) in 7.6 months in the non-BG group, with no significant differences. The factors that were significantly associated with failure of revision were atypical fracture, two or more previous surgeries, and varus and sagittal anterior angulation., Conclusions: The radiological results of closed reamed nailing without BG for subtrochanteric nonunion were satisfactory. In the effort of percutaneous realignment, gap reduction, and intramedullary reaming, the radiological results of closed nailing without BG were not different from those of open nailing with BG; therefore, closed procedure without BG may be an acceptable option in appropriately selected patients.

Purpose: We classified the articles published in the journal Hip & Pelvis and analyzed the relationship between study characteristics and citation rates., Materials and Methods: All articles published in Hip & Pelvis from 2009 to 2019 were included. We classified the articles according to the type, language, listing in PubMed Central (PMC), treatment modality, material, design, anatomical focus, number of authors, and number of cases. We analyzed the citation rate according to this classification, with yearly citation rate reflecting the exposure period until March 2020., Results: The yearly citation rate increased significantly after the language of the journal was changed from Korean to English in June 2014 (mean=0.96 vs. 1.63, P <0.05), and again after the journal was listed in PMC in March 2016 (mean=1.05 vs. 1.92, P <0.05). The yearly citation rates of review articles was highest, followed by those of editorials, original articles, and case reports (in this order). Among original articles, trauma-related articles had higher yearly citation rates than non-trauma-related articles (mean=1.00 vs. 0.68, P =0.034). Among clinical articles, studies focusing on the pelvis had higher yearly citation rates than studies on the hip or femur (mean=1.85 vs. 0.71 vs. 0.91, P =0.003)., Conclusion: The yearly citation rate of articles increased significantly after the language of Hip & Pelvis was changed to English and after the journal was listed in PMC. The mean yearly citation rate of articles focusing on the pelvis was significantly higher than that of articles focusing on the hip or femur., Competing Interests: CONFLICT OF INTEREST: The authors declare that there is no potential conflict of interest relevant to this article., (Copyright © 2021 by Korean Hip Society.)

The primary objective of this study was to evaluate randomized controlled trials (RCTs) that have reported the effects of teriparatide on bone-healing in osteoporotic hip and pelvic bone fractures to determine the efficacy of teriparatide in lowering the rate of treatment failure. A total of 2,809 studies were identified using a comprehensive literature search (MEDLINE [n=1,061], Embase [n=1,395], and Cochrane Library n=353]). Five RCTs were included in the final analysis. Treatment failure rates at the last follow-up of osteoporotic hip and pelvic bone fractures between the teriparatide and control groups was the primary outcome. Treatment failure was defined as non-union, varus collapse of the proximal fragment, perforation of the lag screw, and any revision in cases due to mechanical failure of the implant during the follow-up period. The number of treatment failures in the teriparatide and placebo groups were 11.0% (n=20 out of 181) and 17.6% (n=36 out of 205), respectively. Although the rate of treatment failure in the teriparatide group was lower than that in the control group, this difference was not significant (odds ratio, 0.81 [95% confidence interval, 0.42-1.53]; P=0.16; I 2 =42%). This meta-analysis did not identify any significant differences in the rate of treatment failure between the teriparatide and control groups at final follow-up. Based on these results, we believe that there is a lack of evidence to confirm efficacy of teriparatide in reducing treatment failures in osteoporotic hip and pelvic bone fractures., Competing Interests: CONFLICT OF INTEREST: The authors declare that there is no potential conflict of interest relevant to this article., (Copyright © 2020 by Korean Hip Society.)

Background: Osteonecrosis of the femoral head (ONFH) is a disabling condition that often necessitates total hip arthroplasty (THA). Although ONFH occurs more frequently among patients with human immunodeficiency virus (HIV) than among the general population, there is little epidemiological information regarding ONFH in Korean patients with HIV. In the present study, we aimed to investigate the incidence and clinical features of ONFH among Korean patients with HIV., Materials and Methods: In this retrospective study, we reviewed the medical records of 1,250 Korean patients with HIV treated from January 1990 to December 2019. A standardised data collection sheet was used to obtain clinical information. Imaging data were analysed by a radiologist in accordance with the 2019 revised version of the Association Research Circulation Osseous (ARCO) staging system for ONFH., Results: Among the 1,250 included patients, 13 patients (1.04%; 3 women, 10 men) were diagnosed with ONFH. The overall incidence of ONFH was 1.29 per 1,000 person-years (PYs) (95% confidence interval [CI]: 0.7 - 2.4 per 1,000 PYs). Median age among the 13 patients with ONFH was 47 years (interquartile range [IQR]: 41 - 57 years). The median duration since HIV diagnosis was 4.8 years (IQR: 2.3 - 10.1 years). The median CD4 cell count at the time of ONFH diagnosis was 381 cells/ mm³ (IQR: 161 - 551 cells/mm³). At the initial diagnosis of ONFH, 83.3% of patients exhibited bilateral involvement. ARCO stage 3 or 4 osteonecrosis was observed in 83% of patients. Among 22 hips, stage 1 ONFH was noted in 2 (9.1%), stage 2 ONFH was noted in 7 (31.8%), stage 3 ONFH was noted in 9 (40.9%), and stage 4 ONFH was noted in 4 (18.2%). THA was eventually performed in 84.6% of patients. Five (38.5%) patients had a history of steroid use, 4 (30.8%) patients had a history of alcohol abuse and 10 (76.9%) were smokers. Eight (61.5%) patients had a history of acquired immune deficiency syndrome-defining illness, including 7 with tuberculosis and 1 with pneumocystis pneumonia. Nine patients (69.2%) had a nadir CD4 cell count <200/μL, and 3 (23.1%) had a history of bone fracture. Overall, 84% of patients were exposed to antiretroviral therapy, while 54% had taken protease inhibitors for more than 1 year., Conclusion: Considering that relatively high incidence of ONFH in patients with HIV, a high index of suspicion for those with risk factors and those with groin or hip pain for is required in HIV-infected patients., Competing Interests: SHL is associate editor of Infect Chemother. However, he did not involve in the peer reviewer selection, evaluation, and decision process of this article. Otherwise, no potential conflicts of interest relevant to this article was reported., (Copyright © 2020 by The Korean Society of Infectious Diseases, Korean Society for Antimicrobial Therapy, and The Korean Society for AIDS.)

Purpose: This study aimed to evaluate the feasibility and effect of triamcinolone acetonide (TA) injection for lateral malleolar (LM) bursitis., Methods: We retrospectively reviewed data of 49 consecutive patients (49 ankles) who received TA injection between March 2016 and March 2019. All cases received 1 ml (40 mg) of TA injection after aspiration of fluid in the LM bursal sac. Subsequently, the ankle was compressed with an elastic cohesive bandage for 2 weeks. Treatment responses were assessed according to the degree of fluctuation, shrinkage of the bursal sac, and soft tissue swelling. We used the Medical Outcomes Study Short Form Health Survey (SF-36) and complications at 2 and 4 weeks and at 3 and 6 months after TA injection., Results: Forty-four patients (89.8%) experienced complete resolution, four (8.2%) had partial resolution, and one (2.0%) had no resolution after the first or second TA injection. The physical component scores of SF-36 improved from 72.8 ± 6.0 to 82.3 ± 6.5 at the last follow-up ( p < 0.001). Associated complications included skin atrophy in three patients (6.1%) and transient hyperglycemia in four (8.2%)., Conclusion: TA injection is an effective and safe procedure for LM bursitis. It should be considered as a primary treatment method.

Background: The aims of the present study are to (1) conduct the longest-to-date follow-up wear analysis of the highly cross-linked polyethylene acetabular liners, (2) assess the incidence of femoral and acetabular osteolysis, and (3) compare the surgical outcomes between standard and elevated-rim acetabular liners in primary total hip arthroplasty (THA)., Methods: In this retrospective cohort study, we evaluated 112 primary THAs performed by a single experienced arthroplasty surgeon at our institution between March 2000 and December 2003. Patients were classified based on the type of acetabular liner used: standard or elevated-rim liner. For evaluation of surgical outcomes, the following data were collected: acetabular cup position (anteversion and inclination), wear rate (linear and volumetric), presence of osteolysis, history of reoperation (all-cause and wear-related), complications (deep joint infection, dislocation, and periprosthetic fracture), and Harris hip score at last follow-up., Results: Linear and volumetric wear rates were 0.028 mm/y (0.000-0.145 mm/y) and 11.641 mm 3 /y (0.000-70.000 mm 3 /y) in the standard group and 0.026 mm/y (0.000-0.094mm/y) and 9.706 mm 3 /y (0.000-33.000 mm 3 /y) in the elevated-rim group, respectively. These rates were not significantly different between groups. One case of osteolysis was confirmed in the standard group, whereas no osteolysis was observed in the elevated-rim group., Conclusion: We suggest that elevated-rim highly cross-linked polyethylene acetabular liners might be a good implant option that can be used safely., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The incidence of hip fractures is rapidly increasing with an aging population and is now one of the most important health concerns worldwide due to a high mortality rate. The effect of delayed surgery on postoperative outcomes has been widely discussed. Although various treatment guidelines for hip fractures in the elderly exist, most institutions recommend that operations are conducted as soon as possible to help achieve the most favorable outcomes. While opinions differ on the relationship between delayed surgery and postoperative mortality, a strong association between earlier surgery and improvement in postoperative outcomes (e.g., length of hospital stay, bedsore occurrence, return to an independent lifestyle), has been reported. Taken together, performing operations for hip fractures in the elderly within 48 hours of admission appears to be best practice. Importantly, however, existing evidence is based primarily on observational studies which are susceptible to inherent bias. Here, we share the results of a literature search to summarize data that helps inform the most appropriate surgical timing for hip fractures in the elderly and the effects of delayed surgery on postoperative outcome. In addition, we expect to be able to provide a more accurate basis for these correlations through a large-scale randomized controlled trial in the future and to present data supporting recommendations for appropriate surgical timing., Competing Interests: CONFLICT OF INTEREST: The authors declare that there is no potential conflict of interest relevant to this article., (Copyright © 2020 by Korean Hip Society.)

Purpose: Total hip arthroplasty (THA) is an available surgical option for failed acetabular fracture, previously managed by open reduction and internal fixation. This study aimed to report the postoperative outcomes of cementless THA in patients with this condition., Materials and Methods: Between November 2000 and September 2016, 25 consecutive cementless THAs for failed internal fixation after acetabular fractures with a minimum follow-up of 2 years were analyzed. The mean age at the time of surgery was 58 years (36-85 years), and the time elapsed between fracture and THA was 70 months (7-213 months). Clinical and radiologic evaluations were performed on all patients., Results: Clinically, the mean Harris hip score at the last follow-up was 88 points. Walking ability recovered to pre-injury status in 92% patients, and activities of daily living recovered in 96% patients. Radiographically, none of the acetabular cups showed evidence of migration and loosening during the mean follow-up of 50 months. All cases showed stable femoral stem fixation at the last follow-up. Dislocation occurred in three cases (12%)., Conclusion: Outcomes of cementless THA after failed internal fixation for acetabular fractures were satisfactory. However, a relatively high incidence of postoperative dislocation is still a concern.

Objective: The study aimed to identify the prevalence of sarcopenia in patients with osteoporotic hip fractures, investigate the anthropometric differences between sarcopenic and non-sarcopenic patients, and evaluate and compare the surgical outcomes between the two groups., Methods: The study included 135 patients (35 men and 100 women; mean age: 74.1 years (range; 25-96)) who received surgical treatment for hip fracture between March 2014 and October 2016 and underwent whole-body dual-energy X-ray absorptiometry (DEXA). The skeletal muscle mass index (SMI) for diagnosis of sarcopenia was measured using whole-body DEXA. The following data were collected to compare the preoperative details of the sarcopenic and non-sarcopenic groups: SMI, age, sex, type of fracture, type of operation, BMI, obesity, American society of Anesthesiologists (ASA) class, pre-injury mobility score, BMD, and follow-up period. We compared clinical outcomes, including Harris Hip Score (HSS) and the walking ability at the last follow-up visit and radiologic outcomes, including non-union and the time to union., Results: The average HHS and Parker's mobility score at the last follow-up were 81.7 and 6.9 in the sarcopenic group, and 77.6 and 6.3 in the non-sarcopenic group, respectively (p=0.149 and 0.122). Non-union was identified 0 (0%) in sarcopenic group and 4 (10%) in non-sarcopenic group (p=0.288). The mean union timer of the patients in the sarcopenia group was 4.0 months and that of patients in the non-sarcopenic group was 4.4 months (p=0.210). Multiple regression analysis did not show any significant association between sarcopenia and postoperative surgical outcomes, including HHS, mobility score at the last follow up, non-union, and time to union., Conclusion: Although the present study showed that the prevalence of sarcopenia in hip fracture patients was 45.9% (62/135), there was no clinical association between sarcopenia and postoperative. Based on these results, the clinical impact of sarcopenia may be confined to increased risk of hip fracture occurrence and surgical outcomes of hip fracture may not be affected by sarcopenia., Level of Evidence: Level III, Therapeutic Study.

Purpose: To evaluate the clinical characteristics of intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures and assess the surgical outcomes of a novel, closed intramedullary nailing surgical approach designed to minimize fixation failure., Materials and Methods: Between May 2013 and April 2017, 31 patients with intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures treated with closed intramedullary nailing or long proximal femoral nail antirotation (PFNA) were enrolled in this study. Preoperative data included age, sex, injury severity score, body mass index, location of shaft fracture, injury mechanism, accompanying traumatic injury, walking ability before injury, and surgical timing. Perioperative outcomes, including follow-up period, types of intramedullary nails, number of blocking screws used, operation time, and blood loss were assessed. Radiologic outcomes, including union rate, time from surgery to union, and femoral shortening, and clinical outcomes, including hip flexion, walking ability, and Harris hip score were also evaluated., Results: A total of 29 unions (93.5%) were achieved. The time to union was 16.8 months (range, 11-25 months) for hip fractures (15.7 weeks for intertrochanteric fractures and 21.7 weeks for subtrochanteric fractures) and 22.8 months for femoral shaft fractures. There were no significant differences in surgical outcomes between the two groups except for type of intramedullary nail., Conclusion: Closed intramedullary nailing in the treatment of intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures may be a good surgical option. However, fixation of femoral shaft fractures might not be sufficient depending on the implant design., Competing Interests: CONFLICT OF INTEREST: The authors declare that there is no potential conflict of interest relevant to this article., (Copyright © 2019 by Korean Hip Society.)

Background: Hip fracture and upper extremity fracture are most important age-related fracture. However, there have been few reports about the analysis of prevalence or risk factors with concomitant hip and upper extremity fractures. This study aimed to describe the prevalence and clinical implications of the concomitant hip and upper extremity fractures in elderly., Methods: We evaluate 1018 patients aged >65 years who were surgically treated for femoral neck or intertrochanteric fractures between March 2008 and December 2018. 35 patients (3.4%) with a hip fracture combined upper extremity fracture. All patients were classified into the isolated hip fracture and the concomitant fracture. We analyzed these patients' characteristics such as age, gender, bone mineral density (BMD), body mass index (BMI), Korean version of Mini-Mental State Examination (MMSE-K), injury mechanism, and length of hospital stay., Results: The most common site of upper extremity fracture was distal radius fracture of 15 patients (42.8%), followed by proximal humeral fracture of 8 (22.8%). Concomitant fractures occurred on the same side in 30 patients (85.7%). The mean age of patients with a concomitant fracture was younger than that of patients with an isolated hip fracture (p < 0.05). Mean preinjury MMSE-K was 22.7 in isolated hip fracture and 25.6 in concomitant fracture patients (p < 0.05). Mean length of hospital stay was statistically significant different between two groups (p < 0.05). According to fracture site of hip, there was no statistically different prevalence of upper extremity fracture in femoral intertrochanteric fracture compared to the neck fracture., Conclusion: We found a 3.4% prevalence of concomitant hip and upper extremity fractures. It was found that the younger the age with preserved cognitive ability in elderly patients with a hip fracture, the higher the prevalence of upper extremity fracture. In addition, it is important to keep in mind that patients with a concomitant fracture have a longer hospital stay and difficulty in rehabilitation., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The main purpose of the present study was to assess the radiologic effect of teriparatide on fracture healing, including union rate, union time, and callus formation, by quantitative measurements using serial follow-up X-ray imaging examinations in patients with complete atypical femoral fractures (AFFs) treated using closed intramedullary nailing., Methods: From January 2010 to October 2017, 58 consecutive patients with complete AFF who were treated with intramedullary nailing at two institutions were enrolled. Patients were classified into two groups: those who received teriparatide therapy (group A) and those who did not (group B). Teriparatide (Forsteo®; Eli Lily Co., Indianapolis, IN, USA) at a once-daily 20 μg dose was prescribed as continuous treatment of osteoporosis or with the expectation of better bone healing. Surgical outcomes, including union rate, union time, modified radiologic union score (mRUS), and callus formation at 3, 6, and 12 months postoperatively, were assessed to evaluate the effect of teriparatide on fracture healing. Quantitative measurement of callus formation was performed using the region of interest (ROI) tool in the picture archiving communication system (PACS)., Results: Non-union was not observed in group A, whereas two patients had non-union in group B. Union time was 18.3 ± 4.8 (range, 12-28) weeks in group A and 23.6 ± 9.5 (range, 12-64) weeks in group B and was significantly shorter in group A than group B (p = 0.010). The average mRUSs during periods A (3-4 months postoperatively), B (6-8 months postoperatively), and C (12-14 months postoperatively) were 10.0, 13.9, and 15.9 in group A, and 8.7, 12.0, and 14.9 in group B, respectively. The average mRUSs during periods A and B were significantly different (p = 0.027 and 0.011, respectively). The medial, posterior, and total callus areas during periods A and B were also significantly greater in group A than in group B. No difference was observed in the union rate between the two groups (p = 0.492)., Conclusion: Teriparatide may improve callus formation and shorten union time in patients with complete diaphyseal AFF who underwent closed intramedullary nailing., Level of Evidence: Level III retrospective comparative study., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: We analyzed the surgical outcomes at two institutions after internal fixation using multiple screws in femoral neck fractures with valgus impaction to determine independent predictors and their cut-off values for nonunion and reoperation., Materials and Methods: Between January 2006 and December 2016, 104 femoral neck fractures with valgus impaction that underwent internal fixation using multiple screws from two institutions were enrolled. The multiple logistic regression model and receiver operating characteristics analysis were used to determine the independent predictors and cut-off values for nonunion and reoperation., Results: There were 20 reoperations (19.2%) due to 11 nonunions (10.6%) and nine cases of femoral head osteonecrosis (8.7%). Multiple logistic regression analysis revealed that independent predictors of nonunion and reoperation were age and posterior tilt angle ( P <0.05). The cut-off value for age and the posterior tilt angle for reoperation were 72.5 years and 12.2°, respectively. The patients with a posterior tilt angle of greater than 13° had poorer radiological and clinical outcomes compared with those with a posterior tilt angle of less than 13°, even though they did achieve bone union., Conclusion: Primary hip arthroplasty should be considered in patients older than 73 years of age with a posterior tilt angle greater than 13°., Competing Interests: CONFLICT OF INTEREST: The authors declare that there is no potential conflict of interest relevant to this article.

Introduction: The aim of our study was to (1) report our surgical outcomes of internal fixation in patients with non-displaced or valgus impaction fractures of the femoral neck, (2) introduce our new three-dimensional assessment method using a combination of X-ray and CT imaging, and (3) determine which radiologic measurements significantly predicted fixation failure., Hypothesis: We hypothesized that high posterior tilt angle and retroversion angle are related to high incidence of non-union and osteonecrosis., Materials and Methods: From January 2009 to December 2016, 64 elderly patients in two institutions with non-displaced or valgus impaction fractures of the femoral neck who had internal fixation using multiple parallel cannulated screws were enrolled. To determine the independent predictors of non-union, osteonecrosis, and re-operation, various clinical variables and radiologic variables, including the valgus angle on coronal CT images, the posterior tilt angle on Lorenz images, and the retroversion angle on axial CT images, were analyzed., Results: Non-union was identified in nine of the 64 patients (14.1%) and nine of the 55 patients (16.4%) who achieved bony union had femoral head osteonecrosis with subsequent segmental collapse. The multiple logistic regression model showed that a low bone mineral density of the femur, a higher posterior tilt angle on Lorenz image, and a higher retroversion angle on axial CT images were independent predictors of non-union and re-operation., Discussion: Primary hip arthroplasty should be considered when a posterior tilt angle of more than 9 degrees on Lorenz images or a retroversion angle of more than 13 degrees on axial CT images is identified in patients with osteoporotic valgus impaction fractures., Type of Study and Level of Proof: III, Retrospective comparative study., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Introduction: Although various clinical applications of geneX ® ds have been reported, no study has reported the clinical application of geneX ® ds in osteoporotic hip fracture. The present study aimed to identify the clinical effect of the application of geneX ® ds in elderly patients with intertrochanteric fracture treated using proximal femoral nail antirotation (PFNA)., Materials and Methods: From March 2014 to October 2017, 233 patients with intertrochanteric fracture (65 men and 168 women) were enrolled in this study. All patients received surgical treatment using PFNA. Patients were classified into two groups: those in whom geneX ® ds which is synthetic osteoconductive bone graft substitute with the unique property of Zeta Potential Control (ZPC ® ), was use, and those in whom it was not. We compared the preoperative details and surgical outcomes, including radiologic outcome (postoperative reduction, tip apex distance, sliding distance of the helical blade, union, and union time) and clinical outcomes (Harris Hip Score and the walking ability at the last follow-up) between the groups., Results: In patients with unstable fracture who achieved anatomical or extramedullary type of reduction, the average sliding distance at 1, 3, and 12 months was 4.9 mm, 7.5 mmm and 8.1 mm in the geneX ® ds group and 7.5 mm, 10.8 mm, and 12.1 mm in the no geneX ® ds group, respectively. There were significant differences in the sliding distance at 1, 3, and 12 months between these two groups., Conclusion: The use of this synthetic osteoconductive bone graft substitute with zeta potential control may have positive effect on the controlled sliding of the helical blade and the healing of intertrochanteric fracture., (Copyright © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: The aim of this study was to investigate the postoperative outcomes of cementless Total hip arthroplasty (THA) following failed internal fixation for femoral neck and intertrochanteric fractures., Method: Ninety-six cementless THAs for failed internal fixation after femoral neck fracture (59, group I) and intertrochanteric fracture (37, group II) with a minimum follow-up of 3 years were analyzed. Clinical and radiologic evaluations were performed on all patients., Results: The intraoperative blood loss and operating time were significantly increased in group II (p = 0.001, p = 0.001, respectively). Harris hip score at last follow-up was significantly improved in group I (p = 0.007) but, there were no differences in hospital stay, Koval score at last follow-up, and perioperative complications between both groups. Long femoral stems for diaphyseal fitting were frequently used in group II (32/37, 86%) (p = 0.001). Radiographically, none of the acetabular cups showed evidence of migration, loosening. All cases showed stable fixation of the femoral stem at last follow-up., Conclusions: Outcomes of cementless THA following failed internal fixation for femoral neck and intertrochanteric fractures were satisfactory; increased intraoperative blood loss, operating time, and requirement of long femoral stem should be considered in the latter type of fracture., (Copyright © 2019 Elsevier Ltd. All rights reserved.)