Early recovery of basic mobility under femoral nerve block after hip fracture surgery – A propensity score matched pilot study

Background: Previous studies have shown better pain reduction utilizing femoral nerve block (FNB) in patients who underwent hip fracture surgery. However, few studies have focused on the recovery of physical function after FNB, and most studies excluded patients with dementia. We investigated the association between FNB performed in the operating room and the recovery of physical function after hip fracture surgery, including patients with dementia.MethodsA total of 103 patients with a mean age of 87.4 years who underwent hip fracture surgery under spinal anesthesia between July 2015 and December 2017 (46 patients receiving a single injection of FNB and 57 standard care) were enrolled. Patients with FNB versus standard care were matched by a propensity score to adjust for patient characteristics. An anesthesiologist performed FNB with 20ml of 0.2% ropivacaine, and the standard care group received intravenous 1000 mg acetaminophen or 50mg flurbiprofen once after surgery. After matching, 78 patients were analyzed. Our primary outcome was 3-day cumulated ambulation score (CAS, 0-18 points) and secondary outcomes were 1-day CAS on postoperative day 1-3 and length of hospital stay. We also stratified patient groups based on the presence of dementia and fracture type.ResultsPatients undergoing FNB had significantly better 3-day CAS compared to standard care (mean [SD], 8.72 [3.42] vs 7.33 [2.62]; mean difference, 1.38 [95%CI; 0.03 - 2.74]; p = 0.048) and 1-day CAS on postoperative day two (mean [SD], 3.10 [1.39] vs 2.56 [0.94]; mean difference, 0.54 [0.01 - 1.07]; p = 0.049). Length of hospital stay did not significantly differ among the two groups (p = 0.65). Larger positive effect was likely to be seen for patients with a femoral neck fractures and for those without dementia.ConclusionsPatients who underwent surgery with spinal anesthesia plus FNB had better ambulatory status early after hip fracture surgery compared to patients not offered FNB. The beneficial association between FNB and ambulatory status was likely to be observed especially in patients with femoral neck fracture and without dementia.     

External validation of the SORG 90-day and 1-year machine learning algorithms for survival in spinal metastatic disease

BACKGROUND CONTEXTPreoperative survival estimation in spinal metastatic disease helps determine the appropriateness of invasive management. The SORG ML 90-day and 1-year machine learning algorithms for survival in spinal metastatic disease were previously developed in a single institutional sample but remain to be externally validated.PURPOSEThe purpose of this study was to externally validate these algorithms in an independent population from another institution.STUDY DESIGN/SETTINGRetrospective study at a large, tertiary care center.PATIENT SAMPLEPatients 18 years or older who underwent surgery between 2003 and 2016.OUTCOME MEASURESNinety-day and 1-year mortality.METHODSBaseline characteristics of the validation cohort were compared to the developmental cohort for the SORG ML algorithms. Discrimination (c-statistic and receiver operating curve), calibration (calibration slope, intercept, calibration plot, and observed proportions by predicted risk groups), overall performance (Brier score), and decision curve analysis were used to assess the performance of the SORG ML algorithms in the validation cohort.RESULTSOverall, 176 patients underwent surgery for spinal metastatic disease, of which 44 (22.7%) experienced 90-day mortality and 99 (56.2%) experienced 1-year mortality. The validation cohort differed significantly from the developmental cohort on primary tumor histology, metastatic tumor burden, previous systemic therapy, overall comorbidity burden, and preoperative laboratory characteristics. Despite these differences, the SORG ML algorithms generalized well to the validation cohort on discrimination (c-statistic 0.75–0.81 for 90-day mortality and 0.77–0.78 for 1-year mortality), calibration, Brier score, and decision curve analysis.CONCLUSION and RELEVANCEInitial results from external validation of the SORG ML 90-day and 1-year algorithms for survival prediction in spinal metastatic disease suggest potential utility of these digital decision aids in clinical practice. Further studies are needed to validate or refute these algorithms in large patient samples from prospective, international, multi-institutional trials.     

Distribution of the alpha-gal epitope on adult porcine bone tissue

INTRODUCTION: Bone xenografts from pig to human appear to be an alternative to resolve the shortage of bone autologous and allografts. However, the major obstacle of pig-to-human xenotransplantation is the interaction between human natural anti-Gal antibody and the alpha-Gal epitope abundantly expressed on pig endothelium. It was important to investigate the expression of alpha-Gal epitopes in porcine bone tissue to look for an ideal method to remove the alpha-Gal epitopes. METHODS: The cortical and trabecular bone were retrieved from five pigs. After the soft tissues and periosteum were removed, the blood and marrow cavity were cleaned with phosphate-buffered solution. All 5 mm x 5 mm x 5 mm samples were imbedded in paraffin and methyl methacrylate resin for histological sections. The mouse IgM M86 monoclonal antibody, which was highly specific for alpha-Gal epitopes, was used to document alpha-Gal epitope expression by immunostaining of tissues and immunofluorescence. RESULTS: Gal-positive immunostaining and immunofluorescence were observed on the surface of osteocytes and Haversian canals. There was a significant difference in Gal expression between cortical and trabecular bone tissues. There was no Gal expression in the extracellular matrix of bone. CONCLUSIONS: Major alpha-Gal epitopes were on the surface of osteocytes of porcine bone tissues. A method should be used to damage the osteocytes and eliminate the alpha-Gal epitopes to avoid the xenogenic rejection in xenotransplantation of porcine bone tissues.     

内固定结合外固定治疗严重下颈椎屈曲扭伤

目的探讨内固定结合外固定治疗严重下颈椎屈曲扭伤的效果。方法9例严重下颈椎屈曲扭伤患者采用前路椎间盘摘除、开放复位、植骨融合、锁定钢板内固定治疗。术后颈支具外固定3个月。结果9例均获随访,时间6~36个月,所有植骨间隙均融合,椎间隙及曲度保持正常。结论前路椎间盘切除,开放复位可降低脊髓损伤风险。内固定结合外固定促进植骨融合,重建颈椎稳定性,是治疗严重下颈椎屈曲扭伤的可靠方法。     

大段冷冻异体骨和人工关节复合物修复股骨下段巨大骨缺损

目的 :研究大段冷冻异体骨和人工关节复合物修复股骨下段肿瘤切除后骨缺损的疗效。方法 :按Enneking分期 ,广泛性边缘切除股骨下段肿瘤 ,选用长柄人工轴心铰链膝关节将大小和形态合适的同种异体骨关节与宿主骨经骨水泥髓内固定 ,假体柄插入宿主骨髓内长度与异体骨轴心长度比≥ 0 8～ 1。结果 :本组 14例中 ,12例平均随访 3 4个月。 2例分别于术后 9和 15个月死亡。所有患者均无关节脱位、假体松动和断裂。异体骨和宿主骨间均达骨性愈合 ,平均愈合时间 7 4月。术后患侧膝关节平均活动度为 82°。结论 :人工关节通过现代骨水泥固定技术将异体骨与宿主骨有机地连接在一起 ,从而达到牢固的髓内固定。异体骨与宿主骨间的生物性连接 ,增加了人工关节的固定臂 ,从而防止了肿瘤人工关节下沉、松动或断裂等并发症 ,具有异体骨和人工关节两者的优点。     

Increase in pancreatic enzymes following spinal alignment changes in the thoracolumbar junction: Potential for acute pancreatitis after kyphosis correction

BackgroundDespite the identification of various risk factors for pancreatitis and hyperamylasemia following spinal surgery, no report has investigated the relationship between spinal alignment changes and elevated serum amylase levels. The purpose of this study was to investigate the relationship between spinal alignment changes and hyperamylasemia after spinal fusion.MethodsA total of 222 patients whose serum pancreatic amylase levels were measured before and after spinal surgery from December 2017 to May 2019 were included. Inclusion criteria were (1) spinal fusion including the thoracolumbar junction (T10-L2) and (2) serum pancreatic amylase measurements before, immediately after surgery (day 0), the day after surgery (day 1), and 1 week after surgery. Ultimately, 37 patients who met the criteria were analyzed. Patients with hyperamylasemia at day 0 and/or day 1 (H group) were then compared with those without hyperamylasemia (N group).ResultsNo significant differences in age, sex, surgical procedure, number of fused segments, intraoperative blood loss, operative time or American Society of Anesthesiologists physical status classification were observed between both groups. The H group had significantly larger preoperative thoracolumbar kyphosis (TLK) (H group: 22.6°, N group: 6.4°), postoperative TLK (H group: 16.8°, N group: 7.6°), and preoperative T12–L1 kyphosis angles (H group: 16.2°, N group: 7.9°) compared with the N group. Moreover, the H group demonstrated a significant decrease in TLK after surgery (H group: ?5.8°, N group: 1.6°).ConclusionsRisk factors for hyperamylasemia included a large preoperative TLK angle and a greater postoperative decrease in TLK. Thus, decreased TLK after spinal fusion surgery should prompt careful attention to abdominal symptoms and elevated pancreatic amylase levels.     

Infection of the sigmoid colon during TNFα antagonist therapy for chronic inflammatory joint disease

We report 7 cases of sigmoid colon infection in patients taking TNFα antagonist therapy to treat chronic inflammatory joint disease. There were 5 women and 2 men with a mean age of 57.5 years (range, 21–77 years). The presenting symptoms were abdominal pain, bowel habit changes, and a fever. These symptoms developed within 6 months after starting TNFα antagonist therapy in 5 of the 7 patients. Empirical antibiotic therapy was used in all 7 patients. Surgical colectomy was performed in 4 patients, including 1 who required a temporary Hartmann's procedure. The risk of infection associated with TNFα antagonist therapy is well documented. However, few cases of colon infection have been reported and little is known about this potentially severe complication. Glucocorticoids or non-steroidal anti-inflammatory drugs may worsen the infection, particularly as they can attenuate the clinical symptoms, thereby delaying the diagnosis. A history of sigmoid colon infection, diverticulosis, and/or diverticulitis must be sought before starting treatment with a biological agent. Prophylactic treatment may be considered if such a history is found. Diagnostic investigations are in order to develop a standardized management strategy in patients with a history of intestinal tract infection.