“In‐Out‐In” Percutaneous Reduction Technique for Treatment of Valgus‐Impacted Femoral Neck Fractures: A Technical Trick and Case Series

ObjectiveValgus‐impacted femoral neck fractures with or without posterior tilt of the femoral head are very common and full of pitfalls in clinical practice, which may lead to femoral neck shortening (FNS) and avascular necrosis (AVN). The study tries to introduce a novel technical trick aiming at anatomical reduction of valgus‐impacted femoral neck fracture with minimally invasive procedure, and summarize the clinical prognosis in case series.MethodsIn this retrospective study, 24 patients (seven men and 17 women) with valgus‐impacted femoral neck fractures between May 2017 and July 2020 were managed by “in‐out‐in” percutaneous reduction technique (percutaneous reduction group). Another 24 cases (10 men and 14 women) suffering the fractures underwent in situ fixation were enrolled as control group for function comparison (in situ fixation group). All patients were followed up for 24–42 months. The clinical outcomes included complications after operations (χ ² test) and Harris Hip Score (HHS) for hip function (unpaired t test) in the two groups. The radiographic outcomes were evaluated by collodiaphyseal angle, posterior tilt angle, and FNS before the operation and during the follow‐up in the percutaneous reduction group (unpaired t test).ResultsPatients'' preoperative data, including age, sex, affected side, fracture types, and medical history, were similar between the two groups, respectively (p > 0.05). After surgery, the mean HHS at 6, 12, and 24 months were all better in the percutaneous reduction group (76 ± 6.72, 85.34 ± 6.33 and 90.54 ± 5.81) than that in the in situ fixation group (70.86 ± 6.91, 80 ± 6.11 and 84.1 ± 7.82), respectively (p < 0.05). One patient suffered fixation failure with screws retreat and one patient suffered AVN in the percutaneous reduction group. In the in situ fixation group, AVN occurred in two patients at last follow‐up. There was no significant difference in complication amounts between the two groups (p > 0.05). In the percutaneous reduction group, collodiaphyseal angle, posterior tilt angle, and amount of FNS were significantly different between preoperative cases and immediately postoperative cases (p < 0.05). However, there was no statistical difference of the measurements among postoperative cases at different time points (within 24 h, 6 months, and 2 years postoperatively) (p > 0.05).ConclusionsOur experience of the technique and the case series show that “in‐out‐in” percutaneous reduction technique for treatment of valgus‐impacted femoral neck fracture with or without posterior tilt of the femoral head is safe and effective for achieving successful bone union and satisfactory function.     

There is No Link Between Birth Weight and Developmental Dysplasia of the Hip

AimsDevelopmental Dysplasia of the Hip (DDH) has been linked to high birth weight and packaging disorders, though the evidence is limited. This has implications on screening strategies. The aim of this study was to establish whether birth weight was truly associated with the incidence of DDH.Patients and MethodsThis cohort study analysed the birth weights of all babies born at our institution over a 24 month period, between 01/01/2017 and 01/01/2019. Babies with DDH and those without DDH were compared. Babies were excluded if born before 38 weeks, had incomplete data or were a non-singleton pregnancy. Sub-analysis was performed for DDH severity (dysplastic versus subluxed/dislocated hips), breech presentation, gestational age, gender and ethnicity. Statistical analysis was performed using SPSS.ResultsThere were 10,113 babies born at our institution during the selected timeframe, of which 884 were excluded for prematurity, 336 for being non-singleton and 19 for incomplete data. This left 8874 for analysis, of which 95 babies had confirmed DDH. Both the Non-DDH and DDH data sets had normal distribution (Shapiro-Wilkes, p = 0.308 and 0.629, respectively), with mean birth weights of 3477.7 g with DDH and 3492.8 g without DDH. No difference in birth weight was found (Independent T test, p = 0.789). Females had a lower birth weight than males (3293.1 g versus 3416.6 g (p < 0.001)) yet have a higher incidence of DDH (ratio 6:1 in this dataset). No significant difference was found between birth weights of females with and without DDH (p = 0.068), nor between males with and without DDH (p = 0.513). There were no significant differences in birth weights even when only displaced hips were analysed (p = 0.543), nor according to breech presentation (p = 0.8). Longer gestation babies weighed more (p < 0.00001), yet showed no increase in DDH incidence (p = 0.64).ConclusionThis study discredits the belief that DDH may be related to higher birth weight, thus casting doubt on the link to DDH being a packaging problem in utero. This, therefore, allows future research to prioritise the investigation of alternative aetiologies.     

A modified surgical approach of the hip in children: is it safe and reliable in patients with developmental hip dysplasia?

PurposeTreatment is easier and complications are less likely to occur if developmental dysplasia of the hip (DDH) is diagnosed early. In this study, we examined the early results of open reduction using a medial approach which we had modified for DDH and analyzed the success of this technique and the associated complication rates, with a focus on avascular necrosis (AVN).Methods This is an Institutional Review Board-approved retrospective review of all patients diagnosed with DDH and treated with a modified medial approach at a single institution from July 1999 to December 2010. The patients'' charts were analyzed for clinical and radiographic features.Results Fifty-five hips of 41 patients, all of whom were treated by open reduction using a modified medial approach due to DDH, were evaluated retrospectively. The mean age of the patients at surgery was 19 (range 11–28) months, and the average follow-up was 5.5 (range 3–9.5) years. AVN was the most important complication in terms of radiological outcomes as assessed according to the Kalamchi–McEwen classification. Radiologic results were excellent or good in 51 hips (92.7 %) and fair–plus in four (7.3 %). Type 1 temporary AVN was detected in only two hips (3.6 %), and the lesions had disappeared completely in the final control graphs of these two patients. A secondary intervention was needed for two hips (3.6 %) of the same patients who were operated on due to bilateral DDH. No other complications, such as infection, re-dislocation, or subluxation, were seen in the operated patients.Conclusions We believe that treatment for DDH using a modified medial approach during early childhood is an effective and reliable method with low AVN rates. As shown here, this method achieves great success in radiological and clinical outcomes after a minimum 3-year follow-up.     

Borderline Developmental Dysplasia of the Hip: A Risk Factor Predicting the Development and Poor Prognosis after Core Decompression for Idiopathic Osteonecrosis of the Femoral Head

ObjectiveIt is unclear whether idiopathic osteonecrosis of the femoral head (ONFH) is associated with borderline developmental dysplasia of the hip (BDDH). This study aimed to compare the incidence of BDDH between patients with idiopathic ONFH and matched control subjects and determine the influence of BDDH on poor prognosis after core decompression (CD).MethodsWe retrospectively examined 78 consecutive patients (111 hips) with idiopathic ONFH undergoing CD and 1:2 matched with 156 control subjects (222 hips). The anteroposterior pelvic radiographs were used to measure the acetabular anatomical parameters and divide included subjects into BDDH or non‐BDDH group. The incidence of BDDH and acetabular anatomical parameters were compared between patients with idiopathic ONFH and matched controls. Clinical outcomes, such as Harris Hip Score (HHS), progression of collapse, and conversion to total hip arthroplasty (THA), were compared between patients with BDDH and without BDDH in the idiopathic ONFH group, with a mean follow‐up of 72.1 ± 36.6 months.ResultsPatients with idiopathic ONFH had a significantly higher incidence of BDDH than matched controls (29.7% vs 12.2%, p < 0.001). Less acetabular coverage was also found in patients with idiopathic ONFH than in matched controls as demonstrated by lower CEA (28.5° ± 4.7° vs 33.1° ± 5.7°, p < 0.001), AHI (82.4 ± 5.0 vs 86.3 ± 5.4, p < 0.001), ADR (299.6 ± 28.4 vs 318.8 ± 31.3, p < 0.001), and a higher sharp angle (40.0° ± 3.4° vs 37.4° ± 3.7°, p < 0.001). In patients with idiopathic ONFH, the BDDH group had a significantly lower mean HHS at the last follow‐up (83.5 ± 17.4 vs 91.6 ± 9.7, p = 0.015) with a different score distribution (p = 0.004), and a lower 5‐year survival rate with both clinical failure (66.7%, 95% CI 52.4%–84.9% vs 83.7%, 95% CI 75.2%–93.1%; p = 0.028) and conversion to THA (74.6%, 95% CI 60.7%–91.6% vs 92.1%, 95% CI 85.6%–99.0%; p = 0.008) as the endpoints than the non‐BDDH group.ConclusionThe incidence of BDDH was significantly higher in patients with idiopathic ONFH than matched controls, and idiopathic ONFH patients who underwent CD with BDDH had lower mean HHS as well as 5‐year survival rate than those without BDDH. Therefore, BDDH should be considered a risk factor predicting the development of idiopathic ONFH as well as poor prognosis after CD.     

Point-of-Care Ultrasound Reduces Visit Time and Cost of Care for Infants with Developmental Dysplasia of the Hip

BackgroundHealthcare institutions and policymakers are searching for system-wide approaches to reduce costs while maintaining quality and improving patient outcomes. In most healthcare systems infants referred for the detecting or treating developmental dysplasia of the hip (DDH) are sent to a radiology department for sonographic evaluation. The total duration of visit and cost of visit are essential variables in any healthcare setting and affect both efficiency and “the bottom line”. By having the treating clinician perform point-of-care ultrasound (POCUS) for the detection and follow-up of patients with DDH, we hypothesize that there would be a significant reduction in the time spent on the visit and the cost incurred without compromising quality or patient satisfaction. To our knowledge, no prior study has examined the effect of incorporating POCUS on the duration and cost of the visit in patients with DDH.PurposeTo determine if there was a difference in the duration of the visit for patients with DDH when POCUS was performed compared to when traditional “formal” sonography was performed. To determine if there was a difference in the cost of the visit for patients with DDH when POCUS was performed compared to when traditional “formal” sonography was performed.MethodsData for visits to a specialized outpatient office were collected over two years at a single-specialty orthopedic hospital, comparing the duration and cost of the visit between patient encounters for infants who had “formal” sonograms performed in the radiology suite to infants who underwent POCUS of the hip. In all, we included 532 patient encounters, 326 patients had POCUS performed, and 206 had a “formal” ultrasonographic evaluation performed. Of these, 140 were new evaluations and 392 were follow-up evaluations for treatment. Of the 140 new patients, 80 were in the POCUS group, and 60 were in the “formal” US group. Of the 392 follow-ups, 246 were in the POCUS group, and 146 were in the “formal” US group.ResultsThe mean duration of the encounter for the POCUS group was 42 min (range 16–75 min), and for the “formal” US group, it was 92 min (range 36–163 min). This difference was statistically significant (p = 0.002). The mean cost of the encounter for the POCUS group was $121.13, and for the “formal” US group, it was $339.38. This difference was statistically significant (p = 0.002).ConclusionUltimately, our study demonstrated a statistically significant reduction in the duration and cost of a patient encounter for infants with DDH when they undergo POCUS rather than “formal” sonographic evaluation.     

The Development of Leg Length Difference and Influence on Persistent Dysplasia in Patients with Developmental Dysplasia of the Hip

IntroductionLeg-length difference (LLD) is common in patients with developmental dysplasia of the hip (DDH). LLD of > 1 cm at skeletal maturity is reported in > 40% of patients, with the majority related to ipsilateral overgrowth. A longer DDH leg might lead to excessive mechanical loading at the acetabular margin, resulting in compromised acetabular development. We hypothesised that the LLD would negatively influence acetabular development. If so, it would be advantageous to identify such patients early in the course of follow-up, and address this if necessary.MethodsA retrospective study was conducted on a consecutive series of DDH patients managed surgically at the Royal National Orthopaedic Hospital, Stanmore, United Kingdom. We included patients with adequate long-leg radiographs at the age of 4–8 years (early-FU) and skeletal maturity (final-FU). Bilateral cases and those who underwent surgical procedures for hip dysplasia during the follow-up period were excluded. Measurements including leg length and centre-edge-angle (CE-angle) were obtained at the 2 time points.ResultsTwenty-seven patients were included, mean age at early-FU 5.7 (± 0.9) years, and 13.9 (± 1.0) years at final-FU. Mean LLD at early-FU was 9.5 (± 7.6) mm and 10.9 (± 9.4) mm at final-FU, p = 0.337. Correlation between early- and final-FU LLD was 0.68 (p < 0.001). The mean CE-angle at early follow-up was 14.6° (± 9.8), this improved to 23.2° (± 8.2) at skeletal maturity (p = 0.003, paired samples t-test). Linear regression analysis showed a non-significant trend towards less CE-angle improvement in patients with more initial residual dysplasia and more initial LLD.ConclusionMost leg-length differences can be identified early in the follow-up period, nevertheless, considerable individual changes in LLD are observed on continued follow-up. Furthermore, a trend was observed towards impaired acetabular improvement in patients with more LLD. These findings justify careful clinical and radiological monitoring of LLD from an early stage in the follow-up period.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43465-021-00492-5.     

A Novel Method of Making Hinges Using a Newly Designed Sharp Rongeur to Enhance Radiological and Clinical Outcomes in French‐Door Cervical Expansive Laminoplasty

ObjectiveAlthough the lamina open angle of making hinges is closely related to the outcomes of French‐door laminoplasty (FDL) for treatment of cervical spondylosis, there have been no methods to predict the lamina open angle preoperatively as yet. The aim of this study was to investigate the accuracy of predicting the laminal open angle using our newly designed sharp rongeur, and to compare the postoperative outcomes and complications between the methods of making hinges using the newly designed sharp rongeur and the traditional high‐speed micro‐drill during the FDL.MethodsThis was a single‐center retrospective study. Following the approval of the institutional ethics committee, a total of 39 patients (Male: 28; Female: 11) diagnosed with cervical spondylos who underwent FDL in our institution between January 2018 and May 2019 were enrolled. Patients were divided into two groups based on the method of making hinges (sharp rongeur: 22 cases; high‐speed micro‐drill: 17 cases). The average age at surgery was 59.1 years (range: 16–85 years). The radiological parameters, clinical outcomes, modified Japanese Orthopaedic Association (mJOA) scale score, and the recovery rate of mJOA were recorded and compared between the groups, respectively. The radiological parameters and clinical measurements at pre‐ and post‐operation stages were compared using the paired‐sample t‐test, the Wilcoxon signed‐rank test, and the Friedman''s test, and variables in the two groups were analyzed using an unpaired Student''s t‐test or a Mann–Whitney U test.ResultsThe average follow‐up period was 20.4 months (range: 14.0–25.9 months), the postoperative open angle was 60.13° ± 3.69° in the rongeur group with 22.78° ± 4.34° of angular enlargement, which was significantly lower than that of 68.96° ± 1.00° in the micro‐drill group with 32.75° ± 4.22° of angular enlargement (U = 19.000, p < 0.001). The rongeur group showed a higher fusion rate (34.1% vs 14.7%, χ ² = 11.340, p = 0.001), and a lower fracture rate of the lamina (7.8% vs 25.5%, χ ² = 14.185, p < 0.001) at 1‐month post‐surgery, compared to the micro‐drill group. There were no significant differences in the clinical outcomes and postoperative complications between the two groups (p > 0.05), except in the recovery rate of mJOA scores (0.836 ± 0.138 vs 0.724 ± 0.180, U = 115.000, p = 0.042) and neck disability index (NDI) at the final follow‐up (7.55 ± 10.65 vs 14.71 ± 8.72, U = 94.000, p = 0.008).ConclusionsThe special sharp rongeur with a tip angle of 20° could be a preferred method to make hinges during FDL, which can predict the laminal open angle accurately and enlarge it to about 23°, thus reducing the fracture rate and accelerating the bony fusion of hinges compared with the outcomes of the traditional micro‐drill method.     

Health-related quality of life outcomes in adolescent Scheuermann’s kyphosis patients treated with posterior spinal fusion: A comparison with age- and sex-matched controls

Purpose:To assess the health-related quality of life and radiographic outcomes of surgically treated adolescent Scheuermann’s kyphosis patients after minimum of 2-year follow-up and to compare the health-related quality of life with age- and sex-matched healthy controls.Methods:Twenty-two consecutive adolescents (mean age = 16.7 years) undergoing posterior spinal fusion for Scheuermann’s kyphosis were included and matched by age and sex with two healthy controls. The health-related quality of life was evaluated using the Scoliosis Research Society-24 questionnaire. Radiographic parameters were measured for comparison preoperatively and at 6 months and 2-year follow-ups. The health-related quality of life parameters were compared with healthy controls at 2 years of follow-up.Results:The mean maximal thoracic kyphosis improved from 79° (range = 75°–90°) to 55° (range = 45°–75°) (p < 0.001), and the mean lumbar lordosis was reduced from 71° (range = 51°–107°) to 52° (range = 34°–68°) (p < 0.001) after 2 years postoperatively. Incidence of proximal junctional kyphosis (PJK) was 18%. The scores of the Scoliosis Research Society-24 improved, with statistical significance observed in pain and self-image domains from preoperative to 2-year follow-up (p = 0.002 in both domains). The self-image and function were significantly lower in the operated patients at their 2-year follow-up visit compared to controls (p = 0.023 for self-image and p < 0.001 for function).Conclusion:Instrumented posterior spinal fusion improves the health-related quality of life of Scheuermann’s kyphosis patients during the 2-year follow-up. The greatest improvement is observed in pain and self-image domains. The health-related quality of life in pain and activity domains reaches the level of healthy individuals, while function and self-image remain at a statistically lower level.     

Change of Pelvic Sagittal Tilt after Total Hip Arthroplasty in Patients with Bilateral Crowe Type IV Developmental Dysplasia of the Hip

ObjectiveTo explore and analyze the change of pelvic sagittal tilt (PST) after total hip arthroplasty (THA) in patients with bilateral Crowe type IV developmental dysplasia of the hip (DDH).MethodsThe study retrospectively evaluated 43 patients with bilateral Crowe type IV DDH undergoing THA from January 2008 to June 2019 who were followed up for 12 months postoperatively. Four parameters, including the ratio between the height and width of the obturator foramina(H/W ratio), the vertical distance between the upper edge of the symphysis and the middle of the sacrococcygeal joint (SSc distance), the vertical distance between the upper edge of the symphysis and the line connecting bilateral hip centers (SC distance) and the vertical distance between the upper edge of the symphysis and the line connecting the bilateral lower ends of the sacroiliac joints (SSi distance), which could indirectly reflect the change of PST, were observed and measured by radiographs. The change of each parameter before operation, immediately after operation, and in 3, 6 and 12 months postoperatively was compared and analyzed.ResultsCompared with the value before operation, the H/W ratio immediately after operation and in 3, 6 and 12 months postoperatively were 0.61 ± 0.12 (t = 0.893, P = 0.377), 0.61 ± 0.11 (t = 1.622, P = 0.112), 0.67 ± 0.10 (t = 5.995, P < 0.001) and 0.76 ± 0.12 (t = −9.313, P < 0.001), respectively, and the SSc, SC and SSi distance in 6 months postoperatively were 30.12 ± 7.06 mm (t = 3.506, P = 0.002), 42.8 ± 7.7 mm (t = 5.843, P < 0.001), 129.3 ± 12.6 mm (t = 5.888, P < 0.001), respectively, and in 12 months postoperatively were 27.24 ± 7.68 mm (t = 6.510, P < 0.001), 36.1 ± 9.1 mm (t = 9.230, P < 0.001), 118.9 ± 14.9 mm (t = 8.940, P < 0.001), respectively. The radiographs obtained in 6 and 12 months postoperatively demonstrated a significantly increased H/W ratio and decreased SSc, SC and SSi distance. At the last follow‐up, the clinical evaluations significantly improved in all patients and there were no revisions.ConclusionThe significant change of pelvic sagittal posterior tilt in patients with bilateral Crowe type IV DDH might be a significant phenomenon after THA, which could occur in 6 months postoperatively.     

Open Reduction and Internal Fixation by Volar Locking Plates and the “Poking Reduction” Technique in Distal Radius Fractures with Displaced Dorsal Ulnar Fragments: A Retrospective Study

ObjectiveTo investigate the clinical and radiological outcomes of distal radius fractures (DRFs) with displaced dorsal ulnar fragments treated with volar locking plate (VLP) and the “poking reduction” technique.MethodsBetween January 2014 and January 2019, 78 unilateral DRFs with displaced dorsal ulnar fragment (AO type C3) treated with VLP were conducted. According to the reduction technique of the dorsal ulnar fragment, the patients were divided into the conventional reduction (CRG) group (33 patients, 14 males and 19 females, mean age 57.2 ± 12.1 years old) and the “poking reduction” (PRG) group (45 patients, 11 males and 34 females, mean age 60.1 ± 12.4 years old). According to the AO classification, there were 21 cases of C3.1 and 12 of C3.2 in the CPG group, 27 cases of C3.1 and 18 of C3.2 in the PRG group. Clinical and radiographic data were extracted from the electronic medical record system. These data were reviewed for clinical outcomes (range of motion, grip strength), radiological outcomes (volar tilt, radial inclination, radial height, step of articular surface), and postoperative complications. The final functional recovery was evaluated by the disabilities of the arm, shoulder, and hand (DASH) score.ResultsThe mean duration of follow‐up was 27 months (range from 12 to 56). The average operation time and intraoperative blood loss did not significantly differ between groups (p > 0.05). Postoperative CT examination showed that the step of articular surface in CPG group (0.8 ± 0.3 mm) was larger than that in PRG group (0.5 ± 0.2 mm) (p < 0.001). The DASH score did not significantly differ between groups (26.1 ± 4.6 in CRG and 24.7 ± 4.0 in PRG, p > 0.05) at 3 months postoperatively. At 6 months and 12 months postoperatively, the DASH score was better in PRG group (11.8 ± 2.5 and 10.4 ± 2.0) than in CRG group (13.6 ± 2.7 and 12.2 ± 2.5) (p = 0.004, p = 0.001, respectively). At 12 months postoperatively, wrist range of motion did not significantly differ between groups (p > 0.05). There was no significant difference in radiological parameters between the two groups (p > 0.05). The incidence of complications was higher in the CRG group (7/33) than in the PRG group (2/45) (p = 0.009).ConclusionThe “poking reduction” technique is a wise option for reduction of dorsal ulnar fragment in DRFs. This innovative technique could restore smoothness of the radiocarpal joint effectively, and the dorsal ulnar fragment could be fixed effectively combined with the volar plate.     

Effect of Duration of Symptoms on the Clinical and Functional Outcomes of Lumbar Microdiscectomy: A Randomized Controlled Trial

ObjectivesThe objective is to determine whether the preoperative duration of symptoms can affect the clinical and functional outcomes after microdiscectomy.MethodThis study is a single blind randomized controlled trial with level 1 evidence. From 3 January 2016 to 15 February 2017, 122 adult patients with symptomatic lumbar disc herniation were divided randomly by computer system into three groups were treated by microdiscectomy at 6 weeks, 3 months and 6 months from onset of symptoms respectively. Ninety‐seven patients, age (19–47) years, 42 males and 55 females, were analyzed at the end of this study with 3 years of follow up. Primary outcome measures are Oswestry Disability Index (ODI), Roland‐Morris Questionnaire (RMQ) and Visual Analogue Scale (VAS) for back pain and leg pain. Secondary outcome measures are post‐operative complications, length of hospital stay and time of return to daily activities.ResultsThere was significant difference in VAS for back pain among study groups (P = 0.002) at 2 weeks). There were significant differences in VAS for leg pain among study groups (P < 0.001) at 2 weeks and at 3 months (P = 0.003). There was significant difference in ODI among study groups at 2 weeks, 3, 6 months, 1, 2 and 3 years (P = 0.037 at 2 weeks and P < 0.001 at other periods of assessments) and we found that the mean of ODI in group 6 weeks was better than group 3 months and this was better than group 6 months in all periods of assessment. Group 6 weeks was better than group 3 months and this was better than group 6 months in postoperative improvements regarding RMQ with significant difference at 2 weeks postoperatively (P < 0.001) and at 3 months postoperatively (P < 0.001).ConclusionDuration of preoperative symptoms, in patients with lumbar disc herniation, can affect the clinical and functional outcomes after lumbar microdiscectomy as the shorter duration of symptoms resulted in better postoperative clinical and functional outcomes.     

Denosumab Can Prevent Collapse in Patients with Early‐Stage Steroid‐Induced Osteonecrosis of the Femoral Head by Inhibiting Osteoclasts and Autophagy

ObjectiveThe osteoclastic bone resorption inhibitors might have positive effect in preventing femoral head collapse in patients with osteonecrosis of the femoral head (ONFH). However, as a novel osteoclastic inhibitor, whether denosumab can prevent collapse in steroid‐induced ONFH remains unknown. This study aims to evaluate the treatment effect of denosumab and the potential protective mechanism.MethodsThis was a retrospective study. A total of 161 patients with steroid‐induced ONFH who underwent denosumab treatment were reviewed, and 209 untreated patients were selected as controls. Their clinical characteristics and radiological exam results were obtained. Patients were treated with 60 mg denosumab every 6 months for 2 years. The primary outcome was the incidence of femoral head collapse at 2 years after the initial diagnosis of ONFH. Secondary outcomes included the Harris hip score, progression of osteosclerosis, increase in necrotic area, bone marrow oedema relief, and bone mineral density increase in the femoral head. The Mann–Whitney U test and chi‐square tests were performed to identify the differences between the continuous and categorical variables, respectively. A multivariate logistic regression model was built to identify the factors associated with the treatment effect of denosumab.ResultsThe incidence of femoral head collapse was 42.24% (68/161) in the denosumab group and 54.07% (113/209) in the control group (χ ² = 5.094, p = 0.024; relative risk = 0.787, 95% CI = 0.627–0.973). The excellent‐good rates of the Harris hip score were 63.98% (103/161) in the denosumab group and 44.98% (94/209) in the control group (χ ² = 13.186, p < 0.001). The incidence of osteosclerosis progression in the denosumab group was 55.28% (89/161), which was significantly higher than that in the control group (43.54%, 91/209, χ ² = 5.016, p = 0.025). Meanwhile, a significant increase in bone mineral density was identified in 29.19% (47/161) and 7.18% (15/209) of patients in the denosumab and control groups, respectively (χ ² = 31.600, p < 0.001). The osteoclastic cytoplasm expression of LC3‐II was more positive in the control group than in the denosumab group (immunohistochemistry scoring: 3.58 ± 2.27 vs 6.33 ± 2.64, Z = −2.684, p = 0.007). A total of three independent factors were considered to be associated with the positive treatment effect of denosumab, the time of first denosumab administration (OR = 2.010, 95% CI = 1.272–3.177), osteosclerosis (OR = 1.583, 95% CI = 1.024–2.445), and the necrotic area before denosumab administration (medium necrotic area: OR = 2.084, 95% CI = 1.245–3.487; large necrotic area: OR = 2.211, 95% CI = 1.255–3.893).ConclusionsThe current study demonstrated that denosumab had a positive effect on preventing femoral head collapse in patients with steroid ONFH. This effect might be closely associated with the inhibition of osteoclasts and their autophagy.     

Effect of national holidays on health outcomes of patients receiving peritoneal dialysis in a single center over a ten-year period

BackgroundNational holidays are associated with high mortality in some diseases, but little is known about patients undergoing peritoneal dialysis (PD). The research aimed to investigate the impact of national holidays on the health outcomes of PD patients.MethodsOver ten years, all episodes of unplanned hospitalization, death, and peritonitis in PD patients were collected in our center. Seven national holidays in China were chosen, and non-holiday days were selected as the control period. The effect of national holidays was observed by comparing the hospitalization, death, and peritonitis rates between holiday and non-holiday groups.ResultsThere were 297 events in all holiday periods and 1247 in non-holiday periods. There is no significant difference in hospitalization rate between holiday and non-holiday groups (32.4% ± 6.4% vs. 29.2% ± 3.4%, p = 0.175). So is the death rate [6.3% (4.8–12.3%) vs.5.0% (4.2–8.9%), p = 0.324] and peritonitis rate [0.19 (0.13–0.53) vs. 0.22 (0.18–0.27), p = 0.445] between the two groups. Significant differences were observed in the distribution of peritonitis causes between the two groups (p = 0.017). The rate of secondary to other infections in the holiday group was significantly higher than in the non-holiday group (25.0 vs. 10.3%, p = 0.015).ConclusionOur study suggested no national holiday effect on health outcomes of PD patients based on ten-year data in our center.     

Hip Preservation or Total Hip Arthroplasty? A Retrospective Case–Control Study of Factors Influencing Arthroplasty Decision‐Making for Patients with Osteonecrosis of the Femoral Head in China

ObjectiveAt present, there is no consensus or guidance on indications for osteonecrosis of the femoral head (ONFH) patients to receive hip arthroplasty (THA) treatment. This study aims to explore the factors that influence the decision‐making for THA in patients with ONFH, and to provide references for clinical decision for ONFH patients to be indicated for THA or hip preservation.MethodsThis retrospective case–control study involved data for ONFH patients from July 2016 to October 2021 from the China Osteonecrosis of the Femoral Head Database (CONFHD). The patients with ONFH, and unilateral hip affected at the first visit were divided into THA group and non‐THA group according to if they had undergone THA treatment. The differences between the two groups of patients in terms of gender, age at the time of consultation, body mass index (BMI), etiology, onset side, association research circulation osseous (ARCO) stage, hip joint function, visual analog scale (VAS), etc. were analyzed. Multivariate binomial logistic regression analysis was then applied to evaluate the risk factors of ONFH patients who underwent THA during the first visit.ResultsA total of 640 patients were recruited for analysis, including 209 cases from the THA group and 431 cases from the non‐THA group. The results of univariate analysis showed that the two groups of patients were significantly different in the following six indicators: age (59 vs. 46, Z = −9.58, p < 0.001), duration of disease (78 vs. 17, Z = –16.14, p < 0.001), gender composition (χ² = 8.09, p = 0.004), disease etiology (χ² = 33.04, p < 0.001), ARCO stage (χ² = 334.86, p < 0.001), flexion of hip joint (χ² = 172.33, p < 0.001). However, the comparison between the two groups on VAS (Z = –0.82, p = 0.41), BMI (Z = –1.35, p = 0.18), and onset side (χ² = 1.53, p = 0.22) did not obviously differ. The results regression analysis showed that the age at the time of consultation, duration of disease, ARCO stage, and the hip joint function affected the decision making if the patients should undergo THA. The results of receiver operating characteristic curve (ROC) analysis showed that aforementioned indicators were satisfactory in predicting whether patients with ONFH would be treated with THA. The regression model using the above four indicators as comprehensive indicators has satisfactory performance in predicting whether to perform THA, and the area under the curve (AUC) is 93.94%.ConclusionThese factors such as age, duration of disease, ARCO stage, and hip flexion function should be considered comprehensively before making decisions to perform THA or not in our clinical practice.     

Is Plating Fixation Through the Kocher–Langenbeck Approach for Associated Posterior Wall Fragment Indispensable in Both‐Column Acetabular Fractures?

ObjectiveThe treatment methods for posterior wall (PW) in both‐column acetabular fractures are controversial. The purpose of this study was to compare reduction quality, clinical outcomes, and complications of nonfixation for posterior wall fragment and plating via the Kocher–Langenbeck (KL) approach after anterior surgical procedures in both‐column acetabular fractures.MethodsForty‐nine patients with both‐column acetabular fractures associated with PW fixed via iliac fossa and Stoppa approaches from October 2012 to October 2017 were recruited into this study and were divided into two groups: Nonfix group (nonfixation for PW) and KL group (PW plating through the KL approach). Operation duration, intraoperative blood loss, reduction quality, fracture healing, and relevant complications of patients were reviewed. Merle d''Aubigné scores were used for assessing functional outcome.ResultsThe mean blood loss and operation durations were lower in Nonfix group than in KL group (both p < 0.05). The mean hospital stay durations were (18.54 ± 6.42) days and (21.17 ± 7.32) days in groups Nonfix and KL, respectively (p = 0.186). All fractures healed well with no significant difference in union time between the two groups (p = 0.210). The rates of satisfactory reduction were 84.62% (22/26) in Nonfix group and 86.96% (20/23) in KL group (p = 1.000). The mean Merle d''Aubigné scores were 15.62 ± 2.28 in Nonfix group and 16.17 ± 2.19 in KL group (p = 0.388). The complication rates were 7.69% (2/26) in Nonfix group and 34.78% (8/23) in KL group (p = 0.046).ConclusionsFor both‐column acetabular fractures associated with PW fragment, although fixation of PW was not performed after anterior surgical procedures, satisfactory outcomes could also be obtained. However, nonfixation was a less invasive choice with a lower complication rate.     

The Impact of Spinal Fusion on Hip Displacement in Cerebral Palsy

Background and study aimsThe aims of this study were to determine the risk of progressive hip subluxation in children with CP after spinal fusion for scoliosis and how frequent the hips follow-up should be scheduled.Patients and methodsPelvis radiography [migration index (MI) and pelvic obliquity (PO)] of Gross Motor Function Classification System (GMFCS) levels IV and V children with CP who received spinal fusion and pelvic fixation were reviewed retrospectively. This population was categorized into three groups based on the MI at spinal fusion: G1 = 0–29%; G2 = 30–59%; and G3 = 60–100%.ResultsFifty children (age 7.5–15.0 years) and categorized into 3 groups (G1 = 19, G2 = 23, G3 = 8; 100 hips in total). Preoperative and last follow-up MI were 22 ± 7% and 30 ± 20% (G1), 41 ± 9% and 43 ± 22% (G2), 92 ± 15% and 97 ± 10% (G3). The MIs at spinal fusion between groups were statistically different (p < 0.001). In G1, the mean MI progression was 5% and 25% at 12 months and 62 months, respectively. In G2, the mean MI progression was 9% and 25% at 12 months and 32 months, respectively. The progression more than 10% occurred within 2 years in G1 and within 1 year in G2. There was no difference between groups based on preoperative degree of PO (p = 0.653) and correction rate in PO (p = 0.421).ConclusionsIn GMFCS IV and V children with the highest risk for progression occurred with increasing preoperative MI, especially over 50%. Hips should be monitored continuously after spinal fusion until hip stability is documented.     

Association Between Body Mass Index and Functional Outcomes in Elderly Patients with Extra-articular Distal Radius Fracture: A Prospective Observational Study

IntroductionThe association between body mass index (BMI) and functional outcomes is unknown in elderly individuals with distal radius fracture (DRF).ObjectiveThe aim of this study is to evaluate if there is association between BMI and functional outcomes in patients older than 60 years with DRF treated conservatively.Materials and MethodsA prospective observational study was performed. A total of 228 patients with extra-articular DRF were prospectively recruited. All patients were categorized by their BMI as normal, overweight, or obese. Functional outcomes were assessed after cast removal and at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH), and Patient-Rated Wrist Evaluation (PRWE) questionnaires were used to assess upper limb and wrist/hand function, respectively, while the Jamar Dynamometer was used to assess grip strength.ResultsOf the total number of patients, 184 were female (80.7%), 87 were overweight (38.2%), and 111 were obese (48.7%). After cast removal, the correlations between BMI and functional outcomes were DASH 0.06 (p = 0.578), PRWE 0.04 (p = 0.692), and grip strength − 0.02 (p = 0.763). At 1-year follow-up, the correlations were DASH 0.55 (p = 0.036), PRWE 0.32 (p = 0.041), and grip strength − 0.21 (p = 0.043).ConclusionThis study suggests that at 1-year follow-up, there was a low-to-moderate association between BMI and poor functional outcomes in elderly patients with extra-articular DRF treated conservatively.Level of EvidenceLevel IV, observational prospective study.     

Comparison of Functional and Radiological Outcomes of Transverse Patellar Fractures Fixed with Tension Band Fixation Using Cannulated Screws and Kirschner Wires: A Prospective Randomized Study

PurposeTo compare functional and radiological outcomes of transverse patella fractures treated with tension band wiring using either two 4.5 mm cannulated screws or Kirshner wire.MethodsThis is a non-blinded prospective randomized study comprising of two groups (n = 30 each) with closed transverse patella fractures treated with tension band wiring using Kirschner wire (K wire group) and two 4.5 mm cannulated screws (CCS group). Outcomes measured were radiological union, Knee Society score, range of motion and post-operative complications.ResultsThe CCS group showed a statistically significant higher range of motion than K wire group for each follow up (p < 0.001 in flexion and p < 0.005 in extension). A statistically significant higher percentage of patients in the CCS group showed signs of union at 6th and 12th post-operative week (p = 0.001 and 0.011 respectively) but no difference at 24th post-operative week (p = 0.313). The rate of hardware complications was significantly higher in K wire group (p = 0.001). No significant difference was noted in in the Knee society score and post-operative complications between the groups.ConclusionThis study concludes that the fixation of closed transverse patella fractures using two 4.5 mm cannulated screws is allows a faster rate of union, a better knee range of motion and lesser hardware complications as compared to Kirschner wires. However more studies with larger sample sizes and longer follow up are required.     

A Comparison Between Retaining and Resecting the Posterior Longitudinal Ligament in Percutaneous Endoscopic Transforaminal Discectomy for Disc Herniation: A Retrospective Cohort Study

ObjectiveTo compare the efficacy and safety of retaining the posterior longitudinal ligament (PLL) with resecting the PLL in inside‐out percutaneous endoscopic transforaminal discectomy (PETD) surgery for lumbar disc herniation (LDH).MethodA total of 135 patients with symptomatic LDH who were treated by inside‐out PETD surgery from January 2015 to January 2017were included in this retrospective analysis. There were 38 males and 30 females in the PLL resection group (mean age = 52.40 ± 8.73 years) and 35 males and 32 females in the PLL retention group (mean age = 53.50 ± 9.24 years). The visual analogue scale (VAS) score, Oswestry disability index (ODI), and modified MacNab criteria were used to evaluate clinical outcomes. Operation time, blood loss, recurrence of LDH, and complications were recorded. Three months after surgery, magnetic resonance imaging was performed to confirm that nerve root compression was relieved.ResultsThe VAS and ODI scores improved significantly immediately after surgery, at 1 month after surgery, at 3 months after surgery, and at last follow‐up compared with those before surgery (P < 0.01). The scores also improved significantly between immediately after surgery and 1 month after surgery in the two groups (P < 0.001). Multivariate analysis indicated that age ≥ 50 years (odds ratio (OR) = 6.33, 95% confidence interval (CI): 1.64–21.98, P = 0.014), pain duration ≥6 months (OR = 4.68, 95% CI: 1.29–6.51, P = 0.025), pre‐ODI score ≥ 40% (OR = 5.97, 95% CI: 2.41–14.86, P = 0.003) were all associated with poor functional outcomes. There was no significant difference in the excellent/good ratio between the two groups and the mean operation time of the retention group was 71.5% of that of the resection group (82.7 ± 18.5 min vs 115.6 ± 24.6 min, P < 0.01). In the patients, no serious complications, such as dural tear, wound infection, or persistent nerve root injury, were observed during the follow‐up period. There was no significant difference in the complication rate between the two groups (6/68 vs 6/67, P = 0.979). Although the recurrence rate was higher in retention group, there was no significant difference between the two groups (1/68 vs 2/67, P = 0.551).ConclusionThe PLL is recommended to be retained for inside‐out PETD surgery.     

Bleeding complications after dual antiplatelet therapy with ticagrelor versus dual antiplatelet therapy with clopidogrel—a propensity-matched comparative study of two antiplatelet regimes in off-pump coronary artery bypass grafting

PurposeTicagrelor combined with aspirin had shown better saphenous vein graft patency than aspirin with clopidogrel after off-pump coronary artery bypass grafting. However, the safety of this drug in regard to bleeding complications remains unknown. The aim of our study was to assess the bleeding complications of dual antiplatelet therapy with aspirin and ticagrelor compared with aspirin and clopidogrel within the first 3 months after off-pump surgery.MethodsThree hundred eighty-two consecutive patients who were prescribed aspirin with ticagrelor (ticagrelor group) were compared with 660 patients who received aspirin and clopidogrel (clopidogrel group). After propensity matching, 144 patients in each group were compared for bleeding events and major adverse cardiac and cerebral events. Major bleeding was defined as composite outcome of re-exploration for bleeding, any fatal bleeding, intracranial bleeding, and any bleeding requiring hospitalization.ResultsPatients in the ticagrelor group had more incidence of re-exploration for bleeding (p = 0.042), pericardial effusion requiring drainage (p = 0.007), readmissions (p < 0.01), gastrointestinal bleeding (p = 0.01), and major bleeding (5.8% vs. 2.1%, p < 0.01, OR 2.8 (1.43–5.58)). After propensity analysis, gastrointestinal bleed (p = 0.024), major bleeding (7.6% vs.1.4%, p < 0.001, OR 5.8 (1.28–26.97)), length of ICU stay (p = 0.039), and readmissions (p = 0.003, OR 11.83 (1.51–92.86)) were more in the ticagrelor group. Major adverse cardiac and cerebral events were similar between the groups.ConclusionDual antiplatelet therapy with aspirin and ticagrelor increased gastrointestinal bleeding events, major bleeding events, and readmission rates compared with aspirin and clopidogrel after off-pump coronary artery bypass grafting.