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Background Deep surgical site infection (DSSI) is one of the most challenging complications in lumbar fusion surgery. Few investigations examined the effect of vancomycin powder mixed with autogenic bone graft (ABG) and bone substitutes on preventing DSSI in degenerative lumbar fusion surgeries as well as any interference with bony fusion. The aim of the study was to investigate the effects of ABG along with bone substitutes as a local vancomycin delivery system on preventing DSSI in lumbar instrumented fusion and compared with those who did not use vancomycin powder. Methods From January, 2015 through December, 2015, a one-year prospective study using vancomycin powder mixed with ABG and bone substitute for degenerative lumbar fusion surgeries as vancomycin (V) group, 1 gm vancomycin for 2 and 3-level, and 2 gm for more than 3-level instrumentation. From December, 2013 through December 2014, patients received degenerative lumbar fusion surgeries without using vancomycin before the vancomycin protocol were retrospectively enrolled as non-vancomycin (NV) group. Vancomycin concentration was checked at post-operative days 1 and 3 for both the serum and drainage. Patients’ demographic data, microbiology reports, fusion status and functional outcomes were evaluated. Results One hundred and ten patients were enrolled prospectively in the V group, and 86 for the NV group. After an average 41 months follow-up (range, 36–54), 3 patients (3.48%) developed postoperative DSSIs in the NV group, thereby requiring revision surgeries and parenteral antibiotics treatment versus no DSSIs (0%, 0/100) in the V group. (p = 0.048). The postoperative serum vancomycin levels were undetectable and no vancomycin related side effects was encountered. The mean vancomycin concentration of drainage at postoperative days 1 and 3 were 517.96 ± 174.4 and 220.14 ± 102.3 μg/mL, respectively. At final follow-up, there was no statistical difference observed in terms of clinical and radiologic outcomes. Conclusions Our vancomycin protocol may reduce the incidence of DSSI in degenerative lumbar fusion surgery without affecting bony fusion. Level of Evidence Level III ambispective comparative study.

Background Involvement in cervical ligamentum flavum is a rare manifestation of the calcium pyrophosphate dihydrate deposition disease. Only few cases of this condition have been reported. We revealed eighteen cases of CPPD in cervical ligamentum flavum that diagnosed at a single medical center. In our case series, clinical characteristics and magnetic resonance imaging findings of patients are described. Methods We retrospectively reviewed the medical charts and imaging studies of the eighteen patients with pseudogout attack of the cervical ligamentum flavum. In addition, we discussed the differences between this disease and ossification of ligamentum flavum in image manifestations. Results There were fourteen men and four women aged between 59 and 87 years. Diabetes mellitus and hypertension were the most common comorbidities. Myelopathy and neck pain were presented in most patients. C4–5 and C5–6 were attacked most frequently, and multiple- rather than single-level involvement could be observed in our series. “Acute on chronic phenomenon” was a specific magnetic resonance image finding in patients whose symptom durations were between 2 to 5 months. Compared to ossification of ligamentum flavum, calcium pyrophosphate dihydrate crystal deposition had different image signs, including morphology, side of the involved ligament, no continuity with the lamina, acute on chronic phenomenon, and presence of retro-odontoid mass. Conclusions Nodular calcifications in cervical ligamentum flavum raise highly suspicion for calcium pyrophosphate dihydrate deposition and must be diagnosed by histological examination and polarized light microscopy. This disease is different from ossification of ligamentum flavum, and it could be recognized by specific image features.

Study design Retrospective cohort study. Objectives To compare the surgical results between targeted therapy and post-operative chemotherapy for patients with spinal metastasis of inoperable non-small-cell lung cancer (NSCLC). Setting Single-center study at an academic orthopedic department in Taiwan. Methods Sixty-five patients were treated surgically for spinal metastasis of inoperable NSCLC with long posterior instrumentation with or without posterior decompression according to the patient's neurologic status. Post-operative radiotherapy of the spinal lesion and targeted therapy or chemotherapy were done following surgery after the surgical wound healed. Post-operative clinical outcomes and survival were evaluated and compared between these two groups. The overall survival represented survival from the date of diagnosis to death. Results Thirty-five patients were grouped as the targeted therapy group and 30 patients as the chemotherapy group. The overall median survival times were 12.0 and 10.0 months in the targeted therapy and chemotherapy groups, respectively. Sixty-two patients were able to walk with or without an aid postoperatively. There was no significant difference observed between these two groups in terms of pain relief, neurologic improvement, ambulatory improvement, and survival. Conclusions Surgical stabilization with or without laminectomy improved functional outcomes in patients with inoperable non-small-cell lung cancer, and post-operative functional outcomes were similar between chemotherapy and targeted therapy groups. A longer survival was observed with targeted therapy for the patients whose NSCLC was diagnosed before spinal metastasis, however, the longer survival was not statistically significant.

Purpose To investigate the tunnel enlargement rate and clinical function by comparing double-bundle anterior cruciate ligament reconstruction (ACLR) using different fixation devices. Methods Patients receiving primary arthroscopic double-bundle ACLR were screened and divided into 2 groups on the basis of the method of graft fixation: bioabsorbable interference screw (BS) group and cortical button (CB) group. Bone tunnel size was assessed digitally using magnetic resonance imaging, which was performed a minimum of 2 years postoperatively. Clinical evaluations were performed using the Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee score, and KT-1000 arthrometer 2 years postoperatively. Results Sixty patients receiving primary arthroscopic double-bundle ACLR were included. Overall, the BS group showed greater tunnel enlargement than the CB group, as well as a significantly increased rate of tunnel communication (P = .029). The average anteromedial tunnel enlargement rates for the BS and CB groups were 50% and 28%, respectively. The enlargement rate of the posterolateral (PL) femoral tunnel was similar in both groups. In the PL tibial tunnel, the CB group showed a significant increase in enlargement compared with the BS group (64% vs 45%, P = .0001). Both groups showed functional improvement in the Knee Injury and Osteoarthritis Outcome Score and International Knee Documentation Committee score. No significant difference in postoperative functional outcomes was found between the 2 groups. Conclusions The BS group showed significantly greater tunnel enlargement in anteromedial tunnels and an increased tunnel communication rate compared with the CB group. On the other hand, the CB group showed greater tunnel enlargement in tibial PL tunnels. Tunnel communication was observed mostly on the tibial side in the BS patients. Equivalent clinical function outcomes were noted at 2 years after surgery in both groups of patients. Level of Evidence Level II, randomized controlled clinical trial.

To evaluate the impact of the preoperative severity of facet joint arthropathy on long-term functional outcomes and spinopelvic parameters in patients undergoing lumbar-stability-preserving decompression and Dynesys fixation. In this retrospective study, 88 patients undergoing combined surgery at our hospital from 2008 to 2015 were included. The patients were divided into two groups, the less and more than mean degeneration groups, based on preoperative facet joint arthropathy of the index level(s). The clinical outcomes were the Visual Analogue Scale (VAS) score, the Oswestry Disability Index (ODI) score and spinopelvic parameters. The mean follow-up durations for the less and more than mean degeneration groups were 84.83 ± 27.58 and 92.83 ± 20.45 months, respectively. The combined surgery significantly improved VAS and ODI scores, and increased sacral slope (SS) regardless of preoperative arthropathy severity. In addition, facet joint arthropathy at adjacent levels continued to worsen after surgery in both arthropathy severity groups. Preoperative facet joint arthropathy did not influence most long-term clinical outcomes in patients undergoing lumbar-stability-preserving decompression and Dynesys fixation. This combined surgery may be suitable for patients with facet joint arthropathy regardless of disease severity.

Study design A retrospective cohort study. Objective To determine the risk factors of cage subsidence in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and its correlation with patient-reported outcomes. Summary of background data Cage subsidence is among the cage-related complications after TLIF and may lead to poor outcomes. Few studies have addressed the incidence of cage subsidence in MI-TLIF. Methods This retrospective study of a prospectively collected database was conducted from October 2015 to October 2017. All patients received MI-TLIF with a minimum of 2-year follow-up. All levels were separated into the cage subsidence (CS group) and no cage subsidence (non-CS group) groups. Cage subsidence was evaluated using lateral radiographs and defined as more than 2 mm migration of the cage into the endplate of adjacent vertebral body. Patient demographics, perioperative details, and radiographic parameters were recorded. Cage-related parameters were cage height, cage insertion level, and cage position. Cage position was recorded using central point ration (CPR). Patient-reported outcome was analyzed using the Oswestry Disability Index (ODI) questionnaire and Visual Analog Scale (VAS) preoperatively and at 2 years postoperatively. Results Ninety-three patients (126 levels) were included. Mean age was 66.5 years with an average follow-up of 36.9 months. Overall incidence of cage subsidence was 34.1%. The CS group had significantly higher body mass index, less bone mineral density (BMD), shorter disc height, and higher CPR than the non-CS group. BMD, disc height, and CPR were significantly negatively correlated with depth of cage subsidence. ODI improvement was significantly lesser in the CS group than in the non-CS group. Fusion rate and complications were unrelated to cage subsidence. Conclusion The BMD, disc height, and cage position were the most significant risk factors that were negatively correlated with depth of cage subsidence. Placing a TLIF cage anteriorly if possible may reduce the risk of cage subsidence. Level of evidence 3.

This study aimed to compare the accuracy of navigation-assisted percutaneous pedicle screw insertions between traditional posterior superior iliac spine (PSIS) fixed and cutaneously fixed dynamic reference frame (DRF) in minimally invasive surgery of transforaminal lumbar interbody fusion (MIS TLIF). This is a prospective randomized clinical study. Between May 2016 and Nov 2017, 100 patients who underwent MIS TLIF were randomly divided into bone fixed group (with PSIS fixed DRF) and skin fixed group (with cutaneously fixed DRF). The pedicel screws were inserted under navigational guidance using computed tomography (CT) data acquired intraoperatively with a Ziehm 3-dimensional fluoroscopy-based navigation system. Screw positions were immediately checked by a final intraoperative scan. The accuracy of screw placement was evaluated by a sophisticated computed tomography protocol. Both groups had similar patient demographics. Totally Five-hundred Twelve pedicle screws were placed in the lumbar spine. There were 2 moderate (2-4 mm) pedicle perforations in each group. The accuracy showed no significant difference between bone fixed and skin fixed DRF. There were no significant procedure-related complications. The skin fixed DRF provides similar accuracy in pedicle screw insertions with bone fixed DRF using intraoperative 3D image guided navigation in MIS TLIF. Skin fixed DRF not only serves as an alternative method but also saves a separate incision wound for bony attachment.

Spinal epidural abscess (SEA) can cause neurologic deficits and needs urgent surgical intervention. Many clinical factors had been proposed to predict surgical outcomes in patients with SEA, but the predictive radiographic risk factors for residual neurologic deficits were not addressed sufficiently.To analyze the clinical and radiographic risk factors for residual neurologic deficit in patients with SEA after surgical intervention of the thoracic or lumbar spine.A retrospective consecutive case series.From January 2005 through December 2014, 53 patients with primary SEA, confirmed by culture or histopathology, in the thoracic or lumbar spine who underwent posterior-only approach surgery at our hospital.Neurologic status was assessed using the Frankel grading system preoperatively, postoperatively, and at final follow-up.The patients were allocated into two groups based on the presence of postoperative residual neurologic deficits. Patients' demographic, clinical, and factors based on magnetic resonance imaging (MRI) were analyzed for their influence on residual neurologic deficits. Clinical factors included age, sex, diabetes, comorbidities, pathogens, affected spinal levels, the interval between onset of symptoms to surgery, preoperative neurologic status, presence of cauda equina syndrome, and surgical procedures. MRI factors included the distribution of abscesses within the spinal canal, presence of ring enhancement, presence of paravertebral abscess or psoas abscess, canal compromise anteroposterior (AP) ratio and cross-sectional area ratio, abscess length, and abscess thickness.Thirty-five of the 53 patients (66%) had preoperative neurologic deficits, and 21 of 53 patients (40%) had postoperative residual neurologic deficits. Patients' neurologic status improved significantly after the surgery (p.001). Risk factors including age, diabetes, cauda equina syndrome, presence of anterior with posterior (A+P) dural abscess, canal compromise AP ratio, cross-sectional area ratio, abscess length, and abscess thickness were significantly correlated with postoperative residual neurologic deficits. In multivariate logistic regression analysis, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the four most significant factors related to residual neurologic deficits.In patients with SEA of the thoracic and lumbar spine, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the most significant preoperative risk factors for residual neurologic deficits after surgery.

Background Context To improve correction and fusion rates, an anterior release is often needed for the treatment of idiopathic scoliosis with a curve of more than 75° before posterior correction, instrumentation, and fusion. However, there are disadvantages to anterior release, and we are concerned about whether it is necessary for anterior-posterior spinal fusion in these patients. Purpose The objective of this study was to compare the surgical results for idiopathic scoliosis with a curve of more than 75° and a flexibility of less than 25% between using posterior-only approach and combined anterior release followed by posterior correction with a hybrid construct (hooks and pedicle screws) and spinal fusion. Study Design/Setting This was a retrospective cohort study. Patient Sample From 2000 to 2014, 388 consecutive patients with idiopathic scoliosis were treated surgically at our hospital. Of these patients, 53 whose primary curves were more than 75° with a flexibility of less than 25%, at an incidence of 13.6%, were included and divided into two groups. Thirty-one patients (mean age: 16.3 years old) who underwent anterior release followed by posterior correction, instrumentation, and fusion were included in the A+P group, and the remaining 22 patients (mean age: 17.3 years old) were designated as the P group for posterior procedure alone. Outcome Measures The clinical outcomes were analyzed in terms of correction and loss of correction and by the Scoliosis Patient Questionnaire: Version 30 functional questionnaire. Materials and Methods In the A+P group, halo-femoral traction was applied for 1 week between the anterior release and the posterior procedure. Posterior instrumentation with a hybrid construct with hooks and pedicle screws was used for both groups. The radiological and functional outcomes were compared between the two groups. Results The average preoperative Cobb angle was 85.3° for the A+P group, with an average 17.4% flexibility, and 80° for the P group, with 15.3% flexibility. The postoperative Cobb angle was 53.1° for the A+P group and 45.6° for the P group. The Cobb angle at the final follow-up for the A+P group was 55.2° and that for the P group was 48°. The average correction rates of the A+P and P groups were 37% and 43.4%, respectively. There were no statistically significant differences between the groups in gender, age, number of levels fused, and flexibility of coronal curve. With a minimum 2-year follow-up, similar results were found between these two groups in terms of correction rate, loss of correction, and functional outcome. Conclusions In this study, we found that a posterior-only approach with hybrid construct (hooks and pedicle screws) could provide a correction similar to that of an anterior-posterior approach. Also, the disadvantages of anterior release could be avoided by the posterior-only approach.

Polymethylmethacrylate (PMMA) augmentation is a common method to increase pullout strength fixed for osteoporotic spines. However, few papers evaluated whether these pedicle screws migrated with time and functional outcome in these geriatrics following PMMA-augmented pedicle screw fixation. From March 2006 to September 2008, consecutive 64 patients were retrospectively enrolled. VAS and ODI were used to evaluate functional outcomes. Kyphotic angle at instrumented levels and horizontal and vertical distances (HD and VD) between screw tip and anterior and upper cortexes were evaluated. To avoid bias, we used horizontal and vertical migration index (HMI and VMI) to re-evaluate screw positions with normalization by the mean of superior and inferior endplates or anterior and posterior vertebral body height, respectively. Forty-six patients with 282 PMMA-augmented screws were analyzed with mean follow-up of 95 months. Nine patients were further excluded due to bed-ridden at latest follow-up. Twenty-six females and 11 males with mean T score of − 2.7 (range, − 2.6 to − 4.1) and mean age for operation of 77.6 ± 4.3 years (range, 65 to 86). The serial HD and kyphotic angle statistically progressed with time. The serial VD did not statistically change with time (p = 0.23), and neither HMI nor VMI (p = 0.772 and 0.631). Pre-operative DEXA results did not correlate with kyphotic angle. Most patients (80.4%) maintained similar functional outcomes at latest follow-up. The incidence of screws loosening was 2.7% of patients and 1.4% of screws, respectively. The overall incidences of systemic post-operative co-morbidities were 24.3% with overall 20.2 days for hospitalization. Most patients (80%) remained similar functional outcomes at latest follow-up in spite of kyphosis progression. The incidence of implant failure was not high, but the post-operative systemic co-morbidities were higher, which has to be informed before index surgery.

Retrospective cohort study.To compare the surgical results between targeted therapy and post-operative chemotherapy for patients with spinal metastasis of inoperable non-small-cell lung cancer (NSCLC).Single-center study at an academic orthopedic department in Taiwan.Sixty-five patients were treated surgically for spinal metastasis of inoperable NSCLC with long posterior instrumentation with or without posterior decompression according to the patient's neurologic status. Post-operative radiotherapy of the spinal lesion and targeted therapy or chemotherapy were done following surgery after the surgical wound healed. Post-operative clinical outcomes and survival were evaluated and compared between these two groups. The overall survival represented survival from the date of diagnosis to death.Thirty-five patients were grouped as the targeted therapy group and 30 patients as the chemotherapy group. The overall median survival times were 12.0 and 10.0 months in the targeted therapy and chemotherapy groups, respectively. Sixty-two patients were able to walk with or without an aid postoperatively. There was no significant difference observed between these two groups in terms of pain relief, neurologic improvement, ambulatory improvement, and survival.Surgical stabilization with or without laminectomy improved functional outcomes in patients with inoperable non-small-cell lung cancer, and post-operative functional outcomes were similar between chemotherapy and targeted therapy groups. A longer survival was observed with targeted therapy for the patients whose NSCLC was diagnosed before spinal metastasis, however, the longer survival was not statistically significant.

Background Ulnar shortening is a common and useful method for treating ulnar wrist pain from many causes. Many devices used to perform osteotomy have been introduced in the literature; however, the devices are not universally available. The standard freehand technique is still commonly used in clinical practice; however, it is associated with several complications and is time-consuming. We present a freehand technique for ulnar-shortening osteotomy using a predrilled hole method. Methods From 2011 to 2013, we performed the predrilled hole method for ulnar shortening in 18 cases using the six-hole limited-contact dynamic compression plate (LC-DCP) and in two cases using the Acumed six-hole Locking Midshaft Ulna Plate. Results All patients had uneventful union, and the average operative time was 39.7 minutes (range, 32–50 minutes). The average follow-up period was 21 months (range, 12–30 months). There were no complications except in three patients in the LC-DCP group who complained of implant irritation. Good functional outcomes were achieved with this method. Conclusion Our technique is easy and quick to use and can minimize soft-tissue manipulation. The union rate is high and complications are few.

To evaluate the effect of intra-articular injection of tranexamic acid (TXA) in patients receiving arthroscopic anterior cruciate ligament reconstruction (ACLR).A total of 304 patients were included in this study, which was performed between August 2017 and April 2018. Single-bundle reconstructions using autologous hamstring tendon grafts were performed in all patients. Patients were randomized into 2 groups: Group 1 patients (TXA group) received the index procedure with a 10-mL intra-articular injection of TXA (100 mg/mL). Group 2 patients (control group) received the index procedure without TXA injections. An intra-articular suction drain was placed in the joint and clamped for 2 hours after the procedure. The volume of drainage was recorded 24 hours after surgery. Clinical evaluations using the International Knee Documentation Committee functional score, range of motion, and a visual analog scale pain score were performed on day 3 and at week 4 postoperatively.Twenty-four hours after surgery, a significant decrease in the amount of drainage was observed in patients receiving intra-articular injections (TXA group, 56.1 ± 34.1 mL; control group, 80.1 ± 48 mL; P.05). On day 3 and at week 4, significantly reduced pain scores were reported in the TXA group. However, at week 4, clinical function scores did not show significant differences between the 2 groups.Intra-articular injection of TXA could significantly reduce postoperative intra-articular bleeding in the first 24 hours in patients receiving arthroscopic ACLR. TXA injection may also decrease pain and the grade of hemarthrosis in the early postoperative period. No systemic side effects or need for aspiration was noted during the follow-up period. Therefore, intra-articular injection of TXA could be considered an effective and relatively safe solution to reduce postoperative bleeding and pain in ACLR patients.Level II, prospective comparative study.

Intervertebral discs (IVDs) are important biomechanical components of the spine. Once degenerated, mesenchymal stem cell (MSC)-based therapies may aid in the repair of these discs. Although hypoxic preconditioning enhances the chondrogenic potential of MSCs, it is unknown whether bone marrow MSCs expanded under hypoxic conditions (1% O2 , here referred to as hypoxic MSCs) are better than bone marrow MSCs expanded under normoxic conditions (air, here referred to as normoxic MSCs) with regards to disc regeneration capacity. The purpose of this study was to compare the therapeutic effects of hypoxic and normoxic MSCs in a rabbit needle puncture degenerated disc model after intra-disc injection. Six weeks after needle puncture, MSCs were injected into the IVD. A vehicle-treated group and an un-punctured sham-control group were included as controls. The tissues were analyzed by histological and immunohistochemical methods 6 and 12 weeks post-injection. At 6 and 12 weeks, less disc space narrowing was evident in the hypoxic MSC-treated group compared to the normoxic MSC-treated group. Significantly better histological scores were observed in the hypoxic MSC group. Discs treated with hypoxic MSCs also demonstrated significantly better extracellular matrix deposition in type II and XI collagen. Increased CD105 and BMP-7 expression were also observed upon injection of hypoxic MSCs. In conclusion, hypoxic MSC injection was more effective than normoxic MSC injection for reducing IVD degeneration progression in vivo. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1440-1450, 2019.

Patients with lumbar spondylolisthesis typically suffer from symptom discomfort and various degrees of disability for months or years prior to receiving surgical treatments. Knowing the factors that influence the disability status of these patients will help healthcare providers develop effective preventive measures.To explore preoperative disability and its important predictive factors in patients with lumbar spondylolisthesis.A predictive correlational design was used and a convenience sample of eighty-six lumbar spondylolisthesis preoperative patients were recruited from a medical center in northern Taiwan. Data were collected using a study questionnaire, which included the Oswestry disability index, the revised geriatric depression scale-short form, and a pain numeric rating scale.The average disability index of the participants was 48.52 (SD = 16.14). The multiple linear regression analyses identified lower back pain, depression, age, and gender as significant predictors of preoperative disability, collectively explaining 40.9% of the variation in disability severity. Being female, being older, having a higher degree of lower back pain, and having depression were significantly associated with preoperative disability.The results of the present study indicate that lumbar spondylolisthesis patients who are older in age, female, currently experiencing lower back pain, and suffering from depression face a higher risk of preoperative disability. Patients in these at-risk categories should be assessed actively and provided with appropriate patient education in order to enhance their quality of life.腰椎滑脫病人術前失能情形及其影響因素探討.腰椎滑脫的病人在接受手術治療前，大多經歷長達數月至數年的不適症狀，且有不同程度的失能情形，探討失能情形之影響因素，有助於發展有效之預防措施。.探討腰椎滑脫病人術前失能情形的重要預測因子。.本研究採預測相關性研究設計，以方便取樣，於臺灣北部某醫學中心招募86位腰椎滑脫術前病人。以問卷進行資料收集，內容包括疼痛數字等級量表、修正版簡式老年憂鬱量表及歐氏失能量表。.研究對象平均失能指數為48.52（SD = 16.14）分。多元線性迴歸分析結果顯示下背痛、憂鬱、年齡和性別為失能嚴重程度之重要預測因子，共可解釋40.9%之變異量。女性、年長、下背疼痛及憂鬱程度高的腰椎滑脫病人有較高的失能嚴重度。.女性、高齡、下背疼痛和憂鬱情緒的腰椎滑脫術前病人為失能的高危險群，應積極評估並給予適當的護理指導，以期得到較佳的生活品質。.

Methods In this study of patients who underwent internal fixation without fusion for a burst thoracolumbar or lumbar fracture, we compared the serial changes in the injured disc height (DH), and the fractured vertebral body height (VBH) and kyphotic angle between patients in whom the implants were removed and those in whom they were not. Radiological parameters such as injured DH, fractured VBH and kyphotic angle were measured. Functional outcomes were evaluated using the Greenough low back outcome scale and a VAS scale for pain. Results Between June 1996 and May 2012, 69 patients were analysed retrospectively; 47 were included in the implant removal group and 22 in the implant retention group. After a mean follow-up of 66 months (48 to 107), eight patients (36.3%) in the implant retention group had screw breakage. There was no screw breakage in the implant removal group. All radiological and functional outcomes were similar between these two groups. Although solid union of the fractured vertebrae was achieved, the kyphotic angle and the anterior third of the injured DH changed significantly with time (p < 0.05). Discussion The radiological and functional outcomes of both implant removal and retention were similar. Although screw breakage may occur, the implants may not need to be removed. Take home message: Implant removal may not be needed for patients with burst fractures of the thoracolumbar and lumbar spine after fixation without fusion. However, information should be provided beforehand regarding the possibility of screw breakage. Cite this article: Bone Joint J 2016;98-B:109–16.

Background Osteonecrosis of the femoral head (ONFH) is an important indication for total hip arthroplasty in Taiwan. We demonstrated the etiologies of ONFH and outcomes based on stratification of patients according to different etiologies. Methods We reviewed medical records and images from January 2000 to May 2010 in our database with the diagnosis of “osteonecrosis of the femoral head.” We categorized all patients into different etiologies, including corticosteroid, alcohol, and idiopathic. All patients received subsequent follow up for ipsilateral precollapse ONFH and contralateral disease-free femoral head status after initial diagnosis. Results Of the 1153 patients who had undergone 1674 hip surgeries including core decompression and total hip replacement, alcohol use was the most prevalent etiology in our population (45.2%). Patients with corticosteroid- and alcohol-associated ONFH were younger and more likely to have bilateral disease. Patients with alcohol- or steroid-associated ONFH were found to have a higher rate of contralateral disease and faster progression of precollapse ONFH than patients who had or had not undergone core decompression. Conclusion Alcohol use had the greatest impact on ONFH in our population. Nonidiopathic ONFH patients had the worst outcome. Understanding the nature of progression of ONFH and incidence of contralateral disease may provide great prognostic value to detect and perform early intervention.

Postoperative radiation for prevention of heterotopic ossification (HO) has been proven effective for the patients with ankylosing spondylitis (AS) after total hip arthroplasties (THA). This study aims to evaluate the effect of postoperative radiation in HO formation following THA in patients with AS. We retrospectively reviewed 129 hips from 91 patients with AS receiving primary THA from July 2004 to December 2012. There were total 38 patients (53 hips) did not receive postoperative prophylaxis in Group I. Moreover, 53 patients (76 hips) received postoperative single-fraction radiotherapy of 500 cGy in Group II. After a minimum 12-month follow-up, there was no significant difference in HO formation between the two groups (P=0.210). This study suggests that postoperative radiation may not be necessary in Asian patients.

Pigmented villonodular synovitis (PVNS) is a benign tissue proliferation characterized by its hyper-vascularity within the lesion. The true etiology and cell source of this disease entity still remain unclear. Mesenchymal stem cells (MSCs) exist in various tissues of human body. However, it has not been clarified whether MSCs could be isolated from tissue of PVNS. Here, we isolated MSCs from PVNS (PVNS-SCs), and by comparing to the MSCs from normal synovium (Syn-SCs) of the same individual, we investigated whether PVNS-SCs differed in the capacity for multi-differentiation and inducing angiogenesis. We first demonstrated that PVNS-SCs existed in the lesion of PVNS of three individuals. Moreover, we showed PVNS-SCs had better osteogenic differentiation potential than Syn-SCs, whereas Syn-SCs had better capacity for adipogenic and chondrogenic differentiation. By genome-wide analysis of gene expression profile using a complementary DNA microarray and comparing to Syn-SCs, we identified in PVNS-SCs a distinct gene expression profile characterized by up-regulation of genes involved in angiogenesis. In vitro and in vivo studies further confirmed that PVNS-SCs had better capacities for promoting angiogenesis. In summary, the identification of PVNS-SCs in PVNS tissue and their distinct angiogenic potential may help elucidate the underlying etiology of this disease.

Purpose of the study Minimally invasive procedures for total hip arthroplasty (THA) provide less surgery related trauma, and perhaps a fast recovery and satisfaction. Using modified instruments, we reported clinical follow-up data for a modified anterolateral approach. Basic procedures Using specialised retractors to expose the acetabulum and femur, this single-incision technique preserved more gluteus medius tendon and provided access for soft tissue repair. The demographic data for 1003 patients undergoing THA with this technique are presented, including operative variables, complications, Harris Hip Score for clinical evaluation and cup inclination angle for radiographic evaluation. Average follow-up was 59 months (range 24-121). Main findings In 1077 primary THAs performed in 1003 patients, the median wound length was 6 cm (range 4.8-9.2), median operation time was 68 minutes (range 45-112). The mean perioperative blood loss was 422 mls (range 56-990). The median cup inclination angle was 44 degrees (range 33-54), median acetabular version angle was 17° (range 12-24) median length of hospitalisation was 4 days (range 3-8). A total of 22 (2.0%) complications were noted including 5 cases of stem subsidence, 4 cup loosening, 5 greater trochanter fractures, 4 infections, 2 intraoperative proximal femur fractures and 2 iliopsoas impingement. In total, 13 (1.2%) received additional surgery. No neurovascular injury or dislocation was noted. For the clinical results, Harris Hip Score improved from 53 (range 33-67) preoperatively to 94 postoperatively (range 87-100). Principal conclusions Minimally invasive surgery via this modified anterolateral approach is a safe and reliable method.

Objective To compare treatment outcomes and complications between the computer-assisted preoperative planning of lateral entry approach and the traditional approach for L5 percutaneous vertebroplasty. Methods In this prospective randomized clinical study performed from January 2008 to December 2014, 68 patients scheduled for L5 percutaneous vertebroplasty were divided at random into group A, in which the traditional transpedicle approach was used, and group B, in which the computer-assisted lateral entry point approach was used. A visual analog scale and Oswestry Disability Index were evaluated preoperatively, postoperatively, and at the latest follow-up. Results Patient demographics were similar in the 2 groups. The mean duration of follow-up was 65 months. The mean distance between the entry point and the midline was 3.05 ± 0.5 cm in group A and 7.04 ± 0.7 cm in group B. The mean inclination angle measured on the preoperative axial image was 17.1 ± 3.4° in group A and 41 ± 3.8° in group B. Clinical outcomes were comparable in the 2 groups; however, cement leakage was significantly greater in group A ( P Conclusions Owing to the hemispherical morphology and convergent pedicle axis of the L5 vertebrae, a more lateral skin entry point and convergent angle of the puncture needle should be emphasized to reach the optimal point according to the preoperative assessment. The approach involving computer-assisted preoperative planning of the lateral entry point was associated with a higher rate of bilateral cement infiltration with fewer complications.

To compare the clinical outcomes, radiographic results and fusion rate of ACDF between empty PEEK cages and PEEK cages packed with β-tricalcium phosphate. Forty-five patients were prospectively enrolled with cervical degenerative disc disease who requiring ACDF with a PEEK cage. 23 patients were randomised to the study group (empty cages) and 22 patients were in the control group (cages filled with β-tricalcium phosphate). Both patient groups were fixed with a cervical locking plate. A CT scan was performed 12 months postoperatively and 24 months if not confirmed fused at 12 months to evaluate the status of fusion. Clinical status was evaluated using the Japanese Orthopaedic Association (JOA) score, the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS). 46 levels (97.88%) in the study group and 44 levels (97.77%) in the control group were confirmed as fused at 24 months. There was no significant difference between the fusion rates observed in the study and control groups (p = 0.82). There was no significant difference in JOA, ODI, or VAS scores at 24 months follow-up. The results showed that the members of the non-fusion group tended to be older than the individuals in the fusion group at 12 months, but was not significant in statistics. Similar fusion rates and clinical outcomes were achieved when using ACDF with PEEK cages and instrumentation, regardless of whether the cage was filled with bone substitute at 24 months follow-up. Fusion rates improved over time and are comparable between both groups. These slides can be retrieved under Electronic Supplementary material.

We conducted a chronoamperometric study to observe the electrochemical behaviors of the nucleation mechanism of electrodeposited Cu(In,Al)Se 2 films. A change from instantaneous nucleation to progressive nucleation was observed by increasing the copper concentration. SEM and EDS analyses demonstrated that the surface morphologies and chemical compositions of precursor and post-annealed Cu(In,Al)Se 2 films were influenced by the nucleation mechanism. They exhibited that Cu(In,Al)Se 2 films had roughly cauliflower-like and triangular structures with Cu-poor composition at the instantaneous nucleation mechanism, whereas smooth and round structures with Cu-rich composition at the progressive nucleation mechanism. Additionally, the quality, growth orientation, composition phase, and optical energy band gap of Cu(In,Al)Se 2 films were examined using X-ray diffraction (XRD) patterns, Raman spectra, and ( αhν ) 2 vs. hν plots (UV–vis). Thereafter, the performances of rudimentary Cu(In,Al)Se 2 solar cells fabricated at various copper concentrations were discussed, the conversion efficiency of electrodeposited Cu(In,Al)Se 2 solar cells were unpublished in previous literatures. Our studies demonstrated that the performances of Cu(In,Al)Se 2 solar cells were significantly related to the surface morphology and composition of Cu(In,Al)Se 2 absorber layer. The highest conversion efficiency of Cu(In,Al)Se 2 solar cells fabricated at a 2-mM copper concentration was 1.96% with open-circuit voltage, short-circuit current, fill factor, R sh and R s values of 0.189 V, 29.21 mA/cm 2 , 35.4%, 125 Ω and 2.82 Ω, respectively.

Background The local recurrence rate after surgical excision of intramuscular hemangioma reported is between 18% and 61%. The aim of this study was to review the clinical outcome and local recurrence rate after surgical excision of nonpalpable intramuscular hemangioma using preoperative ultrasound-guided hookwire localization. Methods We performed ultrasound-guided hookwire localization before excision surgery for nonpalpable intramuscular hemangioma in 37 cases between January 1997 and 2011. There were 20 females and 17 males, with a mean age of 30.2 years (range, 17–49 years). The mean localization procedure time was 10.6 minutes (range, 3–20 minutes). Results The average operation time was 48.6 minutes (range, 30–80 minutes). The average length of the excision wound was 5 cm (range, 4–11 cm), and the average hospital stay was 2.5 days (range, 2–4 days). The postoperative therapeutic report confirmed the diagnosis of intramuscular hemangioma. The average tumor size was 2.11 cm and all excision margins were free in all specimens. After the mean follow-up of 92.9 months (range, 14–179 months), one of the 37 patients had local recurrence (recurrence rate 2.7%). Conclusion The use of ultrasound-guided hookwire localization before excision surgery is safe and effective in treating nonpalpable intramuscular hemangioma and could provide a better cosmetic result and functional recovery.

Cu-poor electrodeposited CuIn1−xAlxSe2 (CIAS) precursor films were prepared to investigate the alteration in surface morphology of post-annealed CIAS films through post-annealing temperature adjustment. Scanning electron microscopy (SEM) and atomic force microscope (AFM) analyses demonstrated that surface morphology and root–mean–square (RMS) roughness of post-annealed CIAS films exhibited uneven and rough triangular structures. The crystal size of post-annealed CIAS films can be increased by increasing post-annealing temperature. The precursor film structure was modified by substituting Cu–Se/CIAS binary structure with CIAS single structure to proceed with the investigation. The apparent variation in surface morphology of post-annealed CIAS films changed from rough triangular structures to smooth round structures, and the RMS roughness of post-annealed CIAS films was reduced to

Population-based evaluation on the incidence of postoperative venous thromboembolism (VTE) has not yet been reported for Asians receiving arthroplasty. In Taiwan, thromboprophylaxis was not commonly applied for patients. The population-based cohort study aimed to investigate the epidemiology, and to determine the risk factors VTE for patients receiving hip or knee replacement without pharmacological thromboprophylaxis in Taiwan.We retrospectively acquired patients' data from National Health Insurance databases representing more than 99% of about 23 million Taiwanese citizens. The primary outcome was the incidence of composite symptomatic VTE within 28d ays after receiving hip or knee replacement surgery.During 2002 to 2006, there were 114,026 patients undergoing hip (n=61,460) or knee (n=52,566) replacement surgery. The occurrence rate of overall postoperative VTE was 0.44%. The incidence of pulmonary embolism was four in 10,000 patients receiving hip replacement or seven in 10,000 individuals undergoing knee replacement. The weekly cumulative incidence of VTE was persistently rising up to 28 days after surgery. Dramatic increase in risk of post-surgical VTE was associated with prior disease history of PE (p0.001 for hip replacement, p=0.01 for knee replacement) or DVT (p=0.004 for hip replacement, p0.001 for knee replacement). Prior claim of congestive heart failure was an independent risk factor associated with patients receiving knee arthroplasty (p=0.01).Life-threatening PE occurred and increased cumulatively up to 28 days after hip or knee arthroplasty in Asians. Proper prophylaxis for patients with the exposure of high risks needs to be scrutinized.

Background Pulmonary embolism is a relatively uncommon, but serious, postoperative complication of hip and knee arthroplasty; however, little information is available about the prevalence of pulmonary embolism in Taiwan. Methods We report here a series of five patients who sustained a symptomatic pulmonary embolism after undergoing total knee arthroplasty (TKA). These patients were identified during a retrospective study of 1768 patients carried out between January 2007 and January 2010. Results Five (0.28%) patients who sustained a symptomatic pulmonary embolism after TKA were identified in a series of 1768 patients. The diagnosis was confirmed by computed tomography angiography findings in four patients and an increased d-dimer level in one patient. All the patients were women, with a mean age of 68.0 years (range 64–76 years). The average body mass index of these patients was 32.6 kg/m 2 (24–38 kg/m 2 ). Four patients underwent simultaneous bilateral TKA, and one patient who was undergoing unilateral TKA also underwent revision TKA for a previously treated contralateral knee. None of the patients had a history of pulmonary embolism, and none was given prophylaxis for venous thromboembolism. The time at which pulmonary embolism occurred ranged from 2 to 8 days in five patients. After treatment, no patient had died by the end of the follow-up period. These case reports highlight the equal incidence of pulmonary embolism after TKA in Taiwanese and Western populations. Conclusion Steps to prevent pulmonary embolism should be undertaken in selected patients, such as these patients with a high body mass index and simultaneous bilateral TKA.

Background Concomitant tibial shaft and posterior malleolar fractures (PMFs) are often encountered in clinical settings. Plain films were reviewed for concomitant PMF, and fracture patterns were analyzed by focusing on the integrity of the fibula and the location of the fibular fracture. Methods A retrospective review of patients who presented with tibial shaft fractures between January 2005 and January 2010 was performed. Patients were included if they were at least 18 years of age and had a tibial diaphyseal fracture. Exclusion criteria were age less than 18 years, previous surgery on the same leg, and pathological fractures. Medical records were reviewed for information on injury mechanisms. Pre- and post-operative radiographs were analyzed for PMFs, tibial fracture pattern, fibular integrity, fibular fracture pattern, treatment type, and time to fracture union. Descriptive statistical tests were used. Results Among 240 patients, there were 20 cases (15 male and 5 female) of concomitant PMF, all detected in lateral radiograph views. The incidence of PMF was 8.3%. Most patients had a motorcycle injury ( n = 15, 75%). Distal tibia spiral fracture was the most common fracture pattern (85%) and there was no proximal tibia fracture (0%). Combined fibular fractures were found in 17 patients (85%). There were nine proximal fibular fractures (45%). Intact fibulas were found in three patients (15%). Only one PMF was treated with screw fixation. All PMFs showed radiographic evidence of healing within 5 months post-operatively. Conclusion We recommend careful radiographic examination to evaluate PMF, especially in patients with distal tibial spiral fractures combined with proximal fibular fractures or intact fibulas.

Background The Brantigan and Bagby and Kuslich (BAK) cages for posterior lumbar interbody fusion have different geometric characteristics. However, both cage designs have been demonstrated to be helpful in restoring disc space across spinal motion segments in clinical observations. This study was designed to compare the biomechanical performance of these devices at one-motion segments and to determine the effects of posterior instrumentation on their stabilities. Methods Eight intact fresh human cadaver spines (L2-S1) were affixed within a testing frame for in vitro biomechanical testing: four randomly assigned spines for the BAK cage group and four for the Brantigan cage group. For each spine, the three-dimensional load-displacement behavior of each vertebra was quantified using the Selspot II Motion measurement system during the following steps: (1) intact state; (2) destabilization after laminectomy and discectomy across L4-L5; (3) stabilization using a pair of BAK cages or Brantigan cages; and (4) additional stabilization using variable screw plates (VSP) across L4-L5. Results The Brantigan cage alone did not show satisfactory results in improving the stability of one-motion segment destabilized spines in left and right axial rotation. However, the BAK cages appeared to provide significant stability in extension, flexion, left and right lateral bending, and left axial rotation. After implanting the additional posterior instrumentation, both cages provided similar and significantly improved stabilities. Conclusion Although the results indicate that the Brantigan cage did not provide satisfactory improvement in the stabilities as the BAK cage in the one-motion segment model, implantation with additional posterior instrumentation may significantly improve the stabilities and reduce the differences between the two cage designs.

Patellofemoral arthrosis is commonly encountered in clinical practice. This morbid condition can critically affect the patient's quality of life. Many treatments have been reported to address this problem, including operative and nonoperative modalities. Patellofemoral arthroplasty had been reported to have an excellent outcome in some reports, although the treatment is still controversial. We report a case of a complication that arose after isolated resurfacing of an arthritic patella with a polyethylene component. Serious femoral cartilage wear with severe synovitis was noted in the early postoperative period. Clinicians are therefore cautioned to avoid isolated patellar resurfacing for treating patellofemoral arthritis.

This is a retrospective study carried out to evaluate the clinical results of patients with osteoporosis and various spinal diseases treated surgically with polymethylmethacrylate (PMMA)-augmented cannulated pedicle screws, and to compare this method with the needle injection technique in terms of the clinical results and fixation strength.To report a technique using PMMA-augmented cannulated pedicle screws for fixation in osteoporotic spines and to compare its clinical results and biomechanical characteristics with the needle injection technique.Many studies have shown that PMMA-augmented pedicle screws can significantly increase the stiffness and strength of the screw. Various designs of cannulated screws have been used for cement augmentation in experimental studies; however, clinical reports using these screws in osteoporotic patients are rare. A practical and reliable technique and optimal screw design have not yet been established.Forty-five patients (23 women, 22 men), mean age of 71.37 years (range, 53-94 y), with osteoporosis and various spinal diseases underwent spinal decompression and instrumentation with PMMA augmentation of cannulated pedicle screws. Preoperative and postoperative visual analog scale scores for pain and the Oswestry disability index questionnaire data were analyzed. Screw migration, which is the distance from the screw tip to the anterior cortex and the upper endplate of the vertebra, was also evaluated immediately after surgery and at the mean follow-up of 15.9 months. These clinical results were then compared with those reported for the needle injection technique. The pullout strength, insertional, and backout torque of these 2 techniques were compared using osteoporotic synthetic bone (0.12 g/cm).A total of 255 out of 283 cannulated screws were augmented with PMMA. The mean visual analog scale pain score of these patients improved from 9.5 to 3.1 (P0.01) and the functional Oswestry disability index score improved from 71% to 28.9% (P0.01). Kyphotic deformity of the compression fracture group (19 patients) was improved from an average of 9.38 to 3.27 degrees after surgery, and to 5.45 degrees at the final follow-up (P0.01). There was no significant vertical screw migration when the screws' distances were compared just after the operation and at the final follow-up (P0.01). However, significant horizontal screw migration was found in lesions below the L2 level (P0.01). There was no major neurovascular injury, except in 1 patient, who had persistent left thigh pain due to cement leakage at the L1 level, and the symptom was controlled with analgesics. The clinical results of both techniques were satisfactory and there were no significant differences. Although the pullout strength and screw backout torque was significantly higher in the needle injection group (234.1 vs. 187.8 N, 1119.6 vs. 836.7 N mm, respectively), the operation time was shorter and the cement leakage rate was less in the cannulated pedicle screw group than that of the needle injection group (211.4 vs. 296.3 min, 14.05% vs. 26.2%, respectively).The technique of cannulated pedicle screws with PMMA augmentation used in this study can be an option for osteoporotic patients with various spinal diseases who require spinal instrumentation.

Treatment of complex severe spinal deformities, such as scoliosis with a Cobb angle greater than 90°, critical spinal kyphosis, or vertebral and rib deformity with impaired lung capacity, remains a great challenge. Preoperative image studies including plain film radiography, computed tomography, and magnetic resonance imaging provide only two-dimensional (2D) images and limited information about these severe deformities. In addition, these studies cannot directly offer visual or tactile feedback for surgeons and patients. On the contrary, the rapid prototyping (RP) technique provides surgeons with full-scale, 3D models, which make more accurate and more direct morphometric information of the complex spinal deformity obtainable. In this study, we intend to share our experience with the RP technique in pediatric spine deformity cases and to provide a literature review. In our study, two patients with severe spinal deformity were included. A real-size spinal model was produced for each patient on the basis of contiguous computer tomography with a slice thickness of 1 mm. All models were used to plan the resection and to identify the anatomic landmarks during the operation. With the aid of these full-scale spinal models, all surgical procedures were performed exactly according to the preoperative plan. A 16-year-old girl with congenital scoliosis with a Cobb angle greater than 90° received staged surgery, including vertebral column resection, correction, and posteriolateral spinal fusion. The other patient was a 3-year-old boy with 80° of Gibbus spine deformity. By means of an anteriolateral approach after thoracotomy, the paraspinal abscess debridement, vertebral column resection, and vertical expandable prosthetic titanium rib application were performed. No postoperative complications such as spinal cord, nerve root, or major vascular injuries were found. The 3D RP models are really helpful in providing direct visual and tactile feedback, improving preoperative planning, identifying the important anatomic landmarks during the surgery, and communicating with patients. If the RP technique can be improved in the future, it is likely to become more acceptable and practical.