Jihyo Hwang

Autologous Bone Marrow Transplantation in Osteonecrosis of the Femoral Head

Goal: This study evaluated clinical and radiological results of autologous bone marrow transplantation (BMT) for early stage osteonecrosis of the femoral head (ONFH) and analyzed prognostic factors. Materials and Methods: From November 2003 to January 2006, 49 hips in 43 patients with early stage ONFH underwent autologous BMT were followed for at least 2 years. For clinical results, preoperative and postoperative Harris hip score (HSS) were evaluated and survival rate was obtained at the point of performing the total hip arthroplasty. Radiologic results were assessed by changes in necrosis size on MRI performed preoperatively and postoperatively. To evaluate prognostic factors, survival rate was analyzed according to age, gender, etiology, and duration of the symptom. Results: Postoperative average HHS was significantly increased and there were no significant changes in necrosis size on MRI. Eleven of the 79 hips were required the arthroplasty and the group with use of steroid and short duration of symptom less than 6 months showed lower survival rate. Conclusion: Autologous BMT for early ONFH can be one of the treatments to improve clinical feature and delay radiologic progress. However the steroid-induced ONFG and short duration of symptom seemed to be poor prognostic factors.

The effect of the timing and dose of dexmedetomidine on postoperative delirium in elderly patients after laparoscopic major non-cardiac surgery: A double blind randomized controlled study

STUDY OBJECTIVE There were few clinical data dosing and timing regimen for preventing postoperative delirium. The present study aimed to investigate the effect of the timing and dose of dexmedetomidine on postoperative delirium in elderly patients after laparoscopic major non-cardiac surgery. PATIENTS AND INTERVENTIONS A total of 354 patients >65 years of age undergoing laparoscopic major non-cardiac surgery under general anesthesia received a dexmedetomidine 1 μg/kg bolus followed by 0.2-0.7 μg/kg/h infusion from induction of anesthesia to the end of surgery [group D1]); a dexmedetomidine (1 μg/kg bolus [group D2]); or saline (group S) 15 min before the end of surgery. MEASUREMENTS The incidence and duration of delirium for 5 days after surgery and the cytokine (tumor necrosis factor-alpha TNFα, interleukin [IL]-1 β, IL-2, IL-6, IL-8, and IL-10) and cortisol levels were measured 1 h and 24 h after surgery. MAIN RESULTS Group D1 reduced incidence and duration of delirium and group D2 decreased its duration in patients with delirium compared to group S. IL-6 levels were significantly lower at 1 h and 24 h after surgery in group D1 than in group S, and lower at 24 h after surgery than in group D2. IL-6 levels in group D2 were significantly lower only at 1 h after surgery than in group S. However, IL-6 levels in delirious patients in group D2 were significantly lower at 1 h and 24 h after surgery than those in group S. Cortisol levels 1 h after surgery were significantly lower in groups D1 and D2 than in group S. CONCLUSIONS The dose and timing of dexmedetomidine appeared to be important in preventing delirium. The reduced incidence and duration of delirium by dexmedetomidine was associated with reduced levels of IL-6 24 h after surgery.

Unstable intertrochanteric versus displaced femoral neck fractures treated with cementless bipolar hemiarthroplasty in elderly patients; a comparison of 80 matched patients

BACKGROUND While hemiarthroplasty (HA) is considered the treatment of choice for displaced femoral neck (FN) fractures in elderly patients, HA has been partly performed as an alternative treatment option for unstable intertrochanteric (IT) fractures. However, there is a paucity of data regarding the risk and availability of HA for unstable IT fractures compared to HA for displaced FN fractures in elderly patients. Therefore, we performed this case-control study to determine whether HA for unstable IT fractures provides clinical results and survival comparable to HA for displaced FN fractures in elderly patients. HYPOTHESIS HA for unstable IT fractures in elderly patients provides clinical results and 1-year survival comparable to HA for displaced FN fractures in the same aging group. MATERIALS AND METHODS We identified 80 patients aged 75years or older, who underwent cementless bipolar HA for unstable IT fracture (AO/OTA type 31-A2.2/3 and A3.3). Their clinical results and 1-year survival were compared to the matched control group of 80 patients with displaced FN fractures (Garden type 3 and 4) treated with the same procedure. Perioperative results, postoperative complications, and 1-year survival were investigated between the two groups. Functional outcome was assessed by walking status and Harris hip score (HHS) 6months after surgery. RESULTS Operating time was significantly longer in the IT group than the FN group (97.3min [50 to 255] vs. 79.3min [40 to 175], P=0.016). However, the two groups did not significantly differ regarding perioperative results, such as total blood loss, transfusion, intraoperative fracture, length of hospital stay, and postoperative complication. No statistically significant differences in walking status and HHS were observed between the groups. No significant difference in cumulative survival was observed between the two groups (P=0.836), with a 1-year survival rate of 80% (95% confidence interval [CI], 71.8 to 87.5) in the IT group and 82% (95% CI, 73.1 to 89.4) in the FN group. CONCLUSION HA for unstable IT fractures in elderly patients showed clinical results and 1-year survival comparable to HA as the treatment of choice for displaced FN fractures in the same aging group. LEVEL OF EVIDENCE Level III, case-control study.

Quality of life, effects on Asian Lifestyle, and perceived satisfaction after total hip arthroplasty in Japan and Korea

BACKGROUND The Asian lifestyle requires deep hip flexion, which increases the risk of dislocation. Hence, Asian total hip arthroplasty (THA) patients may have problems postoperatively. This study aimed to 1) document quality of life (QoL), Asian lifestyle-related items (five postures that require deep hip flexion), and perceived satisfaction in patients who underwent THA in Japan versus Korea, 2) assess the differences in QoL and Asian lifestyle-related items by patient lifestyle, and 3) identify the factors predicting QoL. METHODS This cross-sectional study included 222 THA patients. Korean patients completed the questionnaires. Japanese patients were then matched with Korean patients by age, sex, and post-THA period. Assessed parameters included QoL measured by the EuroQoL, Oxford hip score (OHS), Asian lifestyle (measured by the Asian lifestyle-related items), and perceived satisfaction (measured by the five items of postoperative satisfaction). Multiple regression analysis was used to determine the predictors of QoL. RESULTS Compared with Korean patients, Japanese patients had better QoL, but more difficulty performing postures requiring deep hip flexion. Greater QoL was associated with greater satisfaction. The predictors of decreased QoL after THA were lower OHS in both countries, worse squatting ability in Japan, and worse leg-crossing ability in Korea. CONCLUSIONS In Japan and Korea, the OHS is an important predictor of QoL after THA.

Failure of a Rotation Control Gamma 3 Lag Screw Used to Treat a Trochanteric Fracture

Gamma 3 rotation control lag screws (U-blade) are particularly useful when treating rotational and unstable fractures of the proximal femur. A 93-year-old woman who underwent closed reduction of a trochanteric fracture and internal fixation with a Gamma 3 nail rotation control lag screw. The patient presented with metal failure and U-blade bending following a fall occurring 4 weeks after surgery. Here, we present a case report summarizing removal of the failed lag screw.

Postoperative fever after hemiarthroplasty in elderly patients over 70 years of age with displaced femoral neck fracture: Necessity of routine workup?

OBJECTIVES Displaced femoral neck fracture in elderly patients has been treated with hemiarthroplasty as the treatment of choice. Fever following HA is common in these elderly patients. The aim of this study was to determine which post-HA fever workup could be beneficial in this group of patients. METHODS A total of 272 consecutive patients aged ≥70 years undergoing HA for displaced femoral neck fracture were retrospectively investigated. Postoperative fever (POF) was defined as any recorded body temperature ≥38°C in the early postoperative period. POF in each patient was characterized by the maximum temperature, the day of the first fever, and frequency of fever, stratified as either single or multiple fever spikes. Medical records were reviewed to identify positive fever workups and febrile complications. RESULTS Of 272 patients, 135 (49.6%) developed POF. A total of 428 routine diagnostic tests were performed in all patients with POF, of which only 57 tests (13.3%) were positive. Urinalysis showed the highest positive rate (21.9%), followed by urine culture (14.3%), chest x-ray (12.6%), and blood culture (1.1%). The most common febrile complication was pneumonia (12.6%), followed by urinary tract infection (8.1%). On multivariate logistic regression for positive workups, only fever after postoperative day (POD) 2 was a risk factor for positive chest x-ray (OR 3.86, p=0.016) and urine culture (OR 5.04, p=0.019). Moreover, fever after POD 2 (OR 6.93, p<0.0001) and multiple fever spikes (OR 2.92, p=0.026) were independent predictors of infectious febrile complications. CONCLUSIONS Routine workup for POF following hemiarthroplasty in elderly patients with displaced femoral neck fracture is not warranted. However, for fever after POD 2 and multiple fever spikes, chest x-ray and urinalysis would be necessary to rule out the two most common febrile complications such as pneumonia and urinary tract infection.