Publications by authors named "Byung-Ho Yoon"

77 Publications

Osteonecrosis of the Femoral Head: an Updated Review of ARCO on Pathogenesis, Staging and Treatment.

J Korean Med Sci 2021 Jun 21;36(24):e177. Epub 2021 Jun 21.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.

Non-traumatic osteonecrosis of the femoral head (ONFH) usually affects adults younger than 50 years and frequently leads to femoral head collapse and subsequent arthritis of the hip. It is becoming more prevalent along with increasing use of corticosteroids for the adjuvant therapy of leukemia and other myelogenous diseases as well as management of organ transplantation. This review updated knowledge on the pathogenesis, classification criteria, staging system, and treatment of ONFH.
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http://dx.doi.org/10.3346/jkms.2021.36.e177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216992PMC
June 2021

The Impact of COVID-19 on the Optimal Management of Osteoporosis.

J Bone Metab 2021 May 31;28(2):115-122. Epub 2021 May 31.

Department of Orthopedic Surgery, Ewha Womans University, College of Medicine, Mokdong Hospital, Seoul, Korea.

Osteoporosis does not take a break while Coronavirus disease 2019 (COVID-19) stunned and overtook everyone's lives. Medical resources were immediately shifted, self-isolation and telemedicine were expanded, ambulatory care services such as bone densitometry and osteoporosis-centered clinics came to a near halt. Progress with fracture prevention has been challenged because osteoporotic fracture with low energy injury is more prevalent even though restriction of people's movement. Thus we must re-engage with chronic bone health concerns and fracture prevention. This review discusses challenges in management of osteoporosis during the COVID-19 pandemic and reinforces the need to implementing recommendations concerning the importance of bone fragility care with at least those patients who are already treated with antiosteoporotic drugs maintaining their adherence to treatments.
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http://dx.doi.org/10.11005/jbm.2021.28.2.115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8206610PMC
May 2021

Diagnosis and Treatment of Femoral Head Osteonecrosis: A Protocol for Development of Evidence-Based Clinical Practice Guidelines.

Surg Technol Int 2021 05 27;38. Epub 2021 May 27.

Zhongshan Hospital of Dalian University, Dalian, China.

Introduction: There are many treatment options for patients who have osteonecrosis of the femoral head (ONFH) and management strategies vary widely both among and within individual countries. Although many researchers have attempted to elucidate the optimal strategies for managing this disease, the lack of large-scale randomized control trials and the lack of agreement on disease staging have curtailed the development of clear-cut guidelines.

Materials And Methods: The Association Research Circulation Osseous (ARCO) group sought to address three questions for the management of patients who have ONFH: 1) What imaging studies are most sensitive and specific for the diagnostic evaluation of patients who have ONFH?; 2) What is the best treatment strategy for preventing disease progression in patients who have pre-collapse lesions?; and 3) What is the best treatment strategy for patients who have post-collapse disease? The Patient, Intervention, Comparison, and Outcome (PICO) format was used to formulate the search strategy for each research question. A systematic review will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. ARCO participants have been allocated to three groups, each representing one of the PICO questions. After qualitative and quantitative analysis of the data extracted from studies pertaining to each of the three research questions, a set of evidence-based clinical practice guidelines will be proposed for the management of patients who have ONFH.

Discussion: It is not always clear which treatment method is optimal for the management of ONFH. Thus, many surgeons have developed and performed various procedures based on patient-specific factors. As there is no consensus on the optimal treatment for various stages of disease, it was clear that developing evidence-based clinical practice guidelines would provide more structure and uniformity to management of these patients. Therefore, the results of this systematic review will lead to the development guidelines that may improve patient-care strategies and result in better outcomes for patients who have ONFH.
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May 2021

Femoral Neck Stress Fractures in South Korean Male Military Recruits.

Clin Orthop Surg 2021 Mar 11;13(1):24-29. Epub 2020 Dec 11.

Department of Orthopaedic Surgery, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea.

Backgroud: Femoral neck stress fractures (FNSFs) are rare but potentially disabling injuries if the diagnosis is missed or delayed and proper treatment is not provided. The aim of this study was to investigate and describe the characteristics and clinical course of FNSFs in South Korean male military recruits.

Methods: Between May 2015 and October 2019, 16 fractures in 12 young male military recruits were reviewed. The characteristics of the fractures were ascertained by detailed analysis of the history and clinical course, as well as radiographs, bone scintigrams, and magnetic resonance images.

Results: The median duration between endurance training and the development of hip pain was 5 weeks, while the median duration of pain before the patient sought medical attention was 3 weeks. Four patients (33.3%) exhibited bilateral fractures, and concomitant lesions involving the proximal tibia were found in 3 patients (25%). Fourteen of the 16 fractures (87.5%) were compression-type fractures, and surgery was performed for 7 hips. Complete union without malunion or osteonecrosis was achieved in all cases, and all cadets returned to their full activity levels in an average of 10 weeks.

Conclusions: We observed excellent prognosis of FNSFs. Our report highlights the importance of early reporting, detection, and treatment regarding the challenging management of FNSFs. When a military recruit reports hip pain, a FNSF should be considered; furthermore, the bilaterality of the fracture and the presence of concomitant lesions should also be investigated.
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http://dx.doi.org/10.4055/cios20074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948043PMC
March 2021

Does Bone Mineral Density Differ between Fan-Beam and Pencil-Beam?: A Meta-Analysis and Systemic Review.

J Bone Metab 2021 Feb 28;28(1):67-77. Epub 2021 Feb 28.

Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea.

Background: Dual energy X-ray absorptiometry (DXA) has evolved from pencil-beam (PB) to narrow fan-beam (FB) densitometers. We performed a meta-analysis of the available observational studies to determine how different modes of DXA affect bone mineral density (BMD) measurements.

Methods: A total of 1,233 patients (808 women) from 14 cohort studies were included. We evaluated the differences in BMD according to the DXA mode: PB and FB. Additionally, we evaluated the differences in BMD between the 2 types of FB mode: FB (Prodigy) and the most recent FB (iDXA). Pairwise meta-analysis was performed, and weighted mean differences (WMD) were calculated for (total lumbar, total hip, and total body).

Results: No significant difference was observed in total lumbar (pooled WMD, -0.013; P=0.152) and total hip BMD (pooled WMD, -0.01; P=0.889), between PB and FB. However, total body BMD was significantly lower in the PB compared to the FB group (pooled WMD, -0.014; P=0.024). No significant difference was observed in lumbar BMD (pooled WMD, -0.006; P=0.567), total hip (pooled WMD, -0.002; P=0.821), and total body (pooled WMD, 0.015; P=0.109), between Prodigy and iDXA.

Conclusions: The results of this study warrant the recommendation that correction equations should not be used when comparing BMD from different modes. Further research is still needed to highlight the ways in which differences between DXA systems can be minimized.
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http://dx.doi.org/10.11005/jbm.2021.28.1.67DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7973396PMC
February 2021

The risk of gastrointestinal hemorrhage with non-vitamin K antagonist oral anticoagulants: A network meta-analysis.

Medicine (Baltimore) 2021 Mar;100(11):e25216

Department of Orthopedic Surgery, Ewha Womans University, College of Medicine, Seoul, Korea.

Background: Non-vitamin K antagonist oral anticoagulants (NOACs) have been widely used for stroke prevention in atrial fibrillation (AF) and the treatment and prevention of venous thromboembolism. There is an issue with safety, especially in clinically relevant bleeding. We performed a network meta-analysis to evaluate the risk of major gastrointestinal (GI) bleeding associated with NOACs.

Methods: Interventions were warfarin, enoxaparin, apixaban, dabigatran, edoxaban, and rivaroxaban. The primary outcome was the incidence of major GI bleeding. A subgroup analysis was performed according to the following indications: AF, deep venous thrombosis/pulmonary embolism, and postsurgical prophylaxis.

Results: A total of 29 randomized controlled trials (RCTs) and 4 large observation population studies were included. Compared with warfarin, apixaban showed a decreased the risk of major GI bleeding (relative risk [RR] 0.54, 95% confidence interval [CI] 0.25-0.76), and rivaroxaban tended to increase this risk (RR 1.40, 95% CI 1.06-1.85). Dabigatran (RR 1.25, 95% CI 0.98-1.60), edoxaban (RR 1.07, 95% CI 0.69-1.65), and enoxaparin (RR 1.24, 95% CI 0.63-2.43) did not significantly increase the risk of GI bleeding than did warfarin. In the subgroup analysis, according to indications, apixaban showed a decreased risk of major GI bleeding (RR 0.50, 95% CI 0.34-0.74) than did warfarin in AF studies. Dabigatran (RR 2.36, 95% CI 1.55-3.60, and rivaroxaban (RR 1.75, 95% CI 1.10-6.41) increased the risk of major GI bleeding than did apixaban. An analysis of studies on venous thromboembolism or pulmonary embolism showed that no individual NOAC or enoxaparin was associated with an increased risk of major GI bleeding compared to warfarin.

Conclusion: Individual NOACs had varying profiles of GI bleeding risk. Results of analyses including only RCTs and those including both RCTs and population studies showed similar trends, but also showed several differences.
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http://dx.doi.org/10.1097/MD.0000000000025216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982234PMC
March 2021

Pelvic Insufficiency Fractures in Cervical Cancer After Radiation Therapy: A Meta-Analysis and Review.

In Vivo 2021 Mar-Apr;35(2):1109-1115

Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.

Aim: The aim of the study was to estimate the prevalence of pelvic insufficiency fractures (PIFs) after radiation therapy (RT) in patients with cervical cancer.

Patients And Methods: A total of 3,633 patients from 15 cohort studies were included. Proportion meta-analysis was performed to estimate prevalence and subgroup analysis was performed according to imaging modalities for diagnosis of PIF. For continuous variables (age and length of follow-up), meta-regression analysis was performed.

Results: Pooled prevalence estimate of PIF was 14% (95% CI=10-19). Incidence of PIF was higher in studies that used MRI as a diagnostic tool (17%, 95% CI=12-22) than non-MRI (8%, 95% CI=2-14). In meta-regression, we found a significant association of prevalence of PIF with age (p=0.021) but not with length of follow-up (p=0.118).

Conclusion: PIF after RT in patients with cervical cancer is not rare. Physicians need to pay attention to PIFs, especially in patients with high-risk factors for osteoporotic fracture.
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http://dx.doi.org/10.21873/invivo.12356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8045108PMC
June 2021

Ultrasound-guided hydrodilatation for adhesive capsulitis of the hip is a safe and effective treatment.

Int Orthop 2021 06 18;45(6):1455-1461. Epub 2021 Jan 18.

Department of Orthopedic Surgery, Inje University College of Medicine, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, Korea.

Purpose: Adhesive capsulitis of the hip (ACH) is likely that this condition had been previously encountered, but easily unrecognised. We investigated the clinical features of patients with ACH, the efficacy of ultrasound-guided intra-articular hydrodilatation, and the patients' prognosis.

Methods: We enrolled 84 patients (93 hips) who visited the outpatient clinic from August 2018 to November 2019. ACH was diagnosed by restricted range of motion and sharp pain when turning with the affected leg fixed on the ground. We evaluated patient demographics and associated intra-articular pathologies found on magnetic resonance angiography (MRA) images. Injections were performed twice at two week intervals with a mixture of 0.5% lidocaine (25 mL) and triamcinolone (40 mg; 1 mL) with capsular distension under ultrasound guidance. Patients were assessed before and after treatment using a visual analogue scale (VAS), hip disability and osteoarthritis outcome score (HOOS), hip range of motion (ROM), and distance from floor to knee (DFK) when sitting in the cross-legged position.

Results: On MRA, 18 patients had abnormal findings (eight labral tears, seven abductor tendinosis, three primary arthrosis). The mean VAS decreased from 7.1 ± 1.1 to 0.8 ± 0.9 after the last injection, and the HOOS improved in all subsets. The mean DFK decreased from 17.9 ± 4.8 to 9.7 ± 2.8 cm, and passive ROM showed improvement, especially in flexion and rotation. In seven patients, symptom recurrence was reported a mean of 4.1 months after the latest injection, but no independent risk factor for recurrence was identified.

Conclusion: Based on these current observations, patients with ACH may receive relief from hip joint pain and experience improved function with a timely diagnosis and effective treatment.
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http://dx.doi.org/10.1007/s00264-020-04909-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178136PMC
June 2021

Prosthetic Replacement Has a Clinical Outcome Superior to That of Trapeziectomy With Ligament Reconstruction and Tendon Interposition: A Meta-Analysis.

Orthopedics 2021 Mar-Apr;44(2):e151-e157. Epub 2021 Jan 8.

A meta-analysis was performed to compare trapeziectomy with ligament reconstruction and tendon interposition (LRTI) vs prosthetic replacement for first carpometacarpal joint osteoarthritis. Seven prospective and retrospective comparison trials were retrieved. A total of 459 patients receiving trapeziectomy with LRTI and 374 patients receiving prosthesis replacement with a follow-up of 12 to 69 months were identified. There were no differences in visual analog scale scores or complications. However, the mean Disabilities of the Arm, Shoulder and Hand score was 3.73 points lower and the mean pinch power was 1.16 points higher in the prosthesis replacement group, and this was significant. Prosthetic replacement led to a superior clinical outcome compared with trapeziectomy with LRTI, with no difference in complications. [. 2021;44(2):e151-e157.].
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http://dx.doi.org/10.3928/01477447-20210104-06DOI Listing
July 2021

Isolated Avulsion Fracture of the Lesser Trochanter in Adults.

In Vivo 2020 Nov-Dec;34(6):3519-3526

Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.

Background/aim: Isolated fractures of the lesser trochanter (LT) of adults are rare and most of them are pathologic fractures due to an underlying malignancy. The aim of our study was to provide comprehensive information on the epidemiology, etiology, diagnostic approach, and treatment algorithm of adult LT fractures.

Patients And Methods: We present the cases of six patients who were treated for isolated LT fractures between November 2010 and May 2019. A literature review was performed to identify adult LT fracture cases in previous studies.

Results: In two patients, the LT fracture was the first manifestation of the underlying tumors. Through a literature review, we identified 32 adults with isolated LT fractures. Among these, 27 were pathologic fractures. In 11 pathologic fractures, LT avulsion was the first manifestation of malignancy.

Conclusion: Metastasis and the first manifestation of an underlying malignancy should be suspected in adult patients with isolated LT fracture. A stepwise approach can prevent misdiagnosis and offer rational treatment modality.
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http://dx.doi.org/10.21873/invivo.12193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811641PMC
June 2021

Does Teriparatide Improve Fracture Union?: A Systematic Review.

J Bone Metab 2020 Aug 31;27(3):167-174. Epub 2020 Aug 31.

Department of Orthopaedic Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea.

We conducted an updated review of the evidence of teriparatide (TPTD) for fracture healing for the following questions. (1) Does it decrease fracture healing time?; (2) Can it be an alternative treatment for nonunion?; (3) Does it aid the union of atypical femoral fracture (AFF)? We searched PubMed, EMBASE, and Cochrane Library including "Fracture" AND "nonunion" AND "Teriparatide". In total, 57 publications met our inclusion criteria were summarized. This systemic review of the available literature revealed that TPTD works positively with regard to enhancing fracture healing time and union of AFF. There are also many case studies on the use of TPTD could be a potential new safe treatment for nonunion with no side effects. However, level 1 studies on the evidence of TPTD are still lacking so far. Over the last decade, a growing body of evidence has accumulated suggesting that TPTD can be an adjunct to enhance fracture healing or a therapeutic option to treat nonunion, but greater evidences from large volume prospective trials are needed.
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http://dx.doi.org/10.11005/jbm.2020.27.3.167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571240PMC
August 2020

A Simple Percutaneous Technique to Reduce Valgus-Impacted Femoral Neck Fractures.

Clin Orthop Surg 2020 Jun 14;12(2):258-262. Epub 2020 May 14.

Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.

The mainstream surgery for valgus-impacted femoral neck fractures (FNFs) is closed reduction and internal fixation under fluoroscopy. However, femoral neck shortening and anterior femoroacetabular impingement are common complications in healed valgus-impacted FNFs after fixation. Some methods have been reported to prevent complications, but these techniques require the use of a transfixing guide wire that passes through the femoral head, which may cause articular cartilage damage. We introduce a simple reduction technique using one Steinmann pin (S-pin) for valgus-impacted FNFs without any interference of the femur head. A S-pin was placed percutaneously at the inferomedial margin of the fracture, and reduction was achieved by applying manual valgus force along the fracture line. By restoring the anatomical alignment, we confirmed the maximum contact area of the fracture and connection of the medial cortical buttress, so the risk of nonunion was also minimized.
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http://dx.doi.org/10.4055/cios19156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237256PMC
June 2020

Incidence of nonunion after surgery of distal femoral fractures using contemporary fixation device: a meta-analysis.

Arch Orthop Trauma Surg 2021 Feb 9;141(2):225-233. Epub 2020 May 9.

Department of Orthopaedic Surgery, Inje University College of Medicine, Sanggye Paik Hospital, Seoul, South Korea.

Purpose: Nonunion is the most frequent cause of reoperation and is associated with high morbidity after distal femur fracture (DFF). We examined the rates of nonunion requiring reoperation after fixation for DFF using a locking compression plate (LCP) or retrograde intramedullary nail (RIMN).

Methods: We included four studies comparing LCP and RIMN and 38 single-cohort studies reporting LCP or RIMN. In total, 2156 femurs were included and 166 non-unions were detected. We conducted a pair-wise meta-analysis (with a fixed-effects model) on the four comparative studies and a proportional meta-analysis on the 38 articles to estimate the nonunion rate. We performed sensitivity analysis by comparing studies using LCP with less invasive surgical systems (LISS) with those that used RIMN.

Results: The pairwise meta-analysis showed a similar nonunion rate between the groups [odds ratio: 1.02; 95% confidence interval (CI) 0.94-1.11, p = 0.633]. According to proportional meta-analysis, the pooled prevalence of nonunion was 5% (95% CI 4-7) totally, 6% (95% CI 4-8) in the LCP group, and 4% (95% CI 2-6) in the RIMN group (heterogeneity: p = 0.105). According to the sensitivity analysis, there was no difference in the union rate. The pooled prevalence of nonunion from sensitivity analysis was 4 % (95% CI, 3-5); it was 4% (95% CI, 3-6) in LCP with LISS and was 4% (95% CI, 2-6) in RIMN group (heterogeneity: p = 0.941).

Conclusion: Approximately 5% of patients who underwent LCP or RIMN fixation developed nonunion. Therefore, LCP and RIMN are effective DFF techniques and mastering one of them is essential.
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http://dx.doi.org/10.1007/s00402-020-03463-xDOI Listing
February 2021

Characteristics of Appendicular Tissue Components in Patients with Rheumatoid Arthritis.

J Bone Metab 2020 Feb 29;27(1):35-42. Epub 2020 Feb 29.

Department of Orthopaedic Surgery, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea.

Background: The purpose of this study was to identify the characteristics of appendicular lean mass (ALM) associated with rheumatoid arthritis (RA) and to analyze appendicular tissue components in patients with RA.

Methods: We prospectively reviewed of patients with RA who underwent dual energy X-ray absorptiometry in a single center. From data of 28 patients, ALM was calculated. Regression analysis was used to investigate the association between ALM and RA. Using propensity score matching, patients with RA were compared to the control group from 18,698 patients of Korea National Health and Nutrition Examination Surveys data. RA and control group were matched in a 1: 5, respectively.

Results: In regression model, there was significantly negative association between disease activity score and ALM index in patients with RA in unadjusted (β=-0.387, 95% confidence interval [CI], -0.729 to -0.045) and model adjusted for age, sex, and body mass index (β=-0.227, 95% CI, -0.451 to -0.003). In matching with age and sex, the arms fat mass and fat fraction of RA group were significantly lower than that of control group. In matching with age, sex, and body mass index, the ALM index and legs lean mass of RA group were significantly higher than control group.

Conclusions: Patients with RA have a lower ALM with higher disease activity. In addition, we found that patients with RA had different tissue component in arms and legs compared to general population.
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http://dx.doi.org/10.11005/jbm.2020.27.1.35DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7064364PMC
February 2020

Staged Revision of Infected-hip Arthroplasty Using an Antibiotics-loaded Intra-articular Cement Spacer: Impact on Cemented and Cementless Stem Retention.

Hip Pelvis 2020 Mar 26;32(1):26-34. Epub 2020 Feb 26.

Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea.

Purpose: Currently, standard management of a peri-prosthetic infection is a two-stage revision precedure. However, removal of well-fixed cement is technically demanding and associated with numerous potential complications. For theses reasons, two-stage revision with preservation of the original femoral stem can be considered and several previous studies have achieved successful results. While most prior studies used cemented stems, the use of cementless stems during arthroplasty has been gradually increasing; this study aims to assess the comparative effectiveness of a two-stage revision of infected hip arthroplasties at preserving cemented and cementless stems.

Materials And Methods: Between December 2001 and February 2017, Inje University Sanggye Paik Hospital treated 45 cases of deep infections following hip arthroplasty with a two stage revisional arthroplasty using antibiotics-loaded cement spacers. This approach was applied in an effort to preserve the previously implanted femoral stem. Of these 45 cases, 20 were followed-up for at least two years and included in this analysis. Perioperative clinical symptoms, radiological findings, function and complications during insertion of an antibiotics-loaded cement spacer were analyzed in this study.

Results: Peri-prothetic infections were controlled in 19 of the 20 included cases. Clinical outcomes, as assessed using the Harris hip score, Western Ontario and McMaster University score, also improved. Importantly, similarly improved outcomes were achieved for both cemented and cementless femoral stems.

Conclusion: In cases of deep infection following hip arthroplasty, two-stage revision arthroplasty to preserve the previously implanted femoral stem (cemented or cementless) effectively controls infections and preserves joint function.
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http://dx.doi.org/10.5371/hp.2020.32.1.26DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7054080PMC
March 2020

Incidence of Ceramic Fracture in Contemporary Ceramic-on-Ceramic Total Hip Arthroplasty: A Meta-analysis of Proportions.

J Arthroplasty 2020 05 18;35(5):1437-1443.e3. Epub 2019 Dec 18.

Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.

Background: We performed a proportion meta-analysis of currently available data to determine the prevalence of ceramic fracture for each generation.

Methods: A total of 10,571 total hip arthroplasties from 45 studies were included. Proportion meta-analysis with a random-effects model was performed to estimate the prevalence of ceramic fracture. To determine whether the ceramic fractures have a fatigue nature and a risk or latent period for the development, postoperative time lapse, patient age, and body mass index were related with ceramic fracture by metaregression analysis.

Results: As of postoperative 2.0 to 18.8 years, the rate of ceramic fracture was 0.5% (95% CI, 0.3%-0.8%) in the forte group and 0.2% (95% CI, 0.1%-0.4%) in the delta group (P = .059). The ceramic fracture rate for each component was 0.2% (95% CI, 0.1%-0.3%) for the forte head, 0.1% (95% CI, 0.0%-0.2%) for the delta head (P = .210), 0.2% (95% CI, 0.1%-0.3%) for the forte liner, and 0.2% (95% CI, 0.1%-0.4%) for the delta liner (P = .305). The rate of ceramic fracture per 1000 patient-years was 0.9 (95% CI, 0.5-0.13) in the forte group and 0.5 (95% CI, 0.2-0.8) in the delta group (P = .072). In metaregression analysis, no significant associations were found between prevalence of ceramic fracture and postoperative time lapse, patient age, or body mass index.

Conclusions: The rate of ceramic fracture was 0.9/1000 patient-year in the forte group and 0.5/1000 patient-year in the delta group. The results of this study provide baseline data for further studies validating ceramic bearings.

Level Of Evidence: Level I, meta-analysis.
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http://dx.doi.org/10.1016/j.arth.2019.12.013DOI Listing
May 2020

The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head.

J Arthroplasty 2020 04 27;35(4):933-940. Epub 2019 Nov 27.

Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, China.

Background: The Association Research Circulation Osseous (ARCO) presents the 2019 revised staging system of osteonecrosis of the femoral head (ONFH) based on the 1994 ARCO classification.

Methods: In October 2018, ARCO established a task force to revise the staging system of ONFH. The task force involved 29 experts who used a web-based survey for international collaboration. Content validity ratios for each answer were calculated to identify the levels of agreement. For the rating queries, a consensus was defined when more than 70% of the panel members scored a 4 or 5 rating on a 5-point scale.

Results: Response rates were 93.1%-100%, and through the 4-round Delphi study, the 1994 ARCO classification for ONFH was successfully revised. The final consensus resulted in the following 4-staged system: stage I-X-ray is normal, but either magnetic resonance imaging or bone scan is positive; stage II-X-ray is abnormal (subtle signs of osteosclerosis, focal osteoporosis, or cystic change in the femoral head) but without any evidence of subchondral fracture, fracture in the necrotic portion, or flattening of the femoral head; stage III-fracture in the subchondral or necrotic zone as seen on X-ray or computed tomography scans. This stage is further divided into stage IIIA (early, femoral head depression ≤2 mm) and stage IIIB (late, femoral head depression >2 mm); and stage IV-X-ray evidence of osteoarthritis with accompanying joint space narrowing, acetabular changes, and/or joint destruction. This revised staging system does not incorporate the previous subclassification or quantitation parameters, but the panels agreed on the future development of a separate grading system for predicting disease progression.

Conclusion: A staging system has been developed to revise the 1994 ARCO classification for ONFH by an expert panel-based Delphi survey. ARCO approved and recommends this revised system as a universal staging of ONFH.
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http://dx.doi.org/10.1016/j.arth.2019.11.029DOI Listing
April 2020

Use of Bone Turnover Markers in Clinical Practice for the Management of Osteoporosis in Korea: From the Survey on the Prescription Pattern of Bone Turnover Markers.

J Bone Metab 2019 Nov 30;26(4):271-277. Epub 2019 Nov 30.

Division of Endocrinology and Metabolism, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea.

Background: There has been interest in the clinical potential of bone turnover markers (BTMs) as tools both for assessing fracture risk and for monitoring treatment. However, the practical use of BTMs has been limited by their biological variability and difficulties in the interpretation of results. We investigated the current situation of application of BTMs by clinicians in Korea for the management of osteoporosis through a survey asking the patterns of BTMs prescription in clinical practice.

Methods: The survey was conducted online using the "google survey" by the BTM committee authorized by the Korean Society for Bone and Mineral Research.

Results: Total 108 clinicians responded the survey. Most of the respondents prescribed BTMs (80.6%) when they prescribed anti-osteoporotic medications (AOMs). The most frequently prescribed bone resorption and formation markers were serum C-terminal telopeptide of type I collagen (90.7%) and osteocalcin (65.1%), respectively. BTMs were mostly prescribed before starting AOMs (90.8%) and used for the purpose of evaluating treatment response (74.4%). Treatment response and compliance to AOMs were evaluated according to the change of absolute value of BTMs (55.1%). The respondents complained difficulties in the interpretation of BTMs (33.3%), the choice of proper BTMs (17.2%), and the proper sample preparation and handling (13.8%).

Conclusions: In Korea, most of clinicians recognized the benefit of BTMs in the management of osteoporosis. However, there are limitations in the broad use of these markers in clinical practice. Therefore, a clear recommendation for BTM in Korea enhances their use in clinical practice.
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http://dx.doi.org/10.11005/jbm.2019.26.4.271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6901689PMC
November 2019

Position Statement on the Use of Bone Turnover Markers for Osteoporosis Treatment.

J Bone Metab 2019 Nov 30;26(4):213-224. Epub 2019 Nov 30.

Division of Endocrinology and Metabolism, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea.

Current evidences continue to support the clinical application of bone turnover markers (BTMs) in the management of postmenopausal osteoporosis. The limitations of bone mineral density measured by dual energy X-ray absorptiomet especially emphasize the beneficial roles of BTMs, such as serum C-terminal telopeptide of type I collagen and serum procollagen type I N-propeptide, as monitoring tools to assess the responses to treatment. Therefore, the proper application and assessment of BTM in clinical practice is very important. However, their use in Korea is still insufficient. Therefore, the BTM committee has set up by the Korean Society for Bone and Mineral Research have been constituted and provided a position statement which will suggest on the clinical application of BTM for the management of postmenopausal osteoporosis in Korea.
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http://dx.doi.org/10.11005/jbm.2019.26.4.213DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6901690PMC
November 2019

Cementless total hip arthroplasty with delta-on-delta ceramic bearing in patients younger than 30 years.

Hip Int 2021 Mar 25;31(2):181-185. Epub 2019 Nov 25.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.

Background: Despite improvements in the mechanical properties of alumina ceramics, the outcome of total hip arthroplasty (THA) with contemporary ceramic bearings in young patients remains a matter of concern. We evaluated the results of cementless THA with the use of the delta ceramic bearing, and determined the prevalence of osteolysis, squeaking, and ceramic fracture in patients aged < 30 years at mid-term.

Methods: From March 2008 to January 2012, 76 consecutive patients (91 hips), younger than 30 years, underwent cementless THA with Delta ceramic bearings. In each follow-up, the clinical evaluation including noise and radiological evaluations were recorded.

Results: Among them, 72 patients (86 THAs) were followed-up for a minimum of 5 years (mean 70.8; 60-95.9 months). There were 44 men (47 hips) and 28 women (39 hips). The mean age at the time of the index arthroplasty was 25.9 (16-30) years and the mean preoperative Harris Hip Score (HHS) was 59.4 (23-79) points. HHS improved to 96.3 (64-100) points at the final follow-up evaluation. 8 hips (9.3%) exhibited grinding or squeaking. No hip had aseptic loosening and no hip was revised. No osteolysis was detected around any acetabular or femoral components.

Conclusions: Our results suggest that cementless THA with the use of Delta ceramic bearing provides satisfactory results without osteolysis or ceramic fracture in patients aged <30 years at a mid-term follow-up.Clinical Trials.gov Protocol Registration System (trial no. NCT01838096).
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http://dx.doi.org/10.1177/1120700019889592DOI Listing
March 2021

Lessons Learned from Long-Term Management of Hip Fracture in Patients with Osteopetrosis: A Report of Nine Hips in Five Patients.

J Bone Metab 2019 Aug 31;26(3):201-206. Epub 2019 Aug 31.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.

Background: Treating patients with osteopetrosis is very challenging even in very skilled surgeons with many experiences. We present an account of 5 patients treated for hip fracture related problems occurring throughout their life due to this disease. Difficulties encountered during their treatment prompted us to present some general management principles.

Methods: From January 2003 to December 2016, 5 patients with osteopetrosis (9 hips; 3 men, 2 women), who underwent operative or conservative treatment were retrospectively reviewed. We evaluated their clinical features and rate of union, malunion and post-operative infection.

Results: Four of 5 patients (80%) suffered bilateral fracture, and 8 of 9 fractures (89%) are transverse and occurred at subtrochanteric area resulted from minor trauma. Among 9 hips, surgery was performed in seven hips. Nonunion were found in 3 hips (33%), malunion in 1 hip (11%) and oteomyelitis was developed in 2 hips (22%) at a median of 8.1 years.

Conclusions: Clinical features of hip fracture in osteopetrosis are very similar to atypical subtrochanteric femoral fractures. Patients should be informed of the possibilities of several anticipated complications including the risk of nonunion and infection after surgery.
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http://dx.doi.org/10.11005/jbm.2019.26.3.201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746665PMC
August 2019

Preoperative Iron Supplementation and Restrictive Transfusion Strategy in Hip Fracture Surgery.

Clin Orthop Surg 2019 Sep 12;11(3):265-269. Epub 2019 Aug 12.

Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.

Background: Hip fracture surgery (HFS) is often associated with perioperative blood loss, and it frequently necessitates transfusion. However, the hemoglobin (Hb) threshold for transfusion remains controversial in hip fracture patients. We evaluated the usefulness of the restrictive strategy and preoperative intravenous iron supplementation in HFS.

Methods: We retrospectively reviewed the medical records of 1,634 patients (> 60 years of age) who underwent HFS between May 2003 and June 2014 and were followed up for 1 year or more after surgery. We used the liberal transfusion strategy until May 2009 to determine the transfusion threshold; afterwards, we switched to the restrictive transfusion strategy. Patients with the restrictive transfusion strategy (restrictive group) received intravenous iron supplementation before surgery. We compared the transfusion rate, morbidity, and mortality of the restrictive group with those of the patients with the liberal transfusion strategy (liberal group).

Results: Preoperative intravenous iron supplementation was not associated with any adverse reactions. The transfusion rate was 65.3% (506/775) in the liberal group and 48.2% (414/859) in the restrictive group ( < 0.001). The mean hospital stay was shorter in the restrictive group (21.5 vs. 28.8 days, < 0.001). There was no significant difference in the postoperative medical complications including myocardial infarction and cerebrovascular event. Mortality at postoperative 30, 60, and 90 days was similar between the two groups.

Conclusions: Our blood management protocol involving restrictive strategy combined with preoperative intravenous iron supplementation appears to be effective and safe in HFS of elderly patients.
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http://dx.doi.org/10.4055/cios.2019.11.3.265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6695329PMC
September 2019

Assessment of Korea's Orthopedic Research Activities in the Top 15 Orthopedic Journals, 2008-2017.

Clin Orthop Surg 2019 Jun 9;11(2):237-243. Epub 2019 May 9.

Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea.

Background: Bibliometrics is increasingly used to assess the quantity and quality of scientific research output in many research fields worldwide. This study aims to update Korea's worldwide research productivity in the field of orthopedics using bibliometric methods and to provide Korean surgeons and researchers with insights into such research.

Methods: Articles published in the top 15 orthopedic journals between 2008 and 2017 were retrieved using the Web of Science. The number of articles, citations and h-index (Hirsch index), funding sources, institutions, and journal patterns were analyzed.

Results: Of the total 39,494 articles, Korea's contribution accounted for 5.6% (2,161 articles), ranking fifth in the world in the number of publications. Korea ranked sixth (with 29,456) for total citations worldwide but ranked 17th (13.64) in terms of average citation per item and 14th (55) in terms of h-index. Korea showed the most prolific productivity in the field of sports medicine and arthroscopy. The institution that produced the highest number of publications was Seoul National University (n = 386, 17.9%).

Conclusions: Orthopedic research in South Korea demonstrated high productivity in terms of the number of publications in high-quality journals between 2008 and 2017. However, total citations and average citations per article were still relatively low. Efforts should be made to increase citation rates for further improvement in research productivity in the field of orthopedics.
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http://dx.doi.org/10.4055/cios.2019.11.2.237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6526129PMC
June 2019

Use of ceramic-on-ceramic bearing in total hip arthroplasty for posttraumatic arthritis of the hip.

J Orthop Surg (Hong Kong) 2019 May-Aug;27(2):2309499019836378

1 Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.

Purpose: We aimed to evaluate (1) the intraoperative parameters, (2) cup position, (3) complications, (4) long-term results, and (5) the survivorship of cementless total hip arthroplastys (THAs) with use of ceramic bearings in patients with a history of acetabular fracture.

Methods: We compared 57 THAs in patients, who were treated due to previous acetabular fracture (posttraumatic group), with 57 propensity score-matched THAs in patients, who were operated due to femoral head osteonecrosis (osteonecrotic group), at a minimum of 5-year follow-up.

Results: The operation time was longer ( p = 0.008), and the volume of transfusion was larger ( p = 0.0.23) in the posttraumatic group. The cup abduction (39.4° ± 6.0° vs. 39.7°±4.8°) and anteversion (24.7° ± 8.0° vs. 26.7°±7.7°) were similar between the two groups. There was one dislocation in the posttraumatic group. There was no ceramic fracture in either group. One posttraumatic patient underwent excision of exuberant heterotrophic ossification at 3 years after the arthroplasty. The mean University of California, Los Angeles activity improved from 3.6 to 4.9 points in the posttraumatic group and 3.5 to 5.2 points in the osteonecrotic group. All acetabular cups and femoral stems had bone-ingrown stability. When reoperation for any reason was used as the end point, the 10-year survival rate was 98.3% (95% CI: 95.0-100) in the posttraumatic group and 100% in the osteonecrotic group.

Conclusion: In our study, posttraumatic patients had longer operation time and larger volume of transfusion than osteonecrotic patients. However, medium-term results and survivorship were similar with those of osteonecrotic patients.
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http://dx.doi.org/10.1177/2309499019836378DOI Listing
April 2020

Influence of Thyroid-stimulating Hormone Suppression Therapy on Bone Mineral Density in Patients with Differentiated Thyroid Cancer: A Meta-analysis.

J Bone Metab 2019 Feb 28;26(1):51-60. Epub 2019 Feb 28.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.

Background: The effects of subclinical hyperthyroidism on bone mineral density (BMD) induced by thyroid-stimulating hormone (TSH) suppression therapy in patients with differentiated thyroid cancer (DTC) remains unclear. We conducted a meta-analysis to determine the influence of TSH suppression therapy on BMD.

Methods: We performed a systematic search to identify studies which included BMD measurement of femoral neck, total hip or lumbar spine in patients on TSH suppression therapy for DTC. Main outcome measures were difference of BMD of femoral neck, total hip or lumbar spine measured by dual energy X-ray absorptiometry between patients and controls.

Results: A systematic search yielded a total of 11 published controlled cross-sectional studies (including about 571 patients and 836 controls). TSH suppression therapy was associated with the lower BMD of total hip (weighted mean difference [WMD], -0.023; 95% confidence interval [CI], -0.047 to 0.000; =0.050) and spine (WMD, -0.041; 95% CI, -0.057 to -0.026; <0.001) in postmenopausal women with DTC, while it was not associated with that in premenopausal women and men with DTC.

Conclusions: Although the included studies were limited by small numbers, results suggested possible association between chronic TSH suppression therapy and the lower BMD of spine and total hip in postmenopausal women (but not in premenopausal women and men) with DTC. A large, well-designed study with long-term follow-up would provide further insight into the influence of TSH suppression therapy and loss of BMD.
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http://dx.doi.org/10.11005/jbm.2019.26.1.51DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6416150PMC
February 2019

Risk of Osteoporotic Fractures after Thyroid-stimulating Hormone Suppression Therapy in Patients with Thyroid Cancer.

J Bone Metab 2019 Feb 28;26(1):45-50. Epub 2019 Feb 28.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.

Background: The effects of subclinical hyperthyroidism on fracture risk induced by thyroid-stimulating hormone (TSH) suppression therapy in patients with thyroid cancer still remains controversial. We performed a meta-analysis and systematic review to evaluate the effects of TSH suppression therapy on osteoporotic fracture in patients with thyroid cancer.

Methods: We performed a systematic search to identify studies which included osteoporotic fractures (hip fracture and vertebral fracture) in patients on TSH suppression therapy for thyroid cancer. Main outcome measures were occurrence and risk of osteoporotic fractures including hip and vertebral fractures between patients and controls.

Results: A systematic search yielded a total of 8 studies appropriate for review which included osteoporotic fracture outcome in patients on TSH suppression therapy for thyroid cancer. Studies with larger number of subjects showed the higher risk of osteoporotic fracture in group with TSH suppression therapy, although studies with smaller sample size presented a similar risk of fracture with control group.

Conclusions: Although studies were limited by small numbers, results suggested possible association between chronic TSH suppression therapy and the increased risk of osteoporotic fractures in patients with thyroid cancer.
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http://dx.doi.org/10.11005/jbm.2019.26.1.45DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6416149PMC
February 2019

Clinical Application of Bone Turnover Markers in Osteoporosis in Korea.

J Bone Metab 2019 Feb 28;26(1):19-24. Epub 2019 Feb 28.

Division of Endocrinology and Metabolism, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea.

Bone turnover markers (BTMs) have important role in the management of osteoporosis. Recently the clinical application of BTMs has achieved significant progress and measurement of BTMs give us better understanding of pathogenesis of osteoporosis. However, the use of BTMs is still insufficient in Korea. We summarized the available methods and standard interval of the BTMs in Korea. Also we reviewed published literatures on pre-analytical variability in the measurement of BTMs and provided recommendations for standardized sample handling and patient preparation for reducing those pre-analytical variabilities. The clinical application of BTMs in patients with chronic kidney disease who have a higher fracture risk than the general population is summarized.
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http://dx.doi.org/10.11005/jbm.2019.26.1.19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6416153PMC
February 2019

The Effect of Valgus Reduction on the Position of the Blade of the Proximal Femoral Nail Antirotation in Intertrochanteric Hip Fractures.

Clin Orthop Surg 2019 Mar 18;11(1):36-42. Epub 2019 Feb 18.

Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea.

Background: The purpose of this study was to evaluate the quantitative association between the degree of reduction and the position of the blade of the proximal femoral nail antirotation (PFNA) in intertrochanteric hip fractures.

Methods: From March 2009 to April 2015, 530 patients treated with PFNA for intertrochanteric hip fractures were retrospectively reviewed. Patients were divided into a valgus reduced group (group 1) and a non-valgus reduced group (group 2), and the "valgus reduced" was defined as valgus reduction over 5°. We compared the calcar referenced tip-apex distance (calTAD) and the area between the blade of PFNA and the medial cortex of the femoral neck between the two groups.

Results: The calTAD was measured as 22.5 ± 4.1 mm in group 1 and 24.8 ± 3.8 mm in group 2 ( < 0.05). The area between the blade and the medial femoral neck was measured as 135.5 ± 49.8 mm in group 1 and 145.1 ± 54.8 mm in group 2 ( = 0.074). The area corrected for the length difference in the femoral neck was 0.55 ± 0.16 in group 1 and 0.79 ± 0.19 in group 2 ( < 0.05).

Conclusions: Valgus reduction resulted in less calTAD and inferior position of the blade at the femoral neck in the treatment of intertrochanteric hip fractures with PFNA.
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http://dx.doi.org/10.4055/cios.2019.11.1.36DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6389525PMC
March 2019

Osteoporosis and Osteoporotic Fractures in Gastrointestinal Disease.

J Bone Metab 2018 Nov 30;25(4):213-217. Epub 2018 Nov 30.

Department of Orthopaedic Surgery, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea.

Patients with gastrointestinal disease (GI) are at risk for osteopenia or osteoporosis, which can lead to fractures. Although these patients may be at risk from a young age, gastroenterologists often overlook this fact in practice. There are well-known GI diseases associated with osteopenia and osteoporosis, such as the post-gastrectomy state, inflammatory bowel disease (IBD), and celiac disease. As there is an increase in the prevalence of IBD patients, newly diagnosed celiac disease in adulthood, and gastric cancer survivors following gastrectomy, bone disease in these patients becomes an important issue. Here, we have discussed osteoporosis and fractures in GI disease, especially in the post-gastrectomy state, IBD, and celiac disease. Although the pathogenesis of bone loss in each disease has not been fully identified, we have confirmed that the prevalence of osteoporosis and fractures in each of these diseases is high. There are scarce studies comparing the prevalence of osteoporosis or osteoporotic fractures in GI disease patients with studies in postmenopausal women, and specific guidelines for their management in each disease have not been established. Intensive surveillance and management are needed to ensure that these patients attain peak bone mass for age and sex to prevent fractures.
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http://dx.doi.org/10.11005/jbm.2018.25.4.213DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6288610PMC
November 2018

Optimal use of tranexamic acid for total hip arthroplasty: A network meta-analysis.

PLoS One 2018 31;13(10):e0206480. Epub 2018 Oct 31.

Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.

Background: Tranexamic acid (TXA) has been demonstrated to minimize blood loss after total hip arthroplasty. There are three main routes: intravenous (IV), intra-articular (topical), and combined (IV and topical) but little consensus support which is most effective and safe. We performed network meta-analysis.to assess the comparative efficacy and safety of three different administration routes of TXA.

Methods: Twenty-five randomized controlled trials (RCT) were evaluated. Interventions were classified as: combined, IV multiple, IV single, topical and placebo. The primary outcome was effectiveness (transfusion rate, total blood loss, and total drain out). The secondary outcome was safety, based on the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE).

Results: A total of 2227 patients were included in the 5 categories: 564 IV single, 319 IV multiple, 398 topical, 120 combined, and 826 placebo. A network meta-analysis identified the most effective interventions in terms of reducing the need for transfusion as follows: combined = 98.2%, IV single = 54.0%, IV multiple = 78.6%, topical = 66.1%, placebo = 0.0%. Compared with placebo, the IV single, IV multiple, topical, and combined interventions showed no difference in the rate of occurrence of DVT and PE.

Conclusions: A network meta-analysis indicated that combined administration of TXA (IV and topical) was effective in reducing the transfusion rate after hip arthroplasty compared with IV or topical alone. As no high-risk patients were evaluated in the RCTs, it is not known whether the combined method is safer for patients susceptible to DVT or PE.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206480PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6209331PMC
April 2019
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