Low glenoid neck Hounsfield units predict patients at high risk of mechanical complication after total shoulder arthroplasty.

Bone mineral density is often considered in preoperative surgical planning for spinal fusions. CT imaging-based measurement of Hounsfield units (HU) has been suggested as a surrogate marker for dual-energy x-ray absorptiometry scans. However, research establishing a threshold for HU at the uppermost instrumented vertebrae (UIV) that can mitigate the risk of mechanical and junctional complications following posterior spinal fusion is limited. Adults who underwent posterior spinal fusion and had 1-year follow-up data available were included in this retrospective cohort study. HU measurements were collected at various vertebral levels, including at the UIV. Inter- and intrarater reliability were calculated using the using intraclass correlation coefficients (ICCs). HU thresholds for mechanical and junctional complications were established using receiver operating characteristic (ROC) curve analyses, while accounting for age, sex, UIV level, and osteoporosis. Across 70 patients, mean age was 64.4 years, 65.3% were female, and 10.0% had osteoporosis. The intrarater reliability ICCs were classified as excellent (ie, greater than 0.9) for all vertebral levels, whereas the interrater reliability ICCs were classified as good (ie, greater than 0.8) for all vertebral levels. ROC curve analyses identified a HU cutoff of 105. Patients below the HU threshold had markedly higher rates of mechanical and junctional complications (52.0% vs. 8.9%, P < 0.001), specifically adjacent segment disease (32.0% vs. 2.2%, P < 0.001). CT-based measurement of HU at the upper instrumented vertebra has excellent intrarater and good interrater reliability. In this cohort of lumbar and thoracolumbar spinal fusion patients, patients with HU under 105 at the UIV had an increased risk of mechanical and junctional complications following spinal fusions. Future studies may work to refine HU assessment and the association with postoperative complications, as using HU to guide surgical candidacy and UIV selection may be beneficial.

Does pre-arthroplasty antiviral treatment for hepatitis C reduce complication rates after total shoulder arthroplasty? A matched cohort study.

Low glenoid vault bone density is a risk factor for failure of proximal humerus fracture fixation.

Computed tomography (CT) Hounsfield units (HUs) of pathologically confirmed metastatic inguinal lymph nodes (ILNs) were proved to be higher than negative ones. We designed this study to explore the clinical value of CT HU for diagnosing palpable ILN metastasis in patients with penile cancer. A total of 32 patients with penile cancer, including 84 palpable ILNs, were recruited in this study. They all performed 5-mm layer pelvic contrast-enhanced CT (CE-CT) before treatment. The palpable ILNs were matched with CT image. By using radiologic software PACS, the layer with a maximum cross-sectional area of target lymph node was selected, and the short axis was defined as diameter. We outlined the edge of target lymph nodes, and the software automatically calculated its area, maximum CT HU, and average CT HU. All target ILNs were biopsied by surgery to confirm the presence of metastasis. Compared with non-metastatic ILNs, metastatic ILNs had larger diameter, area, maximum non-contrast CT (NC-CT) HU, maximum arterial-phase CE-CT (ACE-CT) HU, average NC-CT HU, and average ACE-CT HU, with statistically significant differences (P < 0.05). Receiver operating characteristic analysis showed the all six parameters (maximum NC-CT HU, maximum ACE-CT HU, average NC-CT HU, average ACE-CT HU, diameter, and area) had significant diagnostic value for ILN metastasis, with an area under the curve of 0.847, 0.853, 0.900, 0.919, 0.809, and 0.789, respectively. The average ACE-CT HU (cutoff: 40.5) had the highest accuracy as 0.857, and maximum NC-CT HU (cutoff: 51.5) had the highest sensitivity of 0.897. ILN CT HU was clinically valuable for the diagnosis of palpable ILN metastasis in patients with newly diagnosed penile cancer.

The aim with this study was to determine the association of preoperative Hounsfield unit (HU) in hip computed tomography (CT) with intra-operative osteoporotic fracture during cementless hemiarthroplasty. In this retrospective study, we reviewed all patients who underwent cementless bipolar hemiarthroplasty for femoral neck fractures between 2014 and 2016. Patients with intra-operative metaphyseal fractures (n = 25) during surgery were identified from a retrospectively collected patient database and matched with nonfracture controls (n = 75) on the basis of age and sex. The differences between patients with intra-operative fractures and without intra-operative fractures were compared regarding preoperative HU. Correlations of HU value of femur neck with BMD and T scores were determined. Analysis of HU values at the fracture level showed a significantly lower value in the fracture group than in the controls (1186 vs 1340, p = 0.005). The correlation between HU and BMD of femur neck was significant (r 2 = 0.347; p < 0.001). The correlation between HU of femur neck and BMD of spine was also significant (r 2 = 0.133; p < 0.001). HU assessment using preoperative CT scan is associated with the presence of intra-operative fracture during bipolar hemiarthroplasty. We believe that HU values of the proximal femur could be used to assess local bone quality.

The purpose of this study was to determine whether CT Hounsfield units (HUs) as a proxy for bone quality can predict postoperative mechanical complications following surgical treatment of distal humerus fractures. One hundred fifty-three patients with both column distal humerus fractures who underwent surgical fixation at single institution and had complete radiographic data available were included. Radiographic measurements included the HU value from the surgical distal humerus as determined by measuring the metaphyseal/supracondylar at the midaxial/coronal/sagittal CT image an average of 1 cm from the articular surface using a freehand region of interest. Zones with fracture lines and cortical impaction were avoided for all measurements. Postoperative complications recorded were implant failure, nonunion, and acute periprosthetic fracture. Patients with and without complications were statistically compared, and binary logistic regression was done to determine if CT HU measurements from the distal humerus were predictive of complications. Five patients (3.3%) developed five mechanical complications, including peri-prosthetic humerus fracture (one), implant failure (two), and nonunion (two). Patients with mechanical complications were more likely to be current smokers (40% vs. 6.8%, P = 0.010). Otherwise, no difference was observed in demographics or AO/Orthopedic Trauma Association classification between the cohorts. Patients with complications had markedly lower HU in the coronal plane ( P = 0.031). Regression analysis found that current smoking was associated with an increased risk of mechanical complications ( P = 0.041, OR = 1.102, 95% confidence interval [CI], 1.087 to 1.710), whereas a higher coronal HU was associated with a decreased risk of complications ( P = 0.048, OR = 0.973, 95% CI, 0.961 to 0.991). A thorough smoking history and CT HU measurements in the coronal plane may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation.

Background: Attention-deficit/hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder characterized by impulsiveness and challenges with adherence, potentially affecting surgical outcomes. While the effects of other mental health disorders, such as anxiety and depression, on orthopedic surgery complications, have been studied, the impact of ADHD – particularly on total shoulder arthroplasty (TSA) – remains unexplored. Purpose: This study aims to assess the influence of adult ADHD on postoperative outcomes following TSA. Methods: Using the TriNetX Database, adults undergoing TSA with and without a diagnosis of ADHD were identified. Cohorts were matched 1:1 using propensity score matching on demographic variables and comorbidities, including substance and mood disorders. Statistical tests, including risk ratios (RR) with 95% confidence intervals, independent t-tests, and chi-square tests, were employed to compare outcomes. Primary outcomes were orthopedic complications measured at two and four years postoperatively. Results: At 90 days postoperatively, patients with ADHD had a higher risk of prosthetic joint infection (PJI) (RR = 1.75; P = 0.015), deep infections (RR = 1.57; P = 0.028), and mechanical complications (RR = 1.96; P = 0.006). At the two-year follow-up, patients with ADHD had a higher risk of prosthetic dislocation (RR = 1.79; P = 0.009), overall mechanical complications (RR = 1.75; P &lt; 0.001), and PJI (RR = 1.62; P &lt; 0.001). Risks remained significant at four years postoperatively for PJI (RR = 1.53; P &lt; 0.001), prosthetic dislocation (RR = 1.57; P = 0.031), overall mechanical complications (RR = 1.72; P &lt; 0.001) and mechanical loosening (RR = 2.06; P = 0.012). Conclusion: Adult ADHD is associated with a significantly increased risk of postoperative orthopedic complications following TSA, including PJI, prosthetic dislocation, overall mechanical complications, and mechanical loosening up to four years after surgery. These findings suggest that ADHD-related behavioral factors may adversely affect postoperative recovery. Enhanced preoperative and postoperative counseling, tailored management, and vigilant long-term monitoring are recommended to mitigate risks and improve outcomes for this patient population.

Computed tomography-based Hounsfield unit (HU) measurements can be used to evaluate localized bone mineral density preoperatively in spinal fusion patients. While multiple studies have reported HU cutoffs predictive of screw loosening, cage subsidence, proximal junctional kyphosis/failure (PJK/PJF), and other mechanical complications, a standardized validated HU threshold has not been established. A comprehensive search of PubMed, Scopus, Embase, and Cochrane Library was performed for articles that reported HU measurements in thoracolumbar or lumbar fusion patients with and without postoperative complications. Random-effects meta-analyses were performed to compare mean HU in patients with and without complications. Global threshold was generated through pooled analyses of studies that reported HU cutoffs. This threshold was validated on studies that did not identify any HU cutoff. Across 42 studies (6,240 patients), mean age was 61.7 years, 39.0% were males, and mean CCI was 2.4. In total, 36.1% had cage subsidence, 29.4% had screw loosening, 32.9% had PJK/PJF, and 18.0% had other mechanical complications. Meta-analyses revealed that patients with mechanical/junctional complications had 0.8 standard deviations (95%CI = 0.7-1.0, p < 0.01) lower HU than control patients. From the 25 studies (3,103 patients) that reported HU cutoffs, a global threshold of 118 HU (sensitivity = 72.9%, specificity = 63.9%) was established. From the remaining 17 studies (3,137 patients) that did not report HU cutoffs, patients below this threshold had 2.8 times (95%CI = 1.9-4.1, p < 0.01) higher odds of complications than patients above this threshold (sensitivity = 45.8%, specificity = 77.4%). In patients undergoing thoracolumbar or lumbar fusions, preoperative Hounsfield unit values under 118 were associated with a 2.8-fold higher risk of postoperative mechanical and junctional complications. Preoperative surgical planning may utilize this threshold to guide surgical optimization and planning. Specifically, a simple stratification model, with < 120 HU as high risk, 120-150 HU as intermediate risk, and > 150 HU as low risk may facilitate clinical application and promote standardized HU assessments. Level III, Therapeutic Study.

BackgroundWhile estrogen is essential for bone remodeling, its impact on joint health is more nuanced. Previous studies suggest that high estrogen states, including those induced by estrogen replacement therapy (ERT), are associated with osteoarthritis and an increased risk of revisions after hip and/or knee arthroplasty. Given the rise in total shoulder arthroplasty (TSA) cases, it is important to investigate factors that may impact its outcomes. This study aimed to evaluate whether ERT use impacts TSA outcomes at 2, 4, and 10 years postoperatively.Materials and methodsThis was a retrospective cohort study of females aged ≥55 years who underwent TSA, using the TriNetX Research Network. Patients were stratified by ERT use for at least 1-5 years preoperatively. One-to-one propensity score matching was performed based on age, race, bone density, osteoarthritis, and other comorbidities. Primary outcomes were revision rates at 2, 4, and 10 years. Secondary outcomes included prosthetic joint infections, mechanical complications, and shoulder instability, as well as 90-day postoperative medical complications. Tests of significance and risk ratios (RR) were calculated to compare outcomes with an alpha of <0.05.ResultsAfter matching, 1,779 patients were included in each group. At 90 days, the ERT cohort had a higher risk of deep vein thrombosis (RR =1.91; P = .012). At 2 and 4 years postoperatively, the ERT group had a significantly higher risk of revisions (RR = 1.71 and 1.59, respectively), shoulder instability (RR = 1.81 and 1.80), and overall mechanical complications (RR = 1.60 and 1.67). At 10 years, the risk for revisions (RR = 1.59; P = .002) and mechanical complications (RR = 1.43; P = .005) persisted.ConclusionOur findings suggest that ERT is associated with long-term increased risk of revision procedures and mechanical complications following TSA. This demonstrates the complex relationship between estrogen and bone health, highlighting the need for future studies investigating the impact of ERT on implant survival and osseointegration.

Single-institution, retrospective cohort study. Determine whether preoperative and intraoperative computed tomography (CT) Hounsfield units (HU) were reliable, consistent, and had similar diagnostic ability for detecting osteoporosis. Osteoporosis is common in spine surgical patients and associated with adverse outcomes. Opportunistic use of preoperative CT HU has been shown to estimate bone quality and fracture risk. Spinal navigation systems utilize intraoperative CT, which may offer an opportunity for osteoporosis assessment. From January 2021 to December 2022, 166 patients who underwent thoracolumbar surgery using spinal navigation and had both preoperative and intraoperative CT scans were included. Regions of interest (ROI) measuring 200mm2 were placed in the centroid of the L1 vertebral body to measure HU, with HU values >150 indicating normal bone, 110-150 osteopenia, and <110 osteoporosis. Preoperative and intraoperative CT HU were compared using the Pearson correlation. Bland-Altman and Cohen kappa analysis were used to determine agreement. Mean (SD) age was 61.11 (8.79), BMI was 30.26 (6.09), and 54% were female. Mean preoperative and intraoperative L1 HU were 150.66 (58.33) and 148.41 (57.59), respectively, which were not significantly different (P=0.339). On the basis of HU, normal bone, osteopenia, and osteoporosis were present in 41%, 39%, and 20% of patients based on preoperative CT compared with 37%, 38%, and 25% on intraoperative CT, k=0.91 [95% CI: 0.87-0.95]. Preoperative and intraoperative CT HU had a strong, positive correlation (r=0.982, P<0.001). Bland-Altman demonstrated agreement between preoperative and intraoperative CT HU, with a mean difference of 2.23 [95% CI: -19.70 to 24.16], P=0.427. Preoperative and intraoperative CT HU values were reliable, consistent, and demonstrated similar diagnostic ability for osteoporosis. Intraoperative HU may be useful for identifying patients at high risk for fracture or adverse surgical outcomes with probable osteoporosis who may require further postoperative bone health evaluation.

Computed tomography scans (CTs) are routinely obtained before hip preservation surgery or to evaluate pelvic and/or hip fractures. Analyzing bone mineral density (BMD) using CT Hounsfield units (HU) before surgical intervention may improve surgical management and outcomes. This systematic review summarizes the current literature on reliability and placement of regions of interest (ROIs) within the hip, pelvis, and sacrum, and their correlation with local and systemic BMD. A systematic review in PubMed, Scopus, and Web of Science was performed. Twenty-four studies reported intraclass correlation coefficients of HU measurements and/or compared the HU value obtained from CT and t-score of DXA for predicting regional BMD within the hip, pelvis, and sacrum. Twenty-four studies were included, enrolling 7,035 patients. The HU measurement was most frequently made at the femoral neck (n = 10). Femur and pelvis intrarater and interrater reliability was moderate to excellent. Moderate to strong correlations between femoral head and femoral neck CT HU and DXA, and poor to moderate correlations between the pelvis CT HU and DXA were found. A variety of ROIs have been described around the pelvis and proximal femur all with reasonable reliability for the measurement of CT HU. The strongest correlations between CT HU and DXA were reported between HU of the femoral neck and DXA of the hip/femur suggesting this ROI may be used for opportunistic BMD screening using preoperative hip/pelvis CT scans. III.

Retrospective Cohort Study. To evaluate the accuracy of intraoperatively measured computed tomography (CT) Hounsfield unit (HU) values by comparison with preoperative CT HU values and to compare the radiation exposure between preoperative and intraoperative CT scans. HU values of lumbar vertebrae were measured and compared between preoperative and intraoperative CT scans in patients undergoing lumbar interbody fusion. In patient group one, Canon CT scanners were used preoperatively and the AIRO CT scanner was used intraoperatively. In patient group two, Canon CT scanners were used preoperatively and the O-arm Cone Beam CT (CBCT) scanner was used intraoperatively. In a subgroup analysis of patient group one, radiation by means of CT Dose Index (CTDI) was compared between Canon and AIRO CT scanners. In the first patient group, a total of 250 vertebrae were analysed in 74 patients showing a strong Pearson correlation of >.94 between pre- and intraoperative HU values. Bland-Altman analysis indicated consistency and equivalence with a bias of 3.9 and 95% limits of agreement from -27.17 to 34.97 when comparing all pre- and intraoperative HU values of L1-5. In the second patient group, a total of 27 vertebrae were analysed in 10 patients showing weak Pearson correlation and Bland-Altman analysis indicated no equivalence. CTDI did not differ between Canon and AIRO CT scanners. Correct and reliable CT HU measurement as mandatory key factor for the intraoperative assessment of bone quality and robotic-assisted surgery is feasible with intraoperative AIRO CT imaging without increase of radiation exposure.

Whole-body CT (WBCT) in polytrauma patients enables the detection of numerous incidental findings, such as estimates of bone mineral density (BMD) at multiple skeletal sites. This could help in better understanding of age- and sex-related changes in BMD through skeleton. Data were retrospectively retrieved from the WBCTs requested during a 2-year period. BMD, expressed in CT Hounsfield units (HU), was measured at frontal and occipital bone, four vertebrae (C4, Th7, L4, and S2), iliac bone, and proximal humerus and femur. Measurements were done on native and postcontrast scans. The population sample was age-, sex-, and visceral fat volume adjusted for analysis. A total of 296 patients were included, with a median age of 51years. BMD varied from the highest HU in cranial bones (629 HU) to the lowest HU in the pelvic bones (114 HU), P < 0.001. Sex differences were independent predictors of BMD in cranial bones and proximal humerus. The age-related decline in BMD was significant in all other bones, but the association with age differed among the measurement's sites. Visceral fat showed the strongest correlation with the lumbar spine and iliac wing, although multivariate analysis revealed it was not an independent predictor of bone density, such as age and sex. BMD varies through skeleton, being the highest in the proximal axial skeleton. Age-related changes in BMD are significant and more pronounced than sex-related changes in almost all bones. Cranial bones do not follow the same pattern compared to other bones.

Folate deficiency is inversely correlated with inflammatory (markers/conditions) and severe osteoarthritis. Osteoarthritis can lead to increased difficulty in shoulder reconstruction and longer operative times in total shoulder arthroplasty (TSA). Our goal is to see if folate deficiency is correlated with complications after TSA. A retrospective cohort analysis using the TriNetX database was used to identify individuals with low (≤2.5 ng/mL) and normal (≥2.6 ng/mL) folate levels before TSA. Outcomes were compared at 90 days, two years, and four years following TSA. At 90 days, folate deficient patients had a higher risk of periprosthetic joint infection (11.4% vs 5.9%, RR = 1.944, p = .016), mechanical loosening (3.3% vs 0%, p = .014), periprosthetic fracture (14.4% vs 7.8%, RR = 1.833, p = .011), dislocation (8.5% vs 3.9%, RR = 2.167, p = .021), any mechanical complications (14.1% vs 6.5%, RR = 2.150, p = .002), and instability/subluxation (10.8% vs 5.6%, RR = 1.941, p = .02) when compared to the control group. At the two-year and four-year time points, TSA folate deficient patients had an increased risk of dislocation, any mechanical complications, and instability/subluxation. Folate deficiency in TSA patients is correlated with significant short- and long-term increase in several orthopedic complications. Folate deficient patients should be counseled on these risks before TSA.

Reliability and Clinical Importance of Teardrop Angle Measurement in Intra-articular Distal Radius Fracture