Journal of Southeast Asian Orthopaedics

Comparison Between Cementless Bipolar Hemiarthroplasty and Proximal Femoral Nail Anti-Rotation for Unstable Intertrochanteric Femoral Fractures in the Elderly: A Retrospective Study

2025-08-18T20:44:32+07:00

Background: Proximal femoral nail anti-rotation (PFNA) is the gold-standard treatment for intertrochanteric fractures in elderly patients. However, some authors have recently recommended the use of cementless bipolar hemiarthroplasty (CLBHA) for unstable intertrochanteric fractures and achieved satisfactory results. This study aimed to compare the results and mortality rate postoperatively five years between CLBHA and PFNA for unstable intertrochanteric fractures of the femur in elderly patients (age > 60 years).

Methods: This retrospective study reviewed in and outpatient medical records and civil registrations between October 2012 and October 2017 at our hospital. In total, 122 patients (43 men, 79 women; aged 60–93 years) with unstable intertrochanteric femurs were treated. Fractures were divided into the CLBHA and PFNA groups. Differences in operative time, intraoperative bleeding, blood transfusion, ambulation-to-walk duration, postoperative hospitalization, postoperative complications and revision rate, ambulation at six months, and five-year mortality rate were collected. The unpaired t-test was analyzed using the χ² test, and statistical significance was set at P < 0.05. The mortality rate is shown as an additional Kaplan–Meier estimate together with the p-value.

Results: The operative time (67.8±24.21 vs. 57±3.22 min, P =0.028), ambulation-to-walk duration with a gait aid (12.47±9.41 vs. 9.02±7.59 days, P <0.001), and postoperative hospitalization (911.55±6.61 vs. 7.11±3.45 days, P =0.037) were significantly different between the CLBHA and PFNA groups. Intraoperative bleeding, blood transfusion, postoperative complication, revision rate, ambulation at six months, and five-year mortality rate had no statistically significant differences.

Conclusions: Although CLBHA showed a longer surgical period, longer postoperative hospitalization, and slower ambulation compared to PFNA, the results showed no statistically significant difference in long-term outcomes and five-year mortality between both procedures for intertrochanteric femoral fractures in the elderly. Moreover, although PFNA remains the gold-standard treatment, CLBHA can be used as an alternative procedure in certain situations; however, the choice of procedure should depend on individual patient factors and surgeon expertise.

Development of an Artificial Intelligence System for Hip Fracture Detection: A YOLOv8 Model Performance Study for Junior Orthopedic Surgeons

2025-10-08T21:29:49+07:00

Purpose: Hip fractures represent a critical orthopedic emergency in the geriatric population; diagnostic delays or inaccuracies may result in severe morbidity and mortality. Contemporary artificial intelligence technologies demonstrate potential for precise and rapid radiographic interpretation, particularly in resource-constrained healthcare environments with limited availability of specialists. We aimed to develop and validate the diagnostic performance of a YOLOv8-based deep learning model by junior orthopedic surgeons for the detection of hip fractures, categorizing images into three classifications: normal anatomy, femoral neck fractures, and intertrochanteric fractures.

Methods: This retrospective study analyzed 2,035 anteroposterior hip radiographs from 942 patients. The YOLOv8 architecture was implemented using Google Colab with standardized hyperparameters. The dataset was stratified into training, validation, and testing sets. The performance evaluation utilized mean average precision (mAP@0.5), F1 score, precision, recall, sensitivity, specificity, and confusion matrix analysis.

Results: The YOLOv8 model achieved an mAP@0.5 of 0.879 and a maximum F1 score of 0.86. The model demonstrated a maximum precision, confidence threshold, and maximum recall of 1.00, 0.961, and 0.91, respectively, at a confidence threshold of 0.000. The sensitivity values were 97.7%, 87.0%, and 95.9% for intertrochanteric fractures, femoral neck fractures, and normal anatomy, respectively. The specificity ranged from 97.1% to 99.0% across all classifications, indicating exceptional screening accuracy, particularly for normal anatomy and intertrochanteric fractures.

Conclusions: The YOLOv8 model demonstrated clinical utility as a diagnostic screening tool for hip fractures, particularly in facilities with limited radiological expertise. However, femoral neck fracture classification requires further refinement through dataset augmentation and advanced training methodologies to enhance detection accuracy for this radiologically challenging entity.

Comparison of Preoperative Pain Scores Between Knee Brace and Skeletal Traction in Patients with Femoral Shaft Fracture

2025-10-29T18:10:29+07:00

Purpose: Femoral shaft fractures, often caused by traffic and occupational accidents, are non-urgent yet severely painful orthopedic injuries. Preoperative skeletal traction, the standard method to mitigate pain and restore bone length before definitive surgery, has potential complications, including infections, nerve injuries, and hardware displacement due to bone drilling. The aim of the study was to assess the efficacy of non-invasive knee brace traction as an alternative to preoperative management of femoral shaft fractures.

Methods: A randomized controlled trial was conducted with 62 patients equally assigned to receive either a knee brace (n=31) or skeletal traction (n=31). Outcomes included pain scores during traction application and maintenance, fracture shortening post-traction, operative duration, intraoperative blood loss, complication rates, and preoperative patient satisfaction.

Results: Mean pain scores during traction application were significantly lower in knee brace group (8.19 ± 0.99) than in the skeletal traction group (10.00 ± 0.00; p<0.05). During maintenance, the scores were 3.96 ± 0.72 and 4.64 ± 0.48, respectively (p<0.05). Post-traction femoral shortening was comparable between groups (1.66 ± 0.38 cm vs. 1.54 ± 0.39 cm; p=0.1326). Complication rates were 12.9% and 16.13% in knee brace and skeletal traction groups, respectively (p=0.7184). Patient satisfaction was significantly higher in the knee brace group (7.90 ± 0.91 vs. 6.93 ± 0.76; p<0.05).

Conclusions: Compared to skeletal traction, knee brace traction significantly reduced preoperative pain and improved patient satisfaction while achieving similar mechanical outcomes and complication rates. It may serve as a safe and non-invasive alternative for preoperative management of femoral shaft fractures.

Predictive Factors for Hamstring Graft Diameter in Anterior Cruciate Ligament Reconstruction

2025-11-04T20:26:54+07:00

Purpose: Hamstring graft diameter is a critical factor in anterior cruciate ligament reconstruction (ACLR), with grafts ≥ 8 mm associated with high failure rates. The accurate prediction of graft size before surgery is particularly important in populations with smaller body frames, such as Asian populations. We aimed to identify the anthropometric and magnetic resonance imaging (MRI) -based predictors of hamstring graft diameters ≥ 8 mm in patients undergoing ACLR.

Methods: A retrospective cohort study was conducted in 210 patients (169 men, 41 women) who underwent single-bundle ACLR with quadrupled hamstring autografts at Maharat Nakhon Ratchasima Hospital between 2017 and 2023. Anthropometric data were collected; preoperative MRI measurements of the semitendinosus and gracilis tendons were performed. Graft diameters were recorded intraoperatively following the MRI assessment. All measurements were performed by a single observer. Logistic regression was used to identify predictive factors; a receiver operating characteristic curve was used to evaluate the diagnostic accuracy of the model.

Results: Among the 210 patients, 51 (24.3%) had graft diameters < 8 mm. Those with grafts ≥ 8 mm were predominantly men and had greater height, weight, and MRI-derived tendon dimensions. Multivariate analysis identified the semitendinosus tendon cross-sectional area (CSA-ST) as the sole independent predictor. A CSA-ST ≥ 13.4 mm² predicted graft diameters ≥ 8 mm with 70.4% sensitivity (95% CI, 62.7–77.4%), 80.4% specificity (95% CI, 66.9–90.2%), a positive predictive value of 91.8% (95% CI, 85.4–96.0%), a positive likelihood ratio of 3.6 (95% CI, 2.1–6.3), and an area under the receiver operating characteristic curve of 0.79 (95% CI, 0.69–0.82).

Conclusions: The CSA ST measured on preoperative MRI is a reliable predictor of hamstring graft adequacy in ACLR. A threshold of 13.4 mm² can assist in surgical planning and graft selection, particularly in patients with smaller body sizes. These findings underscore the importance of incorporating MRI-based assessments into routine preoperative evaluations.

Rates, Predictors of Blood Transfusion, And Changes of Hematocrit Level in Geriatric Hip Fractures

2025-11-13T21:08:56+07:00

Purpose: This study aimed to determine the prevalence and risk factors associated with blood transfusion in elderly patients with hip fractures, along with changes in hematocrit level during the first three days of hospitalization, to create more appropriate preoperative assessment guidelines.

Methods: Patients with intertrochanteric, femoral neck, and subtrochanteric fractures who underwent surgical treatment from May 1, 2021–April 30, 2023, were included. Multivariate analysis was used to identify predictors of blood transfusion. Changes in hematocrit level during the first three days of hospitalization were also calculated.

Results: Blood transfusion rate among elderly patients with hip fractures who underwent surgery was 43.12%. Multivariable analysis identified three significant risk factors for transfusion: age over 75 years (odds ratio [OR] 2.61 [1.38-4.91], p=0.003), intertrochanteric fractures (OR 2.97 [1.10-7.96], p=0.031), and initial hematocrit <30.0% (OR 55.61 [16.26-190.15], p<0.001). Patients with an initial hematocrit level ≥36.0% had a transfusion rate of 16.10%, while those with a level above 43.2% did not require transfusion. The mean hematocrit level decrease was 1.73±0.46% in extracapsular fractures and 0.74±2.65% in intracapsular fractures.

Conclusions: Elderly patients with hip fracture with an initial hematocrit level of <36% should be considered for serial preoperative blood testing and intraoperative blood reservation. For those with a hematocrit level 36.0–43% may not require preoperative blood testing and reservation, based on the physician’s discretion, and levels >43% generally do not necessitate preoperative blood testing or reservation.

Outcomes of Calcaneal Fracture Fixation in a One-Day Surgery Setting

2025-12-19T19:39:37+07:00

Purpose: This study aimed to evaluate the feasibility and outcomes of minimally invasive calcaneal fracture fixation with screws in a one-day surgery setting. This study investigated whether this technique achieves satisfactory clinical, radiographic, and patient-reported outcomes without increasing the incidence of postoperative complications.

Methods: A retrospective review was conducted of 23 consecutive patients with Sanders type II tongue-type intra-articular calcaneal fractures treated with minimally invasive screw fixation in a one-day surgery setting between January 2010 and February 2024. All procedures were performed by one surgeon under regional anesthesia. Standardized perioperative management included a popliteal sciatic nerve block, multimodal oral analgesia, and structured follow-ups. The outcomes assessed were operative time, postoperative pain (visual analog scale [VAS]]), Böhler angle, perioperative complications, and patient satisfaction.

Results: The patients’ mean age was 44.9 ± 10.6 years, with a mean injury-to-surgery interval of 9.2 ± 4.6 days. Sixteen patients underwent fixation via the sinus tarsi approach and seven via a percutaneous approach. Immediate postoperative pain was minimal (VAS; 0.4 ± 1.2), increasing to a mean of 3.2 ± 2.4 at 24 h; one patient (4.3%) experienced severe pain, managed with oral analgesics. The mean Böhler’s angle increased from 3.6 ± 11.4° preoperatively to 25.2 ± 6.3° postoperatively. No hospital readmissions, wound complications, sural nerve injuries, or losses of reduction were observed. Patient satisfaction was high (mean; 4.8 ± 0.4/5). At four weeks, radiographs showed progressive fracture healing with initiation of weightbearing, and by 12 weeks, all cases demonstrated union without implant failure, infection, or delayed union.

Conclusions: Calcaneal fracture fixation with screws through the sinus tarsi approach can be effectively performed in a one-day surgery setting, resulting in favorable outcomes.

The Mechanical Lateral Distal Femoral Angle in Thai Patients With Varus Knee Osteoarthritis

2025-12-19T19:39:35+07:00

Purpose: Varus deformity is commonly observed in knee osteoarthritis (OA) and involves medial compartment degeneration, bone morphologic changes, soft tissue balance, and may complicate mechanical alignment during total knee arthroplasty (TKA), especially involving conventional alignment techniques. We evaluated the distribution of mechanical lateral distal femoral angle (mLDFA) and its association with coronal alignment parameters in Thai patients with varus knee OA to improve preoperative planning.

Methods: Patients with varus knee OA who underwent preoperative orthoroentgenographic imaging between 2020 and 2023 were retrospectively stratified into three mLDFA-based groups (<90° [A], 90° [B], >90° [C]) to compare differences in hip-knee-ankle angle (HKAA), joint line convergence angle (JLCA), and mechanically aligned-anatomical angle (MA-AA).

Results: mLDFA prevalence was determined in 444 patients (Group-wise: A=56.3%; B=28.7%; C=14.9%). Group A had smaller MA-AA values (5.38° ± 1.44°) compared with Group C (6.74° ± 1.69°, p < 0.001). Increased mLDFA values were associated with reduced HKAA values, while mLDFA values positively correlated with those of MA-AA. The mean JLCA value was significantly higher in patients with HKAA <170° compared with those with HKAA ≥170° (7.14° vs. 3.83°, p < 0.001). A JLCA value ≥10° was more prevalent in patients with HKAA <170° (18.2%) than in those with HKAA >170° (0.35%).

Conclusion: Increased mLDFA and MA-AA values were associated with more severe varus deformity (showed reduced HKAA values), indicating a need to individualize distal femoral valgus correction during TKA for patients with severe varus deformity. Preoperative mLDFA assessment may optimize alignment and surgical outcomes.

Association of Vitamin D Levels and Pediatric Long Bone Fractures in Vajira Hospital: A Case-Control Study

2025-12-20T20:31:43+07:00

Purpose: Vitamin D is essential for bone metabolism. The incidence of pediatric fractures in Thailand is increasing. Although vitamin D deficiency is associated with fracture risk in adults, its association with fracture risk in children remains unclear. This study aimed to compare the mean 25-hydroxyvitamin D [25(OH)D] levels in pediatric patients with and without fractures and to evaluate calcium, phosphate, and parathyroid hormone levels.

Methods: This case-control study included 60 pediatric patients with long bone fractures and 60 patients without fractures in the control group, matched for age, sex, underlying disease, sun exposure, and milk consumption. Patients with fractures were recruited from Vajira Hospital, whereas controls were obtained from a prior database. Patients with high-energy trauma or chronic conditions affecting 25(OH)D levels were excluded. Blood levels of 25(OH)D, calcium, phosphate, and parathyroid hormone were compared between the groups.

Results: Mean 25(OH)D levels were not significantly different between the fracture (23.3 ± 7.0 ng/mL) and nonfracture groups (21.2 ± 6.1 ng/mL) (p = 0.08). Calcium levels were slightly higher in the fracture group (9.6 ± 0.5 mg/dL) than in the nonfracture group (9.4 ± 0.4 mg/dL) (p = 0.04). Phosphate and parathyroid hormone levels were not significantly different between groups.

Conclusions: No significant differences in 25(OH)D levels were observed between children with and without fractures, suggesting that other factors may contribute to fracture risk. Although calcium levels were slightly higher in the fracture group than in the nonfracture group, the difference was not clinically significant.

Functional Outcomes of Cruciate-Retaining and Posterior-Stabilized Total Knee Arthroplasty: A Randomized Trial Using the Two-Minute Walk and Timed Up and Go Tests

2025-12-26T18:10:35+07:00

Purpose: To compare early postoperative functional recovery in patients undergoing total knee arthroplasty (TKA) using cruciate-retaining (CR) and posterior-stabilized (PS) implant designs, as measured by the Two-Minute Walk Test (2MWT) and Timed Up and Go (TUG) test.

Methods: This prospective, double-blind, randomized controlled trial included 80 patients with primary knee osteoarthritis (OA) who underwent unilateral TKA. The patients were randomized to receive either a CR or PS implant from the same manufacturer. All surgeries were performed by a single surgeon using a standardized technique. Functional outcomes were assessed preoperatively and at 2, 6, and 12 weeks postoperatively using the 2MWT and TUG tests. Statistical comparisons between the groups were performed using t-tests and repeated-measures ANOVA.

Results: Both groups showed progressive improvement over time. At 12 weeks, the mean increase in 2MWT distance was 32.75 ± 24.55 m for PS and 27.91 ± 15.45 m for CR (p = 0.296). TUG test times also improved, with a decrease of −7.53 ± 7.18 s in the PS group and −8.94 ± 8.45 s in the CR group (p = 0.425). No statistically significant differences were observed between groups at any time point. Both groups exceeded the minimal clinically important difference for the 2MWT.

Conclusions: Both the CR and PS implant designs demonstrated comparable early postoperative functional outcomes, as assessed by the 2MWT and TUG tests, without statistically significant differences. While the PS group achieved greater improvements in walking distance, the CR group exhibited superior mobility. These findings indicate that implant design does not substantially affect early functional outcomes following TKA.

Effectiveness of Early Spinal Fixation for Thoracolumbar Spine Fractures: A Quasi-Experimental Study

2026-01-01T10:35:34+07:00

Purpose: We aimed to evaluate the effectiveness of early spinal fixation for thoracic and lumbar spine fractures.

Methods: We employed a quasi-experimental design with prospective treatment and retrospective control groups (n=37 each). The treatment group received early spinal fixation within 72 hours according to the Royal College of Orthopedic Surgeons of Thailand guidelines, while the control group underwent late fixation after 72 hours. Data from patient medical records were analyzed using statistical tests. Statistical significance was set at p < 0.05.

Results: We observed that the treatment group had a significantly lower morphine consumption compared with the control group within the first 24 hours postoperatively (mean difference 5.8, 95% Confidence Interval [CI] 2.4 to 9.3 and overall mean difference 2.8, 95%CI 0.2 to 5.6), and significantly higher scores in activities of daily living (ADL) at 1 week (mean difference 3.1, 95%CI 0.6 to 5.6) and 8 weeks (mean difference 4.0, 95%CI 1.1 to 6.8) postoperatively, with an overall mean difference of 3.5 (95%CI 0.7 to 6.3), indicating a faster functional recovery. Pain scores and the hospital length of stay did not differ significantly between the groups. The general medical expenses (mean difference 17,982, 95%CI 3,670 to 32,295) and total medical expenses (mean difference 20,174, 95%CI 2,415 to 37,933) were significantly higher in the treatment group, whereas implant costs did not differ significantly.

Conclusions: Early spinal fixation surgery is effective in improving functional recovery for thoracic and lumbar spine fractures. Proper resource planning and further evaluation of cost-effectiveness are recommended.