Delayed debridement affects prognosis in patients with purulent flexor tenosynovitis: a retrospective cohort and multivariate analyses

INTRODUCTION

Purulent flexor tenosynovitis (PFT) is a severe condition, and many patients report serious postoperative complications such as amputation, limited range of motion (ROM), or recurrence of symptoms. However, the ideal protocol for PFT treatment remains unknown owing to the limited number of studies. This retrospective cohort study aimed to identify prognostic factors for PFT treatment outcomes.

MATERIALS AND METHODS

Sixty-six patients (46 men and 20 women) with PFT who underwent surgical debridement at our hospital between September 2005 and January 2023 were included in this study. We conducted multivariate linear regression analysis with permanent deficit as the primary outcome. We defined the number of operations, laboratory data, interval from onset to debridement, previous conservative treatment, aetiology, Kanavel's signs, and medical history of diabetes mellitus as possible prognostic factors. We also defined the interval from onset to debridement as a secondary outcome and performed logistic regression analysis.

RESULTS

Overall, 25 (38%) patients had postoperative deficits. Longer interval from onset to surgery (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.0-1.1) and polymicrobial infection (OR: 7.8, 95% CI: 1.56-38.8) were significant prognostic factors for unfavourable outcomes. Additional multivariate analysis showed that preoperative conservative treatment prolonged the interval to surgery (estimate, 16.4; standard error, 1.6; p < 0.05).

CONCLUSIONS

The results of this study suggest that indications for nonoperative treatment of PFT are limited and that earlier surgical debridement is recommended.

Comparative Study for Postoperative Initial Fixation Patterns of Two Different Types of Cementless Short Stem Using Three-Dimensional Templating Software

Background

While cementless short stems have become popular in total hip arthroplasty (THA), Metha is a relatively recent development that differs from other short stems in its initial fixation concept of partial collum-sparing metaphyseal anchorage. The purpose of this study was to quantify the contact state between Metha and the femur. Additionally, we investigated the difference in contact points between Meta and Fitmore, which is one of the more popular curved short stems.

Methods

We conducted a retrospective review of 42 hips that underwent THA using Metha and 41 hips using Fitmore. Stem-to-femur contact was evaluated by density mapping using a three-dimensional digital template system to quantify the contact condition according to the modified Gruen zone. The criterion for the stem-to-bone contact boundary was defined as a computed tomography value of 543 Hounsfield.

Results

Quantitative evaluation of Metha according to the modified Gruen zones showed the ratio of surface area with high cortical contact in each zone. The results were 4.6% ± 5.7% in zone 1, 0.9% ± 2.3% in zone 2, 19.1% ± 12.9% in zone 3, 1.4% ± 3.2% in zone 5, 29.6% ± 16.4% in zone 6, and 25.1% ± 17.7% in zones 7. Evaluation of Fitmore for the same zones was as follows: 1.6% ± 2.4%, 18.5% ± 16.9%, 20.8% ± 17.4%, 12.7% ± 12.8%, 3.7% ± 5.8%, and 13.3% ± 10.3%. Comparing the two groups, the contact area was significantly greater for Metha in zones 1, 6 and 7 and Fitmore in zones 2 and 5 (p < 0.05).

Conclusions

It is possible for Metha to achieve metaphyseal anchoring by contacting the cortical bone at the proximal femur, thus avoiding proximal offloading. To the best of our knowledge, no previous studies have quantitatively reported stem-to-cortical bone contact conditions in curved short stems.

Vascularised versus non-vascularised bone graft for scaphoid nonunion: Meta-analysis of randomised controlled trials and comparative studies

Background

Numerous studies have investigated surgical techniques for vascularised bone graft (VBG) for scaphoid nonunion; however, their efficacies remain unclear. Thus, to estimate the union rate of VBG for scaphoid nonunion, we performed a meta-analysis of randomised controlled trials (RCTs) and comparative studies.

Methods

A systematic search was conducted using PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials. The search formula was as follows: ((scaphoid nonunion) OR (scaphoid pseudarthrosis)) AND (bone graft). Only RCTs were used in the primary analysis, and comparative studies, including RCTs, in the secondary analysis. The primary outcome was nonunion rate. We compared the outcome between VBG and non-vascularised bone graft (NVBG), pedicled VBG and NVBG, and free VBG and NVBG.

Results

This study included a total of 4 RCTs (263 patients) and 12 observational studies (1411 patients). In the meta-analyses of both RCTs only and RCTs and other comparative studies, no significant difference in nonunion rate was found between VBG and NVBG (summary odds ratio [OR], 0.54; 95% confidence interval [CI], 0.19-1.52 and summary OR, 0.71; 95% CI, 0.45-1.12), respectively. The nonunion rates of pedicled VBG, free VBG, and NVBG were 15.0%, 10.2%, and 17.8%, respectively, and no significant difference was found.

Conclusions

Our results indicated that the postoperative union rate in NVBG is similar to that in VBG; thus, NVBG could be the first choice of treatment for scaphoid nonunion.

Long term results of the Bicontact D stem in dysplastic osteoarthritis: a 10-15 year follow-up study

PURPOSE

The purpose of the present study was to investigate the results of total hip arthroplasty (THA) using the Bicontact D stem with a minimum 10 year follow-up that focused on patients with developmental dysplasia of the hip (DDH).

METHODS

One hundred five patients with osteoarthritis due to DDH who underwent primary THA were included in this study. The mean final follow-up period was 12.7 ± 1.2 years (range 10-15 years). All cases were evaluated both clinically and radiographically, and Kaplan-Meier survivorship was determined as stem revision for any reason as the end point.

RESULTS

Modified Harris hip score averaged 89.0 ± 1.1 (range 60-98) at the final follow-up. The survivorship was 99.0% (95% confidence interval 93.4-99.9%) at 15.0 years, and only one hip with a well-fixed stem required stem revision due to recurrent dislocations. Cortical hypertrophy (CH) was observed in 40 of 105 hips (38.1%), and stress shielding (SS) progressed to grade 3 or 4 in six hips (6 of 105 hips: 5.7%) during the study period. Among the six hips with progressed SS, Dorr type C proximal femoral geometry was seen in five hips.

CONCLUSION

This study of 105 THAs using the Bicontact D stem that focused on DDH patients with a minimum 10 year follow-up period achieved satisfactory clinical and radiological outcomes. Dorr type C proximal femoral geometry could be considered a risk factor for progressed SS.

Factors Affecting Delay in Initial Treatment of Patients with Soft Tissue Sarcomas

Background: Soft tissue sarcomas (STS) are rare, and little is known about the factors that affect the delays in the initial treatment. The aim of this study is to quantify the period between onset of symptoms and start of treatment of STS and determine the factors affecting delays in initial treatment. Methods: This is a retrospective study of all STS treated in our institution between October 2009 and March 2019. We analysed patient record to determine the period from onset of symptoms to start of initial treatment. We also collected data with regard to patient characteristics and features of the tumour. Tumours were classified into upper extremity, lower extremity, trunk and others based on location of the tumour. Statistical tests were done to identify factors that affected delay in initial treatment. Results: The study included 134 patients (76 male and 58 female) with STS with an average age of 56.6 years. The tumours involved the upper extremity in 20 patients, lower extremity and trunk in 50 patients each and other areas in 14 patients. The most frequent histological subtypes were liposarcomas (n = 31, 23.5%) and undifferentiated pleomorphic sarcomas (n = 24, 18.2%). Initial treatment was delayed by an average of 9.9 months for all groups. The period of treatment delay for tumours involving the upper extremity was shorter (7.9 months) and these tumours were smaller at initial presentation (57.6 mm) compared to tumours in other locations (p < 0.05). Other factors that were positively associated with treatment delays were a history of diabetes mellitus (p = 0.037) and smoking (p = 0.026). Conclusion: Patients with upper-extremity STS may have the benefit of a relatively better prognosis as they present earlier and with a smaller tumour. In addition, factors, such as diabetes and smoking, which indicate a low interest in health also influenced the delay in the initial treatment. Level of Evidence: Level III (Therapeutic).

Outcomes of "Cross-Coupling Suture Button Suspensionplasty" for Thumb Carpometacarpal Joint Osteoarthritis: A Preliminary Report

Thumb carpometacarpal joint osteoarthritis is a common condition that is treated nonsurgically. When conservative treatments fail, surgery is considered. Recently, suture button suspensionplasty has attracted attention and yielded good clinical results. We have developed a novel suture button suspensionplasty procedure called "cross-coupling suture button suspensionplasty" (CC-SBS) using a pair of suture button devices after a complete trapeziectomy. This retrospective study aimed to report the short-term clinical results of patients who underwent CC-SBS at our institution. We evaluated 10 hands of 10 patients (9 women and 1 man; average age, 67 years) who were refractory to conservative treatment and underwent CC-SBS at our institution between 2015 and 2017. We evaluated the preoperative Eaton stage and postoperative trapezial space height immediately after surgery and at the final visit; measured the trapezial space height, range of motion of the palmar and radial abduction of the carpometacarpal joint at the final visit; measured the preoperative and postoperative pinch strength; and recorded postoperative complications. The mean trapezial space height was 6.5 mm, and the mean radial and palmar abductions were 47° and 45°, respectively, at the final visit. The average pinch strength improved to 3.8 kg at the final visit compared to that pre-operation. In one case, a second metacarpal fracture occurred 2 weeks post-surgery, but no other complications were reported. Conclusion: CC-SBS showed short-term clinical outcomes similar to those of ligament reconstruction and tendon interposition and demonstrated faster overall recovery. Our procedure does not need a donor tendon for suspension and is technically simple and less invasive than ligament reconstruction tendon interposition. Thus, stronger initial fixation is obtained by using two suture button devices, and rehabilitation can be started from an early stage. We believe that this procedure is a good surgical option for carpometacarpal joint osteoarthritis.

Prognostic factors for outcomes of surgical mobilisation in patients with posttraumatic limited range of motion of the proximal interphalangeal joint: a multivariate analysis

This study aimed to identify the prognostic factors for outcomes of surgical mobilisation in patients with posttraumatic limited range of motion (ROM) of the proximal interphalangeal (PIP) joint and determine which procedure actually improves the PIP joint ROM. A total of 71 fingers (57 patients: 49 men, 8 women; mean age, 41 years) with posttraumatic limited passive ROM of the PIP joint (<60°) who underwent surgical mobilisation were reviewed. Possible prognostic factors, including age, injury type, injured finger, injury in the adjacent finger, and procedure types, were assessed. We defined the PIP joint ROM improvement as the primary outcome in the linear regression analysis. To evaluate surgical efficacy, we classified the surgical treatment options into four categories (volar release, dorsal release, volar and dorsal release, and joint distraction with an external fixator) and compared their outcomes. The mean postoperative improvement in the PIP joint ROM was 12°. In the linear regression analysis, advanced age (estimate, -0.41; 95% confidence interval [CI], -0.76 to -0.06), open injury (estimate, -13.54; 95% CI -27.02 to -0.06), and skin defects (estimate, -23.22; 95% CI -34.83 to -11.61) were associated with worse outcomes; however, the volar approach was associated with favourable outcomes. Surgical mobilisation is strongly recommended when limited ROM of the PIP joint is caused by flexion site contracture. To improve the final outcome of fingers with complex injuries, a tailored treatment strategy is required to avoid dorsal release.

Current practice patterns of osteoporosis treatment in cancer patients and effects of therapeutic interventions in a tertiary center

Cancer and osteoporosis have high incidence rates in older populations. However, the treatment of osteoporosis among cancer patients has not been adequately described. Our purpose was to clarify the current practice patterns of osteoporosis treatment among cancer patients in an academic cancer center, and to analyze the efficacy of treatment interventions. Patient records from April 2009 to March 2018 were retrospectively reviewed, and the study included a total of 316 cancer patients with osteoporosis. After patients’ data extraction, the patients were divided into two groups, with (n = 144) or without treatment (n = 172), and compared the outcomes of these groups to evaluate the medication effect. The primary outcome was new radiographic fragility fractures during the study period. The related factors associated with fracture injuries and the rate of adverse events, such as osteonecrosis in the jaw and atypical femoral fractures, were analyzed. The rate of treatment intervention was 45.6% among the patient groups. Among patients in the study group, breast cancer patients (n = 107) were mostly treated (n = 79, 73.8%) with oral bisphosphonate. A significant difference in new fracture rate was observed between the two groups (treatment group, 30.6%; non-treatment group, 54.7%), and the risk of fracture was 42% lower in the treatment group (hazard ratio, 0.58; 95% confidence interval, 0.39–0.86; p<0.05). Previous chemotherapy, steroid use, and older age were significantly associated with increased rate of new fragility fractures. The adverse event rate was 3.5% (presented in five cases). Older cancer patients who receive chemotherapy or steroids are strongly recommended undergo bone quality assessment and appropriate osteoporosis treatment to improve their prognosis.

Factors Affecting the Range of Motion of the Elbow after Open Reduction of Olecranon Fractures

Background: Although postoperative outcomes of olecranon fractures are relatively favorable, postoperative stiffness of the elbow joint occurs occasionally. We aimed to identify negative prognostic factors for unfavorable outcomes following olecranon fractures. Methods: We retrospectively reviewed the records of 100 patients with olecranon fractures and collected data on the conducted procedures, age, fracture condition, postoperative reduced position, and postoperative active range of motion (AROM) of the elbow joint. The primary outcome was the regaining of an AROM of > 130° flexion and < -30° extension of the elbow joint at the final follow-up. We performed multivariate logistic regression analysis to identify the negative prognostic factors. Results: The mean follow-up period was 11 months. All patients regained an average AROM of 121 degrees. Eighty-one patients regained a favorable AROM of the elbow joint. On univariate logistic regression analysis, diabetes mellitus (OR, 8.2; 95%CI, 1.6-41.7), comminution of the fractured site (OR, 23.1; 95% CI, 13.2-165.0), and utilization of the tension band wiring (TBW) technique (OR, 7.5; 95% CI, 1.16-48.2) were significant factors in aggravating the final result of elbow AROM. On multivariate analysis, patients with diabetes mellitus (OR, 10.9; 95% CI, 2.83-41.9), comminuted fractures (OR, 11.4; 95% CI, 2.61-50.2), or undergoing the tension band wiring technique (TBW) (OR, 5.5; 95% CI, 1.35-50.2) showed reduced postoperative AROM of the elbow joint; postoperative malreduction of the articular surface was not a negative prognostic factor. Seven of 51 patients treated with TBW underwent revision surgery because of non-union or postoperative displacement. Conclusions: TBW for olecranon fractures is a simple and cost-effective procedure; however, negative effects could develop when regaining sufficient postoperative AROM of the elbow joint. Therefore, rigid fixation without reoperation may lead to a favorable outcome. Postoperative malreduction does not always worsen the postoperative AROM of the elbow joint, at least not in the early postoperative period.

Programmed cell death 1 positive lymphocytes at palate tonsils in the elder patients with chronic tonsillitis

Circulating lymphocytes infiltrate into local foci at the inflammatory phase of acute wound healing for activation of the immune system and express an immune checkpoint protein programmed cell death 1 (PD-1) at the resolution phase for inactivation of the immune system. Conversely, the PD-1 expression was still found even on circulating lymphocytes of the elder patients with chronic tonsillitis at the palliative stage. Recently, an adhesion G protein coupled receptor 56 (GPR56) was reported to at least work as a proliferation factor for infiltrated lymphocytes into local foci at the resolution phase of acute wound healing. To preliminary examine a similar role of PD-1 and GPR56 at local foci at chronic inflammation, palate tonsils were prepared from small amounts of patients with chronic tonsillitis and tonsillar hypertrophy. A positive relationship of RNA expression might be observed between PD-1 and GPR56 in the elder patients with chronic tonsillitis. In regard to immunohistopathological findings, there were huge and small amounts of PD-1 and GPR56 expression at the marginal zone of lymphoid follicles of palate tonsils with chronic tonsillitis. Moreover, the positive relationship of RNA expression between PD-1 and GPR56 confirmed in large numbers of the elder patients with chronic tonsillitis. Probably, GPR56 participates in a supplement of PD-1⁺ lymphocytes to circulating bloods of the elder patients with chronic tonsillitis through a lymphocyte cell maintenance system at the marginal zone of the lymphoid follicles of palate tonsils.

Radiological Evaluation of the Relationship Between Cortical Hypertrophy and Stress Shielding After Total Hip Arthroplasty Using a Cementless Stem

Background

Unloading of the proximal medial femoral cortex is usually associated with an increased bone strain at the distal part of the prosthesis, which may cause distal femoral cortical hypertrophy (CH). The objective of this study was to determine the factors that may be considered a predisposition to distal femoral CH and its effect on the stress shielding (SS) or durability of the fixation of the stem.

Methods

A total of 240 total hip arthroplasties were performed between January 2006 and December 2016, with all hips implanted with a Bicontact stem. The minimum follow-up period was more than 2 years, and the mean follow-up period was 7.2 years. The radiographic outcome was assessed on an anteroposterior hip radiograph. CH and SS were assessed on postoperative radiographs in the Gruen zone. We defined CH that appeared in zone 3 or 5 as ‘the focal type’ and defined CH that appeared in zones 2, 3, 4, 5, and 6 as ‘the diffuse type.’ SS followed the procedures from the Engh classification.

Results

CH was found in 72 hips (30% of the 240 hips), the focal type was found in 23 hips (9.6% of the 240 hips), and the diffuse type was found in 49 hips (20.4% of the 240 hips). SS was found in 41 hips (17.1% of 240 hips), including 32 hips with SS, which was found after the development of CH. One hip was from the focal-type CH and 31 hips were from the diffuse-type CH. SS, which is typically found in Engh classification types 1 and 2 developed in 13 hips, and SS, which is widely seen in Engh classification types 3 and 4 developed in 19 hips. All 19 hips with progressed SS were found after the diffuse-type CH had developed. In addition, among the 19 hips with progressed SS, Dorr type A was found in 0 hips, Dorr type B in 8 hips, and Dorr type C in 11 hips.

Conclusions

According to the results of our radiological evaluation, development of the diffuse-type CH after total hip arthroplasty using Bicontact stems is one of the critical causes of the later development of SS and could be predicted to progress to SS. To prevent the development of the diffuse-type CH, the indication to choose a Bicontact stem for a Dorr type C with osteoporotic bone should be considered.

New combined anteversion technique in hybrid THA: cup-first procedure with CT-based navigation

PURPOSE

Combined anteversion (CA) technique (stem-first procedure) is generally accepted as the optimal technique to attain an appropriate CA value in total hip arthroplasty (THA). However, cup anteversion is strongly influenced by the native femoral anteversion. Accordingly, anterior protrusion of the cup in the acetabulum might occur. The purpose of the present study is to investigate the achievement of the optimal CA while avoiding anterior cup protrusion and examine the significance of our new CA technique with cup-first procedure in hybrid THA.

METHODS

Seventy-nine hybrid THAs with the cup-first procedure used a CT-based navigation system for cup positioning. In the preoperative planning, cup anteversion was aimed at approximately 20°. However, in actuality, sufficient cup coverage in the original acetabulum based on individual anatomy is given priority over cup placement based on CT-based planning to ensure adequate cup coverage. The target stem anteversion was determined following Widmer's mathematical formula (37.3 = femoral stem anteversion × 0.7 + cup anteversion). Cemented stem was inserted according to the target stem anteversion angle.

RESULTS

Regarding the assessment of overall alignment, the calculated Widmer's CA values during surgery and postoperative CT evaluation were 34.1° ± 6.0° (range 20.7°-51.2°) and 35.1° ± 6.7° (range 21.6°-50.7°). There were 72 hips (91.1%) within 25°-50° of CA. Cup protrusion length averaged 2.0 mm ± 2.6 mm (0-8.8 mm) in the axial view and 0.4 mm ± 1.0 mm (0-3.6 mm) in the sagittal view. Cup protrusion length of more than 5 mm was indicated in 10 hips, and no hips observed more than 10 mm.

CONCLUSION

Our new CA technique (cup-first procedure) with hybrid THA was able to achieve optimal CA value while avoiding anterior cup protrusion.

P1227Remnant lipoprotein is a residual risk of future cardiovascular events in patients with stable coronary artery disease and on statin LDL-cholesterol levels less than 70 mg/dl

Background

Recent guidelines recommend a target of low density lipoprotein cholesterol (LDL-C) <70 mg/dL in patients at very high risk of cardiovascular disease (CVD). However, a considerable residual risk of CVD persists despite achievement of the LDL-C goal on statin treatment.

Purpose

This study examined the predictive value of remnant lipoprotein levels for cardiovascular events (CVE) in patients with stable coronary artery disease (CAD) and LDL-C levels <70 mg/dL on statin treatment.

Methods

Serum levels of remnant lipoproteins (remnant-like lipoprotein particles cholesterol; RLP-C) were measured by an immunoseparation method in 247 consecutive patients with CAD who had on-statin LDL-C levels <70 mg/dL. All the patients were followed prospectively for a period of ≤60 months or until the occurrence of the primary composite endpoint of cardiac death, nonfatal myocardial infarction, unstable angina requiring coronary revascularization, worsening heart failure, peripheral artery diseases requiring endovascular or surgical intervention, aortic events, and ischemic stroke.

Results

During a mean follow-up period of 38 months, 33 CVEs occurred. Kaplan-Meier estimates in time-to-first-event analysis demonstrated that higher RLP-C levels (>3.9 mg/dL, determined by ROC-curve) resulted in a significantly higher probability for the primary endpoint than did lower RLP-C levels (<3.9 mg/dL) (p<0.01 by log-rank test). Stepwise multivariate Cox proportional hazard analysis showed that RLP-C was a significant predictor of the primary endpoint after adjustment for known risk factors and lipid variables including triglycerides (TG), and total apolipoprotein B (ApoB) (HR 1.62, 95% CI 1.26–2.07, p<0.01). The c-statistics showed that addition of RLP-C had a significant incremental effect on the predictive value of traditional risk factors (area under curve; traditional risk factors: 0.68 vs. traditional risk factors + RLP-C: 0.77, p=0.02). Category-free NRI and IDI demonstrated the additive value of RLP-C to the traditional risk factors plus non-high-density lipoprotein (HDL)-C and ApoB levels (NRI 0.52, p<0.01; IDI 0.06, p<0.01).

Conclusions

RLP-C levels are a residual risk factor for future CVEs in patients with CAD and on-statin LDL-C <70 mg/dL.

Acetabular reconstruction for primary and revision total hip arthroplasty using Kerboull-type acetabular reinforcement devices-case-control study with factors related to poor outcomes of surgery

Kerboull-type acetabular support rings (KT) and allogenic bone graft were used for severe periacetabular bone loss with primary and revision total hip arthroplasty (THA). The purpose of this case-control study is to evaluate the risk factors related to poor outcomes of surgery.Sixty patients underwent primary THA and revision THA using allogenic bone graft with KT for large acetabular deficiency. These patients were retrospectively evaluated postoperatively and followed-up by radiograph. The minimum follow-up period was 4 years and averaged 7 years. A radiological failure was defined by the following criteria:Expected risk factors were defined as female, age >75 years, body mass index (BMI) >25%, medical history of hypertension, renal failure, liver steatosis, diabetes, hyperlipidemia, cardiac infarction, smoking, American Academy of Orthopedic Surgery (AAOS) classification III or IV, bleeding>500 mL, time of surgery >3hours, high hip center-type KT, inclination of KT >45 degrees, screw angle >25 degrees, morselized bone graft, Kawanabe's classification stage 3 or 4 and revision surgery. Nineteen hips (31.6%) revealed radiological failure according to our criteria, and revision THA was performed in 2 hips (3.3%). In the statistical analysis, morselized bone graft and high hip center-type KT were identified as factors of poor outcomes of surgery.

Epigenetic modulators hydralazine and sodium valproate act synergistically in VEGI-mediated anti-angiogenesis and VEGF interference in human osteosarcoma and vascular endothelial cells

Vascular endothelial growth inhibitor (VEGI; also referred to as TNFSF15 or TL1A) is involved in the modulation of vascular homeostasis. VEGI is known to operate via two receptors: Death receptor‑3 (DR3) and decoy receptor‑3 (DcR3). DR3, which is thus far the only known functional receptor for VEGI, contains a death domain and induces cell apoptosis. DcR3 is secreted as a soluble protein and antagonizes VEGI/DR3 interaction. Overexpression of DcR3 and downregulation of VEGI have been detected in a number of cancers. The aim of the present study was to investigate the effects of sodium valproate (VPA), a histone deacetylase inhibitor, in combination with hydralazine hydrochloride (Hy), a DNA methylation inhibitor, on the expression of VEGI and its related receptors in human osteosarcoma (OS) cell lines and human microvascular endothelial (HMVE) cells. Combination treatment with Hy and VPA synergistically induced the expression of VEGI and DR3 in both OS and HMVE cells, without inducing DcR3 secretion. In addition, it was observed that the combination of VPA and Hy significantly enhanced the inhibitory effect on vascular tube formation by VEGI/DR3 autocrine and paracrine pathways. Furthermore, the VEGI/VEGF‑A immune complex was pulled down by immunoprecipitation. Taken together, these findings suggest that DNA methyltransferase and histone deacetylase inhibitors not only have the potential to induce the re‑expression of tumor suppressor genes in cancer cells, but also exert anti‑angiogenic effects, via enhancement of the VEGI/DR3 pathway and VEGI/VEGF‑A interference.

Citation Analysis of Articles about Hand Surgery Published in Orthopaedic and Hand Surgery Journals

BACKGROUND

To date, little is known about the characteristics of highly cited studies in hand surgery compared with other orthopaedic subspecialties. We aimed to assess the position of hand surgery within the orthopedic surgery literature.

METHODS

We conducted a bibliographic analysis using the Web of Science database to review 1,568 articles published between January 2012 and December 2012 in 4 relevant general orthopedic and 2 hand surgery journals. We used the number of citations within 3 years of publication to measure the impact of each paper. To analyze prognostic factors using logistic regression analysis, we extracted data on orthopedic subspecialty, published journal, location of authorship, and type of study for all articles. For clinical studies, we also recorded details on study design and sample size.

RESULTS

Of eligible hand surgery articles (n = 307), the majority (62%) were case reports/series. Only 19% were comparative studies, comprising a significantly smaller proportion of comparative studies from other subspecialties in general orthopedic journals. Systematic reviews/meta-analyses generated a significantly higher number of average citations, whereas educational reviews were consistently cited less frequently than other study types (14.9 and 6.1 average citations, respectively). Being published in the Journal of Bone and Joint Surgery, American volume, having authorship in North America or Europe and Australia, focusing on subspecialties like hip & knee, sports, or shoulder, utilizing a comparative or randomized clinical trial study design, and having a larger sample size increased the odds of receiving more citations.

CONCLUSIONS

Clinical studies related to hand surgery published in general orthopedic journals are most often of lower quality study design. Having a larger sample size or using a comparative study or randomized clinical trial design can improve the quality of study and may ultimately increase the impact factor of hand surgery journals.

Comparison of G-guide and Image-free Navigation System in Accuracy of Stem Anteversion Assessment During Total Hip Arthroplasty

Introduction:

We have developed and utilized the Gravity-guide (G-guide) as a simple manual instrument for intraoperative assessment and adjustment of stem anteversion (AV). Since 2013, we simultaneously measured stem AV using the G-guide and image-free navigation during THA procedure. The purpose of this study was to compare the measurement accuracy of the G-guide and navigation system using the postoperative CT results as a reference.

Methods:

In total, 59 hips in 56 patients who underwent primary THA using both the G-guide and image-free navigation system were included in the study. All patients underwent postoperative CT examination, and the femoral stem AV was assessed using a 3D image analysis system (Zed hip, LEXI, Japan). The AV angle derived from the postoperative CT image analysis was used as the reference value to assess the accuracy of the two intraoperative measurement systems.

Results:

The discrepancy between the G-guide and the postoperative CT-measured values averaged 5.0° ± 3.9°, while the corresponding value for the navigation system was 5.2° ± 4.1°. Acceptable accuracy with a measurement error of less than 10° was achieved in 86% and 90% of the cases for the G-guide and navigation measurements respectively.

Conclusion:

Consequently, it was shown that both navigation and G-guide measurements can achieve comparative accuracy and are clinically useful.

Utility of early active motion for flexor tendon repair with concomitant injuries: A multivariate analysis

INTRODUCTION

Flexor tendon injury often occurs with concomitant injuries such as fracture, vascular injury, and extensor tendon injury. These injuries are repaired independently, without a comprehensive strategy. We aimed to identify the effect of concomitant injuries and treatment choice on the outcome of flexor tendon repair.

PATIENTS AND METHODS

We evaluated 118 fingers of 102 adult patients with zone 1-3 flexor digitorum profundus (FDP) tendon injuries who underwent primary surgery at our hospital between April 2009 and December 2017. The 2-strand pull-out, 4-strand Tsuge, 6-strand Lim & Tsai, and 8-strand cross-locked cruciate suturing techniques were used. We performed multivariate analyses, with the active range of motion (AROM) of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints as dependent variables, and age, existence of concomitant injuries, and their treatment as independent variables.

RESULTS

The average AROM of the PIP + DIP joints was 130° at the last follow-up, and 'excellent' or 'good' function was obtained in 74 (63%) of 118 fingers by using the Strickland criteria. Old age, concomitant diaphyseal fractures, and specific methods of osteosynthesis, such as pinning, flexor digitorum superficialis injury, and immobilisation for 3 weeks, significantly worsened the results. However, wiring for osteosynthesis and early active motion protocol improved postoperative functional outcome. Although the outcome did not differ among the suture techniques, the 4-strand Tsuge procedure was performed for the two surgically confirmed ruptures of repair that occurred in our series.

DISCUSSION

We clarified the superiority of early mobilisation protocols with rigid osteosynthesis procedure, other than pinning. To minimise tendon adhesion or joint stiffness, surgeons should repair the tendon and fractured bone appropriately, to ensure early mobilisation without serious complications.

The threat of longitudinal cracking after distal radius fracture treatment with volar locking plate

The purpose of this study was to examine the occurrence rate of longitudinal cracks and associated characteristics following volar locking plate fixation of the distal radius. Using case records from Shizuoka Saiseikai General Hospital dated between March 2008 and March 2015, a total of 419 eligible adult patients were identified. Standard anteroposterior postoperative radiographs were evaluated to classify longitudinal crack occurrence. Documented variables were compared between patients with longitudinal cracking and those without. Univariate analyses were conducted among each plate group. There were 38 confirmed cases of cracking (Acu-Loc: n = 25, Acu- Loc 2: n = 11, VA-TCP: n = 2). All cracks healed within 4 to 6 weeks after the operation. Plate type, along with patient age and sex were significantly associated with the occurrence of a longitudinal crack (p < 0.05). Although no severe complications related to longitudinal cracking were observed, associated risks for specific patient groups should be considered.

Subtrochanteric femoral shortening osteotomy concomitantly performed with revision total hip arthroplasty: A case report

RATIONALE

Total hip arthroplasty (THA) concomitant with subtrochanteric femoral shortening osteotomy for Crowe type IV dysplastic hip has been reported. However, the combination of subtrochanteric femoral osteotomy and revision THA has only been mentioned in one case report.

PATIENT CONCERNS

A 67-year-old female had a history of congenital dislocation of both hips.

DIAGNOSES

Right hip was diagnosed the aseptic loosening of THA with extremely high replacement of the acetabular component.

INTERVENTIONS

Revision THA concomitant with subtrochanteric femoral shortening osteotomy using a cement stem was performed. Before the revision surgery, primary THA with subtrochanteric shortening osteotomy was performed on the opposite side. Regarding leg length, the actual leg length of the affected side was 9 mm longer, and the subjective leg length discrepancy was 45 mm shorter in the affected limb due to pelvic obliquity. Subtrochanteric osteotomy was performed with an amount of osteotomy equal to the amount of distal translation of the hip center to the original acetabulum.

OUTCOMES

As a result, pelvic obliquity improved, and the subjective leg length discrepancy disappeared after revision surgery.

LESSONS

The combination of subtrochanteric femoral shortening osteotomy with revision THA resulted in a satisfactory outcome.

Concomitant injuries affect prognosis in patients with central slip tear

Central slip tears often occur with concomitant hand injuries. However, the outcome of a central slip tear and the effect of concomitant injuries are rarely reported. We evaluated 67 fingers in 63 patients with central slip tears who underwent primary surgery in our hospital between April 2009 and June 2017. We performed multivariate analyses, with proximal interphalangeal (PIP) joint active range of motion (AROM) and existing extension lag greater than 10° as dependent variables and age, existence of concomitant fractures, skin defects, collateral ligament injuries, ruptured lateral bands, ruptured flexor tendons or vascular injury in the injured finger as independent variables. Concomitant injuries of tendons in the adjacent fingers were also independent variables. The average AROM of the PIP joint was 62°, and extension lag occurred in 34 fingers (51%). Patients aged > 40 years with fractures of the injured finger or flexor tendon injuries in an adjacent finger had low decreases in AROM (partial regression coefficient [95% confidence interval, CI]: -13.7 [43-66], -31.6 [30-57], -34.5 [32-60] and -33.5 [10-43]). Extensor tendon injuries in an adjacent finger caused significantly more extension lag in the PIP joint (odds ratio [95% CI]: 3.2 [1.0-9.6]). The present study indicated the negative impact of a tendon injury on adjacent fingers, a circumstance widely known as the quadriga phenomenon. Ultimately, we can use these prognostic factors in surgical repair planning, particularly when comparing treatments such as central slip reconstruction and primary arthrodesis.

Inhibition of Asparagine-linked Glycosylation Participates in Hypoxia-induced Down-regulation of Cell-surface MICA Expression

BACKGROUND/AIM

Hypoxia down-regulates the expression of cell surface major histocompatibility class I-related chain molecule A (MICA) without increasing its shedding. Recently, the inhibition of N-linked glycosylation was also shown to reduce the cell-surface expression of MICA. We investigated the participation of asparagine (Asn)-linked glycosylation in hypoxia-induced down-regulation of cell-surface MICA using osteosarcoma cells.

MATERIALS AND METHODS

The cell-surface expression and Asn-N-glycosylation of MICA were estimated by flow cytometry, and western blot analyses, respectively.

RESULTS

Hypoxia reduced the expression of N-linked glycosylated MICA, as well as the ratio of N-linked glycosylated to non-glycosylated MICA. 2-Deoxy-D-glucose, which inhibits N-linked glycosylation, reduced the cell-surface expression of MICA under normoxia, while D-Mannose increased N-glycosylated MICA, increasing cell-surface MICA under hypoxia. Cells transfected with wild-type MICA expression vector expressed cell surface MICA more than those transfected with mutant MICA expression vectors designed for abrogation of N-linked glycosylation.

CONCLUSION

The inhibition of Asn-N-linked glycosylation participates in hypoxia-induced down-regulation of cell-surface expression of MICA.

Accuracy of Component Orientation and Leg Length Adjustment in Total Hip Arthroplasty Using Image-free Navigation

Purpose:

The purpose of this study was to examine the accuracy of implant orientation and leg length in total hip arthroplasty (THA) with an image-free navigation system based on a comparison of the intraoperative navigation and postoperative CT evaluations.

Material and Methods:

A consecutive series of 111 patients (118 hips) who underwent THA using the current version of the image-free navigation system constituted the basic study population. Subsequently, a total of 101 patients (108 hips) meeting the inclusion and exclusion criteria were selected as study subjects for the analysis. THA was performed using an image-free navigation system that was capable of adjusting both the prosthetic position and leg length. Postoperative CT examination was performed for all study subjects, and the prosthetic position and leg length were measured on CT images using the image analysis software. Subsequently, the intraoperative navigation results and the corresponding values obtained from the postoperative CT measurements were compared to test the accuracy of the navigation system.

Results:

The average discrepancies between the intra- and postoperative assessments were 6.8°, 3.7°, and 5.7° for cup anteversion, cup inclination, and stem anteversion, respectively. The corresponding value in leg length averaged 4.1 mm.

Conclusion:

Average discrepancies between the intra- and postoperative measurements were less than 10° in all prosthetic alignment parameters and less than 5 mm in leg length. Intraoperative assessments with the use of the image-free navigation in THA could afford satisfactory result.

Ecological shifts due to anthropogenic activities in the coastal seas of the Seto Inland Sea, Japan, since the 20th century

Multiproxy analyses were conducted using sediment cores in a low-polluted coastal site (Hiuchi-nada) in the Seto Inland Sea (SIS), Japan. Heavy metal and organic pollution peaked in the 1960s and the bottom environments have ameliorated since the 1980s due to several environmental regulations. First ecological shifts in meiobenthic ostracodes and diatoms occurred in the 1960s due to the initiation of eutrophication. Then, a second ecological shift occurred in the 1980s due to the amelioration of the water and the bottom quality. A compilation of similar analytical results in the coastal seas of the SIS reveals three types of ecological and environmental history since the 20th century. The environmental improvement since the 1980s affects the ecosystems, in particular, in a low-polluted bay. However, ecological compositions are different from those prior to the 1960s, suggesting that the ecosystem was not recovered but changed into the next stage in the SIS.

Significance of Sarcopenia Evaluation in Acute Decompensated Heart Failure

In patients with chronic heart failure (HF), the clinical importance of sarcopenia has been recognized in relation to disease severity, reduced exercise capacity, and adverse clinical outcome. Nevertheless, its impact on acute decompensated heart failure (ADHF) is still poorly understood. Dual-energy X-ray absorptiometry (DXA) is a technique for quantitatively analyzing muscle mass and the degree of sarcopenia. Fat-free mass index (FFMI) is a noninvasive and easily applicable marker of muscle mass.This was a prospective observational cohort study comprising 38 consecutive patients hospitalized for ADHF. Sarcopenia, derived from DXA, was defined as a skeletal muscle mass index (SMI) two standard deviations below the mean for healthy young subjects. FFMI (kg/m²) was calculated as 7.38 + 0.02908 × urinary creatinine (mg/day) divided by the square of height (m²).Sarcopenia was present in 52.6% of study patients. B-type natriuretic peptide (BNP) levels were significantly higher in ADHF patients with sarcopenia than in those without sarcopenia (1666 versus 429 pg/mL, P < 0.0001). Receiver operator curves were used to compare the predictive accuracy of SMI and FFMI for higher BNP levels. Areas under the curve for SMI and FFMI were 0.743 and 0.717, respectively. Multiple logistic regression analysis showed sarcopenia as a predictor of higher BNP level (OR = 18.4; 95% CI, 1.86-181.27; P = 0.013).Sarcopenia is associated with increased disease severity in ADHF. SMI based on DXA is potentially superior to FFMI in terms of predicting the degree of severity, but FFMI is also associated with ADHF severity.

Treatment strategy for amyloid hip arthropathy in long-term hemodialysis patients

BACKGROUND

The number of hemodialysis patients has been progressively increasing in our country. On the other hand, chronic hip arthropathy associated with long-term hemodialysis is a devastating problems affecting patients' quality of life. In our previous study, we proposed a classification system for radiological abnormalities seen in hemodialysis-related hip lesions. The purpose of the study was to propose the surgical strategy for hip disorders caused by long-term hemodialysis.

METHODS

Patients with a history of hemodialysis for more than 10 years, 191 hip lesions in 165 consecutive patients who visited our institute due to hip symptoms. Various abnormalities were identified in 116 out of 191 hips. A retrospective assessment of the patient record and radiographs was performed for the included subjects examining the natural course of the disease process as well as the results of surgical treatment.

RESULTS

Seventy-six hip lesions (69.0%) were conservatively managed at the time of the initial visit. Surgeries were performed for 75 hips (64.7%) during the study period. Among those, surgical treatment was indicated for 40 hips at the time of the initial visit. On the other hand, surgeries were performed for 35 hips during the subsequent follow-up period due to progression of the disease process.

CONCLUSIONS

Based on the analysis of our surgical experiences by the retrospective chart review, we have established a flowchart of the treatment strategy for chronic hip arthropathy in long-term hemodialysis patients.

STUDY DESIGN

This study is retrospective clinical study.

Comparison of Continuous Femoral Nerve Block with and Without Combined Sciatic Nerve Block after Total Hip Arthroplasty: A Prospective Randomized Study

In association with the growing interests in pain management, several modalities to control postoperative pain have been proposed and examined for the efficacy in the recent studies. Various modes of peripheral nerve block have been proposed and the effectiveness and safety have been examined for each of those techniques. We have described our clinical experiences, showing that continuous femoral nerve block could provide a satisfactory analgesic effect after total hip arthroplasty (THA) procedure. In this study, we compared the effectiveness and safety of continuous femoral nerve block with and without sciatic nerve blockade on pain control after THA. Forty patients scheduled for THA were included in the study and randomly divided into 2 groups. Postoperative analgesic measure was continuous femoral nerve block alone, while the identical regimen of continuous femoral nerve block was combined with sciatic nerve block. The amount of postoperative pain was evaluated in the immediate postoperative period, 6 hours, and 12 hours after surgery. Moreover, postoperative complications as well as requirement of supplemental analgesics during the initial 12 hours after surgery were reviewed in the patient record. The obtained study results showed that the supplemental sciatic nerve blockade provided no significant effect on arrival at the postoperative recovery room, while the NRS pain score was significantly reduced by the combined application of sciatic nerve blockade at 6 and 12 hours after surgery. In the investigation of postoperative analgesiarelated complications, no major complication was encountered without significant difference in complication rate between the groups.

Relationship Between Glucose Fluctuations and ST-Segment Resolution in Patients With ST-Elevation Acute Myocardial Infarction

This study was conducted to assess whether any relationships exist between glucose fluctuations and electrocardiographic surrogate markers of reperfusion injury in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).We prospectively studied 63 consecutive patients with STEMI undergoing primary PCI. Patients had either diabetes (n = 30), impaired glucose tolerance (n = 26), impaired fasting glucose (n = 1), or normal glucose tolerance (n = 6). STsegment resolution (STR, %) was measured using electrocardiograms recorded 60 minutes after PCI. STR was categorized as ≥ 30% and < 30%. Glucose fluctuations were assessed by the following parameters obtained from a continuous glucose monitoring system: mean amplitude of glucose excursion (MAGE, mg/dL); and area under curve with reference to mean blood glucose (AUC_MBG, mg/ dL/day).Both MAGE and AUC_MBG were significantly higher in STR < 30%. In univariate analysis, MAGE ≥ 70 mg/dL (OR = 17.0; 95%CI, 1.93-150.12; P < 0.01), AUC_MBG ≥ 20 mg/dL/day (OR = 10.9; 95%CI, 1.92-61.77; P < 0.01), and reperfusion arrhythmias (OR = 7.6; 95%CI, 1.32-44.29; P < 0.05) were significantly associated with suboptimal STR. Multiple logistic regression analysis showed only MAGE ≥ 70 mg/dL was predictive of suboptimal STR (OR = 22.5; 95%CI, 2.43-208.66, P < 0.01).Parameters of glucose fluctuations correlated with electrocardiographic surrogate markers of impaired myocardial salvage in STEMI after reperfusion therapy. Our results suggest that glucose fluctuations may represent a potential therapeutic target to reduce myocardial reperfusion injury in STEMI.

Use of the G-guide for Measuring Stem Antetorsion During Total Hip Arthroplasty

Implant positioning is one of the critical factors influencing postoperative outcomes in total hip arthroplasty (THA). Several studies have reported that the postoperative antetorsion (AT) measurement for the femoral stem inserted without navigation showed wide variability. The current authors developed a simple instrument, the Gravity-guide (G-guide), for intraoperative assessment of stem AT and adjustment. They evaluated the effectiveness of the G-guide with postoperative computed tomography (CT) examination. Ninety patients (96 hips) who underwent primary THA using the G-guide for stem adjustment were evaluated. The G-guide consists of 2 parts: one attached to the lower leg and the other attached to the handle of the rasp. The G-guide was used to evaluate the AT at the time of inserting the final rasp. In addition, the AT value in the G-guide evaluation system required correction by the angle obtained in the preoperative epicondylar view. Intraoperative stem AT was defined as the sum of the intraoperative G-guide value and the correction angle. Postoperative AT was evaluated by CT examination. The discrepancy between the intra- and postoperative measurements was 4.6°±4.1°. Acceptable accuracy with discrepancy of less than 5° and 10° was achieved in 66 (69%) hips and 85 (89%) hips, respectively. The use of the G-guide could effectively reduce the variability of stem anteversion compared with manual adjustment. This study proved the effectiveness of the newly developed G-guide system in intraoperative stem AT adjustment.

Mid- to long-term outcomes after surgical treatment of chronic anterior dislocation of the radial head in children

BACKGROUND

To evaluate the mid- to long-term clinical and radiographic outcomes after surgical treatment of chronic anterior dislocation of the radial head in children.

METHODS

Open reduction was performed in 16 children (mean age, 9.3 years [range, 2.6-13.6 years]) with chronic anterior dislocation of the radial head. Twelve patients had a history of preceding injuries, with a mean interval between injury and surgery of 24 months (range, 2-86 months); 4 patients did not have injuries. Eight patients who had undergone reduction within 16 months were treated by open reduction and ulnar osteotomy. The other 8 patients who had not sustained trauma or had been injured >2 years previously required either annular ligament reconstruction or radial shortening in addition to ulnar osteotomy.

RESULTS

The average preoperative Kim's elbow performance score was 77.2 ± 10.5, which significantly improved to 97.5 ± 5.8 at the final follow-up. The radial head was maintained in a reduced position in 14 patients and was subluxed in 2. Slight osteoarthritic changes of the elbow were observed in 2 patients with good reduction. The functional results were excellent in 15 and were good in 1 patient with an average follow-up of 6.5 years (range, 2.6-15.1 years).

CONCLUSIONS

Our surgical procedure provided good mid- to long-term clinical and radiographic outcomes.

Morphological characteristics of olecranon fractures in adults : a Computed Tomography-based study

The aim of this study was to identify the fragment's shape by evaluating olecranon fractures. We examined the CT images of 48 olecranon fractures (28 women and 20 men). Mean age was 59.9 years. On the olecranon's posterior surface, we measured the distance between the apex of the olecranon fragment and the radial edge of the flat spot on the short axis and the width of the flat spot on the same short axis. The tip radial ratio (i.e., the tip radial edge to the flat spot width) was derived from these parameters. The mean tip radial edge was 1.96 mm, and the flat spot width was 12.64 mm ; therefore, the tip radial ratio was 0.15 mm. Radial inclination on the articular surface was 30.55°. Our findings confirmed our hypothesis that the fracture lines run from the proximal ulnar side to the distal radial side on the olecranon's posterior and articular surfaces.

Assessment of Accuracy and Reliability in Acetabular Cup Placement Using an iPhone/iPad System

Implant positioning is one of the critical factors that influences postoperative outcome of total hip arthroplasty (THA). Malpositioning of the implant may lead to an increased risk of postoperative complications such as prosthetic impingement, dislocation, restricted range of motion, polyethylene wear, and loosening. In 2012, the intraoperative use of smartphone technology in THA for improved accuracy of acetabular cup placement was reported. The purpose of this study was to examine the accuracy of an iPhone/iPad-guided technique in positioning the acetabular cup in THA compared with the reference values obtained from the image-free navigation system in a cadaveric experiment. Five hips of 5 embalmed whole-body cadavers were used in the study. Seven orthopedic surgeons (4 residents and 3 senior hip surgeons) participated in the study. All of the surgeons examined each of the 5 hips 3 times. The target angle was 38°/19° for operative inclination/anteversion angles, which corresponded to radiographic inclination/anteversion angles of 40°/15°. The simultaneous assessment using the navigation system showed mean±SD radiographic alignment angles of 39.4°±2.6° and 16.4°±2.6° for inclination and anteversion, respectively. Assessment of cup positioning based on Lewinnek's safe zone criteria showed all of the procedures (n=105) achieved acceptable alignment within the safe zone. A comparison of the performances by resident and senior hip surgeons showed no significant difference between the groups (P=.74 for inclination and P=.81 for anteversion). The iPhone/iPad technique examined in this study could achieve acceptable performance in determining cup alignment in THA regardless of the surgeon's expertise. [Orthopedics. 2016; 39(4):e621-e626.].

Histologic evaluation of the bone-ceramic interface of an alumina ceramic cup arthroplasty retrieved after 25 years in vivo

A 47-year-old man underwent ceramic cup arthroplasty when he was 22 years old. Revision total hip arthroplasty was performed 25 years later because of limited range of motion without implant loosening. Histologic examination revealed that the femoral head and ceramic implant were well fixed through a thin fibrous membrane. The energy-dispersive X-ray analysis indicated that calcium and phosphorus were detected in the same peak pattern as cancellous bone in the bone-ceramic interface.

Surgical Treatment of Synovial Osteochondromatosis of the Hip Using a Modified-Hardinge Approach with a Z-Shaped Capsular Incision

Synovial osteochondromatosis of the hip is a rare condition, and the surgical treatment approach for this condition requires complete removal of loose bodies combined with synovectomy. While these, procedures are generally accepted as the optimal treatment method, this is still controversial topic. Recent studies have reported that open surgical procedures remain acceptable for synovial osteochondromatosis of the hip. These procedures include the dislocation of the femoral head, and complications such as femoral head necrosis and bursitis or great trochanter non-union due to trochanteric osteotomy have been reported. The present study reports a modified technique for surgical dislocation through a Z-shaped capsular incision without trochanteric flip osteotomy for the treatment of synovial osteochondromatosis of the hip.

Significance of preoperative 3D-CT angiography for localization of the femoral artery in complicated THA

BACKGROUND

Major vascular injury is one of the most devastating complications in total hip arthroplasty (THA). Risk for intraoperative vascular injury is increased when the normal vascular anatomy is distorted by previous surgery or dislocation with displacement. Therefore, an appreciation of the vascular anatomy in relation to the anticipated surgical field is critical to avoid this complication during preoperative assessment for a complicated THA.

METHODS

Preoperative three-dimensional (3D) CT angiography was performed for 24 complicated THAs when altered vascular anatomy around the acetabulum was suspected. When assessing the CT images, the presence of apparent proliferation of vessels close to the original acetabulum as well as a distance of <10 mm from the artery to the acetabulum was deemed a potential risk factor for intraoperative vascular injury. Additionally, the relationships of clinical characteristics and the presence of these risk factors were analyzed to identify the patient population at risk.

RESULTS

The incidence of proliferation of collateral vessels was higher in patient groups with proximal femoral migration of 5 cm or more and multiple previous surgeries prior to the index THA. Moreover, in three ankylosed hips, lateral deviation of the main vascular trunk with an artery-acetabulum distance of <10 mm was identified in all cases.

CONCLUSION

Preoperative 3D-CT angiography in cases of complicated THA revealed altered vascular anatomy which may increase the risk for intraoperative vascular injuries. Patient characteristics related to the risk for this complication were marked proximal femoral migration, multiple previous surgeries, and hip ankylosis. Preoperative image examination of the vascular anatomy is thought to help reduce the risk of inadvertent vascular injury in these complicated THA cases.

Comparison of Continuous Femoral Nerve Block, Caudal Epidural Block, and Intravenous Patient-controlled Analgesia in Pain Control After Total Hip Arthroplasty: A Prospective Randomized Study

Thirty-six patients who underwent primary unilateral total hip arthroplasty (THA) were randomly allocated to 4 groups with different pain control protocols; continuous femoral nerve block (FNB group), single-shot caudal epidural block with morphine (EB group), intravenous patient-controlled analgesia with fentanyl (IV-PCA group), and systemic administration of nonsteroidal anti-inflammatory drugs (NSAIDs group). Postoperative pain was assessed using the numerical rating scale (NRS) scores and the analgesic effect was compared among the groups. The NRS upon arrival at the recovery room and 6 hours after surgery in the FNB, EB, and IV-PCA groups were significantly lower than that in the NSAIDs group. The amount of additional analgesics requested by the patient was smaller in the FNB, EB, and IV-PCA groups as compared to the NSAIDs group. Regarding the complications related to the analgesia, 5 of the 9 patients in the IV-PCA group complained nausea and vomiting and received antiemetic drugs. Delay in the rehabilitation process due to drowsiness was encountered in 3 patients in this group, while no patient in the FNB and EB groups suffered from delayed rehabilitation. Considering both the analgesic effect and the potential risk of complications, continuous femoral nerve blocks and caudal epidural blocks for are recommended for postoperative pain control after THA procedure.

Fascia iliaca compartment block: its efficacy in pain control for patients with proximal femoral fracture

BACKGROUND

Proximal femoral fractures are common in elderly patients. Recently, use of regional blockade has gained popularity as a means of relieving pain among this patient population. Among the procedures, fascia iliaca compartment block (FICB) is believed to be advantageous because of its safety and efficacy.

METHODS

In this study fifty-six consecutive patients who sustained a proximal femoral fracture were assigned to two groups. For 31 patients in group 1, FICB was used to control pre and postoperative pain. FICB was performed by an orthopaedic resident on arrival of the patient at the hospital and in the immediate postoperative period. Systemic administration of non-steroidal anti-inflammatory drugs (NSAIDs) alone was adopted for pain control for 25 patients in group 2. The severity of pain was assessed by use of a visual analog scale (VAS).

RESULTS

Neither blockade-associated complications nor analgesic failure were encountered among patients who underwent FICB (group 1). In this group of patients, the mean preoperative VAS scores before FICB and at 10 min and 12 h after the blockade were 91, 31, and 36 respectively, indicating significant pain reduction. The corresponding values for group 2 patients were 92, 92, and 81. In addition, postoperative pain was also successfully managed by FICB with mean VAS scores at immediate, 6-h and 12-h time points of 15, 22, and 31 respectively, whereas the corresponding values for the group 2 patients were 62, 49, and 59. Consequently, significant differences in VAS scores were demonstrated between the groups in both the pre and postoperative periods.

CONCLUSION

FICB is clinically safe and efficient, providing consistent analgesic effects irrespective of the performing doctor's experience of elderly patients with proximal femoral fracture.

Outcome of surgical reconstruction after traumatic total brachial plexus palsy

BACKGROUND

Double free muscle transfer for the treatment of traumatic total brachial plexus injury provides useful prehensile function. We studied the outcome of this muscle transfer procedure, including the changes in disability and quality-of-life scores.

METHODS

Thirty-six patients with traumatic total brachial plexus injury who underwent double free muscle transfer for reconstruction from 2002 to 2008 and had a minimum follow-up of twenty-four months after the second free muscle transfer were studied. All were evaluated preoperatively and postoperatively with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) questionnaires. A separate questionnaire was used to determine job status, pain, use of the reconstructed hand, and satisfaction with the procedure.

RESULTS

The mean patient age was twenty-nine years (range, sixteen to forty-nine years), and the mean duration of follow-up was thirty-six months (range, twenty-four to seventy-nine months). The mean active range of motion was 23° (range, 0° to 80°) for shoulder flexion, 31° (range, 0° to 90°) for shoulder abduction, -18° (range, -80° to 40°) for shoulder external rotation, 62° (range, 0° to 130°) for the shoulder rotation arc, 119° (range, 90° to 150°) for elbow flexion, and -33° (range, -60° to -20°) for elbow extension. The power of elbow flexion was M4 in twenty-five patients and M3 in eleven. Twenty-three patients had triceps nerve reconstruction; extension was M0 in two of these patients, M1 in seven, M2 in ten, and M3 in four. Total active motion of the fingers was 46° (range, 0° to 98°), with a mean hook grip strength of 4 kg (range, 0 to 12 kg). Wilcoxon tests revealed significant improvements in the DASH score and the SF-36 physical functioning, role physical, and physical component summary scores. The majority of patients worked but had changed their type of work, used the reconstructed hand in activities of daily living that required both hands, and were satisfied with the procedure.

CONCLUSIONS

Double free muscle transfer yielded satisfactory function and allowed use of the reconstructed hand in activities that required both hands. The improvement in the DASH score was greater than that in the SF-36 score.

Lipopolysaccharide of Aggregatibacter actinomycetemcomitans up-regulates inflammatory cytokines, prostaglandin E2 synthesis and osteoclast formation in interleukin-1 receptor antagonist-deficient mice

BACKGROUND AND OBJECTIVE

The interleukin (IL)-1 receptor antagonist (Ra) binds to IL-1 receptors and inhibits IL-1 activity. However, it is unclear whether the IL-1Ra plays a protective role in periodontal disease. The purpose of this study was to compare IL-1Ra knockout (KO) and wild-type (WT) mice in regard to proinflammatory cytokine production, osteoclast formation and bone resorption in response to periodontal bacterial lipopolysaccharide (LPS).

MATERIAL AND METHODS

Peritoneal macrophages (Mφs) were obtained from 13-wk-old IL-1Ra KO and WT mice. Peritoneal Mφs were cultured with or without 10 μg/mL of Aggregatibacter actinomycetemcomitans LPS for 24 h. The levels of IL-1alpha (IL-1α), IL-1beta (IL-1β), tumor necrosis factor-α (TNF-α) and IL-6 were measured in periotoneal Mφs supernatant fluid (PM-SF) using an ELISA. Bone marrow cells were obtained from the mice and stimulated with PM-SF for 9 d, then stained with TRAP. The frequency of TRAP-positive multinucleated giant cell formation was calculated based on a fusion index. PM-SF-stimulated calvarial bone resorption was analyzed using micro-computed tomography, and calvarial histological analysis was performed using hematoxylin and eosin and TRAP staining. The expression of cyclooxygenase-2 (Cox2), prostanoid receptor EP4 (Ep4) and Rank mRNAs in bone marrow cells were measured using real-time quantitative PCR, while prostaglandin E2 (PGE2 ) production was determined by ELISA.

RESULTS

The levels of IL-1α, IL-1β, TNF-α and IL-6 in IL-1Ra KO mice PM-SF stimulated with A. actinomycetemcomitans LPS were significantly increased by approximately 4- (p < 0.05), 5- (p < 0.05), 1.3- (p < 0.05) and 6- (p < 0.05) fold, respectively, compared with the levels in WT mice. Moreover, osteoclast formation, expression of Rank, Ep4 and Cox2 mRNAs and production of PGE2 were significantly increased by approximately 2- (p < 0.05), 1.6- (p < 0.05), 2.5- (p < 0.05), 1.6- (p < 0.05) and 1.9- (p < 0.05) fold, respectively, in IL-1Ra KO mice stimulated with A. actinomycetemcomitans LPS compared with WT mice.

CONCLUSION

IL-1Ra regulates IL-1 activity and appears to reduce the levels of other inflammatory cytokines, including TNF-α and IL-6, while it also reduces expression of the EP4 receptor related to prostanoid sensitivity and osteoclast formation. These results suggest that IL-1Ra is an important molecule for inhibition of inflammatory periodontal bone resorption.

Assessment of acetabulum anteversion aligned with the transverse acetabulum ligament: cadaveric study using image-free navigation system

The transverse acetabulum ligament (TAL) has been used as an intraoperative anatomical landmark to position the acetabulum cup in total hip arthroplasty (THA). However, the validity of the use of TAL has not been clarified. The purpose of this study was to examine the orientation of the cup component aligned with the TAL in cadaveric study. The 31 hips in 25 whole-body embalmed cadavers were examined. The donors were 12 men and 13 women. Simulated THA procedure using image-free navigation system was performed and a trial cup with a diameter of approximately 2 mm less than the size of the acetabulum were inserted and snugly fitted on the TAL through the posterior wall of acetabulum. The orientation of the cup component was measured using an image-free THA navigation system. The measured radiographic anteversion and inclination angles averaged 18.2±7.2° (range: 2.0-33.2°) and 43.5±4.2° (range: 33.1-51.0°) respectively. Based on the Lewinnek's safe zone criteria, 26 hips (80.6%) were judged to be within the. Moreover, in the analysis of the gender difference of TAL angles, the average anteversion angle was shown to be significant larger in female than male population. The TAL can be effectively used an intraoperative landmark to align the acetabulum component helping reduce the risk of dislocation after surgery. In the intraoperative judgment, a gender difference in the alignment of the TAL should be taken into consideration.

Combined anteversion of the total hip arthroplasty implanted with image-free cup navigation and without stem navigation

In total hip arthroplasty (THA), combined anteversion (CA), the sum of cup anteversion (AV) and stem antetorsion (AT) are used as parameters to assess the appropriateness of overall prosthetic alignment. In this study, we evaluated the CA value based on the post-operative computed tomography (CT) measurements in our patient population who underwent THA using the OrthoPilot™ image-free navigation system (B/BRAUN-Aesculap, Tuttlingen, Germany). During surgery, cup alignment was adjusted with the use of the navigation system while the positioning of the femoral stem was arbitrarily adjusted by the surgeon. Seventy-nine THAs were included in the study. Post-operative CT assessment for the prosthetic alignment showed the average cup inclination and AV values to be 40.5°±4.1° and 20.6°±4.6°, respectively, demonstrating the effectiveness of the navigation system by small values of standard deviation. By contrast, the AT value measured for the stem showed wide variability (mean 23.6°±11.2°). Consequently, the resulting CA was also inconsistent (mean 44.4°±11.2°) and only 61 of the 79 THAs (77.2%) were defined as satisfactory.

Simple clinical test to detect deltoid muscle dysfunction causing weakness of abduction--"akimbo" test

INTRODUCTION

Full range of motion and powerful shoulder abduction can be performed without any deltoid muscle function by the supplemental action of the supraspinatus and biceps brachii muscles. For evaluation of deltoid muscle function, we need to negate these actions, which can be done with the "akimbo test," in which patients place their hands on the iliac crest with abduction in the coronal plane and internal rotation of the shoulder joint while simultaneously flexing the elbow joint and pronating the forearm.

METHODS

We examined the akimbo test in five patients with incomplete upper-type brachial plexus injury, five patients with suprascapular nerve palsy, and six patients with axillary nerve palsy. Presence of some abduction is a prerequisite to perform this test.

RESULTS

No patient with incomplete upper-type brachial plexus injury could demonstrate this sign when the deltoid did not show a certain level of the power to abduct the shoulder joint. All patients with suprascapular nerve could demonstrate this sign as the deltoid was normal. No patient with axillary nerve paralysis could demonstrate this sign.

CONCLUSION

The akimbo test is a simple clinical test to determine deltoid muscle paralysis or dysfunction, especially when patients can demonstrate shoulder abduction due to supplementary action of other muscles.