A contrivance of tick removal to prevent skin damage: Injection into the tick before removal.

Ticks adhere to the host skin outdoors. Methods for tick removal without causing skin damage are controversial, and surgical excision along with the skin is mainly performed. A 6-week-old infant who lived indoors with a family cat contracted a tick bite. Tick killing before removal by injection of carbocaine into the tick led to successful removal without damaging the skin. This method can be useful for preventing damage to the skin during tick removal. A pet that roams outdoors can be a transmitter of ticks. We should be aware that this risk of tick bites can be hidden indoors.

Comparing the usefulness of a fluoroscopic navigation system in femoral trochanteric fracture for orthopaedic residents with the conventional method.

INTRODUCTION: Lag screw insertion into the ideal position is essential to obtain good results in open reduction and internal fixation for femoral trochanteric fracture. Tip-apex distance (TAD) is a widely adopted method for evaluating the risk of lag screw cut-out. Adaptive positioning technology (ADAPT) is a fluoroscopic computer-assisted surgery system that enables orthopaedic surgeons to guide the screw into a proper position intraoperatively. A randomized control study concluded that ADAPT resulted in excellent TAD. However, it was not significantly better than conventional methods when performed by fellowship-trained traumatologists. Therefore, we hypothesised that ADAPT would be useful to orthopaedic residents and evaluated this usefulness. METHODS: We reviewed 102 patients who underwent open reduction and internal fixation for femoral trochanteric fracture from May 2017 to March 2019 using Gamma-3 intertrochanteric nails. Two residents performed all procedures; 51 patients underwent surgery using ADAPT and the others underwent surgery without navigation. The number of attempts to drill guide-wire, operation time, lag screw insertion time, radiation exposure time, TAD, and lag screw position were evaluated for each surgeon. RESULTS: In one resident, when using the ADAPT system, the number of attempts to drill guide-wire (p=0.001), lag screw insertion time (p=0.000), radiational exposure time (p=0.009) and TAD (p=0.007) were lower, and the percentage of ideal lag screw position (p=0.035) were better than that in the conventional method. However, there was no significant difference in the performance of another resident with respect to the aforementioned factors, whether using ADAPT or not. CONCLUSION: One resident showed better results with the ADAPT system than with conventional osteosynthesis. However, another resident received no benefit from ADAPT. The efficiency may not apply to everyone as individual competence can influence efficiency when using ADAPT system. Therefore, as a new device, it must be used cautiously because skill or experience may influence its use, especially by orthopaedic residents.

Metronidazole-induced encephalopathy in a patient with pyogenic spondylitis: a case report.

BACKGROUND: Metronidazole is an antimicrobial agent commonly used in the treatment of several protozoal and anaerobic infections. Neurotoxicity associated with metronidazole has been rarely reported, and the incidence of metronidazole-induced encephalopathy is unknown. Therefore, the accurate diagnosis of metronidazole-induced encephalopathy is often difficult because of the rarity of the disease. CASE PRESENTATION: An 86-year-old woman suffered from pyogenic spondylitis of the lumbar spine. Parvimonas micra, a gram-positive anaerobic bacterial species and a resident of the flora of the oral cavity, was identified in the biopsy specimens. Oral administration of metronidazole (1500 mg/day) was initiated. Forty-four days after initiating metronidazole (total intake of 66 g), she complained of tingling sensations in the upper limbs. After 4 days, she complained of additional symptoms including sensory disturbance of the tongue, dysarthria, and deglutition disorder. Characteristic brain magnetic resonance imaging findings on T2-weighted fluid-attenuated inversion recovery and diffusion-weighted imaging led to the diagnosis of metronidazole-induced encephalopathy. Metronidazole was discontinued, and her neurological symptoms improved 10 days after discontinuation. At 14 days after discontinuation of oral metronidazole, abnormal findings on diffusion-weighted imaging almost disappeared. CONCLUSIONS: With the possibility of needing to prescribe metronidazole in the orthopedic field for the treatment of various infections, orthopedic surgeons are likely to encounter cases of metronidazole-induced encephalopathy. Thus, they should be able to recognize the condition and its potential complications. With increased awareness, early diagnosis with magnetic resonance imaging and discontinuation of metronidazole may become feasible when such patients are referred. Our report presents a detailed account of such a case, which may help in the early diagnosis and treatment of patients with metronidazole-induced encephalopathy. Furthermore, we recommend that patients treated with metronidazole should undergo careful and constant surveillance after starting antibiotic therapy.

Recurrent dislocations of the atlantooccipital and atlantoaxial joints in a halo vest fixator are resolved by backrest elevation in an elevation angle-dependent manner.

BACKGROUND CONTEXT: Halo fixation is now universally performed in the initial reduction and fixation of unstable upper cervical spine injuries; however, persistent high instability and recurrent dislocations of the atlantooccipital and atlantoaxial joints after fixation are not well recognized. PURPOSE: The aim was to describe persistent instability of traumatic dislocations of the atlantooccipital and atlantoaxial joints after halo fixation and a useful method for preventing instability. STUDY DESIGN: This was a case report of a patient who survived traumatic dislocations of the atlantooccipital and atlantoaxial joints. PATIENT SAMPLE: A 73-year-old woman diagnosed with dislocations of the atlantooccipital and atlantoaxial joints along with multiple other injuries sustained in a traffic accident was included. METHODS: After initial closed reduction and halo fixation, congruity of the atlantooccipital and atlantoaxial joints was evaluated using, condylar gap, atlantodental interval, and flexion angulation of C1-C2 after the initial examination and before surgery. RESULTS: Changes in parameters 12 hours after halo fixation revealed re-dislocations and instability of the joints. Backrest elevation with halo fixation tended to reduce re-dislocations. Therefore, we carefully increased the backrest angle and measured the parameters at several angles of elevation within a range that did not affect vital signs to observe the effectiveness of elevation against re-dislocations. Elevation changed the parameters in an elevation angle-dependent manner, and these changes suggested that elevation was effective for reducing re-dislocation of both the atlantooccipital and atlantoaxial joints during halo fixation. With no major complications, this method enabled us to maintain good congruity of the joints for approximately 2 weeks until posterior spinal fusion with internal fixation. CONCLUSIONS: Backrest elevation with halo fixation appears safe to be performed without any other devices and is beneficial for blocking re-dislocation of both the atlantooccipital and atlantoaxial joints as well as possible secondary damage to the upper cervical spinal cord during the external fixation period.