Preoperative respiratory intervention eliminated the operation cancelations of lobectomy surgery.

In Nagasaki University Hospital, the patients undergoing surgery with abnormal respiratory function have been automatically referred to specialized clinic by Medical Support Center (MSC) since July 2016 to reduce surgery cancellations due to insufficient preoperative evaluation. Whether the MSC system decreased post-hospital surgery cancellation, variance rate, or length of hospital stays in patients received "lobectomy" were retrospectively compared between Period A (n = 264, before MSC introduction) and Period B (n = 264, after MSC introduction). Four patients' operations were cancelled after hospitalization in Period A, while 0 patients in Period B (p < 0.05). The length of hospital stay, operation time, anesthesia time, and postoperative extubation oxygen administration time were all shorten in Period B significantly. "Period B", "operation time", and "postoperation oxygenation time" were independent factors for "hospital days", but chronic obstructive pulmonary disease or age were not. The preoperative intervention eliminated the operation cancellation. Preoperative MSC interventions may have contributed to the reduction in hospital days even for the patients with pulmonary dysfunction.

Guideline-based Treatment of Glucocorticoid-induced Osteoporosis in Patients with Rheumatoid Arthritis: A Retrospective Study with the AORA Registry.

Glucocorticoid-induced osteoporosis (GIOP) is one of the side effects associated with glucocorticoid (GC) therapy. In 2014, the Japanese Society for Bone and Mineral Research (JSBMR) provided new guidelines for the management and treatment of GIOP. The aim of the present study was to clarify the prevalence of patients with rheumatoid arthritis (RA) requiring treatment according to the new guidelines and to identify risk factors associated with lack of treatment in these patients. Patients in the 2018 Akita Orthopedic group on Rheumatoid Arthritis (AORA) database were enrolled. Of 2,234 patients with RA in the database, 683 (30.6%) met the 2014 JSBMR guideline treatment criteria, and 480 (70.3%) had been treated. The untreated group included a larger number of males, younger patients, and patients treated in clinics rather than hospital (p<0.001, p=0.015, and p<0.001, respectively). Multivariate analyses found that male sex, younger age, and clinic-based RA care were significant risk factors associated with lack of treatment (p<0.001, p=0.013, and p<0.001, respectively). Thus, male sex, younger age, and clinic-based care were identified as risk factors.

Characteristic imaging findings of tendinosis of the direct head of rectus femoris and their interpretation.

BACKGROUND: Tendinosis at the origin of the direct head of rectus femoris causing anterior hip pain is termed AIISpinitis, but no study has investigated its imaging findings. The aim of the present study was to determine the characteristic imaging findings of AIISpinitis and clarify their pathological significance. METHODS: We reviewed the preoperative imaging findings of 62 hips in 58 patients who had undergone endoscopy with a diagnosis of AIISpinitis. The origin of the direct head of rectus femoris was evaluated by ultrasound (US) and magnetic resonance imaging (MRI), and the positive rate of abnormal findings and their agreement with endoscopy regarding injury of the direct head of rectus femoris were measured. Signal changes in the fat pad around the anterior inferior iliac spine (AIIS fat pad) in MRI were compared with the pathological findings of that harvested endoscopically. RESULTS: Hypoechoic regions in US (53/62, 85%) and signal change in MRI (55/62, 89%) were observed with high frequency and corresponded with injury of the direct head of rectus femoris observed by endoscopy (58/62, 94%) (kappa coefficient, 0.43 [moderate agreement], 0.69 [good agreement] respectively). Hypoechoic regions had high sensitivity (85%) and specificity (86%) for AIISpinitis. Regarding the AIIS fat pad, punctate and completely hypo-intense change relative to normal fat corresponded to fibrosis and scar formation, respectively (weighted kappa coefficient, 0.51 [moderate agreement]). CONCLUSIONS: Hypoechoic regions on US which had high sensitivity and specificity; and signal change at the origin of the direct head of rectus femoris and hypo-intensity of the AIIS fat pad on MRI were characteristic findings of tendinosis of the direct head of rectus femoris. These findings correspond pathologically to injury of the direct head of rectus femoris and fibrosis or scar formation in the AIIS fat pad, respectively.

Clearance of Aspergillus fumigatus is impaired in the airway in allergic inflammation.

BACKGROUND: Aspergillus fumigatus (Af) sometimes colonizes and persists within the respiratory tree in some patients with asthma. To date, the precise reasons why the clearance of Af is impaired in patients with asthma remain unknown. OBJECTIVE: To characterize the effects of allergic airway inflammation on clearance of Af. METHODS: Control and Dermatophagoides farinae (Df) allergen-sensitized BALB/c mice were intranasally infected with Af. After 2 and 9 days of infection, the pathology, fungal burden, and cytokine profile in lung tissue were compared. In a different set of experiments, the phagocytotic activity of alveolar macrophages and the expression of their pathogen recognition receptors also were determined. RESULTS: The Af conidia and neutrophilic airway inflammation disappeared by day 9 after infection in control mice. In Df-sensitized mice, Af conidia and neutrophilic and eosinophilic airway inflammation persisted at day 9 after infection. Compared with control mice, Df allergen-sensitized mice showed significant increases in interleukin (IL)-5 and decreases in IL-12 and interferon-γ in lung tissues at day 2 after infection. Most importantly, compared with Af-infected non-Df-sensitized mice, IL-17 in lung tissues was significantly decreased in Df allergen-sensitized Af-infected mice at day 2 after infection but was significantly increased at day 9. Alveolar macrophages isolated from Df allergen-sensitized mice exhibited significant decreases in phagocytotic activity and expression of Toll-like receptor-4 and dectin-1 compared with those from control mice. CONCLUSION: In the airway of patients with allergy, T-helper cell type 2-dominant immunity potentially affects the expression of pathogen recognition receptors and attenuates cellular defense against Af. Prolonged IL-17 production also could play an important role.

Cysteinyl leukotriene receptor antagonist regulates allergic airway inflammation in an organ- and cytokine-specific manner.

BACKGROUND: Cysteinyl leukotrienes (cys-LTs) are very important factors in the pathophysiology of bronchial asthma. Cys-LT receptor antagonists (LTRAs) decrease allergic airway inflammation. The aim of the present study was to determine the differential effects of LTRAs and corticosteroids on allergic airway inflammation and allergen-specific cytokine production from lymphoid tissues using a murine model of asthma. MATERIAL AND METHODS: Four groups of female BALB/c mice [control (Cont); Dermatophagoides farinae allergen-sensitized (AS); pranlukast (Prl), an LTRA-treated AS; and dexamethasone (Dex)-treated AS] were examined. Lung pathology and cytokine production by prepared mononuclear cells isolated from mediastinal lymph nodes (MLNs) and spleen were compared among these groups. RESULTS: AS mice exhibited allergic airway inflammation and significant increases in allergen-specific Th1 and Th2 cytokines in MLNs and spleen. Prl-treated mice showed significant attenuation of allergic airway inflammation concomitant with reduction of Th2 cytokines and IFN-g in MLNs but not in spleen. In contrast, Dex significantly decreased Th1 and Th2 cytokines in MLNs and also decreased them (except IL-13 and IL-2) in spleen. CONCLUSIONS: The inflammatory effects of cys-LTs could differ in lymphoid organs. LTRAs potentially regulate allergic airway inflammation in an organ- and cytokine-specific manner, while systemic corticosteroid shows nonspecific effects.

Pediatric femoral shaft fracture requiring revision surgery for nonunion associated with vitamin D and K deficiencies: a case report.

BACKGROUND: Nonunion of femoral shaft fractures in children is rare, and there is no clear treatment protocol. In this case report, a pediatric femoral shaft fracture that developed in nonunion due to vitamin deficiency after osteosynthesis, which was successfully treated with vitamin augmentation and replacement with a rigid antegrade intramedullary nail, is described. CASE PRESENTATION: The patient is an 11-year-old Japanese girl. She injured her right femoral shaft fracture when she hit a wall after kickboarding down a hill and underwent osteosynthesis with a titanium elastic nail. Six months postoperatively, she developed nonunion, was found to be deficient in vitamins D and K, and was started on vitamin supplementation. She underwent replacement with a rigid antegrade intramedullary nail at 7 months postoperatively, and bone union was achieved 3 months after reoperation. CONCLUSION: When delayed union of a fracture is observed postoperatively, even in children without underlying disease, the cause of the problem must be investigated and treated promptly.

Preventing Loss of Femoral Periprosthetic Bone Mineral Density in Cementless Total Hip Arthroplasty Using a Tapered Wedge Stem: A Retrospective, Cohort Study in Osteoporotic Patients Treated with Denosumab.

Purpose: Bone quality is an important issue in elderly osteoporotic patients who undergo total hip arthroplasty (THA) because periprosthetic fracture or aseptic loosening of implant caused by periprosthetic bone loss is a serious concern. Denosumab has been approved for osteoporosis patients. Thus, the purpose of this study was to investigate whether denosumab prevents loss of proximal femoral periprosthetic bone mineral density (BMD) in cementless THA using a tapered wedge stem in patients with osteoporosis. Methods: Seventy consecutive patients who had undergone primary THA were included in this study. Twenty-seven patients who received denosumab for osteoporosis formed the denosumab group, and 43 patients without denosumab formed the control group. Bone turnover markers and femoral periprosthetic BMD were measured at two weeks, six months, and 12 months after THA. BMD was evaluated in seven regions of interest according to the zones of Gruen. Results: BMD in zone 1 was significantly increased from baseline at both six and 12 months after THA in the denosumab group (10.0±10.2%, p<0.001 and 13.1±12.7%, p<0.001, respectively) and significantly decreased in the control group (-3.6±9.7%, p<0.05, and -5.9±9.4%, p<0.001, respectively). BMD in zone 7 was significantly decreased compared to baseline at both six and 12 months after THA in the control group (-19.2±20.2%, p<0.001 and -22.3±16.8%, p<0.001, respectively) but not in the denosumab group (-0.7±18.5% and -1.1±16.6%, respectively). The use of denosumab for THA patients with osteoporosis was independently related to preventing loss of periprosthetic BMD of the femur at 12 months after surgery in zones 1 (p<0.001) and 7 (p<0.001) on multivariate analysis. Conclusions: Denosumab significantly increased proximal femoral periprosthetic BMD in zone 1 and prevented loss of BMD in zone 7 in patients with osteoporosis after cementless THA using a tapered wedge stem at both seven and 12 months. Future studies of denosumab treatment following THA in patients with osteoporosis should focus on clinical outcomes such as the risk of periprosthetic fracture and revision THA.

Differential airway inflammatory responses in asthma exacerbations induced by respiratory syncytial virus and influenza virus a.

BACKGROUND: Although respiratory viral infections cause acute exacerbations of asthma, the inflammatory responses vary depending on the causative virus. The purpose of this study was to compare the inflammatory responses in the airways of acute exacerbations of asthma induced by respiratory syncytial virus (RSV) and influenza A virus. METHODS: Sputum induction was performed in asthmatic patients with acute exacerbations induced by RSV (n = 6), influenza A (n = 7), and non-upper respiratory infection (URI)-related factors (n = 8). Sputum concentrations of cysteinyl leukotrienes (cysLTs), TNF-α and IFN-γ were measured. RESULTS: Sputum cysLTs were significantly higher in RSV-induced exacerbations than in influenza A- and non-URI-induced exacerbations. Sputum TNF-α was significantly higher in influenza A-induced exacerbations than in RSV- and non-URI-induced exacerbations. Sputum IFN-γ was significantly lower in RSV-induced exacerbations than in the others. CONCLUSIONS: RSV and influenza A cause acute exacerbations and have different effects on airway inflammation in asthmatic patients. RSV significantly increased cysLTs, while influenza A significantly increased TNF-α in the airway. The underlying mechanism in virus-induced asthma might depend on the viral species.

Dissociation between sensitizing and colonizing fungi in patients with allergic bronchopulmonary aspergillosis.

BACKGROUND: Because allergic bronchopulmonary aspergillosis (ABPA) does not require the presence of Aspergillus fumigatus for diagnosis, serological and radiological findings without cultures usually confirm this condition. OBJECTIVE: To determine which fungi colonize the airways of patients with definitive ABPA. METHODS: We enrolled 11 patients (ages 57.5 ± 17.1 years; male: female, 4:7) with ABPA diagnosed by serological and radiological criteria. Fungi colonizing the airway were identified from mucous plugs that were naturally expectorated or obtained by fiberoptic bronchoscopy. RESULTS: Aspergillus spp. (n = 8) was the most frequently isolated, followed by Schizophyllum commune (n = 4), Candida albicans (n = 2), Rhizopus oryzae (n = 1), and Penicillium spp. (n = 1). Among the Aspergillus spp., A. niger, A. terreus, and A. sydowii were more frequently isolated (total, n = 6) than A. fumigatus (n = 2). Many patients were sensitized with several fungi in addition to Aspergillus, which were dissociated with airway-colonizing fungi. CONCLUSION: Multiple fungal species can colonize the airway, and dissociation between colonizing and sensitizing species frequently occurs in definitive ABPA. Considering the increased prevalence of azole-resistant Aspergillus spp., administering antifungal drugs that target A. fumigatus without identifying which fungal species colonize the airway might be problematic.

Differential effects of dexamethasone and itraconazole on Aspergillus fumigatus-exacerbated allergic airway inflammation in a murine model of mite-sensitized asthma.

BACKGROUND: Fungal exposure is associated with particularly severe asthma. Nevertheless, the effects of anti-fungal treatments on fungus-exacerbated asthma need to be determined. OBJECTIVES: The present study aimed to compare the effects of itraconazole (ITCZ) and dexamethasone (Dex) on Aspergillus fumigatus (Af)-exacerbated preexisting Dermatophagoides farinae (Df) allergen-sensitized allergic airway inflammation. METHODS: Four groups of BALB/c mice were prepared: control, Df-sensitized plus Af-infected mice (Df-Af), and Df-Af mice treated with Dex (Df-Af-Dex) or with ITCZ (Df-Af-ITCZ). Pulmonary pathology and cytokine profiles in the airway were evaluated. In a different set of experiments, the effects of Dex on alveolar macrophage (AM) phagocytosis of Af conidia were determined in Df-sensitized mice. RESULTS: Af infection significantly increased the level of eosinophils and neutrophils in the airway of Df-sensitized mice. While Dex significantly decreased eosinophils, ITCZ significantly decreased both eosinophils and neutrophils in Df-Af mice. Dex significantly decreased IL-5, whereas ITCZ significantly reduced MIP-2 in the airway. Compared to controls, AM isolated from Df-sensitized mice had significantly reduced phagocytotic activity of Af conidia. However, Dex significantly improved phagocytotic activity of AM in Df-sensitized mice. CONCLUSIONS: The present study showed that Dex and ITCZ differently regulated Af-exacerbated allergic airway inflammation; the former inhibits eosinophilic inflammation and the latter inhibits neutrophilic as well as eosinophilic inflammation by regulating different cytokines. Additionally, Dex enhanced the phagocytotic activity of AM in allergic asthma. Thus, a combination of Dex and ITCZ might be effective for the management of fungus-exacerbated asthma.

Characteristics and Treatment Strategies for Basicervical and Transcervical Shear Fractures of the Femoral Neck.

This study aimed to define basicervical and transcervical shear fractures using area classification and to determine the optimal osteosynthesis implants for them. The clinical outcomes of 1042 proximal femur fractures were investigated. A model of the proximal femur of a healthy adult was created from computed tomography images, and basicervical and transcervical shear fractures were established in the model. Osteosynthesis models were created using a short femoral nail with a single lag screw or two lag screws and a long femoral nail with a single lag screw or two lag screws. The minimum principal strains of the fracture surfaces were compared when the maximum loads during walking were applied to these models using finite element analysis software. Basicervical fractures accounted for 0.96% of all proximal femur fractures, 67% of which were treated with osteosynthesis; the failure rate was 0%. Transcervical shear fractures accounted for 9.6% of all proximal femur fractures, 24% of which were treated with osteosynthesis; the failure rate was 13%. Finite element analysis showed that transcervical shear fracture has high instability. To perform osteosynthesis, multiple screw insertions into the femoral head and careful postoperative management are required; joint replacement should be considered to achieve early mobility.

Effect of respiratory syncytial virus infection on plasmacytoid dendritic cell regulation of allergic airway inflammation.

BACKGROUND: Respiratory syncytial virus (RSV) can infect myeloid dendritic cells (mDCs) and regulate their function in the development of allergy. It has been widely reported that plasmacytoid DCs (pDCs) play a critical role in antiviral innate immunity. In contrast, not much is known about the role of pDCs in the interaction between allergy and viral infection. The purpose of the present study was to investigate the effect of RSV infection on pDC function in the regulation of allergic airway inflammation in a murine model of Dermatophagoides farinae-sensitized allergic asthma. METHODS: Splenic pDCs isolated from D. farinae-sensitized donor mice were infected with live RSV ex vivo. Subsequently, these pDCs were inoculated into the airways of D. farinae-sensitized recipient mice. Lung pathology, lung tissue cytokine profiles, the number of regulatory T cells (T(reg)) and mDCs as well as the effects of IL-10 neutralization in the lung tissue of recipient mice were determined. RESULTS: Intranasal inoculation of D. farinae-sensitized pDCs significantly inhibited the development of allergic airway inflammation and both Th1 and Th2 immunity. Live RSV infection of these pDCs prior to inoculation interfered with their inhibitory effects through decreasing T(reg) and IL-10 and increasing mDCs. CONCLUSIONS: In asthmatic airways, pDCs mediate tolerance to inhaled allergens through the regulation of T(reg), IL-10 and mDCs. RSV infection of pDCs potentially inhibits their immunotolerogenic effects and thus exacerbates allergic airway inflammation.

Effects of a short course of pranlukast combined with systemic corticosteroid on acute asthma exacerbation induced by upper respiratory tract infection.

BACKGROUND: Upper respiratory tract infections (URIs) represent the most frequent cause of acute asthma exacerbation. Systemic corticosteroid (CS) is presently recommended for URI-induced asthma exacerbation, although it might inhibit cellular immunity against respiratory virus infection. OBJECTIVES: To determine the effects of adding a short course (2 weeks) of a leukotriene receptor antagonist (LTRA) to systemic CS on URI-induced acute asthma exacerbation. METHODS: Twenty-three adult asthmatics (mean age, 42.8 ± 9.8 y; Male:Female, 10:13) with URI-induced acute asthma exacerbation confirmed by a questionnaire and physical findings were randomly assigned to receive either oral prednisolone (PSL) alone or oral PSL plus the LTRA pranlukast (PRL) for 2 weeks (PSL + PRL). The cumulative doses of PSL and the amount of time required to clear asthma-related symptoms were determined. Levels of respiratory syncytial virus (RSV) RNA and influenza viral (IV) antigen in nasopharyngeal swabs were also determined. RESULTS: Adding PRL significantly reduced the cumulative dose of PSL and tended to reduce the time required to clear asthma-related symptoms. Either RSV or IV was detected in about one-third of the patients. CONCLUSION: The combination of an LTRA and CS might be more useful than CS alone for treating URI-induced acute exacerbation of asthma and reducing the cumulative CS dose.

Acetaldehyde at a low concentration synergistically exacerbates allergic airway inflammation as an endocrine-disrupting chemical and as a volatile organic compound.

BACKGROUND: Acetaldehyde is an endocrine-disrupting chemical (EDC) and a volatile organic compound (VOC). It is also a carcinogen and teratogen that causes bronchoconstriction in a subset of asthmatics. However, the mechanism through which acetaldehyde acts as an EDC/VOC causing allergic airway inflammation remains unknown. OBJECTIVES: To determine the effects of a low concentration of acetaldehyde, which itself did not trigger airway inflammation, on extant allergic airway inflammation in a murine model of allergic asthma. METHODS: We compared airway hyperresponsiveness (AHR), lung pathology, serum IgE and airway concentrations of cytokines among four groups of BALB/c mice [control, Dermatophagoides farinae(Df) allergen-sensitized (AS), intranasally acetaldehyde-injected (ALD) and AS-ALD mice]. RESULTS: Physiological and histological differences were not evident between ALD and control mice. AS mice developed AHR and allergic airway inflammation characterized by goblet cell hyperplasia and eosinophilic infiltration. Both AHR and airway eosinophilia were significantly enhanced in AS-ALD compared with AS mice. Serum total and Df-specific IgE were significantly increased in both AS and AS-ALD mice compared with control and ALD mice, but comparable between AS and AS-ALD mice. Mite allergen sensitization significantly increased interleukin-5 and granulocyte macrophage colony-stimulating factor, and decreased interferon-γ levels in the airways; injecting acetaldehyde into airways with allergic inflammation significantly increased the levels of these inflammatory cytokines. CONCLUSIONS: Exposure to acetaldehyde can enhance allergic airway inflammation in asthma.

What is the most fixable intramedullary implant for basicervical fracture and transcervical shear fracture? - A finite element study.

Objective: The objectives of this study are 1) to biomechanically compare six different intramedullary fixations for basicervical fracture (AO 31-B3, Type 2 in area classification) and transcervical shear fracture (AO 31-B2.3, Type 1-2 in area classification) using the finite element (FE) method, and 2) to investigate the effects of two different unstable fracture types on fixation. Methods: FE models of two different types of proximal femoral fractures are constructed from CT scan images of a patient with osteoporosis. The fracture models are fixed with a short femoral nail with a single lag screw, short femoral nail with a single blade, and short femoral nail with double lag screws, and then fixed with long femoral nails for each of the three nail types. Subsequently, the maximum loads during walking and stair climbing, as well as the minimum principal strain and compressive failure elements are calculated to assess the fixation of each implant. Results: In both fracture types, the long nail with double lag screws show the smallest volume of compressive failure elements (basicervical fracture, 2 mm3; transcervical shear fracture, 217 mm3). In all types of implants, the volume of the compressive failure elements is larger in the transcervical shear fracture than in the basicervical fracture. A similar trend is observed for the minimum principal strain (compressive strain). Conclusion: The present study shows that a long nail with double lag screws is the most fixative intramedullary nail device for basicervical fracture and transcervical shear fracture in any condition. Furthermore, it is shown that transcervical shear fracture is considerably more unstable than basicervical fracture.

Redetermination of synthetic warwickite, Mg(3)TiO(2)(BO(3))(2).

Single crystals of warwickite, trimagnesium titanium(IV) dioxide bis-(borate), Mg(3)TiO(2)(BO(3))(2), were prepared by slow cooling of the melt. The title compound is isotypic with Co(3)TiO(2)(BO(3))(2). In contrast to the previous refinement of warwickite [Moore & Araki (1974 ▶). Am. Mineral.59, 985-1004], that reported only isotropic atomic displacement parameters for all atoms, anisotropic displacement parameters of all atoms were refined during the current redetermination. All atoms are situated on special positions (site symmetry .m.). One of the two Mg sites is statistically disordered with Ti atoms (ratio 1:1), while the other is fully occupied by Mg atoms. The occupancy ratio of the Mg and Ti atoms is similar to that reported in the previous study. Metal atoms (M) at the Ti/Mg and Mg sites are coordinated by six O atoms in form of distorted octa-hedra. Four edge-sharing MO(6) octa-hedra form M(4)O(18) units, which are connected by common corners into layers parallel to (010). Adjacent layers are linked along [010] into a framework structure by sharing common edges. The B atoms are located in the triangular prismatic tunnels of the framework.

[A trial of hierarchical cluster analysis of hospitalized wheezy infants and young children based on clinical factors].

BACKGROUND: It has been estimated that there are several phenotypes constituting wheezy infants, in addition to true asthma. OBJECTIVE: The aim of this study is categorized wheezy infants and young children by cluster analysis and to turn out of categorized frequency. SUBJECTS AND METHODS: The study included 53 subjects aged less than 2 years old who were admitted with wheezy exacerbation. Based on clinical factors, we classified these subjects into several clinical phenotypes using cluster analysis. RESULTS: The following four phenotypes were identified; cluster 1: almost all were exacerbated by RSV infection without previous wheezy episodes; cluster 2: almost all were younger, males, without previous wheezy episodes, sensitized to allergens and parental asthma, who tended to be exposed to passive smoke and have no siblings; cluster 3: almost all were slightly older males with recurrent wheezy episodes who tended to be sensitized to various allergens; cluster 4: almost all were younger females with exposure to passive-smoke, whose mother or father has a history of asthma. Cluster 4 patients tended to attend a day-care center and to be exclusively breast-fed. CONCLUSION: Although this study covers only a limited number of subjects, cluster analysis is a new and useful method of categorizing heterogeneous wheezy infants and young children. Further analysis may establish clinical classifications of these patients.

Changes in Invasiveness and Latent Infection Rate Associated with Switching the Approach in Total Hip Replacement.

PURPOSE: Muscle-sparing approaches for total hip replacement (THR) involve learning curves. This study aimed to clarify changes in invasiveness and infection rate with changes in approach. METHODS: One surgeon changed the approach of THR from Dall's approach (Dall) to anterolateral modified Watson-Jones approach (OCM). Another changed from Dall to a direct anterior approach (DAA). Another 3 surgeons changed from posterolateral approach (PL) to OCM. Subjects were 150 cases, comprising the last 25 cases with conventional approaches and the first 25 cases with new approaches (Dall to OCM: 25 + 25; Dall to DAA: 25 + 25; PL to OCM: 25 + 25 cases). Differences in operative time, bleeding volume, hospital stay, haemoglobin (Hb), white blood cell count, lymphocyte count, creatine kinase (CK) and C-reactive protein (CRP) were investigated. RESULTS: In the change from Dall to OCM, only hospital stay decreased. In the change from Dall to DAA, hospital stay and CRP decreased, but bleeding volume increased. In the change from PL to OCM, operative time, CRP and CK decreased, but Hb also decreased. Cases with lymphocyte count <1000/µL or lymphocytes comprising <10% of total white blood cells at around day 4 after surgery were defined as latent infection cases. In these cases, operative time was longer, Hb was lower and CK was higher. CONCLUSION: Introducing muscle-sparing approaches improved many markers of invasiveness, but some items deteriorated. In the early stages of introducing a new approach, choosing cases without obesity and without high muscle volume may reduce the risk of infection.