Treatment experience with continuous local antibiotic perfusion for periprosthetic joint infection.

BACKGROUND: Antibiotic concentrations 100-1000 times higher than the minimum inhibitory concentration are necessary for eradicating biofilms in periprosthetic joint infections (PJI). Achieving this with intravenous antibiotics is challenging, but continuous local antibiotic perfusion (CLAP) can increase the local concentration of antibiotics. Although there are several reports on CLAP therapy in the fracture-related infection, there are only few reports on its application in PJI. Here, we report our experience with CLAP therapy for PJI. METHODS: Eight patients with PJI (two males and six females, with mean age of 73.5 years [±11.6]) were treated at our department, and their clinical characteristics were analyzed. The parameters considered were the classification of PJI, surgical procedure, duration of CLAP, duration of transvenous antibiotic administration, time of CRP-negative status, whether the infection resolved or recurred, and whether there were complications due to CLAP. RESULTS: Initial surgery included total knee arthroplasty in five cases, unicompartmental knee arthroplasty in one case, and total hip arthroplasty in two cases. There were four cases of early postoperative infection, two of acute delayed infection, and two of chronic delayed infection. The surgical procedures performed were two-stage revision for two patients, and debridement, antibiotics, and implant retention (DAIR) for the other six. The mean durations of CLAP and transvenous antibiotic administration were 8.5 (±2.4) and 22.4 days (±13.7), respectively, and the mean time to CRP-negative status was 23.3 days (±10.7). All eight patients successfully resolved without additional irrigation or debridement, and no recurrence was observed at the last follow-up after discontinuation of oral antibiotics. No systemic side effects of gentamicin or other complications associated with CLAP were observed. CONCLUSION: All patients achieved infection resolution with the combined use of CLAP. This suggests that CLAP is a useful treatment option for PJI.

Ridge Preservation and Augmentation Using a Carbonated Apatite Bone Graft Substitute: A Case Series.

The newly developed mineral carbonated apatite has recently been proposed as a bone graft material for bone regenerative treatment in implant therapy. This case series details the clinical and radiographic outcomes of ridge preservation and ridge augmentation using only carbonated apatite as bone graft material for implant treatment. Twenty patients (36 sites) who required bone regeneration and implant placement were retrospectively assessed. Simultaneous carbonated apatite implant placement was performed using the simultaneous ridge preservation or augmentation approach on 24 sites in 13 patients with sufficient bone quantity for primary stabilization based on preoperative evaluation results. A staged ridge preservation or augmentation approach was used for the remaining 12 sites in seven patients with insufficient bone quantity. The mean regenerated bone height for each treatment method was as follows: simultaneous preservation, 7.4 ± 3.3 mm; simultaneous augmentation, 3.6 ± 2.3 mm; staged preservation, 7.2 ± 4.5 mm; and staged augmentation, 6.1 ± 2.7 mm. The mean regenerated bone width for each treatment method was as follows: simultaneous preservation, 6.5 ± 2.9 mm; simultaneous augmentation, 3.3 ± 2.5 mm; staged preservation, 5.5 ± 1.7 mm; and staged augmentation, 3.5 ± 1.9 mm. Ultimately, the use of carbonated apatite alone as a bone graft material in implant therapy resulted in stable and favorable bone regeneration.

Laparoscopic median arcuate ligament section for median arcuate ligament compression syndrome initially detected as splenic infarction: a case report.

BACKGROUND: Median arcuate ligament compression syndrome (MALS) causes upper abdominal pain and at times hemodynamic abnormalities in the pancreaticoduodenal region. Herein, we present a case of a 70 year-old man, initially diagnosed with splenic infarction and was successfully treated laparoscopically. CASE PRESENTATION: A 70-year-old man with abdominal pain admitted to our hospital. Abdominal-enhanced computed tomography revealed a poorly contrasted area in the spleen and stenosis at the root of the celiac artery. Arterial dilatation was observed around the pancreaticoduodenal arcade, however, no obvious aneurysm formation or arterial dissection was observed. Abdominal-enhanced magnetic resonance imaging indicated the disappearance of the flow void at the root of the celiac artery. The patient had no history of atrial fibrillation and was diagnosed with splenic infarction due to median arcuate ligament compression syndrome. We performed a laparoscopic median arcuate ligament section with five ports. Intraoperative ultrasonography showed a retrograde blood flow in the common hepatic artery and the celiac artery. After releasing the compression, the antegrade blood flow from the celiac artery to the splenic artery, and the common hepatic artery were visualized using intraoperative ultrasonography. The postoperative course of the patient was uneventful, and he was discharged on postoperative day 9. Postoperative computed tomography a month after surgery revealed no residual stenosis of the celiac artery or dilation of the pancreaticoduodenal arcade. Furthermore, the poorly contrasted area of the spleen improved. CONCLUSIONS: Reports indicate that hemodynamic changes in the abdominal visceral arteries due to median arcuate ligament compression are related to the formation of pancreaticoduodenal aneurysms. In this case, median arcuate ligament compression syndrome caused splenic infarction by reducing blood flow to the splenic artery.

Novel Flowchart Guiding the Non-Surgical and Surgical Management of Peri-Implant Complications: A Narrative Review.

Peri-implant diseases, such as peri-implant mucositis and peri-implantitis, are induced by dysbiotic microbiota resulting in the inflammatory destruction of peri-implant tissue. Nonetheless, there has yet to be an established protocol for the treatment of these diseases in a predictable manner, although many clinicians and researchers have proposed various treatment modalities for their management. With the increase in the number of reports evaluating the efficacy of various treatment modalities and new materials, the use of multiple decontamination methods to clean infected implant surfaces is recommended; moreover, the use of hard tissue laser and/or air abrasion techniques may prove advantageous in the future. Limited evidence supports additional effects on clinical improvement in antimicrobial administration for treating peri-implantitis. Implantoplasty may be justified for decontaminating the implant surfaces in the supracrestal area. Surgical treatment is employed for advanced peri-implantitis, and appropriate surgical methods, such as resection therapy or combination therapy, should be selected based on bone defect configuration. This review presents recent clinical advances in debridement methods for contaminated implant surfaces and regenerative materials for treating peri-implant bone defects. It also proposes a new flowchart to guide the treatment decisions for peri-implant disease.

Laparoscopic and endoscopic cooperative surgery for leiomyosarcoma of the stomach: a case report with a review of the literature.

BACKGROUND: Leiomyosarcoma is a rare tumor that could originate from the gastrointestinal tract, uterus, kidney, retroperitoneum, and the soft tissues of the extremities. It accounts for only 1% of all gastrointestinal mesenchymal tumors and primary leiomyosarcoma of the stomach is extremely rare. Most cases reported as leiomyosarcoma of the stomach before the development of KIT immunohistochemistry might be gastrointestinal stromal tumors (GISTs) of the stomach and only 18 cases of leiomyosarcoma of the stomach have been reported since early 2000s. We report here a patient with leiomyosarcoma of the stomach treated by laparoscopic and endoscopic cooperative surgery (LECS). CASE PRESENTATION: A 59-year-old man was referred to our hospital for an early gastric cancer, which was initially treated by endoscopic submucosal dissection. Six months after his initial treatment, a follow-up esophagogastroduodenoscopy revealed a small polypoid lesion at the lesser curvature of the proximal stomach, which appeared to be a hyperplastic polyp. However, one and a half years later, the lesion grew and showed more irregular surface. Biopsy at the time revealed smooth muscle cell proliferation suggestive of leiomyoma. Three years later, the lesion grew even larger and biopsy showed pleomorphic spindle cells. Immunohistochemical study showed positive staining for alpha-smooth muscle actin and desmin, but negative for c-kit and CD34. Ki-67 labeling index was nearly 60%. Based on these findings, the diagnosis of leiomyosarcoma was established. The patient subsequently underwent a partial gastrectomy by LECS. The patient is currently in good condition without recurrence or metastasis at 12 months after surgery. CONCLUSIONS: Leiomyosarcoma of the stomach is extremely rare. This is the first report of leiomyosarcoma of the stomach treated by LECS. We could also follow its appearance change through endoscopic examination for 3 years.

Malignant solitary fibrous tumor of the pancreas: a case report.

BACKGROUND: Solitary fibrous tumors (SFTs) are rare tumors, mostly derived from connective tissue mesenchymal cells that arise from the pleura. There are very few reports of primary pancreatic SFT. Preoperative diagnosis is difficult owing to the lack of distinctive radiological findings. We report a case of pancreatic SFT with particularly rare malignant findings. CASE PRESENTATION: A 60-year-old man was referred to the hospital because of a right upper quadrant mass and abnormal liver function test results. Contrast-enhanced computed tomography (CT) showed a well-defined enhanced tumor measuring approximately 8 cm in the pancreatic head. Magnetic resonance imaging (MRI) showed T1WI hypointensity, T2WI hyperintensity, and DWI hyperintensity. The main pancreatic duct and common bile duct were dilated owing to obstruction by the tumor. The following tumor markers were mildly elevated: carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), SPan-1, and DUPAN-2. The histological diagnosis obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was negative for pancreatic ductal carcinoma, malignant lymphoma and neuroendocrine tumor, suggesting the possibility of mesenchymal tumor, but the diagnosis was not confirmed. The patient was judged suitable for surgery and underwent subtotal stomach-preserving pancreatoduodenectomy with D2 lymph node dissection. On histopathological examination of the resected specimen, infiltrating spindle-shaped cells had proliferated, containing numerous mitotic figures, with necrotic findings inside the tumor. Immunostaining was positive for cluster of differentiation-34 (CD34), B cell CLL/lymphoma-2 (Bcl-2), and signal transducer and activator of transcription (STAT6). On the basis of these findings, a diagnosis of malignant pancreatic SFT was made. The patient remains free of recurrent disease after 12 months of follow-up without adjuvant therapy and he is being carefully followed up as an outpatient. CONCLUSIONS: We experienced a case of malignant pancreatic head SFT. Immunohistochemical staining of the extracted specimens was useful for diagnosis.

Evaluation of bone healing following Er:YAG laser ablation in rat calvaria compared with bur drilling.

The Er:YAG laser is currently used for bone ablation. However, the effect of Er:YAG laser irradiation on bone healing remains unclear. The aim of this study was to investigate bone healing following ablation by laser irradiation as compared with bur drilling. Rat calvarial bone was ablated using Er:YAG laser or bur with water coolant. Er:YAG laser effectively ablated bone without major thermal changes. In vivo micro-computed tomography analysis revealed that laser irradiation showed significantly higher bone repair ratios than bur drilling. Scanning electron microscope analysis showed more fibrin deposition on laser-ablated bone surfaces. Microarray analysis followed by gene set enrichment analysis revealed that IL6/JAK/STAT3 signaling and inflammatory response gene sets were enriched in bur-drilled bone at 6 hours, whereas the E2F targets gene set was enriched in laser-irradiated bone. Additionally, Hspa1a and Dmp1 expressions were increased and Sost expression was decreased in laser-irradiated bone compared with bur-drilled bone. In granulation tissue formed after laser ablation, Alpl and Gblap expressions increased compared to bur-drilled site. Immunohistochemistry showed that osteocalcin-positive area was increased in the laser-ablated site. These results suggest that Er:YAG laser might accelerate early new bone formation with advantageous surface changes and cellular responses for wound healing, compared with bur-drilling.

Effective removal of calcified deposits on microstructured titanium fixture surfaces of dental implants with erbium lasers.

BACKGROUND: Recently, the occurrence of peri-implantitis has been increasing. However, a suitable method to debride the contaminated surface of titanium implants has not been established. The aim of this study was to investigate the morphologic changes of the microstructured fixture surface after erbium laser irradiation, and to clarify the effects of the erbium lasers when used to remove calcified deposits from implant fixture surfaces. METHODS: In experiment 1, sandblasted, large grit, acid etched surface implants were treated with Er:YAG laser or Er,Cr:YSGG laser at 30 to 60 mJ/pulse and 20 Hz with water spray. In experiments 2 and 3, the effects of erbium lasers used to remove calcified deposits (artificially prepared deposits on virgin implants and natural calculus on failed implants) were investigated and compared with mechanical debridement using either a titanium curette or cotton pellets. After the various debridement methods, all specimens were analyzed by stereomicroscopy (SM), scanning electron microscopy (SEM), and energy dispersive X-ray spectroscopy (EDS). RESULTS: Stereomicroscopy and SEM showed that erbium lasers with optimal irradiation parameters did not influence titanium microstructures. Compared with mechanical debridement, erbium lasers were more capable of removing calcified deposits on the microstructured surface without surface alteration using a noncontact sweeping irradiation at 40 mJ/pulse (ED 14.2 J/cm2 /pulse) and 20 Hz with water spray. CONCLUSION: These results indicate that Er:YAG and Er,Cr:YSGG lasers are more advantageous in removing calcified deposits on the microstructured surface of titanium implants without inducing damage, compared to mechanical therapy by cotton pellet or titanium curette.

Clinicolaboratory characteristics of patients with primary biliary cirrhosis associated with CREST symptoms.

Aims: Patients with primary biliary cirrhosis (PBC) occasionally suffer complications from other autoimmune diseases. When PBC was associated with calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly and telangiectasias (CREST) symptoms, it has been proposed that it is a distinct clinical entity. This study aimed to investigate whether PBC associated with CREST symptoms is a distinct disease complex. Method: Clinicolaboratory data, HLA type of leukocytes and disease prognosis were compared between 31 patients with PBC associated with CREST symptoms and 68 patients with PBC alone. Results: The characteristic findings and significant differences observed in patients with PBC associated with CREST symptoms compared with PBC alone are as follows: all women with older age with milder clinical features of both PBC (asymptomatic PBC in 84%) and CREST syndrome (incomplete CREST in 81%), more frequent occurrence of esophageal varices (28.6 vs. 9.3%), better prognosis (87.5 vs. 45.5% in 10 years survival), lower serum levels of AST (39.8 vs. 63.6 IU/l) and IgM (460 vs. 676 mg/dl), higher prevalence of discrete speckled pattern of antinuclear antibodies (93.5 vs. 12.3%), higher median titers of anti-CENP-B antibodies (1.22 vs. 0.31), lower median titers of antimitochondrial antibody (1:80 vs. 1:160), and a higher prevalence of HLA-DR9 (54.5 vs. 24.3%). Conclusion: These findings support the presence of a subgroup in PBC as PBC associated with CREST symptoms.

[An autopsy case with subacute spinal cord disease showing progressive paraplegia].

We report a 72-year-old woman who died of respitory failure. History included onset of diabetes mellitus at the age of 67 years and hypertension at the age of 72 years. The patient had been in good health otherwise until 2000, when she had onset of numbness or tingling of the bilateral lower limbs. On December 3, 2000, she was admitted to a hospital in the vicinity of her home because of the above-mentioned complaints. Neurological examinations revealed progressive paraplegia. Symptoms and signs suggested Guillain-Barré syndrome. Examinations of cerebrospinal fluids revealed cell count of 338/3 (mono 72%, poly 18%) and protein value of 100 mg/dl. Later the patient course deteriorated. On December 15, 2000, she was admitted to Hakujikai Memorial Hospital for the second time. Ten days later, MRI examination showed diffuse swelling of the spinal cord from the cervical (C 3/4) level to the thoracic level. Gd-enhanced T 1-weighted MRI performed 22 days later showed a partially enhanced lesion at the thoracic (Th 5/6) level of the spinal cord. The patient was treated with steroid therapy (methylprednisolone 500 mg/dl). She died of respiratory failure on January 6, 2001. The patient was presented in a neurological CPC. Neurological and imaging findings suggested a transverse myelopathy. However, there were several points in this case that were unusual for a typical transverse myelopathy, such as total sensory loss below spinal segments of thoracic level (Th 5) and motor weakness of the upper limbs of upper segment of the same level. A clinical neurologist concluded that the patient had subacute transverse myelopathy with fused multiple pathy pathologic lesions. We discussed whether this case was a transverse myelopathy or multiple sclerosis. Post mortem examination revealed acute necrotic myelopathy affecting the spinal cord from the second cervical to the tenth thoracic vertebrae, with conspicuous infiltration of CD 68-positive macrophages involving both gray and white matter, partially necrotic associated with scattered UCHL-1 dominants lymphocytic infiltration of T cells around vessels. There were relatively older lesions with demyelinating features in the spinal roots that were particularly dominant in the anterior roots. No demyelinated plaques in the optic chiasm, tracts and nerves, or in the cerebero-cerebellar white matter were found. Systemic pathological diagnosis was lung edema with fresh hemorrhage, pancreatic atrophy consistent with diabetes mellitus and choleductlithiasis.

Hepatocellular carcinoma that relapsed 54 months after living donor liver transplantation.

We report the case of a 41-year-old woman with hepatocellular carcinoma (HCC). She received living donor liver transplantation (LDLT) from her husband for HCC at 36 years of age. She had few risk factors for HCC recurrence, such as elevated alpha-fetoprotein (AFP), protein induced by vitamin K absence (PIVKA) II, vascular invasion, and number, size of tumors. However, recurrent tumors were found in the graft at 54 months after LDLT. Although we examined the sex chromosomes of the HCC by fluorescence in situ hybridization (FISH) methods, the origin of the HCC was unclear. This is a very rare case of recurrent HCC appearing more than 4 years after LDLT in the absence of risk factors for recurrence.

Three-dimensional assessment of the hip joint by two-directional arthrography.

This retrospective study involved assessment of the three-dimensional bony and cartilaginous cover of the hip acetabular shelf of the hip joint using arthrograms. The extent of lateral and anteroposterior cover, the time course of the changes of cover in each direction, and the relationship between lateral and anteroposterior cover were investigated. It was found that the final extent of acetabular cover could be predicted sooner from the cartilaginous cover than from the bony cover on both the contralateral side and the affected side. There was no significant correlation between lateral and anteroposterior cover on the contralateral side, suggesting the need for assessment of anteroposterior cover to avoid a late diagnosis of anterior acetabular dysplasia.