Advancements in pelvic ring fracture surgery: Assessing INFIX screw placement accuracy with CT navigation.

The management of unstable pelvic ring fractures, typically resulting from high-energy trauma, presents a significant clinical challenge due to the complexity of injuries. While effective in many cases, the traditional stabilization methods are fraught with various complications that can significantly impact patient recovery and quality of life (QOL). This study aims to evaluate the efficacy and precision of the anterior subcutaneous internal fixator (INFIX) technique when used with intraoperative computed tomography (CT) navigation, a novel approach intended to mitigate the limitations of conventional treatment modalities. Our retrospective case series encompasses 43 patients who sustained traumatic pelvic injuries and were subsequently treated with the INFIX technique from December 2020 to January 2024. The focus of this analysis was to assess the accuracy of INFIX screw placement facilitated by intraoperative CT navigation. A total of 81 INFIX screws were inserted, and our study findings reveal a high level of precision in screw placement, with only one screw deviating, resulting in an inaccuracy rate of merely 1.2 %. This highlights the significant advantage provided by intraoperative CT navigation. The high level of accuracy not only enhances the stability of the pelvic fixation but also substantially reduces the risk of complications commonly associated with screw misplacement, such as abdominal damage, vascular injury, and issues related to incorrect hardware positioning. In conclusion, the integration of the INFIX technique with intraoperative CT navigation in the treatment of unstable pelvic ring fractures represents a significant advancement in orthopedic trauma surgery. This study provides compelling evidence supporting the efficacy and precision of this approach, suggesting its potential as a superior alternative to traditional fixation methods. Further research, ideally through prospective studies involving larger patient cohorts, is needed to validate these findings and explore the long-term implications of this technique on patient recovery and QOL.

Preoperative Body Composition Correlates with Postoperative Muscle Volume and Degeneration after Total Hip Arthroplasty.

Impaired muscle recovery after total hip arthroplasty (THA) may affect gait and activities of daily living. Bioelectrical impedance analysis (BIA) can assess body composition and muscle volume, and computed tomography (CT) can assess muscle volume and the fatty degeneration of muscle. This study aimed to explore the effectiveness of BIA, and the correlation between preoperative body composition and postoperative muscle volume and degeneration after THA using BIA and CT. Thirty-eight patients who underwent THA and had BIA and CT performed pre- and postoperatively were retrospectively assessed. The BIA-derived measurements of preoperative body composition (fat mass index, fat-free mass index, and phase angle) were correlated with the CT-derived measurements (pre- and postoperative muscle volume and gluteus maximus and quadriceps Hounsfield Units of the affected hip). The preoperative fat mass index negatively correlated with the postoperative muscle volume of the gluteus maximus (p = 0.02) and quadriceps (p < 0.001) and the Hounsfield Units of the gluteus maximus (p = 0.03) and quadriceps (p = 0.03). The preoperative fat-free mass index positively correlated with the postoperative muscle volume of the quadriceps (p = 0.02). The preoperative phase angle positively correlated with the postoperative muscle volume of the quadriceps (p = 0.001) and the Hounsfield Units of the gluteus maximus (p = 0.03) and quadriceps (p = 0.001). In patients who underwent THA, preoperative body composition correlated with postoperative muscle volume and the fatty degeneration of the affected lower limb. Preoperative body composition may help predict postoperative muscle volume and fatty degeneration and thus, postoperative recovery.

Do metal implants for total hip arthroplasty affect bioelectrical impedance analysis? A retrospective study.

BACKGROUND: Evaluation of body composition after total hip arthroplasty (THA) is essential because it can be used to evaluate muscle and functional recovery. Muscle volume and degeneration are evaluated using computed tomography (CT). However, CT evaluation of muscle volume has several limitations, such as radiation exposure and high medical cost. Bioelectrical impedance analysis (BIA) has gained attention for resolving these limitations of CT. BIA takes advantage of the microelectric current; thus, metal implants may affect the results. Therefore, this study aimed to elucidate the effects of metal implants on BIA after THA. METHODS: Two groups of patients were assessed (Group 1: 70 patients who underwent unilateral THA and BIA; Group 2: 35 patients who underwent THA and BIA before and after THA). Electric impedance (resistance and reactance) of the operated and non-operated lower limbs was compared in Group 1. The pre- and post-operative impedances of the torso and operated ipsilateral limbs were compared in Group 2. RESULTS: Regarding electric impedance in Group 1, no significant differences were observed in electrical resistance and reactance between the operated and non-operated lower limbs. Concerning electric impedance in Group 2, postoperative electric resistance of the torso was significantly lower than that preoperatively. However, no significant difference was seen in electric resistance and reactance of the operated ipsilateral limbs preoperatively and postoperatively. CONCLUSIONS: Electrical resistance and reactance of the limbs did not change significantly after THA. BIA is useful for measuring body composition after THA.

Minimally Invasive 360° Fusion Using a Combination of INFIX and Minimally Invasive Spinopelvic Fixation by Intraoperative Computed Tomography Navigation for Unstable Pelvic Ring Fracture: A Technical Note.

OBJECTIVE: Fluoroscopy is often used in the surgery of unstable pelvic ring fractures, and improved safety in implant placement is an issue. An anterior subcutaneous pelvic fixator (INFIX) combined with a percutaneous screw has been reported to be a minimally invasive and effective surgical technique for unstable pelvic ring injuries. However, although percutaneous screw fixation is minimally invasive, its indications for fracture fixation and fractures with large fragment displacements in the vertical plane remain controversial. Therefore, this technical note aims to describe a new technique for unstable pelvic ring fractures. METHODS: We describe a 360° fusion of the pelvic ring to treat unstable pelvic ring fractures, including vertical shear pelvic ring fractures, using an intraoperative CT navigation system. Seven patients were treated with 360° fusion for type C pelvic ring fractures. In surgery, after reducing the fracture with external fixation, intraoperative CT navigation is used to perform a 360° fusion with INFIX and minimally invasive surgical spinopelvic fixation (MIS-SPF). We will introduce a typical case and explain the procedure. RESULTS: A 360° fixation was performed, and no perioperative complications were noted. The mean blood loss was 253.2 ± 141.0 mL, and the mean operative time was 224.3 ± 67.4 min. In a typical case, bone union was obtained 1 year after surgery, and we removed all implants. CONCLUSIONS: MIS-SPF has a strong fixation force and helps reduce fractures' horizontal and vertical planes. In addition, 360° fusion with intraoperative CT navigation may help treat unstable pelvic ring fractures.

Effect of spinal fusion on joint space narrowing of the hip: comparison among non-fusion, short fusion, and middle or long fusion.

BACKGROUND: Lumbar fusion corrects spinal deformities and improves spinal complications. Hip osteoarthritis (OA) is strongly correlated with spinal mobility, and joint space narrowing of the hip after spinal fusion has gained attention. This study aimed to elucidate the effect of spinal fusion on hip joint space narrowing. MATERIALS AND METHODS: We retrospectively examined 530 hips of 270 patients who underwent spinal surgery. All the patients underwent whole-spine radiography before and at the final follow-up. Patients were divided into three groups (N group: non-spinal fusion, S group: up to three interbody fusions, and L group: more than four interbody fusions). The rates of joint space narrowing, spinal parameters (sagittal vertical axis, thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and pelvic incidence), and limb length discrepancy at the final follow-up were compared. A multilinear regression analysis was performed to identify the risk factors for the rate of joint space narrowing. RESULTS: The rate of joint space narrowing was significantly higher in the L group than in the N and S groups (P < 0.001). No significant difference in the rate of joint space narrowing was observed between the N and S groups. Multiple linear regression analysis revealed that the number of fusion levels (p < 0.05) and follow-up period (p < 0.001) were independent risk factors for joint space narrowing. Spinal parameters at the final follow-up were not independent risk factors. CONCLUSIONS: Long spinal fusion (more than four levels) led to significantly greater joint space narrowing of the hip than short (up to three levels) or no fusion. Spinal alignment did not affect joint space narrowing of the hip. Surgeons should be aware that more than four interbody fusions may result in worse joint space narrowing of the hip. LEVEL OF EVIDENCE: IV, retrospective study.

The anatomical features of the lateral femoral cutaneous nerve with total hip arthroplasty: a comparative study of direct anterior and anterolateral supine approaches.

BACKGROUND: Lateral femoral cutaneous nerve (LFCN) injury after total hip arthroplasty causes patient dissatisfaction. This cadaveric study aimed to assess the risk for LFCN injury after the direct anterior approach (DAA) and anterolateral supine approach (ALS) with a focus on the anatomical variations of the LFCN. METHODS: Thirty-seven hemipelves from 20 formalin-preserved cadavers (10 males and 10 females) were dissected to identify the LFCN, evaluate variations, and measure the distance from the LFCN to each approach. The LFCN was classified as classical, late, multi trunk, or primary femoral. RESULTS: There were no significant variations in the LFCN between the sexes. The distance from the LFCN to DAA incision (10 [0-17.8] mm) was significantly less than that from the LFCN to ALS incision (27 [0-40] mm); moreover, 64.9% of DAA incisions crossed the LFCN. The classical type LFCN was closest to the DAA incision. The DAA incision most frequently crossed the LFCN at the proximal third, and the frequency of intersection of the LFCN and DAA incisions decreased by 25% by a 10-mm shortening of the DAA proximal incision. In contrast, 27% of ALS incisions crossed the LFCN. Multi trunk type LFCN was closest to the ALS incision. There were no significant differences between each approach and LFCN variations, and the frequency of intersection of the LFCN and ALS incisions decreased by 20% by a 10-mm shortening of the ALS proximal incision. CONCLUSIONS: The intersection rates between the LFCN and the DAA and between the LFCN and the ALS were approximately 65 and 30%, respectively. Approximately 20-25% of these injuries may be avoidable by a 10-mm shortening of the proximal incision.

The combination of intraoperative CT navigation and C-arm fluoroscopy for INFIX and percutaneous TITS screw placement in the treatment of pelvic ring injury: technical note.

BACKGROUND: The subcutaneous screw rod system, commonly known as the internal pelvic fixator (INFIX), is useful in managing unstable pelvic ring fractures. Conventional INFIX and transiliac-transsacral (TITS) screw techniques are performed using C-arm fluoroscopy. There have been problems with medical exposure and screw insertion accuracy with these techniques. This work describes new INFIX and TITS techniques using intraoperative computed tomography (CT) navigation and C-arm fluoroscopy for pelvic ring fracture. METHODS: A typical case is presented in this study. An 86-year-old woman suffered from an unstable pelvic ring fracture due to a fall from a height. INFIX and TITS screw fixation with intraoperative CT navigation were selected to optimize surgical invasiveness and proper implant placement. RESULTS: The patient was placed in a supine position on a Jackson table. An intraoperative CT navigation was imaged, and screws were inserted under the navigation. Postoperative X-rays and CT confirmed that the screw was inserted correctly. This technique was less invasive to the patient and had little radiation exposure to the surgeon. Rehabilitation of walking practice was started early after the surgery, and she was able to walk with the assistance of a walker by the time of transfer. CONCLUSIONS: The technique employed in our case study has the cumulative advantages of safety, accuracy, and reduced radiation exposure, together with the inherent advantages of functional outcomes of previously reported INFIX and TITS screw techniques. Further experience with this approach will refine this technique to overcome its limitations and facilitate its wider use.

Comparison of periarticular multidrug injection versus epidural catheter in 55 patients undergoing total hip arthroplasty: A prospective randomized controlled trial.

INTRODUCTION: Epidural catheter (EC) and periarticular multidrug injection (PMDI) are widely performed for reducing total hip arthroplasty (THA) postoperative pain. However, the more effective analgesic technique between the two is unclear. Thus, we aimed to answer the following questions: (1) does PMDI contribute to less postoperative pain than EC? (2) is there any difference in side-effect occurrence between the methods? (3) does PMDI provide better functional recovery than EC? (4) is there any difference in inflammatory parameters between the methods? HYPOTHESIS: PMDI would reduce postoperative pain and side effects, provide better functional recovery, and contribute to lower inflammation compared with EC. MATERIALS AND METHODS: This single-center, randomized controlled trial was conducted from 2017 to 2019 and enrolled 55 patients randomly allocated into two groups (28 patients: PMDI, 27 patients: EC). The primary outcome was evaluated using the pain visual analogue scale (VAS). The secondary outcomes were narcotic consumption, side effects, hip range of motion (ROM), ratio of patients performing the straight leg raise (SLR) on postoperative day (POD) 1, the day the patient started using a walker and cane, and inflammatory parameters (white blood cell [WBC], and C-reactive protein [CRP]). Paired t-tests and Fisher's exact test were used for comparisons. RESULTS: There were no significant differences in the pain VAS scores between groups. The EC group experienced significantly more side effects than the PMDI group (p<0.01). ROM of the PMDI group on POD 3 was significantly better than the EC group (p<0.05). Furthermore, more patients in the PMDI group could perform SLR than those in the EC group on POD 1 (p=0.01). On POD 1, the WBC count was significantly higher (p<0.01) in the PMDI group, whereas CRP levels were significantly lower in the PMDI group (p<0.05) and remained lower than the EC group on POD 3 (p<0.01). DISCUSSION: The patients in the PMDI and EC groups had comparable postoperative pain. Those in the PMDI group had lower side effects. Functional recovery was comparable between the patients in the PMDI and EC groups. Compared to the EC group, the PMDI group had higher WBC count and lower CRP levels. LEVEL OF EVIDENCE: I; Prospective randomized controlled trial.

Effect of nutritional status before femoral neck fracture surgery on postoperative outcomes: a retrospective study.

BACKGROUND: Although nutritional status is crucial in gait recovery after femoral neck fracture surgery, the relationship between preoperative nutritional status and postoperative outcomes remains unknown. This study examined the effects of preoperative nutritional status on postoperative outcomes in patients undergoing femoral neck fracture surgery. METHODS: Data regarding the joints of 137 patients (29 men, 108 women) who underwent bipolar hemiarthroplasty for femoral neck fractures at our hospital from January 2015 to December 2019 were retrospectively examined. The Geriatric Nutritional Risk Index (GNRI), an index of nutritional status, was used to classify patients into two groups: a normal group (GNRI ≥92; n = 62) and an undernourished group (GNRI < 92; n = 75). The study endpoints included age at surgery, sex, Mini Mental State Examination (MMSE), American Society of Anesthesiologists Physical Status (ASA) classification, preoperative waiting period, intraoperative blood loss, surgery time, perioperative hemoglobin levels, blood transfusion rate, complication rate, 6-month mortality rate, transfer rate, percentage of patients unable to walk at discharge or transfer, and inability to walk 6 months postoperatively. RESULTS: The patients in the undernourished group was significantly older at surgery (p < 0.01) and had a lower perioperative hemoglobin levels (p < 0.01), a higher blood transfusion rate (p < 0.01), a lower MMSE (p < 0.01), a longer preoperative waiting period (p < 0.05), a higher transfer rate (p < 0.05), were more likely to be unable to walk 6 months postoperatively (p < 0.01), a higher complication rate (p < 0.05), and a higher 6-month mortality rate (p < 0.01) than the normal group. Patients in the undernourished group had worse rates of postoperative complications, transfer, mortality, and inability to walk 6-month after surgery than those in the normal group. CONCLUSIONS: A poor nutritional status affects the gait function and systemic condition of patients undergoing femoral neck fracture surgery; therefore, early nutritional interventions may reduce mortality rates and shorten rehabilitation. These results suggest that the GNRI effectively predicts postoperative complications, mortality, and gait function.

Comparison of properties determined using electromechanical assessment (Arthro-BST™) with macroscopic and histological properties in symptomatic human articular cartilage of the hip.

BACKGROUND: Cartilage degeneration is assessed using various methods. Although macroscopic evaluation can directly measure cartilage degeneration, it cannot accurately assess cartilage properties. Histological examination is one of the most accurate methods for evaluating cartilage degeneration. However, it is invasive and requires collection of cartilage tissue. In contrast, the Arthro-BST™ probe can assess cartilage properties noninvasively. This study aimed to evaluate the effectiveness of the Arthro-BST in assessing cartilage degeneration by comparing macroscopic (International Cartilage Repair Society [ICRS] classification) and histological evaluations (modified Mankin score and Osteoarthritis Research Society International [OARSI] histological grade). METHODS: Fourteen femoral heads were excised from 13 patients during surgery to treat hip osteoarthritis or femoral fracture. The ICRS score was used for macroscopic evaluation of cartilage degeneration. The Arthro-BST was applied at sites matching the areas of cartilage damage. The sites assessed using the ICRS classification and Arthro-BST were evaluated histologically (modified Mankin score and OARSI histological grade), and these were compared with the Arthro-BST results. RESULTS: The ICRS classification identified significant differences between grades 1 and 3 (p < 0.01), between grades 1 and 4 (p < 0.01), between grades 2 and 3 (p < 0.01), and between grades 2 and 4 (p < 0.01). Significant correlations were observed between the Arthro-BST results and the ICRS score, modified Mankin score (structure, cellularity, matrix staining, total score), and OARSI histological grade. CONCLUSIONS: In the assessment of hip osteoarthritis, the Arthro-BST results correlated with those of macroscopic and histological evaluations. The Arthro-BST is useful for assessing hip osteoarthritis and may be helpful for noninvasive assessment of cartilage degeneration.

Evaluation of muscle volume and degeneration after total hip arthroplasty: a comparison of the posterolateral approach and the anterolateral supine approach.

BACKGROUND: Muscle strength around the hip after total hip arthroplasty (THA) is crucial for preventing dislocation and limping. This study aimed to assess and compare muscle volume and degeneration after THA using the posterolateral (PL) and anterolateral (AL) approaches. METHODS: Sixty-four hips in 64 patients who underwent primary THA were retrospectively analyzed. Patients were segregated into the PL group (35 hips) and AL group (29 hips) for evaluating pre- and postoperative muscle volumes and degeneration around the hip. Computed tomography (CT) examinations were performed preoperatively and 6 months post THA. The muscle volume and Hounsfield units (HU) of the gluteus maximus (G-max), gluteus medius (G-med), tensor fasciae latae, internal obturator muscle, and external obturator muscle were measured. RESULTS: In the PL group, the postoperative muscle volume of the G-max significantly increased than the preoperative muscle volume. In contrast, the postoperative muscle volume of the internal obturator muscle was significantly lower than the preoperative muscle volume. The postoperative HU of the internal and external obturator muscles were significantly lower than the preoperative HU. In the AL group, the postoperative muscle volumes of the G-max, G-med, and tensor fasciae latae significantly increased than their preoperative muscle volumes. The postoperative HU of the G-med and tensor fasciae latae were significantly higher than the preoperative HU values. CONCLUSION: The PL approach can lead to degeneration of the internal and external obturator. The AL approach is more beneficial for recovering the G-med, tensor fasciae latae, and internal obturator muscle than the PL approach.

Comparison of short-term outcomes of anterolateral supine approach and posterolateral approach for primary total hip arthroplasty: a retrospective study.

BACKGROUND: This study aims to evaluate postoperative pain and functional and clinical outcomes of anterolateral supine (ALS) and posterolateral (PL) approaches for primary total hip arthroplasty. MATERIALS AND METHODS: We retrospectively examined the joints of 110 patients who underwent primary total hip arthroplasty (THA). The ALS group was compared with the PL group using the pain visual analog scale (VAS) and narcotic consumption as pain outcomes. Functional outcomes included postoperative range of motion (ROM) of hip flexion, day on which patients could perform straight leg raising (SLR), day on which patients began using a walker or cane, duration of hospital stay, rate of transfer, and strength of hip muscles. Clinical outcomes included pre and postoperative Harris Hip Scores. RESULTS: No significant differences were found in the pain VAS scores or narcotic consumption between the two groups. The PL group could perform SLR earlier than the ALS group (P < 0.01). The ALS group started using a cane earlier (P < 0.01) and had a shorter hospital stay (P < 0.01) than the PL group. Degrees of active ROM of flexion at postoperative day (POD) 1 were significantly lower in the ALS group than in the PL group (P < 0.01). Regarding hip muscle strength, hip flexion was significantly weaker in the ALS group than in the PL group until 1-month POD (P < 0.01). External rotation from 2 weeks to 6 months postoperatively was significantly weaker in the PL group than in the ALS group (P < 0.01). CONCLUSION: The ALS approach was more beneficial than the PL approach because ALS enabled better functional recovery of the strength of external rotation, improved rehabilitation, and involved a shorter hospital stay. LEVEL OF EVIDENCE: Level IV retrospective observational study.

Retrospective analysis of risk factors for deep infection in lower limb Gustilo-Anderson type III fractures.

BACKGROUND: Open fractures are among the most severe injuries observed in orthopedic patients. Treating open fractures is difficult because such patients with infections may require multiple operations and amputations. Furthermore, only a few studies have focused on antibiotic prophylaxis in open fractures and evaluated how to cover lost soft tissue to increase the success rate of reconstruction. We evaluated the risk factors for deep infection in lower limb Gustilo-Anderson (G-A) type III fractures. MATERIALS AND METHODS: This retrospective study investigated patients who underwent surgical procedures for lower limb G-A type III fractures between January 2007 and January 2017 at our institution. We enrolled 110 patients with 114 lower limb G-A type III fractures (77 G-A type IIIA fractures and 37 G-A type IIIB fractures) who were followed up for at least 2 years. We compared patients presenting infections with those without infections by assessing the following factors: severe contamination, diabetes, smoking, Injury Severity Scale, segmental fracture, location of fracture, G-A classification, damage control surgery, methods of surgery, timing of fixation, combination of antibiotics used, duration of antibiotic prophylaxis, timing of wound closure, and soft-tissue reconstruction failure. RESULTS: Eighteen fractures presented deep infections. Compared with patients without infections, patients developing infections differed significantly in terms of severe contamination (P < 0.01), G-A classification (P < 0.01), duration of antibiotic prophylaxis (P < 0.01), timing of wound closure (P < 0.01), and incidence of soft-tissue reconstruction failure (P < 0.01). Skin grafting was associated with significantly higher failure rates than muscle and free flap reconstructions (P = 0.04). Treatment with antibiotics was significantly longer in patients with drug-resistant bacterial infections than in those without infections (P < 0.01). CONCLUSION: Early flaps rather than skin grafting should be used to cover G-A type IIIB fractures, because skin grafting resulted in the highest failure rate among soft-tissue reconstructions in open fractures. Longer duration of antibiotic use had a significant impact not only on deep infection rates but also on the presence of drug-resistant bacteria. These findings suggest that prolonged use of antibiotics should be avoided in cases of open fractures. LEVEL OF EVIDENCE: Level IV retrospective observational study.

Softness sensing probe with multiple acoustic paths for laparoscopic surgery.

PURPOSE: Surgeon's tactile sense is restricted during laparoscopic surgery. We aim to develop a softness sensing probe for endometriosis. Identification of the boundary of the lesion through a tactile sensor during laparoscopic surgery can provide an appropriate cut line, reducing excessive cut. METHOD: We expand our acoustic reflection-based sensing to the proposed probe, which has three force-sensing points to measure the softness of the object. The compensation of the sensor posture with the three sensor outputs was additionally proposed. This sensor has a simple structure and no electrical elements in the part inserted into the body. The sensing principle was verified using the theoretical analysis. Fundamental experiment to make the estimation model and evaluation test with the simulated environment were conducted. RESULT: The fundamental experiment showed that different softness can be estimated and that leave-one-out cross-validation resulted that the root-mean-square-error of the softness estimation was 31.5 kPa within the range of 7.5° in the probe posture. Samples which have similar softness as normal and lesioned uterus were used for the evaluation test using laparoscopic box trainer and a general trocar. Six participants operated the sensor, and the results showed that the samples were significantly discriminated by the softness estimated. CONCLUSION: The experimental results showed that the sensor can estimate the softness while compensating the posture and discriminate model samples of normal and lesioned uterus in the simulated environment, indicating the possibility of boundary identification between normal and lesioned tissues during laparoscopic surgery of endometriosis.

Comparison of periarticular multidrug infiltration and epidural catheter use in total knee arthroplasty: A prospective randomized controlled study.

PURPOSE: The purpose of this study was to assess the effectiveness of periarticular multidrug infiltration (PMDI) and compare it with that of epidural catheter use. METHODS: Fifty-eight patients (58 joints) who underwent total knee arthroplasty were included in this single-center, prospective, parallel, randomized, controlled trial. Preoperatively, patients were randomly categorized into the PMDI and epidural catheter groups. We evaluated postoperative pain (visual analog scale (VAS) and narcotic consumption), functional outcomes (range of motion (ROM) of knee flexion, the day patients could perform the straight-leg raising (SLR) test, and day of starting cane use), and laboratory data (white blood cell (WBC) and C-reactive protein (CRP)). RESULTS: There was no significant difference in the VAS score, ROM of knee flexion, the day patients could do SLR, and the day of starting cane use between the PMDI and epidural catheter groups. However, the PMDI group could perform SLR on a postoperative day (POD) 1 (p < 0.05). WBC level on POD 1 was significantly higher in the PMDI group (p < 0.05), whereas the CRP levels on POD 1 (p < 0.01), 3 (p < 0.01), and 5 (p < 0.01) were significantly lower in the PMDI group than in the epidural catheter group. The frequency of side effects was not significantly different between the groups. CONCLUSION: PMDI was as effective as epidural catheter use for pain control. A higher percentage of patients who underwent PMDI could perform SLR on POD 1; therefore, the functional recovery was earlier in the PMDI group than in the epidural catheter group. PMDI may suppress inflammation in the whole body because of steroids.

A Patient with Pediatric Septic Arthritis of the Hip Complicated with Osteomyelitis Responds to Clindamycin.

A 5-year-old girl was referred to our institution with complaints of right hip pain and fever (39.0°C); blood tests and magnetic resonance imaging (MRI) were performed. Blood biochemical results revealed a high inflammatory reaction. MRI results revealed inflammation in the hip joint. She was diagnosed with pediatric septic arthritis of the hip, which required arthrotomy and lavage drainage. Treatment with intravenous vancomycin was initiated on the assumption that the causative bacterial species was Staphylococcus aureus. However, Group A Streptococcus pyogenes (GAS) was subsequently isolated from an intraoperative sample, and the antimicrobial agent was switched to aminobenzylpenicillin (ABPC). Clindamycin (CLDM) was added to the treatment regimen 14 days after surgery as MRI indicated the development and spread of osteomyelitis. Three months post-surgery, MRI findings indicated that the osteomyelitis had resolved and antimicrobial therapy was discontinued. To prevent the spread of osteomyelitis, a combination of CLDM and ABPC should be considered at an early stage, particularly in pediatric patients with GAS-induced septic arthritis.

Clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments: a retrospective analysis of risk factors for delayed union.

BACKGROUND: This study retrospectively evaluated the clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments and analyzed the risk factors for delayed union. METHODS: Retrospective analyses involving 51 patients who underwent intramedullary nailing of femoral shaft fractures with third fragments (AO classification type B, 35 cases; type C, 16 cases) were conducted. Delayed union was defined as either more than 10 months required for callus formation in more than three of the four cortical bone surfaces observed in the frontal and lateral radiographic views or the requirement for additional surgery such as nail conversion or bone transplantation. Seventeen patients developed delayed union (D group). Thirty-four patients achieved bony union within 9 months (U group). The following background variables were compared between groups: age at the time of the injury; AO classification; ratio of open fracture; waiting period before surgery; rate of the infraisthmal fracture; diameter of the intramedullary nail; ratio of the intramedullary nail to the femur; length and displacement of the third fragment; and use of open reduction, poller screws, or dynamization. RESULTS: Significant differences were found between the D and U groups for age (32.2±14.1 vs. 25.3±9.6 years), open fracture ratio (35.3% vs. 11.8%), and displacement of the third fragment (13.7±6.4 vs. 9±6.3 mm). Multiple logistic regression analysis only identified displacement of the third fragment as a risk factor for delayed union (p=0.03; OR 1.13; 95% CI 1.01 to 1.26). DISCUSSION: Delayed union was observed in 17 cases (33.3%) after intramedullary nailing of femoral shaft fractures with third fragments. Displacement of the third fragment influenced delayed union. LEVEL OF EVIDENCE: Level III.

Opioid administration via epidural catheter is a risk factor for postoperative nausea and vomiting in total hip arthroplasty: A retrospective study.

BACKGROUND: Postoperative nausea and vomiting (PONV) may lead to extended hospital stay due to severe discomfort and restriction of patient activity. We retrospectively studied PONV incidence following total hip arthroplasty (THA) to evaluate the effect of opioid administration via epidural catheter. METHODS: Our study included 155 affected joints in 136 patients who underwent a first THA from 2011 to 2016. For postoperative analgesia, an epidural catheter was preoperatively placed and used for continuous analgesic delivery into the epidural space up to 2 days after surgery. We analyzed patient age, sex, body mass index (BMI), opioid use via epidural catheter, amount of opioid used intraoperatively, amount of opioid used immediately before the end of the operation, anesthesia duration, and amount of opioid used postoperatively. RESULTS: PONV was reported for 51 affected joints. Opioid was infused via epidural catheter in 114 affected joints, but not in 41 affected joints. Logistic regression analysis for PONV occurrence revealed a significant difference according to sex (P < 0.05), BMI (P < 0.01), and opioid use via epidural catheter (P < 0.05). Correlation analysis evaluating the occurrence of PONV and BMI using the χ2 test demonstrated a significantly higher incidence of PONV in the subgroup of patients with a BMI ≤20 kg/m2 (P < 0.01). CONCLUSIONS: These results indicate that without using opioid or other action should be considered when epidural catheter is used in female patients with a BMI ≤20 kg/m2.

Diffusion tensor imaging can detect the early stages of cartilage damage: a comparison study.

BACKGROUND: In the present study, we measured damaged areas of cartilage with diffusion tensor (DT) imaging and T2 mapping, and investigated the extent to which cartilage damage could be determined using these techniques. METHODS: Forty-one patients underwent arthroscopic knee surgery for osteoarthritis of the knee, a meniscus injury, or an anterior cruciate ligament injury. Preoperative magnetic resonance imaging of the knee was performed, including T2 mapping and diffusion tensor imaging. The presence of cartilage injury involving the medial and lateral femoral condyles and tibia plateau was assessed during surgery using the Outerbridge scale. The ADC, T2 values and fractional anisotropy of areas of cartilage injury were then retrospectively analysed. RESULTS: The ADC results identified significant differences between Outerbridge grades 0 and 2 (P = 0.041); 0 and 3 (P < 0.001); 1 and 2 (P = 0.045); 1 and 3 (P < 0.001); and 2 and 3 (P = 0.028). The FA results identified significant differences between grades 0 and 1 (P < 0.001); 0 and 2 (P < 0.001); and 0 and 3 (P < 0.001). T2 mapping identified significant differences between Outerbridge grades 0 and 2 (P = 0.032); 0 and 3 (P < 0.001); 1 and 3 (P < 0.001); and 2 and 3 (P < 0.001). Both the T2 mapping (R(2) = 0.7883) and the ADC (R(2) = 0.9184) correlated significantly with the Outerbridge grade. The FA (R(2) = 0.6616) correlated slightly with the Outerbridge grade. CONCLUSIONS: T2 mapping can be useful for detecting moderate or severe cartilage damage, and the ADC can be used to detect early stage cartilage damage. The FA can also distinguish normal from damaged cartilage.

Usefulness of using laser-induced photoacoustic measurement and 3.0 Tesla MRI to assess knee cartilage damage: a comparison study.

BACKGROUND: T2 mapping is an MRI method particularly reflective of the collagen arrangement in the cartilage, and diffusion tensor (DT) imaging captures the diffusion of water molecules. Laser-induced photoacoustic measurement (LIPA) makes it possible to assess not only the thickness of the cartilage layer but also its viscoelastic properties. By assessing cartilage damage assessment using LIPA and 3.0 Tesla MRI (T2 mapping and DT imaging), this study investigates the usefulness of the various methods. METHODS: The International Cartilage Repair Society (ICRS) classification was used to classify 29 bone cartilage pieces excised during surgical procedures. At the same time, LIPA was performed at sites matching the area of cartilage damage. MRI was performed preoperatively to measure the T2 and the apparent diffusion coefficient. In addition, tissue sections for histological assessment using the Mankin score were prepared for each ICRS grade, and the results with the various methods were compared. RESULTS: With DT imaging, significant differences were observed in all grades (P < 0.01). With T2 mapping, significant differences were observed in all grades except for grade 1 versus grade 2 (P < 0.01). With LIPA, significant differences were observed in ICRS grade 1 versus grade 3 (P < 0.05), grade 1 versus grade 4 (P < 0.01), grade 2 versus grade 4 (P < 0.01), and grade 3 versus grade 4 (P < 0.05). With the Mankin score, significant differences were observed in ICRS grade 1 versus grade 3 (P < 0.01), grade 1 versus grade 4 (P < 0.01), grade 2 versus grade 4 (P < 0.01), and grade 3 versus grade 4 (P < 0.01). Correlations were observed in all combinations of ICRS grade with DT imaging, T2 mapping, LIPA, and Mankin score. Correlations were observed between the degree of histological degeneration and DT imaging, T2 mapping, and ICRS grade, but LIPA had a weaker correlation than MRI. CONCLUSIONS: In the assessment of knee osteoarthritis, there are instances where it is difficult to assess the damaged cartilage site with MRI alone, and we believe that it is desirable to use a combination of LIPA and MRI.