Arthroscopic labral repair combined with less invasive open-shelf acetabuloplasty for patients with developmental dysplasia of the hip.

Hip arthroscopy has become widely used for intra-articular lesions, such as labral tears and femoral acetabular impingement. However, its use in patients with developmental dysplasia of the hip (DDH) has been controversial and has historically demonstrated mixed results, as acetabular dysplasia may cause instability due to insufficient bony coverage of the femoral head, thus causing excessive stress on the repaired labrum and cartilage. We devised a combined hip arthroscopic labral repair and a less invasive open-shelf procedure using a small skin incision as an anterolateral portal in hip arthroscopy. This novel procedure may improve the stability of the repaired labrum with a bony covering in a minimally invasive manner. Moreover, the shelf procedure can be performed under direct vision in a comparatively safe and precise manner. In total, 13 hips with DDH underwent the procedure for labral tears. All patients were females, with a mean age of 30 years. The mean follow-up period was 33 months. The mean Harris hip score improved from 74.2 to 93.6, and Oxford Hip score improved from 32.4 to 19.3. According to the Tönnis classification, the grade of arthritis preoperatively was grade 0 for nine hips and grade I for four hips. No radiographic progression of osteoarthritis was observed. It is possible that this novel procedure could be an effective treatment for labral tears with DDH and may prevent the early onset of secondary osteoarthritis. In this technical tip, we describe hip arthroscopic labral repair combined with a less invasive open-shelf acetabuloplasty in further detail.

Prevalence of iliopsoas bursitis in patients with end-stage hip osteoarthritis.

OBJECTIVES: Iliopsoas bursitis (IB) is a relatively rare condition that is associated with hip diseases. It can cause neurological symptoms and swelling of the lower extremities by compressing the femoral nerve and vessels. The aim of this study is to examine the prevalence of IB in patients with end-stage hip osteoarthritis. METHODS: A total of 544 patients underwent total hip arthroplasty between May 2010 and May 2019. All patients were examined using computed tomography (CT) to perform preoperative planning. We reviewed the CT images and examined the prevalence and size of IB. These lesions were divided into three types based on their shape (round type, oval type, and heart-shaped type). RESULTS: Of the 544 patients, IB was found in 37 patients. We observed the round type in 4 patients, the oval type in 31 patients, and the heart-shaped type in 2 patients. Two patients showed severe swelling in the legs and had a blood circulatory disorder of the legs. Both cases were heart-shaped bursitis. CONCLUSION: Symptomatic IB was observed in two cases, both of which had a heart shape surrounding the iliopsoas tendon and femoral neurovascular bundle. Although symptomatic IB is a rare condition, special attention is required for heart-shaped IB.

Chronic postsurgical pain after total knee arthroplasty: A prospective cohort study in Japanese population.

OBJECTIVES: To elucidate the prevalence and risk factors of chronic postsurgical pain (CPSP) after primary total knee arthroplasty (TKA) in Japanese population. METHODS: Consecutive patients undergoing primary TKA in a Japanese tertiary hospital (211 knees) were assessed. CPSP after TKA was defined as moderate to severe pain (VAS >30 mm), either at rest or during walking, one year after surgery. Clinical and radiographic data were compared between CPSP and non-CPSP groups and multivariate logistic regression was used to identify predictors of CPSP. RESULTS: The prevalence of CPSP was 8.8%. CPSP group showed significantly higher preoperative WOMAC subscales (pain, function and stiffness), higher rate of postoperative coronal malalignment (femorotibial angle >178° or <170°) and larger varus angle of tibial component compared with non-CPSP group. Logistic regression analysis revealed that preoperative higher WOMAC pain and postoperative coronal malalignment were independent risk factors of CPSP. In a subgroup analysis of patients with well-aligned TKA, preoperative pain VAS at rest was the only risk factor of CPSP. CONCLUSION: Preoperative severe pain and postoperative coronal malalignment were independent risk factors of CPSP after TKA. Preoperative pain management in patients with severe pain and good coronal alignment after TKA possibly minimize the development of CPSP.

Impact of Changing Surgical Strategies on Clinical Outcomes in Patients with Parotid Carcinoma: A 53-Year Single-Institution Experience.

Background and Objectives: We investigated the clinical outcomes of patients who underwent surgery for parotid carcinoma in a single institution during a 53-year period. This study aimed to estimate the impact of changing the surgical approach to parotid carcinoma on clinical outcomes including the incidence rate of the facial nerve palsy. Materials and Methods: Sixty-seven patients with parotid carcinoma who underwent surgery between 1966 and 2018 were retrospectively reviewed. Group A consisted of 29 patients who underwent surgery from 1966 to 2002, and Group B consisted of 38 patients from 2002 to 2018. Treatment outcomes were estimated. Additionally, candidate prognostic factors of Group B, the current surgical approach group, were evaluated. Results: Partial parotidectomy and total parotidectomy were performed in 35 and 32 patients, respectively. Partial parotidectomy was performed in 4 patients in Group A and 31 patients in Group B, with a predominant increase in Group B. The facial nerve was preserved in 43 patients, among whom 8 in Group A (8/17; 47.1%) and 7 in Group B (7/26; 26.9%) had temporary postoperative facial nerve palsy. Postoperative radiotherapy was performed on 35 patients. The 5-year OS, DSS, and DFS rates for Group A were 77.1%, 79.9%, and 71.5%, respectively. The 5-year OS, DSS, and DFS rates for Group B were 77.1%, 77.1%, and 72.4%, respectively. Clinical T4 stage, clinical N+ stage, stage IV disease, and tumor invasion of the facial nerve were independent prognostic factors in Group B. Conclusions: The incidence of facial nerve palsy in the current surgical approach group decreased compared with that in the previous surgical approach group. The current surgical management and treatment policies for parotid carcinoma have led to improved outcomes.

Additional benefit of local infiltration of analgesia to femoral nerve block in total knee arthroplasty: double-blind randomized control study.

PURPOSE: Multimodal analgesia has become an important concept in current pain management following total knee arthroplasty (TKA). However, controversy remains over what is the most accepted combination. In this study, the additional benefits of local infiltration of analgesia to femoral nerve block were evaluated. METHODS: Forty patients were randomly allocated into a combined local infiltration of analgesia and femoral nerve block or femoral nerve block alone group. In the former, analgesic drugs consisting of ropivacaine and dexamethasone were injected into the peri-articular tissues, while the same amount of saline was injected into the femoral nerve block group. The primary outcome measure was the total amount of fentanyl consumption by the patient-controlled analgesia pump during the 48-h post-operative period. RESULTS: A combination of local infiltration of analgesia and femoral nerve block had less total fentanyl consumption and a larger knee ROM at post-operative day 2 than femoral nerve block alone (p < 0.05). C-reactive protein levels in the combined treatment group were significantly lower than the femoral nerve block group at post-operative day 3 (p < 0.01). There was no difference between the two groups, post-operatively, on the visual analogue scale for pain at rest or while walking, quadriceps strength, timed up and go test, circumference of thigh, Knee Society Score, and Western Ontario and McMaster Universities Osteoarthritis Index. CONCLUSION: The addition of local infiltration of analgesia to femoral nerve block promoted post-operative pain relief and the recovery of knee ROM in the early post-operative period. This combination is an effective method for post-operative pain management after TKA. LEVEL OF EVIDENCE: Randomized controlled trial, Level I.

Less invasive modified Spitzy shelf procedure for patients with dysplasia of the hip.

The shelf procedure for developmental dysplasia of the hip (DDH) is a simpler technique compared with periarticular acetabular osteotomies. However, the most commonly used approach involves the exposure of a large section of the outer iliac surface via a long skin incision and is relatively invasive. We have developed a mini one-incision technique for shelf procedure using bioabsorbable material, based on a modified Spitzy method. In the present report, we describe this procedure and outcomes. For the procedure, the patients are positioned in the lateral position and a 6-8-cm skin incision is made. The interval between the gluteus medius and the tensor fascia lata is developed without any muscle splitting. Thereafter, image intensification is used for accurate positioning of a slot for the new shelf, and a bone graft for the new shelf is obtained from the internal cortex of the iliac wing. The patient is then positioned with the hip in flexion; through the same sliding skin incision, the bone graft is impacted into the slot, and bioabsorbable screws or plates are implanted to cover and stabilise the new shelf. Cancellous bone chips are packed into the triangular space surrounded by the outer iliac surface, the new shelf, and the bioabsorbable screws or plate. We performed this procedure in 9 patients (12 hips). No progression of osteoarthritis was observed during the follow-up period (mean 28 months). The advantages of this procedure include the small, single, skin incision and minimal removal of the gluteus medius from the outer iliac surface. Based on our results, we believe that this procedure could be effective for the treatment of DDH.

[Parotidectomy for parotid gland tumor using a retrograde approach from the peripheral branches of the facial nerve].

There are two techniques for excising a parotid gland tumor. The first technique is the anterograde approach, and the second is the retrograde approach. Although the anterograde approach has generally been adopted, the retrograde approach may be useful depending on the identification and dissection of the facial nerve and the localization of the tumor. We reviewed 35 patients who were surgically treated with a parotidectomy using the retrograde approach between 2002 and 2012 at Tenri Hospital. We also reviewed the clinical records for evidence of temporary or definitive injury to the facial nerve. In cases where the identification of the main nerve trunk was expected to be difficult, the parotidectomy was performed using the retrograde approach guided by the mandibular branch. In cases where a tumor was located in the marginal region of the parotid gland, the retrograde approach was guided by the mandibular branch or the zygomatic branch. Of the 35 patients, 17 underwent the retrograde approach guided by the mandibular branch and 18 underwent this approach guided by the zygomatic branch. The mean surgical time and amount of bleeding using the retrograde approach were 70.7 minutes and 33.9 g, respectively. Two of the 35 patients in the retrograde group exhibited a temporary facial deficit.

Safety and efficacy of high tracheostomy with inferior retraction of the thyroid isthmus.

OBJECTIVE: In typical surgical tracheostomy, the thyroid isthmus is divided or retracted superiorly and preserved. However, at our institution, the thyroid isthmus is retracted inferiorly and preserved. Thereafter, a tracheal incision is made above the thyroid isthmus. This method, hereinafter defined as high tracheostomy, has the advantage of facilitating immediate access to the trachea in a superficial position; moreover, it can be quickly replaced with cricothyrotomy in emergency situations. However, tracheotomies placed too high can potentially damage the cricoid cartilage, thereby causing subglottic granulation and tracheal stenosis. We aimed to validate the safety and efficacy of high tracheostomy with inferior retraction of the thyroid isthmus. METHODS: This was a retrospective cohort analysis. We analyzed the operative method and other relevant characteristics of 90 patients who underwent surgical tracheostomy between April 2016 and June 2022. For those who underwent high tracheostomies, we analyzed the duration of surgery, amount of intraoperative bleeding, occurrence of complications, problems with stoma closure, and perioperative mortality. RESULTS: High tracheostomy was performed in 73 patients. Subglottic granulation occurred in one patient, and the granulation tissue spontaneously shrank. Subcutaneous emphysema occurred in two patients. No patient developed wound infection or tracheoinnominate artery fistula. Moreover, no patient experienced false route tracheotomy tube insertion because the thyroid glands were located under the stoma. CONCLUSION: The frequency of complications was comparable to that reported in other studies on tracheostomy. Additionally, no patient developed tracheal stenosis secondary to tracheostomy above the thyroid isthmus. Therefore, high tracheostomy with inferior retraction and preservation of the thyroid isthmus is safe and advantageous.

Novel evaluation method for facial nerve palsy using 3D facial recognition system in iPhone.

OBJECTIVE: While subjective methods like the Yanagihara system and the House-Brackmann system are standard in evaluating facial paralysis, they are limited by intra- and inter-observer variability. Meanwhile, quantitative objective methods such as electroneurography and electromyography are time-consuming. Our aim was to introduce a swift, objective, and quantitative method for evaluating facial movements. METHODS: We developed an application software (app) that utilizes the facial recognition functionality of the iPhone (Apple Inc., Cupertino, USA) for facial movement evaluation. This app leverages the phone's front camera, infrared radiation, and infrared camera to provide detailed three-dimensional facial topology. It quantitatively compares left and right facial movements by region and displays the movement ratio of the affected side to the opposite side. Evaluations using the app were conducted on both normal and facial palsy subjects and were compared with conventional methods. RESULTS: Our app provided an intuitive user experience, completing evaluations in under a minute, and thus proving practical for regular use. Its evaluation scores correlated highly with the Yanagihara system, the House-Brackmann system, and electromyography. Furthermore, the app outperformed conventional methods in assessing detailed facial movements. CONCLUSION: Our novel iPhone app offers a valuable tool for the comprehensive and efficient evaluation of facial palsy.

Hemostasis for a Post-tonsillectomy Hemorrhage in a Patient With Coronavirus Disease.

During the coronavirus disease 2019 (COVID-19) pandemic, otolaryngologists should be careful when performing upper airway surgery because of the risk of aerosol generation. This paper describes the case of a 23-year-old male who was diagnosed with COVID-19 four days after undergoing tonsillectomy. COVID-19 was complicated by pulmonary thromboembolism, and anticoagulation was administered, which caused postoperative hemorrhage. The patient had to undergo another surgery for the control of hemorrhage, during the infective period of COVID-19. COVID-19 is sometimes associated with venous embolism, and for postoperative patients, treatment should be carefully considered because of the risk of bleeding. The administration of heparin as an anticoagulant would be preferable because heparin allows for dosage adjustment by measuring activated partial thromboplastin time and also allows the rapid cessation of the anticoagulant effect when the administration is discontinued together with antagonization by protamine administration, even if bleeding occurs. When performing surgery for patients with COVID-19, special care is necessary in order not to spread the infection. Even if the preoperative polymerase chain reaction (PCR) test is negative, the patient may be in the incubation period of COVID-19; therefore, caution should be exercised when performing upper respiratory tract surgery such as tonsillectomy.

Validation of indications for enucleation for benign parotid gland tumors.

BACKGROUND: Enucleation has been reported as a minimally invasive surgery for Warthin's tumor (WT). However, the definite indications for enucleation have not been clarified. METHODS: Enucleation was indicated by the following findings: findings of WT, cystic fluid, or benign leukocytes by fine-needle aspiration cytology; a well-margined and homogeneous pattern on imaging; and a tumor location in the tail or preauricular area of the parotid gland. We reviewed 552 cases treated with parotid gland surgery in our hospital. RESULTS: A total of 108 tumors were treated with enucleation and included no malignant solid tumors or pleomorphic adenoma. Enucleation demonstrated low invasiveness and complication rates. Revision surgery for WT reappearance after enucleation was rare and showed minimal scarring, with a lower risk of facial weakness. CONCLUSIONS: The indication criteria for enucleation were validated. Such enucleation is useful, as it is associated with minimal invasiveness, low complication rates, and safety in revision surgery.

Comparison of in vivo bioactivity and compressive strength of a novel superporous hydroxyapatite with beta-tricalcium phosphates.

INTRODUCTION: Superporous hydroxyapatite (HAp-S) is a novel bone substitute that contains three-dimensionally interconnected macropores with micropores, which stimulate bone ingrowth into the material. METHOD: We investigated the in vivo behaviour of HAp-S by comparing its bioactivity and biomechanical properties with beta-tricalcium phosphates (ß-TCP). HAp-S or ß-TCP was implanted in the lateral femoral condyle of rabbits. In vivo bioactivity of each material, including bone ingrowth and material resorption, was quantitatively evaluated by micro-CT and the ultimate compressive strength of the bone-material composite was also measured. Micro-CT showed that bone ingrowth in the HAp-S group significantly increased over time, while no significant increase was observed after 8 weeks in the ß-TCP group. RESULTS: Although both materials showed gradual material resorption, ß-TCP resorption was significantly greater than HAp-S. The ultimate compressive strength in the HAp-S group significantly increased over time up to six times its original value, while there was no significant increase in the ß-TCP group. These results show that HAp-S resorption is concurrent with bone ingrowth, resulting in increasing compressive strength over 12 weeks. On the other hand, ß-TCP resorption is fast but unaccompanied by bone ingrowth; consequently, it remains relatively fragile at least in the early period after implantation. Although these highly porous materials themselves are structurally and mechanically similar, there are significant differences in in vivo behaviour depending on the material composition. CONCLUSION: These findings should be kept in mind when choosing the highly porous ceramics.

Classification of Voice Disorders Using a One-Dimensional Convolutional Neural Network.

OBJECTIVES: Auditory-perceptual voice analysis is a standard method for quantifying pathological voice quality, but perceptual ratings are based on subjective evaluations and therefore may vary among examiners. Although many acoustic metrics have been studied for potential use in the objective evaluation of pathological voices, the interpretation of acoustic metrics in individual cases is difficult and the technique is not widely used by clinicians. The aim of this study was to establish standardized methods to discriminate grade, roughness, breathiness, asthenia, strain (GRBAS) scale scores of pathological voices directly using one-dimensional convolutional neural network (1D-CNN) models. METHODS: We constructed an original dataset utilizing 1,377 voice samples of sustained phonation of the vowel /a/. Each voice sample was rated by three experts according to the GRBAS scale and the median values were used as the correct answer label. We designed an end-to-end 1D-CNN model with a raw voice waveform input having a frame width of 9,600 samples. The models were trained with our original dataset for each GRBAS category individually and the model performance was tested by the five-fold cross validation method. RESULTS: The accuracy, F1 score, and quadratic weighted Cohen's kappa for the testing dataset were determined. The metrics for the G scale showed the most balanced model performance, with high accuracy (0.771) and substantial agreement (kappa = 0.710). The model for the R scale had relatively high accuracy (0.765) and F1 score (0.743) with moderate agreement (kappa = 0.536). The accuracy (0.883) and the F1 score (0.865) for the S scale were the highest among the five categories, whereas the Cohen's kappa was the lowest (0.190). CONCLUSIONS: The end-to-end 1D-CNN models can evaluate overall pathological voice quality with a reliability comparable to human evaluations. The efficiency with which the machine learning models can be trained and evaluated is closely related to the dataset quality.

A New Device for Fine-Needle Aspiration Cytology Consisting of a Vibrating Linear Resonant Actuator.

OBJECTIVE: To evaluate the efficacy of a new device for fine-needle aspiration cytology (FNAC) consisting of a vibrating linear resonant actuator (LRA). STUDY DESIGN: Prospective clinical study. METHODS: The LRA frequency was optimized by visualization of the needle motion using a high-speed camera. The FNAC device consists of a vibrating motor fixed to the stopper of a 5-ml syringe and piston. Upon insertion of the syringe needle into a thyroid nodule (with the stopper attached to the syringe piston), sufficient negative pressure with 1-ml suction was maintained. Subsequently, samples were obtained using vibration generated by an LRA or an eccentric rotating mass (ERM). Surgically resected thyroid specimens from 10 patients were evaluated. The number of follicular groups required for adequate diagnosis and the number of larger follicular groups were counted. Next, 254 thyroid nodules from 187 patients were also evaluated by FNAC. The inadequacy rate was determined, and final cytology was classified according to thyroid Bethesda categories. RESULTS: The optimized LRA frequency was 155 Hz. Both the LRA and ERM devices resulted in sufficient amounts of diagnostic material and achieved low inadequacy rates. The number of large follicular groups obtained was significantly greater with the LRA device compared with the ERM device. CONCLUSIONS: The vibrating device using an LRA for thyroid FNAC resulted in sufficient amounts of thyroid follicular groups and achieved low inadequacy rates. In addition, the LRA device allowed for collection of larger follicular groups sufficient to diagnose appropriate thyroid Bethesda categories. LEVEL OF EVIDENCE: 2 Laryngoscope, 131:E1393-E1399, 2021.

Objective Assessment of Pathological Voice Using Artificial Intelligence Based on the GRBAS Scale.

OBJECTIVES: The validity and reliability of the psychological assessment of auditory perceptions, as typified by the grade, roughness, breathiness, asthenia, and strain (GRBAS) scale, have been widely recognized. However, due to their subjective nature, inter- and intra-examiner reliability are unavoidable. In this study, we aimed to add objectivity to the GRBAS scale using artificial intelligence and to compare the accuracy of two methods-one based on Google's TensorFlow and another based on Apple's Core ML. METHODS: The GRBAS scale of 1,377 vowel samples was evaluated and used as training data to create a machine learning model. We used TensorFlow and Apple's Create ML to create two machine learning models and examined the difference in their accuracies for classifying the severity of pathological Voice data based on the GRBAS scale. RESULTS: Absolute comparisons are difficult to make because of the difference in methods; however, both training models could objectively evaluate GRBAS scales and were statistically correlated in G and B. CONCLUSION: While TensorFlow requires creation of a training model from scratch, Create ML is a relatively easy way to create a training model for voice by adding training data for GRBAS scales to an existing training model for sounds. Although the data handling and learning methods are different, both models performed well. Findings from this study could be used for medical screening purposes, and there is the potential to change the clinical approach to voice diagnostics in the future.

Ear-pick injury as a traumatic ossicular damage in Japan.

This retrospective study examined the etiology and treatment results for traumatic, conductive hearing loss in 22 patients who underwent surgery between 1998 and 2008 at Osaka Red Cross Hospital. All patients underwent computed tomography (CT) of the temporal bone preoperatively. The ear surgery comprised closure of the ruptured tympanic membranes and restoration of the sound-transmitting function of the ossicular chain. Their mean age was 30.3 years, and the average delay from injury until treatment was 6.0 years. Of the injuries due to foreign-body insertion, the most common cause was ear-pick injury. Incudostapedial disarticulation was the most common finding, which was diagnosed preoperatively using CT in seven cases and identified at surgery in 15 cases. Closure of the air-bone gap to within 10 and 20 dB was observed in 50.0 and 68.2% of the patients, respectively. The hearing threshold improved by 10 dB or more in 16 (72.7%) patients. If no improvement in hearing loss follows the absorption of hemotympanium or closure of an eardrum perforation, dislocation of the ossicular bones should be suspected. Ossicular reconstruction following trauma produces more stable and better hearing results, even after delayed treatment.

Adrenal insufficiency following nivolumab therapy in patients with recurrent or metastatic head and neck cancer.

Nivolumab, an anti-programmed cell death-1 monoclonal antibody, is currently used to treat many types of advanced cancers including recurrent and metastatic head and neck cancer. However, there are increasing reports concerning immune-related adverse events related to nivolumab therapy. Here, we report three patients who presented with adrenal insufficiency following nivolumab therapy. Two were diagnosed as having isolated adrenocorticotropic hormone (ACTH) deficiency and one was diagnosed as having primary adrenal insufficiency. All three patients complained of progressive fatigue and appetite loss, so we measured their blood cortisol and ACTH levels and diagnosed them as having adrenal deficiency. Treatment with nivolumab was discontinued for all three patients, and replacement therapy using hydrocortisone was successful after a few days in all cases. Two patients subsequently resumed nivolumab therapy because their general condition had improved. Complaints of fatigue and appetite loss during cancer treatment are common and tend to be regarded as unimportant. Although adrenal insufficiency due to nivolumab is relatively rare, complaints of these symptoms could lead to the detection of adrenal insufficiency at an early stage. The present report highlights the importance of the early recognition of adrenal insufficiency.