Augmented Reality- vs Accelerometer-Based Portable Navigation System to Improve the Accuracy of Acetabular Cup Placement During Total Hip Arthroplasty in the Lateral Decubitus Position.

BACKGROUND: There have been no studies regarding the effectiveness of augmented reality (AR)-based portable navigation systems compared with accelerometer-based portable navigation systems in total hip arthroplasty (THA). METHODS: We retrospectively compared THAs performed using an AR-based portable navigation system (n = 45) and those performed using an accelerometer-based portable navigation system (n = 42). All THAs were performed with the patient in the lateral decubitus position. The primary outcome was the absolute difference between cup placement angles displayed on the navigation screen and those measured on postoperative X-ray. RESULTS: The mean absolute differences were significantly smaller in the AR-based portable navigation system group than the accelerometer-based portable navigation system group in radiographic inclination (2.5° ± 1.7° vs 4.6° ± 3.1°; 95% confidence interval 1.1°-3.2°, P < .0001). Similarly, the mean absolute differences were significantly better in the AR-based portable navigation system group in radiographic anteversion (2.1° ± 1.8° vs 6.4° ± 4.2°; 95% confidence interval 3.0°-5.7°, P < .0001). Neither hip dislocation, surgical site infection, nor other complications associated with use of the navigation system occurred in either group. CONCLUSION: The AR-based portable navigation system may provide more precise acetabular cup placement compared with the accelerometer-based portable navigation system in THA.

Positivity rate of interferon-γ release assays for estimating the prevalence of latent tuberculosis infection in renal transplant recipients in Japan.

Renal transplant recipients are at increased risk of reactivating latent tuberculosis infection (LTBI) and developing active tuberculosis. QuantiFERON®-TB Gold Plus (QFT-Plus) has two TB-specific antigens tubes (TB1 and TB2). TB1 elicits CD4 T-cell response, and TB2 elicits both CD4 and CD8 T-cells responses, with expected increased sensitivity. The aim of this study was to estimate the prevalence of LTBI in renal transplant recipients in Japan. We conducted a cross-sectional study by using two interferon-γ release assays (IGRAs), QFT-Plus and T-SPOT®.TB (TSPOT). One hundred thirty-five recipients were prospectively enrolled. The median age was 49 years (range: 20 to 79). The positivity rates of QFT-Plus and TSPOT were 5.9% (95%CI 3.0-11.3) and 3.7% (95%CI 1.6-8.4), respectively, with no significant difference. The concordance rate was 95.5% (κ coefficient, 0.76). Age of 60 years and higher was related to the higher positivity rate in both QFT-Plus and TSPOT. The positivity rates of TB1 and TB2 were 5.1% (95%CI 2.5-10.2) and 5.9% (95%CI 3.0-11.2), respectively, with no significant difference. The concordance rate was 99.3% (κ coefficient, 0.93). TB2 did not show a higher positivity rate compared with TB1. The estimated prevalence of LTBI by using the both IGRAs was 3.7-5.9% in renal transplant recipients. These results were equivalent to the IGRAs positivity rate in the general Japanese population, even under the condition of immunosuppressive therapy. In consideration of the higher risk of developing active TB from LTBI, we can use both IGRAs as acceptable tools for LTBI diagnosis in renal transplant recipients.

Impact of primary diabetic nephropathy on arteriolar hyalinosis lesions in patients following kidney transplantation.

AIM: Arteriolar hyalinosis (AH) is a common lesion in allograft biopsies taken following kidney transplantation. Recent studies have shown that severe AH may predict transplant outcomes and provide information about previous exposure to certain drugs, such as calcineurin inhibitors (CNI). However, the incidence of AH as a direct result of diabetic nephropathy (DN) after kidney transplantation has not been fully evaluated. This study aimed to assess the impact of primary DN on the development of AH lesions in patients who underwent kidney transplantation. METHODS: Eighty-three patients who underwent living-donor kidney transplantation between April 2005 and June 2015 were enrolled in this study. A total of 33 patients had DN prior to transplantation. Allograft biopsies were scored according to the Banff classification, and the relationship between the individual histological lesions and clinical baseline data was assessed. RESULTS: At early biopsy (3-12 months), there were no differences in the rates of AH lesions between the DN group and the non-DN group (ah ≥ 1: 37% vs. 41.3%, P = 0.719; aah ≥ 1: 14.8% vs. 6.5%; P = 0.453). However, there were significant differences between the groups in biopsies taken more than 3 years after the transplant (ah ≥ 2: 83.3% vs. 36.8%, P = 0.013; aah ≥ 2: 66.7% vs. 21.1%, P = 0.011). Multivariable analysis showed that both the length of time after transplantation and the presence of DN were independent risk factors for ah ≥ 2 (odds ratio [OR]: 2.55, 95% confidence interval [CI]: 1.47-19.54, P = 0.011) and aah ≥ 2 (OR: 7.55, 95% CI: 1.49-38.33, P = 0.015). CONCLUSION: This is the first report showing that the presence of primary DN disease contributes to the development of severe AH late in the course after kidney allografts.

Comparison of interferon-γ release assays, QuantiFERON TB-GIT and T-Spot.TB, in renal transplantation.

Renal transplant recipients are at increased risk of reactivating latent tuberculosis infection (LTBI) and progressing to active tuberculosis (TB). This study was conducted in National hospital for tuberculosis and renal transplantation (RT) in Japan. The purpose is to compare two interferon-γ release assays (IGRAs), QuantiFERON®-TB Gold in Tube (QFT) and T-SPOT®.TB (TSPOT), in patients after renal transplantation for detecting latent TB infection (LTBI). Total 92 renal transplant recipients (median age 46 years, range 17-75) were prospectively enrolled, and QFT and TSPOT were concurrently examined. Total subjects were 92 patients (median age 46 years, range 17-75). The positive rate in QFT and TSPOT were 6.5% (95% confidence interval (CI) 3.0-13.5) and 2.2% (95% CI 1.0-7.6), respectively. There was a significant difference in IGRAs positivity (P < 0.05). The negative rate in QFT and TSPOT were 91.3% (95% CI 83.8-95.5) and 95.7% (95% CI 89.3-98.3), respectively. There was no significant difference in IGRAs negativity. No patients among either IGRAs negative patients developed active TB during median follow-up of 994 days. Neither QFT nor TSPOT reaches estimated TB infection rate in Japan, especially elderly recipients aged 60 year-old or more. Therefore, both IGRAs might underestimate LTBI owing to immune suppressive therapy and aging. Physicians for renal transplantation need to understand the characteristics of both IGRAs and pay attention to the possibility of developing active TB even in patients of negative IGRAs results.

Focal segmental glomerular sclerosis recurrence with massive proteinuria and anuria immediately after kidney transplantation.

Here, we report a case of focal segmental glomerular sclerosis (FSGS) recurrence immediately (47 minutes) after transplantation. A 1-hour biopsy specimen showed large periodic acid-Schiff-positive granules within the cells of the swollen proximal tubule, while electron microscopy revealed podocyte swelling and partial foot process effacement. These findings were worse on day 2 biopsy. Massive proteinuria and anuria were then observed. Two courses (2 × 2 times) of plasmapheresis and rituximab were administered, and the graft function gradually recovered. A day 22 biopsy specimen showed improvement in findings compared to those observed on day 2. One year after transplantation, no signs of FSGS recurrence are evident, and graft function remains good.

Surgical advantages of gastric SMTs by laparoscopy and endoscopy cooperative surgery.

BACKGROUND/AIMS: The treatment of gastric submucosal tumors (SMTs) is strictly surgical and enucleation of the tumor or wedge resection of the stomach is efficient to achieve R0 resection. Laparoscopic and endoscopic cooperative surgery (LECS) can be safely performed with adequate cutting lines. This study describes the initial 16 cases treated by LECS and evaluates the advantages by LECS for gastric SMTs retrospectively. METHODOLOGY: Sixteen patients with gastric SMT underwent LECS from June 2007 to December 2010, their surgical data, clinical characteristics and surgical specimens of SMTs were compared. The surgical specimens of 9 gastric SMTs treated by laparoscopic wedge resection (LWR) were compared as a control. RESULTS: The median (range) length of operation time, blood loss, hospital stay after surgery were minutes 172 (115- 220), <5mL (<5-115) and 10 days (6-17), respectively. The median (range) ratio of the longest diameter of the tumor divided by the longest diameter of the surgical specimen in LECS and LWR were 0.86 (0.625-1.0) and 0.69 (0.44-1.0), respectively (p=0.0189, Wilcoxon rank sum test). CONCLUSIONS: LECS minimizes the surgical specimen while still providing sufficient surgical margins to successfully cure gastric SMTs.

A double-scope technique enabled a patient with an esophageal plastic fork foreign body to avoid surgery: a case report and review of the literature.

Foreign body ingestion is a common problem, and endoscopic removal is often performed with ancillary equipment. However, long, sharp foreign bodies are much more difficult to remove endoscopically than other objects and require emergent surgery. A 68-year-old man with a history of distal gastrectomy accidentally swallowed a plastic fork. He complained of chest pain at the visit. The plastic fork was located between the thoracic esophagus and remnant stomach. Endoscopic removal of the plastic fork was considered difficult, and surgery was deemed necessary. However, we were able to avoid surgery to remove the object using two endoscopes with hoods and a polypectomy snare. The first endoscope covered the sharp edge with a hood, and the snare grasped the neck of the plastic fork. The second endoscope covered the remaining sharp tip. A single operator held the two endoscopes and the snare and pulled them out together. This new double-scope technique is simple and useful for removing long, sharp foreign bodies, such as forks, from the esophagus.

Stener-like lesions of collateral ligament ruptures of the metacarpophalangeal joint of the finger.

BACKGROUND: The Stener lesion of the ulnar collateral ligament of the metacarpophalangeal (MP) joint of the thumb is characterized by an interposition of the adductor aponeurosis between a distally avulsed ligament and its insertion into the base of the proximal phalanx. Stener-like lesions of the MP joint of the finger have been previously reported in only a few cases. METHODS: The authors experienced 38 cases of collateral ligament injuries of the MP joint of the finger. The two most frequently affected sites were the radial side of the little finger (21 cases) and the radial side of the ring finger (8 cases). We have previously reported some of these cases (22 cases), as well as clinical features and arthrographic findings. One Stener-like lesion in a collateral ligament injury of the MP joint of the ring finger was also reported earlier (Ishizuki, 1988). Additionally, Stener-like lesions were found postoperatively in six of eight cases surgically treated for collateral ligament injuries of the MP joint of the finger (little finger involvement in 5 cases and long finger involvement in 1 case). RESULTS: We experienced six cases of a Stener-like lesion of the MP joint of the finger. In five of these cases the distally avulsed collateral ligament was trapped by the opened window of the injured sagittal band. In the other case the ligament was avulsed at a proximal site, and the ruptured end was trapped by the sagittal band. All of the little fingers involving Stener-like lesions were abducted and unable to adduct. Therefore, an abducted little finger is an important sign of this lesion and is considered to warrant surgical treatment. Arthrograms provided information useful for identifying the lesions. In the radial three fingers, palpation of the tumor at the level of the collateral ligament may also be an important examining tool for identifying a displaced ruptured collateral ligament of the MP joint of the finger. CONCLUSION: We experienced six cases of Stener-like lesions of the MP joint of the finger. In all cases, the avulsed collateral ligament was trapped by the ruptured sagittal band. Surgical treatment was thought to be indicated in these cases. Therefore, it is important to avoid overlooking Stener-like lesions of the MP joint of the finger.

The Clinical Pathway with Regional Alliance (CPRA) system for proximal femoral fractures in the southern region of Ibaraki prefecture: comparison of the proportion of patients who return to living at home from acute care and rehabilitation (kaihukuki) hospitals.

Objective: We investigated whether elderly patients treated for a proximal femoral fracture would be able to return home. Patients and Methods: The subjects of this study were 834 patients. We defined the acute care hospital group as patients who returned home from the acute care hospital and the kaihukuki group as patients who were transferred from an acute care hospital to a rehabilitation hospital. We recorded the proportion of patients who returned home. We also analyzed walking ability and the Barthel index (BI) of patients. Results: After 2013, the proportion of patients who returned home from the acute care hospital fell below 20%. The proportion of patients who returned home from the kaihukuki hospital stayed within the 75-85% range. The BI before injury and at discharge was 86 and 76 points, respectively, in the acute care hospital group. The acute care hospital group included patients who walked without an aid before the injury or when leaving the hospital. In the kaihukuki group, the BI before an injury, at admission, and at discharge from the rehabilitation hospital was 85, 56, and 74 points, respectively. In the kaihukuki group, the ability of patients to walk recovered more slowly than that of patients in the acute care hospital group. Conclusion: Walking ability and BI are important factors for determining whether patients with a proximal femoral fracture are able to return home.

A Case of Epstein-Barr Virus-Associated Leiomyosarcoma Concurrently With Posttransplant Lymphoproliferative Disorders After Renal Transplantation.

Epstein-Barr virus (EBV) infection might induce not only posttransplantation lymphoproliferative disorder (PTLD) but also leiomyosarcoma. We report a case of EBV-associated leiomyosarcoma concurrently with PTLD after renal transplantation. The patient was a 30-year-old woman who underwent living donor kidney transplantation at 27 years of age. Preoperative EBV viral capsid antibody immunoglobulin M, immunoglobulin G (IgG), and EBV nuclear antigen IgG were negative. Multiple lung and liver tumors were detected 1.5 years after transplantation. She was diagnosed with PTLD after tumor biopsy. Her EBV DNA was 110 copies/mL detected by real-time polymerase chain reaction when PTLD was diagnosed. She received dose reduction of immunosuppressive therapy and several chemotherapies. Because her hepatic lesion was still progressive while pulmonary lesion was reduced, a liver tumor biopsy was performed, but the biopsy specimens were necrotic. A left lateral segmentectomy was performed as a third biopsy for treatment-resistant hepatic lesion 2.5 years after her first PTLD diagnosis. Pathologically, she was diagnosed with EBV-associated leiomyosarcoma. She was treated with sirolimus, but died 7 months after the operation. This is the first case of the coincidence of leiomyosarcoma associated with EBV and PTLD. This case was exceedingly rare; however, we must consider the coincidence of leiomyosarcoma associated with EBV and PTLD when encountering treatment-resistant PTLD.

A Novel Method for Real-Time Audio Recording With Intraoperative Video.

OBJECTIVE: Although laparoscopic surgery has become widespread, effective and efficient education in laparoscopic surgery is difficult. Instructive laparoscopy videos with appropriate annotations are ideal for initial training in laparoscopic surgery; however, the method we use at our institution for creating laparoscopy videos with audio is not generalized, and there have been no detailed explanations of any such method. Our objectives were to demonstrate the feasibility of low-cost simple methods for recording surgical videos with audio and to perform a preliminary safety evaluation when obtaining these recordings during operations. DESIGN: We devised a method for the synchronous recording of surgical video with real-time audio in which we connected an amplifier and a wireless microphone to an existing endoscopy system and its equipped video-recording device. We tested this system in 209 cases of laparoscopic surgery in operating rooms between August 2010 and July 2011 and prospectively investigated the results of the audiovisual recording method and examined intraoperative problems. SETTING: Numazu City Hospital in Numazu city, Japan. PARTICIPANTS: Surgeons, instrument nurses, and medical engineers. RESULTS: In all cases, the synchronous input of audio and video was possible. The recording system did not cause any inconvenience to the surgeon, assistants, instrument nurse, sterilized equipment, or electrical medical equipment. Statistically significant differences were not observed between the audiovisual group and control group regarding the operating time, which had been divided into 2 slots-performed by the instructors or by trainees (p > 0.05). CONCLUSIONS: This recording method is feasible and considerably safe while posing minimal difficulty in terms of technology, time, and expense. We recommend this method for both surgical trainees who wish to acquire surgical skills effectively and medical instructors who wish to teach surgical skills effectively.