Diagnostic Value of Synovial White Blood Cell Count and Serum C-Reactive Protein for Acute Periprosthetic Joint Infection After Knee Arthroplasty.

BACKGROUND: The diagnosis of periprosthetic joint infection (PJI) remains difficult, particularly in acute postoperative stage. The purpose of this study was to investigate the optimal cutoff value of synovial white blood cell (WBC) count, percentage of polymorphonuclear cells, erythrocyte sedimentation rate, and C-reactive protein (CRP) for diagnosing early postoperative infection after knee joint arthroplasty. METHODS: We retrospectively reviewed primary total knee arthroplasties and unicompartmental knee arthroplasties, with a knee aspiration within 3 weeks of surgery, from January 2006 to November 2016. Twelve infected cases and 185 uninfected cases met the inclusion criteria of our study. We compared the laboratory parameters (synovial WBC count, percentage of polymorphonuclear cells, erythrocyte sedimentation rate, and CRP levels) between the 2 groups. Receiver operating characteristic curves were constructed to determine the optimal cutoff values for each parameter. Each parameter was studied to determine its sensitivity, specificity, and positive and negative predictive values (PPV and NPV) in diagnosing acute PJI. RESULTS: There were 2 optimal cutoff values for synovial WBC count and CRP levels. With the cutoff value of synovial WBC set at 11,200 cells/µL, acute PJI could be diagnosed with the highest sensitivity (100%) and specificity (98.9%); with the cutoff value set at 16,000 cells/µL, the best PPV and NPV were found (100% and 99.5%, respectively). Similarly, the CRP level >34.9 mg/L had the best sensitivity (100%) and specificity (90.3%), whereas the CRP level >74.5 mg/L had the best PPV (100%) and NPV (99.2%). CONCLUSION: Synovial WBC count and CRP levels are useful in diagnosing acute PJI between 1 and 3 weeks after primary knee arthroplasty.

Ultrasound-guided injection for De Quervain's disease: Accuracy and its influenceable anatomical variances in first extensor compartment of fresh cadaver wrists.

BACKGROUND: This study was designed to evaluate the accuracy of ultrasound-guided injection targeting EPB tendon sheath and influenceable anatomical variances to the accuracy in the first extensor compartment of fresh cadaver wrists. METHODS: Thirty wrists of 15 cadavers were used. The wrists were divided into right-sided wrists (control group) and left-sided wrists (group A) to compare the accuracy of the manual injection technique (control group) and ultrasound-guided injection technique (group A) targeting EPB tendon sheath. To estimate the influence of anatomical variances within first extensor compartment to the accuracy of each injection techniques, control group (manual injection group) was divided into Control group I (right-sided wrists without septum) and II (right-sided wrists with septum) and group A (ultrasound-guided injection group) was also divided into group AI (left-sided wrists without septum) and group AII (left-sided wrists with septum), respectively. After the methylene blue dye injection, the location of methylene blue dye and anatomical variances in the first extensor compartment was identified by dissection. RESULTS: The accuracy was higher in the group A (93.3%) than in control group (40.0%, p < 0.05). The accuracy in control group I (55.6%) was higher than in control group II (16.7%, p < 0.05). The accuracy between group AI (100%) and group AII (85.7%) was not significantly different (p > 0.05). Wrists with more EPB or APL tendon slips showed a tendency not to have septum and all intratendinous injections was occurred in the wrist with 1 EPB tendon slip or 1 or 2 APL tendon slip. CONCLUSIONS: Ultrasound-guided injection targeting EPB tendon ensures correct needle placement through the visualization of compartmental anatomy and improves accuracy of injection though the septum in first extensor compartment encourage inaccurate injections.

Open debridement and prosthesis retention is a viable treatment option for acute periprosthetic joint infection after total knee arthroplasty.

PURPOSE: Open debridement with prosthesis retention (ODPR) has been considered as a reasonable treatment option for acute periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). However, multiple recent studies have challenged this contention. This study was undertaken to determine the success rate of ODPR, whether the success rate was affected by the ODPR timing or by the microorganisms. METHOD: We retrospectively reviewed 52 cases of ODPR performed in four institutions to treat acute PJI which met the definition of PJI by the International Consensus Group on PJI. We recorded patient demographics; time from index TKA and symptom duration; the microorganisms involved; and whether the infection was controlled or not. RESULTS: The overall success rate of ODPR was 71 %, and early postoperative infection and acute hematogenous infection had a success rate of 82 and 55 %, respectively. Success rate was associated with a shorter symptom duration in patients with acute hematogenous infections (p = 0.040). However, success was not influenced by the type (p = 0.992) or virulence of the causative microorganisms (p = 0.706). CONCLUSION: ODPR should be considered as a viable treatment option for acute PJI following TKA. The promptness of ODPR is of paramount importance for success of ODPR, rather than the causative organism type or virulence.

Differences in bone mineral density between the right and left hips in postmenopausal women.

Bone mineral density (BMD) using dual energy radiography absorptiometry are commonly used for the diagnosis of osteoporosis. It is usually measured at the spine and also at one hip joint. Controversy still exists regarding the use of bilateral hip scanning. We analyzed the difference of BMD at bilateral hips in 384 postmenopausal women, retrospectively. The concordance and discordance rates of the lowest T-score and BMD between both hips were evaluated. The BMDs of the femoral neck and trochanter were significantly different between both hips (P < 0.05). There were also discrepancies between the lowest T-scores of both hips (P < 0.05). The discordance rates were about 30%. Due to significant differences in BMD between both hips at the femoral neck and trochanter and high discordance rate, bilateral hip measurements using DEXA are recommended to avoid underestimating osteoporosis.

Natural progress of D-dimer following total joint arthroplasty: a baseline for the diagnosis of the early postoperative infection.

BACKGROUND: Early detection followed by prompt intervention is essential for the treatment of periprosthetic joint infection (PJI). D-dimer, a fibrin degradation product, characteristically changes rapidly during early postoperative period and has a short half-life. The aim of this prospective study was to measure postoperative change of D-dimer level after joint arthroplasty in conjunction with ESR and CRP. METHODS: ESR, CRP, and D-dimer levels were measured on the day before surgery, postoperative days 1, 2, 3, and 5 and weeks 2 and 6 in 65 patients who underwent elective primary total hip arthroplasty (38 hips in 38 patients) or total knee arthroplasty (27 knees in 27 patients). We compared perioperative changes of the three biomarkers. RESULTS: ESR level was elevated from postoperative day 1 and reached a peak level of 45 mm/h at postoperative day 5. The elevation persisted until postoperative week 6. CRP level was elevated from postoperative day 1 and reached a peak level of 10 mg/dl between postoperative day 2 and day 3. The CRP level was decreased to the normal level around postoperative week 2. D-dimer level was sharply elevated and peaked to 4.5 µg/dl at postoperative day 1. At postoperative day 2, it decreased to baseline level. After then, it slowly elevated again and reached a second peak at postoperative week 2. CONCLUSION: D-dimer showed a more rapid rise and fall than ESR and CRP in very early postoperative period. The D-dimer test might be effective in early detection of PJI, if combined with levels of ESR and CRP. The postoperative change of D-dimer in our study can serve as a baseline for early diagnosis of PJI.

The role of transforming growth factor-beta and bone morphogenetic protein with fibrin glue in healing of bone-tendon junction injury.

Bone-tendon junction injuries have poor healing potential. This study evaluated the role of TGF-beta and BMP-2 in a fibrin glue carrier in healing of injuries at bone-tendon junction. Seventy-two skeletally mature male rabbits were divided into 4 groups. The tendo-Achilles was surgically transected at its insertion and reattached with a pullout suture. Group 1 served as a control. In groups 2, 3, and 4, fibrin glue, a mixture of TGF-beta and fibrin glue, and a mixture of BMP-2 and fibrin glue were injected into the bone-tendon junction. The animals were sacrificed at 2, 4 and 8 weeks after surgical procedure. The addition of TGF-beta to fibrin glue did not significantly improve the biomechanical properties of repair tissue. BMP-2 in combination with fibrin glue accelerates healing in a bone-tendon injury and also improves the histological and biomechanical properties of the repair tissue so formed.

Isolated smoke inhalation injuries: acute respiratory dysfunction, clinical outcomes, and short-term evolution of pulmonary functions with the effects of steroids.

Relatively few reports exist regarding isolated smoke inhalation injuries in human patients. In this study, we describe the acute manifestations and short-term evolution of respiratory injuries after isolated smoke inhalation in victims of fires. Ninety-six patients admitted as the result of a subway fire were examined for acute respiratory dysfunction with clinical outcomes. Some of the survivors suffering from less severe injuries were evaluated for changes in pulmonary function over time, with the effects of steroid treatment. In 13 patients (14%), immediate respiratory failure resulted from ventilatory insufficiency, which was induced principally by mechanical airway obstruction, and manifested as significantly lowered pH and higher PaCO2 levels than in the patients requiring no mechanical ventilation. Toilet bronchoscopy allowed for early liberation from mechanical ventilation. Along with the death of 4 patients (4%), vocal cord and tracheal stenosis were noted in 5 patients and 1 patient, respectively, among 17 patients for whom endotracheal intubation was required. Pulmonary functions improved significantly after 3 months, with no further changes being observed within the subsequent 3 months. Steroid therapy resulted in no additional improvements in the pulmonary functions of these patients. In patients with isolated smoke inhalation injuries, immediate ventilatory insufficiency resulting from mechanical airway obstruction should be watched for, and managed via toilet bronchoscopy. Vigilance is required to avoid airway complications after endotracheal intubation. The improvement of pulmonary functions progressed primarily within the first 3 months, whereas short-course steroid therapy exerted no influence on the eventual recovery of pulmonary functions in the less severe cases.

The Effect of Valsalva Leak Point Pressure on Outcomes of the Needleless ®System in Female Stress Urinary Incontinence.

PURPOSE: This study aimed to investigate the effects of preoperative Valsalva leak point pressure (VLPP) on the outcomes of the single-incision midurethral sling procedure (Needleless® System) in female stress urinary incon­tinence (SUI). MATERIALS AND METHODS: We evaluated 112 patients who underwent midurethral sling placement for SUI using the Needleless® System. Patients were divided into two groups according to their preoperative VLPP values: VLPP >90 cmH2O (group 1) and VLPP 60-90 cmH2O (group 2). After the postoperative period, SUI status and satisfac­tion were compared between the two groups. Subjective cure was defined as the absence of any episodes of urinary incontinence associated with conditions that increase intra-abdominal pressure in daily life. Treatment satisfaction was analyzed according to patient responses as 'satisfied', 'neutral', and 'dissatisfied'. Postoperative other lower urinary tract symptoms except SUI were compared between the two groups too. RESULTS: There were no significant differences in age, body weight, and urodynamic parameters (except VLPP) between the two groups. The mean VLPPs were 105.9 ± 12.3 cmH2O (range, 93.6-118.2 cmH2O) in group 1 and 75.4 ± 10.5 cmH2O (range, 65-85.9 cmH2O) in group 2. The overall subjective cure rates were 65.0% in group 1 and 62.5% in group 2 (P = .744). The overall satisfaction rates were 58.8% in group 1 and 68.8% in group 2 (P = .600). Complication rates did not differ between the two groups. CONCLUSION: When stratified as > 90 cmH2O or ≤ 90 cmH2O, preoperative VLPP did not affect Needleless® Sys­tem outcomes in female SUI patients.

Preoperative factors affecting postoperative early quality of life during the learning curve of holmium laser enucleation of the prostate.

PURPOSE: The aim of this study was to investigate the preoperative factors related to early quality of life (QoL) in patients with benign prostatic hyperplasia after holmium laser enucleation of the prostate (HoLEP) during the surgeon's learning curve. METHODS: The medical records of 82 patients with a follow-up period of at least 3 months who were treated with HoLEP during the time of a surgeon's learning curve were analyzed retrospectively. We divided the patients into two groups on the basis of the QoL component of the International Prostate Symptom Score (IPSS) 3 months after HoLEP: the high QoL group (IPSS/QoL≤3) and the low QoL group (IPSS/QoL≥4). Preoperative factors in each group were compared, including prostate volume, prostate-specific antigen, history of acute urinary retention (AUR), urgency incontinence, IPSS, and urodynamic parameters. Detrusor underactivity was defined as a bladder contractility index less than 100 on urodynamic study. RESULTS: A total of 61 patients (74.3%) had a high QoL, whereas 21 (25.7%) had a low QoL. A history of AUR, detrusor pressure on maximal flow (PdetQmax), bladder outlet obstruction grade, bladder contractility index, and detrusor underactivity were associated with postoperative QoL in the univariate analysis. In the multivariate analysis, a history of AUR and PdetQmax were independent factors affecting postoperative QoL. CONCLUSIONS: A history of AUR and bladder contractility affect early QoL, and preoperative urodynamic study plays an important role in the proper selection of patients during the HoLEP learning curve.

Glucosamine hydrochloride specifically inhibits COX-2 by preventing COX-2 N-glycosylation and by increasing COX-2 protein turnover in a proteasome-dependent manner.

COX-2 and its products, including prostaglandin E(2), are involved in many inflammatory processes. Glucosamine (GS) is an amino monosaccharide and has been widely used for alternative regimen of (osteo) arthritis. However, the mechanism of action of GS on COX-2 expression remains unclear. Here we describe a new action mechanism of glucosamine hydrochloride (GS-HCl) to tackle endogenous and agonist-driven COX-2 at protein level. GS-HCl (but not GS sulfate, N-acetyl GS, or galactosamine HCl) resulted in a shift in the molecular mass of COX-2 from 72-74 to 66-70 kDa and concomitant inhibition of prostaglandin E(2) production in a concentration-dependent manner in interleukin (IL)-1beta-treated A549 human lung epithelial cells. Remarkably, GS-HCl-mediated decrease in COX-2 molecular mass was associated with inhibition of COX-2 N-glycosylation during translation, as assessed by the effect of tunicamycin, the protein N-glycosylation inhibitor, or of cycloheximide, the translation inhibitor, on COX-2 modification. Specifically, the effect of low concentration of GS-HCl (1 mM) or of tunicamycin (0.1 microg/ml) to produce the aglycosylated COX-2 was rescued by the proteasomal inhibitor MG132 but not by the lysosomal or caspase inhibitors. However, the proteasomal inhibitors did not show an effect at 5 mM GS-HCl, which produced the aglycosylated or completely deglycosylated form of COX-2. Notably, GS-HCl (5 mM) also facilitated degradation of the higher molecular species of COX-2 in IL-1beta-treated A549 cells that was retarded by MG132. GS-HCl (5 mM) was also able to decrease the molecular mass of endogenous and IL-1beta- or tumor necrosis factor-alpha-driven COX-2 in different human cell lines, including Hep2 (bronchial) and H292 (laryngeal). However, GS-HCl did not affect COX-1 protein expression. These results demonstrate for the first time that GS-HCl inhibits COX-2 activity by preventing COX-2 co-translational N-glycosylation and by facilitating COX-2 protein turnover during translation in a proteasome-dependent manner.

Stress fractures of the femoral diaphysis in children: a report of 5 cases and review of literature.

The authors report five new cases of the stress fracture of the femoral diaphysis in children. These injuries usually occurred without a history of recent increase of activity. Recently regained normal activity after long-term immobilization and a fibrous cortical defect were predisposing factors. The periosteal reactions were usually identified in the initial radiograph and were not confined to the medial cortex of the distal femur; they might occur in any part of the femoral diaphysis, and also concomitantly on the multiple cortex. The atypical radiographic presentations frequently required MRI for differential diagnosis. Even though the MRI may be confusing to the inexperienced observer, it can lead to the diagnosis of a stress fracture with confidence, negating the need for biopsy. Clinicians should be aware of this diagnostic entity in the differential diagnosis of femoral diaphyseal lesions in children because the occurrence might be more common than reported. Serial simple radiographic examinations taken at intervals to look for the evidence of progressive fracture healing and the restriction of activity or immobilization may be an adequate approach for management.

Cytogenetic Study in Suspicious Cases of Malignant Pleural Effusion.

PURPOSE: This study was performed to detect malignant cells in suspicious cases of malignant pleural effusion by cytogenetic analysis. MATERIALS AND METGODS: Eleven cases with pleural effusion were included in this study. Cells in pleural effusion were treated by direct, or short term, culture to prepare chromosomes. To analyze chromosomes, the G-banding method was used. RESULTS: Chromosome preparations succeeded in 10 cases. 5 cases had normal karyotypes, but in 2 of these cases malignant cells were detected on cytological examination. The other 5 cases had abnormal chromosomes, but on cytological examination showed normal cell appearances. CONCLUSION: Cytogenetic analysis of pleural effusions is not used routinely, but is more sensitive than the cytological examination of malignant pleural effusions. So, chromosome analysis is a good diagnostic tool, when chromosomal abnormalities are detected in an effusion. If a combination of cytology and cytogenetic study are used, the chance of detecting malignant cells in pleural effusion will be higher, and then more invasive diagnostic procedures, such as thoracoscopy or thoracotomy, could be avoided.