Outcome and complication rate of total hip arthroplasty in patients younger than twenty years: which bearing surface should be used?

PURPOSE: Total hip arthroplasty (THA) in younger patients remains controversial due to concerns regarding long-term implant survival and potential complications. This study aimed to evaluate long-term clinical outcomes, complications, differences in complication and revision rates by bearing surfaces, and Kaplan-Meier survival curves for THA in patients under 20 years old. METHODS: A retrospective review was conducted for 65 patients (78 hips) who underwent THA between 1991 and 2018. Their mean age was 18.9 years. Their clinical outcomes were assessed using the Harris Hip Score (HHS). Radiological outcomes were evaluated based on the presence of loosening, osteolysis, and heterotopic ossification. Complications such as dislocation, periprosthetic fractures, and infections were assessed. The mean follow-up period was 13.2 years (range, 5.0-31.2 years). RESULTS: The mean HHS improved from 44.6 to 90.1. There were two cases of dislocation. However, no periprosthetic fracture, deep infection, or ceramic component fracture was noted. There were 19 revisions of implants. Eighteen of 19 hips were operated with hard-on-soft bearings in the index surgery (p < 0.01). The 23-year survivorship was 97.8% for THA using ceramic-on-ceramic bearings, while the 31-year survivorship was 36.7% using hard-on-soft bearings. CONCLUSION: THA in patients under 20 years old yielded promising clinical and radiological outcomes, although polyethylene-bearing-related concerns persisted. Previously operated patients with hard-on-soft bearing should be meticulously examined during the follow-up. As ceramic-on-ceramic bearing showed excellent survivorship in this particular cohort, we recommend the use of this articulation as the bearing of choice.

Effect of severity and cause of preoperative anemia on the transfusion rate after total knee arthroplasty.

This study aimed to (1) evaluate the preoperative Hb cut-off value for transfusion after unilateral and bilateral staged (1 week apart) TKAs, respectively, and (2) determine whether cause of preoperative anemia can affect transfusion rate after TKA. A total of 951 patients who underwent TKA (unilateral: 605, bilateral staged: 346) from 2016 to 2019 were reviewed retrospectively. Patient demographics, comorbidities, preoperative Hb level, surgery types, and cause of anemia were evaluated as possible risk factors. The cut-off values for preoperative Hb level to reduce transfusion after TKA were evaluated in each surgery type. Preoperative Hb level, surgery type, and cardiac disease were identified as the risk factors for transfusion after TKA, and preoperative Hb levels of 11.8 (AUC 0.88) and 12.8 (AUC 0.76) were the cut-off values for transfusion after unilateral and staged bilateral TKAs, respectively. Although transfusion rate was higher in anemia with iron deficiency (ID) group than anemia without ID group, preoperative Hb level was also lower in anemia with ID group than anemia without ID group. Single use of preoperative Hb level with different cut-offs depending on the surgery types can be useful indicator for preoperative optimization regardless of cause of anemia.

Evaluation and management of facial granuloma caused by various injection materials.

BACKGROUND: Various substances are currently being used for cosmetic or postsurgical reconstruction reasons. Injecting of various materials into the face may provoke inflammatory or granulomatous reactions, infection and tissue necrosis. Among these reactions are foreign body granulomas. This study aims to describe the clinical characteristics of and therapeutic approaches used in patients with facial foreign body granulomas caused by the injection of various substances. METHODS: From 2007 to 2020, a total of 64 patients visited our hospital due to inflammatory signs, palpable masses or surface irregularities. We reviewed patient characteristics, type of injected material, medical history and treatment outcomes. The treatment results were scored with patient satisfaction and statistical analysis of the treatment period was performed. RESULTS: Most patients underwent conservative treatment followed by surgical treatment because of persistent symptoms; one patient did not require surgery. All patients reported good treatment results and satisfaction. The earlier the surgical treatment was performed, the shorter the treatment period and the higher patient satisfaction scoring. CONCLUSION: Granulomatous changes to the face are an emerging concern in various cosmetic procedures and surgeries, including fillers, silicone implants and autologous fat injections. Our findings strongly suggest that patient symptoms require accurate diagnosis and surgical treatment.

Surgical management in a severe OSA patient diagnosed with Stickler syndrome.

Stickler syndrome is a genetic disorder of connective tissue. One of the major symptoms associated with this disorder is an oro-facial malformation, which may cause a submucous cleft or a complete cleft of the hard palate. A 32-year-old man diagnosed with Stickler syndrome and a submucosal cleft palate (SMCP) visited our hospital with a chief complaint of excessive daytime sleepiness. The patient was diagnosed with severe obstructive sleep apnea (OSA), and administration of a polysomnography test revealed an apnea-hypopnea index (AHI) of 30.9 events/hour (h). Auto-titrating continuous positive airway pressure was initiated to control the OSA symptoms and subsequently the patient showed some improvement. However, due to continuous velopharyngeal insufficiency symptoms, intravelar veloplasty was performed. Three months after surgery, the AHI had decreased to 12.4 events/h. Recent studies have described a greater risk for OSA in individuals with cleft palate, than in the general population. The present case demonstrates surgical success in a patient with OSA and SMCP, suggesting that palatal surgery may be considered an optional surgical treatment for OSA patients with SMCP.

Comparisons between fresh and cryopreserved fat injections in facial lipofilling.

BACKGROUND: Autologous fat is considered an ideal filler material, and the use of cryopreserved fat grafts is promising in terms of flexibility and efficiency. Therefore, cryopreserved fat grafts have become more common in recent years; however, their complications require further consideration. METHODS: We evaluated 53 patients who underwent facial lipofilling at our institution to confirm the clinical usefulness and safety of cryopreserved fat. Fresh fat injections with or without cryopreserved fat were administered. At one or more sites, 22 patients had a single fresh fat injection, four patients had two or more fresh fat injections, 16 patients had one fresh fat injection followed by one cryopreserved fat injection, six patients had one fresh fat injection followed by two cryopreserved fat injections, and five patients had two fresh fat injections and one or more cryopreserved fat injections. RESULTS: In total, 281 sets of injection procedures were performed at various sites, of which 170 involved one fresh fat injection, 89 involved one fresh fat injection and one cryopreserved fat injection, and 11 involved one fresh fat injection and two cryopreserved fat injections. One patient experienced self-resolving inflammation as a complication after the second injection in the right cheek. No statistically significant differences were found between the fresh and cryopreserved fat injections. CONCLUSION: We suggest that cryopreserved fat is a useful and safe resource for multiple fat injections, with advantages including aseptic fat handling and the delicacy of the technique.

Cutaneous metastatic renal cell carcinoma to the scalp.

Renal cell carcinoma (RCC) represents 2% to 3% of human cancers and is aggressive, with metastatic capability. The frequent metastatic sites are lung, bone, and liver. Reports of RCC metastatic to skin, and especially scalp are rare. Here we present an 83-year-old woman who was diagnosed with RCC 19 years prior and had a metastatic scalp lesion. An 83-year-old woman presented with a red-to-purple, protruding lesion at the right parietotemporal area. Twenty-three years ago, a right renal mass was incidentally discovered on ultrasound through a routine medical examination. She underwent right nephrectomy for RCC 4 years later. Five months after nephrectomy, new lung nodules were observed. Fifteen years after nephrectomy, metastatic lesions were found in the pelvic bone. She visited dermatology department for evaluation of the new scalp lesion, a year before she first visited our department. Despite chemotherapy, the mass was gradually enlarged. She consulted the plastic surgery department for management of the metastatic RCC was successfully treated with total excision including a 1-cm safety margin, local flap, and STSG coverage. Complete healing was observed, without evidence of recurrence during a 7-month followup. Metastases to the skin are rare, but must be kept in mind because of its high metastatic ability and poor prognosis.

A case of intramuscular xanthelasma palpebrarum found during blepharoplasty.

Xanthelasma palpebrarum is the most common cutaneous xanthoma found on the medial side of the eyelid. The typical lesion is usually a flat and yellowish plaque on the skin. However, we report on a unique case of intramuscular xanthoma found during blepharoplasty for the correction of ptosis. A 53-year-old male patient visited our department with a complaint of a ptotic eyelid. He was concerned about the cosmetic appearance and the uncomfortable feeling while opening his eyes, and wanted these problems to be solved. A yellowish plaque of about 0.3 × 0.3 cm in size was found in the orbicularis oculi muscle during the surgery. The lesion was excised and xanthelasma was confirmed with biopsy. We have found this specific case of xanthelasma palpebrarum in the only muscle. Therefore, a careful approach to clinical and histologic examination and imaging is required for patients with these lesions.

Gynecomastia: glandular-liposculpture through a single transaxillary one hole incision.

Gynecomastia is characterized by the benign proliferation of breast tissue in men. Herein, we present a new method for the treatment of gynecomastia, using ultrasound-assisted liposuction with both conventional and reverse-cutting edge tip cannulas in combination with a pull-through lipectomy technique with pituitary forceps through a single transaxillary incision. Thirty patients were treated with this technique at the author's institution from January 2010 to January 2015. Ten patients were treated with conventional surgical excision of the glandular/fibrous breast tissue combined with liposuction through a periareolar incision before January 2010. Medical records, clinical photographs and linear analog scale scores were analyzed to compare the surgical results and complications. The patients were required to rate their cosmetic outcomes based on the linear analog scale with which they rated their own surgical results; the mean overall average score indicated a good or high level of satisfaction. There were no incidences of skin necrosis, hematoma, infection and scar contracture; however, one case each of seroma and nipple inversion did occur. Operative time was reduced overall using the new technique since it is relatively simple and straightforward. According to the evaluation by the four independent researchers, the patients treated with this new technique showed statistically significant improvements in scar and nipple-areolar complex (NAC) deformity compared to those who were treated using the conventional method. Glandular liposculpture through a single transaxillary incision is an efficient and safe technique that can provide aesthetically satisfying and consistent results.

A Wrapping Method for Inserting Titanium Micro-Mesh Implants in the Reconstruction of Blowout Fractures.

Titanium micro-mesh implants are widely used in orbital wall reconstructions because they have several advantageous characteristics. However, the rough and irregular marginal spurs of the cut edges of the titanium mesh sheet impede the efficacious and minimally traumatic insertion of the implant, because these spurs may catch or hook the orbital soft tissue, skin, or conjunctiva during the insertion procedure. In order to prevent this problem, we developed an easy method of inserting a titanium micro-mesh, in which it is wrapped with the aseptic transparent plastic film that is used to pack surgical instruments or is attached to one side of the inner suture package. Fifty-four patients underwent orbital wall reconstruction using a transconjunctival or transcutaneous approach. The wrapped implant was easily inserted without catching or injuring the orbital soft tissue, skin, or conjunctiva. In most cases, the implant was inserted in one attempt. Postoperative computed tomographic scans showed excellent placement of the titanium micro-mesh and adequate anatomic reconstruction of the orbital walls. This wrapping insertion method may be useful for making the insertion of titanium micro-mesh implants in the reconstruction of orbital wall fractures easier and less traumatic.

Treatment of Verruca Vulgaris in Both External Auditory Canals Using Bleomycin Injections.

Verruca vulgaris is caused by human papillomavirus (HPV) infections. Verruca in the external auditory canal (EAC) has rarely been reported. A previous case report introduced surgical excision as a treatment for verruca in the EAC. We present a case of verruca vulgaris in both EACs that was successfully treated with an intralesional bleomycin injection. A 32-year-old male patient presented with ear fullness and palpable lumps in both EACs. Both of his canals were filled with multiple pinkish, papillomatous masses. Verruca vulgaris was confirmed by skin biopsy. An otolaryngologist referred this patient and recommended surgical excision. However, we performed intralesional bleomycin injections for treatment. Twice intralesional bleomycin injections at one-month intervals had excellent results without recurrence, ulceration or scar formation. This result indicates that bleomycin injections may prove to be an effective first-line treatment of verruca in the EAC.

Full-thickness skin grafting with de-epithelization of the wound margin for finger defects with bone or tendon exposure.

BACKGROUND: Full-thickness skin grafts (FTSGs) are generally considered unreliable for coverage of full-thickness finger defects with bone or tendon exposure, and there are few clinical reports of its use in this context. However, animal studies have shown that an FTSG can survive over an avascular area ranging up to 12 mm in diameter. In our experience, the width of the exposed bones or tendons in full-thickness finger defects is <7 mm. Therefore, we covered the bone- or tendon-exposed defects of 16 fingers of 10 patients with FTSGs. METHODS: The surgical objectives were healthy granulation tissue formation in the wound bed, marginal de-epithelization of the normal skin surrounding the defect, preservation of the subdermal plexus of the central graft, and partial excision of the dermis along the graft margin. The donor site was the mastoid for small defects and the groin for large defects. RESULTS: Most of the grafts (15 of 16 fingers) survived without significant surgical complications and achieved satisfactory functional and aesthetic results. Minor complications included partial graft loss in one patient, a minimal extension deformity in two patients, a depression deformity in one patient, and mild hyperpigmentation in four patients. CONCLUSIONS: We observed excellent graft survival with this method with no additional surgical injury of the normal finger, satisfactory functional and aesthetic outcomes, and no need for secondary debulking procedures. Potential disadvantages include an insufficient volume of soft tissue and graft hyperpigmentation. Therefore, FTSGs may be an option for treatment of full-thickness finger defects with bone or tendon exposure.

Reconstruction of Chronic Complicated Scalp and Dural Defects Using Acellular Human Dermis and Latissimus Dorsi Myocutaneous Free flap.

We present reconstruction of a complicated scalp-dura defect using acellular human dermis and latissimus dorsi myocutaneous free flap. A 62-year-old female had previously undergone decompressive craniectomy for intracranial hemorrhage. The cranial bone flap was cryopreserved and restored to the original location subsequently, but necessitated removal for a methicillin-resistant Staphylococcal infection. However, the infectious nidus remained in a dermal substitute that was left over the cerebrum. Upon re-exploration, this material was removed, and frank pus was observed in the deep space just over the arachnoid layer. This was carefully irrigated, and the dural defect was closed with acellular dermal matrix in a watertight manner. The remaining scalp defect was covered using a free latissimus dorsi flap with anastomosis between the thoracodorsal and deep temporal arteries. The wound healed well without complications, and the scalp remained intact without any evidence of cerebrospinal fluid leak or continued infection.

Minimally Invasive Excision of Epidermal Cysts through a Small Hole Made by a CO2 Laser.

To improve the cosmetic results of removing epidermal cysts, minimally invasive methods have been proposed. We proposed a new minimally invasive method that completely removes a cyst through a small hole made by a CO2 laser. Twenty-five patients with epidermal cysts, which were 0.5 to 1.5 cm in diameter, non-inflamed, and freely movable, were treated. All of the patients were satisfied with the cosmetic results. This method is simple and results in minimal scarring and low recurrence rates without complications.

Microplate Fixation without Maxillomandibular Fixation in Double Mandibular Fractures.

BACKGROUND: Maxillomandibular fixation (MMF) is usually used to treat double mandibular fractures. However, advancements in reduction and fixation techniques may allow recovery of the premorbid dental arch and occlusion without the use of MMF. We investigated whether anatomical reduction and microplate fixation without MMF could provide secure immobilization and correct occlusion in double mandibular fractures. METHODS: Thirty-four patients with double mandibular fractures were treated with open reduction and internal fixation without MMF. Both fracture sites were surgically treated. For bony fixations, we used microplates with or without wire. After reduction, each fracture site was fixed at two or three points to maintain anatomical alignment of the mandible. Interdental wiring was used to reduce the fracture at the superior border and to enhance stability for 6 weeks. Mouth opening was permitted immediately. RESULTS: No major complications were observed, including infection, plate exposure, non-union, or significant malocclusion. Five patients experienced minor complications, among whom the only one patient experienced a persistant but mild malocclusion with no need for additional management. CONCLUSION: This study showed that double mandibular fractures correction with two- or three-point fixation without MMF simplified the surgical procedure, increased patient comfort, and reduced complications, due to good stability and excellent adaptation.

Vascularized bipedicled pericranial flaps for reconstruction of chronic scalp ulcer occurring after cranioplasty.

BACKGROUND: Intractable chronic scalp ulcers with cranial bone exposure can occur along the incision after cranioplasty, posing challenges for clinicians. They occur as a result of severe scarring, poor blood circulation of the scalp, and focal osteomyelitis. We successfully repaired these scalp ulcers using a vascularized bipedicled pericranial flap after complete debridement. METHODS: Six patients who underwent cranioplasty had chronic ulcers where the cranial bone, with or without the metal plate, was exposed along the incision line. After completely excising the ulcer and the adjacent scar tissue, subgaleal dissection was performed. We removed the osteomyelitic calvarial bone, the exposed metal plate, and granulation tissue. A bipedicled pericranial flap was elevated to cover the defect between the bone graft or prosthesis and the normal cranial bone. It was transposed to the defect site and fixed using an absorbable suture. Scalp flaps were bilaterally advanced after relaxation incisions on the galea, and were closed without tension. RESULTS: All the surgical wounds were completely healed with an improved aesthetic outcome, and there were no notable complications during a mean follow-up period of seven months. CONCLUSIONS: A bipedicled pericranial flap is vascularized, prompting wound healing without donor site morbidity. This may be an effective modality for treating chronic scalp ulcer accompanied by the exposure of the cranial bone after cranioplasty.

Prognosis of full-thickness skin defects in premature infants.

BACKGROUND: In the extremities of premature infants, the skin and subcutaneous tissue are very pliable due to immaturity and have a greater degree of skin laxity and mobility. Thus, we can expect wounds to heal rapidly by wound contraction. This study investigates wound healing of full-thickness defects in premature infant extremities. METHODS: The study consisted of 13 premature infants who had a total of 14 cases of full-thickness skin defects of the extremities due to extravasation after total parenteral nutrition. The wound was managed with intensive moist dressings with antibiotic and anti-inflammatory agents. After wound closure, moisturization and mild compression were performed. RESULTS: Most of the full-thickness defects in the premature infants were closed by wound contraction without granulation tissue formation on the wound bed. The defects resulted in 3 pinpoint scars, 9 linear scars, and 2 round hypertrophic scars. The wounds with less granulation tissue were healed by contraction and resulted in linear scars parallel to the relaxed skin tension line. The wounds with more granulation tissue resulted in round scars. There was mild contracture without functional abnormality in 3 cases with a defect over two thirds of the longitudinal length of the dorsum of the hand or foot. The patients' parents were satisfied with the outcomes in 12 of 14 cases. CONCLUSIONS: Full-thickness skin defects in premature infants typically heal by wound contraction with minimal granulation tissue and scar formation probably due to excellent skin mobility.

Single-stage reconstruction of skin-involving nasal paraffinoma with pericraniosubgaleal flap.

BACKGROUND: The removal of a paraffinoma over the nasal bridge may result in thinning and even loss of involved skin as well as a saddle nose deformity. For nasal reconstruction, a variety of techniques using a free graft of autogenous tissue such as fascia, dermofat, or cartilage have been used, either in immediate, single-stage or in delayed, multiphase treatment. However, such reconstructions can be challenging largely due to absorption of the grafted tissue and poor blood supply to the surrounding nasal tissue infiltrated with paraffin. This article reports the successful clinical outcomes of immediate, single-stage reconstructions by wrapping a pericraniosubgaleal flap over the nasal implant after removing a paraffinoma. METHODS: Eleven patients with a paraffinoma showing a palpable lump, redness, or telangiectasia over the nasal skin were treated between November 1998 and March 2011. The mean follow-up period was 20.1 months. As much of the paraffinoma as possible was removed via a bidirectional approach (open rhinoplasty and frontal hairline incision), and the resulting deformity was reconstructed simultaneously using a pericraniosubgaleal flap and turning it over the sculpted nasal implant (ePTFE; GORE-TEX(®) in nine cases and silicone in two cases). RESULTS: Nine patients (81.8%) were treated successfully without complications and were satisfied with their results. However, the other two patients complained of incomplete removal of the paraffinoma requiring additional removal. Telangiectasia over the nose improved in four out of six patients after surgery. CONCLUSION: Nasal reconstruction using a pericraniosubgaleal flap is one of the most reliable surgical options for treating skin-involving nasal paraffinomas. The advantage of such a method is that a well-vascularized and durable flap, which is resistant to infection, is wrapped over the sculpted nasal implant in a single step. It also reinforces the thinned skin, which makes it easier to form various shapes, producing excellent cosmetic results. Finally, it can also serve as a tolerable graft bed in the case of overlying skin loss.

Polymorphisms of 5,10-methylenetetrahydrofolate reductase and thymidylate synthase in squamous cell carcinoma and basal cell carcinoma of the skin.

Genetic instability resulting from mutations in repair genes, defects in folic acid metabolism or DNA synthesis has been reported to contribute significantly to the development of skin cancer. The enzymes 5,10-methylenetetrahydrofolate reductase (MTHFR) and thymidylate synthase (TS) are essential participants in folic acid metabolism and DNA synthesis. Thus, the present case-control study was conducted to determine whether an association exists between the MTHFR/TS polymorphisms and squamous cell carcinoma (SCC) and/or basal cell carcinoma (BCC) among Korean individuals. The study subjects comprised 95 patients with SCC, 100 patients with BCC and 207 controls with no evidence of malignancy or pre-malignant lesions. Patients with skin cancer and control samples were analyzed for polymorphisms of the MTHFR or TS genes by means of polymerase chain reaction-restriction fragment length polymorphism. The MTHFR 677C>T and MTHFR 1298A>C polymorphisms showed no significance with regard to the development of SCC and BCC. However, within the 6 bp insertion (ins)/deletion (del) polymorphism in the 3'-untranslated region (3'-UTR) of the TS gene, the BCC group showed statistical significance with a 2.8-fold increased risk of cancer development [adjusted odds ratio (AOR)=2.821] in heterozygous mutations (0 bp/6 bp), 7.5-fold (AOR=7.539) in homozygous mutations (6 bp/6 bp) and 3-fold (AOR=3.079) upon combination of heterozygous mutations and homozygous mutations (0 bp/6 bp + 6 bp/6 bp). We thus conclude that the 6 bp ins/del polymorphism in the 3'-UTR is associated with increased risk of the development of skin cancer among Korean individuals with BCC.

Polymorphisms in the DNA repair gene XRCC1 associated with basal cell carcinoma and squamous cell carcinoma of the skin in a Korean population.

DNA in most cells is regularly damaged by endogenous and exogenous mutagens. Unrepaired damage can result in apoptosis or may lead to unregulated cell growth and cancer. Inheritance of genetic variants at one or more loci results in reduced DNA repair capacity. This hospital-based case-control study examined whether polymorphisms in the DNA repair gene X-ray repair cross-complementing groups 1 (XRCC1) (Arg194Trp[C > T], Arg280His[G > A] and Arg399Gln[G > A]) play a role in susceptibility to skin cancer. We genotyped these polymorphisms for 212 histopathologically confirmed skin cancer cases (n = 114 basal cell carcinoma, n = 98 squamous cell carcinoma) and 207 age- and sex-matched healthy control cases in Korea. We found that individuals with the Arg/Gln and Arg/Gln + Gln/Gln genotypes at XRCC1 Arg399Gln(G > A) had an approximately 2-fold increased risk of basal cell carcinoma compared to individuals with the Arg/Arg genotype (adjusted odds ratio [AOR] = 2.812, 95% confidence interval [CI] 1.32-5.98, and AOR = 2.324, 95% CI 1.11-4.86). However, we observed that the 194Trp allele of the Arg194Trp(C > T) polymorphism was inversely associated with squamous cell carcinoma risk (Trp/Trp, AOR = 0.06, 95% CI 0.006-0.63). Our data suggest that the Arg194Trp and Arg399Gln polymorphisms may be differentially associated with skin cancer risk.

Parapharyngeal branchial cleft cyst extending to the skull base: a lateral transzygomatic-transtemporal approach to the parapharyngeal space.

Second branchial cleft cysts (BCCs) can occur anywhere from the tonsillar fossa to the supraclavicular area. Second BCCs usually lie on the great vessels of the neck, deep in the sternocleoidomastoid muscle or along its anterior border at the mandibular angle. Parapharyngeal second BCCs are an uncommon neoplasm and rarely extend to the skull base. We report the case of a 45-year-old male with symptoms of conductive hearing loss. Temporal bone CT scan showed effusion in the left middle ear cavity. Magnetic resonance imaging (MRI) revealed a cystic mass that was located at the left parapharyngeal space and eroded the skull table of the left temporal base. Excision of the lesion was achieved via a transzygomatic-transtemporal approach to the parapharyngeal space. Histopathological examination of the cyst wall showed a single layer of ciliated columnar epithelium without goblet cells or lymphoid tissue. The patient recovered without any complications and experienced complete resolution of left-sided hearing difficulty. We conclude the lateral transzygomatic-transtemporal approach allows surgeons direct access to the parapharyngeal space with satisfactory exposure for treating benign lesions of the parapharyngeal space.