Efficacy of preoperative autologous blood storage in one-stage bilateral total knee arthroplasty.

BACKGROUND: One-stage bilateral total knee arthroplasty (TKA) has the advantages of a single hospital stay, shorter rehabilitation, and reduced financial burden on patients. However, perioperative bleeding is greater with one-stage bilateral TKA than with unilateral TKA and is more likely to require allogeneic blood transfusion. At our hospital, we normally store autologous blood about 1 month before surgery to reduce the need for allogeneic blood transfusion and avoid its adverse reactions as much as possible. The purpose of this study was to determine the efficacy of preoperative autologous blood storage for patients undergoing one-stage bilateral TKA. METHODS: We retrospectively examined the allogeneic blood transfusion avoidance rate and the perioperative decrease in hemoglobin (Hb) level in 166 patients according to whether or not they had preoperative autologous blood stored. The patients for whom blood was stored were then subdivided according to whether the amount of blood stored was 400 mL or 200 mL. RESULTS: Excluding allogeneic transfusion cases, the mean perioperative decrease in Hb was significantly lower in the patients with stored blood than in those without stored blood (3.5 g/dL vs 4.4 g/dL, p < 0.001). The allogeneic blood transfusion avoidance rate was significantly higher in the group with stored blood (98.5% vs 86.7%, p < 0.01). In the group with stored blood, the transfusion avoidance rate was higher, but not significantly, in the subgroup with 400 mL of blood stored than in those with 200 mL of blood stored (100% vs 97.5%) and the mean perioperative decrease in Hb was 3.5 g/dL in both blood storage volume groups. CONCLUSIONS: Preoperative autologous blood storage can help increase the likelihood of avoiding allogeneic blood transfusion in patients undergoing one-stage bilateral TKA.

A Rare Case of Extremely Severe Heterotopic Ossification after Primary Total Hip Arthroplasty due to Persistent Mild Periprosthetic Joint Infection.

Periprosthetic joint infection (PJI) caused by coagulase-negative staphylococci (CNS) can be a mild, persisting infection. Although heterotopic ossification (HO) is common following total hip arthroplasty (THA), the etiology of severe HO remains unclear. Herein, we describe a rare case of extremely severe HO after a PJI associated with a Staphylococcus caprae infection in a 78-year-old male patient. The patient had poorly controlled diabetes mellitus with no diabetic complications. The patient had no previous history of hip surgery, hip injury, or systemic bacterial infection. Immediately after the initial THA, he developed intermittent low-grade fever (37°C), which persisted for 3 months; consequently, he also reported mild hip pain during walking. He experienced a gradual decrease in hip range of motion within 5 years after the surgery, with progressive gait impairment. Two revision surgeries were required for the successful treatment of this difficult case. The patient's hip function improved, and the PJI was controlled following the second revision surgery. Based on the clinical course, CNS-caused PJI may lead to severe HO. This possibility warrants verification from an accumulated number of cases.

Changes in muscle strength of the hip after rotational acetabular osteotomy: a retrospective study.

AIMS: Rotational acetabular osteotomy (RAO) is an effective joint-preserving surgical treatment for acetabular dysplasia. The purpose of this study was to investigate changes in muscle strength, gait speed, and clinical outcome in the operated hip after RAO over a one-year period using a standard protocol for rehabilitation. PATIENTS AND METHODS: A total of 57 patients underwent RAO for acetabular dysplasia. Changes in muscle strength of the operated hip, 10 m gait speed, Japanese Orthopaedic Association (JOA) hip score, and factors correlated with hip muscle strength after RAO were retrospectively analyzed. RESULTS: Three months postoperatively, the strength of the operated hip in flexion and abduction and gait speed had decreased from their preoperative levels. After six months, the strength of flexion and abduction had recovered to their preoperative level, as had gait speed. At one-year follow-up, significant improvements were seen in the strength of hip abduction and gait speed, but muscle strength in hip flexion remained at the preoperative level. The mean JOA score for hip function was 91.4 (51 to 100)) at one-year follow-up. Body mass index (BMI) showed a negative correlation with both strength of hip flexion (r = -0.4203) and abduction (r = -0.4589) one year after RAO. Although weak negative correlations were detected between strength of hip flexion one year after surgery and age (r = -0.2755) and centre-edge (CE) angle (r = -0.2989), no correlation was found between the strength of abduction and age and radiological evaluations of CE angle and acetabular roof obliquity (ARO). CONCLUSION: Hip muscle strength and gait speed had recovered to their preoperative levels six months after RAO. The clinical outcome at one year was excellent, although the strength of hip flexion did not improve to the same degree as that of hip abduction and gait speed. A higher BMI may result in poorer recovery of hip muscle strength after RAO. Radiologically, acetabular coverage did not affect the recovery of hip muscle strength at one year's follow-up. A more intensive rehabilitation programme may improve this. Cite this article: Bone Joint J 2019;101-B:1459-1463.

One-Stage Reconstruction for Re-rupture of Achilles Tendon with Soft Tissue Infection: Using an Anterolateral Thigh Flap Incorporating a Vascularized Muscle Flap and a Strip of Iliotibial Tract.

Reconstruction is challenging in a patient with loss of a segment of Achilles tendon and infection in the overlying soft tissue. Here the authors describe one-stage tendon reconstruction, using an anterolateral thigh free flap incorporating a vascularized muscle flap and a strip of iliotibial tract in a patient with re-rupture of an Achilles tendon and soft tissue infection. Postoperative immobilization of the affected ankle using an external fixator enabled us to observe the flap directly and reduce pressure on the flap. The patient had a successful outcome, with no difficulty in walking, running, or climbing stairs and no limitation of range of motion at the ankle joint postoperatively. This is a promising technique for reconstruction of the Achilles tendon and treatment of infection as a one-step procedure.

Comparison of a highly porous titanium cup (Tritanium) and a conventional hydroxyapatite-coated porous titanium cup: A retrospective analysis of clinical and radiological outcomes in hip arthroplasty among Japanese patients.

BACKGROUND: The use of 3-dimensional highly porous acetabular cups is increasing. Their structure and mechanical properties mimic those of natural bone; therefore, they should promote stronger biological fixation. In our experience with total hip arthroplasty, radiolucent lines are observed when a 3-dimensional highly porous cup (Stryker Tritanium) is used. We compared the clinical and radiographic results between a Tritanium cup and a conventional cup (Stryker Trident HA) over a short time period. METHOD: We retrospectively compared consecutive cases of primary total hip arthroplasty using a Tritanium cup (130 cases in 118 patients) and a matched cohort using a Trident cap (130 cases in 130 patients) between January 2011 and December 2014. RESULTS: The mean follow-up duration was 41.3 and 38.1 months (p = 0.06) for the Tritanium and Trident groups, respectively. There were significant differences between the groups for radiolucent lines, cup abduction angle, and cup-center-edge angle. There were no significant differences in the clinical results. Radiolucent lines increased in the Tritanium group (36.1% at 3 months and 60.7% at final follow-up), whereas they decreased in the Trident group (2.5% at 3 months and 0.8% at final follow-up). The occurrence of radiolucent lines was significantly higher in the Tritanium group than in the Trident group at each follow-up period. Radiolucent lines were seen in 36.1% of patients in the Tritanium group during follow-up, without initial gaps. One cup loosening in the Tritanium group was identified at the final follow-up evaluation. CONCLUSION: Both groups showed successful clinical results over short-term follow-up; however, the Tritanium group had a significantly higher rate of radiolucent line occurrence around the cups than did the Trident group. Thus, radiolucent lines can occur when using highly porous titanium cups; these lines indicate the possibility of future cup loosening. Longer follow-up and assessment of the results of using this implant are necessary.

Screening for nasal carriage of Staphylococcus aureus among patients scheduled to undergo orthopedic surgery: Incidence of surgical site infection by nasal carriage.

BACKGROUND: Staphylococcus aureus (S. aureus), including MRSA, is considered to be the leading cause of surgical site infection (SSI) after orthopedic surgery. We screened for nasal carriers of S. aureus among patients who were scheduled to undergo orthopedic surgery at our hospital to reveal the effect of nasal S. aureus carriage on SSI. Our study design clearly has the intent of finding S. aureus nasal carriage and eradicating MRSA when found, and this strategy is to verify whether it's effective for preventing orthopedic surgical infections. METHODS: Subjects were 4148 patients who underwent preoperative screening for nasal carrier and subsequently underwent orthopedic surgery during a 7-year period between April 2007 and March 2014. The incidence of SSI among patients who were operated in our department was investigated, and the rates were compared between patients with and without nasal carriage to reveal the effect of preoperative nasal carriage on SSI. RESULTS: In total, 1036 patients were nasal carriers of S. aureus (carriage rate, 25.0%), whereas 140 patients carried MRSA (carriage rate, 3.4%). SSI developed in 24 patients [incidence, 0.58% (24/4148)] consisting of 12 non-carriers [0.39% (12/3112)] and 12 carriers [1.16% (12/1036)] with a significant difference in the incidence between the groups. Among 24 cases of SSI, more than half (13 cases) were caused by bacterial species other than S. aureus or those that could not be detected by the tests used. Only 7 patients out of 24 SSI patients, S. aureus was the bacterium detected in preoperative nasal cultures and the causal bacterium for SSI (concordance rate of 29.2%). CONCLUSIONS: It was difficult to reduce the incidence rate of SSI in eradication group to the same level as nasal culture negative group. However, nasal carriage of S. aureus or MRSA may be a risk factor for SSI in orthopedic surgery.

Failure rates of Asian-type anatomic medullary locking stemmed metal-on-metal total hip replacement: A cause for adverse tissue reactions to metal debris (ARMD).

BACKGROUND: Adverse tissue reaction to metal debris (ARMD) as a secondary complication of Metal-on-metal total hip replacement (MoM THR) has been of concern. We have been performing cementless MoM THR using an Asian-type anatomic medullary locking (AML) stem. The purpose of this study is to examine the incident rate of ARMD, and the implant survival rate. METHODS: The study included 187 patients (211 hip joints) who underwent MoM THR between February 2007 and November 2009 at our hospital and who were followed up for a minimum of 6 years. The cases included 174 female joints and 37 male joints. The average age at the time of surgery was 68.4 years. The average postoperative follow-up period was 87.5 months. RESULTS: ARMD was observed in 23 joints postoperatively, and the incidence rate was 10.9%. Most of the instances occurred within the first 30 months postoperatively. Revision surgery was performed for 14 joints after conservative treatment failed, and we changed the bearing surface. During the intraoperative observation, black-colored deposition of metal debris on the head-neck junction was observed in 13 cases. Kaplan-Meier analysis using the replacement surgery as the end point showed that this implant has a survival rate of 93.8% 7 years after the primary surgery. CONCLUSIONS: We conclude that the major cause of failure of Asian-type AML stemmed MoM THR is likely the breakage of the fixation between the taper neck and metal head at the head-neck junction.

Percutaneous endoscopic lumbar discectomy utilizing ventral epiduroscopic observation technique and foraminoplasty for transligamentous extruded nucleus pulposus: technical note.

Percutaneous endoscopic discectomy (PED) is a minimally invasive disc surgery that can be performed under local anesthesia and requires only an 8-mm skin incision. For transligamentous extruded nucleus pulposus with foraminal stenosis, it is very hard to remove the migrated mass with a simple transforaminal approach. For such difficult cases, foraminoplasty and an epiduroscopic technique is useful. A 29-year-old man visited the authors' hospital, complaining of low-back and right leg pain. MRI revealed a massive herniated nucleus pulposus with foraminal stenosis. A transforaminal PED was planned to remove the herniated mass. Through the inside-out technique, the base of the herniated mass was removed. Following the foraminoplasty, the cannula was moved into the epidural space. With epidural observation just beneath the nerve root, the extruded transligamentous fragment was confirmed and removed en bloc. Immediately after the surgery, the patient's symptoms resolved. The combination of foraminoplasty and epiduroscopic observation during the transforaminal approach for PED is a useful and reliable technique to remove extruded transligamentous disc fragments.

Open dislocation of the proximal interphalangeal joint of the little finger subsequent to chronic radial collateral ligament injury: a case report of primary ligament reconstruction with a half-slip of the flexor digitorum superficialis: Case Report.

Open dislocation of the proximal interphalangeal (PIP) joint is relatively rare. We report a case of a 32-year-old man who had open dislocation of the PIP joint of the little finger while playing American football. He had a history of chronic radial collateral ligament injury. We reconstructed the radial collateral ligament with a half-slip of the flexor digitorum superficialis tendon.

Irreducible Palmar Dislocation of the Distal Interphalangeal Joint Due to Closed Degloving of the Distal Phalanx of the Little Finger.

Since irreducible dislocation of the distal interphalangeal joint (DIP joint) is dorsal dislocation, irreducible palmar dislocation of the DIP Joint is very rare. This case was associated with a closed degloving injury of the distal phalanx of the little finger and required operative treatment.

Osteomyelitis Caused by Candida glabrata in the Distal Phalanx.

Osteomyelitis caused by Candida glabrata is rare and its optimal treatment is unknown. Here we report a case of osteomyelitis caused by C. glabrata in the distal phalanx in a 54-year-old woman. Despite partial resection of the nail and administering a 1-month course of antibiotics for paronychia, the local swelling remained and an osteolytic lesion was found. C. glabrata osteomyelitis of the distal phalanx was later diagnosed after curettage. Thereafter, the patient was treated with antifungal agents for 3 months. The infection eventually resolved, and radiological healing of the osteolytic lesion was achieved. Antifungal susceptibility testing should be performed in the case of osteomyelitis caused by nonalbicans Candida species, due to their resistance to fluconazole.

Bilateral atypical femoral fractures in a patient with multiple myeloma treated with intravenous bisphosphonate therapy.

Bisphosphonates are currently the standard approach to managing bone disease in multiple myeloma. Bisphosphonates have high bone affinity that inhibits osteoclastic activity and additionally reduces the growth factors released from malignant or osteoblastic cells, thereby impairing abnormal bone remodeling which leads to osteolysis. However, patients of multiple myeloma may be at a higher risk of atypical femoral fractures because the treatment for malignant myeloma requires notably higher cumulative doses of bisphosphonates. Here we present a patient with bilateral atypical femoral fractures and multiple myeloma treated with intravenous bisphosphonate therapy.

Incidence for progression of hypervascular HCC in hypovascular hepatic nodules showing hyperintensity on gadoxetic acid-enhanced hepatobiliary phase in patients with chronic liver diseases.

PURPOSE: The purpose of this study was to elucidate the incidence and risk factors for the progression of hyperintense nodules, observed in the hepatobiliary phase of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (Gd-EOB-DTPA-enhanced MRI), to hypervascular hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Hypovascular nodules (n = 157) showing hyperintensity in the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI were examined in 41 patients. All patients underwent computed tomography (CT) during hepatic arteriography and CT during arterial portography within one month of Gd-EOB-DTPA-enhanced MRI. The incidence of progression to hypervascular or classical HCC was calculated using the Kaplan-Meier method. RESULTS: Tumor size was determined by univariate and multivariate analysis to be an important risk factor of hypervascularization (p = 0.041, odds ratio 1.135). The cumulative incidences of hypervascularization in hypovascular nodules showing hyperintensity on the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI were 2.4, 4.5, and 6.2 % at 12, 24, and 36 months, respectively. The incidence of hypervascularization was significantly increased in nodules >10 mm in diameter (p = 0.00035). CONCLUSION: In patients with chronic liver disease, hypovascular nodules presenting as hyperintense in the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI and >10 mm in diameter have malignant potential for progression to hypervascular HCC and require careful management.

Intrapelvic migration of the lag screw in intramedullary nailing.

Internal fixation with intramedullary devices has gained popularity for the treatment of intertrochanteric femoral fractures, which are common injuries in the elderly. The most common complications are lag screw cut out from the femoral head and femoral fracture at the distal tip of the nail. We report here a rare complication of postoperative lag screw migration into the pelvis with no trauma. The patient was subsequently treated with lag screw removal and revision surgery with total hip arthroplasty. This case demonstrated that optimal fracture reduction and positioning of the lag screw are the most important surgical steps for decreasing the risk of medial migration of the lag screw. Furthermore, to prevent complications, careful attention should be paid to subsequent steps such as precise insertion of the set screw.

Subchondral cysts in dysplastic osteoarthritic hips communicate with the joint space: analysis using three-dimensional computed tomography.

INTRODUCTION: Bone cyst formation in hips increases as osteoarthritis worsens. Although bone cysts in hips have been described in many studies, their etiology remains unclear and under debate. The purpose of this study was to investigate the communication between a bone cyst and the joint space, as well as the relationship between the severity of osteoarthritis and the formation of subchondral bone cysts in dysplastic hips. METHOD: We studied bone cysts from 150 dysplastic hips in 97 patients by computed tomography (CT) and plain radiography. We investigated the distribution of the bone cysts and the presence or absence of a communication path between the cysts and the joint space by three-dimensional (3D) CT. RESULT: Of the 150 hips, 94 acetabula and 55 femoral heads were found to contain cysts. Of the 94 hips containing acetabular cysts, 89 and 5 hips showed black lines and gray lines connecting the cyst and the joint space, respectively, on 3D-CT. The rate of cyst presentation in the hip increased as the joint space became narrower. The number of hips that possessed cysts in the anterior and/or middle portion was significantly higher than that in the posterior portions. CONCLUSION: Bone cysts in dysplastic osteoarthritic hips were found to communicate with the joint space in all cases. This suggests that the formation and enlargement of the cysts in dysplastic hips may be greatly influenced by the joint fluid. Cyst formation was initially observed in the anterior acetabulum, gradually progressing to involve the entire joint, including the posterior acetabulum and the femoral head, with worsening of the osteoarthritis.

New surgical treatment using a docking nail for postoperative periprosthetic femoral fracture after total hip arthroplasty.

We report 2 cases of patients (75 and 81 years old) who had a femoral shaft fracture around the femoral prosthesis after total hip arthroplasty. Using information on the implanted stem and the preoperative radiographs, we cut and trimmed an ordinary supracondylar type intramedullary nail, after which we have termed a "docking nail." We then performed osteosynthesis using the docking nail, which is connected to the tip of the implanted stem to ensure proper alignment. Within 3 months, bony union with good alignment was observed in both patients without malunion or infection. Clinical and radiographic examination during the follow-up period showed good results. The advantages of this method are that it is less invasive and simpler compared with the conventional methods.

Two cases of inferior dislocation of the patella with impaction into the femoral trochlea of osteophytes on the superior pole of the patella.

Traumatic dislocation of the patella is classified as lateral, medial, or intra-articular according to the direction of dislocation. Lateral dislocation is the most common type of patellar dislocation, and intra-articular dislocation is rare. Intra-articular dislocation is classified as superior, inferior, or vertical dislocation. Inferior dislocation is categorized as Type I, which occurs in young people, and Type II, which occurs in the elderly. In Type II, osteophytes on the superior pole of the patellar are believed to become entrapped in the intercondylar notch, dislocating the patella inferiorly. These were two extremely rare cases of inferior dislocation of the patella in elderly people. The mechanism involved was considered to be the exertion of sudden upward traction on the patella due to the muscular force of the quadriceps when the knee was flexed, causing osteophytes on the superior pole of the patella to become impacted into the femoral trochlea. Dislocations were successfully reduced without anesthesia, and osteophyte resection or complete osteophyte fracture during reduction meant that there was no recurrence of the dislocation.

Risk of hypervascularization in small hypovascular hepatic nodules showing hypointense in the hepatobiliary phase of gadoxetic acid-enhanced MRI in patients with chronic liver disease.

PURPOSE: The purpose of this study was to elucidate the incidence and risk factors for the progression of hypointense nodules observed in the hepatobiliary phase of gadoxetic acid-enhanced magnetic resonance imaging (Gd-EOB-DTPA-enhanced MRI) of hypervascular hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Hypovascular nodules (112) showing hypointensity in the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI were examined in 54 patients. All patients underwent computed tomography during hepatic arteriography and computed tomography during arterial portography (CTAP) within a month after Gd-EOB-DTPA-enhanced MRI. According to the tumor size, 112 nodules were divided into two groups: those >10 mm in diameter (group A, n = 39) and those ≤10 mm in diameter (group B, n = 73). The incidence of progression to hypervascular HCC was calculated using the Kaplan-Meier method. RESULTS: The incidence of hypervascularization was significantly higher in group A nodules than in group B nodules (p < 0.0001). Tumor size (p < 0.0001) and hypoattenuation in CTAP (p = 0.0004) showed significant correlation with hypervascularization. CONCLUSION: Hypointense nodules observed in the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI with diameters of >10 mm had a high probability of hypervascularization.

Autophosphorylation of heme-regulated eukaryotic initiation factor 2α kinase and the role of the modification in catalysis.

Heme-regulated eukaryotic initiation factor 2α (eIF2α) kinase (HRI), functions in response to heme shortage in reticulocytes and aids in the maintenance of a heme:globin ratio of 1:1. Under normal conditions, heme binds to HRI and blocks its function. However, during heme shortage, heme dissociates from the protein and autophosphorylation subsequently occurs. Autophosphorylation comprises a preliminary critical step before the execution of the intrinsic function of HRI; specifically, phosphorylation of Ser-51 of eIF2α to inhibit translation of the globin protein. The present study indicates that dephosphorylated mouse HRI exhibits strong intramolecular interactions (between the N-terminal and C-terminal domains) compared to phosphorylated HRI. It is therefore suggested that autophosphorylation reduces the intramolecular interaction, which induces irreversible catalytic flow to the intrinsic eIF2α kinase activity after heme dissociates from the protein. With the aid of MS, we identified 33 phosphorylated sites in mouse HRI overexpressed in Escherichia coli. Phosphorylated sites at Ser, Thr and Tyr were predominantly localized within the kinase insertion region (16 sites) and kinase domain (12 sites), whereas the N-terminal domain contained five sites. We further generated 30 enzymes with mutations at the phosphorylated residues and examined their catalytic activities. The activities of Y193F, T485A and T490A mutants were significantly lower than that of wild-type protein, whereas the other mutant proteins displayed essentially similar activity. Accordingly, we suggest that Tyr193, Thr485 and Thr490 are essential residues in the catalysis.

Osseous erosion by herniated nucleus pulposus mimicking intraspinal tumor: a case report.

Erosion of spinal osseous structure, so-called scalloping, has been rarely reported associated with herniated nucleus pulposus (HNP). We report a rare case of HNP causing erosion of the spinal osseous structure (including lamina). The patient was an 81-year-old woman with 3-year history of low-back pain and left leg radiating pain. Muscle weakness of the left leg was also apparent. Computed tomography following myelography showed severe compression of the dural sac at the level of L3-L4; furthermore, erosion of the lamina, pedicle, and vertebral body was noted, indicating that the space-occupying mass was most probably a tumorous lesion. The mass also showed calcification inside. During the surgery, the mass was confirmed to be an HNP with calcification. Following resection, the pain disappeared. Surgeons should be aware of the possibility of scalloping of the vertebrae caused by HNP mimicking a tumorous lesion.