Radiation Exposure During Lumbar Interbody Fusion Surgery Can Be Reduced by Using a Three-Dimensional Patient-Specific Template Guide.

BACKGROUND: The use of posterior lumber interbody fusion (PLIF) using cortical bone trajectory (CBT) with a patient-specific 3D template guide is increasingly widespread. To our knowledge, no studies have extensively evaluated the reduction of radiation exposure when using patient-specific drill template guides. The purpose of this study is to compare the intra-operative radiation dose and surgeon's exposure to radiation in CBT-PLIF when using a patient-specific drill guide with that in traditional minimally invasive (MIS)-PLIF. METHODS: In this observational study, we retrospectively compared data from five patients who were treated with single-level CBT-PLIF using a patient-specific drill guide (G group) and five patients who were treated with single-level traditional MIS-PLIF (M group). We compared the surgical time, surgeon's exposure to radiation, and intra-operative radiation time and dose between the two groups of patients. RESULTS: The mean age of the patients was 67.0 years in the M group and 74.2 years in the G group. The average surgical time was 242.8 min in the M group and 189.6 min in the G group (p = 0.020). The surgeon's exposure to radiation was 373.7 µSv in the M group and 81.75 µSv in the G group at chest level outside the protector (p = 0.00092); 42.0 µSv (M group) and 3.6 µSv (G group) at chest level inside the protector (p = 0.0000062); and 4.33 µSv (M group) and 1.20 µSv (G group) at the buttocks of the surgeon (p = 0.0013). Radiation time was 269.8 s (M group) and 56.6 s (G group) (p = 0.0097), and radiation dose was 153.7 mGy (M group) and 30.42 mGy (G group) (p = 0.00057). CONCLUSION: The patient-specific drill template guide is an invaluable tool that facilitates the safe insertion of CBT screws with a low radiation dose from the outset.

Postoperative complications of reverse total shoulder arthroplasty: a multicenter study in Japan.

Background: Reverse total shoulder arthroplasty (RSA) has been approved since 2014 in Japan, and the number of RSA cases has been accumulating. However, only short-to medium-term outcomes have been reported, with a small number of case series, because of its short history in Japan. This study aimed to evaluate complications after RSA in hospitals affiliated with our institute, with comparison to those in other countries. Methods: A multicenter retrospective study was performed at 6 hospitals. In total, 615 shoulders (mean age: 75.7 ± 6.2 years; mean follow-up: 45.2 ± 19.6 months) with at least 24 months of follow-up were included in this study. The active range of motion was assessed pre-and postoperatively. The 5-year survival rate was evaluated for reoperation for any reason in 137 shoulders with at least 5 years of follow-up using Kaplan-Meier analysis. Postoperative complications were evaluated, including dislocation; prosthesis failure; deep infection; periprosthetic, acromial, scapular spine, and clavicle fractures; neurological disorders; and reoperation. Furthermore, imaging assessments, including scapular notching, prosthesis aseptic loosening, and heterotopic ossification were evaluated on postoperative radiography at the final follow-up. Results: All range of motion parameters were significantly improved postoperatively (P < .001). The 5-year survival rate was 93.4% (95% confidence interval: 87.8%-96.5%) for reoperation. Complications occurred in 256 shoulders (42.0%), with reoperation in 45 (7.3%), acromial fracture in 24 (3.9%), neurological disorders in 17 (2.8%), deep infection in 16 (2.6%), periprosthetic fracture in 11 (1.8%), dislocation in 9 (1.5%), prosthesis failure in 9 (1.5%), clavicle fracture in 4 (0.7%), and scapular spine fracture in 2 (0.3%). Regarding imaging assessments, scapular notching was observed in 145 shoulders (23.6%), heterotopic ossification in 80 (13.0%), and prosthesis loosening in 13 (2.1%). Conclusion: This is the first large case series to investigate the complications after RSA in Japan, and the overall frequency of complications after RSA was similar to that in other countries.

Effective screening methods to prevent surgical site infections in orthopedic surgery: an observational study.

BACKGROUND: The bacterial source of surgical-site infections (SSIs) can have either endogenous and/or exogenous origins, and some studies have revealed that endogenous transmission is an important pathway for SSIs in orthopedic surgery. However, since the frequency of SSIs is low (0.5-4.7%), screening all surgery patients is labor-intensive and cost-prohibitive. The goal of this study was to better understand how to improve the efficacy of nasal culture screening in preventing SSIs. METHODS: Nasal cultures for 1616 operative patients over a 3-year period were evaluated for the presence of nasal bacterial microbiota and the species identity. We also investigated the medical factors that influence colonization and evaluated the ratio of agreement between nasal cultures and SSI-causing bacteria. RESULTS: In a survey of 1616 surgical cases, 1395 (86%) were normal microbiota (NM), 190 (12%) were MSSA carriers, and 31 (2%) were MRSA carriers. The risk factors for MRSA carriers were significantly higher than the NM group in patients with a history of hospitalization (13 [41.9%], p = 0.015), patients who had been admitted to a nursing facility (4 [12.9%], p = 0.005), and patients who were > 75 years of age (19 [61.3%], p = 0.021). The incidence of SSIs was significantly higher in the MSSA group (17/190 [8.4%]) than the NM group (10/1395 [0.7%], p = 0.00). The incidence of SSIs in the MRSA group (1/31 [3.2%]) tended to be higher than that in the NM group, but there was no statistically significant difference (p = 0.114). The concordance rate between causative bacteria of SSI and species present in nasal cultures was 53% (13/25 cases). CONCLUSIONS: The results of our study suggest screening patients with a history of past hospitalization, a history of admission in a long-term care facility, and older than 75 to reduce SSIs. TRIAL REGISTRATION: This study was approved by the institutional review board of the authors' affiliated institutions (the ethics committee of Sanmu Medical Center, 2016-02).

Novel within ring fixation using iliac screws and an iliosacral screw locking system technique for fragility fracture of the pelvis.

Background: Surgical indications for fragility fracture of the pelvis (FFP) have been reconsidered recently, and the indications to perform surgery have increased. However, the optimal surgical method to obtain sufficiently strong fixation in elderly patients with minimal invasiveness is not yet clear. In this report, we present the case of a patient with FFP who was treated with a novel posterior within ring fixation technique using a combination of iliac screws and an implant that locks the original iliosacral (IS) screw in the sacrum. Case Description: A 90-year-old man was diagnosed with FFP (Rommens classification: Type IIc) and hospitalized for conservative treatment. However, 6 weeks after the injury, pain reappeared in his right buttock and computed tomography showed additional fractures of the right subpubic branch and right sacrum (Rommens classification: Type IVb). The fracture was considered to have progressed from being stable to unstable, and surgical treatment was planned. To obtain strong fixation with minimal invasion, we performed posterior fixation using E.Spine Tanit (Euros, France) compact posterior thoracolumbar instrumentation, an implant that combines an IS screw with a sacral anchoring system. The patient started walking unaided 2 weeks after the surgery, suggesting a good outcome of this surgical approach to FFP. Conclusion: We performed posterior fixation surgery for a patient with an unstable FFP that recurred and progressed after conservative treatment. We have achieved good results using a minimally invasive, strong, and within ring fixation technique.

Penetrating Endplate Screw Fixation for Thoracolumbar Pathological Fracture of Diffuse Idiopathic Skeletal Hyperostosis.

With the advancement of cancer treatment and minimally invasive surgery, the indications for surgery for metastatic spinal tumors are expanding. Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory skeletal disease characterized by calcification and ossification of ligaments and entheses. In Japan, the prevalence of DISH is increasing with its superaging society. The purpose of this article is to report a case of applying a novel screw technique for pathological fracture in a patient with DISH and spinal metastasis. An 80-year-old man with spinal metastasis presented with acute onset of severe back pain, and investigations revealed a fracture of a metastatic lesion in T10-T12 in the range of DISH. We performed posterior fixation with a percutaneous pedicle screw system using a penetrating endplate technique. The patient's back pain improved, and he was able to mobilize with minimal assistance and survived for 8 months with a good quality of life. Spinal fracture accompanied by DISH sometimes occurs with severe instability because of injury across 3-column injury and its long lever arm. Spinal instability neoplastic score indicates instability of pathological fractures of spinal metastases but needs to be evaluated carefully when DISH is present. The prevalence of DISH is increasing in the elderly, and penetrating endplate screws can be an effective option in posterior fusion surgery for patients with DISH and spinal metastases.

Open Reduction and Internal Fixation of Simultaneous, Bilateral, Atypical Femoral Shaft Fractures After Nine Years of Bisphosphonate Treatment.

Bisphosphonates are generally used to treat osteoporosis and decrease the risk of femoral neck and vertebral fractures in patients with osteoporosis. Recently, it has been suggested that long-term bisphosphonate use can lead to decreased bone remodeling and an increased risk of atypical fractures. Atypical fractures often occur in the femur. The purpose of the present report is to describe a rare case of simultaneous, bilateral, atypical femoral fractures. An 80-year-old female was walking when she sustained bilateral femoral fractures that were diagnosed as atypical. The patient had received bisphosphonate treatment over the prior nine years.

Lateral Bowing of Femur Associated With Older Age, Shorter Stature, and Lower Bone Mineral Density.

We often encounter elderly patients with femur bowing. According to literature, femoral bowing is correlated with patient characteristics such as aging, race, atypical femoral fracture (AFF), and osteoporosis. However, the clear relationships between these factors and femoral bowing are still unknown. In addition, most previous reports have been based only on X-rays and may not provide accurate information due to femur rotation and inter-operator reliability when compared to the information obtained using computed tomography (CT) scans. The purpose of this study was to examine the factors associated with anterior and lateral bowing in detail, by using three-dimensional preoperative measurement software Zed Hip®ï¸Ž (LEXI Co. Ltd., Tokyo, Japan). A total of 364 patients with trochanteric hip or femoral neck fractures, or osteoarthritis, treated in our hospital were included in this study. Of these, 61 patients older than 50 years, who had complete CT volume data for the entire length of the femur on the healthy side and bone mineral density (BMD) measured by trunk dual-energy X-ray absorptiometry (DXA), were investigated. There were 13 males and 48 females, aged 53-97 years (mean 78.7±10.8 years). We defined the starting and ending points of the femoral diaphysis to measure anterior bowing (AB) and lateral bowing (LB) of the femoral diaphysis. The correlation between AB or LB with each patient's characteristics (age, height, weight, lumbar BMD, and femoral BMD) was examined retrospectively. AB did not correlate with any of the patient parameters. LB weakly positively correlated with age and was negatively correlated with height and femoral (greater trochanter) bone density. Weight was in no correlation with either AB or LB. A novel three-dimensional approach was used for measurements that may be more accurate than plain two-dimensional radiographs.

Preferential Adsorption of Propylene over Propane on a Ag-Exchanged X-Type Zeolite Membrane.

We investigated the adsorption properties of propylene and propane on an olefin-selective Ag-X membrane and discussed the contribution of adsorption selectivity to propylene/propane separation performance through this membrane. The isotherms of propylene and propane on Ag-X membranes were measured in unary systems at 313 K. The amount of propylene adsorbed on the Ag-X membrane at a lower pressure increased remarkably compared with that on the Na-X membrane. Such a change of adsorption property could induce excellent separation property for the Ag-X membrane. We compared the adsorption properties in a binary system calculated based on the Markham-Benton approach with the results of a permeation test. The molar fractions of propylene in the adsorbed phase in the binary system provided good agreement with propylene purity on the permeation side of the Ag-X membrane. These results clearly show that permeation selectivity of the Ag-X membrane for the propylene/propane mixture is mainly governed by adsorption selectivity.

Influence of a nerve injury proximal to the suprascapular nerve on healing of repaired rotator cuff tear.

BACKGROUND: Massive rotator cuff tears have a high rate of re-injury because of severe fatty infiltration. Our data showed that injuries proximal to the suprascapular nerve may be one cause of massive rotator cuff tears. The purpose of this study was to evaluate, using a rat model, how brachial plexus injury associated with a massive rotator cuff tear influences healing of the rotator cuff repair. METHODS: Seventy Sprague-Dawley rats were divided into three groups: rotator cuff tear with BP injury (DT group) (n = 28), rotator cuff tear without brachial plexus injury (T group) (n = 28), and a sham-operated group (n = 14). In the DT group, the rotator cuff tear was made and repaired 4 weeks after brachial plexus ligation. The gross assessment (evaluated the wet weight), biomechanical testing (evaluated the yield stress and the Young's modulus) and histological analyses (using the Bonar scale) were performed at baseline in the sham group, and at 4 and 12 weeks postoperatively in the DT and T groups (n = 7/group/time). RESULTS: Mean wet weight and yield stress were significantly lower in the DT group than in the T group. Additionally, the mean Young's modulus was significantly higher in the DT group than in the T group. Histologically, greater tendon degeneration was observed around the musculotendinous junction in the DT group than in the T group. CONCLUSION: The gross, biomechanical and histological data show that the repaired rotator cuff tendon with brachial plexus injury in rats does not heal as well as a repaired tendon without an accompanying brachial plexus injury. This suggests that more proximal neuropathy is one risk factor for re-tear of a repaired rotator cuff tendon.

Nuclear oncology as seen by me in Japan: a historical review and future perspective.

Since 1964 the author has seen and experienced the progress of nuclear medicine in Japan. The purpose of this review article is to trace the application of radiopharmaceuticals and instruments for the diagnosis of tumors and treatment of cancers in the past 55 years. The application of various radiopharmaceuticals for the detection of tumors and therapy of cancers are historically reviewed based on the author's personal clinical experience and research work. Nuclear medicine has been advanced by coordinated developments of instruments and radiopharmaceuticals like two wheels of a vehicle. The journey of nuclear medicine in the past was not necessarily a smooth one having met with periodic difficulties that changed its direction. The ways by which nuclear oncology has progressed by having overcome episodic problems are described. Future perspectives focusing on the recent trend of theranostics are described with the emphasis on efforts being made by the leadership of JSNM to contribute to the progress of nuclear medicine worldwide. The author believes that the multi-and trans-disciplinary collaboration of related specialists as well as other concerned parties will be necessary for the further progress of nuclear oncology in the future.

Relative contribution of sensory characteristics for different types of pork loin, assessed by temporal dominance of sensations.

BACKGROUND: Sensory perception is a dynamic process occurring sequentially. The dynamic analysis of the perception of sensory characteristics in meat is important to understand complex meat sensory characteristics. Temporal dominance of sensations (TDS) is a dynamic sensory method that captures the 'dominance of sensations' throughout food consumption, and it is possible to calculate the relative contribution of various sensory characteristics by 'dominance rate' over time. The objective of this study was to assess the major sensory characteristics of the dynamic sensory perception of pork loin. Using the TDS, we evaluated pork loins derived from pigs with different genetic and feeding backgrounds. Moreover, we checked the integrity of the TDS by comparing the TDS results with a descriptive sensory analysis and a physico-chemical analysis. RESULTS: Seven types of pork loin were evaluated by TDS, and 'tender and/or soft,' 'tough and/or hard,' 'juicy,' 'dry,' 'fat melting,' 'smoothness,' 'sourness,' 'umami,' and 'beast odors' became dominant in at least one type of pork loin. The dynamics of the perception of pork sensory characteristics was also depicted by TDS. In addition, TDS and descriptive analysis demonstrated similarity in principal component analysis. CONCLUSION: TDS demonstrated the major sensory characteristics on the dynamic sensory perception of pork loin. © 2019 Society of Chemical Industry.

Olefin Selective Ag-Exchanged X-Type Zeolite Membrane for Propylene/Propane and Ethylene/Ethane Separation.

Propylene/propane and ethylene/ethane separation was examined with Ag-exchanged X-type zeolite membrane (Ag-X membrane). The Na-X membrane was prepared on a porous tubular α-alumina support by a secondary growth method. The resulting Na-X membrane was ion-exchanged by using AgNO3 aq. Olefin selectivities in both mixtures were markedly improved after the ion exchange from Na to Ag cation. The Ag-X membrane exhibited a maximum propylene selectivity of 55.4 with a permeance of 4.13 × 10-8 mol m-2 s-1 Pa-1 at 353 K for a propylene/propane (50:50) mixture. This membrane also exhibited a maximum ethylene selectivity of 15.9 with a permeance of 9.04 × 10-8 mol m-2 s-1 Pa-1 at 303 K for an ethylene/ethane (50:50) mixture. We consider that the strong interaction between olefin and Ag cation plays an important role for the appearance of such high selectivity of olefin.

Histological analysis and biomechanical evaluation of fatty infiltration after rotator cuff tear and suprascapular nerve injury in a rat model.

BACKGROUND: Rotator cuff tears are the most common shoulder injury, and little is known about the underlying etiology of fatty infiltration after rotator cuff tear. Previous studies speculated that rotator cuff tears lead to neural injury due to tethering of the suprascapular nerve at the notch. This study aimed to evaluate fatty infiltration after suprascapular nerve injury and rotator cuff tears. METHODS: Ninety adult male Sprague-Dawley rats were used and were divided into four groups: sham, tendon transection only, suprascapular nerve ligation, and tendon transection plus suprascapular nerve ligation. The suprascapular nerve injury models were created by tying the suprascapular nerve. At 2, 4, and 8 weeks postoperatively, histological analysis and biomechanical testing were performed to evaluate fatty infiltration and elastic change in the supraspinatus muscles. RESULTS: The amount of fatty infiltration in the supraspinatus muscle was significantly higher in both the suprascapular nerve ligation and tendon transection plus suprascapular nerve ligation groups than in the tendon transection only group at 2, 4, and 8 weeks. The ultimate failure load and tensile strength were significantly different among the tendon transection only, suprascapular nerve ligation, and tendon transection plus suprascapular nerve ligation groups at 8 weeks postoperatively. Furthermore, the mean Young's modulus of the muscle was significantly greater in the tendon transection plus suprascapular nerve ligation group than in both the tendon transection only and suprascapular nerve ligation groups at 8 weeks postoperatively. CONCLUSIONS: In this study, based on the results of histological and biomechanical examinations in our rat models, the etiology of fatty infiltration after massive rotator cuff tear might be different from the suprascapular nerve injury.

Relationship between neuropathy proximal to the suprascapular nerve and rotator cuff tear in a rodent model.

BACKGROUND: Rotator cuff tears are believed to coexist with cervical spine lesions. In cases of preexisting neuropathy, such as cervical spine lesions, fatty degeneration has likely already occurred due to the neuropathy. In these cases, rotator cuff tear is thought to occur easily because of preexisting extensive fatty degeneration and degeneration of the tendons due to neuropathy. This study aimed to evaluate the effects of paralysis due to neuropathy proximal to the suprascapular nerve on the supraspinatus and infraspinatus tendons using a rat model of brachial plexus paralysis. METHODS: This study included fifteen, 8-week-old Sprague-Dawley rats. The left shoulder was included in the paralysis group and the contralateral shoulder constituted the sham group. Biomechanical testing (evaluated maximum tear force, maximum displacement and Young's modulus) (n = 10) and histological analyses (n = 5) (using the Bonar scale) were performed at 12 weeks postoperatively to confirm the degeneration of the tendon. RESULTS: The mean maximum tear force was significantly lower in the paralysis group than in the sham group (P = 0.008), indicating that rotator cuff tears occurred with a lower force in the paralysis group. Additionally, the average Young's modulus was significantly greater in the paralysis group than in the sham group (P = 0.003), indicating that the rotator cuff muscle became hard and inflexible in the paralysis group. The Bonar scales of the histological analyses were significantly higher in the paralysis group (total score = 7.04 ± 0.61) than the sham group (total score = 0) (p < 0.0001). CONCLUSIONS: If neuropathy of proximal to the suprascapular nerve, such as cervical spine or brachial plexus lesion, exists, weakness and degeneration of the rotator cuff tendon and stiffness of the rotator cuff muscle develop. Neuropathy is likely a cause of rotator cuff tears.

Macroscopic and histologic evaluation of a rat model of chronic rotator cuff tear.

BACKGROUND: The major cause of rotator cuff tears in humans is thought to be tendon degeneration. Although some studies have reported chronic rotator cuff tear models in animals, few studies of chronic rat models have demonstrated persistent defects for a relatively long time. The purpose of this study was to establish a chronic rotator cuff tear model in the rat and to evaluate the model macroscopically and histologically. METHODS: Sixty Sprague Dawley rats were divided into 2 groups: tendon detachment only (tear group) and tendon detachment plus figure resin (chronic group). The contralateral shoulder served as a sham-operated control (sham group). In the tear group, the supraspinatus and infraspinatus tendons were completely detached. In addition to cuff detachment, figure resin was placed on the greater tuberosity to prevent cuff reattachment and scar formation in the chronic group. Macroscopic and histologic changes were assessed at 4 and 12 weeks after surgery. RESULTS: A full-thickness cuff defect was observed in all chronic-group rats at both 4 and 12 weeks after surgery, and it could be repaired secondarily by traction in lower tension. However, no cuff defects were observed in the tear group because of obvious scar tissue formation. On histologic evaluation, progressive tendon degeneration, muscle atrophy, and fatty infiltration were observed in the chronic model at 12 weeks after surgery. CONCLUSION: We established a rat model of chronic rotator cuff tears using figure resin. This chronic rotator cuff tear model might be useful for further clinical investigations of rotator cuff repair.

In vivo 3-dimensional analysis of scapular and glenohumeral kinematics: comparison of symptomatic or asymptomatic shoulders with rotator cuff tears and healthy shoulders.

BACKGROUND: Alteration in shoulder kinematics has been suggested as one cause of symptoms in shoulders with rotator cuff tears (RCTs). However, only a few studies comparing symptomatic and asymptomatic RCTs using kinematic analysis have been performed. The purpose of this study was to compare 3-dimensional (3D) scapular and glenohumeral kinematics during scapular-plane abduction among symptomatic RCTs, asymptomatic RCTs, and healthy shoulders. METHODS: This study included 7 healthy shoulders in subjects with a mean age of 62 years, 5 symptomatic RCTs in subjects with a mean age of 70 years, and 7 asymptomatic RCTs in subjects with a mean age of 67 years. All shoulders with RCTs had medium-sized tears (1-3 cm in the coronal plane) that were confirmed with magnetic resonance imaging. Biplane fluoroscopic images during scapular-plane abduction were recorded, and computed tomography-derived 3D bone models were matched with the silhouettes of the bones on the fluoroscopic images using 3D/2-dimensional model-image registration techniques. Angular values of the scapula and glenohumeral kinematics were compared among the 3 groups. RESULTS: Posterior tilt of the scapula was significantly smaller in the symptomatic RCTs (3.1° ± 1.8°) than in healthy shoulders (10.4° ± 0.8°) (P = .049). The humerus of the symptomatic shoulders was less externally rotated relative to the scapula throughout the activity than the healthy shoulders and asymptomatic RCTs (P = .006 and P = .028 respectively). However, there were no kinematic differences between the asymptomatic RCTs and healthy shoulders. CONCLUSION: Kinematic changes in symptomatic RCTs might be associated with development of symptoms. Improvement of these kinematic changes may be a key to successful conservative treatment for symptomatic RCTs.

Efficacy of hyaluronic acid or steroid injections for the treatment of a rat model of rotator cuff injury.

This study evaluated dorsal root ganglia from C3-C7, analyzed gait, and compared the expression of calcitonin gene-related peptide (CGRP) which was a marker of inflammatory pain in a rat rotator cuff tear model in which the supraspinatus and infraspinatus tendons were detached; comparisons were made to a sham group in which only the tendons were exposed. Fluorogold was injected into the glenohumeral joint 21 days after surgery in both groups, and saline, steroids, or hyaluronic acid was injected into the glenohumeral joint in the rotator cuff tear group 26 days after surgery. The proportions of CGRP-immunoreactive neurons were higher and the gait parameters were impaired in the rotator cuff tear group compared to in the sham group. However, the CGRP expression was reduced and the gait was improved with steroid or hyaluronic acid injection compared to saline, suggesting that both hyaluronic acid and steroid injections suppressed of inflammation which thought to be provided pain relief. While there were no significant differences, the suppression of CGRP expression and the improved gait after hyaluronic acid and steroid injections suggested that both methods were effective for rat rotator cuff tear model.

Potential requirement of positron emission tomography apparatuses in Asia and latin america including Mexico.

The number of positron emission tomography (PET) machines has been increasing in regions of East-, Southeast-, and South-Asia as well as in Latin America including Mexico. This study was performed to assess the potential requirement of PET machines in 19 countries which already use PET in the aforementioned regions. Data on the number of PET machines and internationally available characteristics of the restrictive countries such as the land area, the total population, the gross national income (GNI), and the average life span of inhabitants were obtained from IAEA, UN, WB, and WHO. Correlation between the number of PET machines and the characteristics of each country was evaluated. The potentially required number of PET machines, which was obtained by adjusting the number of PET machines with statistically significant, correlative characteristics of each country, standardized on the state of Japan, were compared. The number of PET machines could be significantly correlated to the GNI of a country and the average life span of its inhabitants (P < 0.05). Based on Japan, most of the countries in the regions would require considerably more PET machines. With installation of the potentially required number of PET machines in each of the countries, the number of PET machine per 10(6) population would increase by 1.1- to 12-fold, in comparison with the current situation. With regards to the potentially required number of PET machines, most of the countries in these regions may require a considerable increase of PET machines. Nevertheless, some countries in the Asia seem to require outside assistance such as international support in order to introduce PET and enhance the efficacy of their health services.

Two-staged hindfoot reconstruction with vascularized fibula graft for calcaneal osteomyelitis caused by methicillin-resistant Staphylococcus aureus: a case report.

Hindfoot reconstruction after calcaneal osteomyelitis is a challenging procedure designed to restore the weight bearing function of the heel and to allow a functional reconstruction of the Achilles tendon. Some patients require subtalar arthrodesis after primary calcaneal osteosyntesis or hindfoot reconstruction due to the considerable pain associated with weight-bearing caused by the irregular surface of the subtalar joint. To date, no reports have shown a case of hindfoot reconstruction with subtalar arthrodesis using a pedicled vascularized fibula graft. We report a case of a 24-year-old woman who presented with calcaneal methicillin-resistant Staphylococcus aureus osteomyelitis after open comminuted fracture due to a fall. Radical debridement of bone and soft tissue was repeated six times in combination with negative pressure wound therapy, followed by hindfoot reconstruction with pedicled vascularized fibula and subtalar arthrodesis. Good functional restoration had been achieved by the final follow-up 18 months after surgery.