Local Postoperative Complications after Surgery for Intertrochanteric Fractures Using Cephalomedullary Nails.

PURPOSE: Cephalomedullary nails (CMN) are commonly used for the surgical treatment of intertrochanteric fractures. This study aimed to evaluate overall postoperative local complications by reviewing patients who received surgical treatment using three different types of implants. MATERIALS AND METHODS: The study sample included 353 patients (107 males, 246 females) who underwent surgery using CMN for intertrochanteric fractures. Three different types of implants were used: i) the Gamma3® (Stryker) in 80 cases, ii) the Targon® PF (Aesculap) in 225 cases, and iii) the Compression Hip Nail® (Trademedics) in 48 cases. The mean age was 82.6 (range, 60-109) years and the average follow-up period was 15 (range, 6-80) months. Postoperative local complications and risk factors of cut-out were assessed. RESULTS: The most common complication was cut-out (n=26). Other complications included non-union (n=3), periprosthetic fracture (n=2), avascular necrosis (n=1), heterotopic ossification (n=1), and sleeve pull out (n=1). Multivariate analysis revealed that the cut-out group had a higher rate of poor reduction compared to the non-complicated group (P<0.001). Although the mean tip-apex distance (TAD) was 18.4 mm in the non-complicated group, lower than that of the cut-out group (P=0.001), multivariate analysis revealed that TAD was not a significant risk factor for cut-out (P=0.065). CONCLUSION: Cut-out is the most common local complication associated with surgical treatment of intertrochanteric fractures using CMN. Proper reduction appears to be important in lowering the risk of cut-out. Maintaining low TAD is another critical factor in achieving sufficient fixation of lag screw to the subchondral bone of the femoral head.

Result of Modular Necks in Primary Total Hip Arthroplasty with a Average Follow-up of Four Years.

PURPOSE: This study aimed to investigate the outcomes of modular neck-utilization in primary total hip arthroplasty (THA). MATERIALS AND METHODS: Thirty patients (34 hips) who had modular stem THA between April 2011 and January 2013 were evaluated. There were 19 men and 11 women with a mean age of 61.2 years at the time of surgery. There were 20 cases of osteonecrosis of femoral head, 7 cases of osteoarthritis, 6 cases of femur neck fracture, and 1 case of rheumatoid arthritis. No patients presented with anatomical deformity of hip. Patients were operated on using a modified Watson-Jones anterolateral approach. All patients underwent clinical and radiological follow-up at 6 weeks, 3, 6, and 12 months, and every year postoperatively. The mean duration of follow-up was 48.2 months (range, 39 to 59 months). RESULTS: The average Harris hip score improved from 63.7 to 88.1 at the final follow-up. Radiographically, mean acetabular cup inclination was 45.3°(range, 36°-61°) and anteversion was 21.7°(range, 11°-29°). All were neutral-positioned stems except 5 which were varus-positioned stems. In only 3 cases (8.8%), varus or valgus necks were required. A case of linear femoral fracture occurred intraoperatively and 1 case of dislocation occurred at postoperative 2 weeks. No complications at modular junction were occurred. CONCLUSION: Our study shows that the use of modular necks had favorable clinical and radiographic results. This suggests that the use of modular neck in primary THA without anatomical deformity is safe at a follow-up of 39 months.

Proximal tibial resection in varus-deformed tibiae during total knee arthroplasty: an in vitro study using sawbone model.

PURPOSE: This study was designed to investigate accuracy of the tibial component in the coronal plane when the lateral condylar eminence was determined as the proximal reference of proximal tibial cutting in varus-deformed knees. METHODS: Varus-deformed tibiae were designed using the entire tibia sawbone models of four categories (varus 0°, 5°, 10° and 15°). Each of ten sawbones was allocated into four in each group. All sawbones were osteotomised with the proximal reference of proximal tibial cutting as the lateral intercondylar eminence. The thickness of the cut tibial medial and lateral condyles were measured. After implantation of the tibial component, anteroposterior (AP) radiographs were obtained. An independent examiner evaluated angles between the perpendicular line to the tibial tray and the shaft/mechanical axes of the tibia. RESULTS: The mean angular difference between the axis perpendicular to the prosthesis and the mechanical/shaft axes of the tibia were not significant in any group. When the tibial component coronal alignment was measured based on the tibial mechanical axis, no significant difference was observed in any group, but when based on the shaft axis of the tibia, it was significantly different between Group A and Group D. CONCLUSIONS: Accuracy of the tibial component alignment was acceptable in varus-deformed knees when the lateral intercondylar eminence was used as a reference for tibial osteotomy, although any prolonged clinical benefits will require long-term in vivo study.

Treatment of Intertrochanteric Fractures Using the Compression Hip Nail.

PURPOSE: To investigate the clinical and radiologic outcomes following treatment of intertrochanteric fractures using the Compression Hip Nail® (CHN), which has a sliding lag screw. MATERIALS AND METHODS: Twenty-eight cases of intertrochanteric fractures treated with CHN from November 2012 to October 2013 and followed-up for >6 months were included. The patient population consisted of 11 men and 17 women with a mean age of 75.2 years at the time of surgery. For the initial 11 cases, 10 mm sliding lag screws were used; the remaining 17 cases used 20 mm sliding lag screws. Clinical variables including operation time, amount of transfusion, weight-bearing start time, postoperative physical activity, and complications were investigated. The average sliding of lag screws and the average union were investigated radiologically at 3 and 6 months after surgery. RESULTS: In an analysis of 23 cases (exclusion of 3 cases of lag screw cutout and 2 cases of nonunion), 11 (48%) recovered their pre-injury activity level. In an analysis of 25 cases (exclusion of 3 cases of cutout), 17 (68%) and 23 (92%) showed radiological union at postoperative months 3 and 6, respectively. Seven complications were noted. Cutout of the lag screw and the lateral protrusion of barrels were significantly greater in the group with 10 mm sliding lag screws as compared to the group using 20 mm sliding lag screws. CONCLUSION: The use of CHN for the treatment of intertrochanteric fracture yielded poor results. However, results from patients in the 20 mm sliding lag screw group were better than for the 10 mm sliding lag screw group. Therefore, use of the 20 mm sliding lag screw is advisable.

Comparison of the effects of maxillary protraction using facemask and miniplate anchorage between unilateral and bilateral cleft lip and palate patients.

OBJECTIVE: To determine the difference in the effects of facemask with miniplate (FM-MP) anchorage on maxillary protraction in growing cleft patients between unilateral (UCLP) and bilateral cleft lip and palate (BCLP) groups. MATERIALS AND METHODS: The samples consisted of a UCLP group (N  =  15, 13 boys and 2 girls; mean age 10.98 years; mean protraction duration 2.37 years) and a BCLP group (N  =  15, all boys; mean age 11.42 years; mean protraction duration 2.36 years), who were treated with the same surgical technique (rotation and advancement flap and double opposing Z-plasty) by one surgeon and with FM-MP by one orthodontist. Lateral cephalograms were taken before (T1) and after FM-MP (T2). Fourteen skeletal and dental variables were measured. Independent and paired t-tests were performed for statistical analysis. RESULTS: There were no differences in mean age and values of variables at the T1 stage and in the duration of protraction between the two groups. The BCLP group showed less advancement of point A than the UCLP group (ΔA-vertical reference plane, 2.51 mm vs 4.06 mm, P < .05; ΔA-N perpendicular, 0.79 mm vs 2.26 mm, P < .05; ΔSNA, 0.45° vs 2.85°, P < .01). Since counterclockwise rotation of the palatal plane in two groups was minimal (-0.36° vs -0.87°), no difference was observed with regard to clockwise rotation of the mandible (0.46° vs -0.07°). There were no differences in the degree of labioversion of the maxillary incisor (8.16° vs 7.10°), linguoversion of the mandibular incisor (-2.66° vs -2.14°), and increase in overjet (5.39 mm vs 5.70 mm) between the two groups. CONCLUSION: In FM-MP therapy of growing cleft patients under the conditions of this study, the UCLP group shows a more favorable change in maxillary advancement than the BCLP group.

Peripheral vascular reconstruction using deep vein graft for critically ill patients.

The great saphenous veins are gaining wide popularity as acceptable native vascular grafts, but in terms of flow capacity, their small caliber may be unsuitable for immediate replacement of arterial flow. Ten peripheral vascular or central venous reconstructions were performed using superficial femoral vein free grafts for re-establishment of immediate high-flow patency. Seven of the patients were men with a mean age of 61.5 ± 17.9 years (range, 21-81 years). The majority of the patients were of preoperative or intraoperative critically ill statuses in that they had extensive infection (n = 5), bleeding (n = 4), renal failure (n = 3) or hepatic failure (n = 1). The mean preoperative physiology score of the vascular POSSUM was 24.1 ± 8.8 (range, 15-37), and the mean operative severity score was 18.4 ± 4.9 (range, 10-26). All patients survived and recovered from systemic infection or critical hemodynamic instability. During the mean 28.9 months of follow-up, complications such as aneurysmal dilation, recurrent infection, graft stenosis/occlusion, lower limb edema and other clinical problems that required attention were not observed. In conclusion, we determined that deep veins can be applied as ideal graft conduits for reconstructing the major peripheral vessels under complicated conditions in select patients.

A Case of Bladder Cancer Found during a Workup for Urge Incontinence.

Irritative urinary symptoms may suggest the possibility of bladder cancer. We report a case of metastatic bladder cancer that was discovered during a workup for urge incontinence in a 65-year-old woman with a history of stomach cancer. She had a medical history of gastrectomy due to stomach cancer 4 years previously. The patient complained of urgency unresponsive to anticholinergic therapy. Cystoscopy revealed the presence of suspicious bladder mucosal lesions that were biopsied. The pathology was consistent with metastatic signet-ring cell adenocarcinoma. This case suggests that irritative urinary symptoms can be the first clinical manifestation in patients with bladder cancer.

New treatment modality for maxillary hypoplasia in cleft patients. Protraction facemask with miniplate anchorage.

OBJECTIVE: To present cleft patients treated with protraction facemask and miniplate anchorage (FM/MP) in order to demonstrate the effects of FM/MP on maxillary hypoplasia. MATERIALS AND METHODS: The cases consisted of cleft palate only (12 year 1 month old girl, treatment duration = 16 months), unilateral cleft lip and alveolus (12 year 1 month old boy, treatment duration = 24 months), and unilateral cleft lip and palate (7 year 2 month old boy, treatment duration = 13 months). Curvilinear type surgical miniplates (Martin, Tuttlinger, Germany) were placed into the zygomatic buttress areas of the maxilla. After 4 weeks, mobility of the miniplates was checked, and the orthopedic force (500 g per side, 30 degrees downward and forward from the occlusal plane) was applied 12 to 14 hours per day. RESULTS: In all cases, there was significant forward displacement of the point A. Side effects such as labial tipping of the upper incisors, extrusion of the upper molars, clockwise rotations of the mandibular plane, and bite opening, were considered minimal relative to that usually observed with conventional protraction facemask with tooth-borne anchorage. CONCLUSIONS: FM/MP can be an effective alternative treatment modality for maxillary hypoplasia with minimal unwanted side effects in cleft patients.

Validation of hippocampal volumes measured using a manual method and two automated methods (FreeSurfer and IBASPM) in chronic major depressive disorder.

INTRODUCTION: To validate the usefulness of the packages available for automated hippocampal volumetry, we measured hippocampal volumes using one manual and two recently developed automated volumetric methods. METHODS: The study included T1-weighted magnetic resonance imaging (MRI) of 21 patients with chronic major depressive disorder (MDD) and 20 normal controls. Using coronal turbo field echo (TFE) MRI with a slice thickness of 1.3 mm, the hippocampal volumes were measured using three methods: manual volumetry, surface-based parcellation using FreeSurfer, and individual atlas-based volumetry using IBASPM. In addition, the intracranial cavity volume (ICV) was measured manually. RESULTS: The absolute left hippocampal volume of the patients with MDD measured using all three methods was significantly smaller than the left hippocampal volume of the normal controls (manual P = 0.029, FreeSurfer P = 0.035, IBASPM P = 0.018). After controlling for the ICV, except for the right hippocampal volume measured using FreeSurfer, both measured hippocampal volumes of the patients with MDD were significantly smaller than the measured hippocampal volumes of the normal controls (right manual P = 0.019, IBASPM P = 0.012; left manual P = 0.003, FreeSurfer P = 0.010, IBASPM P = 0.002),. In the intrarater reliability test, the intraclass correlation coefficients (ICCs) were all excellent (manual right 0.947, left 0.934; FreeSurfer right 1.000, left 1.000; IBASPM right 1.000, left 1.000). In the test of agreement between the volumetric methods, the ICCs were right 0.846 and left 0.848 (manual and FreeSurfer), and right 0.654 and left 0.717 (manual and IBASPM). CONCLUSION: The automated hippocampal volumetric methods showed good agreement with manual hippocampal volumetry, but the volume measured using FreeSurfer was 35% larger and the agreement was questionable with IBASPM. Although the automated methods could detect hippocampal atrophy in the patients with MDD, the results indicate that manual hippocampal volumetry is still the gold standard, while the automated volumetric methods need to be improved.