Long-term course of developmental dysplasia of the hip: follow-up of the non-operated hips of patients undergoing unilateral rotational acetabular osteotomy for twenty-four years.

PURPOSE: To follow-up the non-operated hips of patients who underwent unilateral rotational acetabular osteotomy (RAO) for bilateral developmental dysplasia of the hip (DDH) for a minimum of 20 years to clarify (1) the timing of onset of hip osteoarthritis (OA) in DDH, and (2) factors associated with the development of OA. METHODS: This study included 92 non-operated hips of patients who underwent unilateral RAO for bilateral DDH. We examined the timing of OA onset and total hip arthroplasty (THA) and the joint survival rate in the studied hips. Furthermore, the patients were divided into those with OA onset (progression group) and those without OA onset and compared in terms of lateral center-edge angle (LCEA), sharp angle, acetabular head index (AHI), acetabular roof obliquity (ARO), joint congruity, and the presence or absence of OA progression on the RAO side. RESULTS: The progression group experienced OA onset 12 years after RAO and underwent THA 6 years after OA onset. The 20-year joint survival rate was 73% with the endpoint of OA onset and 81% with the endpoint of THA. The progression group had significantly smaller LCEA and AHI and larger ARO. The risk of developing OA was 8.2 times greater in patients with LCEA ≤ 7° than in those with LCEA > 7°. CONCLUSION: The patients with OA progression group experienced OA onset at an average age of 55 years. A small LCEA (≤ 7°) was identified as a risk factor for the development of OA.

Chronological changes in the rate of surgical field contamination in the shoulder joint.

BACKGROUND: In shoulder surgery, low-virulence bacteria such as Cutibacterium acnes and coagulase-negative staphylococci can cause postoperative infection. However, the degree of sterility during surgery after disinfection is not known, and the efficacy of double skin preparation for such bacteria is unclear. This study aimed to evaluate chronological changes in the surgical field contamination rate in the shoulder joint and to compare single and double skin preparation. METHODS: In total, 126 shoulders in 121 patients undergoing shoulder surgery (64 men, 62 women; mean age 64 years) were enrolled. Patients were divided into two groups: single skin preparation, where the site was painted with 10% povidone iodine, and double skin preparation, where the site was treated with 1% chlorhexidine gluconate/83% isopropyl alcohol and painted 10% povidone iodine. Swab samples from the axillary and proximal areas in the surgical field were collected chronologically before starting surgery and at 30, 60, and 120 min after starting surgery (MAS). The contamination rate of each sample was compared and detected species were evaluated. RESULTS: The contamination rate for the axillary area was 48.4%, 85.9%, 95.3%, and 97.1% in the single-preparation group and 32.3%, 72.6%, 87.1%, and 91.2% in the double-preparation group before starting surgery and 30, 60, and 120 MAS, respectively, and that the proximal area was 12.5%, 26.6%, 29.7%, and 35.3% in the single-preparation group and 16.1%, 19.4%, 27.4%, and 38.2% in the double-preparation group, respectively. Significant differences were not seen between the groups by area or time point. Most detected species were Cutibacterium acnes and coagulase-negative staphylococci. CONCLUSIONS: The incidence of surgical field contamination in shoulder joint was high from immediately after starting surgery. In the axillary area, the contamination rates exceeded 70% from 30 MAS in both groups. Measures against infection should be instituted considering these findings when performing shoulder surgery.

Arthroscopic Treatment of a Ganglion Cyst Originating from the Transverse Acetabular Ligament in the Hip Joint A Case Report.

Introduction: Intra-articular ganglion in the hip joint is rare. Here, we present a case of ganglion cyst originating from the transverse acetabular ligament (TAL) in the hip joint treated by arthroscopic surgery. Case Report: A 48-year-old man presented with the right groin pain after activity. A cystic lesion was found on magnetic resonance imaging. Under arthroscopic view, a cystic mass was identified between the TAL and ligamentum teres that discharged yellowish viscous liquid after puncture. The remaining lesion was resected in its entirety. A diagnosis of ganglion cyst was consistent with the histological findings. The patient has had no recurrence on magnetic resonance imaging as of 6 years postoperatively and had no complaints at the 6-year follow-up visit. Conclusion: Arthroscopic resection is useful for an intra-articular ganglion cyst in the hip joint.

What is the most cost-effective strategy for nasal screening and Staphylococcus aureus decolonization in patients undergoing total hip arthroplasty?

BACKGROUND: To reduce periprosthetic joint infection after total hip arthroplasty (THA), several nasal screening and decolonization strategies for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) have been performed. These include universal decolonization (UD; i.e., no screening and decolonization for all patients), universal screening and target decolonization (US; i.e., screening for all patients and decolonization for bacterial positive patients), and target screening and decolonization (TS; i.e., screening and decolonization for high-risk populations only). Although TS is the most cost-effective strategy, useful risk factors must be identified. The purpose of this study was to evaluate the presence of predictive factors that enable the TS strategy to be successfully implemented and to compare the costs of each strategy. METHODS: A total of 1654 patients scheduled for primary or revision THA (1464 female, 190 male; mean age 64 years) were screened prior to surgery for bacterial colonization of the nasal mucosa. Risk factors for positive MRSA and S. aureus (including both MRSA and MSSA) tests were analyzed according to the following parameters: sex, age ≥ 80 years, body mass index ≥ 30 kg/m2, antibiotic use within 3 years, corticosteroid use, serum albumin < 3.5 g/dL, glomerular filtration rate < 50 mL/min, presence of brain, thyroid, cardiac, or pulmonary disease, diabetes, asthma, smoking status, and whether revision surgery was performed. The average cost of each strategy was calculated. RESULTS: In total, 29 patients (1.8 %) tested positive for MRSA and 445 (26.9 %) tested positive for S. aureus. No parameters were identified as independent risk factors for MRSA and only female sex was identified as a risk factor for S. aureus (p = 0.003; odds ratio: 1.790; 95 % confidence interval: 1.210-2.640). The average cost of each strategy was 1928.3 yen for UD, 717.6 yen for US, and 717.6 yen for TS (for eradicating MRSA), and 1928.3 yen for UD, 1201.6 yen for US, and 1160.4 yen for TS (for eradicating S. aureus). CONCLUSIONS: No useful predictive parameters for implementing the TS strategy were identified. Based on cost implications, US is the most cost-effective strategy for THA patients.

Can sterility of stripped iodophor-impregnated plastic adhesive drape be maintained at the time of incision closure in total hip arthroplasty?

OBJECTIVE: The aim of this study was to analyze the contamination rates of the skin under the iodophor-impregnated plastic adhesive drape (IOD) at the time of incision closure in total hip arthroplasty (THA). METHODS: A total of 225 patients undergoing primary THA (28 men, 197 women; mean age=65 years; age range=30-85) were included in this study. After asepsis using a solution of 1% chlorhexidine with 83% alcohol by volume, the surgical site was painted with a 10% povidone-iodine solution, and IOD was attached tautly at the start of surgery. Swabs of the surgical site were collected as follows: swab A from the skin before IOD application, swab B from the surface of the IOD at the time of incision closure, and swab C from the skin after peeling back the IOD. The obtained samples were promptly sent for microbiological analysis. The contamination rate was determined for swabs A, B, and C, and the contamination rate of swab C was compared with that of swabs A and B, and the bacterial species were identified. RESULTS: Positive cultures were seen in 8 cases (3.6%) for swab A, 10 cases (4.4%) for swab B, and 22 cases (9.8%) for swab C. The contamination rate of swab C was significantly higher than that of swabs A (p=0.008) and B (p=0.028). Coagulase-negative Staphylococcus (n=10) and Cutibacterium acnes (n=7) were the most frequently cultured microorganisms from swab C. CONCLUSION: In THA, the contamination rate of the skin after peeling off the IOD before incision closure was higher than that of the skin immediately after sterilization with povidone-iodine and higher than that on the IOD at the time of incision closure. The detected bacterial species were considered clinically significant pathogens. Preventive measures against infection, such as minimizing stripping of the IOD or re-sterilizing bare skin after IOD stripping, should be instituted in consideration of these findings when performing THA using IOD.

Postoperative creatine kinase elevation following hip arthroscopy and associated risk factors.

OBJECTIVE: The aim of this study was to investigate postoperative CK and risk factors for CK elevation after hip arthroscopy. METHODS: This retrospective study reviewed 122 patients (50 males, 72 females; mean age, 44.1 years) who underwent hip arthroscopy from September 2012 to March 2018. For all patients, CK was investigated preoperatively, on postoperative days 1 and 3, and at postoperative weeks 1 and 2. Univariate and multivariate analysis was performed for parameters including sex, age, body mass index, preoperative glomerular filtration rate, diagnosis, duration of surgery, and duration of traction to determine the risk factors for CK > 10 upper limit of normal (CK > 10 ULN; 1900 IU/L for males and 1500 IU/L for females) after surgery. RESULTS: Mean CK was 104.7 ± 68.7 IU/L preoperatively and 839.2 ± 2214.0, 523.9 ± 1449.4, 186.0 ± 690.7, and 122.0 ± 307.1 IU/L on postoperative days 1 and 3 and at postoperative weeks 1 and 2, respectively. CK was significantly higher on postoperative days 1 and 3 than before surgery. In total, 11 patients (9.0%), including 8 males (16.0%) and 3 females (4.2%), had CK > 10 ULN. Younger age and longer duration of traction are independent risk factors for CK > 10 ULN. CONCLUSION: After hip arthroscopy, CK levels should be monitored, especially in young patients and cases of prolonged duration of traction during surgery. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Preoperative Pain Control in Arthroscopic Rotator Cuff Repair: Does It Matter?

BACKGROUND: The purpose of this study was to clarify the importance of preoperative pain control using corticosteroid injections in patients with persistent rest pain (RP) before arthroscopic rotator cuff repair (ARCR). METHODS: A total of 360 patients (374 shoulders) who underwent primary ARCR and were followed up for at least 2 years were enrolled. After one-to-one propensity score matching, 266 patients (145 men and 128 women, 273 shoulders) were included in the study. Their mean age was 65.2 ± 7.7 years (range, 42 to 88 years) at the time of surgery. The patients were divided into three groups: those who required several intra-articular or subacromial bursa corticosteroid injections preoperatively for refractory RP (group A+), those in whom RP was resolved preoperatively (group A-), and those who had no RP and did not require any injections (group B). The incidence of postoperative RP and preoperative and final follow-up American Shoulder and Elbow Surgeons (ASES) scores were compared among the three groups. RESULTS: The incidence of postoperative RP was significantly higher in group A+ (35/91 cases, 38.5%) than in group A- (10/91, 11.0%) and group B (7/91, 7.7%, p < 0.001 for both). The preoperative ASES score was significantly lower in group A+ (33.2 ± 14.2) than in group A- (53.9 ± 11.9) and group B (62.3 ± 11.2, p < 0.001 for both), and it was significantly lower in group A- than in group B (p = 0.000). The final follow-up ASES score was significantly lower in group A+ (92.1 ± 8.4) than in group A- (97.6 ± 5.4) and group B (99.0 ± 2.5, p < 0.001 for both). There was no significant difference in the final follow-up ASES score between group A- and group B (p = 0.242). CONCLUSIONS: Patients in whom preoperative RP could be resolved before surgery achieved postoperative outcomes comparable to those in patients who had no RP before surgery, whereas the outcomes in patients with refractory preoperative RP were inferior. The results suggest that preoperative pain control is important in patients undergoing ARCR.

Target range of motion at 3 months after arthroscopic rotator cuff repair and its effect on the final outcome.

PURPOSE: The postoperative protocol after arthroscopic rotator cuff repair (ARCR) is still controversial. Some surgeons recommend slower rehabilitation in order to improve the integrity of the repair, while others prefer early range-of-motion (ROM) exercise to avoid postoperative stiffness. The purpose of this study was to determine target ROM (T-ROM) measurements at 3 months after ARCR that are predictive of eventual full recovery without structural failure. METHODS: The cases consisted of 374 shoulders in 360 patients who underwent primary ARCR and were followed up for at least 2 years. Forward flexion (FF) and side-lying external rotation (ER) were measured preoperatively at 3, 6, 9, 12, and 24 months after surgery, and the patients were divided into six subgroups according to the values for each type of ROM at 3 months (ROM-3M). In each subgroup, the final ROM at 24 months after surgery was compared to determine the T-ROM. The average ROMs with time and re-tear rate were then compared between the under-T-ROM and over-T-ROM groups. RESULTS: The only significant difference in FF was between the 120-129° and 110-119° ROM-3M groups. Therefore, the T-ROM for FF was determined to be 120°. Similarly, the T-ROM for ER was determined to be 20°. Each ROM in the over-T-ROM group was significantly better than that in the under-T-ROM group at all assessments. There was no significant difference in the re-tear rate between the groups. CONCLUSION: To acquire sufficient ROM in 2 years without high re-tear rate, a target FF of 120° and ER of 20° should be achieved within 3 months after surgery.

Prospective analysis of health-related quality of life and clinical evaluations in patients with anterior cruciate ligament injury undergoing reconstruction.

INTRODUCTION: This study aimed to evaluate the treatment outcome of patients with anterior cruciate ligament (ACL) injury using the patient-based quality of life (QOL) survey SF-36, and investigate the correlation with conventional objective assessment methods. Our hypothesis that SF-36 is a useful assessment method for QOL in patients with ACL injury, and this assessment clarifies the concord and the discord between doctor-based objective assessment. PATIENTS AND METHODS: A prospective study was conducted on patients who underwent ligament reconstruction. Eighty-one patients with a mean age of 27.4 years were analyzed. Clinical evaluations comprising SF-36 survey, Lysholm scoring, and anterior tibial translation measurement were conducted before as well as after surgery. The changes over time and the correlation between these evaluation methods were analyzed. RESULTS: All SF-36 subscales were significantly improved after surgery. Regarding QOL of patients with ACL injury, the preoperative scores of all the subscales except vitality and mental health were lower than the national standard values, while the postoperative scores of all subclasses were not different from the national standards. A correlation was found between Lysholm score and all SF-36 subscale scores except general health before surgery, but a correlation was observed only with physical functioning, bodily pain and role emotional at 6 months after surgery, and with physical functioning, role physical, bodily pain and vitality at 12 months. No correlation between SF-36 scores and distance of anterior tibial translation was observed both before and after surgery. DISCUSSION: The QOL of patients with ACL injury as assessed by SF-36 improved significantly after reconstruction surgery. The mental health subscales of SF-36 correlate with Lysholm score before surgery suggesting that apart from the physical impairment, lowered mental health is also an important clinical issue in patients with ACL injury.

Health-related quality of life in patients with an anterior cruciate ligament injury.

INTRODUCTION: We evaluated the quality of life (QOL) in patients with an anterior cruciate ligament injury through SF-36 survey, which was a global health-related QOL survey, and investigated the correlation of its results with other clinical parameters. PATIENTS AND METHODS: Fifty-one patients (mean age 28.7 years) with an anterior cruciate ligament injury were studied. Clinical evaluations using SF-36 version 2 and Lysholm scoring system were conducted, and the ratio of anterior tibial translation in affected compared to unaffected knees was obtained. RESULTS: In SF-36 survey, scores of both physical and mental health summary measures in our subjects were lower than the national standard values. The mean ratio of anterior tibial translation was 7.8 +/- 6.0, and no correlation with SF-36 scores was observed. The mean Lysholm score was 53.3 +/- 17.1; which tended to be correlated with the mental health score of SF-36, but not with the physical health score. DISCUSSION: Our results clearly demonstrated that patients with an anterior cruciate ligament injury had a deterioration of mental health as well as physical health.

Fracture of the anterior extremity of calcaneus together with calcaneocuboid joint dislocation.

The calcaneocuboid joint is very stable, and dislocation or fracture is rare. We report a very rare case of dislocation fracture at the anterior articular surface of the calcaneocuboid joint. This is, to our knowledge, the first report of calcaneus fracture.

Separation of a bipartite patella combined with quadriceps tendon rupture: a case report.

Separation of a bipartite patella is very rare. We found only seven cases in the literature [Carter SR. Traumatic separation of a bipartite patella. Injury 1989;20:244; Ireland ML, Chang JL. Acute fracture bipartite patella; case report and literature review. Med Sci Sports Exerc 1995; 27:299-302; Ishii M, Yabuno K, Ishikawa T, Tsujino H, Yamaguchi K. A case of bipartite patella separation accompanied by subcutaneous rupture of quadriceps tendon. Seikeigeka (Orthopedic Surgery) 2003;54:1563-5. [In Japanese]; Canizares GH, Selesnick FH. Bipartite patella fracture. Arthroscopy 2003;19:215-7; Okuno H, Sugita T, Kawamata T, Ohnuma M, Yamada N, Yoshizumi Y. Traumatic separation of a type 1 bipartite patella; a report of four knees. Clin Orthop 2004;420:257-60]. Among these cases only one was complicated with quadriceps tendon rupture, and the patient had diabetes as underlying disease [Ishii M, Yabuno K, Ishikawa T, Tsujino H, Yamaguchi K. A case of bipartite patella separation accompanied by subcutaneous rupture of quadriceps tendon. Seikeigeka (Orthopedic Surgery) 2003;54:1563-5. [In Japanese]]. To our knowledge, there have been no reports of this condition in a healthy subject. In this report, we present a case of bipartite patella separation complicated with quadriceps tendon rupture in a patient with no underlying disease. Treatment involving suturing the tendon to the patella and osteosynthesis of the bipartite patella produced a good result.

Usefulness of radial contrast-enhanced computed tomography for the diagnosis of acetabular labrum injury.

PURPOSE: The purpose of this study was to evaluate the usefulness of radial contrast-enhanced computed tomography (CT) in the diagnosis of acetabular labrum injury. METHODS: We studied 21 hip joints in 21 patients (8 joints in 8 male patients and 13 joints in 13 female patients), aged between 16 and 81 years (mean, 43 years) at examination, who underwent both radial contrast-enhanced CT and hip arthroscopy. Plain radiography showed no abnormalities in the bone and joint in 19 joints and acetabular dysplasia in 2 joints. When we performed radial contrast-enhanced CT, a mixture of 5 mL of 2% lidocaine chloride and 10 mL of 64% iotrolan was injected intra-articularly under x-ray fluoroscopy. CT was conducted with a 4-slice multidetector CT system operated at a voltage of 120 kilovolt peak, current of 300 mA, collimation beam of 2 mm, field of view of 320 mm, slice thickness of 0.5 mm, table speed of 44 mm/s, and helical pitch of 5.5. Images were reconstructed by computer software for radial slices at 15 degrees intervals perpendicular to the labral rim. The mean interval between the CT scan and arthroscopy was 13.2 days. RESULTS: By contrast-enhanced CT, acetabular labrum tears were observed in 12 joints, loss of acetabular labrum was found in 1 joint, and no abnormalities were present in 8 joints. By arthroscopy, acetabular labrum tears were observed in 13 joints, loss of acetabular labrum was found in 1 joint, and no abnormalities were present in 7 joints. When the results of the 2 methods were compared, 12 joints had true-positive findings, 8 joints had true-negative findings, and 1 joint had a false-negative finding. Therefore contrast-enhanced CT had a sensitivity of 92.3%, specificity of 100%, and accuracy of 95.2%. CONCLUSIONS: The sensitivity, specificity, and accuracy of radial contrast-enhanced CT for the diagnosis of acetabular labrum injury are 92.3%, 100%, and 95.2%, respectively. We recommend radial contrast-enhanced CT for the diagnosis of acetabular labrum injury in patients in whom magnetic resonance imaging is contraindicated. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Prediction of ambulation prognosis in the elderly after hip fracture.

We investigated the factors influencing ambulation prognosis after hip fracture in the elderly patient and examined whether it is possible to predict the ambulation status upon hospital discharge at the time of admission. Two hundred and five patients aged 60 or older with a hip fracture who were ambulant before injury were studied. The patients were divided into two groups according to their ability to walk at the time of discharge from hospital: the ambulatory group and the non-ambulatory group. We assessed the value of various predictive factors. At discharge, 136 patients (66.3%) were ambulatory while 69 patients (33.7%) were non-ambulatory. Factors significantly affecting walking ability at discharge were: (1) age, (2) dementia, (3) residence before injury, (4) anaemia, (5) electrolyte abnormality, (6) abnormal chest X-ray, and (7) chronic systemic disease. Each patient was scored on the basis of the above factors (1=yes, 0=no), and the total was used as the predictive score. The mean score was significantly higher (p<0.0005) in the non-ambulatory group. It is possible to predict ambulation prognosis after hip fracture using our scoring system at the time of admission.