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In order to improve cancer care in Japan further, it is now required for orthopaedic surgeons to get actively involved in managing locomotive organs such as bones, muscles and nerves in cancer patients. In 2018, the Japanese Orthopaedic Association (JOA) conducted a questionnaire survey to investigate the current status of cancer treatment at the orthopaedic training facilities certified by the JOA. We analyzed the results of that questionnaire survey, focusing on the data from the core hospitals for cancer care (designated cancer hospitals), to clarify the involvement of orthopaedic surgeons in cancer treatment.A nationwide survey was conducted in the orthopaedic training facilities certified by the JOA using an online questionnaire from March 15th to 31st, 2018. To clarify the involvement of orthopaedic surgeons in cancer treatment, we analyzed the results of that questionnaire survey, focusing on the data from the designated cancer hospitals in Japan.From the questionnaire survey, it became clear that 24% of the orthopaedic training facilities certified by the JOA are designated cancer hospitals. There were significant differences concerning cancer treatment and the prospect of orthopaedic surgeons' involvement in the treatment for bone metastases between institutions classified according to number of both certified orthopaedic surgeons by the JOA and specialists for bone and soft tissue tumors. In addition, in 45% of the designated cancer hospitals, orthopaedic surgeons treated bone metastases that occur in cancer patients, but in the rest of the institutions, orthopaedic surgeons did not yet adequately respond.In order to further improve the locomotive function and quality of life (QOL) in cancer patients, it was seemed to be necessary that all medical professionals engaged in cancer treatment, including orthopaedic surgeons, recognize the importance of locomotive management for cancer patients. In addition, the results of this study suggested that the presence of more than six certified orthopaedic surgeons by the JOA, including one or more specialists for bone and soft tissue tumors, may be able to create an environment conducive to the involvement of orthopaedic surgeons in cancer treatment at the facility.

Background: Poor oral health status can lead to a deteriorated level of general health and is common among patients undergoing cardiovascular surgery. However, the effect of oral health status on postoperative outcomes in cardiovascular surgery patients remains unclear. Thus, we investigated the effect of preoperative oral health status on postoperative complications and functional recovery after cardiovascular surgery. Methods: This single-centre retrospective cohort study included 884 inpatients undergoing elective cardiovascular surgery. Oral health status was assessed based on the number of remaining teeth, use of dentures, occlusal support, and periodontal status. We investigated postoperative complications related to surgery and postoperative functional recovery by measuring the reacquisition of walking ability, activities of daily living, and length of postoperative hospital stay. Results: In this cohort (age 66.9 ± 13.4 years), the mean number of remaining teeth was 18.7 ± 9.4. Patients were grouped based on tertiles of the data distribution of remaining teeth: ≥ 20 teeth (470 patients); 10-19 teeth (137 patients); < 10 teeth (185 patients). The number of missing teeth was associated with age (P < 0.001). The prevalence of postoperative pneumonia and reintubation after surgery was 3.2% and 2.5%, respectively, which was significantly higher in patients with severe tooth loss (P < 0.05 for both). After adjusting for age and other confounding factors, the number of remaining teeth was a statistically significant predictor of functional recovery (P < 0.05). Conclusions: Preoperative oral health status was related to postoperative respiratory complications and independently associated with functional recovery. Preoperative oral intervention may improve functional recovery after cardiovascular surgery. Résumé: Contexte: Une mauvaise santé buccodentaire peut avoir des répercussions néfastes sur la santé générale et est fréquemment observée chez les patients subissant une intervention chirurgicale cardiovasculaire. Cependant, l’effet de l’état de santé buccodentaire sur les issues postopératoires chez les patients ayant subi une telle intervention est mal connu. Nous avons donc étudié l’effet de l’état de santé buccodentaire avant l’intervention sur les complications postopératoires et le rétablissement fonctionnel après une intervention chirurgicale cardiovasculaire. Méthodologie: Cette étude de cohorte rétrospective menée dans un seul centre réunissait 884 patients subissant une intervention chirurgicale cardiovasculaire non urgente. L’état de santé buccodentaire des patients a été évalué en fonction du nombre de dents restantes, du recours à des prothèses dentaires, de la présence d’appuis occlusaux et de la santé parodontale. Nous avons examiné les cas de complications postopératoires liées à l’intervention chirurgicale ainsi que le rétablissement fonctionnel après l’intervention en évaluant la réacquisition de la capacité de marcher, la capacité d’accomplir les activités de la vie quotidienne et la durée du séjour à l’hôpital après l’intervention. Résultats: Dans cette cohorte (âge moyen : 66,9 ± 13,4 ans), les sujets avaient en moyenne 18,7 ± 9,4 dents restantes. Les patients ont été répartis en trois groupes en fonction du nombre de dents restantes : ≥ 20 dents (470 patients); de 10 à 19 dents (137 patients); < 10 dents (185 patients). Il y avait un lien entre le nombre de dents manquantes et l’âge (p < 0,001). La prévalence des cas de pneumonie postopératoire et de réintubation après l’intervention s’établissait à 3,2 % et à 2,5 %, respectivement, et était significativement plus élevée chez les patients à qui il restait très peu de dents (p < 0,05 dans les deux cas). Après correction pour tenir compte de l’âge et d’autres facteurs de confusion, le nombre de dents restantes s’est révélé être un facteur de prédiction statistiquement significatif du rétablissement fonctionnel (p < 0,05). Conclusions: L’état de santé buccodentaire avant l’intervention chirurgicale était lié à des complications respiratoires postopératoires et associé de manière indépendante au rétablissement fonctionnel. Des soins buccodentaires préopératoires pourraient améliorer le rétablissement fonctionnel après une intervention chirurgicale cardiovasculaire.

Background Oral health is important for maintaining general health and is associated with components of physical frailty among the elderly. Oral health problems are common in hospitalized patients; however, no reports on oral health problems pertain to patients with cardiovascular diseases (CVD). The present study aimed to evaluate the association between oral health and physical frailty in these patients. Methods In this retrospective cohort study, we included consecutive patients admitted for CVD to our hospital between May 2014 and December 2018. Physical frailty was assessed using the Short Physical Performance Battery (SPPB). Oral health characteristics, such as the number of remaining teeth, denture use, occlusal support, and periodontal status, were assessed. Results In our cohort (n = 457), 111 (24.3%) patients had physical frailty. Univariate linear regression showed that the number of teeth present and the prevalence of occlusal support were significantly lower in patients with than without physical frailty. Pearson correlation indicated that the number of teeth significantly correlated with the nutritional status (r = 0.27) and SPPB score (r = 0.24), grip strength (r = 0.33), and 6-minute walking distance (r = 0.26). Multiple linear regression analysis showed that the number of teeth was independently associated with physical frailty after adjusting for confounders. Conclusions Oral health was closely associated with physical frailty, and nutritional status in patients with CVD; thus, it could be an important screening marker for early frailty symptoms and a predictor of future malnutrition risk.

Background Muscle atrophy causes difficulty in resuming daily activities after a fracture. Because transcutaneous carbon dioxide (CO2) application has previously upregulated oxygen pressure in the local tissue, thereby demonstrating its potential in preventing muscle atrophy, here we investigated effects of CO2 application on muscle atrophy after femoral shaft fracture. Methods Thirty fracture model rats were produced and randomly divided into a no treatment (control group) and treatment (CO2 group) groups. After treatment, the soleus muscle was dissected at post-fracture days 0, 14, and 21. Evaluations were performed by measuring muscle weight and performing histological examination and gene expression analysis. Results Muscle weight was significantly higher in the CO2 group than in the control group. Histological analysis revealed that the muscle fiber cross-sectional area was reduced in both groups. Nevertheless, the extent of atrophy was lesser in the CO2 group. Muscle fibers in the control group tended to change into fast muscle fibers. Vascular staining revealed that more capillary vessels surrounded the muscle fibers in the CO2 group than in the control group. Messenger RNA (mRNA) analysis revealed that the CO2 group had a significantly enhanced expression of genes that were related to muscle synthesis. Conclusion Transcutaneous CO2 application may be a novel therapeutic strategy for preventing skeletal muscle atrophy after fracture.

Background Elderly patients undergoing cardiac surgery often show poor nutritional status, muscle wasting, and sarcopenia, which are reported to affect postoperative functional recovery and incidence of complications. Amino acids are essential in maintaining nutritional status, synthesizing muscle protein, and promoting beneficial energy balance of the heart muscle. β-Hydroxy β-methylbutyric acid (HMB) is a leucine metabolite known to increase muscle protein synthesis and inhibit protein catabolism; it has been used to more effectively support patients with muscle wasting due to wearing diseases. However, the efficacy of amino acid administration comprising HMB in patients undergoing open heart surgery remains unclear. This study aims to examine whether preoperative short-term aggressive amino acid administration helps support postoperative recovery of physical function and prevent complications. Methods This is a single-center prospective randomized controlled trial (UMIN000030490). Patients aged ≥65 years who will be hospitalized for medical examination before cardiac surgery will be recruited. The participants will be randomly assigned to the experimental or control group. The experimental group will be administered with an amino acid supplement with HMB 1200 mg, l -glutamine 7000 mg, and l -arginine 7000 mg once or twice per day depending on the degree of renal dysfunction, for 14–28 days preoperatively. The control group will not receive any nutritional intervention. The main outcome will be a change in the 6-min walking test distance pre- and postoperatively as a sign of functional recovery. Secondary outcomes such as the incidence of complications; physical, nutritional, and psychological states; mortality; and length of hospital stay will also be evaluated. Conclusion This clinical study will determine the effects of preoperative short-term oral amino acid supplementation with HMB, l -glutamine, and l -arginine on postoperative physical function in elderly patients undergoing cardiac surgery.

Objectives The aim of the present study was to investigate the impact of preoperative cachexia on postoperative length of stay (LOS) in elderly patients with gastrointestinal cancer. Methods This prospective cohort study enrolled 98 patients (≥60 y of age) with gastric or colorectal cancer who were scheduled to undergo curative surgery and were categorized as either having cachexia or as being in a non-cachexia group. The definition of cachexia was patients with >5% loss of stable body weight over the previous 6 mo, a body mass index (BMI) 2%, or sarcopenia and ongoing weight loss >2%. Multivariable Poisson regression analysis was performed with postoperative LOS as the dependent variable and the presence of cachexia as the independent variable, and age, sex, Eastern Cooperative Oncology Group performance status, education, cancer type, clinical stage, surgical approach, and the Charlson Comorbidity Index as confounding variables. Results Twenty-two patients (22.4%) were diagnosed with cachexia. Postoperative LOS was 17.1 ± 8.7 d in the non-cachexia group and 20.6 ± 10.8 d in the cachexia group. Multivariable Poisson analysis showed that preoperative cachexia was significantly associated with prolonged postoperative LOS after adjustment (2.41 d; 95% confidence interval, 0.28 to 4.55; P = 0.027). Conclusions Our results suggested that preoperative cachexia prolongs postoperative LOS in elderly patients with gastrointestinal cancer, implying that cachexia should be assessed and treated before surgery.

Background and aim Among elderly patients undergoing cardiac surgery, malnutrition is very common and related to muscle wasting known as sarcopenia. Cardiac surgery causes a further decline of nutritional status due to reduced dietary intake (DI); however, the impact of postoperative DI on functional recovery is unclear. Methods and results We enrolled 250 consecutive patients undergoing cardiac surgery. Daily DI was measured between postoperative days 3 and 7. Patients were categorized as having sufficient or insufficient DI based on whether their DI met or was less than estimated total energy requirements. Functional capacity was measured using the 6-minute walking distance (6MWD) preoperatively and at discharge. Mean postoperative DI was 22.4 ± 3.0 kcal/kg/day, and postoperative DI was insufficient in 92 patients (36.8%). The prevalence of sarcopenia was not different by postoperative DI. Although there was no significant difference in preoperative 6MWD results (P = 0.65), the sufficient DI group had longer 6MWD at discharge than the insufficient DI group (P = 0.04). In multivariate regression analysis, preoperative poor nutritional status (β = −0.29), duration of surgery (β = −0.18), and postoperative DI (β = 0.40) remained statistically significant predictors for improvement of 6MWD (P Conclusions Postoperative DI was independently associated with functional recovery, but preoperative sarcopenia was not. Regardless of preoperative nutritional status or the presence of sarcopenia, aggressive nutritional intervention in the early stage after surgery helps support functional recovery.

Summary Introduction Skin flap procedures are widely used to reconstruct skin and soft tissue defects. Skin flap necrosis is a serious postoperative complication. Many researchers have introduced pharmacological agents to improve flap ischemia in experimental studies. However, outcomes of these studies remain controversial. We previously demonstrated that transcutaneous CO2 application improves hypoxia in fracture repair. In this study, we hypothesized that improving hypoxia by transcutaneous CO2 application can improve the blood flow in skin flaps and increase angiogenesis. We investigated whether transcutaneous CO2 application can increase the survival of random-pattern skin flaps. Materials and methods Six-week-old male Sprague-Dawley rats were divided into two equal groups: the control group (n = 6) and CO2 group (n = 6). A random-pattern skin flap was constructed in these rats. Topical CO2 was applied using a hydrogel every day for 5 days in the CO2 group. The flap survival area was measured on postoperative days 1, 3, and 5. The vessel density and expression of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and hypoxia-inducible factor-1α (HIF-1α) were evaluated on postoperative day 5. Results A statistically significant difference was found in the percentage of the flap survival area between the two groups on postoperative days 3 and 5 (p Conclusions Transcutaneous CO2 application can improve the blood flow in skin flaps and increase angiogenesis, thus increasing the survival of random-pattern skin flaps.

Background One of the main complications in patients with muscular dystrophies is cardiac dysfunction. The literature on cardiac involvement in patients with Fukuyama congenital muscular dystrophy (FCMD) is limited. Aim To compare cardiac involvement between patients with FCMD and Duchenne muscular dystrophy (DMD). Methods We compared cardiac involvement between 30 patients with FCMD and 181 patients with DMD using echocardiography and serum biomarkers. All patients were receiving regular checkups at Kobe University Hospital. We used single regression analysis to compare echocardiographic parameters, age, and serum biomarkers. Results Almost all clinical and echocardiographic parameters were lower in patients with FCMD than DMD. The brain natriuretic peptide concentration in patients with FCMD showed no correlation with age or left ventricular ejection fraction ( r = 0.231, p = 0.22 and r = 0.058, p = 0.76, respectively). A log-rank test revealed that the risk of left ventricular systolic dysfunction was lower in patients with FCMD than DMD ( p = 0.046, hazard ratio = 0.348). Conclusion The clinical progression of cardiac dysfunction is significantly milder in patients with FCMD than DMD, while skeletal muscle involvement is significantly worse in patients with FCMD. These data suggest that the pathophysiological findings of FCMD can be explained by less severe cardiac dysfunction in FCMD than DMD.

Objectives The number of geriatric patients with esophageal cancer has been increasing. Geriatric syndromes such as sarcopenia might adversely affect postoperative recovery. The aim of this study was to evaluate the relationships between sarcopenia and postoperative complications, and the associations between sarcopenia and perioperative functional changes in patients with esophageal cancer following esophagectomy. Materials and Methods Participants comprised 104 patients who underwent esophagectomy from July 2011 to April 2015. Preoperative sarcopenia was diagnosed by the presence of low muscle mass and low physical functions according to Asian Working Group for Sarcopenia criteria. Low physical function was defined by loss of grip strength and/or slow walking speed. Postoperative pulmonary, cardiac, infectious, and surgical complications were extracted. Perioperative functional changes were calculated (value at postoperative day 30−value before surgery). For statistical analyses, both uni- and multivariate logistic regression analyses were performed. Results Twenty-nine patients (27.9%) were diagnosed with sarcopenia. The incidence of postoperative pulmonary complications was significantly higher in the sarcopenia group (37.9%) than in the non-sarcopenia group (17.3%; P =0.04). There was no relationship between sarcopenia and other complications or perioperative functional changes. Multivariate analysis identified sarcopenia (odds ratio (OR), 3.13; 95% confidence interval (CI), 1.12–8.93) and high Brinkman index (OR, 3.46; 95% CI, 1.20–11.77) as independent risk factors for the development of pulmonary complications. Conclusion The assessment of sarcopenia may be useful to predict the postoperative pulmonary complications following esophagectomy. On the other hand, sarcopenia does not predict cardiac, infectious, and surgical complications or perioperative function.

Background The treatment of established orthopaedic infection is challenging. While the main focus of treatment is wide surgical debridement, systemic and local antibiotic administration are important adjuvant therapies. Several reports have described the clinical use of antibiotic-impregnated calcium phosphate cement (CPC) to provide local antibiotic therapy for bone infections. However, these were all individual case reports, and no case series have been reported. We report a case series treated by a single surgeon using antibiotic-impregnated CPC as part of a comprehensive treatment plan in patients with established orthopaedic infection. Methods We enrolled 13 consecutive patients with osteomyelitis ( n = 6) or infected non-union ( n = 7). Implantation of antibiotic-impregnated CPC was performed to provide local antibiotic therapy as part of a comprehensive treatment plan that also included wide surgical debridement, systemic antibiotic therapy, and subsequent second-stage reconstruction surgery. We investigated the rate of successful infection eradication and systemic/local complications. The concentration of antibiotics in the surgical drainage fluids, blood, and recovered CPC (via elution into a phosphate-buffered saline bath) were measured. Results The mean follow-up period after surgery was 50.4 (range, 27–73) months. There were no cases of infection recurrence during follow-up. No systemic toxicity or local complications from the implantation of antibiotic-impregnated CPC were observed. The vancomycin concentration in the fluid from surgical drainage ( n = 6) was 527.1 ± 363.9 μg/mL on postoperative day 1 and 224.5 ± 198.4 μg/mL on postoperative day 2. In patients who did not receive systemic vancomycin therapy ( n = 3), the maximum serum vancomycin level was In vitro vancomycin elution was observed from the CPC that was surgically retrieved ( n = 2). Conclusions Implantation of antibiotic-impregnated CPC is an option to provide local antibiotic therapy as part of a comprehensive treatment plan.

Osteosynthesis of periprosthetic femoral fractures around hip arthroplasties is challenging, and locking plate fixation has been found to be a reasonable treatment. However, there is a paucity of evidence of the extent to which patients recover their activities of daily living (ADL). The purpose of this study was to study the clinical results, particularly recovery of ADL, radiological results, and potential complications arising from the use of locking plate fixation for periprosthetic femoral fractures around hip arthroplasties. We conducted a retrospective, multi-center study. Patients with periprosthetic femoral fractures around hip arthroplasties who were treated by osteosynthesis with use of locking plates and who underwent follow-up for at least 6 months postoperatively were enrolled in the study. For each patient, recovery of ADL, in terms of social and ambulatory recovery and Parker mobility score, were compared before fracture and at last follow-up. Postoperative complications were investigated. Bony union, loss of reduction, and malunion were assessed radiologically. Thirty-two patients were enrolled in this study. Mean follow-up was 25.1 months. For 84.4, 68.8, and 53.1 % of patients, respectively, social status, ambulation, and Parker mobility score at last follow-up were determined to be equal to that before the fracture. Bony union was observed for 30 patients within the follow-up period. Four patients had not achieved bony union 6 months postoperatively. There was no loss of reduction, malunion, or implant breakage, and no infection. For one patient each, partial pullout of the locking screws and a supracondylar fracture at the plate end were observed, and additional surgery was required. Our results reveal that locking plate fixation provided sufficient stability for satisfactory recovery of ADL for most elderly patients with periprosthetic femoral fractures around hip arthroplasties.

Introduction/Background There has been increasing recognition of combination therapy of low-frequency repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) in upper limb hemiparesis. But few studies have reported on the long-term effect. We report the long-term effect of this therapy in upper limb paralysis in chronic stroke patients. Material and method Twenty-two patients with chronic hemiparesis, who received combination therapy of low-frequency rTMS and OT were enrolled (age: 55.4 ± 14.8 years; time after onset: 1522 ± 1332 days). Patients underwent 15 days therapy while Wolf Motor Function Test (WMFT) and Action Research Arm Test (ARAT) were recorded before, after, and 6-month after the therapy. Differences in scores were tested for statistical significance by using ANOVA and Tukey. Results All patients completed the therapy without any adverse effects. All of the score improved significantly between before and after the therapy (WMFT time: from 722 to 590 s, P Conclusion A combination therapy of low-frequency rTMS and OT enhances motor recovery of the upper limb paralysis in chronic stroke patients. These results suggest that the effect lasts for 6 months after the therapy. This is an area of ongoing research and further studies are needed.

In Europe, carbon dioxide therapy has been used for cardiac disease and skin problems for a long time. However there have been few reports investigating the effects of carbon dioxide therapy on skeletal muscle. Peroxisome proliferators-activated receptor (PPAR)-gamma coactivator-1 (PGC-1α) is up-regulated as a result of exercise and mediates known responses to exercise, such as mitochondrial biogenesis and muscle fiber-type switching, and neovascularization via up-regulation of vascular endothelial growth factor (VEGF). It is also known that silent mating type information regulation 2 homologs 1 (SIRT1) enhances PGC-1α-mediated muscle fiber-type switching. Previously, we demonstrated transcutaneous application of CO(2) increased blood flow and a partial increase of O(2) pressure in the local tissue known as the Bohr effect. In this study, we transcutaneously applied CO(2) to the lower limbs of rats, and investigated the effect on the fast muscle, tibialis anterior (TA) muscle. The transcutaneous CO(2) application caused: (1) the gene expression of PGC-1α, silent mating type information regulation 2 homologs 1 (SIRT1) and VEGF, and increased the number of mitochondria, as proven by real-time PCR and immunohistochemistry, (2) muscle fiber switching in the TA muscle, as proven by isolation of myosin heavy chain and ATPase staining. Our results suggest the transcutaneous application of CO(2) may have therapeutic potential for muscular strength recovery resulting from disuse atrophy in post-operative patients and the elderly population.

Introduction/Background The frailty has been based on only physical in the previous studies, and neither cognitive and social frailty are clear in elderly cancer patients. The aims of this study are to estimate the preoperative prevalence of physical frailty, cognitive frailty, and social frailty and to determine the cross-sectional associations with health-related quality of life (HRQOL) in elderly cancer patients. Material and method We examined 190 cancer patients (≥ 60 years; mean age: 71.9 ± 7.0 years; 43 females) with esophageal, gastric, colorectal, oral, or pharyngeal cancers, who were scheduled to undergo the radical surgery. Physical frailty was defined as ≥ 3 out of the following criteria: slow walking speed, muscle weakness, exhaustion, low physical activity and weight loss. We used the validated tool assessed for cognitive impairments, which includes tests of word list memory, attention, and executive function, and processing speed to screen for cognitive impairments. Cognitive frailty was defined by the presences of ≥ 2 cognitive impairments and physical frailty. Social frailty was defined by ≥ 2 signs (going out less frequently, rarely visiting friends, feeling unhelpful to friends or family, living alone, and not talking with someone every day). HRQOL was measured using the EORTC QLQ-C30. The prevalence of each frailty was presented using a multiple imputation method. Associations between multidimensional frailty and the EORTC QLQ-C30 subscales were studied using multivariable regression analyses among complete cases. Results The prevalence of physical frailty, cognitive frailty, and social frailty were 32.9%, 4.7%, and 50.8%, respectively. Only social frailty was associated with the worse EORTC QLQ-C30 subscales (global QOL, physical functioning, role functioning, emotional functioning, cognitive functioning, fatigue and insomnia) after adjusting for covariates. Conclusion Our results showed that the prevalence of frailty in elderly cancer patients were much more than that in population-based elderly, and preoperative HRQOL was especially affected by social frailty.

This article presents a rare case of traumatic complete expulsion of the helical blade after successful treatment of an inter-trochanteric fracture with proximal femoral nail anti-rotation (PFNA). A 94-year-old woman sustained an inter-trochanteric fracture of the left femur. Fracture fixation was performed by using PFNA-II. At six months FU, the patient presented with pain at the proximal lateral left thigh after she had fallen. A protrusion was noted. Radiographs showed a complete expulsion of the helical blade with a healed inter-trochanteric fracture. The PFNA-II was removed and a cemented bipolar hemi-arthroplasty was performed. At 5 months after surgery, the patient was able to walk with a walker without pain. Traumatic complete expulsion of the blade should be considered as a possible complication of PFNA/PFNA-II.