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Objective: To determine the association of providing or receiving social support on mortality risk among the elderly with pre-frailty or frailty. Method: In this notional longitudinal study, data were retrieved from the Taiwan Longitudinal Study on Aging (TLSA) from 1996 to 2007. Data for 1492 males and 1177 females (total 2669) aged ≥67 years were collected. Participants were divided into three groups: no frail older adults, pre-frail older adults and frail older adults. These elderly received social supports, and they also actively provided social supports to others. The study was examined using Cox regression analysis to evaluate the association between providing or receiving social support on mortality of pre-frail or frail older adults after adjusting several covariates. Results: Results showed the average age of these participants was 73.8 (SD=5.5) years, and more than half of the participants were male (55.9%). The number and percentage of frail elderly, pre-frail elderly and frail elderly groups were 402(16.9%), 1501(63.1%) and 474(19.9%) respectively. Final results of the multivariate Cox regression analysis showed a significant association between providing social supports with lower mortality rates among the pre-frail older adults after adjusting several covariates. [hazard ratio (HR) = 0.886; 95% confidence interval (CI) = 0.814–0.964; p = 0.005]. Conclusion: Providing social support to others may prolong life expectancy of the pre-frail older adults.

Synovitis contributes to the development of osteoarthritis (OA) of the knee. MicroRNAs regulate joint microenvironment homeostasis and deterioration. This study was undertaken to characterize the actions of microRNA-29a (miR-29a) to synovial remodeling in OA joints. Synovial specimens isolated from patients with end-stage OA knees showed abundant fibrotic matrix and vessel histopathology concomitant with weak miR-29a expression. In vitro, miR-29a knockdown caused synovial fibroblasts to exhibit high expressions of collagen III, TGF-β1, MMP9, MMP13, and ADAMTS5, whereas miR-29a overexpression diminished these joint-deleterious factors. In collagenase-mediated OA pathogenesis, miR-29a-overexpressing transgenic mice showed minor responses to hyperplasia, macrophage infiltration, fibrosis, hyperangiogenesis, and VEGF expression in synovial lesions. These effects mitigated articular cartilage loss and gait aberrance of injured joints. Intra-articular administration of miR-29a precursor lessened the collagenase aggravation of excessive synovial remodeling reactions and thereby sustained joint tissue integrity. miR-29a lowered VEGF production and angiogenic activities in synovial fibroblasts through targeting the 3′-UTR of VEGF. Taken together, miR-29a deficiency exacerbated synovitis pathogenesis in the end-stage OA knees. miR-29a signaling fends off excessive synovial angiogenesis and fibrosis, which delays joint destruction. This study sheds new light on the protective effects against synovial deterioration and the therapeutic advantage of miR-29a in OA knees.

Background Two-stage reimplantation arthroplasty is one of the standard treatments for chronic periprosthetic joint infection (PJI). Scanty data exist regarding the risk factors for failure after two-stage reimplantation for periprosthetic hip infection. The purpose of this study was to investigate and identify the risk factors associated with failure after two-stage reimplantation hip arthroplasty. Methods Sixty-two patients with hip PJI treated with a two-stage reimplantation protocol at our institution from 2005 to 2012 were reviewed. Patients requiring medical treatment or reoperation for recurrent infection were defined as treatment failure. A multivariate Cox proportional hazards model was used to analyze the risk factors associated with treatment failure. Results Of the 62 patients, 11 (17.7%) patients had developed reinfection after the two-stage reimplantation with a mean follow-up of 5.7 years. The implant survival was 82.2% (95% confidence interval [CI] 75.19−92.55) at 10 years. Multivariate analysis revealed BMI ≥30 kg/m2 (hazard ratio [HR] 9.16; 95% CI 1.51−55.3; p = 0.0158), liver cirrhosis (HR 6.39; 95% CI 1.09−37.4; p = 0.0398), gram-negative organism (HR 5.68; 95% CI 1.18−27.4; p = 0.0303), and presence of sinus tract (HR 18.2; 95% CI 2.15−153; p = 0.0077) as the independent risk factors for treatment failure. Conclusions We found obesity, liver cirrhosis, gram-negative organism, and the presence of sinus tract were significantly related to the risks of failure after reimplantation arthroplasties.

Background Although the loss of bone mineral density (BMD) after total hip arthroplasty (THA) is a known problem, it remains unresolved. This study prospectively examined the effect of zoledronic acid (ZA) on bone turnover and BMD after cementless THA. Methods Between January 2010 and August 2011, 60 patients who underwent cementless THA were randomly assigned to receive either ZA infusion or placebo (0.9% normal saline only) postoperatively. ZA was administered at 2 day and 1 year postoperatively. Periprosthetic BMD in seven Gruen zones was assessed preoperatively and at given time points for 2 years. Serum markers of bone turnover, functional scales, and adverse events were recorded. Results Each group contained 27 patients for the final analysis. The loss of BMD across all Gruen zones (significantly in zones 1 and 7) up to 2 years postoperatively was noted in the placebo group. BMD was significantly higher in the ZA group than in the placebo group in Gruen zones 1, 2, 6, and 7 at 1 year and in Gruen zones 1, 6, and 7 at 2 years (p

Periprosthetic joint infection (PJI) is one of the severe complications of prosthetic joint replacement. Delayed PJI diagnosis may anchor bacteria in periprosthetic tissues, and removal of the prosthesis might be inevitable. The diagnosis of PJI depends on the identification of microorganisms by standard microbiological cultures or more advanced molecular diagnostic methods for detection of bacterial genes. However, these methods are relatively time-consuming, labor-intensive and not human error-free. Moreover, it is challenging to distinguish live from dead bacteria by using DNA-based molecular diagnostics since bacterial DNA will be remained in the tissue even after the death of the bacteria. In this work, an integrated microfluidic system has been developed to perform the entire molecular diagnostic process for the PJI diagnosis in a single chip. We combined the loop-mediated isothermal amplification (LAMP) with ethidium monoazide (EMA) in an integrated microfluidic system to identify live bacteria with reasonable sensitivity and high specificity. All the diagnostic processes including bacteria isolation, cell lysis, DNA amplification and optical detection can be automatically performed on the integrated microfluidic system by using a compact custom-made control system. The integrated system can accommodate four primers complementary to six regions of the target genes and improve the detection limit by using LAMP. The limit of detection in this multiple EMA-LAMP assay could be as low as 5 fg/reaction (~1 CFU/reaction) when choosing an optimized primer set as we demonstrated in mecA gene detection. Thus, the developed system for PJI diagnosis has great potential to become a point-of-care device.

This study tested the hypothesis that combined therapy with exendin-4 (Ex4) and autologous adipose-derived mesenchymal stem cells (ADMSCs) was superior to either alone for protecting renal function against acute kidney ischemia-reperfusion (IR; 40-min ischemia/27-h reperfusion) injury when complicated by sepsis syndrome (SS; by cecal-ligation-puncture). Adult-male Sprague-Dawley rats (n=40) were equally divided into group 1 (sham-control), group 2 (IR-SS), group 3 (IR-SS + Ex4, 10 μg/kg subcutaneously 30 min after reperfusion and daily for 3 days), group 4 [IR-SS + ADMSC (1.2 × 106)], and group 5 (IR-SS + Ex4 + ADMSC). The circulating levels of BUN and creatinine and the ratio of urine protein to creatinine were highest in group 2, lowest in group 1, significantly higher in groups 3 and 4 than group 5, and significantly higher in group 3 than in group 4 (all P

Subchondral bone deterioration and osteophyte formation attributable to excessive mineralization are prominent features of end-stage knee osteoarthritis (OA). The cellular events underlying subchondral integrity diminishment remained elusive. This study was undertaken to characterize subchondral mesenchymal stem cells (SMSCs) isolated from patients with end-stage knee OA who required total knee arthroplasty. The SMSCs expressed surface antigens CD29, CD44, CD73, CD90, CD105, and CD166 and lacked CD31, CD45, and MHCII expression. The cell cultures exhibited higher proliferation and greater osteogenesis and chondrogenesis potencies, whereas their population-doubling time and adipogenic lineage commitment were lower than those of bone marrow MSCs (BMMSCs). They also displayed higher expressions of embryonic stem cell marker OCT3/4 and osteogenic factors Wnt3a, β-catenin, and microRNA-29a (miR-29a), concomitant with lower expressions of joint-deleterious factors HDAC4, TGF-β1, IL-1β, TNF-α, and MMP3, in comparison with those of BMMSCs. Knockdown of miR-29a lowered Wnt3a expression and osteogenic differentiation of the SMSCs through elevating HDAC4 translation, which directly regulated the 3'-untranslated region of HDAC4. Likewise, transgenic mice that overexpressed miR-29a in osteoblasts exhibited a high bone mass in the subchondral region. SMSCs in the transgenic mice showed a higher osteogenic differentiation and lower HDAC4 signaling than those in wild-type mice. Taken together, high osteogenesis potency existed in the SMSCs in the osteoarthritic knee. The miR-29a modulation of HDAC4 and Wnt3a signaling was attributable to the increase in osteogenesis. This study shed an emerging light on the characteristics of SMSCs and highlighted the contribution of SMSCs in the exacerbation of subchondral integrity in end-stage knee OA.Subchondral MSCs (SMSCs) from OA knee expressed embryonic stem cell marker Oct3/4. The SMSCs showed high proliferation and osteogenic and chondrogenic potencies. miR-29a regulated osteogenesis of the SMSCs through modulation of HDAC4 and Wnt3a. A high osteogenic potency of the SMSCs existed in mice overexpressing miR-29a in bone. Aberrant osteogenesis in SMSCs provides a new insight to subchondral damage in OA.

// Pei-Hsun Sung 1, * , Hsin-Ju Chiang 2, 3, * , Mel S. Lee 4 , John Y. Chiang 5, 6 , Hon-Kan Yip 1, 7, 8, 9 and Yao-Hsu Yang 10, 11, 12 1 Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan 2 Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan 3 Chung Shan Medical University School of Medicine, Taichung, Taiwan 4 Department of Orthopedics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan 5 Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung, Taiwan 6 Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan 7 Institute for Translational Research in Biomedicine and Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan 8 Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan 9 Department of Nursing, Asia University, Taichung, Taiwan 10 Department for Traditional Chinese Medicine and Center of Excellence for Chang Gung Research Datalink, Chang Gung Memorial Hospital, Chiayi, Taiwan 11 Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan 12 School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan * These authors have contributed equally to this work Correspondence to: Hon-Kan Yip, email: han.gung@msa.hinet.net Yao-Hsu Yang, email: r95841012@ntu.edu.tw Keywords: autosomal-dominant polycystic kidney disease, cerebrovascular accident, renin-angiotensin-aldosterone system blockade, statin, population-based cohort study Received: March 01, 2017 Accepted: May 22, 2017 Published: June 27, 2017 ABSTRACT Fairly limited data reported the incidence and risk of cerebrovascular accident (CVA) in autosomal dominant polycystic kidney disease (ADPKD). Additionally, little is known regarding the therapeutic impact of renin-angiotensin-aldosterone system (RAAS) blockade and statin on reducing the occurrence of CVA in ADPKD. We utilized the data from Taiwan National Health Insurance Research Database (NHIRD) to perform a population-based cohort study (1997-2013). A total of 2,647 patients with ADPKD were selected from 1,000,000 general population after excluding patients with age

We analyzed the effects of acute ischemia-reperfusion (KIR) injury on the status of kidney function and architecture in dipeptidyl peptidase4-difficient (DPP4D) rats and the effect of remote small bowel ischemia-reperfusion (BIR) preconditioning. DPP4-deficient (DPP4D) and normal Fischer344 (F344) rats were divided into 6 groups: (1) sham-F344, (2) sham-DPP4D, (3) KIR-F344 (4) KIR-DPP4D, (5) DPP4D-KIR-extendin-9-39 and (6) BIR-KIR-F344. Blood creatinine and urea nitrogen levels and the urinary protein-to-creatinine ratio was higher in KIR-F344 rats than BIR-KIR-F344 or KIR-DPP4D rats 72 h after acute KIR. Conversely, the circulating glucagon-like peptide 1 (GLP-1) levels were higher in BIR-KIR-F344 and KIR-DPP4D than KIR-F344 rats after acute KIR. KIR-F344 rats showed greater inflammation, oxidative stress, apoptosis, DNA damage and kidney injury than other rat groups. Damage to the kidney architecture in KIR-F344 rats was greater than in BIR-KIR-F344 or KIR-DPP4D rats. Expression of antioxidant proteins and GLP-1 receptor was higher in kidneys from KIR-DPP4D and BIR-KIR-F344 than KIR-F344 rats, which suggests better intrinsic responses. We therefore suggest that elevated circulating GLP-1 levels due to DPP4 deficiency and BIR preconditioning protect kidney function and architecture during acute IR injury.

Staphylococcus aureus (S. aureus) is one of the most common causes of biofilm infections in periprosthetic joint infections (PJIs). Accumulating evidence has shown that the immunosuppressive environment established by S. aureus biofilm infection in PJIs involves the presence of myeloid-derived suppressor cells (MDSCs) and M2-macrophages. Due to the diversity of MDSCs, little is known about whether S. aureus biofilm preferentially expands specific MDSC subsets or whether MDSCs can further differentiate into M2-macrophages during S. aureus biofilm infection. Here, we show that in agreement with the results from an established rat PJI model, S. aureus biofilm cocultured with freshly isolated bone marrow cells (BMCs) in vitro significantly increases the proportions of MDSCs, total macrophages and M2-macrophages. Interestingly, we find that treatment of the BMCs in vitro with S. aureus biofilm preferentially promotes the expansion of monocytic MDSCs but not granulocytic MDSCs. Biofilm treatment also substantially enhances the overall MDSC immunosuppressive activity in addition to the MDSC expansion in vitro. Importantly, we provide evidence that S. aureus biofilm is capable of further stimulating the conversion of monocytic MDSCs into M2-macrophages in vitro and in vivo. Collectively, our studies reveal a direct link between MDSCs and M2-macrophages occurring in S. aureus-associated PJIs.

A simple microfluidic device which can perform antimicrobial susceptibility testing (AST) of combined antibiotics against antibiotics-resistant bacteria has been presented. A new approach to determine the fractional inhibitory concentration (FIC) index of two antibiotics by performing broth dilutions automatically was proposed and its performance was highly consistent with manual operation. The experimental results showed that the developed device could achieve on-chip dispensation/dilution/mixing accurately and interpret AST results visually. A test using two common antibiotics (vancomycin and ceftazidime) was performed on one clinical isolate of vancomycin-intermediate Staphylococcus aureus (VISA) based on the FIC indices. It is the first time that a microfluidic device was demonstrated to be capable of determining the FIC index of combined antibiotics against bacteria by performing AST automatically. With its high flexibility and reliability, the proposed device provides a simple method to explore drug cocktails for combined antibiotic therapy.

Long-term data and information indicating whether minimally invasive surgery (MIS) approaches are safe and effective with total hip arthroplasty (THA) are lacking. Between 2004 and 2006, 75 patients with alcohol-related osteonecrosis of the femoral head (ONFH) who underwent 75 THAs with the two-incision approach were studied. The medical records, radiographic parameters, and functional outcomes were collected prospectively. All data were compared with those for matched patients who underwent a modified Watson-Jones (WJ) approach. THA using the two-incision approach was associated with longer operation time, more blood loss, more lateral femoral cutaneous nerve injury, and more periprosthetic femoral fractures (p<0.05for all four) than the modified WJ approach. The Harris Hip Score (HHS) and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) increased significantly from the period preoperatively to 6 weeks postoperatively and thereafter up to the last follow-up in both groups. However, there were no significant differences in terms of radiographic parameters and functional outcomes between the two groups throughout the study period. Both the two-incision and the modified WJ approach provided satisfactory results and survival rates at a mean follow-up of 10.8 years. A prospective, randomized, large-scale cohort study is still warranted for evidence-based recommendations.

Systemic tranexamic acid can decrease blood loss and rates of transfusion in patients undergoing total hip arthroplasty (THA). However, the efficacy of topical tranexamic acid in THA has only recently been characterized in a small number of studies.The purpose of this study was to compare (1) the greatest hemoglobin decrease after surgery; (2) transfusion rates; and (3) symptomatic thromboembolic events among patients undergoing THA who did and did not receive topical tranexamic acid.We retrospectively compared 135 patients (154 THAs) who received 10 mL 5% tranexamic acid added in a topical cocktail solution during surgery between January 2009 and July 2011 with 211 patients (234 THAs) who received only the topical cocktail solution (analgesic and antibiotic agent) between January 2005 and December 2008. Contraindications for the use of tranexamic acid included a documented history of a venous thromboembolic event, an allergy to tranexamic acid, thrombophilia, or a high risk of venous thromboembolism based on the guidelines of the American Academy of Orthopaedic Surgeons; the 135 patients who received it during that period represented 99.4% of the patients undergoing THA during that time. We compared changes in Hb, transfusion rates, estimated blood loss, surgical results, and complications between the groups. The transfusion threshold was the same, when the Hb values were 10 g/dL. Patients were screened for thromboembolic disease if symptoms or signs appeared.Hb decreased less in the tranexamic acid group (1.87 ± 1.10 g/dL) than in the control group (2.2 ± 1.36 g/dL; p = 0.01) on the first postoperative day. The frequency of transfusion was lower in patients receiving tranexamic acid (17% as compared with 35% in the control group; p 0.001). There was only one nonfatal pulmonary embolism in the control group during the study period.Use of topical tranexamic acid in patients undergoing THA reduces postoperative bleeding and decreases blood transfusion rates. No increase in major complications was identified in patients managed with topical tranexamic acid. This retrospective study confirms the results of a smaller randomized trial on the same topic by another group.Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

This study tested the hypothesis that exposure to ambient fine particulate matter (PM2.5) pollution increased susceptibility of rat lung to damage from acute ischemia-reperfusion (IR) injury that was reversed by melatonin (Mel) treatment. Male-adult SD rats (n = 30) were categorized into group 1 (normal control), group 2 (PM2.5 only), group 3 (IR only at day 8 after PM2.5 exposure), group 4 (PM2.5 + IR) and group 5 (PM2.5 + IR + Mel), and all animals were sacrificed by day 10 after PM2.5 exposure. Oxygen saturation (%) was significantly higher in group 1 than in other groups and significantly lower in group 4 than in groups 2, 3 and 5 but it did not differ among the latter three groups (p

Objective The current study aimed to perform a biomechanical analysis of the effect and distribution of stress and strain values in the femur and its residual screw holes from the implantation of different lengths of total hip prostheses following failed dynamic hip screw (DHS) fixation of AO type A1.1 and A1.3 intertrochanteric fractures. Methods Medical image processing, computer-assisted engineering design, and finite element analysis were combined for the analysis and the reliability of the model confirmed by convergence testing and comparison with a physical model. Using finite element analysis, patterns of stress from implantation of total hip prostheses with different stem length were obtained. Results Stress distribution was concentrated over the third and fourth residual screw holes, especially in the models with shorter stem length. Fracture type (AO type A1.1 or A1.3) did not alter its distribution. In proximal cancellous bone, a stress-shielding effect was seen at the region of the residual fracture fragment, especially in the A1.1 fracture. In the fracture fixed with 2 cable wires, the maximum von Mises stress was in the proximal cable wire. Conclusion The results suggest that an increase in the original stem length equal to the diameter of the femoral isthmus, or a distance between the most distal residual screw hole and the end of the femoral prosthesis, provide improved stress distribution.

Objectives This study describes a fast and efficient method that uses a prevalidated videotape of an objective structured clinical examination (OSCE) in a fracture scenario to evaluate raters and to measure the consistency of raters from different subspecialties and with varying levels of seniority. Study Design We videotaped clinical scenarios for the purpose of evaluating residents' communication and clinical assessment skills. All orthopedic staff used prevalidated checklists to assess residents' performance in the videotape at 3 different time points. Cronbach's α was calculated to evaluate the internal consistency of the OSCE checklist construct. Kendall's W and KR-20 were used to investigate rater agreement. Expert validity was calculated to compare OSCE experts with the present raters. Results A high Cronbach's α for the 23-item scale regarding global assessment in all 3 tests confirmed construct validity. Kendall's W showed only moderate interrater reliability. KR-20 was 0.96 for the pretest, 0.968 for the posttest, and 0.892 for the long-term test, indicating high internal consistency. The p-value for expert validity was 0.626 (independent t -test, n.s.). Conclusions This efficient and fast video-based assessment of raters was reliable and yielded satisfactory rater consistency and some evidence for validity.

Background context Disc degeneration is a multifactorial disease that may cause clinical symptoms such as chronic back pain or radiculopathy in the extremities. Periostin, an extracellular matrix protein involved in the process of fibrosis, expressed in tissues subjected to mechanical stress such as intervertebral disc. However, the expression of periostin during disc degeneration has not yet been studied. Purpose The aim of this study is to elucidate the difference in gene expression profiles between degenerative and nondegenerative intervertebral discs for a better understanding of disc degeneration. Study design Degenerative and nondegenerative nucleus pulposus cells were isolated from elderly patients with degenerative disc disease and younger patients with adolescent idiopathic scoliosis, respectively. Methods Affymetrix GeneChip Human arrays were used to derive gene expression profiles for disc degeneration, and gene expressions of periostin and other degeneration-related markers were confirmed by reverse transcription-polymerase chain reaction (RT-PCR), real-time RT-PCR, and western blot analysis. Immunohistochemical analysis of periostin and Gomori trichrome stain was performed to show the relationship of periostin, fibrosis, and disc degeneration. The mechanical stress experiment was designed to demonstrate the relationship of periostin, stress, and disc degeneration. Results Fourteen genes were identified to express at significantly different levels between degenerative and nondegenerative groups. An increase of periostin gene expression was observed in human degenerative nucleus pulposus cells for the messenger RNA and protein levels. Histological examination demonstrated an increased positive staining of periostin in degenerative discs from human tissues and rat needle-punctured tails and more fibrosis with architectural disorder and fragmentation in human degenerative disc as compared with nondegenerative discs. The expression of periostin was significantly induced by stress in human degenerative nucleus pulposus cells but not in nondegenerative cells. Conclusions This study demonstrates for the first time an upregulation of periostin in addition to the expression levels of Type I collagen and matrix metalloproteinase-2 in human disc degeneration. It suggests that periostin may be a candidate gene that shows promise as a new prognostic marker and a therapeutic target that is worth further study to expand our knowledge of its role in disc degeneration.

Background Fractures of the odontoid process make up 9–15% of adult cervical fractures; Type II odontoid fractures are the most common type. Most patients with these fractures recover after early treatment utilizing the proper surgical approach. Purpose/Aims A retrospective study was performed to evaluate the bone union rate and to identify factors that might contribute to non-union in patients undergoing anterior single-screw fixation for Type II odontoid cervical fractures. Methods From November 2000 to December 2008, 24 patients (16 males, 8 females) underwent anterior single-screw fixation for Type II odontoid cervical fractures. Prior to surgery, all patients had cervical spine radiographs and computed tomographic (CT) scans. Surgery to correct the fractures used the technique of Abfelbaum et al, and fluoroscopy was used to confirm spinal stability. At follow-up, bone fusion was considered successful if trabeculation across the fracture site was seen on lateral radiographic studies. Non-union was confirmed when the fracture line was visible on follow-up lateral radiographic studies. After surgery, all patients were followed at approximately 2 weeks, 4 weeks, 6 weeks, 3 months, 6 months, 9 months, and annually thereafter. Results All 24 patients had odontoid fractures confirmed by radiographic films and CT scans. Twenty-three patients had Type II odontoid fractures that were posterior-oblique or horizontal, and one had an anterior oblique fracture. Twenty patients achieved successful fusion. The presence of a lag effect was significantly different between patients who had successful fusion and the four patients with fusion failure. All patients achieved immediate spinal stabilization after surgery and none experienced major neurologic sequelae. Conclusions Anterior single-screw fixation is an effective and safe surgical approach for patients with Type II odontoid fractures. A satisfactory long-term outcome depends upon careful selection of patients for fracture orientation and attention to the technical aspects of surgery.

Background For osteoporotic femoral neck fractures, suitable bone-implant stability is critical for pain relief, early return to daily activities and reduction of complications. Teriparatide (parathyroid hormone [PTH1-34]) can improve bone-implant stability in some basic studies. However it’s use in osteoporotic femoral neck fractures treated by cementless hemiarthroplasties for the beneficial effects on bone-implant stability is sparse in the literature. The aim of this study was to determine if post-operative teriparatide administration can reduce femoral stem migration and improve early functional recovery and health-related quality of life (HRQoL). Methods Between 2010 and 2014, patients with osteoporotic femoral neck fracture who underwent cementless bipolar hemiarthroplasty were included into this retrospective cohort study. Group A included patients treated with cementless bipolar hemiarthroplasty only; Group B patients had additional teriparatide. Demographic data, complications, radiographic and functional outcomes as well as health-related quality of life (HRQoL) were compared. Results There were 52 hips in group A (no teriparatide) and 40 hips in group B (patient who received teriparatide). The subsidence of the femoral stem tended to be significantly decreased in the teriparatide group at 6 and 12 weeks post-operatively (p = 0.003 and p = 0.008, respectively). The Harris Hip Score (HHS) increased significantly from pre-operation to 6 weeks post-operatively and thereafter up to one year in both groups. However, there were no significant differences in terms of subsequent fracture, mortality, HHS, and HRQoL between two groups during the entire study period. Conclusions Teriparatide significantly reduces the subsidence of the cementless femoral stem in elderly patients in the early post-operative period, but this benefit does not reflect better functional outcomes and HRQoL. Further prospective randomized large-scale cohort study is warranted for evidence-based recommendations.

Bacterial resistance to antimicrobial compounds is increasing at a faster rate than the development of new antibiotics; this represents a critical challenge for clinicians worldwide. Normally, the minimum inhibitory concentration of an antibiotic, the dosage at which bacterial growth is thwarted, provides an effective quantitative measure for antimicrobial susceptibility testing, and determination of minimum inhibitory concentration is conventionally performed by either a serial broth dilution method or with the commercially available Etest® (Biomerieux, France) kit. However, these techniques are relatively labor-intensive and require a significant amount of training. In order to reduce human error and increase operation simplicity, a simple microfluidic device that can perform antimicrobial susceptibility testing automatically via a broth dilution method to accurately determine the minimum inhibitory concentration was developed herein. As a proof of concept, wild-type (ATCC 29212) and vancomycin-resistant Enterococcus cells were incubated at five different vancomycin concentrations on-chip, and the sample injection, transport, and mixing processes occurred within five reaction chambers and three reagent chambers via the chip's automatic dispensation and dilution functions within nine minutes. The minimum inhibitory concentration values measured after 24h of antibiotic incubation were similar to those calculated using Etest®. With its high flexibility, reliability, and portability, the developed microfluidic device provides a simple method for antimicrobial susceptibility testing in an automated format that could be implemented for clinical and point-of-care applications.

Osteoporotic intertrochanteric fractures result in serious health problems and decrease health-related quality of life (HRQoL). Faster time-to-union is important for early return to daily activities and reduction of complications. Teriparatide has been shown to accelerate fracture healing, but the literature is sparse on this topic. The aim of this study is to assess whether teriparatide accelerates fracture healing. Between 2008 and 2014, patients with osteoporotic intertrochanteric fractures who underwent surgical interventions were enrolled in this retrospective cohort study. Group 1 included patients who were not on any osteoporosis medication prior to fracture and who postoperatively received only calcium and vitamin D; patients in Group 2 were not on any osteoporosis medication prior to fracture, and received teriparatide and calcium and vitamin D postoperatively. Patients in Group 3 were those who were on alendronate prior to fracture and postfracture received teriparatide as well as calcium and vitamin D. Demographics, time-to-union, HRQoL (short-form health survey [SF]-12 physical component summary [PCS] and SF-12 mental component summary [MCS]), morbidities, mortalities, and radiographic and functional outcomes between groups were compared. A total of 189 patients were enrolled in this study. There were 83 patients in Group 1, 47 patients in Group 2, and 59 patients in Group 3. A significantly shorter time-to-union was found in the teriparatide-treated groups (mean, 13.6, 12.3, and 10.6 weeks, respectively [P = 0.002]). With regard to SF-12 PCS, the scores were significantly better in teriparatide-treated groups at 3 months (mean, 19, 28, and 29, respectively [P = 0.002]) and 6 months (mean, 28, 37, and 38, respectively [P = 0.008]). Similar inter-group differences were noted when comparing the pain scores, the ability to get around the house, the ability to get out of the house, and the ability to go shopping at 3 and 6 months. Complications and mortality were also markedly reduced in the teriparatide-treated groups. Postoperative use of teriparatide for 6 months appears to be an effective adjunct therapy in the treatment of patients with osteoporotic intertrochanteric fractures. However, because of the limited power of the study, a prospective, randomized, large-scale cohort study is still required for determining the efficacy of teriparatide.

Although low-energy shock wave (SW) is adopted to treat ischemic diseases because of its pro-angiogenic properties, the underlying mechanism remains unclear. This study is aimed at testing whether SW-induced angiogenesis may be through endothelial vascular endothelial growth factor receptor 2 (VEGFR2) signaling and trafficking. Phosphorylation of VEGFR2-Akt-eNOS axis and production of nitric oxide (NO) were determined in human umbilical vein endothelial cells (HUVECs) treated with SW. Carotid artery in ob/ob mice was treated with SW before evaluation with sprouting assay. Critical limb ischemia was induced in ob/ob mice to evaluate blood flow recovery post-SW treatment. Tube formation and migration assays were also performed with/without SW treatment in the presence/absence of SU5416 (VEGFR2 kinase inhibitor) and siRNA-driven silencing of VEGFR2. Chloroquine was used for disrupting endosome, and Rab11a controlling slow endocytic recycling was silenced with siRNA in vitro. Following SW treatment, augmented ligand-independent phosphorylation in VEGFR2-Akt-eNOS axis and endogenous NO production, increased cellular migration and tube formation and elevated sprouting of carotid artery and blood flow in ischemic limb in ob/ob mice were noted. Moreover, SU5416 and VEGFR2 silencing both inhibited SW-induced angiogenesis. SW-induced angiogenesis, accompanied by increased VEGFR2 protein expression without transcriptional change, was suppressed by chloroquine and Rab11a silencing. We concluded that SW enhanced angiogenesis via ligand-independent activation of VEGFR2 and further prolonged angiogenesis through endosome-to-plasma membrane recycling in endothelial cells.

Digital loop-mediated amplification (LAMP) is an isothermal, quantitative DNA amplification approach which has high sensitivity and specificity and could be used to analyze extremely low amount of DNA within a short period of time. In this study, an integrated self-driven microfluidic chip was proposed herein for performing a digital LAMP process for vancomycin-resistant Enterococcus (VRE) diagnosis. The entire bacterial diagnosis could be automatically performed by capillary forces through the new polydimethylsiloxane (PDMS) surface treatment without using external pumps. Moreover, digitized droplets could be separated from each other by normally-close valves such that it could be quantitated. The contact angle of the treated PDMS surface was measured to be only 24°, which was the lowest value in literatures. This is the first time that a rapid (within 1 hour), simple, and hydrophilic PDMS surface modification method has been reported, which could be used in self-driven microfluidic devices for digital LAMP. This device may become a promising tool for clinical diagnosis and point-of-care applications.

This study presents an integrated microfluidic system which can identify the vancomycin resistant gene (vanA) from live hetero-bacteria automatically. In this study, a new approach to diagnose the vanA gene from live hetero-bacteria by using ethidium monoazide (EMA) and loop-mediated isothermal amplification (LAMP) was proposed and its feasibility was tested and verified. In addition, an integrated microfluidic system including a microfluidic chip and a home-made control system was also demonstrated. The experimental results showed that the developed system can detect the vanA gene from “live” Enterococcus but not “dead” Enterococcus successfully with a detection limit of 10 colony formation units (CFU). The entire process including the sample pre-treatment process could be automated within 1 hour. This is the first time that an integrated microfluidic system was demonstrated to diagnose the vanA gene from live bacteria by using a molecular diagnosis approach. With its high sensitivity and accuracy, the proposed system may be promising to verify antibiotic resistance genes from live hetero-bacteria which cannot be achieved by using the existing diagnostic methods.

Background Proper limb and component alignments as well as soft tissue balance are vital for the longevity and optimal long-term outcomes of total knee arthroplasty (TKA). This procedure is technically demanding in patients with Ranawat type-II valgus arthritic knees with marked coronal femoral bowing. Computer-assisted surgery (CAS) and intra-articular bone resection with TKA are the treatments of choice for patients with ipsilateral extra-articular deformity. In theory, both CAS and intra-articular bone resection are beneficial in Ranawat type-II valgus arthritic knees with marked coronal femoral bowing deformity, but the literature on this topic is sparse. We compared the benefits of using these two techniques for TKA under this circumstance. Methods Patients who had Ranawat type-II valgus arthritic knees and marked coronal femoral bowing deformity and had undergone TKA at our hospital between 2005 and 2013 were enrolled in this retrospective study. Patients treated with CAS were assigned to the CAS-TKA group; patients treated with intra-articular bone resection were assigned to the Bone-Resect-TKA group. Radiographic parameters and clinical outcomes (International Knee Society (IKS) scores and patellar scores) in both groups were compared. Results Forty-seven patients (50 knees) met the inclusion criteria: 22 knees in the CAS-TKA group and 28 knees in the Bone-Resect-TKA group. Lateral retinaculum release was significantly (P = 0.008) higher in the Bone-Resect-TKA group. The joint-line was significantly properly restored in the CAS-TKA group (P = 0.011). The reconstructed mechanical axis was significantly (P = 0.012) closer to normal in the CAS-TKA group than in the Bone-Resect-TKA group. For component alignment, the femoral valgus and femoral flexion angles were significantly better in the CAS-TKA group (P = 0.002 and P = 0.006, respectively), but not the tibial valgus, tibial flexion, or patellar tilting angles. IKS scores and patellar scores were not significantly different between groups at a mean follow-up of 60.2 months. Conclusions CAS-TKA was effective for obtaining proper alignment and joint-line restoration in patients with Ranawat type-II valgus arthritic knees and marked coronal femoral bowing deformity, but not for yielding better clinical outcomes. Additional large-scale prospective randomized cohort studies with long-term follow-ups are necessary to make evidence-based recommendations.

This study tested the hypothesis that circulating microparticles (MPs) exacerbated vascular wall (VW) remodeling after endothelial denudation by 0.014 wire in a rat model. Adult male Sprague Dawley rats (n = 40) were equally categorized into group 1 [sham-control (SC); 3.0 mL saline intravenous injection], group 2 [SC + intravenous MPs (1.0 × 107) derived from patients with carotid artery stenosis (CAS)], group 3 [femoral arterial endothelial denudation (FAED)], group 4 (FAED + MPs derived from healthy subjects), and group 5 (FAED + CAS-derived MPs). Animals were euthanized by day 28 after FAED procedure. The results demonstrated that neointimal area (NIA) (mm2), medial area, and number of infiltrated cells in medial layer were highest in group 5 and lowest in groups 1 and 2, and significantly higher in group 4 than those in group 3 (all P

Vibrio vulnificus necrotizing skin and soft tissue infections (VNSSTIs), which have increased significantly over the past few decades, are still highly lethal and disabling diseases despite advancing antibiotic and infection control practices. We, therefore, examined the spatiotemporal distribution of worldwide reported episodes and associated mortality rates of VNSSTIs between 1966 and 2014. The PubMed and Cochrane Library databases were systematically searched for observational studies on patients with VNSSTIs. The primary outcome was all-cause mortality. We did random-effects meta-analysis to obtain estimates for primary outcomes; the estimates are presented as means plus a 95% confidence interval (CI). Data from the selected studies were also extracted and pooled for correlation analyses. Nineteen studies of 2227 total patients with VNSSTIs were analyzed. More than 95% of the episodes occurred in the subtropical western Pacific and Atlantic coastal regions of the northern hemisphere. While the number of cases and the number of deaths were not correlated with the study period (rs = 0.476 and 0.310, P = 0.233 and 0.456, respectively), the 5-year mortality rate was significantly negatively correlated with them (rs = −0.905, P = 0.002). Even so, the pooled estimate of total mortality rates from the random-effects meta-analysis was as high as 37.2% (95% CI: 0.265–0.479). These data suggest that VNSSTIs are always an important public health problem and will become more critical and urgent because of global warming. Knowing the current distribution of VNSSTIs will help focus education, policy measures, early clinical diagnosis, and appropriate medical and surgical treatment for them.

From the joint registry of 2831 primary total hip arthroplasties (2351 patients) performed between 1998 and 2003, we identified 15 patients (16 hips) who had a documented history of substance abuse disorders at the time of the index surgery. The patients included 13 men (14 hips) and 2 women (2 hips), with the mean age of 49 years (range, 29-65 years). On the basis of the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 13 patients had alcohol abuse disorders, 1 had amphetamine abuse disorder, and 1 had heroin abuse disorder. We found high rates of postoperative substance withdrawal delirium and psychosis (46%), late complication (25%), and lost to follow-up (27%) in these patients. Because patients with substance abuse disorders have unexpected perioperative psychotic episodes, poor compliance, and a tendency to not follow medical advice after surgery and show early discontinuation of follow-up, we suggest that surgeons should work with other medical professionals and carefully perform total hip arthroplasty in such patients.

Objective To use finite element analysis to study the stability of different fixation methods used to repair Vancouver type B1 periprosthetic fractures occurring after total hip arthroplasty (THA). Methods An artificial femur was used as the basis for the solid model; U2 series femoral stem (United Orthopedic Corporation, Hsinchu, Taiwan) was used for modelling of the prosthesis; and the modelling of the cable plate, wires and screws was based on information given in the manufacturer's catalogue (Zimmer, Warsaw, IN, USA). The analysis model was constructed using the ANSYS software, and all material settings were based on literature values. A six-orifice cable plate, unicortical screws (20 mm long and 4.5 mm in diameter) and bicortical screws (50 mm long and 4.5 mm in diameter) were constructed. Four analysis models were defined. The basic model had a plate and three cable wires above the fracture line and two bicortical screws below the fracture line. In the second model, two unicortical screws were added above the fracture line. In the third model, three wires were added below the fracture line. In the fourth model, both the proximal screws of the second model and the distal wires of the third model were added to the basic model. To ensure that the numerical values produced by analysis reached convergence, mesh convergence was tested. Results Adding two proximal unicortical screws to the basic Ogden construct (plate, proximal wires and distal screws) lessened displacement of the fracture and decreased the von Mises stress on the repair. Adding three distal wires to the basic construct had no noticeable effect. Conclusion Better fixation power is achieved by using both proximal and distal screws (the locking-plate concept) in treating Vancouver type B1 periprosthetic fracture after THA.

The aim of this study was to investigate the pain patterns in patients with end-stage hip disease and to assess the response after total hip arthroplasty (THA).The pain patterns of patients undergoing THA for end-stage hip diseases were prospectively evaluated by requesting them to mark a map of body areas before and after surgery. Patients were excluded if they had coexisting pathology of the knee or spine. The pain measurements were quantified using visual analog scales, and factors that may contribute to different pain patterns were also evaluated.Among 113 patients (113 hips) enrolled in the study, the groin, anterior thigh, buttock, anterior knee, and greater trochanter were the most common pain locations before THA. Pain over the lower back, shin, and calf areas, which were not generally considered referral pain areas from hip diseases, was present in 21.2, 7.1, and 2.7% patients, respectively. The presence of lower back pain (LBP) was statistically more common in patients with longer duration of hip symptoms. Regardless of the different pain patterns, 97.3% (110 of 113) of patients reported complete pain relief within 12 weeks after THA.The distribution of pain from end-stage hip diseases is versatile, and presence of pain in areas other than around the hip is not uncommon. LBP was more common in patients with longer duration of symptoms. THA satisfactorily resolves the pain in all areas soon after surgery.

Introduction Predicting severity of pancreatitis is an important goal. Clinicians are still searching for novel and simple biomarkers that can better predict persistent organ failure (OF). Lipoproteins, especially high-density lipoprotein (HDL), and apolipoprotein A-I (APO A-I), have been shown to have anti-inflammation effects in various clinical settings. Severe acute pancreatitis (SAP) is associated with hypo-lipoproteinemia. We studied whether the concentrations of HDL and APO A-I can predict persistent OF in patients with predicted SAP admitted to the ICU. Methods In 66 patients with predicted SAP, we prospectively evaluated the relationship between lipid levels, inflammatory cytokines and clinical outcomes, including persistent OF and hospital mortality. Blood samples were obtained within 24 hours of admission to the ICU. Results HDL and APO A-I levels were inversely correlated with various disease severity scores. Patients with persistent OF had lower levels of HDL and APO A-I, while those with transient OF had lower levels of interleukin-6, tumor necrosis factor-α and lower rates of hospital mortality. Meanwhile, hospital non-survivors had lower concentrations of HDL, and APO A-I compared to the survivors. By using the area under the receiver operating characteristic (AUROC) curve, both HDL and APO A-I demonstrated an excellent discriminative power for predicting persistent OF among all patients (AUROC 0.912 and 0.898 respectively) and among those with OF (AUROC 0.904 and 0.895 respectively). Pair-wise comparison of AUROC showed that both HDL and APO A-I had better discriminative power than C-reactive protein to predict persistent OF. Conclusions Serum levels of HDL and APO A-I at admission to the ICU are inversely correlated with disease severity in patients with predicted SAP and can predict persistent OF in this clinical setting.

This study investigated whether aging was associated with epigenetic changes of DNA hypermethylation on immune gene expression and lymphocyte differentiation. We screened CG sites of methylation in blood leukocytes from different age populations, picked up genes with age-related increase of CG methylation content more than 15%, and validated immune related genes with CG hypermethylation involved in lymphocyte differentiation in the aged population. We found that 12 genes were associated with promoter or exon one DNA hypermethylation in the aged group. Two genes, GSTM1 and LMO2, were chosen to validate its aging-related CG hypermethylation in different leukocytes. Modulation of aging-associated GSTM1 methylation may be able to promote Th1 immunity in the elders.

The objective of this study was to evaluate the antibacterial effects of polymethylmethacrylate (PMMA) bone cements loaded with daptomycin, vancomycin, and teicoplanin against methicillin-susceptible Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-intermediate Staphylococcus aureus (VISA) strains. Standardized cement specimens made from 40 g PMMA loaded with 1 g (low-dose), 4 g (middle-dose) or 8 g (high-dose) antibiotics were tested for elution characteristics and antibacterial activities. The patterns of release of antibiotics from the cement specimens were evaluated using in vitro broth elution assay with high-performance liquid chromatography. The activities of broth elution fluid against different Staphylococcus aureus strains (MSSA, MRSA, and VISA) were then determined. The antibacterial activities of all the tested antibiotics were maintained after being mixed with PMMA. The cements loaded with higher dosages of antibiotics showed longer elution periods. Regardless of the antibiotic loading dose, the teicoplanin-loaded cements showed better elution efficacy and provided longer inhibitory periods against MSSA, MRSA, and VISA than cements loaded with the same dose of vancomycin or daptomycin. Regarding the choice of antibiotics for cement loading in the treatment of Staphylococcus aureus infection, teicoplanin was superior in terms of antibacterial effects.

Total hip arthroplasty through a reduced wound has been popularized in the past decade. Supporters advocate that the minimally invasive approach can have better functional recovery by decreasing tissue trauma as compared with the conventional approach. Accumulated data published recently, however, demonstrated no additional benefits and possible more complications associated with the minimally invasive techniques as compared with conventional approach. No matter how controversy remains about the clinical outcomes and benefits of minimally invasive total hip arthroplasty, surgeons nowadays adopt some forms of the minimally invasive approach into their practice and patient care. The advocate of minimally invasive technique has revolutionized the perspectives of patient care in joint replacement surgery. The perception of a successful joint replacement has also shifted from surgeons to patients. An excellent result is no longer excellent radiographic measurements and functional scores. Patient's satisfaction is now prioritized by holistic implementation of multidisciplinary collaborations. Orthopedic surgeons should take the full responsibility and master their most familiar and comfortable technique of minimally invasive approach, in the best interests of the patients, to provide long-lasting clinical outcomes and minimize trauma to the patients.

Purpose Hyperbaric oxygen (HBO) therapy has been shown to enhance bone, muscle, skin, and wound healing, particularly in conditions of ischemia and low oxygen tension. Preliminary data show that HBO therapy may be beneficial in the treatment of muscle–tendon and ligament injury. However, the effects of HBO therapy on ligament healing have not been thoroughly investigated. The purpose of this study was to assess the effects of HBO on the healing of the medial collateral ligament (MCL) by using biomechanical and histological analyses in a rabbit model. Methods We investigated the effects of intermittent HBO therapy on ligamentous healing in rabbits. Sixty-four male rabbits were divided into eight groups consisting of eight animals each. The experimental group (32 rabbits) was subjected to HBO at 2.5 atmospheres absolute for 2 hours per day, whereas the control group (32 rabbits) did not undergo HBO therapy. All animals underwent a standardized surgical severance of the right MCL, whereas the left MCL was not surgically lacerated. Rabbits from each group were euthanized at 2, 4, 8, and 12 weeks postoperatively for biomechanical testing (six rabbits) and histological analysis (two rabbits). Results By using the intact left MCL as a control, the mean percentages of failure load calculated at 2, 4, 8, and 12 weeks in the HBO group were 20.6%, 49.1%, 63.9%, and 76.3%, respectively, whereas in the non-HBO group, the mean percentages of failure load at 2, 4, 8, and 12 weeks were 13.5%, 25.3%, 36.5%, and 57.3%, respectively. For all time intervals, the mean percent failure load of the severed MCLs from the HBO group was significantly higher than that from the non-HBO group. The mean percentages of regenerative collagen fibers in the HBO group at 2, 4, 8, and 12 weeks were 53.2%, 75%, 87.8%, and 95.1%, respectively, and 32.4%, 55.7%, 72.4%, and 82%, respectively, in the non-HBO group. For all time intervals, the HBO group showed a significantly higher amount of regenerative collagen fibers than the non-HBO group. Conclusion The present study results suggest that the healing of the MCL is enhanced by intermittent HBO therapy. HBO therapy may be useful in shortening the healing time of the injured ligaments.

The prognosis of osteonecrosis of the femoral head is highly dependent on the grading of the lesion size. A small lesion ( 30%) is doomed to collapse if left untreated. To calculate the necrosis volume, the most accurate method is to use three-dimensional magnetic resonance imaging (MRI) segmentation method. However, in clinical practice, the commonly used methods are to multiply the area percent of involvement or to use proxy, such as the necrotic index, by multiplying the angles of necrosis on two-dimensional (2D) images. The aim of this work was to find the relationship between the angular measurement proxy and the true necrosis volume. Results from different methods were compared with those of the MRI segmentation method in 29 hips. It was found that the area percent method tended to underestimate the volume and disagreed with 48% of the hips on the grading by the MRI segmentation method. As a contrast, the agreement could be improved to 90% of the hips by an index that was deduced from the original necrotic index. This study found that to estimate the necrosis volume by 2D projections is at the expense of inaccuracy but is still satisfying for clinical use. This study also found that the angular measurement proxy could be used to extrapolate the necrosis volume, whereas the bias of the measurement and grading could be decreased.

Background Controversy remains regarding the outcomes after total joint arthroplasty (TJA) among patients with or without liver transplantation (LT). This study aimed at investigating the prevalence of TJA in patients after LT and comparing the morbidity and mortality with the non-LT group. Methods We conducted a nationwide, population-based study, with data extracted from a universal health insurance database, based on the International Classification of Disease, Ninth Revision, Clinical Modification. Patients who underwent TJAs between January 2001 and December 2014 were included. Patients who had bilateral TJAs or a TJA before LT were excluded. A total of 43 patients with LT and 350,337 patients without LT were included. The analysis was implemented using data from all patients and those matched by 1-to-10 propensity score matching. Multivariable logistic regression was used to control confounding variables. Results The prevalence of patients undergoing TJA after LT was 1.3% (43/3276). After propensity score matching, patients with LT were not associated with 30-day complications (adjusted odds ratio [aOR], 0.98; 95% confidence interval [CI], 0.93-1.03; P = .35), 30-day readmission rates (aOR, 0.93; 95% CI, 0.92-1.08; P = .87), 90-day complication rates (aOR, 0.95; 95% CI, 0.88-1.02; P = .16), 1-year infection rates (aOR, 1.04; 95% CI, 0.96-1.12; P = .35), reoperation rates (aOR, 1.06; 95% CI, 0.92-1.23; P = .41), or mortality (aOR, 0.91; 95% CI, 0.80-1.04; P = .18). Conclusion The morbidity and mortality seem to be comparable whether TJA is performed in patients with or without LT. Methods for risk assessment would be feasible in liver transplant recipients.

We investigated the antibiotic concentration in fresh-frozen femoral head allografts harvested from two groups of living donors. Ten samples were collected from patients with osteoarthritis of the hip and ten from those with a fracture of the neck of the femur scheduled for primary arthroplasty. Cefazolin (1 g) was administered as a pre-operative prophylactic antibiotic. After storage at −80°C for two weeks the pattern of release of cefazolin from morsellised femoral heads was evaluated by an in vitro broth elution assay using high-performance liquid chromatography. The bioactivity of the bone was further determined with an agar disc diffusion and standardised tube dilution bioassay. The results indicated that the fresh-frozen femoral heads contained cefazolin. The morsellised bone released cefazolin for up to four days. The concentration of cefazolin was significantly higher in the heads from patients with osteoarthritis of the hip than in those with a fracture. Also, in bioassays the bone showed inhibitory effects against bacteria. We concluded that allografts of morsellised bone from the femoral head harvested from patients undergoing arthroplasty of the hip contained cefazolin, which had been administered pre-operatively and they exhibited inhibitory effects against bacteria in vitro.

Instillation of local anesthetics into a surgical site has been gaining popularity in post-operative pain management.To determine whether continuous intra-articular infusion of bupivacaine via pain-control infusion pumps (PCIP) enhances and sustains analgesia after total hip arthroplasty (THA).Ninety-two patients undergoing THA were randomized to receive continuous intra-articular infusion of either 0.5% bupivacaine or 0.9% normal saline at a flow rate of 2 mL/h via a PCIP for 48 h. The primary outcome measure was pain intensity on Visual Analogue Scale (VAS) scores in the first 72 h. Other measures included time to first rescue dose of narcotics, amount of narcotic use, presence of adverse events, length of hospital stay, and hip function evaluated with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index.Despite a longer time to first narcotic rescue (56 versus 21 min, p0.0001) in patients receiving bupivacaine, the two groups did not differ significantly in overall pain relief (p=0.54). A lower VAS score was found only at time 0 and 2 h; no difference in VAS score was noted at any other time point. Additionally, no difference was found in terms of amount of narcotic use, incidence of adverse events, hospitalization days, and the WOMAC score.Continuous intra-articular infusion of 0.5% bupivacaine at 2 mL/h via a PCIP does not provide sustained post-operative pain relief in patients undergoing THA.

Necrotic fasciitis (NF) is a particularly aggressive and serious infection of the fascia that can penetrate into the musculature and internal organs, resulting in death if not treated promptly. In this work, an integrated microfluidic system composed of micropumps, microvalves, and micromixers was used to automate the detection of pathogens associated with NF. The entire molecular diagnostic process, including bacteria isolation, lysis, nucleic acid amplification and optical detection steps, was enacted on this developed system. Mannose binding lectin coated magnetic beads were first used as probes to isolate all bacteria in a sample. In this work, polymerase chain reaction assays featuring primers specific to genes from each of four NF-causing bacteria (Vibrio vulnificus, Aeromonas hydrophila, and methicillin-sensitive and resistant Staphylococcus aureus) were used to rapidly and exclusively verify the presence of the respective bacterial strains, and the limits of detection were experimentally found to be 11, 1960, 14, and 11 400 colony forming units/reaction, respectively; all values reflect improvement over ones reported in literature. This integrated microfluidic chip may then be valuable in expediting diagnosis and optimizing treatment options for those with NF; such diagnostic improvements could ideally diminish the need for amputation and even reduce the morality rate associated with this life-threatening illness.

Background: Vascularized iliac bone-grafting has been reported to be successful for patients with osteonecrosis of the femoral head. However, its benefit in patients with segmental collapse of the femoral head has not been determined. The purpose of this study was to analyze the results of vascularized iliac grafting in osteonecrotic femoral heads with segmental collapse. Methods: We retrospectively analyzed thirty-three hips in thirty-two patients in whom an osteonecrotic femoral head with segmental collapse (Association Research Circulation Osseous [ARCO] stage IIIA [

Patients with systemic lupus erythematosus (SLE) frequently received corticosteroid therapy, resulting in osteonecrosis of the femoral head (ONFH). Prior studies demonstrated the effectiveness of extracorporeal shockwave treatment (ESWT) for ONFH.. This study evaluated the effectiveness of ESWT for ONFH in patients with SLE. We studied 39 patients, including 15 patients with SLE (26 hips) and 24 controls (29 hips). To each affected hip we applied ESWT (6000 impulses at 28 kV in a single session). Patients were ambulated with partial weight bearing for 4–6 weeks. The primary endpoint was the need for hip replacement. The secondary endpoints were improvement in hip pain and function and image changes on X-ray and MRI. Patients received total hip replacement in 12% of patients with SLE and in 14% of controls ( P = 0.802). There was no statistically significant difference in pain scores (0.86 vs. 0.89; P = 0.467) and function scores (89% vs. 91%; P = 0.194) between patients with SLE and controls. SLE response to ESWT for ONFH is comparable with ONFH in patients without SLE.

Cocktail therapy consists of extracorporeal shock wave treatment (ESWT), hyperbaric oxygen therapy (HBO) and alendronate. We hypothesized that this combined therapy may produce better results than ESWT alone when treating hip necrosis. This prospective, randomized study evaluated the effectiveness of cocktail therapy in early hip necrosis, and then compared it to shock wave treatment alone. Sixty-three patients (98 hips) were randomly divided into two groups. Group A consisted of 28 patients (50 hips) who received cocktail therapy, and group B consisted of 35 patients (48 hips) who received only ESWT. Each affected hip was treated with 6,000 shocks of ESWT at 28 kV (equivalent to 0.62 mJ/mm2) in a single session. Cocktail patients also received HBO therapy performed in a multi-place chamber daily for 20 treatments, and they were administered 70 mg of alendronate orally per week for 1 year. The evaluations included clinical assessment, radiograph and MRI. After a minimum of 2-years of follow-up, the overall results showed 74% improved, 16% unchanged and 10% worsened in group A; and 79.2% improved, 10.4% unchanged and 10.4% worsened in group B (P = 0.717). Total hip replacement (THR) was performed for 10% of group A and 10.4% of group B (P = 0.946). MRI showed significant reduction in bone marrow edema and a trend of decrease in the size of the lesions in both groups, however, no difference was noted between the two groups. Cocktail therapy is effective for early hip necrosis, but the results are comparable to ESWT in short-term follow up. The joint effects of HBO and alendronate over EWST were not observed. Long-term results are needed to determine whether or not the synergistic effects of ESWT, HBO and alendronate over ESWT alone exist in early hip necrosis.

Studies comparing the minimally invasive surgery with 2-incision technique (MIS-2) technique with the conventional transgluteal technique are lacking in the literatures. We compared the clinical outcomes in a series of 166 hips, including 83 MIS-2 total hip arthroplsty (THA) (group I) and another 83 matched-pair series (group II) using conventional transgluteal approach. Demographic data, hospital course, radiographic data, and functional outcome (Western Ontario and McMaster University Osteoarthritis Index and Harris hip score [HHS]) were investigated. The 2 groups significantly differed in 3 and 6-month HHS with a higher HHS in MIS-2 group. But the MIS-2 group had longer operation time, increased blood loss, and more complications. The current study indicates that the benefit of MIS-2 technique was only short-term with quicker functional recovery and shorter duration use of nonsteroid antiinflammatory drugs postoperatively.

OBJECTIVES The optimal duration of systemic antibiotic therapy in patients with prosthetic hip infection (PHI) undergoing staged exchange arthroplasty (SEA) has not been determined. We hypothesized that with an antibiotic-loaded cement spacer (ALCS), in the interim, short-term antibiotic therapy is as effective as a conventional prolonged treatment course. PATIENTS AND METHODS We reviewed 99 patients with PHI who were managed with SEA using an ALCS from February 2002 to October 2005. A standard (4-6 week) antibiotic treatment course was administered in the first 46 patients and a short-term (1 week) therapy was adopted in the subsequent 53 patients. RESULTS Eight patients (four in each group) had persistent infection following the first attempt of surgery and antibiotic treatment; in three of them the infection was cured by additional debridement prior to re-implantation. Forty-two (91%) patients in the long-term group and 47 (89%) patients in the short-term group were free of infection (P = 0.67) at an average follow-up of 43 months (range, 24-60 months). Five (11%) patients developed complications related to prolonged antibiotic therapy. The short-term treatment resulted in a shorter hospital stay (18 versus 43 days, P < 0.001) and a lower direct medical cost (US$13 732 versus US$21 756, P < 0.001). CONCLUSIONS Short-term antibiotic therapy was not associated with a higher rate of treatment failure. Given the higher costs and incidence of complications, protracted courses of antibiotic administration may not necessarily be routine practice in patients with PHI undergoing SEA, provided that an ALCS is used.

Objective. This study reports a novel local bone graft technique for the treatment of osteonecrosis of femoral head (ONFH). Materials and methods. From 1998 to 2005, a procedure using local bone grafting was performed for the treatment of ONFH in 11 patients. The local bone grafts were obtained from the intertrochanteric region and then impacted into the necrotic lesion. A wire coil was inserted into the remaining space after the grafting. Results. At a mean follow-up of 61 months (range, 30 to 103 months), all 5 ARCO stage IIC hips survived but 3 of the 6 ARCO stage IIIA hips failed. The overall clinical success rate was 73%. Conclusions. This study demonstrates that local cancellous bone grafting combined with a space-filling device implanted into the ONFH is a promising procedure and the wire coil showed no interference to the remodeling of the femoral head after grafting.

Summary The treatment for mangled lower extremities poses a clinical challenge for orthopaedic surgeons. The complexities of soft-tissue injury combined with open fractures and osteomyelitis have frequently resulted in amputation of the lower extremity. The current advances in soft-tissue flap reconstruction techniques have significantly improved the results of limb-salvage attempts. Understanding the reconstructive ladders around the zone of injury, debridement, timing and nuances of techniques regarding skin graft, local and distant flaps and microsurgical reconstruction is necessary to complete limb salvage in a timely and appropriate fashion. Various soft-tissue flap applications have been described, including emergent flow-through flap, acute soft-tissue flap, acute combined soft-tissue and bone flap, pedicle gastrocnemius/soleus flap, pedicle sural artery flap, soft-tissue flap for chronic osteomyelitis, composite osseous-myocutaneous flap for chronic osteomyelitis and free functioning muscle flap for functional reconstruction of mangled lower limbs. Clinical experience of 850 flaps reconstructions for mangled lower limbs in both acute and chronic stages has revealed that adequate application of flap technique was able to achieve quite acceptable results. This article provides a comprehensive review of the soft-tissue injury management and flap reconstruction for mangled lower limbs.

Multiple drilling is reported to be an effective treatment for osteonecrosis of the head of femur, but its effect on intra-osseous pressure has not been described. We undertook multiple drilling and recorded the intra-osseous pressure in 75 osteonecrotic hips in 60 patients with a mean age of 42 years (19 to 67). At a mean follow-up of 37.1 months (24 to 60), 42 hips (56%) had a clinically successful outcome. The procedure was effective in reducing the mean intra-osseous pressure from 57 mmHg (SD 22) to 16 mmHg (SD 9). Hips with a successful outcome had a mean pressure of 26 mmHg (SD 19). It was less effective in preventing progression of osteonecrosis in hips with considerable involvement and in those with a high intra-osseous pressure in the intertrochanteric region (mean 45 mmHg (SD 25)). This study is not able to answer whether a return of the intra-osseous pressure to normal levels is required for satisfactory healing.

Accurate femoral rotational alignment is of vital importance for successful total knee arthroplasty (TKA). The value of computer-assisted surgery TKA (CAS-TKA) in increasing the accuracy of femoral rotational alignment remains controversial. We hypothesize that outcomes are related to the severity of preoperative varus and valgus deformity and that CAS-TKA may be beneficial under certain circumstances. Between January 2007 and December 2013, patients with osteoarthritis and varus angulation in the mechanical axis (MA) ≥ 15° and valgus angulation in the MA ≥ 10° (based on hip-to-ankle standing radiography) who underwent TKA were divided into four groups. CAS-TKA and conventional TKA outcomes were compared in patients who had preoperative advanced genu varum and advanced genu valgum deformities. The accuracy of component alignment and postoperative limb alignment was determined using radiographic parameters and computed tomography (CT). One hundred and eight patients (144 knees) were included in the analysis. For patients with preoperative advanced genu varum deformity, a significant difference was detected in the sagittal femoral angle (p

Background Vibrio vulnificus necrotizing skin and soft tissue infections (VNSSTIs) usually predispose patients with or without preexisting liver disease to septic shock, and then evolve to multiple organ dysfunction syndrome (MODS), thus resulting in high mortality in humans. However, clinicians do not have a valid prediction model to provide a reliable estimate of case-fatality rate when caring for these acutely and/or critically ill patients. Methods/Principal Findings We retrospectively analyzed 39 consecutive patients with VNSSTIs (mean age: 65.7 ± 11.3 years) at our institution between 2007 and 2010. All patients were treated with the same protocol. Demographic and clinical characteristics, disease severity on admission, treatment details, and outcomes were collected for each patient and extracted for analyses. We studied the predictive value of the model for end-stage liver disease (MELD), modified MELD including sodium (MELD-Na), and laboratory risk indicator for necrotizing fasciitis (LRINEC) scores for case-fatality. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed. The mean MELD, MELD-Na and LRINEC scores on admission were 15.1 ± 1.1, 17.7 ± 1.1, and 3.4 ± 0.4 points, respectively. After admission, these patients had temporary or progressive deterioration of nearly all their scores and lab values. The area under the ROC curve for the MELD and ΔMELD scoring models were 0.929 (p = 0.002) and 0.897 (p = 0.005), respectively. An optimal MELD/ΔMELD cutoff value ≥ 20/2 had a good sensitivity and specificity (all > 80%), with a 64/13-fold increased odds for case-fatality. Additionally, the development of severe forms of anemia (p = 0.014) and hypoalbuminemia (p = 0.019) were associated with an increased case-fatality rate. Discussion The MELD/ΔMELD scoring model is an effective risk stratification indicator at the time of admission and also an excellent condition monitor during hospitalization for medical care of acutely and/or critically ill patients with VNSSTIs., Author Summary VNSSTIs have increased significantly over the last two decades, with cases now regularly reported globally. Despite advancing antibiotic and infection control practices, these infections are still highly lethal and disabling diseases. They usually predispose patients to septic shock and then evolve to liver dysfunction and MODS, thus resulting in high mortality in humans. However, clinicians do not have a valid prediction model to provide a reliable estimate of case-fatality rate when caring for these acutely and critically ill patients. MELD scoring system was originally developed to assess the short-term prognosis of cirrhotic patients undergoing the transjugular intrahepatic portosystemic shunt procedure. By using the MEGX test, the strong negative association between the scores and the residual liver function has been confirmed. Therefore, it has been validated and applied to a wide spectrum of clinical scenarios in recent years. In this work, we studied the predictive value of the MELD scoring system for case-fatality in patients suffering VNSSTIs. We have found that the MELD scoring system is an effective risk stratification indicator at the time of admission, and also an excellent condition monitor during hospitalization for medical care of acutely and critically ill patients with VNSSTIs.