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Background Open pelvic fractures are associated with pelvic-perineal soft tissue injuries and pelvic infections as late complications. The study aimed to analyse and compare the clinical results and medical costs of the conventional and modified instillation negative-pressure wound therapy (cNPWT and m-iNPWT, respectively). Methods This retrospective study compared the outcomes of cNPWT and m-iNPWT for soft tissue management in patients with open pelvic fractures. We analysed the Injury Severity Score (ISS), hospital stay, medical costs, number of NPWT, time required to reach definite wound coverage, and occurrence of complications. Results Seventeen patients with open pelvic fractures were treated with NPWT. The median ISS (interquartile range) for m-iNPWT and cNPWT were 40 (26–48) and 43 (35–43), respectively. The numbers of NPWT changes were 6 (3–8) for m-iNPWT and 21 (20–32) for cNPWT. The time to wound coverage for patients who underwent m-iNPWT and cNPWT was 30 and 49 days, respectively. The overall medical costs of m-iNPWT and cNPWT were 80076 and 248395 USD. The hospital and intensive care unit (ICU) stay was 53 (41–70) and 12 (5–26) days for m-iNPWT and 167 (107–284) and 43 (23–151) days for cNPWT. One patient receiving cNPWT died of pelvic sepsis during ICU treatment. Conclusions Our study findings indicate that m-iNPWT would be a feasible method for complex pelvic soft tissue infection in open pelvic fractures to reduce complication rates, hospital stay, and medical costs.

Introduction The aim of this study was to analyze and describe the fracture patterns of the acetabular posterior wall based on quantitative measurements of the fracture characteristics. Materials and methods Computed tomography images of 51 patients with acetabular posterior wall fractures from an initial cohort of 216 acetabular fractures were imported into a three-dimensional (3D) virtual software. The reconstructed 3D images were utilized to evaluate the following: (i) fracture line mapping on the inner articular and retro-acetabular surfaces, (ii) common zones of fracture and marginal impaction, and (iii) categorization by location and pattern of comminution. The clock-face position was applied for description: the midpoint of the transverse acetabular ligament served as the +180° reference point, and the 0° reference point was set perpendicular to the ligament. The fracture angle on the articular surface was defined as the intersection between the start and end points. The fracture span on the retro-acetabular surface was defined as the ratio of the perpendicular distance, which is between the fracture beak and acetabular rim, to the entire length, which is from the edge to the rim. Quantitative measurements were performed, and the fracture patterns were analyzed. A color scale bar was used to visualize the common and marginal impaction zones. Results The articular surface mapping of all the cases demonstrated that the average starting point of the fracture line was +6.2° (±12.8°) and the endpoint was 96.7° (±13.3°), and the average fracture angle was 119.6° (±7.6°) with 80.6% of the fragments having angles within 18.7–117°. The retro-acetabular surface mapping demonstrated that the average fracture span was 0.65 ±0.20, and 61.7 % of the fracture lines were located within 0.6 to 0.9. Marginal impaction was found in 21 cases (21/51, 41.2%; range: between +7° and +105°). Conclusion The fracture maps showed fracture patterns and recurrent fracture zones on the articular and retro-acetabular surfaces. However, there was no remarkable pattern of marginal impaction. Level of evidence Retrospective cohort study

Summary The incidence of intertrochanteric femoral fractures has rapidly increased with the extended lifespan of the elderly population. Surgery enables early ambulation by achieving anatomic reduction and stable internal fixation. However, reduction usually involves postoperative evaluation. Here, we present reliable parameters obtained from analyses of three-dimensional computed tomography images from cadavers to serve as guidelines during the reduction of intertrochanteric fractures. We included 184 three-dimensional modeling samples from cadavers placed in two standardized positions, similar to C-arm imaging. We recorded the level of the orthogonal line from the greater trochanter (GT) tip to the femoral head (GT orthogonal line [GTOL]) in the anteroposterior view and the line along the anterior femoral cortex passing through the femoral head (anterior cortical line) in the axial view. Correlations between these lines and angular alignments were statistically determined. The GTOL passed above the femoral head center at mean 2.36 mm in all patients; 77.17% of such instances were in the upper second quadrant of the femoral head. The anterior cortical line passed under the femoral head center at mean 10.82 mm; 73.37% of such instances were in the inferior one-third of the femoral head. Consistent correlations were found between the GTOL and neck-shaft angle and between the anterior cortical line and anteversion. The GTOL and anterior cortical line passed through a constant level of the femoral head in most samples and were correlated with angular alignments. The intraoperative use of these simple imaginary lines improves the intertrochanteric fracture reduction quality.

Background We investigated the overall clinical outcome of the expanded paratricipital approach in complex articular fractures of the distal humerus and the effect of lack of visualization in the surgical field. In addition, we performed a cadaveric study to investigate the expansion or limitation of articular access in the expanded paratricipital approach. Methods Forty-one AO/OTA type 13C fracture cases treated using the expanded paratricipital approach at a single trauma center from 2013 to 2017 were enrolled in this study. We evaluated the overall clinical outcome and analyzed the effect of lack of visualization in the surgical field with the expanded paratricipital approach by comparing outcomes between 2 groups classified by the location of the main articular fracture (group 1, limited visualization; group 2, without limited visualization). The length of inaccessible and accessible articular segments were analyzed using 40 matched-pair elbows. Results The average duration of follow-up was 15.1 months. All fractures (type C1 in 11 cases, type C2 in 21, and type C3 in 9) were radiologically healed at 3.2 months after surgery. No cases required additional surgery because of implant irritation. The average Mayo Elbow Performance Score was 90.5. The mean Disabilities of the Arm, Shoulder and Hand score was 18.5. Among the 41 cases, the limited visualization group (group 1, n = 21) had a longer surgical time and higher percentage of nonanatomic reduction than group 2. Although the expanded paratricipital approach allowed more articular exposure than the conventional approach, there was still a 20mm inaccessible articular segment (30% of transepicondylar width) in cadaveric dissection. Conclusions The expanded paratricipital approach can be used in type C1, type C2, and selective type C3 articular fractures of the distal humerus with favorable results. Relative to surgical times and achieving anatomic reduction, it is more successful in a fracture with a main articular fragment and with good visualization.

The purposes of the study were to introduce surgical technique of fragment-specific fixation technique using multiple 2.7-mm variable-angle locking compression plates (VA LCPs) in comminuted posterior wall acetabular fractures and reported its clinical results. Among the 68 patients, 23 with comminuted posterior wall factures with ≥ 3 fragments in the CT scan and no column involvement with a minimum follow-up duration of 12 months were enrolled in this study. We evaluated the clinical results after the treatment of comminuted posterior wall acetabular fractures via the fragment-specific fixation technique using 2.7-mm variable-angle locking compression plates (VA LCPs) retrospectively. The average duration of follow-up was 26.8 months. Anatomical reduction was achieved in eighteen patients. Imperfect reduction was achieved in five patients. 22 patients achieved fracture union and one patient underwent revision surgery owing to acute postoperative infection. There were no complications, including loss of reduction, fixative failures, sciatic nerve palsy, heterotopic ossification, and early posttraumatic arthritis among 22 patients. The average functional outcome was measured as ‘very good’. Fragment-specific fixation technique using 2.7-mm VA LCPs for comminuted posterior wall acetabular fractures could be an acceptable alternative means of surgical fixation.

Antibiotics are widely used in the treatment of uncomplicated left-sided colonic diverticulitis. In Asian countries, however, right-sided colonic diverticulitis is more common than left-sided colonic diverticulitis. The aim of the present study was to evaluate the need for antibiotics in the treatment of uncomplicated right-sided colonic diverticulitis in an Asian population. Patients were randomized to two management strategies: antibiotics and no antibiotics. At 4–6 weeks after discharge, the patients in both groups underwent computed tomography or were contacted by phone to confirm the effectiveness of the treatment. The primary end point was the treatment failure rate of the initial treatment, and secondary end points were the length of hospital stay and total admission costs. Patients were randomized to treatment with (61 patients) or without (64 patients) antibiotics. The rates of treatment failure in the antibiotics and no antibiotics groups were 1.7% and 4.6%, respectively, with no significant difference (P = 0.619). There was also no significant difference in the length of hospital stay between the groups (P = 0.983). Total admission costs were lower in the no antibiotics group than in the antibiotics group (US$1004.70 vs US$1112.40, respectively, P = 0.037). Conservative management of uncomplicated right-sided colonic diverticulitis without antibiotics shows similar treatment failure rates and length of hospital stay, and is associated with lower hospital costs, compared with standard antibiotic treatment. Therefore, conservative management can be considered as a safe treatment option. ClinicalTrial.gov No. NCT02314013

The aim of this study was to introduce various applications of miniplate augmented tension-band wiring (TBW) for comminuted patella fractures and to evaluate the clinical outcomes. Comminuted articular patella fractures were managed with anterior cortical miniplate fixation with a TBW technique from January 2014 to January 2016. The primary end point was radiographic union. Secondary end points were complications related to the procedure. Functional outcomes including range of motion were also evaluated. Thirty patients were followed up for a mean of 20 months (range, 12-28) postoperatively. The primary union rate was 96% (29 of 30 patients). Mean time to union was 3.2 months. One patient required additional surgery because of acute postoperative infection. Twenty-five patients recovered a full range of motion relative to the contralateral limb. The mean Bostman score at the last follow-up was 28.6 points (range, 26-30). In conclusion, miniplate augmented TBW is a versatile and useful technique for comminuted patella fracture fixation.

The role of AlN on the internal oxidation behavior was investigated in an Al-containing high Mn steel. The sequential formation of internal oxidation and AlN+γ-matrix layers on the γ-matrix was observed using an EPMA, an SEM, and a TEM after the heat-treatment in air. The heterogeneous nucleation of MnAl2O4 on the AlN was identified in between the internal oxidation and AlN+γ-matrix layers. MnAl2O4 shows the [2-1-10]AlN//[110]MnAl2O4 and (0002)AlN//(-11-1)MnAl2O4 orientation relationship with the pre-existing AlN by sharing Al atoms. The coherency between MnAl2O4 and AlN and the evolution of oxides in an Al-containing high Mn steel were further discussed.

Introduction Local delivery of high dose antibiotics in the form of antibiotic impregnated polymethyl methacrylate (PMMA) cement beads or coated rods is commonly used in the management of long bone infections. The downsides of antibiotic cement beads for intramedullary long bone infections are associated with difficulty in removal from the medullary canal, bead breakage, and lack of stability. Antibiotic cement-coated smooth flexible guide wires, rods and nails can have complications such as delamination or debonding of the cement. In addition, the current techniques for cement rod insertion have a risk of iatrogenic joint contamination. To improve upon this technique and decrease potential complications, we propose the use of an antibiotic cement-coated hinged threaded rod as a temporary intramedullary spacer. This technique utilizes both an antegrade and retrograde insertion of the threaded rod into the medullary canal through the bony defect site with connection at the hinge to treat intramedullary long bone infections and infected nonunions. Material and Methods A total of 40 patients were included in the study. The details in making the cement rod were well documented. The shape of cement rod and the integrity of the cement at the time of rod insertion and rod removal were compared to identify any cement debonding or delamination. Potential postoperative complications including iatrogenic joint infection, displacement or breakage of the threaded cement rods, and fracture displacement were all carefully documented. The preliminary biological effect of the initial debridement and antibiotic cement rod placement was determined using the negative conversion rate of intraoperative cultures. Results A single antibiotic coated threaded rod was inserted in 18 cases. Two separate antibiotic coated threaded rods were inserted and connected via hinge in 22 cases. There were zero cases of rod breakage and no secondary loss of reduction from antibiotic rod placement to the definitive staged operation. There were zero iatrogenic joint infections. There were zero cases of cement debonding or delamination from the rod. The conversion rate to a negative culture after initial debridement and antibiotic rod placement was 85% (34/40 cases). Conclusions The use of an antibiotic coated cement threaded rod with a hinge as an intramedullary spacer provides the benefits of local antibiotic delivery, offers improved construct stability, makes implant removal easier without delamination of the cement mantle, and utilizes the versatility of a hinge to prevent violation of native joints when treating infected nonunions and intramedullary long bone infections.

OBJECTIVE To evaluate the effectiveness of an additional rim plate [3.5-mm precontoured locking compression plate (LCP)] for stabilizing the posterolateral fragment in lateral tibial plateau fractures. METHODS Standard lateral locking plates [either a proximal tibial plate (PTP) or a proximal tibial locking plate (PTLP)] were applied to 40 matched pair knees from 20 fresh-frozen cadavers followed by the application of a secondary rim plate [variable angle LCP (VALCP)] posterior laterally. RESULTS The mean ratio of supported articular surface in the PTP group was 0.692, whereas that in the PTLP group was 0.569. This difference was statistically significant (P < 0.001). Additional rim plating with a VALCP could only be performed for 27 of 40 knees; 8 of 20 knees in the PTP group and 5 of 20 knees in the PTLP group could not be fitted with a VALCP due to anatomic limitations. For the total standard plating group alone, the mean ratio of supported articular surface was 0.596, whereas the mean ratio of supported articular surface with additional rim plating was 0.798 (P < 0.001). In contrast, additional rim plating was possible for more knees that received a PTLP than a PTP. Ultimately, there was no significant difference in the ratio of supported articular surface after additional rim plating between the 2 different types of standard plates (P = 0.087). CONCLUSION Our results identified a bare area in the posterolateral corner of the lateral plateau that was unsupported by rafting screws following conventional, 3.5-mm, precontoured LCP plating. Thus, additional rim plating may be useful for treating plateau fractures with a posterolateral fragment.

s In this work, the qualCONVERSION(0ities of sheet formability (i.e., stretchability and drawability), of twinning-induced plasticity (TWIP), steel-cored thr$ee-layer steel sheets were investigated in terms of tensile parameters (i.e., strain hardening exponent, strain rate sensitivity, normal anisotropy, mean R -value, and total elongation). The tensile parameters of TWIP steel-cored three-layer steel sheets follow the force-based rule of mixtures. The limit drawing ratio, the measure of drawability, of the three-layer steel sheet was proportional to the mean R -value and the strain rate sensitivity while the limit dome height (LDH), the measure of stretchability, could not be correlated with any tensile parameters. The LDH of the TWIP steel-cored layer sheet was superior to that of the single layer due to the inhibition of serration in the TWIP steel-core during the Erichsen test.

We present the surgical technique of rim-plate-augmented separate vertical wiring for comminuted inferior pole fracture of the patella and report the clinical outcomes. Between July 2013 and January 2016, 13 patients (7 male and 6 female) who were diagnosed with comminuted inferior pole fracture of the patella in preoperative computed tomography and underwent a minimum of 1 year of follow-up were enrolled in this study. Mean patient age was 57.7 years (range 28–72 years). All patients underwent open reduction and internal fixation by rim-plate-augmented separate vertical wiring. Bony union, complications, range of motion and Bostman score were the clinical outcomes. Bony union was achieved in all cases at an average of 10 weeks after surgery (range 8–12). There was no loss of reduction and fixative failure during follow-up. The average range of motion was 127° (range 120°–130°). The mean Bostman score at last follow-up was 29.6 points (range 27–30) and graded excellent in 12 patients. Rim-plate-augmented separate vertical wiring demonstrated secure fixation and favorable clinical outcomes. This study provides evidence for its effectiveness as a fixation method for treating displaced, comminuted inferior pole fracture of the patella.

Objectives The objectives of the study were to introduce a circumferential bone graft around an absorbable gelatin sponge core using an induced membrane technique, to assess its ability to reduce the required amount of graft and to maintain the bone graft, and to evaluate the clinical outcomes in the management of critical-size bone defects. Patients and methods Circumferential bone grafting using a staged induced membrane technique for managing critical-size bone defects was performed in 21 patients. Postoperative computed tomography scans were performed 7 days after Hemovac drain removal and 3 months after bone grafting. Volumetric measurements of the defect size, gelatin sponge proportion, and amount of grafted bone were performed by two independent observers using three-dimensional (3D) software. Results The critical-size defects were located at the metadiaphyseal area of 11 tibias, eight femurs, and two humeri. The average defect size was 8.9 cm in length and 65.2 cm3 in volume. The absorbable gelatin sponge core replaced 21.4% (average) of the defect volume. There was no significant deterioration in the shape of the grafted bone among the serial 3D models. Eighteen patients (86%) were healed radiographically at 9.1 months (average). Conclusion Our study suggests that circumferential bone grafting in association with the induced membrane technique could reduce the required amount of bone graft and adequately maintain graft position and shape, with favourable clinical outcomes.

To review available approaches and fixation methods for posterolateral fracture fragment (PLF) in tibial plateau fracture, and to propose an algorithm to treat various types of plateau fractures which all involve the PLF. This article reviews multiple surgical approaches for PLF and suggests an algorithm for suitable approach and fixation method according to PLF with combined plateau fracture. The modified anterolateral approach is a suitable single approach for fractures with a PLF combined with an anterolateral plateau fracture and for isolated posterolateral fracture fragments. For a multicolumn tibia plateau fracture involving the lateral, medial and posterior columns, dual approaches (modified anterolateral and posteromedial approach) can be used to access the entire plateau area. When considering approaches of this complex fracture pattern, one must consider local soft tissue condition, plateau fracture morphology, associated injuries, and fixation options. After review of multiple approaches described in the literature for PLF fixation, we can suggest an algorithm for the approach and fixation to treat tibial plateau fractures with posterolateral fracture fragments.

Commercialization of TWinning Induced Plasticity (TWIP) steels has been delayed because of deteriorated surface quality, delayed fracture, and liquid metal embrittlement in spite of their excellent tensile properties. In order to complement these drawbacks, TWIP/low-carbon (LC) steel clad sheets were fabricated by hot rolling, and their dynamic tensile properties were measured by a Hopkinson tensile bar. In all TWIP/LC clad sheets, TWIP/LC interfaces were well bonded without pores or voids by mechanical and metallurgical bonding. Thanks to well-activated dynamic Hall-Petch effect in the TWIP steel region of the clad sheets, the dynamic strength and ductility of the clad sheets were higher than quasi-static ones because the twin formation was more activated under the dynamic loading. They were also considerably higher than those calculated by a rule of mixtures because the interfacial area took most of dynamic applied tensile stress and strain. The present TWIP/LC clad sheets covered wide ranges of excellent dynamic tensile strength and ductility ( e.g ., 792–1076 MPa and 50–57%, respectively) by controlling the volume fraction of TWIP region, which can readily discover new applications for automotive structural steel sheets.

Although twinning-induced plasticity (TWIP) steels have high tensile strength with high strain hardening and large uniform elongation due to the formation of deformation twins during plastic deformation, sheet formabilities of TWIP steels are relatively poor. In this study, to overcome this problem, TWIP-cored three-layer architectured steel sheets are produced using cladding with low carbon steel sheaths. For an optimum design of layer architectured materials, strain hardening exponent n and strain rate sensitivity m of the layer sheets are theoretically and experimentally investigated. The forced-based rule-of-mixtures well reproduces the experimental values of the equivalent n and m. Contrary to the conventional rule-of-mixtures, the equivalent n and m of the TWIP-cored mild steel-sheath layered sheets are governed not only by volume fractions and n and m of parent materials but also by the strength of strong layer.

Residual stress effect of the deep drawn TWIP steel on delayed fracture was investigated. Microstructural features of the TWIP steels did not change after stress relief annealing, while the elastic lattice strain dropped to 0.0007. Delayed fracture of the drawn TWIP steel occurred after 203 hours of HCl immersion testing, but did not occur in the annealed one. It is clear that residual stress after the drawing is the primary reason for the delayed fracture of TWIP steels.

In this study, TWIP-cored three-layer steel sheets containing thin surface layers of low-carbon (LC) or interstitial-free (IF) steel were fabricated by solid-state hot-roll-bonding followed by cold-rolling. Interfaces were well bonded without any pores or voids, which indicated a successful fabrication of the TWIP-cored sheets. According to the tensile test results, both strength and elongation of TWIP-cored sheets increased proportionally with the volume fraction of TWIP-cored region, and were well matched with strength and elongation calculated by a rule of mixtures. However, yield point (YP) was observed in most of TWIP-cored sheets as well as mono-layer TWIP and LC sheets. After the sheets were quenched from 830 °C, the YP disappeared because the dislocation density was greatly increased by effects of thermal stresses formed during the rapid cooling. A bainitic microstructure, which was generally characterized by the continuous yielding, was formed along TWIP/LC or TWIP/IF interfaces, and also beneficially influenced to the elimination of YP. These TWIP-cored sheets covered a wide range of yield and tensile strength and ductility levels requiring in automotive steel sheets by controlling the volume fraction of TWIP-cored region, and thus present new applications to multi-functional automotive steel sheets.

The grain size dependence of the damping capacity of Fe-17 wt%Mn steel was investigated. A high damping capacity was measured in the ultra-fine grained steel, despite its lower volume fraction of e martensite and lower density of e variant boundaries and e/γ phase boundaries. Dilatometry of the ultra-fine grained Fe-17 wt%Mn steel revealed that the e↔γ phase transformation was largely suppressed. The features of the damping spectra were related to the anti-ferromagnetic transition in the γ phase, the thermo-elastic e↔γ phase transformation and the motion of grain boundaries in the ultra-fine grained microstructure. The damping spectrum of the ultra-fine grained Fe-17 wt%Mn steel was dominated by grain boundary damping effects.

Purpose This study aims to evaluate the effect of different pneumoperitoneum pressures on postoperative pain, especially by subcategorizing the pressures into 3 groups during laparoscopic cholecystectomy (LC). Methods We conducted a prospective randomized, double-blinded study of 150 patients with benign and uncomplicated gallbladder disease. They were categorized into 3 groups. Each group (50 patients) underwent LC with different pneumoperitoneum methods: group VLP, very-low pressure (6-8 mmHg); group LP, low pressure (9-11 mmHg); and group SP, standard pressure (12-14 mmHg). The 3 groups were compared for pain intensity, duration, analgesic requirement, and complications. Results The characteristics of the patients were similar among all groups. Postoperative pain scores at each time point (1, 2, 4, 6, 12, 24, and 48 hours) were not significantly different among the 3 groups. Further, operation time, hospital stay, the number of analgesic consumption doses, and postoperative complications were not significantly different among the 3 groups. Conclusion This study demonstrates no difference in postoperative pain among various pneumoperitoneum pressures during LC. Therefore, routine use of lower-pressure pneumoperitoneum is not recommended unless in selected patients who require low-pressure pneumoperitoneum surgery.

Purpose: The major pelvic trauma results in high mortality with associated fatal other injuries. During early stage of resuscitation, multidisciplinary approach is essential to improve the survival and outcomes. This study aims to report the effect and positive outcome of the trauma team approach on the management of hemodynamically unstable pelvic bone fracture. Methods: This retrospective review included all patients with hemodynamically unstable pelvic bone fracture admitted between March 2007 and December 2015. Patients were divided into group A, which comprised those admitted before the trauma team approach was started, and group B, which comprised those admitted after the approach was started. The advanced trauma life support protocol was followed for all patient. The comparisons between the two groups were based on medical records. Study variables included demographics, initial vital sign, injury severity score, fracture type, and injury mechanism. We analyzed the outcomes in each group with respect to the time interval for doctors` arrival, total length of stay in the emergency department (ED), time interval for computed tomography evaluation, 24-hour mortality, time interval for definitive fixation, and definitive fixation in the time-window of opportunity. Results: Fifty-three patients met the inclusion criteria. No statistically significant differences in demographic data existed between the two groups. The time interval for doctors` arrival (min, 63.09±50.48 vs 21.48±17.75; p=0.038) and total length of stay in the ED (min, 269.33±105.96 vs 115.49±56.24; p=0.023) were significantly improved. The 24-hour mortality was not significantly different between the two groups.(%, 14.3 vs 12.0; p=1.000) However, the time interval for definitive fixation and definitive fixation in the time-window of opportunity showed better results. Conclusion: The trauma team approach has positive effects, which include initial resuscitation through multidisciplinary approach and shortening the time interval to definitive fixation, on the management of hemodynamically unstable pelvic bone fracture. [ J Trauma Inj 2016; 29: 139-145 ]

Herein, we report the results of our experimental and computational investigation of the deep drawing behavior of twinning-induced plasticity (TWIP)-cored three-layer steel sheet. Various directional tensile tests for monolayer sheets of the TWIP and low-carbon (LC) steels were performed for evaluation of flow curves and anisotropic coefficients, which are used as input data of the finite element analyses for deep drawing of the monolayer and three-layer sheets. The experimental deep drawing behaviors of the layered sheets of three thickness ratios, and of the monolayer sheets, are computationally analyzed in terms of earring and variations of local thickness along the positions in the drawn cups. It was found that the three-layer sheets are more planar-isotropic in the sense of earring than the monolayer sheets, even more than the TWIP steel sheet. The thickness uniformity along the initial radial direction in the layered sheets is in between the heterogeneous TWIP steel and the relatively homogeneous LC steel. The present results shed light on the future direction of development of steel sheets with planar-isotropic and homogeneous deep-drawing characteristics.

The effect of the magnetic transition of γ austenite phase on γ → e martensitic transformation in Fe Mn binary alloys was investigated to calm a longstanding controversy over whether or not γ → e martensitic transformation is terminated at the Neel temperature of γ phase (TNγ), where the paramagnetic-to-antiferromagnetic transition occurs during cooling. Literature review on both martensite start (Ms) temperature and TNγ, experiments, and thermodynamic calculation clearly revealed that the γ → e martensitic transformation in Fe Mn binary alloys is not terminated at TNγ, but suppressed at temperatures below TNγ due to the high stability of antiferromagnetic γ phase.

During nailing of intertrochanteric fractures, there is always a risk of reduction loss despite achieving an acceptable reduction status after a percutaneous procedure. Most surgeons usually attempted to maintain the reduction with a manual endeavor. However, we experienced varying amounts of intraoperative reduction loss and had to perform readjustments several times. These struggles motivated us to attempt provisional pin fixation as an alternative method. The purpose of this study was to analyze the factors affecting intraoperative reduction loss, especially in comparison between two methods. Sixty-eight patients with intertrochanteric fractures were included. They were divided into two groups based on the method, by retrospective analysis of the intraoperative c-arm image. In the manual maintenance group, an assistant maintained the instruments during the procedure. In the provisional pin fixation group, the reduction was temporaryily held by a 3.2mm guide pin fixation across the fracture. A displacement of more than one cortical thickness in any plane or angular deformity during any point in the procedure after acceptable reduction was judged as an intraoperative reduction loss. Multivariate logistic regression was used for statistical analysis. The number of cases with intraoperative reduction loss was 18 (18 of 38, 46.1 %) in the manual maintenance group and 6 (6 of 30, 20.0 %) in the provisional pin fixation group. The odds ratio of intraoperative reduction loss in the manual maintenance group was 5.182 (95% confidence interval, 1.455–18.452) compared with the provisional pin fixation group as the reference. As a reasonable approach for maintaining reduction, provisional pin fixation can significantly decrease intraoperative reduction loss after percutaneous reduction of intertrochanteric fractures during nailing.

This study aimed to evaluate the incidence and morphologic features of posterolateral fragments in lateral and bicondylar tibial plateau fractures.This study used retrospective chart and computed tomography (CT) reviews.The study was conducted in a university hospital.All patients in whom lateral and bicondylar tibial plateau fractures had been diagnosed from May 2005 to December 2011 were reviewed.Two hundred seventy-eight OTA type B and type C tibial plateau fractures were identified using a retrospective chart review. Of the 197 patients who underwent CTs before surgery, 7 CTs were excluded because they had no sagittal or axial view, and the remaining 190 cases were enrolled to determine the incidence and morphologic characteristics of posterolateral fragments. The parameters for the morphologic evaluation included the lateral major articular fracture angle, posterior major articular fracture angle, diagonal distance, lateral anteroposterior distance (LAPD), posterior horizontal distances, posterior cortical height, sagittal fracture angle, and articular surface area. The displacement of posterolateral fragment was measured on axial image and classified as none, minor, or major by a gap of 5 mm.The incidence of posterolateral fragments included 84 cases (44.2%). Based on the OTA fracture classification system, 37 type B (35.9%) and 47 type C (54%) posterolateral fragments were identified. The mean lateral major articular fracture angle was 12.69 degrees (range, -56.02 to 72.44 degrees), and the mean posterior major articular fracture angle was 19.13 degrees (range, -39.47 to 61.10 degrees). The average diagonal distance was 32.75 mm (range, 15.03-59.14 mm). The LAPD averaged 10.22 mm (range, -11.18 to 31.17 mm), and the mean posterior horizontal distance was 22.93 mm (range, 4.1 to 49.95 mm). The average posterior cortical height was 31.12 mm (range, 10.84-63.93 mm), and the average sagittal fracture angle was 78.48 degrees (range, 41.69-105.12 degrees). The mean articular surface area was 522.18 mm2 (14.5%) of the total tibial articular surface.Posterolateral fragments are not uncommon in lateral and bicondylar tibial plateaus. This fragment has an inverted conical shape that is in a vertically oriented pattern and occupied nearly one-third of the surface area of the lateral tibial plateau. The preoperative CT measurement, especially for the LAPD, can be used for determining the best fixation strategy for the posterolateral fragment.Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

TWIP-cored three-layer steel sheets were newly fabricated by hot rolling of TWIP steel sheet surrounded by low-carbon (LC) or interstitial-free (IF) steel sheets. TWIP/LC or TWIP/IF interfaces were well bonded without pores or voids, while a few pearlites were thinly formed along the interfaces. The strengths and elongation of the TWIP-cored sheets increased as the volume fraction of TWIP-cored region increased, and were also well matched with the ones calculated by a rule of mixtures based on volume fraction or force fraction. According to digital image correlation and electron back-scatter diffraction analyses, very high strain hardening effect in the initial deformation stage and active twin formation in the interfacial region beneficially affected the overall homogeneous deformation in the TWIP-cored sheets without any yield point phenomenon occurring in the LC sheet and serrations occurring in the TWIP sheet, respectively. These TWIP-cored sheets can cover a wide range of yield strength, tensile strength, and ductility levels, e.g., 320~498 MPa, 545~878 MPa, and 48~54%, respectively, by controlling the volume fraction of TWIP-cored region, and thus present new applications to multi-functional automotive steel sheets requiring excellent properties.

The purpose of this study is to identify the safety and feasibility of laparoscopic caudate lobectomy.Caudate lobectomy has been considered as technically difficult because of the deep location of the caudate lobe and its proximity to great vessels. Due to the technical difficulty, laparoscopic caudate lobectomy was not feasible in patients with malignancy in the caudate lobe.Six consecutive patients with caudate hepatic malignancy received laparoscopic caudate lobectomy at Samsung Medical Center from September 2007 to May 2014. Demographic data, intraoperative parameters, and postoperative outcomes were assessed.All procedures for these 6 patients with caudate malignancy were completed with totally laparoscopic technique. Only 1 patient who had hepatocellular carcinoma in the Spiegel lobe underwent partial caudate lobectomy, and others underwent complete caudate lobectomy. The mean tumor size was 2.65 cm (range 0.9-5.1 cm). The mean operative time was 382 minutes (range 168-615 minutes) and none required transfusion. The mean duration of hospital stay was 8 days (range 6-13 days). There was no perioperative complication and patient mortality in this series. The resected margins of the specimens were tumor free (R0 resections, range 0.1-1.2 cm). The mean follow-up period was 56 months (range 12.9-93.7 months). No patient died during the follow-up period.Our experience demonstrated that laparoscopic caudate lobectomy is safe and feasible in selected patients with malignancy in the caudate lobe.

A3 intertrochanteric fracture has a higher incidence of intraoperative re-displacement than A1 and 2. The authors have also experienced difficulty with maintenance of reduction in A3 intertrochanteric fractures, as the technique depends on manual effort and can fail easily during the procedure. It induced us to develop this surgical technique to ease the surgical procedure and improve clinical outcomes. This paper introduces a modified provisional guide pin fixation technique applicable to even AO/OTA A3 intertrochanteric fractures, and presents preliminary results of 11 patients who were treated by provisional pin fixation-assisted nailing in A3 intertrochanteric fractures. Using this technique, we have reduced the chances of intraoperative reduction loss and achieved favorable clinical outcomes.

Introduction A residual postoperative fracture gap between major bone fragments following intramedullary nailing of long-bone fractures is recognised as one of the major risk factors for delayed union and non-union. The most common method for reducing a fracture gap after nail insertion is through application of the backstroke technique. We introduce forward-striking as a new and simple technique that can be used to reduce fracture gaps during cephalomedullary or intramedullary nailing. Patients and methods The forward-striking technique was used in 20 patients with subtrochanteric or femoral shaft fractures and three patients with tibial shaft fractures who underwent cephalomedullary or intramedullary nailing at two university teaching hospitals between February 2013 and March 2014. Results Bone union was achieved in all cases, with a mean time of 5.7 months (range, 3–9 months). No major complications, including, non-union, implant failure, or infection, were encountered during the follow-up period. Conclusion A forward-striking technique is simple, convenient, and highly efficient in terms of reducing fracture gaps during cephalomedullary or intramedullary nailing. The advantage of this technique is that it carries no risk of deforming the proximal interlocking screw, prevents excessive protrusion of the nail, and enables the lag screw to be placed into the optimal lag screw position relative to the femoral head at the time of cephalomedullary nailing. The forward-striking technique is particularly useful if no compression screw system is available.

Study design Prospective case series study. Objective To study the effect of posterior multilevel vertebral osteotomy (posterior crack osteotomy) on coronal and sagittal balance in patients with the fusion mass over the spine caused by previous surgery. Summary of background data Few studies have investigated revisional scoliosis surgery with the fusion mass using osteotomy. Methods Among patients who had a history of prior surgery for scoliosis correction and posterior fusion, those showing progression of the curve postoperatively due to nonunion, implant failure, or adding-on phenomenon were enrolled. All patients were treated using posterior crack osteotomy. For clinical evaluation, the pre- and postoperative Gross Motor Function Classification System score for walking status and the Berg balanced scale were used. For radiological evaluation, pre- and postoperative Cobb angle, and coronal and sagittal balance factors were used. Results Ten patients (5 males and 5 females) were enrolled. The preoperative diagnosis was neuromuscular scoliosis (3 cases), syndromic scoliosis (1 case), congenital scoliosis (5 cases), and neurofibromatosis (1 case). Osteotomies were performed at 3.3±1.3 levels on average. Pre- and postoperative Cobb angles were 70.8°±30.0° and 28.1°±20.0° (P=0.002 (0.97)), respectively. In pre- and postoperative evaluation of coronal balance, the coronal balance, clavicle angle, and T1-tilt angle were 36.8±27.1 mm and 10.4±8.5 mm, 6.7°±8.0° and 3.3°±1.5°, and 7.8°±19.0° and 4.7°±2.1°, respectively (P=0.002, 0.002, 0.002). In pre- and postoperative evaluation of sagittal balance, the spinal vertical axis, thoracic kyphosis, and lumbar alignments were 25.1±37.8 mm and 14.1±21.8 mm, 33.5°±51.1° and 29.7°±27.4°, and 45.7°±34.8° and 48.9°±23.1° (P=0.002, 0.169, 0.169). The walking and functional statuses did not change (P=0.317, 0.932). Although pulmonary and gastrointestinal complications were noted, the patients were discharged without complications. Conclusion Posterior crack osteotomy can be used effectively in revisional scoliosis surgery and the clinical and radiological results seem to be acceptable. Level of evidence 4.

Background The aims of our study were to evaluate the success rate of irrigation and debridement with component retention (IDCR) for acutely infected total knee arthroplasty (TKA) (< 4 weeks of symptom duration) and to analyze the factors affecting prognosis of IDCR. Methods We retrospectively reviewed 28 knees treated by IDCR for acutely infected TKA from 2003 to 2012. We evaluated the success rate of IDCR. All variables were compared between the success and failure groups. Multivariable logistic regression analysis was also used to examine the relative contribution of these parameters to the success of IDCR. Results Seventeen knees (60.7%) were successfully treated. Between the success and failure groups, there were significant differences in the time from primary TKA to IDCR (p = 0.021), the preoperative erythrocyte sedimentation rate (ESR; p = 0.021), microorganism (p = 0.006), and polyethylene liner exchange (p = 0.017). Multivariable logistic regression analysis of parameters affecting the success of IDCR demonstrated that preoperative ESR (odds ratio [OR], 1.02; p = 0.041), microorganism (OR, 12.4; p = 0.006), and polyethylene liner exchange (OR, 0.07; p = 0.021) were significant parameters. Conclusions The results show that 60.7% of the cases were successfully treated by IDCR for acutely infected TKA. The preoperative ESR, microorganism, and polyethylene liner exchange were factors that affected the success of IDCR in acutely infected TKA.

Osteochondromas are very common benign tumors composed of cartilage and bone. They are usually found at the end of the growth plate of long bones, most often at the area of the joints, and are contiguous with the medullary cavity. Extraskeletal osteochondromas, the same as their namesake, are composed of cartilage and bone. However, unlike typical osteochondromas, extraskeletal osteochondromas are not contiguous with bone, as their name implies. They usually arise from the synovial tissue and tendon sheaths. Although rare, extraskeletal osteochondromas have been reported to occur within the knee and around the hip; however, they are more commonly reported to occur in the hands and feet. When found in the hands or feet, these new growths are often very small and only occasionally symptomatic. We present the case of a 49-year-old female who had a slow-growing mass of 4 years' duration, located on the plantar aspect of her left foot. The mass was slowly becoming more palpable as it increased in size and was progressively causing pain and discomfort during ambulation. Imaging studies revealed an ossified mass bearing no connection to any other structure on the plantar aspect of her foot. An excision biopsy was performed, and the easily dissectible mass, although much larger than its usual presentation, proved to be an extraskeletal osteochondroma.