Chien-Fu Jeff Lin

Cefuroxime-impregnated cement in primary total knee arthroplasty: a prospective, randomized study of three hundred and forty knees.

Background: A prospective, randomized study was conducted to evaluate the efficacy of cefuroxime-impregnated cement in the prevention of deep infection after primary total knee arthroplasties performed without so-called clean-air measures, such as laminar flow and body-exhaust suits. Methods: Three hundred and forty primary total knee arthroplasties were performed with cementless fixation of the femoral component and cement fixation of the patellar and tibial components. The knees were randomly divided into two groups. In Group 1 (178 knees), cefuroxime-impregnated cement was used for fixation, whereas in Group 2 (162 knees), the cement did not contain cefuroxime. There was no significant difference between the two groups regarding demographic variables, the preoperative or postoperative knee score, the duration of the operation or of the use of the tourniquet, or the amount of blood transfused perioperatively. The average duration of follow-up was forty-nine months (range, twenty-six to eighty months). Results: No deep infection developed in the 178 knees in Group 1, whereas a deep infection developed in five (3.1%) of the 162 knees in Group 2 (p = 0.0238). Two superficial wound infections developed in each group. Conclusions: Cefuroxime-impregnated cement was shown to be effective in the prevention of early to intermediate deep infection after primary total knee arthroplasty performed with use of perioperative systemic antibiotic prophylaxis but no so-called clean-air measures.

Closed humeral shaft fractures: a prospective evaluation of surgical treatment.

OBJECTIVE We tried to define the roles of the rigid dynamic compression plate (DCP) and the semi-rigid Ender nail (EN) in the treatment of closed humeral shaft fractures. DESIGN A prospective, randomized clinical study was performed with detailed comparison parameters. MATERIALS AND METHODS Ninety-one closed humeral shaft fractures were treated. Randomly, 30 humeri were treated with open reduction and internal fixation with DCP and no bone grafting (BG), 29 were treated with the same procedure but with BG, and 32 were treated with closed reduction and internal fixation with Ender nails. The average follow-up period was 32 months (range, 13-54 months). MEASUREMENTS AND MAIN RESULTS In the group with DCP without BG, the average blood loss was 270 mL, operation time was 92 minutes, hospital length of stay was 6.5 days, and union time was 12.5 weeks. In the group with DCP with BG, the average blood loss was 325 mL, operation time was 108 minutes, hospital length of stay was 6.9 days, and union time was 9.4 weeks. In the EN group, the average blood loss was 114 mL, operation time was 54 minutes, hospital length of stay was 5.6 days, and union time was 9.9 weeks. Analysis of variance and Fishers exact test were used to evaluate the statistical significance. CONCLUSION In our experience, for humeral shaft fractures fixed surgically, EN is better than DCP without BG. When DCP is chosen for the means of fixation, prophylactic BG is recommended, especially in cases with more comminution.

Antibiotic-impregnated cement in revision total knee arthroplasty. A prospective cohort study of one hundred and eighty-three knees.

BACKGROUND Deep infection following total knee arthroplasty is a devastating complication, and it is very important to prevent it. A prospective cohort study was conducted to evaluate the effect of vancomycin-impregnated cement on the prevention of deep infection after revision total knee arthroplasty performed in a setting in which so-called clean-air measures such as laminar flow and space suits were not available. METHODS From 1993 to 2004, 183 first-time revision total knee arthroplasties were performed with fixation of all components with cement. The knees were divided randomly into two groups to evaluate the effect of vancomycin-impregnated cement in the prevention of postoperative infection. In Group 1 (ninety knees), the cement was not mixed with antibiotics; in Group 2 (ninety-three knees), vancomycin-impregnated cement was used for fixation. All of the patients were evaluated preoperatively and intraoperatively and found to be without infection at those times. RESULTS At an average of eighty-nine months postoperatively, no deep infection had developed in the ninety-three knees in Group 2, whereas a deep infection had developed in six (7%) of the ninety knees in Group 1. This difference between Groups 1 and 2 was significant (p = 0.0130). One superficial wound infection developed in Group 1. CONCLUSIONS Vancomycin-impregnated cement was shown to be effective in the prevention of postoperative deep infection after revision total knee arthroplasty performed with antibiotic prophylaxis but not with so-called clean-air measures. This study provides preliminary evidence to justify larger trials.

Periacetabular osteotomy through a modified ollier transtrochanteric approach for treatment of painful dysplastic hips

Background: Elimination of abnormally high joint-loading resulting in excessive contact stresses may prevent or reduce the onset of osteoarthrosis in a dysplastic hip. A number of periacetabular osteotomies have been shown to be effective in restoring normal hip-joint mechanics. We treat acetabular dysplasia with a periacetabular osteotomy performed through a modified Ollier transtrochanteric approach. In this report, we describe the operative technique and the clinical and radiographic results.Methods: Thirty-six patients (thirty-eight hips) in whom a painful dysplastic hip had been treated with a periacetabular osteotomy between March 1991 and June 1999 were included in the study. There were thirty-five female patients and one male patient with a mean age (and standard deviation) at the operation of 29.42 ± 9.1 years. The technique utilizes a u-shaped skin incision, and a routine osteotomy of the greater trochanter with distal transfer if needed, and allows excellent visualization enabling the surgeon to perform the periacetabular osteotomy without penetrating the joint.Results: At a mean of five years and six months postoperatively, the mean modified Harris hip score had improved from 59.1 ± 15.8 points preoperatively to 87.97 ± 14.3 points. Radiographically, the degree of osteoarthrosis had decreased in eleven hips, remained unchanged in twenty-four, and worsened in three. The mean anterior center-edge angle had increased from 22.0° ± 12.9° to 36.1° ± 12.3°, the mean lateral center-edge angle had increased from -2.7° ± 14.4° to 26.6° ± 14.1°, the mean acetabular index angle had improved from 23.4° ± 6.6° to 12.7° ± 4.6°, and the mean acetabular head index had increased from 48.2% ± 12.7% to 73.1% ± 16.0%. The Shenton line was restored in eleven hips. Thirty patients (thirty-two hips; 84%) had a satisfactory result. A poor preoperative functional score was associated with an unsatisfactory outcome (p = 0.00191). Complications included prolonged limping (eleven hips); numbness in the distribution of the lateral femoral cutaneous nerve (four); osteonecrosis of the rotated acetabular fragment (two); and acetabulofemoral impingement, heterotopic ossification, and a defect on the rotated ilium (one hip each).Conclusions: Painful dysplastic hips should be treated before function becomes seriously impaired. We believe that periacetabular osteotomy through a modified Ollier approach, which allows osseous cuts to be made under direct vision, can be learned readily. It provides improved femoral head coverage and relief of symptoms in most painful dysplastic hips in adolescents and young adults.

Co-overexpression of cyclooxygenase-2 and microsomal prostaglandin E synthase-1 adversely affects the postoperative survival in non-small cell lung cancer.

Introduction: Cyclooxygenase (COX)-2 and microsomal prostaglandin E synthase (mPGES)-1 have been found to be overexpressed in non-small cell lung cancer (NSCLC). The aim of this study was to investigate the expression profiles of COX-2 and mPGES-1 and their correlation with the clinical characteristics and survival outcomes in patients with resected NSCLC. Methods/Results: Seventy-nine paired adjacent normal-tumor matched samples were prospectively procured from patients undergoing surgery for NSCLC. The protein levels of COX-2 and mPGES-1 were assessed by Western blot analysis. Overexpression in the tumor sample was defined as more than twofold increase in protein expression compared with the corresponding adjacent normal tissue. Co-overexpression of COX-2 and mPGES-1 were further confirmed by immunohistochemistry. COX-2 was overexpressed in 58% and mPGES-1 in 70% of the tumor samples (p < 0.0001). Co-overexpression of mPGES-1 and COX-2 was noted in 43%, and they were unrelated to each other (p = 0.232). Co-overexpression of both proteins was significantly associated with less tumor differentiation (p = 0.046), tumor size larger than 5 cm (p = 0.038), and worse survival status during the follow-up (p = 0.036). Multivariate analysis showed that in addition to overall stage, co-overexpression of both proteins adversely affected the overall (hazard ratio, 2.40; p = 0.045) and disease-free survivals (hazard ratio, 2.27; p = 0.029). Conclusions: Overexpression of either COX-2 or mPGES-1 is common but unrelated in NSCLC. Co-overexpression of both COX-2 and mPGES-1 adversely affects postoperative overall and disease-free survivals.

Clinical Implications of Microsomal Prostaglandin E Synthase-1 Overexpression in Human Non–Small-Cell Lung Cancer

BackgroundMicrosomal prostaglandin E synthase-1 (mPGES-1) has recently been found to overexpress in human cancers, including non–small-cell lung cancer (NSCLC). However, the clinical value is largely unknown. The aim of this study was to investigate the associations between mPGES-1 expression in NSCLC and the clinical characteristics and survival outcome.MethodsBetween 2001 and 2003, paired fresh tumorous and nontumorous samples were prospectively procured from patients undergoing surgery for NSCLC. The expression of mPGES-1 was assessed by using Western blot in 93 subjects and reverse transcriptase-polymerase chain reaction in 35. Overexpression of mPGES-1 was defined as a more than 2-fold expression in the tumorous sample compared with the corresponding nontumorous one. Immunohistochemistry was used to confirm its localization to the tumor cells. In a subset of 30 cases, cyclooxygenase-2 (COX-2) was also analyzed to assess its association with mPGES-1.ResultsThe protein and messenger RNA of mPGES-1 were both expressed at higher levels in the tumor samples (P < .001 and P = .006, respectively). The expressions of mPGES-1 and COX-2 were unrelated (P = .715). Overexpression of mPGES-1 protein was observed in 61 (65.6%) of 93 patients, but it was not significantly associated with the clinicopathologic characteristics or overall and disease-free survivals. However, mPGES-1 overexpression seemed to be associated with the likelihood of subsequent pulmonary metastases and a lower tendency for developing bony metastases (P = .001 and P = .006, respectively).ConclusionsOur results demonstrated that mPGES-1 was overexpressed in NSCLC, unassociated with COX-2. Overexpression of mPGES-1 per se was not a prognostic indicator, but it might be implicated in the organ preference of metastasis.

Distal linear osteotomy compared to oblique diaphyseal osteotomy in moderate to severe hallux valgus.

Background: There are no comparative studies of proximal and distal osteotomy for treatment of moderate to severe hallux valgus. Our purpose was to compare the surgical outcomes of modified proximal Ludloff (oblique diaphyseal) osteotomy with modified distal Bösch (distal linear) osteotomy by a single surgeon in moderate to severe hallux valgus. Methods: This retrospective study included feet with a hallux valgus angle greater than 30 degrees. A total of 30 feet (average age, 64.5 years) underwent Ludloff and 32 feet (average age, 61.1 years) underwent Bösch osteotomy. Both osteotomies were combined with distal soft tissue procedure. Clinical outcomes including AOFAS score and satisfaction rate were compared and radiographic parameters analyzed at 2 years of followup. Results: AOFAS scores were equivalent (p = 0.483), with comparable satisfaction rates in both groups (p = 0.418). The radiographic results including hallux valgus angle (p = 0.026), intermetatarsal angle 1-2 (p < 0.001), sesamoid position (p = 0.008), correction of intermetatarsal angle 1-2 (p < 0.001), and change of sesamoid position (p < 0.001) were significantly better in the Bösch group. Correction of hallux valgus angle (p = 0.308) and shortening of the first metatarsal (p = 0.086) were insignificant with the numbers available. Recurrence developed in eight feet of the Ludloff group and two of the Bösch group (p = 0.040). Dorsiflexion malunion occurred in four feet in the Bösch group, as compared with one in the Ludloff group. Conclusion: Our study found that distal linear osteotomy was a more reliable reconstruction with equivalent function outcomes than an oblique diaphyseal osteotomy. Additional fixation may be necessary to decrease sagittal malunion in distal Bösch osteotomy. Level of Evidence: III, Retrospective Comparative Study

Comparison of the Insall–Salvati ratio of the patella in patients with and without an ACL tear

The object of this prospective study is to compare the Insall–Salvati ratio between the patients who have an anterior cruciate ligament (ACL) tear and receive arthroscopic–assistant ACL reconstruction and the patients who have no ACL tear but do have an internal disorder of the knee and receive arthroscopic surgery. We prospectively and consecutively collected into two groups a total of 217 patients who had sport injuries and received arthroscopic surgery. The study group included 115 patients who had an ACL tear and received arthroscopic–assistant ACL reconstruction with middle-third bone–patella tendon–bone graft. The control group included 102 patients with internal disorders of the knee joint, including meniscus tear, plicae, or other chondral lesion, but without an ACL tear. We measured the patellar Insall–Salvati ratio [12] on the pre-operative X-ray films for all patients. The Insall–Salvati ratio in the ACL-tear study group is significantly smaller than the control group of internal disorders of the knee (0.99±0.11 vs 1.05±0.12, p=0.001). There is no significant difference in age, gender, the side of the involved knee, duration of symptoms, patella length and patella tendon length between the two groups. In conclusion, our study shows that patella infra has an association with ACL tears, and patella infra may be a risk factor for ACL tears. In patients with an ACL tear who had patella baja, the middle-third patellar tendon may not be an ideal graft for reconstruction.

Comparison of a minimally invasive technique with open tension band wiring for displaced transverse patellar fractures

Background: Open reduction and internal fixation with tension band wire is the standard treatment for displaced transverse patellar fractures. Recently, some minimally invasive techniques have been proposed as possible alternative methods. This retrospective study compared a newly reported percutaneous osteosynthesis with conventional open method for the treatment of displaced transverse patellar fractures. Methods: The minimally invasive technique was performed by percutaneous osteosynthesis with modified Carpenter’s (POMC) technique, using figure‐eight wiring through two‐paired cannulated screws under the control of arthroscopy and fluoroscopy. The conventional open surgery was performed with open modified anterior tension band (OMATB) technique. Totally 60 displaced transverse fractures were included in our study. Twenty were treated with percutaneous technique and 40 with open method. Outcome assessment included analysis of radiographic images, range of motion, Lysholm scores, complications, and reoperations. Results: Mean follow‐up was 37.3 months. Comparison of POMC and OMATB groups showed statistically significant results as follows: shorter surgical time, 70.4 ± 12.5 minutes for POMC group; greater degrees of flexion, 140.4 ± 6.1 for POMC group; better total range of motion, 139.6 ± 8.2 for POMC group; higher Lysholm scores, 93.6 ± 3.1 for POMC group. Frequencies of total complications and reoperations were significantly lower in POMC group. Conclusion: POMC method was a reproducibly reliable method, offering better functional outcome, lower incidence of complications, and reoperations, as compared with standard OMATB group for transverse patellar fractures. Nevertheless, it is not recommended for severely comminuted fractures.

Subtalar distraction arthrodesis using fresh-frozen allogeneic femoral head augmented with local autograft.

Background: Tricortical autograft has been commonly used in subtalar distraction arthrodesis (SDA) for severe calcaneal malunion. Structural allograft enriched with orthobiological agents is an alternative. This study was performed to evaluate the results of SDA using fresh-frozen allogeneic femoral head without the addition of orthobiological agents. Materials and Methods: We retrospectively reviewed 15 consecutive SDA procedures (13 patients) with allogeneic femoral head augmented with local autograft for the treatment of severe calcaneal malunion. Clinical outcome was evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) pain score, Short Form-12 (SF-12), range of motion (ROM) of the ankle joint, and patient satisfaction rate. Radiographic assessment included the talar declination angle (TDA), calcaneal inclination angle (CIA), lateral talocalcaneal angle (LTCA), heel height, calcaneal length, and union time. Results: At a median follow-up of 36.0 months (range, 24-47 months), all 15 feet (100%) achieved union, at a median of 13.0 weeks (range, 12-18 weeks). The AOFAS score and VAS pain score improved significantly, with a satisfaction rate of 93.3%. The TDA, CIA, LTCA, and heel height improved significantly. The median increase in heel height was 8.6 mm (range, 1.9-20.1 mm). There was a significant reduction in calcaneal length. Complications included 1 varus malalignment, 1 complex regional pain syndrome, 1 hardware irritation, and 1 sural neuralgia. Conclusion: This study found that SDA using fresh-frozen femoral head allograft without an orthobiological agent was cost-effective and may have outcomes comparable to those using autograft or allograft enriched with orthobiological agents. Level of Evidence: Level IV, retrospective case series.