Kuo-Yao Hsu

Gram-negative Prosthetic Joint Infections: Risk Factors and Outcome of Treatment

BACKGROUNDnLittle information is available regarding the demographic characteristics and outcomes of patients with prosthetic joint infection (PJI) resulting from gram-negative (GN) organisms, compared with patients with PJI resulting from gram-positive (GP) organisms.nnnMETHODSnWe performed a retrospective cohort analysis of all cases of PJI that were treated at our institution during the period from 2000 through 2006.nnnRESULTSnGN microorganisms were involved in 53 (15%) of 346 first-time episodes of PJI, and Pseudomonas aeruginosa was the most commonly isolated pathogen (21 [40%] of the 53 episodes). Patients with GN PJI were older (median age, 68 vs. 59 years; P<.001) and developed infection earlier (median joint age, 74 vs. 109 days; P<.001) than those with GP PJI. Of the 53 episodes of GN PJI, 27 (51%) were treated with debridement, 16 (30%) with 2-stage exchange arthroplasty, and 10 (19%) with resection arthroplasty. Treating GN PJI with debridement was associated with a lower 2-year cumulative probability of success than treating GP PJI with debridement (27% vs. 47% of episodes were successfully treated; P=.002); no difference was found when a PJI was treated with 2-stage exchange or resection arthroplasty. A longer duration of symptoms before treatment with debridement was associated with treatment failure for GN PJI, compared with for GP PJI (median duration of symptoms, 11 vs. 5 days; P=.02).nnnCONCLUSIONSnGN PJI represents a substantial proportion of all occurrences of PJI. Debridement alone has a high failure rate and should not be attempted when the duration of symptoms is long. Resection of the prosthesis, with or without subsequent reimplantation, as a result of GN PJI is associated with a favorable outcome rate that is comparable to that associated with PJI due to GP pathogens.

Total Knee Arthroplasty in Patients with Liver Cirrhosis

BACKGROUNDnPatients with liver cirrhosis have an increased risk of surgical morbidity and mortality. We are aware of no study that has investigated the risks and outcomes of elective orthopaedic procedures in these patients. The purposes of the present study were to review the results of total knee arthroplasty in patients with cirrhosis and to identify risk factors leading to poor results.nnnMETHODSnFifty-one patients with cirrhosis who had undergone sixty total knee arthroplasties for osteoarthritis were studied. The medical records and laboratory data were collected retrospectively. All data were compared with those for matched patients without cirrhosis. Forty-two patients (fifty-one knees) with complete follow-up were evaluated with regard to complications, mortality, and factors leading to poor results.nnnRESULTSnTotal knee arthroplasty was associated with significantly more blood loss, a longer hospital stay, more complications, and a higher mortality rate in patients with cirrhosis as compared with control patients (p </= 0.006 for all). Twenty-six complications occurred in twenty patients (twenty-two knees). Logistic regression analysis showed that a history of hepatic decompensation or variceal bleeding was an independent predictor of complications. Infection was the most common complication (prevalence, 21%). Age, platelet count, and hepatitis-B-related cirrhosis were independent predictors of infection. There were no perioperative deaths. Fifteen patients died at a mean of forty-three months after total knee arthroplasty; two deaths were related to the procedure. The presence of a hepatoma was found to be a significant predictor of mortality (p < 0.001).nnnCONCLUSIONSnThe rate of complications after total knee arthroplasty was significantly higher in patients with cirrhosis than in control patients (p < 0.001). We believe that total knee arthroplasty should not be performed in patients with a history of hepatic decompensation or variceal bleeding. The risk of infection was high in older patients, patients with a low platelet count, and patients in whom the cirrhosis was related to the hepatitis-B virus. Aggressive prophylaxis against infection should be performed. Patients with Child class-A cirrhosis without these risk factors may do well following a total knee arthroplasty. The benefit of total knee arthroplasty should be cautiously weighed against its potential risks in patients with cirrhosis.

Video-assisted thoracoscopic treatment of spinal lesions in the thoracolumbar junction

AbstractBackground: The endoscopic treatment of spinal lesions in the thoracolumbar junction (T11–L2) poses a great challenge to the surgeon. From November 1, 1995 to December 31, 1996, we successfully used a combination of video-assisted thoracoscopy and conventional spinal instruments to treat 38 patients with anterior spinal lesions. Twelve of them had lesions in the thoracolumbar junction.n Methods: The so-called extended manipulating channel method was used to perform vertebral biopsy, discectomy, decompressive corpectomy, interbody fusions, and/or internal fixations in these patients. The size of the thoracoscopic portals was greater than usual in order to allow conventional spinal instruments and a thoracoscope to enter the chest cavity freely and be manipulated by techniques similar to those used in standard open surgical procedures. In this series, the procedures were performed by using either a three-portal approach (2.5–3.5 cm) or a modified two-portal technique involving a 5–6 cm larger incision and a small one for introducing the scope.n Results: None of the operations resulted in injury to the great vessels, internal organs, or spinal cord. The total time for the operation ranged from 1.5 to 4.5 h (average, 3); and the total blood loss ranged from 50 to 3000 cc (average, 1050). One patient was converted to an open procedure due to severe pleural adhesion. Complications included two instances of transient intercostal neuralgia, one superfical wound infection, and one residual pneumothorax.n Conclusions: The video-assisted technique with the extended manipulating channel method presented in this report simplifies thoracoscopic spinal surgery in the thoracolumbar junction and makes it easier. It avoids division of the diaphragm, removal of the rib, and wide spread of the intercostal space, and it allows greater control of intraoperative vessel bleeding. Using this technique, the number of portals required during the procedure can be reduced. In addition, the technique reduces the endoscopic materials required, thus lowering overall cost. It is an effective and promising approach.

Video-assisted thoracoscopic surgery to the upper thoracic spine

AbstractBackground: The standard open technique for exposure of the upper thoracic spine, T1–T4, usually requires a difficult thoracotomy. From November 1, 1995 to June 30, 1997, eight patients underwent video-assisted thoracoscopic spinal surgery in our institute to treat their upper thoracic spinal lesions endoscopically.n Methods: A new approach, the so-called ``extended manipulating channel method, was used in this series that allows the combined use of video-assisted thoracoscopy and conventional spinal instruments to enter the chest cavity freely for the procedures. Patients ages ranged from 44 to 89 years (average, 60 years). Definitive diagnoses included two pyogenic spondylitis and six spinal metastases. Five patients presented initially with myelopathy.n Results: There were no deaths or neurologic injuries associated with this technique. The mean surgical time was 3.1 h. The mean duration of chest tube retention was 3.3 days. The mean total blood loss was 1,038 ml, and two patients had a blood loss of more than 2,000 ml owing to bleeding from epidural veins or raw osseous surfaces. Complications included one superficial wound infection and one subcutaneous emphysema that resolved spontaneously. In this series, there was no need of conversion to open thoracotomy for the patients.n Conclusions: The thoracoscopy-assisted spinal technique using the extended manipulating channels, usually 2.5–3.5 cm, allows variable instrument angulations for manipulation. The mean surgical time (3.1 h) was considered no longer than for an open technique for the equivalent anterior procedure. Such an approach can achieve less procedure-related trauma and has proved to be a good alternative to other treatment modalities.

Analysis of techniques for video-assisted thoracoscopic internal fixation of the spine

Between November 1, 1995, and January 31, 1996, four separate thoracoscopic spinal fixation surgeries were performed via extended manipulating channels using the so-called three-portal technique. The diagnoses included three spinal metastases and one T11 burst fracture. All patients had myelopathy at presentation. Using the three-portal technique, the conventional spinal instruments and fixation devices could be passed freely through the extended manipulating channels (usually 3–4 cm) into the chest cavity and manipulated by techniques similar to those used in standard open procedures. A reduction-fixation spinal plate with variable screw and plate anchoring angles was successfully inserted in the procedures. The total length of the operation ranged from 3.5 to 5 h (average 4.3 h), and the total blood loss was 1000–2500 ml (average 1500 ml). There were no intraoperative deaths, and no patient showed neurological deterioration following the procedures. On the basis of these results, we believe that the combination of video-assisted thoracoscopy and conventional spinal instruments presented in this report would be an ideal method for performing these procedures. Throughout the operation, only one trocar was employed for introducing the thoracoscope. The thoracoports were used temporarily during tumor tissue retrievals. This technique makes thoracoscopy-assisted spinal fixation simple and easy. It allows greater control of intraoperative vessel bleeding and reduces the number of portals required during the procedure (on average to 3). In addition, the technique reduced the amount of endoscopic materials required for the procedure, thus reducing the cost of treatment.

Correction of foot deformity by the Ilizarov method in a patient with Segawa disease.

Hereditary progressive dystonia, or Segawa disease, is rare. Diagnosis depends on typical clinical features with normal laboratory findings. It responds well to levodopa treatment. This article contains a case report of a patient with Segawa disease with a fixed equinovarus foot. A 21-year-old woman was diagnosed with Segawa disease since she was 8 years old; she became wheelchair dependent at the age of 15. The dystonia responded well to levodopa, except for the fixed-foot deformity. The deformity was corrected successfully by the Ilizarov method. The patient returned to independent ambulation after surgery. Because similar types of foot deformities appeared in several progressive degenerative neurologic diseases, the treatable Segawa disease should be added to the list of differential diagnoses of progressive degenerative neurologic diseases with talipes equinovarus.

Shoulder ultrasonography performed by orthopedic surgeons increases efficiency in diagnosis of rotator cuff tears

BackgroundRotator cuff tears are very common and their incidence increases with age. Shoulder ultrasonography has recently gained popularity in detecting rotator cuff tears because of its efficiency, cost-effectiveness, time-saving, and real-time nature of the procedure. Well-trained orthopedic surgeons may utilize shoulder ultrasonography to diagnose rotator cuff tears. The wait time of patients planned to have shoulder MRI (magnetic resonance imaging) to rule in rotator cuff tears may decrease after orthopedic surgeon start doing shoulder ultrasonography as a screening tool for that. Patients with rotator cuff tears may be detected earlier by ultrasonography and have expedited surgical repair. The efficacy in determination of rotator cuff tears will also increase.MethodsPatients were retrospectively reviewed from January 2007 to December 2012. They were divided into 2 groups: Ultrasound (-) group and the Ultrasound (+) group. Age, gender, wait time from outpatient department (OPD) visit to MRI exam, MRI exam to operation (OP), and OPD visit to OP, patient number for MRI exam, and number of patients who finally had rotator cuff repair within two groups were compared.ResultsThe wait time of OPD visit to OP and MRI to OP in patients who received shoulder ultrasonography was significantly less than that in patients did not receive shoulder ultrasonography screening. Only 23.8% of the patients with a suspected rotator cuff injury undergone arthroscopic rotator cuff repair before ultrasonography was applied as a screening tool. The percentage increased to 53.6% after orthopedic surgeon started using ultrasonography as a screening tool for rotator cuff tears.ConclusionsOffice-based shoulder ultrasound examination can reduce the wait time for a shoulder MRI. The efficacy of determination of rotator cuff tears will also increase after the introduction of shoulder ultrasonography.

Outcomes and second-look arthroscopic evaluation after combined arthroscopic treatment of tibial plateau and tibial eminence avulsion fractures: a 5-year minimal follow-up

BackgroundTibial eminence avulsion fracture often co-occurs with tibial plateau fracture, which leads to difficult concomitant management. The value of simultaneous arthroscopy-assisted treatment continues to be debated despite its theoretical advantages. We describe a simple arthroscopic suture fixation technique and hypothesize that simultaneous treatment is beneficial.MethodsPatients with a tibial eminence avulsion fracture and a concurrent tibial plateau fracture who underwent simultaneous arthroscopically assisted treatment between 2005 and 2008 were enrolled in this retrospective study. Second-look arthroscopic evaluation and Rasmussen scores of clinical and radiographic parameters were used to assess simultaneous treatment.ResultsForty-one patients (41 knees) met the inclusion criteria. All 41 fractures were successfully united. All patients had side-to-side differences of less than 3xa0mm and negative findings in Lachman and pivot-shift tests at their final follow-up. The mean postoperative Rasmussen clinical score was 27.3 (range: 19–30), and the mean radiologic score was 16.5 (range: 12–18). Clinical and radiographic outcomes in 98xa0% of the patients were good or excellent. There were no complications directly associated with arthroscopy in any patient.ConclusionsSimultaneous arthroscopic suture fixation of associated tibial eminence avulsion fracture did not interfere with the plates and screws used to stabilize the tibial plateau fracture. It gave the knee joint adequate stability, minimal surgical morbidity, and satisfactory radiographic and clinical outcomes in a minimum follow-up of 5xa0years and in the arthroscopic second-look assessments.

Mid-term survivorship of cruciate-retaining versus posterior-stabilized total knee arthroplasty using modular mini-keel tibial implants

BackgroundReports of diverse outcomes in modular mini-keel tibial componentry for total knee arthroplasty (TKA) have raised concerns about early aseptic loosening. Cruciate-retaining (CR) prostheses, using mini-keel implants, have yet to be reported and compared to posterior-stabilizing (PS) designs.MethodsA retrospective, case-matched study of 91 consecutive TKAs (nu2009=u200946 CR; nu2009=u200945 PS prostheses), using modular mini-keel tibial componentry with a 45-mm drop down stem extension, was conducted. The Knee Society Score functional survey, radiographic analysis including alignment and periprosthetic radiolucency, TKA prosthesis longevity, and surgical complications were reported and compared between CR and PS groups.ResultsThe Knee Society Score at 5-year follow-up averaged 81.67u2009±u200911.97 and 80.12u2009±u200914.16 in the CR and PS groups, respectively (pu2009=u20090.29). The femorotibial angle averaged 5.85°u2009±u20092.62° and 5.85°u2009±u20093.27° valgus in the CR and PS groups, respectively (pu2009=u20090.60). The average tibial component angle was 0.46°u2009±u20091.6° and 0.61°u2009±u20091.3° varus in the CR and PS groups, respectively (pu2009=u20090.30); posterior inclination averaged 2.28°u2009±u20092.36° and 1.93°u2009±u20092.72° in the CR and PS groups, respectively (pu2009=u20090.51). Radiolucency was noted in 17 zones of the CR group and in 9 zones of the PS group (pu2009=u20090.24). Three TKAs required further surgery: one locking plate fixation for a periprosthetic tibial fracture (PS group) and two revision TKAs (one CR infection and one PS fracture).ConclusionModular mini-keel tibial components showed good reliability and results with both CR and PS prostheses in minimally invasive surgery TKA.