Liang-Tseng Kuo

Prognostic factors and monomicrobial necrotizing fasciitis: gram-positive versus gram-negative pathogens.

BackgroundMonomicrobial necrotizing fasciitis is rapidly progressive and life-threatening. This study was undertaken to ascertain whether the clinical presentation and outcome for patients with this disease differ for those infected with a gram-positive as compared to gram-negative pathogen.MethodsForty-six patients with monomicrobial necrotizing fasciitis were examined retrospectively from November 2002 to January 2008. All patients received adequate broad-spectrum antibiotic therapy, aggressive resuscitation, prompt radical debridement and adjuvant hyperbaric oxygen therapy. Eleven patients were infected with a gram-positive pathogen (Group 1) and 35 patients with a gram-negative pathogen (Group 2).ResultsGroup 2 was characterized by a higher incidence of hemorrhagic bullae and septic shock, higher APACHE II scores at 24 h post-admission, a higher rate of thrombocytopenia, and a higher prevalence of chronic liver dysfunction. Gouty arthritis was more prevalent in Group 1. For non-survivors, the incidences of chronic liver dysfunction, chronic renal failure and thrombocytopenia were higher in comparison with those for survivors. Lower level of serum albumin was also demonstrated in the non-survivors as compared to those in survivors.ConclusionsPre-existing chronic liver dysfunction, chronic renal failure, thrombocytopenia and hypoalbuminemia, and post-operative dependence on mechanical ventilation represent poor prognostic factors in monomicrobial necrotizing fasciitis. Patients with gram-negative monobacterial necrotizing fasciitis present with more fulminant sepsis.

Computed Tomography Evaluation in Total Knee Arthroplasty: Computer-Assisted Navigation Versus Conventional Instrumentation in Patients With Advanced Valgus Arthritic Knees

Arthritic knees with advanced valgus deformity present with soft tissue and osseous anomalies that make total knee arthroplasty (TKA) difficult. We conducted a retrospective chart review of 41 patients (51 knees) to determine whether computer-assisted surgery-TKA (CAS-TKA) is superior to TKA using conventional guiding systems. A significantly higher rate of lateral retinaculum release as well as outlier of sagittal mechanical axes and position of the femoral component (femoral flexion and femoral rotational angle) was recorded in the conventional TKA group versus the CAS-TKA group. Both groups had significant postoperative improvement in clinical performance, but results did not differ significantly between groups. Despite its radiographic benefit, CAS-TKA showed no significant benefit over TKA in short-term clinical functional outcomes when performed by an experienced surgeon.

The effect of endoskeleton on antibiotic impregnated cement spacer for treating deep hip infection

BackgroundsA two-stage revision arthroplasty was suggested optimal treatment for deep infections in hip joint. The effect of endoskeleton of cement spacers on the interim function and infection control remains unclear.MethodsFrom Jan. 2004 to Dec. 2007, we collected a prospective cohort of consecutive 34 patients who treated with two-stage revision total hip arthroplasty for deep infection of hip joint. In group 1, fifteen patients were treated by a novel design augmented with hip compression screw while nineteen patients were treated by traditional design in group 2.ResultsNo fracture of cement spacer occurred in group 1 while 6 cases developed spacer failure in group 2. (p < 0.05) There were significant differences in bodily pain and general health perception between groups (p < 0.05).ConclusionsPatients being treated for deep infection of hip joint using cement spacer augmented with stronger endoskeleton have lower pain levels and better joint function between stages.

The Computer-Aided-Surgery Improved the Accuracy of Femoral Component Rotation in Total Knee Arthroplasty for the Advanced Osteoarthritis with Valgus Deformity

Purpose: Arthritic knees with genu valgus deformity present with soft tissue and osseous anomalies that make Total Knee Arthroplasty (TKA) difficult. We retrospectively investigate whether advanced valgus deformity would benefit from Computer-Aided Surgery-TKA (CAS-TKA). Materials and methods: From January 2003 to September 2011, twenty-six patients having osteoarthritis with valgus deformity in the mechanical axis more than 10 degrees who underwent CAS-TKA were entered into this retrospective study. The usefulness of CAS-TKA was analyzed by the accuracy of placement of the components and postoperative alignment determined using radiographic parameters and Computed Tomography (CT). The Hospital for Special Surgery (HSS) and International Knee Society (IKS) functional scores were obtained for all patients preoperatively and postoperatively. Results: The mean postoperative mechanical axis was 181° (range, 176°-181°). The CT revealed proper femoral and tibial rotational alignment. The joint line was not substantially elevated. No patient required conversion to a constrained TKA to achieve stability. At a mean follow-up of 43 months, the Hospital for Special Surgery (HSS) knee score improved from a mean preoperative score of 54 to 92 postoperatively. The International Knee Society (IKS) clinical score improved from 38 to 97. The IKS for pain improved from 15 to 48, and the IKS knee function score improved from 32 to 96. The active range of motion from 95° to 115°. Conclusions: Computer-aided surgery-TKA is a useful alternative technique for advanced valgus knee arthritis where accurate restoration of the joint line, proper alignment of the limb and prosthetic components in coronal, sagittal and axial plane may be challenging because of bony deformities and soft tissue contractures.

Epinephrine in irrigation fluid for visual clarity in arthroscopic shoulder surgery: a systematic review and meta-analysis

PurposeTo investigate whether epinephrine in irrigation fluid improves visual clarity in arthroscopic shoulder surgery.MethodsWe performed a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared the surgical outcomes of patients who did and did not receive epinephrine during arthroscopic shoulder surgery. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for relevant RCTs. We used the Cochrane Collaboration’s tool to assess the risk of bias and adopted random-effects model meta-analysis to combine data. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to evaluate the overall quality of the body of the retrieved evidence. The primary outcome was visual clarity. The secondary outcomes were operative time, amount of irrigation fluid, the need for increased pump pressure, and adverse cardiovascular events.ResultsThis study included three RCTs with a total of 238 participants (124 in the epinephrine group and 114 in the non-epinephrine group). The use of epinephrine in irrigation fluid for shoulder arthroscopy achieved better visual clarity (standardized mean difference, 1.01; 95% confidence interval [CI] 0.63 to 1.39; p < 0.0001) and less need for increased pump pressure (risk ratio, 0.40; 95% CI 0.25 to 0.64; p = 0.0001) compared to the non-epinephrine group. No significant differences were noted in operative time (mean difference − 5.08; 95% CI − 14.46 to 4.31; p = 0.29) and amount of irrigation fluid (mean difference − 1.04; 95% CI − 2.38 to 0.39; p = 0.12) between the two groups. No adverse events were recorded in any of the included trials.ConclusionsThe current evidence shows that the use of epinephrine in arthroscopic shoulder surgery may improve visualization and does not appear to have any major disadvantages.Level of evidenceLevel I

Effect of Extracorporeal Shockwave Therapy on Passive Ankle Stiffness in Patients With Plantar Fasciopathy

ABSTRACT Plantar fasciopathy (PF) is the most common cause of heel pain. Extracorporeal shockwave therapy (ESWT) improves the gait pattern in patients with PF. However, the effects of ESWT on the biomechanics of the ankle in these patients remains unclear. Sixteen participants were included in the present study. Of the 16 participants, 8 patients with PF were assigned to receive extracorporeal shockwave therapy, and 8 healthy participants served as an external control group. ESWT was applied to the PF group for 1500 pulses at an energy flux of 0.26 mJ/mm2 every 3 weeks for 3 sessions. The biomechanics of the ankle joints were then assessed using an isokinetic dynamometer, and a health‐related quality of life questionnaire was administered at baseline and at the final follow‐up session 12 weeks after the initial treatment. Passive stiffness was calculated and compared between the foot affected with PF, the opposite foot, and both feet of those in the healthy control group. The Kruskal‐Wallis 1‐way analysis of variance with repeated measures was performed, and statistical significance was considered present at the 5% (p ≤ .05) level. Ankle dorsiflexion in the affected limb increased from 14° ± 3° to 17° ± 2° after ESWT (p < .05). No statistically significant differences were noted in the strength of dorsiflexion or plantarflexion at baseline and after ESWT. However, a statistically significant increase in the ratio of strength in ankle dorsiflexion versus plantarflexion was found after ESWT (p < .05). No differences in the passive stiffness of the ankle joint were demonstrated. Patients reported an improved physical function score after ESWT (p < .05). An increased dorsiflexion/plantarflexion torque ratio and maximal dorsiflexion associated with decreased pain might contribute to the improved physical function after ESWT for PF. Level of Clinical Evidence: 4

Bone marrow-stimulating techniques in arthroscopic rotator cuff repair: a systematic review protocol

Introduction Bone marrow-stimulating (BMS) techniques during arthroscopic rotator cuff repair surgery theoretically enhance the biological component for healing and hence improve tendon healing, but their efficacy remains unproven. The purpose of this review is to determine the effects and associated harms of BMS in arthroscopic rotator cuff repair surgery. Methods and analysis We will perform a systematic review and meta-analysis of randomised-controlled trials (RCTs) and retrospective cohort studies (RCS) that compare outcomes following BMS use against no use of BMS during arthroscopic rotator cuff repair surgery. We will search the databases including the Cochrane Central Register of Controlled Trials, Medline and Embase, and clinical trial registries for relevant studies. We will include studies published from start of indexing until 23 August 2018. Two reviewers will independently assess the eligibility for studies. For each included trial, we will conduct duplicate independent data extraction and risk of bias assessment. We will use the Cochrane Collaboration tool to assess the risk of bias of included RCTs, while we will use the Risk Of Bias In Non-randomised Studies - of Interventions tool to evaluate the risk of bias of RCS. We will perform a random-effects meta-analysis in calculating the pooled risk estimates when appropriate. We will assess the overall quality of the data for each individual outcome using the Grading of Recommendations, Assessments, Development and Evaluation approach. The primary outcomes are tendon healing rate, overall pain and shoulder functions. The secondary outcomes are the proportion of participants with adverse events related to interventions, the range of motion and the proportion of participants with return to previous activities. Ethics and dissemination We will report this review according to the guidance of the PRISMA statement. The results of this review will be disseminated through conference presentations and publications in peer-reviewed journals. PROSPERO registration number CRD42018087161.

Chronic kidney disease is associated with a risk of higher mortality following total knee arthroplasty in diabetic patients: a nationwide population-based study

Diabetes and chronic kidney disease (CKD) are associated with a higher rate of complications in patients undergoing total knee arthroplasty (TKA). The purpose of this study was to determine the effects of CKD and diabetes in patients after TKA. Diabetic patients who received unilateral primary TKA between January 2008 and December 2011 were enrolled. The follow-up period was more than 6 months. The primary outcome was a TKA-related infection and the secondary outcome was all-cause mortality. The study cohort included 13844 patients who were followed for a mean period of 2 years, of whom 1459 (10.5%) had CKD. The patients with CKD were older than those without CKD (71.6 versus 70.3 years, P<0.0001) and had higher rates of hypertension, gouty arthritis, ischemic heart disease, chronic pulmonary obstructive disease, pulmonary embolism and deep vein thrombosis (all P<0.0001). After adjustment of comorbidities, the CKD group had a higher incidence of urinary tract infections (OR: 1.61, 95% CI: 1.19-2.17). There were no significant differences in wound infections, pneumonia, pulmonary embolism or in-hospital death between the two groups. After adjustment of confounders, the CKD group had higher rates of myocardial infarction (HR: 2.06, 95% CI: 1.26–3.39) and mortality (HR: 1.99, 95% CI: 1.59–2.48). The risk of TKA-related infection during follow-up was comparable between the two groups (HR: 1.31, 95% CI: 0.94–1.82). In conclusion, CKD is associated with increased risks of urinary tract infections, myocardial infarction and all-cause mortality after TKA. Surgeons should be aware of this when evaluating TKA patients with renal disease.

Total Knee Arthroplasty Using Computer-assisted Navigation for Osteoarthritic Knees in Conjunction with Excessive Coronal Femoral Bowing Deformity

Background: The value of computer-assisted surgery-total knee arthroplasty (CAS-TKA) for osteoarthritic knees with excessive coronal femoral bowing deformity continues to be debated. We hypothesized that computer-assisted navigation may be beneficial when the coronal bowing deformity is severe.Methods: Patients with osteoarthritic knees in conjunction with excessive coronal femoral bowing deformity (＞ 5° by the Mullaji method) who underwent CAS-TKA were enrolled in this retrospective study. The usefulness of computer-assisted navigation was analyzed by the accuracy of placement of the components and postoperative alignment determined by five radiographic parameters. The Hospital for Special Surgery (HSS) and International Knee Society (IKS) functional scores were obtained for all patients preoperatively and postoperatively. Results: From January 2005 to December 2010, eighty-three patients (83 knees) met the inclusion criteria. Of these, eighty-one patients (97.6%) achieved the targeted goal of a leg axis within 3° of the neutral axis. There was a significant improvement between the preoperative and postoperative mechanical axes (164 ± 4° vs. 179 ± 2°, p ＜ 0.001). After a mean follow-up of 50 months, improvements in the IKS pain score, IKS clinical knee score, IKS functional knee score, and the HSS knee score were noted. Conclusions: Computer-assisted navigation was a valuable adjunct for obtaining proper alignment in patients with excessive coronal femoral bowing deformity, in whom accurate placement of components and restoration of the mechanical axis may be challenging.