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Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 288 - 288
1 Mar 2013
Oe K Okamoto N Asada T Nakamura T Wada T Iida H
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Introduction

It is still controversial whether one or two-stage revision should be indicated for deeply infected hip prosthesis, and there are no scoring systems for the decision of them. An assessment system for the treatment of deeply infected hip prosthesis was evaluated for the patients who had undergone one or two-stage revision total hip arthroplasty (THA).

Materials and Methods

Between February 2001 and November 2009, revision THA for deep infection was carried out in 60 hips on 59 patients by the senior authors. Nineteen hips underwent one-stage revision THA using antibiotic-loaded acrylic cement (ALAC), and 41 hips did two-stage revision THA using ALAC beads, based on the criteria by Jackson and Schmalzried. This study included 47 revisions in 47 patients for which a minimum follow-up of two years (average 4.7 years). Six parameters were employed in the assessment system: 1) general condition, 2) duration of infection, 3) wound complication after initial operation, 4) microorganism, 5) C-reactive protein (CRP), and 6) necessity for grafting bone. Each parameter ranged from 0 to 2 points, giving a full score of 12 points. Healing was defined as the lack of clinical signs and symptoms of infection, a CRP level < 10 mg/l or an erythrocyte sedimentation rate < 20 mm/h, and the absence or radiological signs of infection at the follow-up visit > 24 months after first revision, described by Giulieri et al.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_VIII | Pages 23 - 23
1 Mar 2012
Nagoya S Okazaki S Tateda K Nagao M Wada T Kukita Y Kaya M Sasaki M Kosukegawa I Yamashita T
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Introduction

The purpose of this study was to evaluate the outcome of vascularized iliac bone grafting for idiopathic osteonecrosis of the femoral head.

Methods

We reviewed the clinical and radiological results of 35 operations performed on 29 patients who had osteonecrosis of the femoral head (ONFH) in which a pedicle iliac bone grafting was performed for minimum follow-up of 10 years. The average age was 35 years (range, 17 to 62 years). According to the Japanese Orthopaedic Association classification for ONFH, there were 28 stage 2, 7 stage 3-A, 17 type C-1 hips, and 18 type C-2 hips. After a bone tunnel of 1.5 × 5 cm was made in the anterior aspect of the femoral head and curettage of necrotic lesion was performed, the pedicle bone with the deep circumflex iliac artery (DCIA) was inserted into the anterolateral portion of the femoral head. The average follow-up period was 13 years and 6 months. Weight bearing was not allowed for 2 months after the operation. Survival rate of the femoral head was calculated by Kaplan-Meier methods, and collapse of the femoral head and configuration of the femoral head was investigated at final follow-up.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 162 - 162
1 Mar 2010
Oe K Wada T Ohno H Komuro H Kushida T Iida H
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The treatment of rheumatoid arthritis (RA) has recently seen a paradigm shift with the introduction of biologic therapy, but there is concern that this will result in an increased incidence of infection. The occurrence of infection in RA patients who have undergone biologic therapy has recently been documented in a few reports, but this is the first report of Salmonella infection after total knee arthroplasty (TKA) in a RA patient receiving etanercept therapy. Here we report the successful treatment of a rare case of Salmonella septic arthritis.

A 61-year-old man with a 4-year history of RA was treated with methylprednisolone and methotrexate, and he consulted us because of right gonalgia. Treatment with infliximab was started, but as this was not effective, his medication was changed sequentially to etanercept 6 months later. Finally, TKA was performed on the right knee with antibiotic-loaded acryl cement (ALAC). The postoperative course was uneventful, etanercept was administered routinely from the 2nd postoperative week. The patient was discharged after 4 weeks. Five weeks after TKA, however, the patient visited us because of acute swelling and tenderness around the right knee. His laboratory values included a white blood cell count of 9300/mm3, an erythrocyte sedimentation rate of 81.0 mm/h and a C-reactive protein level of 11.3 mg/dl. Fluid obtained by joint aspiration was cloudy and dark-yellow, and prosthetic joint infection was diagnosed. The patient underwent emergency debridement by arthroscopic surgery, followed immediately by injection of 0.5 g carbapenem every 12 hours and continuous closed irrigation-suction of the joint for 2 weeks. Culture of the joint fluid revealed Salmonella enteritidis infection, which was not sensitive to aminoglycoside which we used as ALAC. The patient was treated with intravenous carbapenem for 3 weeks, oral levofloxacin at a daily dose of 300 mg for 2 weeks successively, and oral minocycline at 200 mg daily for 3 months. At follow-up 12 months after surgery, physical and blood examinations and plain radiographs demonstrated no recurrence of the infection, and the patient has resumed taking etanercept. The range of flexion in the treated knee is 0 to 145 degrees.

Salmonella arthritis is classified as septic arthritis and reactive arthritis, and septic arthritis is more likely if Salmonella is identified by culture of joint fluid. Salmonella septic arthritis has not been considered an intraoperative contaminant during joint replacement. Recently, it has become apparent that biologic therapies can play major roles in the pathogenesis of RA, and also that immuno-suppressive drugs may become risk factors for Salmonella septic arthritis. In conclusion, our patient had a successful outcome after prompt debridement and treatment with appropriate antibiotics, without the need for implant removal. It is important to be mindful of the possibility of infection and to carry out surgery immediately if a patient presents with symptoms after biologic therapy.


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 6 | Pages 784 - 788
1 Jun 2009
Kaya M Wada T Nagoya S Sasaki M Matsumura T Yamashita T

We undertook a prospective study to evaluate the prognostic significance of the serum levels of vascular endothelial growth factor (VEGF) in predicting the survival of patients with osteosarcoma. The levels were measured by an enzyme-linked immunosorbent assay in 15 patients with osteosarcoma before commencing treatment. The patients were divided into two groups, with a high or a low serum VEGF level, and the incidence of metastases and overall survival rate were compared.

No significant relationship was observed between the serum VEGF levels and gender, age, the size of the tumour or the response to pre-operative chemotherapy. Patients with a serum VEGF > 1000 pg/ml had significantly worse survival than those with a level < 1000 pg/ml (p = 0.002). The serum VEGF level may be useful in predicting the prognosis for survival in patients with osteosarcoma.


The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 7 | Pages 924 - 928
1 Jul 2008
Tsuchiya H Shirai T Morsy AF Sakayama K Wada T Kusuzaki K Sugita T Tomita K

We studied the safety of external fixation during post-operative chemotherapy in 28 patients who had undergone distraction osteogenesis (17, group A) or vascularised fibular grafting (11, group B) after resection of a tumour. Four cycles of multi-agent post-operative chemotherapy were administered over a mean period of 14 weeks (6 to 27). The mean duration of external fixation for all patients was 350 days (91 to 828). In total 204 wires and 240 half pins were used.

During the period of post-operative chemotherapy, 14 patients (11 in group A, 3 in group B) developed wire- and pin-track infection. A total of ten wires (4.9%) and 11 half pins (4.6%) became infected. Seven of the ten infected wires were in periarticular locations.

External fixation during post-operative chemotherapy was used safely and successfully for fixation of a vascularised fibular graft and distraction osteogenesis in 27 of 28 patients. Post-operative chemotherapy for malignant bone tumours did not adversely affect the ability to achieve union or cause hypertrophy of the vascularised fibular graft and had a minimal effect on distraction osteogenesis. Only one patient developed osteomyelitis which required further surgery.


The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 5 | Pages 659 - 663
1 May 2007
Wada T Kawai A Ihara K Sasaki M Sonoda T Imaeda T Yamashita T

We evaluated the construct validity of the Musculoskeletal Tumour Society rating scale (Enneking score) as a functional measure for patients with sarcoma involving the upper limb. We compared the Enneking score by examining the correlation between two patient-derived outcome measures, the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Medical Outcomes Study Short Form-36 (SF-36) as indicators of functional status in 40 patients with malignant or aggressive benign bone and soft-tissue tumours of the upper limb who had undergone surgical treatment.

The frequency distributions were similar among the three scoring systems. As for the validity, Spearman’s rank correlation coefficient of the Enneking score to the DASH questionnaire was −0.79 and that of the Enneking to the SF-36 subscales ranged from 0.38 to 0.60. Despite being a measure from the surgeon’s perspective, the Enneking score was shown to be a valid indicator of physical disability in patients with malignant or aggressive benign tumours of the upper limb and reflected their opinion.


The Journal of Bone & Joint Surgery British Volume
Vol. 86-B, Issue 1 | Pages 143 - 147
1 Jan 2004
Kaya M Wada T Nagoya S Kawaguchi S Isu K Yamashita T

Concomitant tumour resistance (CTR) is a unique phenomenon in which animals harbouring large primary tumours are resistant to the growth of smaller metastatic tumours by systemic angiogenic suppression. To examine this clinically, in ten patients with osteosarcoma, we investigated the effects of removal of the primary tumour on the development of pulmonary metastases, the systemic angiogenesis-inducing ability and the serum levels of several angiogenesis modulators.

We found that removal of the primary tumour significantly elevated systemic angiogenesis-inducing ability in five patients who had post-operative recurrence of the tumour. Post-operative elevation of the angiogenesis-induced ability was suppressed by the addition of an angiogenic inhibitor, endostatin. Also, primary removal of the tumour decreased the serum levels of vascular endothelial growth factor and endostatin.

These findings suggest, for the first time, the presence of CTR in patients with osteosarcoma for whom postoperative antiangiogenic therapy may be used to prevent the post-operative progression of micrometastases.


The Journal of Bone & Joint Surgery British Volume
Vol. 82-B, Issue 8 | Pages 1121 - 1124
1 Nov 2000
Nagoya S Usui M Wada T Yamashita T Ishii S

We treated four patients with periacetabular malignant tumours by pelvic reconstruction with a free vascularised fibular graft after resection of the tumour. The mean follow-up period was 32 months (9 to 39). The diagnosis was chondrosarcoma in three patients and osteosarcoma in one. In two patients total resection of the hemipelvis was required and in the other two less, but still massive, resection was undertaken. All were treated with an immediate free vascularised fibular graft which included arthrodesis of the hip and reconstruction of the pelvic ring.

One patient died. The other three have remained free from recurrence. Solid union of the graft was achieved between four and 14 months after surgery. Shortening of the involved limbs was less than 2 cm. The patients had no pain and were independent walkers without external support. Emotional acceptance was satisfactory.

Our results suggest that reconstruction with the use of a free vascularised graft is an alternative to other types of reconstructive procedure after resection of periacetabular tumours.


The Journal of Bone & Joint Surgery British Volume
Vol. 82-B, Issue 4 | Pages 489 - 493
1 May 2000
Wada T Usui M Nagoya S Isu K Yamawaki S Ishii S

We present the results in 12 patients of arthrodesis of the knee using a vascularised fibular graft after resection of a malignant bone tumour. At a mean follow-up of 95 months (60 to 178) all patients were free from disease although 11 had had at least one complication, with stress fracture of the graft in five patients, nonunion in two and deep infection requiring above-knee amputation in one.

Despite the high rate of complications, satisfactory results can be obtained using this technique. Careful preoperative counselling is required.


The Journal of Bone & Joint Surgery British Volume
Vol. 82-B, Issue 1 | Pages 68 - 73
1 Jan 2000
Wada T Ishii S Usui M Miyano S

We treated post-traumatic contracture of the elbow in 13 consecutive patients (14 elbows) by operative release. Through a single medial approach, the posterior oblique bundle of the medial collateral ligament was resected, followed by posterior and anterior capsulectomies. An additional lateral release through a separate incision was required in only four elbows. The results were assessed at a mean interval of 57 months after operation.

Before surgery active extension lacked 43° which improved to 17° after operation. Active flexion before operation was 89°, which improved to 127°. The mean arc of movement increased from 46° to 110°. All 14 elbows showed scarring of the posterior oblique bundle of the medial collateral ligament.

Neither the interval from injury to operative release nor the age of the patient affected the results. A medial approach is useful to reveal and excise the pathological changes in the medial collateral ligament. It is a safe and effective route through which to correct post-traumatic contracture of the elbow.


The Journal of Bone & Joint Surgery British Volume
Vol. 81-B, Issue 5 | Pages 808 - 813
1 Sep 1999
Wada T Usui M Isu K Yamawaki S Ishii S

We assessed the intermediate functional results of eight patients after wide resection of the proximal humerus for malignant bone tumour. We used a free vascularised fibular graft as a functional spacer and a sling procedure to preserve passive scapulohumeral movement. Scapulohumeral arthrodesis was not carried out. Five patients had osteosarcoma, two achondrosarcoma and one a malignant fibrous histiocytoma of the bone. The mean duration of follow-up was 70 months (median, 76) for the seven patients who were still alive at the time of the latest follow-up. One patient died from the disease 12 months after surgery. There were no local recurrences.

The functional results were described and graded quantitatively according to the rating system of the Musculoskeletal Tumour Society. Our results were satisfactory with regard to pain, emotional acceptance and manual dexterity. Function and lifting ability were unsatisfactory in two patients. One patient had delayed union between host and graft, but this united after six months without further surgery. Radiographs of the shoulder showed absorption or collapse of the head of the fibula in four of the eight patients and a fracture in another. No functional problems related to absorption or fracture of the head of the fibula were noted. There was no infection or subluxation of the head. We conclude that this is a reasonably effective technique of limb salvage after resection of the proximal humerus.