Bladder deformity accompanied by pelvic fracture indirectly indicates clinical severity

BACKGROUND

That the bladder can be compressed by extraperitoneal hematoma induced by obstetrics and gynecologic diseases, is well known. However, there have been no reports on the clinical significance of compressed bladder induced by pelvic fracture (PF). We therefore retrospectively investigated the clinical features of compressed bladder induced by the PF.

METHODS

From January 2018 to December 2021, we performed a retrospective review of the hospital medical charts of all emergency outpatients who were treated by emergency physicians at the department of acute critical care medicine in our hospital, and who were diagnosed with PF based on computed tomography (CT) on arrival. The subjects were divided into two groups: the Deformity group, in which the bladder was compressed by extraperitoneal hematoma, and the Normal group. Variables were compared between the two groups.

RESULTS

During the investigation period, 147 patients with PF were enrolled as subjects. There were 44 patients in the Deformity group and 103 in the Normal group. There were no significant differences between the two groups with regard to sex, age, GCS, heart rate or final outcome. However, the average systolic blood pressure in the Deformity group was significantly lower, and the average respiratory rate, injury severity score, rate of unstable circulation, rate of transfusion and duration of hospitalization in the Deformity group were significantly greater in comparison to the Normal group.

CONCLUSIONS

The present study showed that bladder deformity induced by PF tended to be a poor physiological sign that was associated with severe anatomical abnormality, unstable circulation requiring transfusion, and long hospitalization. Accordingly, physicians should evaluate shape of bladder when treating PF.

Early results of intramedullary nail fixation in distal tibia oblique osteotomy for the reduction of soft tissue complications

PURPOSE

During distal tibial oblique osteotomy, external fixators can increase pin site infection risk, whereas plates can cause wound necrosis, necessitating a compromise between soft-tissue position and length. We provide the first report of the early results of intramedullary nail fixation in these osteotomies for avoiding soft tissue complications.

METHODS

Ten ankles, classed as Takakura-Tanaka stages 3a to 4 and unclassified and treated via distal tibial oblique osteotomy for ankle osteoarthritis between 2017 and 2021, were included. Osteotomy was performed obliquely from the distal medial tibia to the tibiofibular joint. The distal tibial fragment was rotated distally in the coronal plane for realignment. An intramedullary nail fixation was applied for stabilization. The resulting gap was filled with iliac bone graft. Ankles were evaluated on the Japanese Society for Surgery of the Foot ankle-Hindfoot Scale and Self-Administered Foot Evaluation Questionnaire before surgery and at final follow-up. Radiographic assessments were performed.

RESULTS

Bone union was achieved within 3 months in all patients. There were no cases of wound necrosis or correction loss postsurgery. Japanese Society scale scores significantly improved from 40.3 ± 15.9 to 87.5 ± 12.6 (P < 0.01). Mean self-evaluation scale scores (pain and pain-related, physical functioning and daily living, social functioning, general health and well-being) improved significantly. shoe-related scores did not change significantly but improved. There was no correction loss after surgery, with an average widening of 24.2 mm and opening angle of 22.6° at the osteotomy site.

CONCLUSION

Our study showed that intramedullary nail for fixation of the osteotomy site in distal tibial oblique osteotomy effectively prevents soft tissues complications even in osteotomy sites with large openings.

Penetrating Aortic Injury due to Broken Ribs and Preventive Measures

We herein report two cases of patients that underwent prophylactic operations to prevent aortic injuries in association with fractured ribs. Penetrating aortic injuries induced by fractured ribs remain fatal. Prophylactic operations appear effective. However, the indication for such operations should be clarified further in the future.

A Report Concerning Collaboration Between a Physician-Staffed Helicopter (Doctor Helicopter) and Police Helicopter

A 35-year-old man injured his right foot by slipping down 200 m into a crater on top of Mount Fuji, where some snow still remained. The next day the patient climbed up from the crater with his friend's assistance and began to descend the mountain; he met the Shizuoka police mountain distress rescue team at the 9th station. The Shizuoka police mountain distress rescue team transported the patient on foot to the snowless 7th station. The Shizuoka police aviation unit, flying a helicopter, then collected the patient. They transported the patient to the nearby Fujinomiya fire department station. The eastern Shizuoka physician-staffed helicopter emergency medical service landed there, and the patient was transported to Juntendo Shizuoka Hospital. On arrival, he had stable vital signs, but his right foot showed a dislocated fracture with frostbite. This is the first case report of collaboration between a helicopter emergency medical service and a police helicopter to rescue a victim from Mount Fuji. When managing victims in high-altitude settings, such as Mount Fuji, collaboration between multiple organizations is necessary.

Seven-year follow-up for malrotation of a radial diaphysis fracture in a child corrected by osteotomy for loss of motion: A case report

A greenstick fracture is an incomplete fracture where the compressive side of the cortex is still intact but plastically deformed. The incidence of poor results following the closed treatment of greenstick fractures in children >10 years of age is seriously underestimated. Therefore, fixing the position of the forearm is important for initial treatment. In cases of greenstick fracture, the possibility of inadequate remodeling of angulated deformities during growth, and in particular, the lack of correction between rotational malalignment and growth when the diaphyseal forearm is involved in the fracture, should be considered. A male, 10-year-old, left hand-dominant, Asian patient fell while playing in the garden and was immediately assessed by an orthopedic doctor at an Emergency Orthopaedic Clinic. Initial examination revealed a deformity of his dominant left forearm and an angulated greenstick fracture of the radius. However, after 3 months, he developed loss of supination of his left forearm and complained of limitation of left forearm supination. Radiography demonstrated a volar angulation of 20°. The patient underwent open reduction, internal fixation and 10° bending with a plate for correction without corrective rotation. At 12 months after injury, the patient did not exhibit pain or limitation of the elbow and wrist. After follow-up for 7 years, the patient was able to perform normal day-to-day activities with no adverse symptoms. The present case indicated that corrective osteotomy is required following the loss of supination after a greenstick fracture of the diaphysis of the radius. The patient of the current study exhibited rotation due to the central band of the interosseous membrane. In the treatment of greenstick fractures, a radius apex angulation of 20° must be corrected via osteotomy due to loss of rotation. The present case indicated that corrective osteotomy of the radius apex alone without rotational correction, in combination with plate bending improved the loss of forearm rotation.

Screw Fixation and Autogenous Bone Graft for an Irreducible Distal Ulna Fracture Associated with Distal Radius Fracture

Distal ulna fractures often occur with distal radius fractures, and their treatment method is still controversial. We considered reduction of the distal radio-ulnar joint (DRUJ) surface the most important factor when treating distal ulna fractures accompanied by residual dislocation. We herein presented a patient with a distal ulna fracture accompanied by dislocation of the DRUJ surface in whom an autogenous bone fragment collected from the radius was grafted onto the ulnar bone defect after open reduction and Herbert screw fixation. In this technique, the bone fragment was supported through the medullary cavity by inserting a Herbert screw, which was less likely to cause irritation between the screw and surrounding tissue, because the screw was almost entirely present in the bone. In addition, an autogenous bone graft from the same surgical field may be less invasive than that from another region.

Total hip arthroplasty for a woman with hemophilia A -case report

Hemophilia A is a congenital bleeding disorder caused by an X-linked hereditary pattern. Female hemophilia A carriers are usually asymptomatic, although some have far lower levels of clotting factor because more X chromosomes with the normal gene are switched off, a phenomenon referred to as "lyonization.” During a medical checkup at our hospital, a 56-year-old Japanese woman with coxalgia was also diagnosed as an obligate hemophilia A carrier based on World Federation of Hemophilia criteria. She underwent total hip arthroplasty using blood product coagulation factor VIII to address her hemophilia. Immediate female relatives (mother, sisters, daughters) of a person with hemophilia should have their clotting factor levels checked, especially prior to any invasive intervention or childbirth, or if any symptoms occur.

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We report a case of total hip arthroplasty for a woman with hemophilia A.

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Some female hemophilia A carriers have far lower levels of clotting factor.

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Immediate female relatives of a person with hemophilia should have their clotting factor level checked.

Is actual surgical experience reflected in virtual reality simulation surgery for a femoral neck fracture?

INTRODUCTION

A virtual reality simulator developed for orthopaedic and trauma surgical training has been introduced. However, it is unclear whether the experiences of actual surgery are reflected in virtual reality simulation surgery (VRSS) using a simulator. The aim of this study is to investigate whether the results in VRSS differ between a trauma expert and a trauma novice.

METHODS

In Group A (expert), there are ten orthopaedic trauma surgeons and in Group B (novice) ten residents within 2 years after medical school graduation. VRSS for a femoral neck fracture using Hansson hook-pins (Test 1) and Hansson twin hook plate (Test 2) was performed. The parameters evaluated were total procedure time (s), fluoroscopy time (s), number of times X-ray was used (defined by the number of times the foot pedal was used), number of retries in guide placement, and final implant position.

RESULTS

In Test 1, the averages of four parameters (distance to posterior cortex (p = 0.009), distal pin distance above lesser trochanter (p = 0.015), distal pin hook angular error (p = 0.004), and distal pin tip distance to centre (lateral) (p = 0.015)) were significantly different between Groups A and B. In Test 2, no parameters in a mean were significantly different between groups, but seven parameters in a variance (guide wire distance to joint surface (p = 0.0191), twin hook length outside barrel (p = 0.011), twin hook tip distance to centre (lateral) (p = 0.042), twin hook distance to centre of lateral cortex (lateral) (p = 0.016), plate end alignment error (lateral) (p = 0.027), guide wire angle with lateral cortex (front) (p = 0.024), and 3.2-mm drill outside cortex (p = 0.000)) were significantly different between groups. In Test 1, Group B showed significantly longer fluoroscopy time than Group A (p = 0.044). In Test 2, Group B showed significantly fewer instances of X-ray use than Group A (p = 0.046).

CONCLUSIONS

Our study showed that the experiences of actual surgery are reflected in the result of VRSS using the simulator.

A complete posterior tibial stress fracture that occurred during a middle-distance running race: a case report

Posterior tibial stress fractures are more frequent than anterior tibial stress fractures, and they are considered to have a good prognosis for returning to sports; cases leading to a complete fracture are rare. A 17-year-old male involved in high school athletics middle-distance running had a 3-week history of pain with training. He was running up to 300 km/week on streets and cross-country in an even distribution. He had posterior tibial stress fractures, but despite the lower leg pain, he continued running. One year later, he was brought to the emergency department after having sustained an injury to the right lower leg while running in a middle-distance race; bilateral tibial stress fractures, with one side complete and the opposite side incomplete, had developed simultaneously. This relatively rare case of bilateral posterior stress fractures, with one side a complete fracture and the opposite side an incomplete fracture, that was treated surgically via exchange intramedullary nailing is reported. The patient could begin light jogging from 3 months after surgery and was without symptoms at 5 months after surgery. He could resume middle-distance racing after 1 year. Posterior tibial cortical fractures are more common and respond better to conservative treatment than anterior tibial stress fractures, and they are a common fracture type in runners. We believe that close, careful follow-up is necessary if patients continue excessive training.

Intraoperative dislocation of the trial bipolar cup into the pelvis during bipolar hip arthroplasty - A case report

INTRODUCTION

Bipolar hip arthroplasty is a good option for treating femoral neck fractures, although some contraindications have been indicated. We report a case of intraoperative dislocation of the trial bipolar cup into the pelvis during bipolar hip arthroplasty.

CASE PRESENTATION

A 74-year-old woman underwent bipolar hip arthroplasty for a femoral neck fracture (AO31-B2). She was placed in a lateral decubitus position, and a direct lateral approach was used. During intraoperative trial reduction, the trial bipolar cup became disengaged and dislocated into the anterior space of hip joint. Several attempts to retrieve it failed. The permanent femoral component was inserted, and the wound was closed. The patient was repositioned supine to allow an ilioinguinal approach, and the component was easily removed. She had an uneventful, good recovery.

DISCUSSION

Several cases of intraoperative dislocation of the femoral trial head during total hip arthroplasty have been reported, this is the first report of dislocation of a bipolar trial cup. A previous report described difficulty retrieving a trial cup.

CONCLUSION

We easily removed our trial cup using another approach. It is vital to plan systematically for this frustrating complication.

Malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber's three indexes in the mortise view

PURPOSE

Malalignment of syndesmosis is generally associated with a poor outcome, yet occurs at a high rate in malleolar ankle fractures. In this study, we examine whether malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber's three indexes in the mortise view.

MATERIALS AND METHODS

Of 156 patients with malleolar ankle fracture who underwent surgery from December 2012 to March 2016 at two medical facilities, 24 patients who received syndesmotic screw fixation were included in the study. Fractures were Danis-Weber types B and C in 8 (8/134, 6.0%) and 16 (16/22, 72.7%) patients, respectively. Using axial computed tomography (CT), we calculated the difference between injured and non-injured sides for each of three parameters: tibiofibular clear space (TFCS), anterior tibiofibular interval (ATF), and fibular rotation (θ^fib). Malreduction was diagnosed if one or more of the three parameters had an abnormal value. Weber's three indexes in the mortise view on the injured side were used to determine whether reduction of syndesmosis was performed successfully. Consistency between the evaluation of reduction of syndesmosis in axial CT images and reevaluation of mortise views was examined by calculation of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

The rate of malreduction of syndesmosis in axial CT images was 29.2% (7/24). Re-evaluation in the mortise view confirmed malreduction of syndesmosis in six of the seven subjects, all of whom also had malreduction based on axial CT images. The one subject in whom malreduction could not be detected in a mortise view showed an abnormal value only for ATF. Use of the mortise view for perioperative diagnosis had a sensitivity of 0.857, specificity of 1.000, PPV of 1.000, and NPV of 0.944.

CONCLUSION

The results of our study show that malreduction of syndesmosis can be avoided by careful interpretation of intraoperative perspective mortise views based on Weber's three indexes. To increase the diagnostic accuracy further, it is important to detect anteroposterior deviation of the fibula in intraoperative lateral views.

Acoustic pattern evaluation during cementless hip arthroplasty surgery may be a new method for predicting complications

BACKGROUND

Although surgeons must perform implantation of the cementless stem during total hip arthroplasty (THA) without complications, assessment is left to the surgeon's intuitive judgement, which could contain inter/intra-observer bias variety. We therefore asked (1) whether the sound created during the stem implantation could be evaluated objectively and (2) whether those sounds are correlate to the complication specific to the cementless stems. Our hypothesis is that the sounds produced during stem insertion could be quantified and related to the complications.

PATIENTS AND METHOD

In 71 THAs, we quantified the sound produced during stem insertion and investigated the relationship between these sounds and the occurrence of intraoperative fracture and subsidence.

RESULTS

The sound data were divided into two patterns: Patterns A and B. The difference between the peak value (dB) at the most common frequency (near 7 kHz) and the second most common frequency (near 4 kHz) of strikes during the final phase of implantation in Patterns A and B showed a significant difference. Adverse events on intraoperative fracture and subsidence were significantly less common in patients with Pattern A than in those with Pattern B (six of 42 hips with Pattern A and 13 of 29 hips with Pattern B, p = 0.004). Pattern A in predicting a clinical course without those adverse events was 69.2% and the specificity was 68.4%. Positive and negative predictive values were 85.7% and 44.8%, respectively.

CONCLUSION

The sound generated during stem insertion was quantified. Those sound patterns were associated with complications.

Treatment of postoperative sciatic nerve palsy after total hip arthroplasty for postoperative acetabular fracture: A case report

Acetabular fracture is usually treated with osteosynthesis. However, in the case of an intra-articular fracture, osteosynthesis can result in arthropathy of the hip joint and poor long-term results, hence, total hip arthroplasty is required. However, in total hip arthroplasty for postoperative acetabular fracture, sciatic nerve palsy tends to develop more commonly than after primary total hip arthroplasty. This is a case report of a 57-year-old Japanese male who had internal skeletal fixation for a left acetabular fracture that had occurred 2 years earlier. One year later, he developed coxarthrosis and severe pain of the hip joint and total hip arthroplasty was performed. After the second surgery, he experienced pain along the distribution of the sciatic nerve and weakness of the muscles innervated by the peroneal nerve, indicating sciatic nerve palsy. We performed a third operation, and divided adhesions around the sciatic nerve. Postoperatively, the anterior hip joint pain and the buttocks pain when the hip was flexed were improved. Abduction of the fifth toe was also improved. However, the footdrop and sensory disturbance were not improved. A year after the third operation, sensory disturbance was slightly improved but the footdrop was not improved. We believe the sciatic nerve palsy developed when we dislocated the hip joint as the sciatic nerve was excessively extended as the hip joint flexed and internally rotated. Sciatic nerve adhesion can occur easily in total hip replacement for postoperative acetabular fracture; hence, adhesiotomy should be conducted before performing hip dislocation to prevent injury caused by nerve tension. The patient agreed that the details of this case could be submitted for publication. The work has been reported in line with the CARE criteria and cite.

A system of delivering medical staff members by helicopter to manage severely wounded patients in an area where medical resources are limited

Aim

We review the case of a severely injured patient to evaluate the system of delivering medical staff by helicopter in areas with limited medical resources.

Methods

The patient's chart was reviewed, summarized, and presented.

Results

A 22‐year‐old woman attempted a suicidal fall after using a knife to stab herself. She was transported to a local hospital. A radiological study revealed fractures to the patient's face and the base of her skull, pneumocephalus, traumatic subarachnoid hemorrhage, stab wounds to the neck and chest, pneumothorax, unstable pelvic fracture, and right femoral shaft fracture. Her circulation status became unstable. We sent medical staff members to the local hospital by doctor helicopter. The patient underwent tracheal intubation and the insertion of a chest drain, and was evacuated by doctor helicopter. After aggressive intensive treatments in our hospital, the patient finally obtained social rehabilitation.

Conclusion

In an area where medical resources are limited, sending trained physicians to a referring hospital to appropriately prepare a severely wounded patient for transportation might be the key for the patient to maximize his or her chance of survival.

New classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line for intertrochanteric fractures

PURPOSE

There are various types of intertrochanteric fractures that are unstable pertrochanteric fractures of the hip. The aim of this study was to develop a systematic and comprehensive classification of intertrochanteric fractures.

MATERIALS AND METHODS

This study enrolled 74 patients with intertrochanteric fractures treated by us between 2012 and 2015. The fractures were classified using 3D-CT images taken immediately after the fractures occurred based on the course of the lateral fracture line (LFL) that extends through the lateral femoral cortex distal to the vastus ridge of the greater trochanter in the intertrochanteric area. Furthermore, the presence or absence of additional typical fractures was also studied. Then, 4 orthopedic specialists examined the 3D-CT images of 20 patients randomly selected from the 74 patients to evaluate both the inter-rater and intra-rater agreement levels.

RESULTS

Intertrochanteric fractures were classified into three types according to the LFL patterns. Type I (41.9%), the Lateral Wall Pattern, has a LFL that extends towards the lateral fiber bundle attachment area of the iliofemoral ligament. Type II (24.3%), the Transverse Pattern, has a LFL that extends towards the medial bundle attachment area. Type III (33.8%), the Reverse Oblique Pattern, has a LFL that extends between the lateral and medial fiber bundle area of the iliofemoral ligament. Each type showed characteristic displacement and was associated with various combinations of typical fractures (fracture across the intertrochanteric line, posteromedial fragment, including the lesser trochanter, posterolateral fragment posterior to the femoral greater trochanter, and banana-shaped big fragment, including both the greater trochanter and the lesser trochanter). The mean κ values for the interobserver and intraobserver agreement levels were 0.77 (0.70-0.85) and 0.76 (0.70-0.85), respectively, which were considered substantial agreement levels.

CONCLUSION

We believe our new classification is a useful communication tool for medical professionals in the diagnosis of fractures.

New Technique for Dorsal Fragment Reduction in Distal Radius Fractures by Using Volar Bone Fenestration

Introduction:

For intra-articular distal radius fractures (AO Classification, type B2) with a displaced dorsal fragment, there remains much discussion on the fixation method for the dorsal fragment. To reduce the displaced dorsal fragment, we developed a new technique consisting of fenestration of the volar bone cortex, reduction using an intramedullary procedure, and fixation using a volar plate. This avoids necessity of dorsal approach.

Technical Note:

We performed this surgical technique in 2 patients and achieved a good reduced position without much injury to the bone cortex at the site of volar plate placement. This surgical technique allows reduction of the dorsal fragment using an intramedullary procedure by only a volar approach, and, therefore, does not affect the dorsal soft tissue (extensor tendon). For intra-articular distal radius fractures, complete reduction of the articular surface is extremely difficult, and, in patients with a remaining gap on the articular surface, a variable angle locking screw system may be useful. In the 2 patients, the angle of the locking screw was adjusted to catch the displaced dorsal fragment, and adequate reduction and fixation could be achieved.

Conclusion:

This technique using fenestration of the volar bone cortex allows reduction and fixation of the displaced dorsal fragment in distal radius fractures and thus avoids the necessity of a dorsal approach.

Iliopsoas impingement after revision total hip arthroplasty treated with iliopsoas muscle transection

Introduction

Iliopsoas tendinitis after revision total hip arthroplasty (THA) is rare and its etiology and optimal treatment are still unclear. We report a case of iliopsoas impingement after revision THA with a Kerboull acetabular reinforcement device requiring two-level iliopsoas muscle transection.

Presentation of case

A 70-year-old woman presented to our hospital complaining of debilitating right groin pain after revision THA with a Kerboull reinforcement device. She had undergone multiple hip operations after experiencing a pelvic fracture in a motor vehicle accident. A lidocaine nerve block at the level of the Kerboull device resulted in temporary but marked reduction in pain and a diagnosis of psoas impingent. We performed surgery via an anterior approach to release the iliopsoas muscle from the lesser trochanter. After iliopsoas tenotomy was performed, the muscle was still under high tension because of dense adhesions. Repeat transection of the iliopsoas muscle at the level of the anterior branch of the Kerboull device resulted in loosening of the iliopsoas muscle and resolution of impingement. Postoperatively, the patient's groin pain completely disappeared, and she can now walk with a single cane and is satisfied with her result.

Discussion

Adhesions around the iliopsoas muscle likely contributed to the patient's groin pain. Open surgery to perform complete release of iliopsoas muscle impingement should be considered in patients with pain after revision THA.

Conclusion

We reported a patient with Iliopsoas tendinitis after revision THA requiring two-level iliopsoas muscle transection.

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We reported a patient with Iliopsoas tendinitis after revision THA.

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Two-level iliopsoas muscle transection was necessary.

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Open surgery should be considered in patients with pain after revision THA.

Inadequate management for secondary fracture prevention in patients with distal radius fracture by trauma surgeons

We evaluated the secondary fracture prevention in 1445 patients with distal radius fracture by trauma surgeons. The rate of patients with distal radius fracture who underwent bone mineral density (BMD) examination was low, suggesting that appropriate treatment for osteoporosis by trauma surgeons is not performed at present.

INTRODUCTION

To clarify the status of osteoporosis interventions after distal radial fractures by trauma surgeons who play the main role in treatment for these fractures, we performed a survey involving multiple institutions in Japan.

METHODS

We asked 155 board members of the Japanese Society for Fracture Repair for their cooperation and performed a survey in 48 institutions with which members who gave cooperation were affiliated. The subjects consisted of consecutive patients with distal radial fractures occurring between January and December 2012. The presence or absence of a diagnosis of osteoporosis and bone mineral density examination after fracture was investigated.

RESULTS

A total of 1445 patients with distal radial fractures were evaluated in this study. BMD examination for diagnosis and treatment for osteoporosis after fracture was performed respectively in 126 (8.7 %) and 193 (13.4 %) of 1445 patients. Treatment for osteoporosis was performed in 93 (73.8 %) of 126 patients who underwent BMD examination after fracture and 100 (8.2 %) of 1219 who did not undergo BMD examination. Of the 126 patients who underwent BMD examination after fracture, 89 showed a BMD <80 % of the young adult mean as a criterion for the initiation of drug treatment for osteoporosis in Japan and 77 (86.5 %) of the 89 patients were treated with drugs.

CONCLUSIONS

The rate of patients with distal radial fractures who underwent BMD examination was low, suggesting that appropriate treatment for osteoporosis by trauma surgeons is not performed at present.

The incidence of and risk factors for developing atypical femoral fractures in Japan

The long-term treatment with anti-resorptive drugs for osteoporotic patients is suggested to be associated with an increase in atypical femoral fractures (AFFs). However, their incidence, patient characteristics, and risk factors have not been fully elucidated especially in Asian countries. This retrospective observational cohort study found fourteen AFFs in ten patients (four bilateral fractures) among 2,238 hip and femoral shaft fractures treated in our associated hospitals between 2005 and 2010; this incidence (0.63%) was similar to Caucasians. Of the ten patients with AFFs, nine (90%) and six (60%) were using bisphosphonates (BPs) and glucocorticoids (GCs), respectively, compared to 14.3 and 8.6% for patients with typical femoral fractures who were using these agents. As comorbid conditions, five patients had collagen disease (CD) and two had diabetes. A fracture location-, age- and gender-matched (1:3) case-control study revealed that administration of BPs, GCs, and suffering from collagen disease (CD) were significant risk factors for developing AFFs [odds ratios 36.0 (95% confidence intervals 3.8-342.2), 13.0 (2.3-74.1) and 9.0 (1.6-50.3), respectively]. Interestingly, all of the patients with atypical subtrochanteric femoral fractures, defined as those within 5 cm of the lesser trochanter, were taking GCs due to CD, and the age of these patients (average of 54.8 years) was significantly younger than those with atypical diaphyseal femoral fractures (average of 77.2 years, p < 0.05). In conclusion, the incidence of AFFs in the Japanese population was similar to that of Caucasians, and taking BPs and GCs and suffering from CD were risk factors for developing AFFs.

A 42-year-old patient presenting with femoral head migration after hemiarthroplasty performed 22 years earlier: a case report

INTRODUCTION

Treatment of femoral neck fractures in young adults may require total hip arthroplasty or hip hemiarthroplasty using a bipolar cup. The latter can, however, result in migration of the femoral head and poor long-term results.

CASE PRESENTATION

We report a case of femoral head migration after hemiarthroplasty performed for femoral neck fracture that had occurred 22 years earlier, when the patient (a Japanese man) was 20 years old. He experienced peri-prosthetic fracture of the femur, subsequent migration of the prosthesis, and a massive bone defect of the pelvic side acetabular roof. After bone union of the femoral shaft fracture, the patient was referred to our hospital for reconstruction of the acetabular roof. Intra-operatively, we placed two alloimplants of bone from around the transplanted femoral head into the weight-bearing region of the acetabular roof using an impaction bone graft method. We then implanted an acetabular roof reinforcement plate and a cemented polyethylene cup in the position of the original acetabular cup. Eighteen months post-operatively, X-rays showed union of the transplanted bone.

CONCLUSIONS

Treatment of femoral neck fractures in young adults is usually accomplished by osteosynthesis, but it may be complicated by femoral head avascular necrosis or by infection or osteomyelitis. In such cases, once an infection has subsided, either hip hemiarthroplasty using a bipolar cup or total hip arthroplasty may be required. However, if the acetabular side articular cartilage is damaged, a bipolar cup should not be used. Total hip arthroplasty should be performed to prevent migration of the implant.

The fracture sites of atypical femoral fractures are associated with the weight-bearing lower limb alignment

Atypical femoral fractures (AFFs) are stress-related fractures that are speculated to associate with long-term treatment with bisphosphonates for osteoporosis. A history of AFF is a high risk factor for the development of a subsequent AFF in the same location of the contralateral femur, suggesting that a patient's individual anatomical factor(s) are related to the fracture site of AFFs. In this study, we investigated the radiographs of fourteen AFFs (four bilateral fractures among ten patients) treated at six hospitals associated with our university between 2005 and 2010. The fracture site and standing femorotibial angle (FTA), which reflects the mechanical axis of the lower limb, were measured on weight-bearing lower limb radiographs. The fracture site and FTA of patients with typical femoral fractures (TFF) were compared to those of patients with AFFs. The correlations were examined using Spearman's rank correlation coefficients. The fracture locations in the femora were almost the same in the patients with bilateral AFFs. There was a positive correlation between the fracture site and the standing FTA in the patients with AFFs (r=0.82, 95% confidence interval; 0.49 to 0.94), indicating that the larger the standing FTA (varus alignment), the more distal the site of the fracture in the femur. The FTA of the patients with atypical diaphyseal femoral fracture were significantly larger compared to that of those with not only atypical subtrochanteric fractures but also TFFs. In conclusion, the fracture sites of AFFs are associated with the standing lower limb alignment, while those of TFFs are not.

New classification focusing on implant designs useful for setting therapeutic strategy for periprosthetic femoral fractures

PURPOSE

In periprosthetic femoral fractures, our hypothesis was that when the bone and implant are stable, the fracture does not occur at the biologic or cement fixation regions but occurs at the no fixation region. The aim of this study was to investigate the validity of our new classification for periprosthetic femoral fractures and compare reliability of radiographic evaluation for implant stability between our classification and the Vancouver classification.

PATIENTS AND METHODS

Sixty-six patients with periprosthetic femoral fracture were operatively treated by us between 2005 and 2013. We investigated the sensitivity and specificity of our new classification with actual implant stability. Twenty patients were randomly selected from 66 patients. After fully explaining the Vancouver and our new classification to four orthopaedic surgeons, plain radiographs acquired in two directions at the time of injury were presented, and the interobserver reliability based on the two classifications and accuracy rates of stem stability were investigated.

RESULTS

The specificity of the new classification was 89%, and sensitivity was 94%. The positive and negative predictive values were 84% and 96%, respectively. Interobserver agreement was separately assessed among all possible pairs of orthopaedic surgeons. The κ values for the Vancouver and the new classification were 0.36 (0.19-0.49) and 0.76 (0.66-1.0), respectively.

CONCLUSIONS

Our classification is based on a completely new concept and was prepared to overcome periprosthetic femoral fracture failures by objective evaluation. We believe this new classification is useful to establish a therapeutic strategy for femoral fractures around the stem.

Type III fracture of the tibial tubercle with avulsion of the tibialis anterior muscle in the adolescent male athlete

INTRODUCTION

Type III fracture of the tibial tubercle by Watson-Jones, or type IIIa injury according to John Ogden's classification has been well described and its management is now well codified in standard orthopaedic textbooks.

MATERIALS AND METHODS

The authors present a case of type III fracture of the tibial tubercle associated with an avulsion of the tibialis anterior muscle.

RESULTS

We demonstrated the effectiveness of bioabsorbable material for fixing the fracture preventing the need for removal of metalware, and that the anterior tibialis muscle had been stripped by the injury.

CONCLUSION

A displaced type III fracture of the tibial tubercle may have an associated with avulsion of the tibialis anterior muscle, particularly in adolescent athletes. Prompt recognition and appropriate surgical treatment can give an excellent outcome.

Subluxation of the hip joint after internal fixation of a trochanteric fracture

The authors report an unusual case of hip subluxation after internal fixation without associated sepsis. We report one recently treated case in which a 75-year-old female experienced subluxation of her hip joint after open reduction and internal fixation for a trochanteric fracture. In this paper, we describe a case of progressive, spontaneous subluxation of the hip joint over several weeks. Most previously reported cases are associated with cerebral palsy. This entity has not been reported previously. Our patient was treated by hemi-arthroplasty and repair of the disrupted capsule, and achieved a good long-term functional result. The cause of this particular condition is discussed.

Recurrent palmar dislocation of the distal radioulnar joint. A case report

Recurrent palmar dislocation of the distal radioulnar joint is not a common injury. We report one case in a 73-year-old female. This injury was incorrectly diagnosed at the first presentation because there has been no distinct deformity at the wrist and extension-flexion was normal. The need for proper physical examination and accurate radiographic positioning is stressed. Distal diaphysis resection combined with distal radioulnar arthrodesis (modified Sauve-Kapandji procedure) was the preferred method of treatment in an old patient. Two years after the injury, the patient was asymptomatic.

Japanese acrylic hemi-arthroplasty of the hip with a 45-year follow-up without revision

We report the case of a patient who underwent acrylic hemi-arthroplasty of the hip and survived 45 years without revision. The patient had undergone hemi-arthroplasty of the hip at the age of 17 years following failure of a previous hemi-arthroplasty at the age of 12 years. We saw her 45 years later and carried out physical examination, standard radiographs of the hip as well as computed tomography. In addition, we reviewed the literature concerning the acrylic prosthesis and discussed the reasons for long-term durability.

Hamatometacarpal fracture-dislocation: distinctive three dimensional computed tomographic appearance

We report here two fully documented cases of hamatometacarpal fracture-dislocation following trauma and treated in our hospital. In our cases, the patients suffered hamate fracture in association with metacarpal dislocation. In the first case, a dorsal oblique fracture of the hamate was associated with a dorsal dislocation of the base of the fourth metacarpal. In the second case, a dorsal oblique fracture of the hamate was not associated with a dorsal dislocation of the base of the fifth metacarpal. This diagnosis should be suspected on initial review of plain radiographs, which must include an oblique view because of diagnostic difficulty for this injury. We recommend three dimensional computed tomography (3D-CT) in any patient presenting with pain after blunt trauma to the hand to prevent in diagnosis. Open reduction and internal fixation of the fracture is indicated and relevant for displaced fracture.

Lunatomalacia in association with congenital synostosis between the capitate and the hamate

This report describes a case of lunatomalacia associated with congenital synostosis between the capitate and the hamate, an association not previously reported. The case was examined in detail, and compared to the findings in the literature including observation regarding prognosis of lunatomalacia.

[A survey on occupational health nursing activities and evaluation in TOHOKU area]

We did a mail survey in 1998 in Tohoku district. We sent questionnaires to approximately 300 Occupational Health (OH) nurses and got 132 replies. Occupations of respondents were 66 public health nurses and 57 nurses. More than 70% did not have a managerial position. About 40% were respondents without colleagues in nursing occupations. Full time occupational physicians were in 40% of companies, and semi-full time occupational physicians were in 60%. Respondents citing good coordination in the former were 60%, and in the latter were 80%. Of all business activities occupying OH nursing employees, persons who performed more than 90% of the tasks numbered more than 30%. Persons not satisfied with present employment positions were 80%. Reasons for dissatisfaction in declining order of incidence were work duties, contract conditions for employment, and personal relations. Planning and summary of OH nursing activities were carefully done highly. For the OH nursing activity evaluation, we examined guidelines for business locations by observing them from the OH nursing aspect and the OH nursing job itself. Guidelines considered for business locales from the OH nursing vantage point show numerically, for example, rates of examinees with abnormal findings, work absenteeism, etc, and expectations as to whether or not health conditions are conspicuously reflected in productivity. Conversely, from the OH nursing vantage point for guidelines on business locales, while receiving affirmative economic evaluation of occupational health and safety measures, progress (process) should also be included in the object of evaluation. Furthermore, guidelines should be mindful of the need to have qualitative and quantitative changes in health behavior of workers and perspectives on health.

Posterolateral dislocation of the ankle without fracture

We report an unusual case of open posterolateral dislocation of the ankle without fracture following a motor vehicle accident. Most of previously reported cases are posteromedial dislocation. The anterolateral, posterolateral, and purely superior dislocations of the talus make up smaller percentage. The mechanism of this injury appears to be forced eversion of the foot when it is maximally plantar flexed and axially loaded. Our case was treated by manual reduction and percutaneous fixation and anatomical repair of the disrupted deltoid ligament at the time of initial débridement, also achieved good long-term functional and radiographic results.

The initial fixation of the press-fit acetabular shell--clinical observation and experimental study

The initial solid fixation of an uncemented acetabular component affects the amount of bone ingrowth. We had several problems with broken screws in cases of acetabular revision. In recent years, the development of uncemented components without screws has attempted to improve these problems. We started to use "press-fit"-type acetabular shells in November 1996. Our thirty cases undergoing 2 mm under-reaming show good initial stability. The aim of our biomechanical study was to assess the most suitable degree of under-reaming of the bony acetabulum for the implantation of an uncemented hemispherical porous coated component.

Establishment of Salmonella strain expressing catalytically active human UDP-glucuronosyltransferase 1A1 (UGT1A1)

Human uridinediphosphate-glucuronosyltransferase 1A1 (UGT1A1) was expressed in Salmonella typhimurium TA1535 cells by transfection of the cells with plasmids carrying the UGT1A1 cDNA. UGT1A1 cDNA was isolated by a polymerase chain reaction from human liver total RNA and was inserted into the pSE420 plasmid, linked to the trc promoter and terminator. The plasmid thus constructed was introduced into Salmonella TA1535 cells. The expression of human UGT1A1 protein was confirmed by Western blot analysis. The maximal expression was observed at 24 h after the addition of isopropyl-beta-D-thiogalactopyranoside, an inducer. However, the bilirubin conjugation activity of the membrane fraction from the Salmonella cells was not detectable. When a beta-glucuronidase inhibitor such as saccharic acid 1,4-lactone, glycyrrhizin or 1-naphtyl-beta-D-glucuronide was added to the reaction mixture, the bilirubin conjugation activity of the human UGT1A1 was detected. When geniposide was added to the reaction mixture, the bilirubin conjugation activity of UGT1A1 was not seen. Taking these results into account, the established Salmonella strain possesses the beta-glucuronidase activity. Since the beta-glucuronidase activity of the Salmonella was lower than that of E. coli, it was concluded that Salmonella seemed to be a good host to express UGT protein. This is the first study to demonstrate the establishment of a bacterial strain expressing native human UGT protein showing catalytic activity.

Cytotoxic necrotizing factor type 2 produced by pathogenic Escherichia coli deamidates a gln residue in the conserved G-3 domain of the rho family and preferentially inhibits the GTPase activity of RhoA and rac1

Cytotoxic necrotizing factor types 1 and 2 (CNF1 and -2) produced by pathogenic Escherichia coli strains have 90% conserved residues over 1,014-amino-acid sequences. Both CNFs are able to provoke a remarkable increase in F-actin structures in cultured cells and covalently modify the RhoA small GTPases. In this study, we demonstrated that CNF2 reduced RhoA GTPase activity in the presence and absence of P122(RhoGAP). Subsequently, peptide mapping and amino acid sequencing of CNF2-modified FLAG-RhoA produced in E. coli revealed that CNF2 deamidates Q63 of RhoA-like CNF1. In vitro incubation of the C-terminal domain of CNF2 with FLAG-RhoA resulted also in deamidation of the FLAG-RhoA, suggesting that this region contains the enzymatic domain of CNF2. An oligopeptide antibody (anti-E63) which specifically recognized the altered G-3 domain of the Rho family reacted with glutathione S-transferase (GST)-RhoA and GST-Rac1 but not with GST-Cdc42 when coexpressed with CNF2. In addition, CNF2 selectively induced accumulation of GTP form of FLAG-RhoA and FLAG-Rac1 but not of FLAG-Cdc42 in Cos-7 cells. Taken together, these results indicate that CNF2 preferentially deamidates RhoA Q63 and Rac1 Q61 and constitutively activates these small GTPases in cultured cells. In contrast, anti-E63 reacted with GST-RhoA and GST-Cdc42 but not with GST-Rac1 when coexpressed with CNF1. These results indicate that CNF2 and CNF1 share the same catalytic activity but have distinct substrate specificities, which may reflect their differences in toxic activity in vivo.

[Use of a butterfly ventilation tube in the treatment of otitis media with effusion]

Sixty-three ears of 49 patients with serous otitis media were treated making use of butterfly ventilation tube in our 4 hospitals and 1 private office. The average time from intubation to extubation was 9 months and the longest case was 33 months. Main complications were infection and spontaneous extubation. The rate of hearing improvement after tympanostomy was more than 80% in all cases. The frequency of the most improvement was observed in 1kHz on the average. It was cleared that the butterfly ventilation tube was easy to use for the wide age patients and at any clinics. It was concluded that the butterfly ventilation tube was useful as a long-term ventilation tube.