Total hip arthroplasty with subtrochanteric femoral shortening osteotomy using a monoblock cylindrical cementless stem for severe developmental hip dysplasia (Crowe type III, IV).

BACKGROUND: Treatment of patients with Crowe type III and IV dislocated hips is challenging because of the hip deformity in these patients. In addition to the usual total hip replacement, shortening and reduction of the femur are often required. We herein report on our surgical technique using a monoblock cylindrical cementless stem and a direct lateral approach. METHODS: This study included patients with a diagnosis of severe developmental dysplasia of the hip (Crowe types III and IV) who underwent primary total hip arthroplasty at our hospital from August 2019 to January 2022. Eleven hips of seven patients were treated. All patients underwent horizontal osteotomy using a monoblock cylindrical cementless stem and a direct lateral approach. Complications such as dislocation, infection, and implant dropout were evaluated. In addition, the clinical assessment included the hip range of motion at the last observation and hip function based on the Japanese Orthopaedic Association (JOA) hip score and the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ). RESULTS: The average operation time was 224 min (range, 194-296 min), and the average bleeding amount was 396.1 g (range, 20-1010 g). The main complications were acetabular implant dislocation, postoperative dislocation, intraoperative arterial injury, intraoperative proximal femoral fracture, subsidence of femoral implant. and postoperative pulmonary infarction, which occurred in one patient each. CONCLUSION: Total hip arthroplasty for Crowe type III and IV hips is associated with various surgical technical difficulties because of its anatomical characteristics. While patients with severe osteoporosis are contraindicated, the use of a cylindrical monoblock cementless stem and the direct lateral approach makes it possible to simplify the procedure for shortening the femur and increase the indications for surgery. LEVEL OF EVIDENCE: Therapeutic Level Ⅳ.

Association between smoking and duration of regional anesthesia - A propensity score matching study.

BACKGROUND: Previous studies have shown shorter duration of general anesthesia in smokers but it is unclear in regional anesthesia among smokers. We investigated the association between smoking status and the duration of regional anesthesia. METHODS: A total of 77 patients with a mean age of 47.3 years who underwent lower extremity orthopaedic surgery under regional anesthesia between January 2021 and June 2022 were enrolled. Sixteen patients were smokers and 57 patients were non-smokers. Propensity score matching was performed to balance patient characteristics. Our primary outcome was the time to onset of motor or sensory blockade and the duration required for full recovery of motor or sensory function. RESULTS: The time to sensory loss was 43.4 (SD 35.9) minutes in the smoking group and 39.6 (SD 31.7) minutes in the non-smoking group (p = 0.69), and the time to motor blockade was 37.0 (SD 28.4) minutes in the smoking group and 30.1 (SD 24.1) minutes in the non-smoking group (p = 0.35). The time for recovery of sensory function was 1146.7 (SD 197.8) minutes in the smoking group and 1024.6 (SD 177.9) minutes in the non-smoking group (p = 0.024). The time to recovery of motor function was 978.3 (SD 220.5) minutes in the smoking group and 1090.9 (SD 222.8) minutes in the non-smoking group (p = 0.08). The duration of sensory effect was significantly longer in the smoking group than in the non-smoking group. CONCLUSIONS: We found no significant association in the onset of regional anesthesia, but the duration of sensory blockade was significantly longer in the smoking group than in the non-smoking group. Hence, attention should be paid to the risks of the insensate limb in smokers due to prolonged sensory blockade as compared to non-smokers, rather than be concerned about delays in the onset of anesthesia.

Use of a Helicopter Emergency Medical Service Hangar as a Staging Care Unit in a Disaster-Affected Area.

OBJECTIVE: There are a few reports regarding the use of a hangar as a temporal medical facility (staging care unit [SCU]) during large-scale disasters. The aim of this study was to describe the activities performed by disaster medical assistance teams (DMATs) at the hangar of the eastern Shizuoka physician-staffed helicopter as an SCU in the 2022 Shizuoka Prefecture disaster drill. METHODS: We selected the narrative method for this study. RESULTS: Four DMATs helped manage the SCU at the hangar. During the training period, there were 3 instances of a mock doctor helicopter landing and takeoff and 1 actual eastern Shizuoka doctor helicopter landing and takeoff while transporting a mock burn patient. Four DMATs treated 3 mock patients in addition to receiving training regarding medical materials. Such an SCU was able to reduce the burden on the disaster base hospital because many severely ill or traumatized mock patients were transported to the hospital. However, an evaluation meeting held after the drill revealed problems with lifelines, safety management, stock, and quality management of materials in an actual disaster situation. CONCLUSION: We reported our experience with a training exercise using a hangar of the eastern Shizuoka doctor helicopter as an SCU in the 2022 Shizuoka Prefecture disaster drill. There are advantages and disadvantages to using the hangar of a doctor helicopter in this way, so further investigation will be necessary.

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.

Repeated anaphylactic reaction after walking following an intraarticular injection of diclofenac etalhyaluronate sodium during a 3-day period.

BACKGROUND: There has been no English report of repeated anaphylactic reaction after exercise-induced anaphylaxis due to a single intraarticular injection of diclofenac etalhyaluronate sodium. CASE PRESENTATION: A 60-year-old woman felt dyspnea, generalized itching, and urticaria following hypotension a few minutes after receiving an intraarticular injection of diclofenac etalhyaluronate sodium for the first time. She immediately received intramuscular adrenaline administration and her symptoms subsided. However, she received intermittent injections of adrenaline three times for repeated anaphylactic reactions after walking over a 3-day period, in addition to complication with Kounis syndrome. She was discharged on foot on day 9 without sequelae. CONCLUSION: Physicians should have patients who receive intraarticular injection of diclofenac etalhyaluronate sodium walk for a short period and evaluate their status.

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.

Preservation of the articular capsule and short lateral rotator in direct anterior approach to total hip arthroplasty.

INTRODUCTION: In total hip arthroplasty via a direct anterior approach, the femur must be elevated at the time of femoral implant placement. For adequate elevation, division of the posterior soft tissues is necessary. However, if we damage and separate the posterior muscle tissue, we lose the benefits of the intermuscular approach. Furthermore, damage to the posterior soft tissue can result in posterior dislocation. We investigate that protecting the posterior soft tissue increases the joint stability in the early postoperative period and results in a lower dislocation rate. METHODS: We evaluated muscle strength recovery by measuring the maximum width of the internal obturator muscle on CT images (GE-Healthcare Discovery CT 750HD). We compared the maximum width of the muscle belly preoperatively versus 10 days and 6 months postoperatively. As clinical evaluations, we also investigated the range of motion of the hip joint, hip joint function based on the Japanese Orthopaedic Association hip score (JOA score), and the dislocation rate 6 months after surgery. RESULTS: The width of the internal obturator muscle increased significantly from 15.1 ± 3.1 mm before surgery to 16.4 ± 2.8 mm 6 months after surgery. The JOA score improved significantly from 50.8 ± 15.1 points to 95.6 ± 7.6 points. No dislocations occurred in this study. CONCLUSIONS: We cut only the posterosuperior articular capsule and protected the internal obturator muscle to preserve muscle strength. We repaired the entire posterosuperior and anterior articular capsule. These treatments increase joint stability in the early postoperative period, thus reducing the dislocation rate. LEVEL OF EVIDENCE: Therapeutic, Level IV.

A biomechanical study of sacroiliac rod fixation for unstable pelvic ring injuries: verification of the "within ring" concept.

PURPOSE: The aim of this study was to compare the fixation power of sacroiliac rod fixation (SIRF), which was developed based on our original "within ring" concept to exclude the lumbar vertebra from the fixation range, and spinopelvic fixation (SPF) in a biomechanical experiment. METHODS: SPF and SIRF were applied to the posterior element in four bones each with the pelvic ring fracture model (AO/OTA classification 61-C1.3). A 300-N axial force was loaded on the fifth lumbar vertebra of the simulated pelvis. Then the stiffness (N/m) and deformation (mm) of SPF and SIRF were determined, and the final displacement (mm) of the fracture region and angular deformity (degrees) were measured. Displacements were measured using the markers at two sites of the sacral fracture [upper margin of the sacral ala (Ala) and second sacral vertebra level (S2)] and one site of the pubic symphysis (PS), and angular deformity was measured at Ala and PS. RESULTS: In SPF and SIRF, the mean stiffnesses and deformations showed no statistically significant difference. Only the vertical displacement at Ala differed significantly between SPF and SIRF (p = 0. 045), and the fixing force of SPF was higher. There was no other significant difference in vertical and horizontal displacement. The mean angular deformities also showed no significant difference between the two methods. CONCLUSIONS: In biomechanics experiments, vertical resistance was stronger in SPF-treated than SIRF-treated bone, but stiffness and deformation, horizontal resistance, and angular deformity did not differ significantly.

A study of the blood flow restriction pressure of a tourniquet system to facilitate development of a system that can prevent musculoskeletal complications.

BACKGROUND: After an emergency or disaster, subsequent trauma can cause severe bleeding and this can often prove fatal, so promptly stopping that bleeding is crucial to preventing avoidable trauma deaths. A tourniquet is often used to restrict blood flow to an extremity. In operation and hospital, the tourniquet systems currently in use are pneumatically actuated by an air compressor, so they must have a steady power supply. These devices have several drawbacks: they vibrate and are noisy since they are pneumatically actuated and they are far from portable since they are large and heavy. INTRODUCTION: Presumably, the drawbacks of pneumatic tourniquets could be overcome by developing a small, lightweight, vibration-free, quiet, and battery-powered tourniquet system. The current study built a small, vibration-free electrohydrodynamic (EHD) pump and then used that pump to restrict blood flow to the leg of rats in an experiment. This study explored the optimal conditions for effective restriction of blood flow by assessing biochemical and musculoskeletal complications following the restriction of blood flow, and this study also examined whether or not an EHD pump could be used to actuate a tourniquet system. METHODS: A tourniquet cuff (width 12 mm × length 150 mm, material: polyolefin) was placed on the thigh of Wistar rats and pressure was applied for 2 hours by a device that uses EHD phenomena to generate pressure (an EHD pump). Animals were divided into four groups based on how much compressive pressure was applied with a tourniquet: 40 kPa (300 mm Hg, n = 13), 30 kPa (225 mm Hg, n = 12), 20 kPa (150 mm Hg, n = 15), or 0 kPa (controls, n = 25). Tissue oxygen saturation (regional oxygen saturation, denoted here as rSO2) was measured to assess the restriction of blood flow. To assess behavior once blood flow resumed, animal activity was monitored for third day and the amount of movement was counted with digital counters. Body weight was measured before and after the behavioral experiment, and changes in body weight were determined. Blood was sampled after a behavioral experiment and biochemically assessed and creatine kinase (CK) levels were measured. RESULTS: Tissue oxygen saturation decreased significantly in each group. When a tourniquet was applied at a pressure of 30 kPa or more, tissue oxygen saturation decreased significantly. The amount of movement (the count) over third day decreased more when a tourniquet was applied at a higher pressure. The control group resumed the same amount of movement per day second after blood flow resumed. Animals to which a tourniquet was applied at a pressure of 20 or 30 kPa resumed the same amount of movement third day after blood flow resumed. In contrast, animals to which a tourniquet was applied at a pressure of 40 kPa did not resume the same amount of movement third day after blood flow resumed. After the behavioral experiment, animals to which a tourniquet was applied at a pressure of 40 kPa had a significantly lower body weight in comparison to the control group. After the behavioral experiment, animals to which a tourniquet was applied at a pressure of 40 kPa had significantly elevated CK levels in comparison to the control group. DISCUSSION AND CONCLUSION: A relationship between blood flow restriction pressure and tissue oxygen saturation was noted. rSO2 measurement can be used to assess the restriction of blood flow during surgery. On the basis of the decrease in rSO2, blood flow was effectively restricted at a pressure of 30 kPa or more. When, however, blood flow was restricted at a pressure of 40 kPa, weight loss and decreased movement were noted and CK levels increased after the behavioral experiment. Thus, complications had presumably developed due to damage to muscle tissue. These findings indicate that blood flow was effectively restricted in this experiment and they also indicate the existence of an optimal blood flow restriction pressure that does not cause musculoskeletal complications. The pressure in question was around 30 kPa. The tourniquet system that was developed here is actuated with an EHD pump that is still in the trial stages. That said, its pressure can readily be controlled and this pump could be used in a tourniquet system since it is quiet, vibration-free, and small. The pressure of this pump can be finely adjusted to prevent musculoskeletal complications.

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.

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.

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 (θfib). 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.

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.

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.

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.

Percutaneous screw fixation for a femoral head fracture: a case report.

Femoral head fracture associated with hip dislocation is relatively rare but very severe injury. Due to its severity and the need of joint exposure for the reduction of femoral head fracture, the surgical treatment cannot but accompany many complications, including the osteonecrosis of the femoral head, heterotopic ossification, and post-traumatic osteoarthritis. We report a case of less invasive percutaneous screw fixation for the femoral head fracture with excellent clinical result. Post operatively, the fracture was healed, and no acute complication was observed. At 4 years post operation, full Harris hip score was achieved, and there were no osteonecrosis of the femoral head, no heterotopic ossification, and no post-traumatic osteoarthritis. We suggest attempting less invasive percutaneous screw fixation for the femoral head fracture.