Pediatric femoral shaft fracture requiring revision surgery for nonunion associated with vitamin D and K deficiencies: a case report.

BACKGROUND: Nonunion of femoral shaft fractures in children is rare, and there is no clear treatment protocol. In this case report, a pediatric femoral shaft fracture that developed in nonunion due to vitamin deficiency after osteosynthesis, which was successfully treated with vitamin augmentation and replacement with a rigid antegrade intramedullary nail, is described. CASE PRESENTATION: The patient is an 11-year-old Japanese girl. She injured her right femoral shaft fracture when she hit a wall after kickboarding down a hill and underwent osteosynthesis with a titanium elastic nail. Six months postoperatively, she developed nonunion, was found to be deficient in vitamins D and K, and was started on vitamin supplementation. She underwent replacement with a rigid antegrade intramedullary nail at 7 months postoperatively, and bone union was achieved 3 months after reoperation. CONCLUSION: When delayed union of a fracture is observed postoperatively, even in children without underlying disease, the cause of the problem must be investigated and treated promptly.

Preoperative inspiratory muscle training in a patient with lung cancer and comorbid chronic obstructive pulmonary disease and respiratory sarcopenia: A case report.

INTRODUCTION: Sarcopenia and chronic obstructive pulmonary disease (COPD) are risk factors for postoperative pulmonary complications (PPCs). Preoperative inspiratory muscle weakness is also a risk factor for PPCs. Sarcopenia and COPD are often associated with inspiratory muscle weakness. Respiratory sarcopenia has been defined as the coexistence of whole-body sarcopenia and respiratory muscle weakness. We report our experience with preoperative pulmonary rehabilitation, including inspiratory muscle training (IMT), in a patient with lung cancer and comorbid respiratory sarcopenia and COPD. CASE PRESENTATION: A 73-year-old man with squamous cell lung cancer (cStage IA2) was hospitalized for pulmonary rehabilitation before lung resection. He had comorbid severe sarcopenia and COPD (GOLD stage III). He also had inspiratory muscle weakness and a thin diaphragm. We conducted IMT on the patient in addition to aerobic exercise and instruction regarding sputum expectoration for 2 weeks before the surgery. Consequently, his pulmonary function, respiratory muscle strength, and exercise capacity improved. Segmentectomy was performed using video-assisted thoracic surgery. No postoperative complications occurred. CONCLUSION: IMT in a patient with lung cancer and comorbid respiratory sarcopenia and COPD resulted in improved respiratory muscle strength and pulmonary function. IMT may have reduced the risk of PPCs by strengthening the respiratory muscles and improving pulmonary function.

Fibrin monomer complex on postoperative day 1 is correlated with the volume of deep vein thrombosis after knee surgery.

PURPOSE: Patients undergoing knee surgery are at high risk for deep vein thrombosis (DVT), which is infrequent but potentially life-threatening. It has not been identified how to efficiently detect high-risk DVT while minimizing bleeding complications from anticoagulation. We hypothesized that the degree of activation of thrombotic markers may correlate with the size of the thrombus. Therefore, we investigated the correlation between thrombotic markers and DVT thrombus volume in patients after knee surgery. METHODS: This retrospective study involved 29 patients who underwent around knee osteotomy or total / unicompartmental knee arthroplasty from 2018 to 2020. Fibrin monomer complex (FMC) at 1, and 7 days after surgery, and D-dimer at 4, and 7 days after surgery were investigated. In addition, the volume of DVT was estimated with ultrasonography at the 7 days after surgery. Body mass index, surgical time, and total volume of blood loss were also evaluated. Factors related to thrombus volume were examined statistically. RESULTS: Nine patients (31.0%) exhibited asymptomatic distal DVT, whereas 1 patient (3.4%) experienced asymptomatic proximal DVT. No patients had pulmonary embolism. Statistical analysis showed that only FMC concentration on postoperative day 1 was significantly correlated with thrombus volume (p <  0.001, 95% confidence interval 0.41 to 0.839, r = 0.679). CONCLUSIONS: The FMC concentration was a useful early indicator of deep vein thrombosis after knee surgery. Monitoring the FMC concentration could enable selective identification of patients with a high thrombus volume, which is associated with a high risk for pulmonary embolism.

Successful treatment of valgus knee osteoarthritis involving external tibial torsion with a double level osteotomy: A case report.

INTRODUCTION: Abnormal torsion of the lower leg affects the alignment of the knee joint and foot, and causes impairment of both knee joint function and gait. We here present a successful adult case treated with a double level osteotomy at the distal femur and tibia. PRESENTATION OF CASE: A 59-year-old woman complained of right knee pain for three years and had a deformity of her right lower limb since childhood. An advanced right tibial external torsion deformity with valgus alignment was revealed. We performed a double level osteotomy to correct both the valgus knee osteoarthritis and the external tibial torsional deformity. At the 2 year follow-up, the patient could run without pain and sit normally. DISCUSSION: The indications for surgery for abnormal rotation in the lower extremity are also not clear. In addition, most prior surgical reports on torsional deformity of the lower leg have been on childhood cases. Surgical treatment of valgus knee osteoarthritis involving external tibial torsion in adult has been rarely reported. CONCLUSIONS: In our current report, we present an adult case of valgus knee osteoarthritis involving external tibial torsion that was successfully treated using a double level osteotomy. A longer follow-up is still needed however despite these positive outcomes. LEVEL OF EVIDENCE: Ⅴ.

Snapping Pes Syndrome Caused by the Gracilis Tendon: Successful Selective Surgery with Specific Diagnosis by Ultrasonography.

We report the case of painful snapping pes syndrome caused by the gracilis tendon. A 26-year-old man presented with acute right knee pain and restricted extension. Although snapping could not be reproduced due to severe pain, the snapping of the gracilis tendon could be specifically diagnosed using ultrasonography and lidocaine injection. Because of the failure of conservative treatment, surgery was performed. The distal attachment of the gracilis tendon was released, and the symptom disappeared quickly. There was no recurrence at the 10-month follow-up.

Short-Term Results of Hybrid Closed-Wedge High Tibial Osteotomy: A Case Series with a Minimum 3-Year Follow-up.

PURPOSE: High tibial valgus osteotomy (HTO) is a well-established surgical procedure for patients with medial compartment osteoarthritis (OA) of the knee. The hybrid closed-wedge HTO (CWHTO) procedure permits extensive correction in patients with severe deformities or patellofemoral joint OA. The aim of this study was to report the short-term results in a consecutive series of patients treated with hybrid CWHTO. MATERIALS AND METHODS: We retrospectively evaluated the clinical outcomes and radiographic parameters in 29 consecutive knees that underwent hybrid CWTHO to correct medial compartment OA at an average follow-up of 52.6 months. Clinical outcomes were assessed using the Lysholm score and knee scoring system of the Japanese Orthopedic Association (JOA). The Kellgren-Lawrence grading system and pre- and postoperative mechanical axis (MA), femorotibial angle (FTA), posterior tibial slope, and patella height were assessed. RESULTS: The FTA and MA significantly changed from 180.7° to 170.4° and from 22.0° to 60.2°, respectively. No significant differences were observed between the mean pre- and postoperative posterior tibial slope, Insall-Salvati ratio, or Caton-Deschamps index. The postoperative JOA and Lysholm scores significantly improved from 76.7 to 95.8 and from 58.8 to 90.2, respectively. CONCLUSIONS: Satisfactory outcomes can be achieved with hybrid CWHTO in patients with medial OA.

Arthroscopic quadriceps tendon repair: two case reports.

Recently, although some studies of open repair of the tendon of the quadriceps femoris have been published, there have been no reports in the literature on primary arthroscopic repair. In our present study, we present two cases of quadriceps tendon injury arthroscopically repaired with excellent results. Case 1 involved a 68-year-old man who was injured while shifting his weight to prevent a fall. MRI showed complete rupture at the insertion of the patella of the quadriceps tendon. The rupture was arthroscopically repaired using both suture anchor and pull-out suture fixation methods via bone tunnels (hereafter, pull-out fixation). Two years after surgery, retearing was not observed on MRI and both Japan Orthopedic Association (JOA) Knee and Lysholm scores had recovered to 100. Case 2 involved a 50-year-old man who was also injured when shifting his weight to prevent a fall. MRI showed incomplete superficial rupture at the insertion of the patella of the quadriceps tendon. The rupture was arthroscopically repaired using pull-out fixation of six strand sutures. One year after surgery, MRI revealed a healed tendon and his JOA and Lysholm scores were 95 and 100, respectively. Thus, arthroscopic repair may be a useful surgical method for repairing quadriceps tendon injury.

Congenital lumbar spinal stenosis with ossification of the ligamentum flavum in achondroplasia: a case report.

INTRODUCTION: Achondroplasia is a genetic disorder of bone growth. Congenital spinal stenosis is a well-known complication of this disease, but, to the best of our knowledge, no cases involving combined stenosis with congenital lumbar spinal stenosis and ossification of the ligamentum flavum in achondroplasia have been reported previously. In this report, we describe a case of a patient with congenital spinal stenosis with achondroplasia combined with ossification of the ligamentum flavum at the lumbar spine, which we treated with decompressive surgery. CASE PRESENTATION: A 75-year-old Japanese woman with achondroplasia was unable to walk due to a neurological deficit of the lower extremities caused by congenital spinal stenosis that resulted from achondroplasia and ossification of the ligamentum flavum at the lumbar spine. Congenital spinal stenosis was observed from L1 to L5, and ossification of the ligamentum flavum was identified from L1/2 to L3/4. A decompressive laminectomy from L1 to L5 and removal of the ossification of the ligamentum flavum were performed. The patient's neurological symptoms improved after surgery. She could walk with T-cane at the time of her four-year follow-up examination. CONCLUSION: In this report, we describe what is, to the best of our knowledge, the first known published case of ossification of the ligamentum flavum in congenital spinal stenosis associated with achondroplasia at the lumbar spine. Although resection of the ossification of the ligamentum flavum at the congenital spinal stenosis at the lumbar spine was technically difficult because of congenital narrowing of the spinal canal, thickening of the lamina and adhesion of the ossified ligamentum flavum, a wide laminectomy and resection of the ossification of the ligamentum flavum resulted in acceptable improvement of the patient's neurological symptoms.