Anatomical quantitative evaluation of popliteal artery visualization during medial approach in supine position.

PURPOSE: The medial approach to the popliteal artery has been less commonly used than the posterior approach in surgical repair of traumatic popliteal injury. This study was performed to quantitatively evaluate the visual field of the popliteal artery obtained by staged myotendotomy in the medial approach to the popliteal artery. METHODS: Twenty legs of fresh-frozen adult cadavers were dissected using the medial approach to the popliteal artery. In stage 1, the popliteal artery was exposed between the vastus medialis and sartorius muscles without myotendotomy. In stage 2, the medial head of the gastrocnemius muscle was dissected. In stage 3, the tendons of the sartorius and semimembranosus muscles were dissected. In stage 4, the tendons of the gracilis and semitendinosus muscles were dissected to fully expose the popliteal artery. The length of the popliteal artery that could be visualized in each stage was measured. RESULTS: The anatomical length of the popliteal artery from the hiatus of the adductor magnus to the tendinous arch of soleus muscle ranged from 15 to 20 cm (mean, 16.3 cm). On average, 45%, 59%, 72%, and 100% of the popliteal artery were visualized in stage 1, 2, 3, and 4, respectively. CONCLUSIONS: The medial approach to the popliteal artery has the advantage of being performed in the supine position, but it requires multiple myotendotomies around the knee. The results of this study may serve as a reference for myotendotomy depending on the site of injury to the popliteal artery.

Recurrence of kyphotic deformity following implant removal in pediatric pure discoligamentous Chance-type injury: A case report.

Pediatric pure discoligamentous Chance-type injury is relatively rare and the appropriate surgical method has not yet been established, particularly, whether spinal fixation with fusion or without fusion is more effective. This case report describes a 10-year-old-boy who sustained an L2-3 pure discoligamentous Chance-type injury following a car accident and underwent an L2-3 posterior fixation without fusion. The implants were removed after eight months of an uneventful postoperative course. However, four months later, the kyphotic deformity recurred. Although the deformity gradually progressed over nine months, the patient remained neurologically intact and asymptomatic. This report suggests that fixation without fusion may not be appropriate in pediatric patients with pure discoligamentous Chance-type injuries. Spinal fixation with fusion may be recommended to prevent loss of correction and ensure secure stabilization.

Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period.

Purpose: Successful cardiopulmonary resuscitation is associated with a high incidence of chest wall injuries. However, few studies have examined chest wall injury as a risk factor for respiratory complications after cardiopulmonary resuscitation. Therefore, herein, we investigated the association of multiple rib fractures on the incidence of post-resuscitation pneumonia. Methods: This single-centre retrospective cohort study enrolled adult, nontraumatic, out-of-hospital cardiac arrest patients who maintained circulation for more than 48 h between June 2015 and May 2019. Rib fractures were evaluated by computed tomography on the day of hospital admission. The association with newly developed pneumonia within 7 days of hospitalisation was analysed using a Fine-Gray proportional hazards regression model adjusted for the propensity score of multiple rib fractures estimated from age, sex, presence of witnessed status, bystander CPR, initial rhythm, and total CPR time and for previously reported risk factors for pneumonia (therapeutic hypothermia and prophylactic antibiotics). Results: Overall, 683 patients with out-of-hospital cardiac arrest were treated; 87 eligible cases were enrolled for analysis. Thirty-two (36.8%) patients had multiple rib fractures identified on computed tomography, and 35 (40.2%) patients developed pneumonia. The presence of multiple rib fractures was significantly associated with a higher incidence of pneumonia, consistently both with and without adjustment for background factors (unadjusted hazard ratio 4.63, 95% confidence interval: 2.35-9.13, p < 0.001; adjusted hazard ratio 4.03, 95% confidence interval: 2.08-7.82, p < 0.001). Conclusions: Multiple rib fractures are independently associated with the development of pneumonia after successful resuscitation.

Treatment of painful median nerve neuroma using pedicled vascularized lateral antebrachial cutaneous nerve with adipofascial flap: a cadaveric study and exploration of clinical application.

The most common procedure for the treatment of painful median nerve neuroma is coverage with vascularized soft tissue following external neurolysis. However, the ideal treatment should include reconnecting the proximal and distal stumps of the damaged nerve to allow the growth of regenerating axons to their proper targets for a functional recovery. We developed a useful technique employing radial artery perforator adipofascial flap including the lateral antebrachial cutaneous nerve (LABCN) to repair the median nerve by vascularized nerve grafting and to achieve coverage of the nerve with vascularized soft tissue. In an anatomical study of 10 fresh-frozen cadaver upper extremities, LABCN was constantly bifurcated into two branches at the proximal forearm (mean: 8.2 cm distal to the elbow) and two branches that run in a parallel manner toward the wrist. The mean length of the LABCN branches between the bifurcating point and the wrist was 18.2 cm, which enabled inclusion of adequate length of the LABCN branches into the radial artery perforator adipofascial flap. The diameters of the LABCN branches (mean: 1.7 mm) were considered suitable to bridge the funiculus of the median nerve defect after microsurgical internal neurolysis. In all cadaver upper extremities, the 3-cm median nerve defect at the wrist level could be repaired using the LABCN branches and covered with the radial artery perforator adipofascial flap. On the basis of this anatomical study, the median nerve neuroma was successfully treated with radial artery perforator adipofascial flap including vascularized LABCN branches.

Minimally invasive 360-degree pelvic ring fixation using a combination of crab-shaped fixation and pelvic internal fixator for unstable pelvic ring fracture: A case report.

Surgery with both anterior and posterior fixation is recommended for unstable pelvic ring fractures; nonetheless, the surgical method remains controversial. Crab-shaped fixation is a minimally invasive and strong posterior fixation method using spinal instruments that can reduce vertical dislocations. The use of pelvic internal fixator as a minimally invasive anterior fixation method has been reported. It is recommended in cases where there is an open wound in the lower abdomen or damage to the pelvic organs. Conversely, to the best of our knowledge, there has been no report on the combined use of crab-shaped fixation and pelvic internal fixator to date. We performed a minimally invasive 360-degree fixation using a combination of crab-shaped fixation and pelvic internal fixator for an unstable pelvic ring fracture (AO-C2) and sacral fracture (Denis zone II) with 15-mm vertical dislocation. The sacral fracture was accompanied by a large bone fragment in the spinal canal, which was suspected to have caused neuropathy. Therefore, in addition to posterior fixation, we performed decompression and removed the bone fragment. Postoperative computed tomography revealed that the sacral vertical dislocation was reduced to 7.5 mm. The patient started getting out of bed on postoperative day 2. His neuropathy improved after surgery. Owing to abdominal discomfort, pelvic internal fixator was extracted at 3 months postoperatively. Bone fusion was completed, and posterior fixation was removed at 9 months postoperatively. Two years after, the patient walks independently and has returned to work. Minimally invasive 360-degree pelvic ring fixation is a treatment option for an unstable pelvic ring fracture (AO-C2).

A new quantitative assessment method for predicting pneumonia caused by chest wall injury.

BACKGROUND: The severity of rib fractures has been previously evaluated by combining categorical data, but these methods have only low predictive capability for respiratory complications and mortality. This study aimed to establish a more accurate method for predicting the development of pneumonia, a frequent complication in chest injuries, using anatomical relationships. METHODS: We analyzed three-dimensional reconstructed images of 644 consecutive trauma patients who underwent whole-body computed tomography (CT) in our institution within a 36-month study period from April 2017. The anatomical relationship between the right and left thoracic volumes of non-rib fracture patients was used to estimate thoracic volume changes on the injured side in unilateral rib fracture patients. The predictive capability of changes in thoracic volume for the development of pneumonia was evaluated according to the area under the receiver operating characteristic curve and compared with that of previous chest wall severity evaluation methods. RESULTS: Of the 644 patients, 133 and 478 patients had unilateral rib fractures and non-rib fractures, respectively. The amount of change in thoracic volume due to unilateral rib fractures was significantly greater in pneumonia patients (400 mL vs. 160 mL, p < 0.01). The area under the receiver operating characteristic curve for the development of pneumonia was 0.83, which tended to be higher than that of the previous severity scoring methods. CONCLUSION: The amount of change in chest volume, which can be estimated using CT images, has better predictive capability for pneumonia than previous severity assessment methods based on categorical data. The amount of change in chest volume measured using whole-body CT can be used to rapidly determine the optimal treatment for severe chest wall injuries. LEVEL OF EVIDENCE: Prognostic study, level IV.

Intercostal artery rupture associated with thoracic spinal hyperextension injury caused by a minor trauma: A case report.

Diffuse idiopathic skeletal hyperostosis is associated with hyperextension injury of the spine caused by a minor trauma and may often be diagnosed late, thus preventing effective treatment. To date, there have been no reported cases of segmental arterial injury associated with a hyperextension injury caused by a minor trauma in super-elderly patients with diffuse idiopathic skeletal hyperostosis. Herein, we present the findings and treatment provided for a 92-year-old woman with a right massive hemothorax and 12th thoracic vertebral fracture. The patient was diagnosed with diffuse idiopathic skeletal hyperostosis. Bleeding stopped naturally, and we successfully treated the patient using posterior fixation with percutaneous pedicle screws. At 6 months post-surgery, there was no complication, instrumentation failure, or correction loss, and she could walk independently using a cane. To our knowledge, this is the first report of intercostal artery rupture and massive hemothorax associated with diffuse idiopathic skeletal hyperostosis fracture caused by a minor trauma. It is notable that diffuse idiopathic skeletal hyperostosis following a minor trauma in such elderly patients may cause segmental arterial rupture associated with spinal burst fracture and hyperextension injury.

Significance of initial hemoglobin levels in severe trauma patients without prehospital fluid administration: a single-center study in Japan.

OBJECTIVES: Hemoglobin (Hb) levels have been considered to remain stable in the early stages of bleeding due to trauma. However, several studies have reported that rapid compensatory fluid shifts cause Hb dilution earlier than previously thought. These reports are from Western countries where it is standard protocol to administer fluids during an emergency, making it almost impossible to eliminate the effect of prehospital intravenous fluid administration on Hb levels. This study aimed to determine the relationship between Hb levels and severity of injury on arrival at the hospital in severe trauma patients without prehospital intravenous fluid administration. METHODS: This single-center observational retrospective study included patients with Abbreviated Injury Scale scores of 3 or above between 2008 and 2014. In Japan, prehospital life-saving technicians were not allowed to administer intravenous fluids until 2014. We investigated whether the difference between the measured blood Hb level at arrival and the corresponding standard blood Hb level for each age group and sex reported in the national survey was associated with the severity of injury and the need for hemostasis. RESULTS: In total, 250 patients were included in this study (median age, 46 years; male patients, 183). The median time from injury to arrival at the hospital was 45 min, and there was no statistical correlation with the initial Hb level on arrival (ρ=0.092, p=0.14). When the study subjects were stratified into four groups according to the initial Hb levels, lower Hb levels correlated with higher rates of requirement for hemostatic interventions (p=0.02) and mortality (p=0.02). In addition, lower Hb levels were associated with the need for hemostasis. CONCLUSION: In severe trauma patients without prehospital intravenous fluid administration, decreased Hb levels on arrival may be associated with the severity of trauma and with the need for hemostasis. LEVEL OF EVIDENCE: Level IV.

Periprosthetic tibial fracture after total knee arthroplasty with popliteal artery injury-A case report.

We present the case of a 79-year-old woman who presented at our center with a periprosthetic tibial fracture with a popliteal artery injury after total knee arthroplasty. Anastomosis of the popliteal artery was performed on the day of injury, and was later treated by open reduction and internal fixation. The patient was able to walk 3 months after injury. The present case was difficult to treat because of the arterial injury associated with periprosthetic fracture. Although revision of the implant was considered, open reduction and internal fixation was selected because of the severity of soft-tissue damage. The mechanism of injury is not uncommon, and it is expected that similar fractures will become more prevalent in the future as the number of knee replacement surgeries increases.

Minimally invasive spinopelvic "crab-shaped fixation" for unstable pelvic ring fractures: technical note and 16 case series.

BACKGROUND: Unstable sacral fractures are high-energy injuries and comprise polytrauma. Internal fixation to enable withstanding vertical loads is required to get up early from the bed after an unstable sacral fracture. We developed a new minimally invasive surgical (MIS) procedure for unstable pelvic ring fractures and reported it in Japanese in 2010. We presented our minimally invasive surgical technique of crab-shaped fixation for the treatment of unstable pelvic ring fractures and report on its short-term outcomes. METHODS: Sixteen patients with unstable pelvic ring fractures (AO types C1, 2, and 3) were treated using crab-shaped fixation. All procedures were performed with the patient in the prone position through 5-cm skin incisions created bilaterally at the level of the posterior superior iliac spine. Four iliac screws were inserted and connected with two rods under the fascia. Percutaneous pedicle screws were inserted at L5 or L4 and connected to the iliac rod using offset connectors. Fracture reduction was then performed. RESULTS: The average surgical time was 158 min (range, 117-230 min), with an intraoperative bleeding volume of 299 ml (range, 80-480 ml). Thirty-three pedicle screws and 64 iliac screws were implanted with no instance of malpositioning or perforation. A surgical site infection developed in 2 of the 16 cases. Both were deep methicillin-resistant Staphylococcus aureus infections, with the removal of the distal implants required in only one of these cases. Bony union was achieved in all patients, and all vertical displacements reduced by 7.0 mm, on average (range, 5.4-9.0 mm), to < 10 cm. Correction was retained in all cases. CONCLUSIONS: Crab-shaped fixation provides a feasible MIS approach for spinopelvic fixation, which allows good reduction of the vertical displacement of unstable pelvic ring fractures and bony union.

Outcomes after Traumatic Brain Injury with Concomitant Severe Extracranial Injuries.

Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. Patients with TBI frequently sustain concomitant injuries in extracranial regions. The effect of severe extracranial injury (SEI) on the outcome of TBI is controversial. For 8 years, we retrospectively enrolled 485 patients with the blunt head injury with head abbreviated injury scale (AIS) ≧ 3. SEI was defined as AIS ≧ 3 injuries in the face, chest, abdomen, and pelvis/extremities. Vital signs and coagulation parameter values were also extracted from the database. Total patients were dichotomized into isolated TBI (n = 343) and TBI associated with SEI (n = 142). The differences in severity and outcome between these two groups were analyzed. To assess the relation between outcome and any variables showing significant differences in univariate analysis, we included the parameters in univariable and multivariable logistic regression analyses. Mortality was 17.8% in the isolated TBI group and 21.8% in TBI with SEI group (P = 0.38), but the Glasgow Outcome Scale (GOS) in the TBI with SEI group was unfavorable compared to the isolated TBI group (P = 0.002). Patients with SBP ≦ 90 mmHg were frequent in the TBI with SEI group. Adjusting for age, GCS, and length of hospital stay, SEI was a strong prognostic factor for mortality with adjusted ORs of 2.30. Hypotension and coagulopathy caused by SEI are considerable factors underlying the secondary insults to TBI. It is important to manage not only the brain but the whole body in the treatment of TBI patients with SEI.

Septic arthritis of the wrist caused by Mycobacterium intracellulare: a case report.

Septic arthritis of the wrist is rare entity, especially; atypical mycobacterial infection of the wrist is extremely rare. We report a case of septic arthritis of the wrist caused by Mycobacterium intracellulare, which was successfully treated by radical debridement followed by wrist arthrodesis using vascularised fibular grafting.

Regional tissue oxygen saturation measured by near-infrared spectroscopy to assess the depth of burn injuries.

UNLABELLED: The burn severity depends on the wound depth and area affected. Hitherto burn depth has been judged mainly by visual observation, although concerns have been raised about its validity. The regional tissue blood flow (rTBF) measured by laser Doppler imaging (LDI) in damaged tissue correlates with the depth. However, very few reports are available on the significance of the regional tissue oxygen saturation (rSO2) as an indicator of burn depth. We investigated whether rSO2 by Near-infrared spectroscopy (NIRS) in burn injuries correlates with rTBF by LDI, which would facilitate quantification of the severity of the tissue damage. METHODS: We measured rTBF and rSO2 in 50 lesions from 14 patients of burn injury within 24 hours after injury. The correlation between rTBF and rSO2 was evaluated by Spearman rank correlation analysis. RESULTS: The rSO2 (%; range, 52-82) by NIRS and the rTBF (perfusion unit; range, 61-704) by LDI in burn lesions were positively correlated (r=0.755, p<0.001). This statistically positive correlation still remained significant (r=0.678, p<0.001) after the rSO2 values were standardized. CONCLUSION: This study suggests that NIRS determination of rSO2 in burn injuries shows promise as a reliable and quick method to estimate the depth of burn lesion.

Functional reconstruction of bilateral injuries to the dorsum of hand using radial forearm tendocutaneous flaps.

We treated a patient with skin and tendon defects of both hands as a result of injury by a heat press. There have been no reports of bilateral hand injuries being treated using simultaneous bilateral tendocutaneous flaps. In this case, we reconstructed the injured tissue using simultaneous bilateral radial forearm tendocutaneous flaps, with satisfactory results.

Wrist arthrodesis with vascularized fibular grafting.

Six patients underwent wrist arthrodesis using vascularized fibular grafting for treatment of a segmental bone defect across the wrist. Five patients had defects resulting from excision of a giant cell tumor at the distal radius, and one patient had a defect after debridement of a chronic infection. In all cases, bone union was achieved within 3 to 6 months after vascularized fibular grafting without additional procedures. Measurement of postoperative roentgenograms revealed that the average of fixed wrist angle was 13 degrees extension. Postoperatively, average grip strength on the affected side was 59% of that on the unaffected side, and the average range of forearm rotation was 123 degrees. The mean Enneking functional score was 84% at a mean follow-up period of 64 months. There was no recurrence of a tumor or infection. Wrist arthrodesis using vascularized fibular grafting is a useful procedure for the treatment of a segmental bone defect across the wrist.

Pedicled vascularized bone graft from the medial supracondylar region of the femur for treatment of femur nonunion.

A free vascularized bone graft harvested from the supracondylar region of the femur was used to treat patients with nonunion but without a massive bone defect. This graft is vascularized by the descending genicular artery (DGA). In patients with femur nonunion, pedicled vascularized bone grafts are usable in some cases. To confirm the applicable range of this graft, we performed dissection of the DGAs in 16 lower limbs of eight embalmed cadavers. A pedicled bone graft from the supracondylar region of the femur was harvested and rotated proximally to the femur as far as possible. The distance from the apex of the medial epicondyle to the central point of the transferred bone (DMEB) was measured. DMEBs ranged from 13.0 to 20.0 cm (mean, 17.3). Dividing the DMEB by femoral length we defined as the transposition ratio. Transposition ratios ranged from 0.48 to 0.70 (mean, 0.60). These results showed we could transfer enough graft to a distal half of the femur. This technique has a good indication for intractable nonunion without significant bone defects of the distal half of the femur where conventional techniques are not practical.

Enhancement of osteoblastic differentiation of mesenchymal stromal cells cultured by selective combination of bone morphogenetic protein-2 (BMP-2) and fibroblast growth factor-2 (FGF-2).

It is well known that bone marrow contains mesenchymal stromal cells (MSCs), which can show osteoblastic differentiation when cultured in osteogenic medium containing ascorbic acid, beta-glycerophosphate and dexamethasone. The differentiation results in the appearance of osteoblasts, together with the formation of bone matrix; thus, in vitro cultured bone (osteoblasts/bone matrix) could be fabricated by MSC culture. This type of cultured bone has already been used in clinical cases involving orthopaedic problems. To improve the therapeutic effect of the cultured bone, we investigated the culture conditions that contributed to extensive osteoblastic differentiation. Rat bone marrow was primarily cultured to expand the number of MSCs and further cultured in osteogenic medium for 12 days. The culture was also conducted in a medium supplemented with either bone morphogenetic protein-2 (BMP-2) or fibroblast growth factor (FGF-2), or with sequential combinations of both supplements. Among them, the sequential supplementation of FGF-2 followed by BMP-2 showed high alkaline phosphatase activity, sufficient bone-specific osteocalcein expression and abundant bone matrix formation of the MSC culture. These data implied that the number of responding cells or immature osteoblasts was increased by the supplementation of FGF-2 in the early phase of the culture and that these cells can show osteoblastic differentiation, of which capability was augmented by BMP-2 in the late phase. The sequential supplementation of these cytokines into MSC culture might be suitable for the fabrication of ideal cultured bone for use in bone tissue engineering.