A nerve-to-implant distance as a novel predictor for lateral femoral cutaneous nerve injuries after anterior subcutaneous pelvic internal fixation.

Although anterior subcutaneous pelvic internal fixation is a valuable tool for the reduction and fixation of unstable pelvic ring injuries, lateral femoral cutaneous nerve irritation by the implant is the most common complication. This study aimed to investigate the association between the nerve-to-implant distance and the postoperative lateral femoral cutaneous nerve symptom. Patients who underwent anterior subcutaneous pelvic internal fixation between 2016 and 2019 were retrospectively analyzed. Lateral femoral cutaneous nerve status was defined as follows: not identified, nerve-to-implant distance <13 mm, and ≥13 mm. The proportion of patients who experienced postoperative nerve disorders was compared using the nerve status. Nerve-to-implant distances were compared using the presence or absence of postoperative lateral femoral cutaneous nerve disorders. The predictive value of a nerve-to-implant distance of 13 mm for postoperative nerve disorders was assessed. Overall, 26 lateral femoral cutaneous nerves were included. Ten patients had postoperative nerve disorders, of which seven had an nerve-to-implant distance <13 mm, while the other three occurred in patients whose nerves were not identified. A nerve-to-implant distance ≥13 mm was significantly associated with a decreased risk of postoperative nerve disorder compared to a nerve-to-implant distance <13 mm (p = 0.017). A nerve-to-implant distance ≥13 mm had a perfect sensitivity (100%) and modest specificity (58.3%). Nerve-to-implant distance was ≥13 mm. Nerve disorders were frequently observed when the nerve-to-implant distance was <13 mm or the nerve was not identified intraoperatively. Efforts to identify the lateral femoral cutaneous nerve may be useful to avoid internal fixation-related nerve disorders.

A rare case of the axillary necrotizing fasciitis.

Necrotizing fasciitis is a rapidly progressive, life-threatening soft tissue infection that needs acute surgical intervention and other types of supportive care. The upper extremities are a less frequent site for this infection than the lower extremities. Axillary necrotizing fasciitis is quite rare and bears a high risk of iatrogenic neurovascular injuries. We report a severe case of a 39-year-old man with a right axillary necrotizing fasciitis caused by Streptococcus pyogenes. While dealing with important nerves and blood vessels at the initial emergency surgery, we marked and preserved them with vascular tapes. The patient underwent several surgical interventions for infection control in addition to supportive care to avoid limb loss and to survive. Intraoperatively, the locations of nerves and vessels could be easily found by checking the vessel tapes. Twelve months after the initial admission, the patient had no symptoms of nerve injuries and resumed work. With necrotizing fasciitis, the risk of an iatrogenic nerve injury exists even if limb amputation is avoided due to repeated debridement. We report that marking and preserving nerves and blood vessels with vascular tapes at the initial surgery may make the subsequent ones easier and may reduce iatrogenic neurovascular injury.

Incidence and Risk Factors for Fracture-Related Infection After Peri-Prosthetic Femoral Fractures: A Multicenter Retrospective Study (TRON Group Study).

Background: Fracture-related infection (FRI) sometimes occurs with peri-prosthetic femoral fracture (PPF) treatment. Fracture-related infection often leads to multiple re-operations, possible non-union, a decreased clinical function, and long-term antibiotic treatment. In this multicenter study, we aimed to clarify the incidence of FRI, the causative organisms of wound infection, and the risk factors associated with post-operative infection for PPF. Patients and Methods: Among 197 patients diagnosed with peri-prosthetic femoral fracture who received surgical treatment in 11 institutions (named the TRON group) from 2010 to 2019, 163 patients were included as subjects. Thirty-four patients were excluded because of insufficient follow-up (less than six months) or data loss. We extracted the following risk factors for FRI: gender, body mass index, smoking history, diabetes mellitus, chronic hepatitis, rheumatoid arthritis, dialysis, history of osteoporosis treatment, injury mechanism (high- or low-energy), Vancouver type, and operative information (waiting period for surgery, operation time, amount of blood loss, and surgical procedure). We conducted a logistic regression analysis to investigate the risk factors for FRI using these extracted items as explanatory variables and the presence or absence of FRI as the response variable. Results: Fracture-related infection occurred after surgery for PPF in 12 of 163 patients (7.3%). The most common causative organism was Staphylococcus aureus (n = 7). The univariable analysis showed differences for dialysis (p = 0.001), Vancouver type (p = 0.036), blood loss during surgery (p = 0.001), and operative time (p = 0.001). The multivariable logistic-regression analysis revealed that the patient background factor of dialysis (odds ratio [OR], 22.9; p = 0.0005), and the operative factor of Vancouver type A fracture (OR, 0.039-1.18; p = 0.018-0.19) were risk factors for FRI. Conclusions: The rate of post-operative wound infection in patients with a PPF was 7.3%. Staphylococcus was the most frequent causative organism. The surgeon should pay attention to infection after surgery for patients with Vancouver type A fractures and those undergoing dialysis.

Posterior sternoclavicular joint dislocation with thoracic costovertebral joints fracture-dislocations: A case report.

Case: A 59-year-old man presented with posterior sternoclavicular joint dislocation concomitant with fracture-dislocations of multiple thoracic costovertebral joints caused by traumatic injury. The posterior sternoclavicular joint dislocation was treated using an ultra-high molecular weight polyethylene fiber cable and the joint was stabilized. The degree of malpositioning of the thoracic costovertebral joints was difficult to reduce. Conclusion: The patient achieved an excellent shoulder range of motion at 12 months postoperatively; however, chronic shoulder stiffness and posterior neck discomfort persisted.

Total Hip Arthroplasty With Impacted Bone Graft on Acetabulum for Osteoporotic Acetabular Fractures: A Report of 3 Cases.

Osteoporotic acetabular fractures in elderly patients have recently been increasing, but the best treatment remains uncertain due to the difficulty in stabilizing these fractures with osteosynthesis. We performed total hip arthroplasty with an impacted bone graft on the acetabula of 3 elderly patients with comminuted acetabular fractures after confirming acetabular callus formation via radiographic imaging 2 months following the patients' initial injuries. Two of the patients presented in the subacute phase after conservative treatment, and 1 patient had no history of trauma or quadrilateral surface destruction. Two patients achieved good functional results at the 3-year follow-up. Furthermore, no loosening of the prosthesis components or subsidence of the acetabular cemented cup was evident on radiographic imaging in any of the patients.

Use of Triceps Tendon and Paratenon Composite Graft for Extensor Tendon Reconstruction in the Hand: A Case Report.

An extensor tendon defect in the hand requires reconstruction to restore extension. We report a 44-year-old woman with a 24-mm extensor tendon defect of the middle finger over the dorsum of the hand that was reconstructed using a composite graft consisting of the triceps tendon and paratenon. This composite graft from the posterior aspect of the distal arm is simple, safe and may be considered in extensor tendon reconstruction. Level of Evidence: Level V (Therapeutic).

Peripherally Inserted Central Catheter-Related Infectious Myositis: A Case Report.

BACKGROUND Peripherally inserted central catheters (PICCs) are commonly used by clinicians in daily practice as a safe and reliable alternative to central venous catheters. While there are advantages to the use of PICCs, such as a low insertion-related complication rate and cost-effectiveness, using PICCs may expose patients to life-threatening severe complications such as a central line-associated bloodstream infection and deep venous thrombosis (DVT). There have been no reports of infectious myositis associated with PICC insertion. CASE REPORT We report a case of infectious myositis related to PICC insertion complicated by brachial DVT in a 43-year-old immunocompromised patient with myelodysplastic syndrome. Despite the administration of broad-spectrum antibiotics, the patient's condition did not improve. He developed septic shock and required emergency excision of the infected and necrotic muscles. Although the pathogen responsible for the infection was unknown, infectious myositis and myonecrosis were observed intraoperatively. Furthermore, histopathological examination revealed evidence of infectious myositis in the biceps brachii and brachial muscles. The septic shock resolved with treatment and the patient survived with residual elbow joint dysfunction. CONCLUSIONS We present a case of infectious myositis related to PICC insertion. We believe that urgent resection of infected and necrotic tissues, rather than broad-spectrum antimicrobial therapy alone, was essential to save the patient's life.

Surgical fixation of ulnar coronoid process fractures via mesh plate: A case report.

Introduction: The coronoid process of the ulna is the primary stabilizer of the elbow joint. There has not yet been an accurate off-the-shelf dedicated implant because fragments of coronoid process fractures are often small and diverse. The variable angle locking compression mesh plate 2.4/2.7 (Depuy Synthes, West Chester, PA, USA) acts as a versatile, low-profile implant that can be cut to suit the specific fracture pattern and fits anatomically. Case presentations: We report two cases of Regan-Morrey type II ulnar coronoid process fractures in terrible triad elbow injuries. In both cases, persistent instability was fluoroscopically diagnosed after repair of the lateral structures. We performed osteosynthesis for the ulnar coronoid process fractures using a mesh plate, which we cut into a rhombus-like shape and used as a buttress plate. Here we report the good results obtained thereof. Conclusion: Considering our positive experience with using mesh plates, the mesh plate may be a good method of fixation for ulnar coronoid process fractures.

The First Fatal Case of Chromobacterium violaceum Infection in Japan.

BACKGROUND Chromobacterium violaceum (C. violaceum) is a gram-negative and facultative anaerobic oxidase-positive bacillus generally seen in tropical or subtropical areas (latitudes between 35°N and 35°S). C. violaceum infection is a rare but serious infection with high morbidity and mortality rates. Most clinicians practicing in non-tropical counties, such as Japan, are unfamiliar with it. CASE REPORT We report the first fatal case of a 49-year-old man infected with C. violaceum after a traffic accident in Japan (latitude 34.8°N). The patient reported brief submergence in a marshy muddy rice field after the accident. There was some evidence of soil and water contamination of the patient's skin and clothing, but he denied swallowing water or soil. There were no findings of pneumonitis or severe open wounds on admission. Until the night of the 7th day of hospitalization, his general conditions remained stable despite a persistent fever. However, he suddenly collapsed on the 8th day of hospitalization and died. C. violaceum bacteremia led to fatal sepsis on dissemination to the iliopsoas abscess, which is a rare combination for this infection. CONCLUSIONS Episodes of exposure to contaminated water or soil, especially in summer, are important predisposing factors for C. violaceum infection. Thus, it is vital to include C. violaceum infections as a differential diagnosis, since the mortality rate of C. violaceum infections is high and the cases of this infection have increased in non-tropical counties.

An intraoperative small distractor for non-open reduction and intramedullary fixation of pediatric displaced diaphyseal forearm fractures.

This report describes technical tools for the treatment of pediatric displaced and unstable diaphyseal forearm fractures, which are difficult to treat by manual closed reduction. During intramedullary fixation with Kirchner wires, we propose our original small distractor as an intraoperative distraction apparatus without open reduction. This apparatus is made using parts of the Ilizarov external fixator. Apart from general external fixation devices, our apparatus is adequate for the effective shortening and lateral dislocation of the fracture site. This adequacy is not only because of the three-dimensional control by ball joints but also owing to the gradual adjustment structure of the Quick adjust strut (Orthofix, Verona, Italy), which allows tight and fine stretching, thus making the distractor an effective reduction tool. Our findings show the feasibility and usefulness of our reduction technique and small distractor. Our small distractor is a useful intraoperative distraction apparatus without open reduction for pediatric displaced and unstable diaphyseal forearm fractures that cannot be treated by manual closed reduction. In this report, we describe the distractor, the closed reduction technique, and the clinical results of four representative cases.

A Young Boy with Neck Pain.

CASE PRESENTATION: A five-year-old boy presented to our emergency department with severe posterior neck pain that was exacerbated upon neck movement. Cervical spine radiography revealed calcification in the cervical intervertebral disk 3-4. DISCUSSION: Pediatric idiopathic intervertebral disk calcification is a benign, rare condition that might be complicated by associated severe neurological symptoms. In this case, the symptoms gradually subsided with conservative management alone.

Adolescent Male with Severe Groin Pain Due to Traumatic Injury.

CASE PRESENTATION: A 14-year-old boy presented to the emergency department complaining of severe groin pain on the right side following a minor fall. Computed tomography and magnetic resonance imaging revealed a hematoma in his right iliacus muscle. He was diagnosed with a traumatic iliacus hematoma, and he recovered spontaneously with short-term oral analgesics. DISCUSSION: Traumatic iliacus hematomas are rare entities and subside with conservative management in most cases. However, this condition may be associated with femoral nerve palsy, and surgery is indicated in severe cases. Traumatic iliacus hematoma should be considered in the differential diagnosis of severe groin pain.

Surgical fixation by mesh plate and intraoperative safe techniques for the manubrium sterni.

Plate osteosynthesis for oblique fracture of the manubrium sterni is quite rare. We present a case of a 37-year-old man with oblique fracture of the manubrium sterni caused by a traumatic injury. He was operated on using a variable-angle locking compression plate Mesh Plate 2.4/2.7 and had a good postoperative result. We also discuss intraoperative safe techniques such as use of a cement spatula for reduction support tools and depth-limited drilling to prevent excess drilling of the opposite cortex.

Plate fixation of acromion fracture using a mesh plate.

In several cases of treatment of acromion fractures of the scapula, plate fixation provides more rigidity to the fractured area. However, no specific plates are available for the acromion because of high interindividual variation in the shape of the acromion. We report two cases of acromion fractures operated using a mesh plate (Depuy Synthes, West Chester, PA, USA), which acts as a versatile, low-profile implant, being cut according to the specific fracture pattern and anatomical fitting. Our positive experiences with using a mesh plate may help to establish it as the operative procedure of choice in cases of acromion fracture.

Early head penetration into cemented Hylamer Ogee socket.

The authors reviewed 18 consecutive cemented total hip arthroplasties with the Hylamer Ogee socket. The average follow-up period was 47 months. All Hylamer Ogee sockets were sterilized by gamma irradiation in air, and the average period from production to surgery was 12 months. Two-dimensional penetration of the femoral head into the Hylamer Ogee socket was determined from anteroposterior radiographs of the pelvis using a digitizer. The average head penetration rate of the present series was 0.36 mm/y. Osteolysis around both components was found in 6 cases (30%). Of 4 cases defined as aseptic loosening, 2 were revised during the follow-up period. To detect component loosening because of catastrophic high wear of the cemented Hylamer Ogee socket as early as possible, precise radiographic follow-up is essential.

Biological reaction to alumina, zirconia, titanium and polyethylene particles implanted onto murine calvaria.

Periprosthetic osteolysis is a serious problem that limits long-term survival of total hip arthroplasty. Ceramics have been introduced as a joint surface material to reduce osteolysis due to wear particles. The aim of this study is to investigate the biological reaction of ceramic particles on murine calvarial bone, in comparison with polyethylene and titanium particles. Sixty CL/BL6 mice were divided into five groups according to the materials implanted onto the murine calvariae: control, Al(2)O(3), ZrO(2), high-density polyethylene (HDP) and Ti6Al4V. One week after the implantation, each calvarial tissue was dissected and the release of proinflammatory mediators (IL-1beta, IL-6, TNF-alpha) and bone resorption were assessed. The particles of HDP and Ti6Al4V induced three and two times larger osteolytic lesions than the control, respectively. The levels of IL-1beta and IL-6 were significantly elevated in the medium subcultured with the calvariae of HDP and Ti6Al4V groups. Any particle type did not increase the levels of TNF-alpha. There were no significant differences observed in the levels of proinflammatory mediators or osteolytic area among Al(2)O(3), ZrO(2) and control groups. The inflammatory response and bone resorption induced by ceramic particles were much smaller than those induced by HDP and Ti6Al4V. These biological features suggest the biocompatibility of ceramics as a joint surface material for artificial joints.

Total hip arthroplasty for a patient with angel-shaped phalango-epiphyseal dysplasia (ASPED). A case report.

Angel-shaped phalango-epiphyseal dysplasia is characterized by the angel shape of the middle phalanx and severe coxarthrosis in adult life. This osteochondrodysplasia shows a further variety of heterogeneous multiple epiphyseal dysplasias. It also shows a late and dysplastic development of the femoral head that leads to osteoarthrotic changes with severe hip pain and gait disturbance. In this report, we show a 35-year-old female with Angel-shaped phalango-epiphyseal dysplasia that was treated by bilateral total hip arthroplasty. She has suffered from her coxalgia since she was 27 and since the age of 30 has been able to walk with the aid of crutches. The radiographs of her bilateral hip showed severe osteochondrotic changes with a progressive disappearance of the joint space. Total hip arthroplasties were performed to treat the osteoarthrosis on the bilateral hip joint due to Angel-shaped phalango-epiphyseal dysplasia. One year after surgery, she is pain-free, and able to walk with a cane. Based on this case, we propose that total hip arthroplasty should be considered one of the treatments for the coxopathy in patients with Angel-shaped phalangoepiphyseal dysplasia.