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.

A novel technique for stabilising sacroiliac joint dislocation using spinal instrumentation: technical notes and clinical outcomes.

PURPOSE: Currently, sacroiliac joint dislocations, including crescent fracture-dislocations, are treated using several techniques that have certain issues. We present the technical details and clinical outcomes of a new technique, anterior sacroiliac stabilisation (ASIS), performed using spinal instrumentation. METHODS: ASIS is performed with the patient in a supine position via the ilioinguinal approach. The displacements are reduced and fixed by inserting cancellous screws from the sacral ala and iliac brim; the screw heads are bridged using a rod and locked. We performed a retrospective review of patients with iliosacral disruption who underwent ASIS between May 2012 and December 2020 at two medical facilities. The patients were assessed for age, sex, injury type, associated injuries, complications, functional outcome by evaluating the Majeed pelvic score after excluding the sexual intercourse score and fracture union. RESULTS: We enrolled 11 patients (median age: 63 years). The median operative time was 195 min, median blood loss was 570 g, and eight patients (72.3%) required blood transfusion. The sacral and iliac screws had a diameter of 6.0-8.0 mm and 6.2-8.0 mm, and a length of 50-70 mm and 40-80 mm, respectively. Bone union was achieved with no marked loss of reduction in the median follow-up period of 12 months in all cases. The median Majeed score at the final follow-up was 85/96. CONCLUSION: ASIS is a rigid internal fixation method that provides angular stability. Despite invasiveness issues compared to iliosacral screw fixation, this method is easy to confirm and achieves precise reduction.

Paradoxical Embolization of the Bilateral Subclavian Arteries After High Tibial Osteotomy.

A patent foramen ovale provides a portal through which a thrombus might pass from the right side of the circulation to the left. A 65-year-old man underwent high tibial osteotomy after the diagnosis of the right knee osteoarthritis. On postoperative day 12, he developed bilateral arm paresthesia. Enhanced CT revealed emboli in the bilateral pulmonary and subclavian arteries and deep vein thrombosis in the left lower limb. Transesophageal echocardiography after treatment revealed a patent foramen ovale during the Valsalva maneuver. It was thought that bilateral arm paresthesias were caused by the arterial emboli in the bilateral subclavian arteries.

Functional Outcomes in Volar-Displaced Distal Radius Fractures Patients with Marginal Rim Fragment Treated by Volar Distal Locking Plates.

Background Treatment of volar-displaced distal radius fractures (DRF) accompanied by marginal rim fragment has recently been actively discussed. It is difficult to obtain a sufficient buttress effect on this fragment. Therefore, we actively apply a distal volar locking plate (DVLP) to fractures with this fragment. Here, we report the treatment outcomes and caveats of surgery of fractures with this fragment. Materials and Methods The subjects were 32 patients (male: 11, female: 21, and mean age: 59.4 years) with volar dislocated DRF accompanied by the marginal rim fragment treated using DVLP. The fracture type of AO classification was B3 in 6 patients, C1 in 12, C2 in 6, and C3 in 8. Results The mean duration of follow-up was 13.8 (12-30) months. The plate could be covered with the pronator quadratus muscle in surgery in all patients. On the final follow-up, visual analog scale score was 1.4/10, quick disabilities of the arm, shoulder, and hand score was 9.2/100, and the Mayo wrist score was 93.7/100. No complication was observed in the soft tissue, such as the nerves and flexor tendons. Conclusion The factor determining retention of the reduction position of the marginal rim fragment is a sufficient buttress effect, and DVLP is a useful implant in terms of this point.

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.

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.

Surgical Treatment of Distal Radius Fractures under the Ultrasound-Guided Brachial Plexus Block Performed by Surgeons.

Background: The upper limb surgery under the ultrasound-guided brachial plexus block is becoming popular due to its safety, effectiveness, and convenience. However, the uneven distribution of anesthesiologists become a social problem. Ultrasound-guided brachial plexus block by surgeons has been widespread especially in hand surgeons. We report the surgical treatment of distal radius fractures under the ultrasound-guided brachial plexus block performed by surgeons in our hospital. Methods: The subjects were 101 patients (41 males and 60 females, average age 61.6 years) who underwent surgery for distal radius fractures under ultrasound-guided brachial plexus block administered by orthopedists at our university or related facilities between January 2014 and June 2016. Brachial plexus block was administered through the supraclavicular approach. The time from initiation of anesthesia to initiation of surgery, mean operative time, the presence or absence of additional anesthesia (local infiltration anesthesia, intravenous anesthesia, and general anesthesia), and complications were evaluated. Results: The mean time from brachial plexus block to initiation of surgery was 35.7 (20-68) minutes, and the mean operative time was 90.5 (35-217) minutes. Surgery was completed with brachial plexus block alone in 62 patients (61.4%), and additional anesthesia was necessary in 39 patients (38.6%). Furthermore, general anesthesia was employed in 6 patients (5.9%). No serious complications occurred. Conclusions: According to our results, the operation could be completed with brachial plexus block alone and additional local infiltration anesthesia or intravenous anesthesia in 94.1% (95 cases). However, 6 cases (5.9%) shifted to general anesthesia. Although it needs training, we consider that hand surgery including distal radius fractures treatment under the ultrasound-guided brachial plexus block is possible. On the other hand, cooperation or a cooperative system with anesthesiologists is necessary for surgeons to administer this anesthesia.

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.

Attrition rupture of ulnar nerve in a patient with rheumatoid elbow arthritis: A case report.

RATIONALE: Cubital tunnel syndrome has been recognized as a common pathology in rheumatoid arthritis (RA) of the elbow. We encountered a patient with RA of the elbow showing attrition rupture of the ulnar nerve. This pathology is extremely rare, and we discussed preventive measures for similar cases in the future based on our case. PATIENT CONCERNS: A 53-year-old woman, received drug treatment for RA since 30 years earlier, had numbness in the left ulnar nerve territory, dorsal interossei muscle atrophy, and resulting claw hand. DIAGNOSES: Plain x-ray examination showed bone destruction of the left elbow joint and marked osteophyte formation in the medial joint space. In nerve conduction velocity (NCV) tests, the Motor NCV was immeasurable in the ulnar nerve territory. Based on these findings, a diagnosis of left cubital tunnel syndrome was made, and anterior transposition of the ulnar nerve was planned. INTERVENTIONS: When the ulnar nerve dissection was advanced, about 80% portion of the ulnar nerve was ruptured. After the ends of the divided nerve were freshened, end-to-end anastomosis was possible by anterior transposition of the ulnar nerve. OUTCOMES: Two years after the operation, numbness and muscle atrophy also remained. There were no changes in the level of daily activities after the operation. However, motor NCV, showed improvement (22.8 m/s) after the operation. LESSONS: In patients with RA showing ulnar neuropathy symptoms, marked osteophyte formation in the medial joint space or valgus deformity may indicate attrition nerve rupture. In the future, when such patients with RA are examined, active nerve exposure and dissection should be considered in terms of ulnar nerve protection.

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.

"Within ring"-based sacroiliac rod fixation may overcome the weakness of spinopelvic fixation for unstable pelvic ring injuries: technical notes and clinical outcomes.

PURPOSE: Spinopelvic fixation and triangular osteosynthesis give firm internal fixation for unstable pelvic ring injuries (UPRI), but with sacrifice of mobility of the lumbar spine. Here, we describe the procedure and outcomes of a new approach, which we refer to as "within ring"-based sacroiliac rod fixation (SIRF). METHODS: The patient was placed in a prone position and longitudinal skin incisions were made at the medial margins of the bilateral posterior superior iliac spines (PSIS). After reduction of fracture, a pedicle screw was inserted into the first sacral vertebra on the injured side and iliac screws inserted through the bilateral PSIS were bridged using rods. RESULTS: SIRF was performed in 15 patients. The AO/OTA classification was 61-B2.3 in 1, C1.3 in 4, C2.3 in 7, C3.3 in 1, and H-type spinopelvic dissociation in two cases. The mean operative time was 179 (110-298) minutes, mean blood loss was 533 (100-2700) cc. One patient died during hospitalization and three patients stopped outpatient treatment. The other 11 patients achieved bone union without major loss of reduction in a mean post-operative follow-up period of 23.8 (4-50) months. The mean Majeed score at final follow-up was 86.7 (73-96) out of 96, excluding scoring sexual intercourse. CONCLUSIONS: "Within ring"-based SIRF not including the lumbar spine in the fixation range is a simple, safe, and low-invasive internal fixation method for UPRI.

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.

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.

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.

Difficulty in Fixation of the Volar Lunate Facet Fragment in Distal Radius Fracture.

Recent reports suggest the presence of a rare fracture type for which reduction and fixation cannot be achieved with volar locking plate (VLP). In particular, it is difficult to achieve reduction and fixation with volar lunate facet (VLF) fragments present on the volar ulnar aspect of the lunate facet, because of the anatomical structure and biomechanics in this region. Herein, we report two challenging cases of difficulty in fixation of the VLF fragment in distal radius fracture. For this fracture type, it is most important to identify the volar ulnar bone fragment before surgery; it may also be necessary to optimize distal placement of the VLP via a dual-window approach and to apply additional fixations, such as a small plate, anchor, and/or external fixation.

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.

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.