Search

Abstract 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.

Objectives: Chronic kidney disease (CKD) complicated by secondary hyperparathyroidism (SHPT) is associated with an increased risk of fragility fractures. Etelcalcetide (EC) is a treatment for SHPT that reduces serum parathyroid hormone (PTH) levels. However, the effects of combined treatment with osteoporosis drugs such as teriparatide (TPTD) remain unclear. This study investigates the combined effects of EC and TPTD on bone in CKD model rats. Methods: The CKD model was established in 8-week-old male Wistar rats by feeding them a 0.75% adenine diet for 4 weeks. At 20 weeks of age, the rats were divided into 4 groups (N = 9–10 in each group): CKD group (vehicle administration), TPTD group (30 μg/kg, 3 times/week), EC group (0.6 mg/kg, daily), and Comb group (TPTD and EC combined). EC was injected for 12 weeks starting at 20 weeks of age, and TPTD was injected for 8 weeks starting at 24 weeks of age. After treatment, the followings were evaluated: bone mineral density, bone strength, biochemical tests, bone and fat histomorphometry, and micro-computed tomography. Results: In CKD model rats, the combination of EC and TPTD was more effective in increasing cortical bone thickness and bone strength and inhibiting porosity. In addition, the combined treatment decreased bone marrow adiposity and fibrosis, and it increased bone mass and improved bone microstructure in trabecular bone. Conclusions: With the observed benefits such as improved bone mass, bone strength, structural properties, and bone marrow adiposity, combination therapy may be a potential way to improve bone fragility in CKD.

This study evaluated changes over time in skeletal muscle atrophy, expressions of skeletal muscle anabolic and catabolic genes, and mitochondrial activity by skeletal muscle type in an adenine-induced chronic kidney disease (CKD) model. A CKD model was successfully established by feeding male Wistar rats a 0.75% adenine diet for 4 weeks starting at 8 weeks of age. Control and CKD groups were sacrificed at 12 and 20 weeks of age. The back muscles were analyzed histologically, and succinate dehydrogenase (SDH) staining was performed to evaluate mitochondrial activity. Gene expressions of myogenic determination gene number 1 and myogenin as indicators of muscle anabolism, atrogin-1 and muscle RING-finger protein-1 (MuRF1) as indicators of muscle catabolism, and peroxisome proliferator-activated receptor-γ coactivator-1-α as a marker of mitochondrial biogenesis were assessed. Type I and type II muscle cross-sectional areas (CSAs) were decreased at 12 weeks, but type I muscle CSA was recovered at 20 weeks. SDH staining was lower in CKD than in control rats at 12 weeks, but no significant difference was observed at 20 weeks. Increased expressions of myogenin, atrogin-1, and MuRF-1 were observed only at 12 weeks, but no differences were observed at 20 weeks. The adenine-induced CKD rat model appears to show changes in muscle atrophy over time.

Abstract Background Gustilo–Anderson type IIIc tibial open fracture with large bone defects in elderly patients with severe osteoporosis is a rare injury that may be a challenging clinical scenario. Case presentation This study presents the case of a 68-year-old Japanese man who sustained a Gustilo–Anderson type IIIc open tibial fracture with a large bone defect. The patient had severe osteoporosis and the bone was contaminated; therefore, we determined that the bone could not be returned to the tibia. The patient underwent acute limb shortening and gradual lengthening with an Ilizarov external fixator combined with low-intensity pulsed ultrasound and teriparatide administration for limb reconstruction, which allowed immediate full weight-bearing capacity. The fixator was removed at 12 months postoperatively, and by this time, the fracture had completely healed. At the most recent 5-year follow-up after the injury, the patient reported full weight-bearing capacity without walking aids and had full knee and ankle range of motion. Conclusions To the best of our knowledge, this is the first study to report the use of combined Ilizarov technique, low-intensity pulsed ultrasound, and teriparatide for limb reconstruction of Gustilo–Anderson type IIIc open tibial fractures with large bone defects in elderly patients with severe osteoporosis.

Objectives: The purpose of this study is to investigate the stage of chronic kidney disease (CKD) in adenine-induced CKD model rats by serum analyses, and to examine bone mineral density (BMD), bone strength, and microstructure of trabecular and cortical bone in these rats. Methods: Eight-week-old, male Wistar rats (n = 42) were divided into 2 groups: those fed a 0.75% adenine diet for 4 weeks until 12 weeks of age to generate CKD model rats (CKD group); and sham rats. The CKD and sham groups were sacrificed at 12, 16, and 20 weeks of age (n = 7 in each group and at 12, 16, and 20 weeks), and various parameters were evaluated, including body weight, renal wet weight, muscle wet weight, renal histology, biochemical tests, BMD, biomechanical testing, and micro-computed tomography (CT). The parameters were compared between the 2 groups at the various time points. Results: In the CKD model rats, at 20 weeks of age, serum creatinine, phosphorus, and intact-PTH levels were elevated, and serum calcium levels were normal, indicating that the CKD was stage IV and associated with secondary hyperparathyroidism. Decreased BMDs of the whole body and the femur were observed as bone changes, and micro-CT analysis showed deterioration of bone microstructure of the cortical bone that resulted in decreased bone strength in the cortical and trabecular bone. Conclusions: These CKD model rats showed stage IV CKD and appear appropriate for evaluating the effects of several treatments for CKD-related osteoporosis and mineral bone disorder.

High tibial valgus osteotomy (HTO) is a well-established surgical procedure to correct a varus malalignment and treat medial compartment osteoarthritis. Recently, double level osteotomy (DLO) was recommended for extensive varus knees as a single level osteotomy (SLO) approach may create an excessive joint line obliquity and eventually result in a new bony deformity. However, a severe varus knee in cases of advanced osteoarthritis involves not only a bony deformity (extra-articular deformity) but also a medial joint space narrowing with a widened lateral joint space (intra-articular deformity). A DLO alone cannot reduce this intra-articular deformity. However, tibial condylar valgus osteotomy (TCVO) can complement DLO as to reduce this intra-articular deformity. This technical note describes a novel modified DLO procedure associated with TCVO which can restore a normal alignment and a joint line and achieve joint preservation even in cases of extensive varus osteoarthritis.

Abstract A 68-year-old female suffering from habitual patellar dislocations following a mal-positioned total knee arthroplasty (TKA) was successfully treated with a biplanar closed wedge distal femoral osteotomy (CWDFO) and medial patello-femoral ligament (MPFL) reconstruction. To the best of our knowledge, no such case has been previously described. Our experience with this case suggests that treatment for a patella dislocation following valgus mal-positioning of TKA should be considered positively. Level of evidence V

Abstract Background Severe varus deformity and soft tissue injury caused by a burn around a complex knee dislocation is a rare injury. Soft tissue reconstruction and deformity correction with circular hexapod external fixation of the knee and hinged total knee arthroplasty (TKA) are challenging and can lead to major complications if not performed appropriately. We present a case in which a combination of soft tissue reconstruction, circular hexapod external fixation, and TKA was used treat severe knee dislocation due to burn scarring. Case presentation We report the case of a 58-year-old woman who presented for knee surgery with soft tissue reconstruction, deformity correction with circular hexapod external fixation, and hinged TKA for a severe complex deformity and soft tissue injury caused by a burn injury at 6 months of age. The left leg was shorter by 35 mm in terms of functional leg length discrepancy. She walked with a limp, with a marked varus deformity of the left knee during the stance phase of walking. After a 3-stage repair, the patient was able to walk without assistance, confirming improvement of mobility. Conclusion The treatment method was an effective use of a combination of soft tissue reconstruction, circular hexapod external fixation, and rehearsal surgery using a 3D printed bone model of the modular rotating hinge component of TKA, which was successfully used to treat a severe knee dislocation due to burn scarring. This staged surgery maintained the leg length and ultimately achieved a satisfactory alignment.

Abstract Background The incidence of periprosthetic fractures after total joint arthroplasty (TJA) is rising due to an increasing number of TJAs performed annually and the growing elderly population. In many elderly patients with periprosthetic fractures, the bone strength is lowered due to the deterioration of bone quality and a decrease in bone quantity; rigid fixation of the fracture is difficult. It is a challenging operation for orthopedic surgeons. The usefulness of circular external fixation for periprosthetic fractures has been reported in several case studies. The aim of this study was to investigate the rate of union and complications associated with circular external fixation in periprosthetic fractures around the knee. Methods We included 19 patients with periprosthetic femur and tibial fractures who underwent osteosynthesis using a circular external fixator and had at least 2 years of follow-up. All patients had comorbidities and high risks associated with anesthesia. Tourniquets were not used in any of the patients. There were no cases in which the skin incision was placed, and the closed reduction technique was used in all cases. Results A 100% union rate was achieved with no serious complications. All fractures healed after a mean time of 14.3 ± 5.2 weeks (range, 8–38 weeks). The walking ability was the same level as before the injury in 13 cases. Discussion There are many comorbidities associated with periprosthetic fractures in elderly patients. Double-plate or revision surgery were largely invasive and had high risks associated with anesthesia. Circular external fixation is a feasible and effective treatment option because it provides stable fixation, prompt postoperative mobilization, and has no major complications, especially in elderly patients who are treated for periprosthetic fractures. Conclusion Circular external fixation is a safe and reliable method for periprosthetic fractures around the knee in elderly patients. Level of evidence Level IV, retrospective case series.

Abstract Background The incidence of periprosthetic fractures after total knee arthroplasty (TKA) is rising due to the increasing number of TKAs performed annually and the growing elderly population. A periprosthetic fracture of the proximal tibia following TKA is a rare injury that may be a challenging clinical scenario. Case presentation The case of an 84-year-old woman who sustained a periprosthetic tibial fracture 10 years after a TKA is presented. This patient had multiple risk factors. The fracture was not deemed amenable to conventional treatment because the bone fragment was too small. This patient underwent fixation of her tibial fracture above the TKA using a five-ring Ilizarov external fixator. This allowed immediate full weight-bearing. The fixator was removed at 12 weeks, at which time the fracture was solidly healed. At the most recent follow-up, 2 years from injury, she was fully weight-bearing without walking aids and had a knee range of motion (ROM) of 0–110°. Conclusion To the best of our knowledge, this is the first report in which Ilizarov external fixation has been used for a periprosthetic tibial fracture after TKA.

Abstract Background In highly active older individuals, end-stage ankle osteoarthritis has traditionally been treated using tibiotalar arthrodesis, which provides considerable pain relief. However, there is a loss of ankle joint movement and a risk of future arthrosis in the adjacent joints. Distraction arthroplasty is a simple method that allows joint cartilage repair; however, the results are currently mixed, with some reports showing improved pain scores and others showing no improvement. Distal tibial osteotomy (DTO) without fibular osteotomy is a type of joint preservation surgery that has garnered attention in recent years. However, to our knowledge, there are no reports on DTO with joint distraction using a circular external fixator. Therefore, the purpose of this study was to examine the effect of DTO with joint distraction using a circular external fixator for treating ankle osteoarthritis. Methods A total of 21 patients with medial ankle arthritis were examined. Arthroscopic synovectomy and a microfracture procedure were performed, followed by angled osteotomy and correction of the distal tibia; the ankle joint was then stabilized after its condition improved. An external fixator was used in all patients, and joint distraction of approximately 5.8 mm was performed. All patients were allowed full weight-bearing walking immediately after surgery. Results The anteroposterior and lateral mortise angle during weight-bearing, talar tilt angle, and anterior translation of the talus on ankle stress radiography were improved significantly (P

Autism spectrum disorder covers a group of behaviorally defined disorders that may result in the patient having difficulty staying calm during medical treatments, due to anxiety-related overreactions. Tibial fractures are the third most common pediatric long-bone fracture. Conservative treatment is selected in many cases, but surgical treatment may be selected in cases of open fracture and no treatment policy has been established. We described the case of a 6-year-old boy with autism spectrum disorder who was unable to stay calm due to anxiety and required sedation. We diagnosed open tibial shaft fracture (Orthopaedic Trauma Association classification 42A1, 4F2A; Gustilo classification type 1). On the day of injury, we performed osteosynthesis using a ring external fixator and primary closure of the open wound. Full weight-bearing was permitted from immediately after surgery. No significant complications were observed postoperatively, and the external fixator was removed 84 days postoperatively. No abnormal alignment of the lower leg, leg-length discrepancy or range of motion disorder was identified. To the best of our knowledge, no other reports have described use of a ring external fixator for open tibial shaft fractures in children with autism spectrum disorder. Using a ring external fixator appears helpful for open tibial shaft fractures in children who are unable to stay calm due to autism spectrum disorder, because there is no need to limit weight-bearing immediately after surgery. For Gustilo classification type 1 pediatric open fracture, primary closure of the open wound is safe after sufficient bone fixation.

Introduction. Charcot neuroarthropathy is a progressive, deforming pathology of the bone and joints, especially affecting the knees and ankles. Although it is rare, it leads to considerable morbidity. The treatment of Charcot arthropathy of the knee and ankle remains controversial. Many authors suggest that knee involvement is an absolute contraindication to total knee arthroplasty. In recent years, however, several studies have shown satisfactory results for total knee arthroplasty. In the ankle, external fixators have recently been advocated by many authors. Their main advantages are that they permit monitoring of soft tissue healing and avoidance of more invasive surgery. Simultaneous Charcot knee and ankle joint surgery involving total knee arthroplasty (TKA) and ankle arthrodesis is rare and challenging and can lead to major complications if not addressed appropriately. Case Presentation. The case of a 71-year-old woman who underwent simultaneous total knee arthroplasty and ankle arthrodesis for severe neurosyphilitic Charcot arthropathy (Eichenholtz classification stage III) and was evaluated three years after surgery is reported. Deformities of the left knee joint and ankle developed. The left leg was shorter by 20 mm, with a functional leg length discrepancy. The patient was limping, and marked varus instability of the left ankle was observed during the stance phase of walking. Postoperatively, the patient was able to walk without assistance, confirming improvement of mobility. Conclusion. To the best of our knowledge, this is the first report of combined, simultaneous neurosyphilitic Charcot knee and ankle joint surgery involving TKA and ankle arthrodesis. It was an effective surgical method that maintained leg length and achieved satisfactory alignment without an autologous iliac bone graft.

The goal of treatment for distal humeral fractures in patients with rheumatoid arthritis (RA) is to obtain sufficient bone union and good elbow function. However, treating comminuted distal humeral fractures in patients with RA and osteoporosis is challenging. We present the case of a 58-year-old woman with RA and osteoporosis who suffered a comminuted distal humeral fracture and was successfully treated with the Ilizarov technique. The Ilizarov technique is minimally invasive compared with conventional open surgery, can obtain good stabilization, and allows earlier rehabilitation, even if the fractured bone is severely osteoporotic. The patient exhibited good elbow function and alignment at the final follow-up examination (18 postoperative months). To the best of our knowledge, the present case is the first in which a comminuted distal humeral fracture in a patient with RA and severe osteoporosis was successfully treated with an Ilizarov external fixator. Keywords: Distal humeral fracture, Rheumatoid arthritis, Ilizarov technique

Category: Lesser Toes Introduction/Purpose: [Introduction] In recent years, joint ultrasonography has been widely used for the diagnosis and treatment of rheumatoid arthritis (RA), allowing visualization of synovitis. Its clinical usefulness in early diagnosis and evaluation of disease activity has been reported. Continuous inflammation, osteochondral destruction, and soft tissue destruction due to synovitis in toe joints result in various clinical pictures of the foot. In the lateral toes in the forefoot, subluxation or luxation of the metatarsophalangeal (MTP) joints may occur, leading to painful callosities and resultant disturbance in activities of daily living. Few reports have addressed toe deformity and joint ultrasonographic findings of synovitis in the forefoot. In this study, lateral MTP joints were assessed using joint ultrasonography in RA patients to examine the correlation with deformity. Methods: [Subjects] Seventy feet of 61 RA patients were examined in the outpatient clinic of our hospital. Patients who underwent surgery were excluded. The mean age of the patients was 66 years (24 to 92 years), and the mean duration of disease was 12 years and 9 months (1 month to 40 years). Biologic products were used for 23 feet. Joint ultrasonography was performed by the same examiner, using the same room and apparatus. Synovitis was defined as Grade 1 or more as determined by the power Doppler method. Based on foot radiographs in upright position obtained before and after ultrasonography, patients with luxation, subluxation, and joint fissure narrowing were classified into the deformity group, those with bone erosion and geode formation into the bone erosion group, and lack of abnormal findings into the normal group. Results: [Results] Synovitis was found in MTP joints in 41 (14.6%) of 280 toes. The incidence rates of synovitis in the deformity group, the bone erosion group, and the normal group were 27.3%, 13.1%, and 6.7%, respectively. Synovitis was found in 21.7% of patients on therapy with biologic products and in 38.3% of those without such therapy. There were no significant differences in the mean duration of the disease, visual analogue scale score, erythrocyte sedimentation rate, matrix metallopeptidase 3 level, or health assessment questionnaire score among the 3 groups. Conclusion: [Discussion] Synovitis was also found in patients who showed no changes on imaging of the toes. Synovitis persisted in some patients even after establishment of toe deformity. Drug therapy, intensification of conservative therapy, and synovectomy should be considered to prevent further deformation.

Category: Ankle Arthritis Introduction/Purpose: Advanced to end-stage ankle osteoarthritis in highly active older individuals has traditionally been treated using tibiotalar arthrodesis. Distal tibial osteotomy without fibular osteotomy, a type of joint preservation surgery, has garnered attention in recent years, but patient satisfaction has yet to be compared between the two treatments. Objective: To compare distal tibial osteotomy and tibiotalar arthrodesis for ankle osteoarthritis (stage IIIb and above under the Takakura classification) in older individuals. Methods: Subjects and Method: A total of 35 patients aged>60 years old who showed medial ankle arthritis were examined. Patients were either treated with tibiotalar arthrodesis (n=18) or distal tibial osteotomy (n=17). The patients’ mean age was 72.1 years (range, 60–81 years) in the tibiotalar arthrodesis group and 67.2 years (range, 60–80 years) in the distal tibial osteotomy group. For distal tibial osteotomy, a circular external fixator was used in all cases. Osteotomy was performed after performing synovectomy and microfracture surgery using ankle arthroscopy. At the time of fixation with a circular external fixator, foot ring (calcaneal) fixation was also performed. In addition, joint distraction was performed, and distraction arthroplasty was also simultaneously performed. Results: The mean preoperative VAS score was 8.2 for tibiotalar arthrodesis (TA) and 8.0 for distal tibial osteotomy (DTO). The mean postoperative VAS score was 1.9 for TA and 1.7 for DTO. The mean preoperative AOFAS score was 40.1 for TA and 43.1 for DTO. The mean postoperative AOFAS score was 86.2 for TA and 90.0 for DTO. The mean preoperative SF-36 physical component score was 30.5 for TA and 38.5 for DTO. The mean preoperative SF-36 mental component score was 33.5 for TA and 37.5 for DTO. The mean postoperative SF-36 physical component score was 42.5 for TA and 56.4 for DTO. It was significantly higher with the DTO (p

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.

Purpose. In knee osteoarthritis, the degree of pain varies despite similar imaging findings. If there were quantitative findings related to the pain of knee osteoarthritis, it could be used for diagnosis or screening. The medial meniscal extrusion was investigated as a candidate quantitative finding related to the pain of knee osteoarthritis. Methods. Seventy-six knees of 38 patients (mean age, 73 years) who received intra-articular injections of hyaluronic acid into unilateral knees at the time of diagnosis of knee arthritis were investigated. Cartilage thickness of the femoral medial condyle and medial meniscal extrusion of bilateral knees were measured by ultrasonography. Thirty-eight knees that had hyaluronic acid injections were compared with 38 other side knees from the same patients as the control group. Results. The average cartilage thicknesses of the knees with pain that received intra-articular injections and the knees without pain that received no injections were 1.02 and 1.05 mm, respectively (P=0.6394). On the other hand, the average medial meniscal extrusions of the knees with and without pain were 7.58 and 5.88 mm, respectively (P=0.0005); pain was associated with greater medial meniscal extrusions. Conclusion. Medial meniscal extrusion is a quantitative finding related to the pain of knee osteoarthritis.

We presented a case in which massive hydroxyapatite accumulation was observed around the artificial hip joint. A 66-year-old female showed a massive accumulation of fluid in and around the hip joint, and milk-like aspirate was obtained. Her aspirate culture was negative, and sediment analysis by X-ray diffraction showed that its component was hydroxyapatite. Since pain was mild, the patient was treated conservatively. To our knowledge, this is the first case in which liquid hydroxyapatite (milk of calcium) was accumulated around the artificial hip joint.

Background/Aim: This study aimed to evaluate the effects of doxorubicin (Dox) on bone microstructure and metabolism in a mouse model of soft tissue sarcoma. Materials and Methods: CCRF S-180? cells (2-4×105 cells/0.2 ml) were injected subcutaneously into the back of mice. The mice were divided into four groups according to tumor and treatment status and were reared and sacrificed after 2 or 4 weeks. Micro-computed tomography (CT) was performed to calculate the architecture of the femoral bone. The proximal tibia was double stained with tartrate-resistant acid phosphatase (TRACP) and alkaline phosphatase (ALP), and bone morphometry was performed. Results: Trabecular bone mass was significantly reduced in the Sarcoma and Sarcoma+Dox groups. Cortical bone thickness was reduced in the DOX group, with a stronger effect observed in the Sarcoma+Dox group. In bone morphometry, osteoclast number at the bone surface (Oc.N/BS) was significantly lower in the Dox, Sarcoma, and Sarcoma+Dox groups than in the Control group at 2 weeks. The osteoblast surface at the bone surface (Ob.S/BS) was significantly lower in the Dox and Sarcoma groups than in the Control group at 2 weeks. At 4 weeks, the differences were smaller for both Oc.N/BS and Ob.S/BS. Conclusion: The use of doxorubicin alone worsened the cortical bone structure; however, the presence of both soft-tissue sarcoma and doxorubicin use worsened both cortical and trabecular bone structures from an early stage. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to orthopedic surgeons. Nonunion and lengthy wound healing in high-risk patients with diabetes, particularly patients with peripheral arterial disease and renal failure, occur secondary to several clinical conditions and are often fraught with complications. Whether diabetic ankle fractures are best treated noninvasively or surgically is controversial. Case presentation: A 53-year-old Japanese man fractured his right ankle. The fractured ankle was treated nonsurgically with a plaster cast. Although he remained non-weight-bearing for 3 months, radiography at 3 months showed nonunion. The nonunion was treated by Ilizarov external fixation of the ankle. The external fixator was removed 99 days postoperatively, at which time the patient exhibited anatomical and functional recovery and was able to walk without severe complications. Conclusion: In patients with diabetes mellitus, severe nonunion of ankle fractures with Charcot arthropathy in which the fracture fragment diameter is very small and the use of internal fixation is difficult is a clinical challenge. Ilizarov external fixation allows suitable fixation to be achieved using multiple Ilizarov wires. [ABSTRACT FROM AUTHOR]

Background: Alagille syndrome is a multisystem disorder, which is characterized by hypoplasia of the intrahepatic bile ducts, malformations of the cardiovascular system, eyes, and vertebral column, and abnormal facies. Several of the characteristics of Alagille syndrome may result in an especially high risk of fracture. The majority of patients suffer from chronic cholestasis, which can have a variety of adverse effects on bone metabolism. In Alagille syndrome, fractures primarily occur in the lower limb long bones in the absence of significant trauma. Case presentation: A 9-year-old Japanese girl with Alagille syndrome was admitted to our institution with marked hyperbilirubinemia and a pathological fracture of the femur. She had been diagnosed with biliary atresia at the age of 1 month and treated with surgical bile duct reconstruction, vitamins D and K, and ursodeoxycholic acid. However, her liver dysfunction and hyperbilirubinemia worsened. The pathological fracture of the femur was treated with low-intensity pulsed ultrasound stimulation (LIPUS) and an Ilizarov ring fixator. Seventy-four days after surgery, the patient had anatomically and functionally recovered. There was no leg-length discrepancy and no angular malalignment of the lower extremities as measured clinically and radiographically. The range of motion of the hip, knee, and ankle of the patient’s operative leg matched the range of motion in the nonoperative leg. Conclusion: To the best of our knowledge, there are no reports on use of the Ilizarov frame and LIPUS in diaphyseal femoral fractures in Alagille syndrome. This case report provides evidence that this procedure is successful for managing such diaphyseal fractures in Alagille syndrome. [ABSTRACT FROM AUTHOR]

Background Low-intensity pulsed ultrasound is a pain-free therapy performed daily at home by the patient and has been shown to promote fracture healing. Teriparatide is a parathyroid hormone preparation that activates osteoblastic bone formation and is also reported to be effective in promoting bony union. Case presentation We report the case of a 56-year-old Japanese male with a femoral shaft fracture who underwent intramedullary osteosynthesis nailing initially. He had no radiologic or clinical sign of healing 3 months later and low-intensity pulsed ultrasound was initiated at that time. He was reassessed in another 3 months, with evidence of mild bone consolidation but the fracture gap persisted. Subsequent treatment with human parathyroid hormone was initiated in combination with low-intensity pulsed ultrasound. Full fracture healing was present 6 months after beginning the combination low-intensity pulsed ultrasound and teriparatide. It is hypothesized that the potential additive effects of low-intensity pulsed ultrasound and teriparatide therapy ultimately triggered sufficient bone formation to support osseous union. Conclusion The case reported herein is a femoral shaft atrophic nonunion in which traditional interventions failed. Successful fracture healing was finally achieved with low-intensity pulsed ultrasound and teriparatide therapy. This is the first reported case of diaphyseal nonunion with deterioration of bone quality in long bones resolved with teriparatide and lowintensity pulsed ultrasound. [ABSTRACT FROM AUTHOR]

The purpose of this retrospective clinical-based observational study was to evaluate the effects of teriparatide (TPTD) on clinical outcomes and radiologic findings of sacral insufficiency fractures (SIFs). Seven elderly women with SIFs received TPTD for at least 6 months. We evaluated the symptoms, pain, and radiological findings. At their initial clinic visit, 86% patients could not walk or sit. Computed tomography (CT) images revealed sacral wing fracture in 6 patients, and bone scintigram showed H-shaped uptake over the bilateral sacral wings in 1 patient. After the treatment, 5 patients could walk. Mean visual analog scale score was significantly lower after (12.9 mm) than before (87.4 mm) TPTD treatment (p < 0.0001). CT images revealed bone union (four patients) and sclerotic changes (three patients) at the fracture sites. Seven elderly women with SIFs had significant improvement in pain and demonstrated bone union or sclerotic changes at fracture sites by TPTD. [ABSTRACT FROM AUTHOR]