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Intrapericardial hernia is a diaphragmatic hernia that extremely rarely causes cardiac tamponade. We present a case of a cardiac tamponade caused by an intrapericardial hernia in a 78-year-old male patient with a history of coronary artery bypass grafting, mimicking ST-segment elevation myocardial infarction, which was successfully treated by emergent laparotomy.

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.

Medical checkups for adolescent athletes aim to prevent or detect sports injuries and manage them before they hamper future sports activities and daily life. However, effective items for evaluation, as well as the areas of intervention to prevent sports injuries, remain unclear. We aimed to clarify the checkup items and intervention areas to prevent sports injuries in adolescent athletes. This is a cross-sectional observational study that investigated the presence or absence of pain in adolescent athletes and associated factors at the time of checkup. We investigated joint laxity, range of motion (ROM), finger-floor distance (FFD), heel–buttock distance (HBD), straight leg raising (SLR) angle, too many toes sign, and presence or absence of low back pain during lumbar extension in 301 junior high school athletes. Additionally, after confirming the developmental stage of the tibial tuberosity using ultrasonography, ultrasound elastography was used to quantify the elasticity of the quadriceps femoris, and items related to pain during sports activities were extracted. Items related to pain included the too many toes sign, low back pain during lumbar extension, and elasticity of the quadriceps femoris. Athletes with a positive too many toes sign were less likely to experience pain; conversely, the harder the quadriceps femoris, the more likely they were to experience pain. Medical checkups focusing on these items are effective for adolescent athletes who are prone to knee pain.

The purpose of this study was to investigate the relationship between clinical outcomes and lateral thrust before and after unicompartmental knee arthroplasty (UKA) using inertial measurement sensor units. Eleven knees were evaluated with gait analysis. The varus angular velocity was used to evaluate lateral thrust. The femorotibial angle (FTA) and hip–knee–ankle angle (HKA) were used to evaluate lower-limb alignment, and the Oxford Knee Score (OKS) and Japanese Orthopaedic Association Score (JOA) were used to evaluate clinical outcomes. The mean pre-UKA peak varus velocity was 37.1 ± 9.8°/s, and that for post-UKA was 28.8 ± 9.1°/s (p = 0.00003), such that instabilities clearly improved. Assuming the definition of lateral thrust is when the varus angular velocity is more than 28.1°/s, 81.8% of patients had lateral thrust preoperatively, but this decreased to 55.6% postoperatively, such that the symptoms and objective findings improved. Both OKS and JOA improved after surgery. In addition, HKA was −7.9° preoperatively and −5.8° postoperatively (p = 0.024), and FTA was 181.4° preoperatively and 178.4° postoperatively (p = 0.012). There was a positive correlation between postoperative JOA and FTA, indicating that changes in postoperative alignment affected clinical outcomes. This study quantitatively evaluated the disappearance of lateral thrust by UKA, and it found that the stability can be achieved by UKA for unstable knees with lateral thrust.

Abstract Background Owing to the aging population, fragility fractures of the pelvis are occurring more frequently. Fixation of the fracture and stabilization of the pelvic ring usually provide good clinical results. A case of distal sacral nerve roots severed by a fragility fracture of the sacrum is presented. Case presentation A 62-year-old Japanese woman with schizophrenia with low back pain, gait disorder, dysuria, and fecal incontinence presented to an emergency department, and plain X-rays showed no findings. She also complained of dysuria, and neurogenic bladder and cystitis were diagnosed. One month later, she was admitted to a psychiatric hospital for exacerbation of schizophrenia. In hospital, she had a urethral catheter inserted and spent 3 months in bed. She was referred to our orthopedic department because a gait disorder was discovered after her mental condition improved and she was permitted to walk. On examination, she could not walk and had decreased sensation from the buttocks to both posterior thighs and around the anus and perineum. Manual muscle testing of her lower limbs showed mild weakness of about 4 in bilateral flexor hallucis longus and gastrocnemius, and bilateral Achilles tendon reflexes were lost. Her anal sphincter did not contract, and urinary retention continued after urethral catheter removal. Imaging examinations showed an H-shaped sacral fracture consisting of a transverse fracture with displacement of the third sacral vertebra and vertical fractures of the bilateral sacral wings, with severe stenosis of the spinal canal at the site of the transverse fracture. The patient was diagnosed as having bladder and rectal dysfunction due to a displaced, unstable sacral fracture. First to third sacral laminectomy and alar–iliac fixation using percutaneous pedicle screws and sacral alar–iliac screws were then performed. The bilateral distal sacral nerve roots (S3, S4, S5) were completely severed at the second to third sacral levels, but bilateral second sacral nerve roots were not compressed from the bifurcation to the sacral foramen. Postoperatively, bladder and rectal dysfunction remained, but the low back pain was alleviated. Two weeks postoperatively, she could walk with a walker and was discharged. Three months after the operation, bone fusion of the fracture was observed. Conclusions In cases of bladder–rectal dysfunction with low back pain, the possibility of sacral fracture should be considered, and computed tomography, magnetic resonance imaging, and X-ray examinations should be performed. Even sacral fractures without displacement require attention because they can cause serious injury in the event of a nerve root being severed if not diagnosed early and given appropriate treatment.

Background: Patellar post impingement (PPI), which occurs when the post impinges on the patella, may reportedly cause poor total knee arthroplasty (TKA) outcomes. The causes of PPI and its effect on clinical outcomes and symptoms were investigated. Material and methods: The study subjects were 100 patients who underwent TKA (65 posterior stabilized TKA, 35 bi-cruciate stabilized [BCS] TKA). Whether PPI occurred during surgery was investigated; the patients were then classified into a PPI+ group and a PPI– group, and whether the implant or patellar shape was related to the occurrence of PPI was examined. The measurement parameters included patellar shape, joint range of motion (ROM), and clinical outcome using the new Knee Society Score. Results: There were 38 knees in the PPI+ group and 62 knees in the PPI– group. There was no difference in patellar shape between the 2 groups, but PPI was more frequent in patients with short patellar tendon and those with low patellar height. In terms of implant type, the PPI+ group included 12 patients (18.5%) who underwent posterior stabilized TKA and 26 (74.3%) who underwent BCS TKA. There was no difference between the 2 groups in either joint ROM or new Knee Society Score. These results suggest that the position of the patella and implant shape that causes the post to be positioned anteriorly may contribute to PPI. Conclusion: PPI occurred more frequently in knees with low patellar height and in patients who had undergone BCS TKA. PPI had no effect on joint ROM or clinical outcome.

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.

The purpose of this study was to propose a novel classification of varus thrust based on gait analysis with inertial motion sensor units (IMUs) in patients with medial knee osteoarthritis (MKOA). We investigated thigh and shank acceleration using a nine-axis IMU in 69 knees with MKOA and 24 (control) knees. We classified varus thrust into four phenotypes according to the relative medial–lateral acceleration vector patterns of the thigh and shank segments: pattern A (thigh medial, shank medial), pattern B (medial, lateral), pattern C (lateral, medial), and pattern D (lateral, lateral). Quantitative varus thrust was calculated using an extended Kalman filter-based algorithm. We compared the differences between our proposed IMU classification and the Kellgren–Lawrence (KL) grades for quantitative varus thrust and visible varus thrust. Most of the varus thrust was not visually perceptible in early-stage OA. In advanced MKOA, increased proportions of patterns C and D with lateral thigh acceleration were observed. Quantitative varus thrust was significantly increased stepwise from patterns A to D. This novel IMU classification has better clinical utility due to its ability to detect subtle kinematic changes that cannot be captured with conventional motion analysis even in the early stage of MKOA.

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 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

In the sale of steel materials such as tool steel, it is important to optimize the size of standard stocks to reduce end material and cutting costs resulting from number of cuts and cutting area. If there is difference between the size of standard stocks and the sales size of steel, excess cutting and end material occur. So, the size of standard stocks is important to reduce end material and cutting cost. However, in the conventional method, stock manager analyzes past orders and determines the size of standard stocks which is not the optimum. Therefore, we developed a method to determine the size of standard stocks that reduce cutting costs and end material by (1) creating candidates for standard stocks, (2) giving evaluation score to all combinations of past orders allocations to standard stocks candidates and (3) sorting out optimum standard stocks by mixed integer programing so that total evaluation score is high. As a result of the computational experiment, the development method reduced 2.7% number of cuts, 17.3% cutting area, and 6.3% end material volume compared to the conventional method.

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

Background and Objectives: Adequate initial fixation of the uncemented acetabular component in total hip arthroplasty is necessary to achieve long-term survival. Although screw fixation contributes to improved cup stability, there is currently no consensus on the use of this method. This study aimed to assess the existing randomized controlled trials (RCTs) on the efficacy and safety of cup fixation in total hip arthroplasty without screws. Materials and Methods: We searched the EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov databases to identify RCTs published before February 2022. Primary outcomes were reoperation, cup migration, and Harris Hip Score. Secondary outcomes were the presence of a radiolucent line in the acetabular region, translation and rotation movement, and polyethylene wear. We conducted meta-analyses using the random-effects models. The revised Cochrane risk-of-bias tool was used to assess the risk of bias for outcomes of interest; the Grading of Recommendations, Assessment, Development, and Evaluation approach was used to summarize the body of evidence. Results: We included six reports from four studies. Total hip arthroplasty without screw fixation to the acetabular cup had little to no effect on reoperation (pooled relative risk, 0.98; 95% confidence interval, 0.14–6.68; I2 = 0%), cup migration (pooled relative risk, 1.72; 95% confidence interval, 0.29–10.33; I2 = 1%), Harris Hip Score (mean difference, 1.19; 95% confidence interval, −1.31–3.70; I2 = 0%), radiolucent line (pooled relative risk, 5.91; 95% confidence interval, 0.32–109.35), translation and rotation of all axes, and polyethylene wear (mean difference, 0.01; 95% confidence interval, −0.01–0.04; I2 = 0%), with very low certainty of evidence on all measures. Conclusions: The efficacy of acetabular cups without screw fixation in total hip arthroplasty remains uncertain, suggesting the need for prudent clinical application. Further large-scale, well-designed studies with low risk of bias are required.

Patients with adult spinal deformity have various standing postures. Although several studies have reported a relationship between sagittal alignment and exacerbation of hip osteoarthritis, information is limited regarding how spinopelvic sagittal alignment changes affect hip joint loading. This study aimed to investigate the relationship between sagittal spinopelvic-lower limb alignment and the hip joint contact force (HCF) using a novel musculoskeletal model. We enrolled 20 women (78.3±6.7 years) from a single institution. Standing lateral radiographs were acquired to measure thoracic kyphosis, lumbar lordosis, the pelvic tilt, sacral slope, sagittal vertical axis (SVA), femur obliquity angle, and knee flexion angle. In the model simulation, the Anybody Modeling System was used, which alters muscle pathways using magnetic resonance imaging data. Each patient’s alignment was entered into the model; the HCF and hip moment in the standing posture were calculated using inverse dynamics analysis. The relationship between the HCF and each parameter was examined using Spearman’s correlation coefficient (r). The patients were divided into low SVA and high SVA groups, with a cutoff value of 50 mm for the SVA. The HCF was 168.2±60.1 N (%BW) and positively correlated with the SVA (r = 0.6343, p

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

Objective. To compare the incidence of venous thromboembolism (VTE) after total hip arthroplasty (THA) using the direct anterior approach (DAA) with that using the direct lateral approach (DLA). In addition, patient background characteristics and the incidence of VTE were compared between the first half and the latter half of the period after introducing DAA and against DLA. Method. This was a retrospective, multicenter study involving 109 patients (116 hips) who had undergone primary unilateral THA. Thirty-six hips underwent THA using DAA and 80 hips underwent THA using DLA. Patient information including sex, age, and preoperative diagnosis was collected. The incidence of VTE was compared between DAA and DLA. Moreover, the patients who underwent THA using DAA were divided into 2 groups (first half and latter half groups), and sex, age, body mass index (BMI), and surgical time were compared between the 2 groups. Moreover, the incidence of VTE was compared among the 3 groups (first half of DAA, latter half of DAA, and DLA). Results. The incidence of VTE in the DAA group was significantly higher than that in the DLA group p=0.014. The incidence of VTE in the first half group was significantly higher than in the latter half group and the DLA group (p=0.035 and p=0.001, respectively), and there was no difference in the incidence of VTE between the latter half group and the DLA group p=0.923. Surgical time was significantly longer in the first half group than in the latter half group p=0.046. Conclusions. In the first half of the period after introducing the DAA, more VTEs occurred than in the DLA. It may be important to shorten the surgical time in the early stage of introducing the DAA, and aggressive anticoagulation therapy may be required until the surgeon becomes familiar with the procedure.

Background. Because the tapered wedge-shaped type cementless stem has a small anteroposterior width and a low occupation rate in the medullary space, postoperative rotational instability and stem subsidence due to inadequate proximal fixation are concerns. The purpose of this study was to clarify the relationship between the rotational instability of the tapered wedge-shaped type cementless stem and femoral canal shape. Methods. A total of 61 primary total hip arthroplasties with the tapered wedge-shaped type cementless stem Accolade® TMZF (11 males, 50 females; mean age 60 years) from January 2012 to June 2015 who underwent computed tomography before surgery and within 4 weeks and 1 year after surgery were evaluated. The preoperative femoral neck anteversion angle, preoperative femoral canal flair index, the degree of postoperative stem subsidence within 1 year after operation, and the degree of rotational change in the stem setting angle within 1 year after operation were investigated. Results. The mean preoperative femoral neck anteversion angle was 32.2° ± 17.8° (0°–69°), and the mean preoperative canal flair index was 3.68 ± 0.58 (2.44–5.55). There were no stem subsidence cases within 1 year after operation. The mean degree of rotational change in the stem from immediately to 1 year after surgery was −0.4° ± 1.7° (−3°–3°). There was no significant correlation between the canal flair index and the rotational change in the stem. In addition, the mean difference between the preoperative femoral neck anteversion angle and the stem rotational angle immediately after surgery was only 1.3° ± 5.3° (−29°–15°). Conclusions. In all cases, including stove-pipe cases, the degree of rotational change in the Accolade® TMZF stem from immediately to 1 year after surgery was within 3°. In other words, regardless of femoral canal shape, the tapered wedge-shaped type cementless stem has little initial rotational instability.

Study DesignIn vivo biomechanical study using a three-dimensional (3D) musculoskeletal model for elderly individuals with or without pelvic retroversion.PurposeTo evaluate the effect of pelvic retroversion on the sagittal alignment of the spine, pelvis, and lower limb in elderly females while standing and walking.Overview of LiteraturePatients with hip–spine syndrome have concurrent hip-joint and spine diseases. However, the dynamic sagittal alignment between the hip joint and spine has rarely been investigated. We used a 3D musculoskeletal model to evaluate global spinopelvic parameters, including spinal inclination and pelvic tilt (PT).MethodsA total of 32 ambulant females (mean age=78 years) without assistance were enrolled in the study. On the basis of the radiographic measurement for PT, participants were divided into the pelvic retroversion group (R-group; PT≥20°) and the normal group (N-group; PT

Background. Assessments for osteoporosis in patients who have undergone total hip arthroplasty (THA) are very important with respect to the clinical results. However, few studies have investigated the status of the assessments and treatments for osteoporosis in post-THA patients. The purpose of this multicenter study was to investigate the status of assessments and treatments for osteoporosis in post-THA patients. Methods. The results of a self-report questionnaire and the medical records of 194 post-THA patients over 40 years of age who visited the outpatient departments of the five hospitals participating in the study were analyzed. Results. A total of 125 patients (64.4%) had been examined for osteoporosis, and 69 patients (35.6%) had never been assessed for osteoporosis. It was assumed, based on the questionnaire results, that 50 (40%) of the 125 patients should have been receiving treatment for osteoporosis. Forty-five (90%) of these 50 patients were actually taking medication for osteoporosis at the time of the investigation. Overall, a total of 58 (29.9%) patients were receiving treatment for osteoporosis. Conclusions. The present survey revealed that 64.4% of post-THA patients had been evaluated for osteoporosis. Moreover, while 40% of post-THA patients over 40 years of age may require treatment for osteoporosis, only 29.9% were actually receiving treatment.

Purpose. Proximal femoral fractures involving both the subcapital area and the trochanteric or subtrochanteric area have rarely been reported, but they are not uncommon. However, few studies have reported the incidence or clinical outcomes of such fractures. This study investigated such fractures. Methods. In area classification, the proximal femur is divided into 4 areas by 3 boundary planes: the first plane is the center of femoral neck; the second plane is the border between femoral neck and femoral trochanter; and the third plane links the inferior borders of greater and lesser trochanters. A fracture only in the first area is classified as a Type 1 fracture; one in the first and second areas is classified as a Type 1-2 fracture. Therefore, proximal femoral fractures involving both the subcapital area and the trochanteric area are classified as Type 1-2-3, and those involving both the subcapital area and the subtrochanteric area are classified as Type 1-2-3-4. In this study, a total of 1042 femoral proximal fractures were classified by area classification, and the treatment methods and the failure rates were investigated only for Types 1-2-3 and 1-2-3-4 cases. The failure rate was defined as the incidence of internal fixator cut-out or telescoping >10 mm. Results. Types 1-2-3 and 1-2-3-4 fractures accounted for 1.72%. Surgical treatment was performed for 89%. Of these, 56% underwent osteosynthesis, but the failure rate was 33%. The other patients (44%) underwent prosthetic replacement. Fracture lines of all these fractures were present along trochanteric fossa to intertrochanteric fossa in posterior aspect and just below the femoral head in anterior aspect. Conclusion. Fracture involving the subcapital area to the trochanteric or subtrochanteric area was found in approximately 2%. In patients for whom prosthetic replacement was selected, good results were obtained. However, 1/3 of patients who underwent osteosynthesis had poor results.

The current definition of atypical femoral fractures (AFFs) excludes periprosthetic fractures. However, a few cases of bisphosphonates (BPs) -associated periprosthetic atypical femoral fractures (PAFFs) have been reported in the literature. Here, we report two rare cases of PAFFs that fulfilled the major criteria for AFFs in patients with prolonged use of BPs. Both cases progressed to a complete fracture with minor trauma from an incomplete fracture at the distal tip of the well-fixed femoral stem. The femoral stem effect on lateral femoral cortical bone, together with the decreased bone elastic resistance induced by BPs, was considered the cause of onset. In each case, we performed open reduction and internal fixation using a locking plate with cable grip and postoperatively prescribed teriparatide and low-intensity pulsed ultrasound (LIPUS). Both cases had a good clinical course. However, as conservative treatment was not effective in these cases, treatment such as non-weight-bearing exercises during hospitalization or prophylactic surgery may be necessary. Further studies are needed to determine the optimal treatment strategy.

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

Background. In atypical femoral fractures, owing to the high rates of complications and delayed healing that accompany the plate fixation, the most favorable treatment is intramedullary nailing. Although there is insufficient evidence, plate fixation is chosen due to anterolateral bowing of the femur. This study compared the bone healing time and rates of complications in atypical femoral shaft fractures and osteoporotic femoral shaft fractures. Methods. We searched the medical records of 3 institutions in Japan for patients with femoral shaft fractures who visited between 1 January 2010 and 31 December 2015. We identified 65 patients and excluded 37 among these due to high-energy injuries or being younger than 65 years. Among the remaining patients, we identified 17 and 11 women with atypical (AFF group) and osteoporotic femoral shaft fractures (OP group), respectively. Results. In surgical method, there were differences in intramedullary nailing (94.1% versus 27.2%) (p

The present case shows a case of progression of osteolysis of the greater trochanter caused by a foreign body granuloma associated with the number 5 Ethibond suture in cementless THA with the direct lateral approach that was completely healed by removal of the Ethibond suture. A 55-year-old Japanese woman with secondary osteoarthritis caused by acetabular dysplasia underwent left cementless THA with the direct lateral approach. After setting of the total hip prosthesis, the gluteus medius muscle and vastus lateralis muscle were reattached to the greater trochanter through two bone tunnels using number 5 Ethibond EXCEL sutures. The left hip pain disappeared after surgery, but the bone tunnels enlarged gradually and developed osteolysis at 10 weeks. The removal of the Ethibond sutures and debridement improved the osteolysis. Histological examination showed the granuloma reaction to a foreign body with giant cell formation. The Ethibond suture has the lowest inflammatory tissue reaction and relatively high tension strength among nonabsorbable suture materials. However, number 5 Ethibond has the potential to cause osteolysis due to a foreign body granuloma, as in the present case.

Purpose. Medial meniscal extrusion (MME) has attracted attention as an index of knee pain in conjunction with clinical symptoms that could be more useful than the diagnosis of knee osteoarthritis on X-ray. However, the size of MME that would cause knee pain has not been clarified. The aim of the present study was to investigate the cut-off value of MME for knee pain. Methods. A total of 318 knees were evaluated. The presence of current or past knee pain was confirmed by interview. Next, MME was measured using vertical sonographic images of the medial joint spaces during weightbearing. Results. Overall, 71 knees were painful (P-group), and 247 knees were not (N-group). MME was 5.9 ± 1.8 mm in the P-group and 2.9 ± 1.5 mm in the N-group (P

The present case shows a case of fracture-redislocation of the hip caused by a depressed fracture of the femoral head similar to a Hill-Sachs lesion. A 59-year-old man fell from a roof and his left hip joint was dislocated posteriorly. He was admitted to a nearby hospital, and he was referred to our hospital more than 24 hours after injury. Computed tomography (CT) suggested a bone chip from the posterior wall of the acetabulum roof and a depressed femoral head that cut into the posterior margin of the acetabulum roof. Immediate manual repositioning was performed under general anesthesia on the same day. He left our hospital to go home on day 26 after repositioning, but his left hip joint was dislocated again when he went down the stairs. It was thought that this patient’s redislocation occurred due to a femoral head depressed fracture involving the same mechanism as the Hill-Sachs injury seen with dislocation of the shoulder. The remplissage method for the Hill-Sachs injury is difficult for the femoral head. Therefore, total hip replacement was performed, and the patient’s postoperative course was good. We conclude that total hip arthroplasty should be considered as one of the best treatment methods for such cases.

One component of conventional total knee arthroplasty is removal of the anterior cruciate ligament, and the knee after total knee arthroplasty has been said to be a knee with anterior cruciate ligament dysfunction. Bicruciate stabilized total knee arthroplasty is believed to reproduce anterior cruciate ligament function in the implant and provide anterior stability. Conventional total knee arthroplasty was performed on the right knee and bicruciate stabilized total knee arthroplasty was performed on the left knee in the same patient, and a triaxial accelerometer was fitted to both knees after surgery. Gait analysis was then performed and is reported here. The subject was a 78-year-old woman who underwent conventional total knee arthroplasty on her right knee and bicruciate stabilized total knee arthroplasty on her left knee. On the femoral side with bicruciate stabilized total knee arthroplasty, compared to conventional total knee arthroplasty, there was little acceleration in the x-axis direction (anteroposterior direction) in the early swing phase. Bicruciate stabilized total knee arthroplasty may be able to replace anterior cruciate ligament function due to the structure of the implant and proper anteroposterior positioning.

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.