Akio Kanda

Introduction of a Physician-Staffed Helicopter Emergency Medical Service in Eastern Shizuoka Prefecture in Japan

OBJECTIVE To analyze the operating situation of a physician-staffed helicopter emergency medical service in eastern Shizuoka prefecture. METHODS A retrospective analysis was performed using the conveyance records reported by staff members of the physician-staffed helicopter. A comparison between 2007 (n = 619) and 2012 (n = 678) was performed. RESULTS There were no significant differences between the 2 groups with regard to the sex, ratio of cardiopulmonary arrest, and survival ratio. In contrast, the duration from the request of dispatch to arrival at the hospital in 2007 was significantly longer than that in 2012 (53.7 vs 48.2 minutes, P < 0.0001). The average age in 2007 was significantly younger than in 2012 (55.7 vs 59.4 years, P < 0.01). The ratio of trauma case in the 2012 was higher than that in 2007 (47 vs 37%, P < 0.001). The ratio of severe cases in 2007 was higher than in 2012 (45 vs 39%, P < 0.05). CONCLUSION Japan is an aging society. In eastern Shizuoka prefecture, the increase in the number of trauma and minor injury cases may have increased due to the emphasis on the importance of early medical intervention by the fire department.

New classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line for intertrochanteric fractures

PURPOSE There are various types of intertrochanteric fractures that are unstable pertrochanteric fractures of the hip. The aim of this study was to develop a systematic and comprehensive classification of intertrochanteric fractures. MATERIALS AND METHODS This study enrolled 74 patients with intertrochanteric fractures treated by us between 2012 and 2015. The fractures were classified using 3D-CT images taken immediately after the fractures occurred based on the course of the lateral fracture line (LFL) that extends through the lateral femoral cortex distal to the vastus ridge of the greater trochanter in the intertrochanteric area. Furthermore, the presence or absence of additional typical fractures was also studied. Then, 4 orthopedic specialists examined the 3D-CT images of 20 patients randomly selected from the 74 patients to evaluate both the inter-rater and intra-rater agreement levels. RESULTS Intertrochanteric fractures were classified into three types according to the LFL patterns. Type I (41.9%), the Lateral Wall Pattern, has a LFL that extends towards the lateral fiber bundle attachment area of the iliofemoral ligament. Type II (24.3%), the Transverse Pattern, has a LFL that extends towards the medial bundle attachment area. Type III (33.8%), the Reverse Oblique Pattern, has a LFL that extends between the lateral and medial fiber bundle area of the iliofemoral ligament. Each type showed characteristic displacement and was associated with various combinations of typical fractures (fracture across the intertrochanteric line, posteromedial fragment, including the lesser trochanter, posterolateral fragment posterior to the femoral greater trochanter, and banana-shaped big fragment, including both the greater trochanter and the lesser trochanter). The mean κ values for the interobserver and intraobserver agreement levels were 0.77 (0.70-0.85) and 0.76 (0.70-0.85), respectively, which were considered substantial agreement levels. CONCLUSION We believe our new classification is a useful communication tool for medical professionals in the diagnosis of fractures.

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

PurposeSpinopelvic 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).MethodsThe 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.ResultsSIRF 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.

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 Webers 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. Webers 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 Webers three indexes. To increase the diagnostic accuracy further, it is important to detect anteroposterior deviation of the fibula in intraoperative lateral views.

Iliopsoas impingement after revision total hip arthroplasty treated with iliopsoas muscle transection

Introduction Iliopsoas tendinitis after revision total hip arthroplasty (THA) is rare and its etiology and optimal treatment are still unclear. We report a case of iliopsoas impingement after revision THA with a Kerboull acetabular reinforcement device requiring two-level iliopsoas muscle transection. Presentation of case A 70-year-old woman presented to our hospital complaining of debilitating right groin pain after revision THA with a Kerboull reinforcement device. She had undergone multiple hip operations after experiencing a pelvic fracture in a motor vehicle accident. A lidocaine nerve block at the level of the Kerboull device resulted in temporary but marked reduction in pain and a diagnosis of psoas impingent. We performed surgery via an anterior approach to release the iliopsoas muscle from the lesser trochanter. After iliopsoas tenotomy was performed, the muscle was still under high tension because of dense adhesions. Repeat transection of the iliopsoas muscle at the level of the anterior branch of the Kerboull device resulted in loosening of the iliopsoas muscle and resolution of impingement. Postoperatively, the patients groin pain completely disappeared, and she can now walk with a single cane and is satisfied with her result. Discussion Adhesions around the iliopsoas muscle likely contributed to the patients groin pain. Open surgery to perform complete release of iliopsoas muscle impingement should be considered in patients with pain after revision THA. Conclusion We reported a patient with Iliopsoas tendinitis after revision THA requiring two-level iliopsoas muscle transection.

A 42-year-old patient presenting with femoral head migration after hemiarthroplasty performed 22 years earlier: a case report

IntroductionTreatment of femoral neck fractures in young adults may require total hip arthroplasty or hip hemiarthroplasty using a bipolar cup. The latter can, however, result in migration of the femoral head and poor long-term results.Case presentationWe report a case of femoral head migration after hemiarthroplasty performed for femoral neck fracture that had occurred 22 years earlier, when the patient (a Japanese man) was 20 years old. He experienced peri-prosthetic fracture of the femur, subsequent migration of the prosthesis, and a massive bone defect of the pelvic side acetabular roof. After bone union of the femoral shaft fracture, the patient was referred to our hospital for reconstruction of the acetabular roof. Intra-operatively, we placed two alloimplants of bone from around the transplanted femoral head into the weight-bearing region of the acetabular roof using an impaction bone graft method. We then implanted an acetabular roof reinforcement plate and a cemented polyethylene cup in the position of the original acetabular cup. Eighteen months post-operatively, X-rays showed union of the transplanted bone.ConclusionsTreatment of femoral neck fractures in young adults is usually accomplished by osteosynthesis, but it may be complicated by femoral head avascular necrosis or by infection or osteomyelitis. In such cases, once an infection has subsided, either hip hemiarthroplasty using a bipolar cup or total hip arthroplasty may be required. However, if the acetabular side articular cartilage is damaged, a bipolar cup should not be used. Total hip arthroplasty should be performed to prevent migration of the implant.

The Massive Bleeding after the Operation of Hip Joint Surgery with the Acquired Haemorrhagic Coagulation Factor XIII(13) Deficiency: Two Case Reports.

Two women, aged 81 and 61, became haemorrhagic after surgery. Their previous surgeries were uneventful with no unexpected bleeding observed. Blood tests prior to the current surgeries indicated normal values including those related to coagulation. There were no problems with the current surgeries prior to leaving the operating room. At 3 hours after the surgery, the 81-year-old patient had an outflow of the drain at 1290 grams and her blood pressure decreased. She had disseminated intravascular coagulation (DIC). The 61-year-old woman had repeated haemorrhages after her current surgery for a long time. Their abnormal haemorrhages were caused by a deficiency of coagulation factor XIII(13). The mechanism of haemorrhagic coagulation factor XIII(13) deficiency is not understood, and it is a rare disorder. The only diagnostic method to detect this disorder is to measure factor XIII(13) activity in the blood. In this paper, we used Arabic and Roman numerals at the same time to avoid confusion of coagulation factor XIII(13) with coagulation factor VIII(8) that causes hemophilia A.

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.

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.

Total Hip Arthroplasty Using a Polished Tapered Cemented Stem in Hereditary Multiple Exostosis

A 61-year-old Japanese man underwent right total hip arthroplasty for hereditary multiple exostosis. At first presentation, he had suffered from coxalgia for a long time. On radiographic images, there was a gigantic femoral head, increased shaft angle, and large diameter of the femoral neck. He had also developed coxarthrosis and severe pain of the hip joint. The transformation of the proximal femur bone causes difficulty in setting a cementless total hip prosthesis. Therefore, total hip arthroplasty using a cemented polished tapered stem was performed via a direct lateral approach. Using a cemented polished tapered stem allowed us to deal with the femoral bone transformation and bone substance defectiveness due to exostosis and also minimized the invasiveness of the operation.