Hironori Ochi

Case report: The operation for the lumbar disk herniation just after cesarean delivery in the third trimester of pregnancy

Highlights • We suggest treatment strategy for a pregnant woman with lumber disk herniation.• The discectomy was performed just after cesarean delivery in the third trimester.• There were not any complications with mother and baby after operation.• It is necessary to cooperate with a pediatrician, an obstetrician, and an anesthesiologist.• It is important to discuss in advance to be able to respond quickly for changeable situation.

Kerboull-type plate in a direct anterior approach for severe bone defects at primary total hip arthroplasty: technical note

Introduction: For cases with extensive acetabular bone defects, we perform surgery combining the Kerboull-type (KT) plate and bone graft through direct anterior approach (DAA) in primary total hip arthroplasty (THA) requiring acetabular reconstruction as minimally invasive surgery. This paper provides the details of the surgical procedure. Methods: The basic structure of the Kerboull-type plate is a cruciform plate. Since the hook of the Kerboull-type plate has to be applied to the tear drop, a space for it was exposed. The tear drop is located in the anterior lower region in surgery through DAA in supine position. It was also confirmed by fluoroscopy as needed. The bone grafting was performed using an auto- or allogeneic femoral head for bone defects in the weight-bearing region of the hip joint. Results: Of 563 patients who underwent primary THA between 2012 and 2014, THA using the KT plate through DAA was performed in 21 patients (3.7%). The mean duration of postoperative follow-up was 31.8 months. The mean operative time was 188.4 min, and the mean blood loss was 770 g. The patients became able to walk independently after 2.4 days on average (1–4 days). On clinical evaluation, the modified Harris Hip Score was 45.6 ± 12.4 before surgery, and it was significantly improved to 85.3 ± 8.97 on the final follow-up. Discussion: DAA is a true intermuscular approach capable of conserving soft tissue. Since it is applied in a supine position, fluoroscopy can be readily used, and it was very useful to accurately place the plate.

Rapid hip osteoarthritis development in a patient with anterior acetabular cyst with sagittal alignment change.

Rapidly destructive coxarthrosis (RDC) is rare and develops unusual clinical course. Recent studies suggest multiple possible mechanisms of the development of RDC. However the exact mechanism of RDC is still not clear. The difficulty of the study on RDC is attributed to its rareness and the fact that the data before the onset of RDC is normally unavailable. In this report, we presented the patient having the radiographic data before the onset who had rapid osteoarthritis (OA) development after contralateral THA, which meets the current criteria of RDC. We thought that the increased posterior tilt of the pelvis after THA reinforced the stress concentration at pre-existed anterior acetabular cyst, thereby the destruction of the cyst was occurred. As a result the rapid OA was developed. We think that there is the case of rapid osteoarthritis developing due to alternating load concentration by posterior pelvic tilt on preexisting anterior acetabular cyst such as our patient among the cases diagnosed as RDC without any identifiable etiology. The recognition of sagittal alignment changes and anterior acetabular cyst may play important role in prediction and prevention of the rapid hip osteoarthritis development similar to RDC.

In total hip arthroplasty via the direct anterior approach, a dual-mobility cup prevents dislocation as effectively in hip fracture as in osteoarthritis

PurposeThe main purpose of this study was to compare the outcome of total hip arthroplasty (THA) via the direct anterior approach (DAA) using a dual-mobility cup (DMC) in patients with femoral neck fracture to those in patients undergoing elective THA for osteoarthritis.Patients and methodsWe retrospectively investigated 40 hips with femoral neck fracture (group A), and 81 hips with osteoarthritis (group B). THA via the DAA using the DMC was performed in both groups. A primary/secondary outcome variable were the presence of dislocation/operative time, intra- and/or peri-operative complication, and mortality.ResultsDislocation did not occur in either group. The complication rate was slightly higher in group A than in group B, but not statistically significant.ConclusionTHA with the DMC using the DAA was as effective for femoral neck facture as it was for elective THA in patients with osteoarthritis.

Total hip arthroplasty via the direct anterior approach with a dual mobility cup for displaced femoral neck fracture in patients with a high risk of dislocation

Introduction: Although total hip arthroplasty (THA) is superior to bipolar hemiarthroplasty (BHA) for displaced femoral neck fracture in terms of hip pain, function and reoperation rate, THA has a higher rate of dislocation. The direct anterior approach (DAA) and a dual mobility cup (DMC) are associated with lower rates of dislocation. The aim of this study was to investigate the outcomes of THA compared with BHA, and in those patients who had a THA we investigated those with a DMC (DMC-THA) and compared them with those had a single conventional cup (Single cup-THA). Materials: A total of 89 patients living independently were included between 2009 and 2015. We assessed patient characteristics, peri- and post-operative outcomes, walking ability and one-year mortality. Adjusted odds ratios (Adjusted ORs) were estimated for decrease of walking ability and one-year mortality using a logistic regression model with adjustment for potential confounders such as age, neuromuscular diseases with weakness, duration of surgery, perioperative blood loss and preoperative walking ability. Results: BHA (20 patients) versus THA (69 patients): There was no significant difference in the walking ability in either group. Multivariable logistic regression analysis demonstrated a significant association with one-year mortality in both groups [THA Adjusted ORs 0.088 (95% CI 0.0007–0.69); p = 0.020]. Single cup-THA (36 patients) versus DMC-THA (33 patients): The DMC-THA group had significantly greater age and more patients with neuromuscular diseases with weakness compared with the Single cup-THA group. Multivariable logistic regression analysis demonstrated no significant difference in the decrease of walking ability and in the one-year mortality between the groups. There were no post operative dislocations in any group. Discussion: THA via the DAA is one of the best treatments for displaced femoral neck fracture with a low risk of dislocation. THA via the DAA with a DMC is a safe and effective treatment for the patients with a high risk of dislocation.

Total Hip Arthroplasty for Implant Rupture after Surgery for Atypical Subtrochanteric Femoral Fracture

Treatment methods for delayed union and nonunion of atypical femoral fracture are still controversial. Moreover, no treatment method has been established for implant rupture caused by delayed union and nonunion. We encountered a 74-year-old female in whom nonunion-induced implant rupture occurred after treatment of atypical subtrochanteric femoral fracture with internal fixation using a long femoral nail. It was unlikely that sufficient fixation could be obtained by repeating osteosynthesis alone. Moreover, the patient was elderly and early weight-bearing activity was essential for early recovery of ADL. Based on these reasons, we selected one-stage surgery with total hip arthroplasty and osteosynthesis with inverted condylar locking plate as salvage procedures. Bone union was achieved at 6 months after surgery. This case illustrated that osteosynthesis-combined one-staged total hip arthroplasty could be considered as one of the options for nonunion-induced implant rupture of atypical femoral subtrochanteric fracture.

Minimally invasive endoscopic decompression of the intermatatarsal nerve for Morton's neuroma

BACKGROUND We presented case reports of endoscopic decompression for a Morton intermetatarsal neuroma. METHODS Three patients underwent surgery using an instrument designed to release the transverse carpal ligament for carpal tunnel syndrome. Each patient was 61, 56 and 24 years old. The mean follow up period was 1.5 years. RESULTS All patients experienced reduced pain postoperatively. The postoperative scar was very small (only 1 cm). There is no loss of sensation, no hematoma and no infection. CONCLUSION This procedure is simple, and the postoperative morbidity for the patient is minimal. There is rapid recovery with minimal risk of complications that are associated with open techniques. Therefore endoscopic decompression for Morton neuroma offers many advantages and should be studied in a larger number of patients.

Preoperative ultrasound to identify distribution of the lateral femoral cutaneous nerve in total hip arthroplasty using the direct anterior approach

Introduction: Recently, the branching pattern of the lateral femoral cutaneous nerve (LFCN) named Fan type has been reported that LFCN injury cannot be avoided in surgical dissections that use the direct anterior approach to the hip joint in the cadaveric study. We hypothesized that the Fan type can be identified by ultrasound The aim of this study was to investigate whether LFCN injury occurs in DAA-THA in cases identified as the Fan type based on preoperative ultrasound of the proximal femur. Methods: Ultrasonography of the proximal femur on the surgical side was performed before surgery and the LFCN distribution was judged as the Fan type or Non-Fan type. A self-reported questionnaire was sent to the patients at two months after surgery, and the presence or absence of LFCN injury was prospectively surveyed. Results: After application of exclusion criteria, 45 hips were included. LFCN injury was observed after surgery in 9 of the 10 patients judged as the Fan type based on the ultrasound of the proximal femur (positive predictive value: 90%), and no LFCN disorder was actually observed in 25 of the 26 patients judged as Non-Fan type (specificity: 96.2%). Conclusions: To prevent injury of the LFCN in patients judged as the Fan type on the ultrasound test before surgery, the risk of direct injury of the LFCN may be reduced through the approach in which an incision is made in the fascia which is opposite to the radial spreading, i.e., between the sartorius and tensor fasciae latae muscles or slightly medial from it.

The Baba classification focused on implant designs is useful in setting the therapeutic strategy for interprosthetic femoral fracture

PurposeThe purpose of this study was to investigate the clinical outcomes of femoral fracture with implants on the proximal and distal sides to verify whether actual fracture morphologies follow the fracture types of Baba classification focusing on implant designs useful for periprosthetic femoral fracture.MethodsProsthesis was present in 85 with periprosthetic femoral fractures. Excluding 73 patients with fracture around the femoral stem or fracture of the TKA femoral component alone, 12 patients with 14 legs with both implants were investigated. All patients were radiographically assessed for implant stability according to the Baba classification. For clinical evaluation, intra- and postoperative complications, the operation time, and intra-operative blood loss were investigated.ResultsThe Baba classification fracture type showed the implant as unstable and stable types in 3 and 11 legs, respectively. The consistency rate between the Baba classification-based judgment of plain radiograms acquired at the time of injury and actual surgical findings was 100%. As a result of treatment according to the Baba classification, bone union was achieved in all patients. There were no intra- or postoperative complications.ConclusionsApplying the Baba classification, implant stability could be sufficiently evaluated in not only periprosthetic femoral fractures following hip arthroplasty, but also interprosthetic femoral fractures, thereby verifying its usefulness in setting the treatment strategy.

Endoscopic Surgery under Fluoroscopic Guidance Is Useful for Diagnosing and Treating Epiphyseal Osteomyelitis Caused by Mycobacterium Species

Osteomyelitis caused by Mycobacterium species may be difficult to diagnose and treat. We report a case of treatment for osteomyelitis caused by Mycobacterium species in the epiphysis of the right proximal tibia. A 28-month-old boy presented to a hospital with symptoms of fever and right knee pain. He had been vaccinated with Mycobacterium bovis Bacille Calmette-Guérin (BCG) at five months of age. The epiphyseal radiolucent lesion had increased in size and extended to the metaphysis through the physis on a plain radiograph of the right proximal tibia. Surgical drainage and curettage of the lesion were performed with an endoscope under C-arm fluoroscopy. The intraoperative histopathological examination revealed granulation tissue composed of caseous necrosis and Langerhans giant cells, revealing Mycobacterium species to be the causative pathogen. Because of suspected osteomyelitis caused by BCG, the antituberculosis drugs were administered orally from an early postoperative stage. A plain radiograph taken eight months postoperatively showed bone regeneration in the area of curettage and a slight physeal bridge, in addition to normalization of the inflammatory response on blood sampling. It was possible to perform accurate diagnosis and rapid treatment for epiphyseal osteomyelitis caused by Mycobacterium species using endoscopic surgery under fluoroscopic guidance.