Gluteal Compartment Syndrome After Femoral Nail Extraction: A Case Report.

Gluteal compartment syndrome is a rare disorder and no definitive treatment has yet been established. Fasciotomy is often the treatment of choice for gluteal compartment syndrome, but there have been only a few cases that have improved with conservative therapy. A 26-year-old male with a body mass index of 40.5 who underwent femoral nail extraction surgery had severe pain in the right buttock and numbness in the right lower extremity. Initially, we suspected transient pain due to prolonged exposure to the same posture, but muscle weakness in the lower extremities and worsening of renal function appeared over time. Orthopedic evaluation revealed physical examination findings and MRI imaging findings consistent with gluteal compartment syndrome. Conservative treatment with temporary dialysis was chosen instead of fasciotomy because of the time required for diagnosis. Dialysis was started on postoperative day 3, renal function and muscle weakness recovered over time, and the patient was discharged home on postoperative day 37. At six months post-op, the patient was walking without pain and he had no changes in his peripheral neurologic examination compared to his preoperative baseline. Orthopedic surgeons should always be aware of the possibility of gluteal compartment syndrome when especially obese patients with prolonged operation times appeal to acute buttock pain. Diagnosis should be made as early as possible to get a good prognosis.

Bisphosphonates Prescription for Patients With Hip Fractures Based on Evaluation by a Dentist.

Background The purpose of this study is to clarify the current status of the prescription of postoperative bisphosphonates for patients with hip fractures and to explore the factors that prevent the postoperative prescription of bisphosphonates. Methods Of 180 patients with hip fractures treated surgically at our hospital between August 2019 and April 2020, 149 patients (46 men and 103 women; mean age: 83.9 ± 9.0 years), excluding 31 patients already prescribed bisphosphonates or denosumab, were included in the study. All patients were treated based on our clinical pathway, and their risk of jaw osteonecrosis was evaluated prior to the initiation of bisphosphonates by a dentist in our hospital. We collected data from the medical records on osteoporosis treatment interventions at admission and discharge, the reasons why postoperative bisphosphonates could not be prescribed at discharge, the proportion of patients who had follow-ups at our hospital, and patients' osteoporosis treatment status. Results Eighteen (12.8%) and 95 (63.8%) patients were prescribed anti-osteoporosis drugs at admission and discharge, respectively. One hundred and twenty-one patients (86.8%) could not be prescribed postoperative bisphosphonates at discharge - 71 (58.7%) because of oral hygiene problems, 34 (28.1%) because they did not have regular dental consultations, seven (5.8%) because of renal dysfunction, eight (6.6%) because of poor cognitive and swallowing function, and one (0.8%) because of medication side effects. Forty-nine patients (32.9%) went to our hospital for follow-up and 11 were introduced to bisphosphonates or denosumab at follow-up. Conclusions The number of patients with hip fractures who were prescribed postoperative bisphosphonates was low in our study. The oral hygiene problems identified by dentists accounted for responsible for the low prescription rate of postoperative bisphosphonates. Therefore, coordination with dentists may be important to increase the postoperative bisphosphonate prescription.

Co-existence of Lumbar Disc Herniation and Posterior Ring Apophyseal Fracture: It Is Not Rare and Computed Tomography Is Useful.

Introduction Posterior ring apophyseal fracture (PRAF) is characterized by the separation of bone fragments and sometimes coexists with lumbar disc herniation (LDH). However, how often these conditions coexist and the details of the clinical course remain unclear. Methods We analyzed 200 patients who underwent surgical treatment for LDH at our hospital from January 2016 to December 2020. Among these, we reviewed 21 patients who underwent microendoscopic surgery to treat PRAF. They consisted of 11 male and 10 female patients, ranging in age from 15 to 63 years. The average age was 32.8 months, and the average follow-up period was 39.8 years. We performed simple roentgenography and magnetic resonance imaging for all patients and computed tomography for about 80% of the patients. We evaluated the type of PRAF fragment (Takata classification), disease level, Japanese Orthopedic Association (JOA) score, Roland-Morris Disability Questionnaire (RDQ) score, operating time, intraoperative blood loss, and perioperative complications. Results A total of 10.5% of patients with LDH also had PRAF. The mean JOA score significantly improved from 10.6 ± 5.7 points before surgery to 21.4 ± 5.1 points at the final observation (p < 0.05). The mean RDQ score significantly improved from 17.1 ± 4.5 preoperatively to 5.5 ± 0.5 at the final observation (p < 0.05). The average operation time was 88.6 minutes. There were no complications requiring early surgery that were due to postoperative infection or epidural hematoma, but one patient required reoperation. Conclusion This study showed that PRAF coexisted with LDH in about 10% of cases, and the outcomes of surgical treatment were generally good. Computed tomography is recommended to improve the diagnostic rate and assist with surgical planning and intraoperative decision-making.

Efficacy of Corticosteroid Addition to a Periarticular Cocktail Injection to Counteract Nausea and Vomiting After Total Knee Arthroplasty.

BACKGROUND: Intraoperative periarticular injection of a "cocktail" of drugs is undertaken commonly in total knee arthroplasty (TKA). The addition of a corticosteroid to the periarticular injection is believed to offer greater pain relief because of its local anti-inflammatory effects, but the prevalence of postoperative nausea and vomiting (PONV) is not known. This retrospective observational study aimed to elucidate the relationship between corticosteroid addition to a periarticular cocktail injection (PCI) and PONV. MATERIALS AND METHODS: Fifty-nine patients who underwent unilateral TKA for primary osteoarthritis were divided into two groups: corticosteroid and non-corticosteroid. The former had triamcinolone acetonide (40 mg) added to the same PCI. The primary outcome was the prevalence of nausea and vomiting within 48 hours following TKA. RESULTS: There was no significant difference between the two groups in terms of patient demographics. The overall prevalence of PONV was 16.9%. Fewer patients in the corticosteroid group complained of PONV than in the non-corticosteroid group (6.4% vs. 58.3%; p = 0.012). CONCLUSIONS: The addition of a corticosteroid to a PCI suppressed PONV. Our results suggested that cocktail injections may have local and systemic effects.

Factors Affecting Postoperative Spinal Epidural Hematoma and the Optimal Order of Vertebral Body Decompression in Multivertebral Microendoscopic Laminectomy.

Purpose Symptomatic postoperative spinal epidural hematoma (POSEH) is a complication of spine surgery that occurs infrequently but may cause ongoing serious neurological damage. Due to the narrow entry portal, the risk of hematoma is increased after microendoscopic laminectomy (MEL) compared with conventional open surgery, and the risk might be even higher for multivertebral MEL (m-MEL). The purpose of this study was to clarify the factors affecting the development of POSEH after m-MEL and identify the optimal order for the decompression of vertebral bodies. Methods A total of 313 patients who underwent m-MEL from 2016 to 2020 were retrospectively assessed. The cohort comprised 238 patients who underwent two-level MEL, 67 who underwent three-level MEL, and eight who underwent four-level MEL. Symptomatic POSEH was defined as the presence of an epidural hematoma at the surgical site on MRI with symptoms such as lower extremity pain or muscle weakness. We elucidated the incidence of POSEH at each vertebral level and investigated the relationship between POSEH and possible risk factors such as clinical and operative variables. Results There were 41 patients in the POSEH group and 272 patients in the non-POSEH group. Seven patients in the POSEH group underwent reoperation. The occurrence of POSEH was related to the number of decompressed vertebral bodies. Patients who underwent L2/3 and L3/4 decompression at the end of the procedure also showed a higher incidence of POSEH at the surgical level. Conclusion In patients undergoing m-MEL, treatment of the upper lumbar vertebrae at the end of decompression surgery might be a risk factor for symptomatic POSEH. The incidence of POSEH was particularly increased at L2/3, suggesting that L2/3 decompression should not be performed at last and that careful hemostasis should be applied.

Efficacy of Nerve Root Block for the Treatment of Lumbar Spinal Canal Stenosis in Adults Older Than 80 Years of Age.

BACKGROUND: Patients with advanced lumbar spinal canal stenosis (LCS) often prefer non-operative treatment owing to decreased physiological function and comorbidities. Although the therapeutic value of selective nerve root block (SNRB) for LCS is confirmed, there are few reports of its effectiveness in the elderly. We investigated the efficacy of SNRB for LCS in patients over 80 years of age. METHODS:  The subjects were 112 patients aged over 80 years (mean age: 84 years; 45 men and 67 women ) with medication-resistant LCS without cauda equina syndrome who underwent SNRB. Cases with acute-onset lumbar disc herniation were excluded. We retrospectively investigated and compared the presence or absence of surgery, effect of SNRB, number of procedures, duration of disease, and magnetic resonance imaging findings. Patients who could avoid the surgery by SNRB were defined as the effective group. Patients whose symptoms were not relieved by SNRB and who underwent surgery and those whose symptoms were not relieved but who continued conservative treatment were defined as the ineffective group. A total of one to seven SNRBs were performed in both groups, and the same spine surgeon performed the entire procedure from SNRB to surgery. RESULTS:  There were 86 nonoperative patients (69 effective cases) and 26 operative patients; the overall rate of effectiveness was 61% (69/112 patients). The area of the spinal canal at the responsible level was 108.63 mm2 in the effective group compared with 77.06 mm2 in the ineffective group. This was significantly narrower in the ineffective group (p=0.0094). There was no significant difference in the duration of illness, number of blocks, or hernia complication rate between the groups. No patient experienced severe neuralgia that may have been caused by neuropathy during SNRB. DISCUSSION: Our outcome showed that more than 60% of older patients with LCS showed symptomatic improvement with SNRB. SNRB can be performed relatively safely in the elderly and appears to be a favorable treatment option for older patients with various risks, such as poor general condition. CONCLUSIONS: Multiple sessions of SNRB may provide older patients with symptomatic improvement and may be an option for treatment.

Massive Lumbar Disc Herniation Causing Cauda Equina Syndrome That Presents As Bladder and Bowel Dysfunction in the Absence of Lower Extremity Weakness.

The purpose of this report is to examine the features of cauda equina syndrome (CES) presenting as bladder and bowel dysfunction in the absence of lower extremity weakness. Between July 2015 and July 2016, we experienced four cases of massive LDH causing CES that presented as bladder and bowel dysfunction in the absence of lower extremity weakness. Herein, we describe the clinical features of these four patients (two males and two females) who were followed for a minimum of two years postoperatively. The mean age at the time of surgery was 46.8 years (range, 37-71 years). The disc herniation lesion was at the L4/5 level in one patient, and the L5/S1 level in three. The mean interval between the onset of CES and complete surgical decompression was 10.5 days (range, 1-18 days). Postoperative outcomes were better than poor in three of four cases, while one case had residual sphincter dysfunction. LDH causing CES is considered an indication for immediate surgical decompression; however, diagnosis of CES is likely to be delayed in atypical cases of CES that present as bladder and bowel dysfunction in the absence of lower extremity weakness. Diagnosis of CES tended to be delayed in cases without lower extremity weakness. Clinicians should recognize even sensory impairment alone of the dominant area supplied by S2-4 is an important diagnostic sign of CES in the early stage.

Midlife and late-life diabetes and sarcopenia in a general older Japanese population: The Hisayama Study.

AIMS/INTRODUCTION: To investigate the association between midlife or late-life diabetes and the development of sarcopenia in an older Japanese population. MATERIALS AND METHODS: A total of 824 Japanese residents aged 65 to 84 years without sarcopenia were followed up from 2012 to 2017. Sarcopenia was determined following the Asian Working Group for Sarcopenia definition. The time of diabetes diagnosis was classified as midlife or late-life diabetes by the age at first diagnosis of diabetes (< 65 or ≥ 65 years) based on annual health checkups data over the past 24 years. The duration of diabetes was categorized into three groups of < 10, 10-15, and > 15 years. The odds ratios of incident sarcopenia according to the diabetic status were estimated using a logistic regression analysis. RESULTS: During follow-up, 47 subjects developed sarcopenia. The multivariable-adjusted odds ratio for incident sarcopenia was significantly greater in subjects with diabetes at baseline than in those without it (odds ratio 2.51, 95% confidence interval 1.26-5.00). Subjects with midlife diabetes had a significantly greater risk of incident sarcopenia, whereas no significant association between late-life diabetes and incident sarcopenia was observed. With a longer duration of diabetes, the risk of incident sarcopenia increased significantly (P for trend = 0.002). CONCLUSIONS: The present study suggests that midlife diabetes and a longer duration of diabetes are significant risk factors for incident sarcopenia in the older population. Preventing diabetes in midlife may reduce the risk of the development of sarcopenia in later life.

Prevalence and Mortality of Sarcopenia in a Community-dwelling Older Japanese Population: The Hisayama Study.

BACKGROUND: The prevalence of sarcopenia defined using the Asian Working Group for Sarcopenia (AWGS) criteria in Asian communities has not been fully addressed. Moreover, few studies have addressed the influence of sarcopenia on mortality. METHODS: A total of 1,371 and 1,597 residents aged 65 years or older participated in health surveys in 2012 and 2017. Sarcopenia was determined using the AWGS definition. Factors associated with the presence of sarcopenia were assessed using a logistic regression model in participants in the 2012 survey. Subjects in the 2012 survey were followed-up prospectively for a median of 4.3 years. Mortality risk for subjects with sarcopenia was examined using the Cox proportional hazards model. RESULTS: The crude prevalence of sarcopenia was 7.4% and 6.6% in participants at the 2012 and 2017 surveys, respectively; there was no significant difference between surveys (P = 0.44). The prevalence of sarcopenia increased significantly with age in both sexes (both P for trend <0.001). Subjects with sarcopenia were more likely to exercise less regularly, to intake less total energy, and to exhibit a disability in activity of daily living than those without. The multivariable-adjusted hazard ratio for all-cause mortality was 2.20 (95% confidence interval, 1.25-3.85) in subjects with sarcopenia, compared to those without. CONCLUSIONS: Approximately 7% of older subjects had sarcopenia in a community-dwelling older Japanese population. Moreover, subjects with sarcopenia had an increased mortality risk. Our findings suggest that a public health strategy for sarcopenia is needed to extend healthy life expectancy.

Tumor-induced osteomalacia caused by a massive phosphaturic mesenchymal tumor of the acetabulum: A case report.

We report a case of tumor-induced osteomalacia (TIO) caused by a massive phosphaturic mesenchymal tumor (PMT) of the acetabulum. A 68-year-old woman presented with progressive bone pain of the rib cage, and polyarthralgia and back pain for 3 years. She was diagnosed with hypophosphatemic osteomalacia because laboratory testing was remarkable for low serum phosphorus and a low level of 1,25(OH)2 vitamin D. Three years later, her hip radiograph revealed an osteolytic lesion of the acetabulum. Magnetic resonance imaging of the acetabulum showed a massive lesion. Laboratory data showed hypophosphatemia and an elevated serum level of fibroblast growth factor 23 (FGF-23). Samples obtained with open biopsy showed a low-grade spindle cell neoplasm with FGF-23 positivity, identified by using immunohistochemical staining, confirming the diagnosis of a PMT mixed connective tissue variant. Curettage of the tumor was performed, and the defects were filled with bone allografts. The hip joint was reconstructed with total hip arthroplasty using a Muller support ring. To our knowledge, this report represents the first documented case of massive PMT of the acetabulum causing TIO.

[A pregnant case on which EC-IC bypass was successfully performed in the acute phase of brain infarction].

A 30 year-old, 28 weeks-pregnant woman (gravida 2, para 2) suffered from a sudden onset of aphasia when she was having a chat in the upright position. Although the initial symptom soon disappeared, transient attacks of aphasia combined with weakness in the right arm occurred intermittently, particularly when she uprose. MR image disclosed a small acute infarcted focus at the genu of the left internal capsule, while MRA showed an occlusion of the intracranial portion of the left internal carotid artery. She was treated conservatively, but the transient attack continued and her consciousness was slightly lowered. Since repeated examination revealed no recanalization of the occluded artery, treatment was reinforced by using heparin and dopamine on day 1. However, her consciousness was not improved, and dopamine evoked nausea and vomiting. On day 2, superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis was carried out. Soon after surgery, she regained alertness and the transient attack subsided. Examinations could not clarify the course of the occlusion. She was treated with heparin until she delivered a sound baby in the 37th week. Although STA-MCA anastomosis for acute ischemic stroke is still debatable, it may be a good option even for a pregnant woman when suffering from intractable progressing stroke.