Following the Fukushima Daiichi Nuclear Power Plant accident, Japan enhanced its nuclear disaster preparedness framework. However, personnel shortages stemming from fear and anxiety persist as a critical issue during such disasters. This study investigated the willingness of medical professionals at four university hospitals in Kyushu to participate in nuclear disaster response activities and explored factors influencing this willingness. A cross-sectional web-based survey was conducted among staff at Nagasaki, Kyushu, Saga and Kagoshima University Hospitals. Participants answered 19 questions assessing their willingness to participate in nuclear or radiological emergency response and associated psychosocial and occupational factors. Multiple regression analysis was used to identify predictors of willingness (Q1). A total of 378 valid responses were analyzed. Demographic variables, including age, sex, occupation and disaster experience, did not significantly influence willingness. However, interest in nuclear or radiological emergencies (β =0.383, P < 0.05), Incentives (β =0.249), Family understanding (β =0.116) and Occupational norms (β =0.114) were positively associated with willingness. Conversely, Anxiety (β = -0.151), Expectation of routine training (β = -0.138) and Perceived frequency of nuclear disasters (β = -0.104) were negatively associated with willingness. Medical staff's willingness to respond to nuclear or radiological emergencies is influenced more by psychological and occupational perceptions than by demographic factors. Interventions such as incentive programs, family support initiatives, targeted training and anxiety-reduction strategies may enhance preparedness for and participation in future nuclear or radiological emergencies.

Background Laryngeal injuries, especially cricoid cartilage fractures, are rare but may present with airway emergencies, and appropriate airway management is vital. Case presentation A 24-year-old man admitted to the emergency room with isolated blunt cervical trauma after a motorcycle accident. The patient presented dysphonia, stridor, hemoptysis, cervical subcutaneous emphysema, and increasing respiratory distress. Oral intubation was initially successful, however, worsening subcutaneous emphysema and loss of effective ventilation suggested airway disruption. Emergency cricothyrotomy was performed, but persistent air leakage from the incision site prompted bronchoscopy, which revealed a 7-mm tracheal laceration on the right side of the larynx. The patient was reintubated under bronchoscopy. Computed tomography showed a cricoid cartilage fracture. Tracheostomy and complete repair were performed 2 days after the injury. The cricoid cartilage was fractured fully circumferentially, with the anterior part deviated toward the caudal side, and its deepest part had perforated the right side of the trachea. The cricoid cartilage was repaired, and the tracheal perforation was dilated to create a laryngo-cutaneous fistula. Persistent hoarseness after fistula closure was associated with scar formation of the left vocal fold and arytenoid cartilage dislocation. Although symptoms gradually improved with voice rehabilitation, increased vocal demand after a job change led to thyroplasty 2 years after injury. Conclusion Cricoid cartilage fractures associated with blunt laryngeal injuries may cause tracheal injury. This case highlights the challenges of managing concurrent cricoid fracture and tracheal injury, where the surgical airway site coincided with the traumatic defect. Rapid decision-making balancing exploration and stabilization was critical.

AbstractAimTo analyze characteristics and investigate prognostic indicators of out‐of‐hospital cardiac arrest (OHCA) in a hilly area in Japan.MethodsA retrospective population‐based study was conducted using the Utstein Registry for 4280 OHCA patients in the Nagasaki Medical Region (NMR) registered over the 10‐year period from 2011 to 2020. The main outcome measure was a favorable cerebral performance category (CPC 1–2). Sites at which OHCA occurred were classified into “sloped places (SPs)” (not easily accessible by emergency medical services [EMS] personnel due to slopes) and “accessible places (APs)” (EMS personnel could park an ambulance close to the site). The characteristics and prognosis based on CPC were compared between SPs and APs, and multivariable analysis was performed.ResultsNo significant improvement in prognosis occurred in the NMR from 2011 to 2020. Prognosis in SPs was significantly worse than that in APs. However, multivariable analysis did not identify SP as a prognostic indicator. The following factors were associated with survival and CPC 1–2: age group, witness status, first documented rhythm, bystander‐initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, use of mechanical CPR (m‐CPR) device or esophageal obturator airway (EOA), and year. Both m‐CPR and EOA use were associated with a poor prognosis.ConclusionIn a hilly area, OHCA patients in SPs had a worse prognosis than those in APs, but SPs was not significantly associated with prognosis by multivariable analysis. Interventions to increase bystander‐initiated CPR and AED use could potentially improve outcomes of OHCA in the NMR.

Background This study aimed to clarify the characteristic features of the anteroinferior and posterosuperior popliteomeniscal fascicles (aiPMF and psPMF, respectively) and popliteal hiatus using three-dimensional (3D) reconstructions of 7 T magnetic resonance imaging (MRI) arthrography. Methods Six knees from human cadavers fixed using the Thiel embalming method were examined using 7 T MRI arthrography. 3D Images of the structures around the popliteal hiatus were reconstructed. Morphologies of the psPMF, aiPMF, and popliteal hiatus were investigated and their positional relationships analyzed. Results The PMFs attached to the periphery of the lateral meniscus (LM) to form the popliteal hiatus. Each coursed in an oblique direction. The mean length of the psPMF and aiPMF attachments to the LM were 6.8 and 21.6 mm, respectively; mean popliteal hiatus length was 12.8 mm. These lengths corresponded to 7.5%, 24.3%, and 14.5% of the total length of the LM, respectively. The aiPMF was thick near the lateral aspect of the articular capsule and became thinner towards the posteromedial aspect of the LM. The psPMF was thick near the posterior aspect of the articular capsule and became thinner towards the posterolateral aspect of the LM. Conclusion Morphological properties of the aiPMF, psPMF, their attachments to the LM, and the popliteal hiatus were consistent across the cadaver specimens examined. Each PMF was thin near the popliteal hiatus and became thicker towards its attachment to the articular capsule. These findings may be useful for anatomical repair for the LM hypermobility.

Zinc plays a role in immune function. This study aimed to investigate the clinical significance of zinc levels in patients with severe trauma by examining the association between serum zinc levels and infectious complications. Inclusion criteria were hospitalization of 2 weeks or more; Abbreviated Injury Scale score of 3 or more; zinc levels measured on admission and at 2 weeks later. Among the 141 included patients on admission, 136 (96.5%) had zinc deficiency, whereas at two weeks later, serum zinc levels increased significantly, with the number of patients with zinc deficiency decreasing to 31 (22.0%). Between the zinc-deficient group and zinc-sufficient group stratified by serum zinc level at two weeks, there were significant differences in lengths of ICU stay and mechanical ventilation, the complication of infection, and positive blood cultures. Logistic regression showed that zinc level at two weeks after admission were significantly associated with the complication of infection (p=0.03). In addition, Age, initial nutrition, Sequential Organ Failure Assessment score, probability of survival, serum phosphate on admission were highly associated with zinc deficiency at two weeks after admission by logistic regression. In the patients with risk factors on admission, zinc supplementation started on the first day of hospitalization might be beneficial.

Aim: This study was conducted to clarify the morphological properties of the quadriceps tendon (QT) and its patella insertion site using three-dimensional computed tomography and magnetic resonance imaging. Methods: Twenty-one right knees from human cadavers were evaluated using threedimensional computed tomography and magnetic resonance imaging. The morphologies of the QT and its patella insertion site were evaluated, along with intra-tendon differences in length, width, and thickness. Results: The QT insertion site on the patella was dome-shaped without characteristic bony features. The mean surface area of the insertion site was 502.5 & PLUSMN; 68.5 mm2 (range, 336.0- 610.7). The QT was longest 2.0 mm lateral to the central width of the insertion and gradually became shorter toward both edges (mean length, 59.7 & PLUSMN; 8.3 mm). The QT was widest at the insertion site (mean width, 39.1 & PLUSMN; 5.3 mm) and gradually became narrower toward the proximal side. The QT was thickest 2.0 mm medial to the center (mean thickness, 11.4 & PLUSMN; 1.9 mm). Conclusion: The morphological properties of the QT and its insertion site were consistent. The characteristics of the QT graft depend on the harvested region. & COPY; 2023 Elsevier B.V. All rights reserved.

It is well known that oxidative stress causes certain diseases and organ damage. However, roles of oxidative stress in the acute phase of critical patients remain to be elucidated. This study aimed to investigate the balance of oxidative and antioxidative system and to clarify the association between oxidative stress and mortality in critically ill patients. This cohort study enrolled 247 patients transported to our emergency department by ambulance. Blood was drawn on hospital arrival, and serum derivatives of reactive oxidant metabolites (dROMs, oxidative index) and biological antioxidant potential (BAP, antioxidative index) were measured. Modified ratio (MR) is also calculated as BAP/dROMs/7.51. There were 197 survivors and 50 non-survivors. In the non-survivors, dROMs were significantly lower (274 vs 311, p<0.01), BAP was significantly higher (2,853 vs 2,138, p<0.01), and MR was significantly higher (1.51 vs 0.92, p<0.01) compared to those in the survivors. The AUC of MR was similar to that for the APACHE II score. Contrary to our expectations, higher BAP and lower dROMs were observed on admission in non-survivors. This may suggest that the antioxidative system is more dominant in the acute phase of severe insults and that the balance toward a higher antioxidative system is associated with mortality.

Background: The aim of our study was to clarify the morphology of the proximal tibiofibu-lar joint (PTFJ), insertion sites of the proximal tibiofibular ligaments (PTFLs), and related osseous landmarks on three-dimensional (3D) computed tomography (CT) images. Methods: Cadaveric knees were evaluated by dissection and 3D CT imaging. The anterior PTFL (A-PTFL) and posterior PTFL (P-PTFL) were isolated, and their tibial and fibular inser-tion sites were identified. The morphology and location of insertion sites and their posi-tional relationships with osseous structures were analyzed on 3D CT images.Results: The A-PTFL comprised up to four bundles, and the P-PTFL comprised two bundles. The mean length of the A-PTFL and P-PTFL was 11.3 mm and 10.3 mm, respectively. On the tibial side of the PTFJ, bony prominences were present at the A-PTFL and P-PTFL insertion sites and were clearly identified as osseous landmarks in all knees. On the fibular side, the A-PTFL and P-PTFL insertion sites were at the edge of the triangular pyramid of the fibular head. The mean PTFJ area was 198.8 mm2, and the mean inclination angle between PTFJ and tibial plane was 38.4 degrees. There was an inverse correlation between the PTFJ surface area and the inclination angle. Conclusion: The present study clearly identified PTFL insertion sites on the tibia and fibula and showed the relationships between these insertions and osseous landmarks. These data improve our understanding of the anatomy of PTFL insertions, which may assist surgeons in performing anatomical reconstruction.(c) 2023 Published by Elsevier B.V.

Background: Knee osteoarthritis (KOA) is associated with reduced quality of life due to knee pain and gait disturbance. However, the evaluation of KOA is mainly based on images and patient-reported outcome measures (PROMs), which are said to be insufficient for functional evaluation. Recently, gait analysis using an accelerometer has been used for functional evaluation of KOA patients. Nevertheless, evaluation of the entire body motion is insufficient. The aim of this study was to clarify the gait characteristics of KOA patients using the distribution of scalar products and the interval time of heel contact during spontaneous walking and to compare them with healthy subjects. Methods: Participants wore a three-axis accelerometer sensor on the third lumbar vertebra and walked for 6 min on a flat path at a free walking speed. The sum of a composite vector (CV) scalar product and a histogram for distribution were used for body motion evaluation. The CV consisted of a synthesis of acceleration data from three axes. In addition to the summation of the CV, a histogram can be created to evaluate in detail the magnitude of the waves. The amount of variation was measured in the left-right and front-back directions. Variability was evaluated from the distribution of heel contact duration between both feet measured from the vertical acceleration. Results: KOA patients showed a smaller sum of CV that converged to small acceleration in the distribution when compared with healthy subjects. In the KOA group, the amount of variation in the forward and backward directions was greater than that in the forward direction. The variability of heel-ground interval time was greater in the KOA group than in healthy subjects. Conclusion: KOA patients walked with less overall body movement, with limited movable range of the knee joint and pain-avoiding motion. The gait of the KOA group was considered unstable, with long time intervals between peaks. The increase in the amount of forward variation was thought to be due to the effect of trunk forward bending during walking. The clinical relevance of this study is that it was possible to evaluate KOA patients' gait quantitatively and qualitatively. (c) 2021 Elsevier B.V. All rights reserved.

INTRODUCTION:Repulsive guidance molecule a (RGMa) is a key protein that negatively regulates neuronal regeneration as its inhibition enhances axonal growth and promotes functional recovery in animal models of spinal cord injury. However, the role of RGMa in traumatic brain injury (TBI) remains elusive. This study aimed to clarify TBI-responsive RGMa expression in a murine model.METHODS:Adult male C57BL/6J mice were subjected to controlled cortical impact. Brains were extracted 6 hours and 1, 3, 7, 14 and 21 days after injury (n = 6 in each group). Changes in the messenger RNA (mRNA) expression of RGMa and its receptor, neogenin, were evaluated by quantitative polymerase chain reaction in the damaged area of the cortex and contralateral cortex, along with expression measurement of inflammation-related molecules. Neurological deficit was also assessed by the cylinder test.RESULTS:Neurological score was consistently lower in the TBI group compared to the sham group throughout the experimental period. The mRNA expressions of representative inflammatory cytokine TNF-α and chemokine receptor CCR2 were remarkably increased in the injured cortex on day 1 and gradually decreased over time, although remaining at higher values at least until day 14. The mRNA expressions of RGMa and neogenin were significantly suppressed in the damaged cortex until day 3. Interestingly, RGMa expression was suppressed most on day 1 and recovered over time.CONCLUSION:In the acute phase of TBI, gene expression of inflammatory cytokines significantly increased, and gene expressions of RGMa and neogenin significantly decreased in the inflammatory milieu of the damaged area. Despite the subsequent remission of inflammation, RGMa gene expression recovered to the normal level 1 week after TBI. Intrinsic regenerative response to acute brain injury might be hampered by the following recovery of RGMa expression, hinting at the possibility of functional RGMa inhibition as a new, effective maneuver against TBI.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

CD4+ regulatory T cells (Tregs) are acutely activated by traumatic injury, which suggests that they may react to injury with similar kinetics as memory T cells. Here, we used a mouse burn trauma model to screen for memory-like T cell responses to injury by transferring T cells from sham or burn CD45.1 mice into CD45.2 mice and performing secondary injuries in recipient mice. Among all T cell subsets that were measured, only Tregs expanded in response to secondary injury. The expanded Tregs were a CD44(high)/CD62L(low)subpopulation, markers indicative of memory T cells. CyTOF (cytometry by time-of-flight) mass cytometry was used to demonstrate that injury-expanded Tregs expressed higher levels of CD44, CTLA-4, ICOS, GITR, and Helios than Tregs from noninjured mice. Next, we tested whether a similar population of Tregs might react acutely to burn trauma. We observed that Tregs with a phenotype that matched the injury-expanded Tregs were activated by 6 h after injury. To test if Treg activation by trauma requires functional MHC class II, we measured trauma-induced Treg activation in MHC class II gene deficient (MHCII-/-) mice or in mice that were given Fab fragment of anti-MHC class II antibody to block TCR activation. Injury-induced Treg activation occurred in normal mice but only partial activation was detected in MHCII(-/-)mice or in mice that were given Fab anti-MHCII antibody. These findings demonstrate that trauma activates a memory-like Treg subpopulation and that Treg activation by injury is partially dependent on TCR signaling by an MHC class II dependent mechanism.

Venous thromboembolism (VTE) is a life-threatening complication after trauma. Several studies have reported VTE prophylaxis using low-molecular-weight heparin; however, there is no consensus for prophylaxis after trauma. This study aimed to assess the efficacy and safety of our new anticoagulation therapy protocol using unfractionated heparin (UFH) plus intermittent pneumatic compression (IPC) to prevent post-traumatic VTE in high-risk trauma patients.This study enrolled 70 trauma patients who were admitted to the emergency medical center of Nagasaki University Hospital and had Risk Assessment Profile (RAP) scores ≥ 5. After stopping bleeding at the trauma site, all patients received intravenous UFH (10,000 U/day) plus IPC, which was continued for 14 days or until the patients could walk. On days 7 and 14, all patients underwent lower extremity sonography for deep-vein thrombosis screening. VTE incidences between patients with the above intervention and historical controls with IPC alone were compared.No significant differences in age, sex, and the RAP score were observed between the 105 controls and intervention patients. VTE occurrence was fewer in patients with the intervention (14.3%) than in the controls (28.6%; P = 0.029). No hemorrhagic complications occurred after UFH administration. Multivariable logistic analysis revealed a significant association between the intervention and low incidence of VTE (odds ratio: 0.390; 95% confidence interval: 0.163-0.913; P = 0.030).Routine UFH administration with IPC may prevent post-traumatic VTE without adverse events.

Abstract Purpose The purpose of this study was to clarify the insertion sites of the anterior inferior tibiofibular ligament (AITFL) and posterior inferior tibiofibular ligament (PITFL) and related osseous landmarks on three-dimensional computed tomography images. Methods Twenty-nine non-paired, formalin-fixed human cadaveric ankles were evaluated. The tibial and fibular insertion sites of the AITFL and PITFL were identified. The morphology and location of the insertion sites and their positional relationships with osseous structures were analyzed on three-dimensional computed tomography images. Results The AITFL had a trapezoidal shape, with fibers that ran obliquely lateral from a wider insertion at the lateral distal tibia to the medial distal fibula. The PITFL had a similar shape to the AITFL; however, it ran more horizontally, with fibers running in the same direction. In the tibia, the anterior capsular ridge and the Chaput’s and Volkmann’s tubercles were useful osseous landmarks for the insertion sites. In the fibula, the centers of the insertion sites of the AITFL and PITFL were located on the edges of the distal anterior and posterior fibula, which were useful osseous landmarks. The mean distances between the center points of the tibial and fibular insertion sites of the AITFL and PITFL were 10.1 ± 2.4 mm and 11.7 ± 2.6 mm, respectively. Conclusions The relationships between the characteristic features of the distal tibia and fibula and the insertions of the AITFL and PITFL were consistent. The present findings improve the understanding of the anatomy of the insertions of the distal tibiofibular syndesmotic joint.

PURPOSE:To clarify the characteristic features of the meniscal root attachments, meniscofemoral ligaments (MFLs), and related osseous landmarks on three-dimensional images using computed tomography.METHODS:Twenty-eight non-paired, formalin-fixed human cadaveric knees were evaluated in this study. The meniscal root attachments were identified and marked. Three-dimensional images were obtained after applying a contrast agent to the entire meniscal surfaces and MFLs, then the morphology of the meniscal root attachments and MFLs, and their positional relationships with osseous landmarks, were analyzed.RESULTS:Parsons' knob divided the medial meniscal anterior root attachment and lateral meniscal anterior root attachment on the anterior portion of the tibial plateau. The medial meniscal posterior root attachment was near the medial intercondylar tubercle. The lateral meniscal posterior root attachment (LMPRA) was closer to the lateral intercondylar tubercle. Both root attachments were near the posterior intercondylar fossa. The positional relationships between the meniscal root attachments and related osseous landmarks were consistent in all specimens. The MFLs originated from the lateral meniscus posterior horn, and the anterior MFL was closer to the LMPRA than the posterior MFL. The posterior MFL originated at approximately the midpoint between the LMPRA and the most posterior margin of the lateral meniscus.CONCLUSION:This study showed that the relationships between the characteristic features of the meniscal root attachments, MFLs, and related osseous landmarks were consistent. The clinical relevance of this study is that it improved understanding of the anatomy of the meniscal root attachments and MFLs.

Learning Objectives: It is difficult to determine the pathophysiology of systemic inflammation with a single biomarker. We previously reported that murine sepsis model showed distinctive gene expression patterns of innate immune receptors. We aimed to clarify the time course change of gene expression profile of innate immune receptors and signaling molecules in infectious or sterile inflammation, and to establish the novel method to discriminate the pathophysiology of systemic inflammation by patterns of gene expression profile using canonical discriminant analysis. Methods: To compare infectious inflammation and sterile inflammation, we employed cecal ligation and puncture (CLP) and 20% full thickness burn injury (Burn) model. C57BL/6 mice underwent sham, CLP, or Burn. 3, 6, 12, and 24 hours later, mice were sacrificed, and total RNA was extracted from whole blood. Using quantitative real-time PCR, we investigated gene expression of innate immune receptors (TLR2, TLR4, TLR9, NLRP3, RIG-I) and signaling molecules (MyD88, TRIF, IRF-3, IRF-7, Caspase-1). To evaluate all the gene expression together as patterns, each value was standardized, and canonical discriminant analysis was performed at each time point. Results: Gene expression of TLR2, TLR4 and NLRP3 was significantly increased in both CLP and Burn compared to sham already from 3 hours after injury (p<0.05). Gene expression of TLR9 was significantly decreased in CLP compared to both sham and Burn in 12 and 24 hours after injury (p<0.05). Gene expression of MyD88, IRF-7 and Caspase-1 was significantly increased in CLP compared to sham from 3 hours after injury (p<0.05). Gene expression of IRF3 was significantly decreased in Burn compared to sham in 12 and 24 hours after injury (p<0.05). In the canonical discriminant analysis, each group showed distinctive gene expression patterns already from 3 hours after injury, and the classification error rates were 0% at all of the time points. Conclusions: Canonical discriminant analysis of gene expression profile of innate immune receptors and signaling molecules could be novel method to discriminate the pathophysiology of systemic inflammation by patterns of innate immune status, and distinguish infection from sterile systemic inflammation from early stage of the injury.

BackgroundAlthough the effects of the trauma center(TC) were researched in several studies, there have been few studies on changes in the regional mortality due to the implementation of a TC. An emergency medical center (EMC) and TC were implemented at Nagasaki University Hospital (NUH) for the first time in the Nagasaki medical region of Japan in April 2010 and October 2011, respectively, and they have cooperated with each other in treating trauma patients. The purpose of this study was to investigate the effects on the early mortality at population level of a TC working in cooperation with an EMC.MethodsThis is a retrospective study using standardized regional data (ambulance service record) in Nagasaki medical region from April 2007 through March 2017. We included 19,045 trauma patients directly transported from the scene. The outcome measures were prognosis for one week. To examine the association between the implementation of the EMC and TC and mortality at a region, we fit adjusted logistic regression models.ResultsThe number of patients of each fiscal year increased from 1492 in 2007 to 2101 in 2016. The number of all patients transported to NUH decreased until 2009 to 70, but increased after implementation of the EMC and TC. Overall mortality of all patients in the region improved from 2.3% in 2007 to 1.0% in 2016.In multivariate logistic regression model, odds ratio of death was significantly smaller at 2013 and thereafter if the data from 2007 to 2011 was taken as reference.ConclusionsImplementation of the EMC and TC was associated with early mortality in trauma patients directly transported from the scene by ambulance. Our analysis suggested that the implementation of EMC and TC contributed to the improvement of the early mortality at a regional city with 500000 populations.Level of evidenceLevel III.

It is very difficult to perform total knee arthroplasty (TKA) for severe varus bowing deformity of femur. We performed simultaneous combined femoral supra-condyle valgus osteotomy and TKA for the case had bilateral varus knees with bowing deformity of femurs.Case presentationA 62-year-old woman consulted our clinic with bilateral knee pain and walking distability. She was diagnosed rickets and had bilateral severe varus bowing deformity of femurs from an infant. Her height was 133 cm and body weight was 51 kg. Bilateral femur demonstrated severe bowing and her knee joint demonstrated varus deformity with medial joint line tenderness, no local heat, and no joint effusion. Bilateral knee ROM was 90 degrees with motion crepitus. Bilateral lower leg demonstrated mild internal rotation deformity. Bilateral JOA knee score was 40 Roentgenogram demonstrated knee osteoarthritis with incomplete development of femoral condyle. Mechanical FTA angles were 206 degree on the right and 201 on the left. She was received r...