Quantitative Analysis of Ultrasonography for de Quervain's Disease: Comparison of the Affected Side With the Asymptomatic Side.

OBJECTIVES: The pathology of de Quervain's disease affects the tenosynovium and rarely the tendons. The ultrasonographic features of de Quervain's disease unresponsive to conservative treatment are unknown. The purpose of this study was to describe and compare the morphological differences between patients with de Quervain's disease that is refractory to conservative treatment and patients who respond to conservative treatment. METHODS: de Quervain's disease unresponsive to conservative treatment was evaluated in 51 patients. The bilateral wrists underwent preoperative ultrasonographic assessments. The asymptomatic side was presumed to be the patient's anatomical baseline and was used for comparison. We measured the diameter and cross-sectional area of the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB), and the thickness of the tendon sheath and the intercompartmental septum, if present. The affected side and asymptomatic side were compared. RESULTS: The APL and EPB cross-sectional area was significantly larger on the affected side than on the asymptomatic side (APL: 13 mm2 versus 8.3 mm2 ; P < .0001; EPB: 5.4 mm2 versus 3.9 mm2 ; P = .031). The tendon sheath was significantly thicker on the affected side (1.5 mm) than on the asymptomatic side (0.95 mm) (P < .0001). The intercompartmental septum was significantly thicker on the affected side (1.1 mm) than on the asymptomatic side (0.72 mm) (P = .0004). Operative findings revealed 41 (80%) patients had an intercompartmental septum. CONCLUSIONS: The ultrasonographic features of de Quervain's disease requiring surgical treatment were a significantly thickened tendon sheath, an intercompartmental septum, and increased cross-sectional area of the APL and EPB.

Fourth Dorsal Interosseous Muscle Transfer to Treat an Abducted Little Finger.

A patient presented with an abducted little finger due to the avulsion of the third volar interosseous muscle. For treatment, we transferred the fourth dorsal interosseous muscle arising from the ulnar side of the fourth metacarpal bone to the lateral band of the little finger.

Bilateral femoral neck fractures resulting from pregnancy-associated osteoporosis showed bone marrow edema on magnetic resonance imaging.

Femoral neck fractures resulting from pregnancy-associated osteoporosis is a rare condition. Herein, we report an undoubted case of pregnancy-associated osteoporosis in a 38-year-old primiparous patient with pre-existing anorexia nervosa who suffered bilateral femoral neck fractures in the third trimester and early post-partum period. Magnetic resonance imaging revealed femoral neck fractures as well as diffuse marrow edema involving both femoral heads, which are considered under ordinary circumstances as characteristic imaging findings of transient osteoporosis of the hip. Based on our experience, we propose that pregnancy-associated osteoporosis might be present in femoral neck fractures attributed to transient osteoporosis of the hip in pregnancy. Conversely, bone status should be carefully and accurately estimated in cases of potential transient osteoporosis of the hip in pregnancy to reduce future fracture risk.

Pins and Rubber Band Traction System Combined with Internal Fixation for Intra-articular Fractures of the Proximal Interphalangeal Joints.

Background: Intra-articular fractures of the proximal interphalangeal joint (PIPJ) can result in poor outcomes if inadequately treated. Dynamic external fixation and internal fixation with plates and/or screws are two treatment options. The role of combining these two methods is unclear. The aim of this study is to determine the outcomes of patients with intra-articular fractures of the PIPJ treated with a combination of dynamic external fixation with a plate and/or screws. Methods: A retrospective review was conducted on 18 consecutive cases of intra-articular fractures of the PIPJ treated with pins and rubber band traction system (PRTS) combined with dorsal internal fixation with plates and/or screws. The patients' average age was 51 years (range: 20-81 years). The fracture patterns were volar-type (n = 2), dorsal-type (n = 4) and pilon-type (n = 12). Data with regard to time to surgery, interphalangeal joint range of motion, grip strength, VAS for pain, Quick DASH score, complications, duration of follow-up and return to work were collected. Results: The levels of articular involvement were stable (n = 1), tenuous (n = 5) and unstable (n = 12). The average time to surgery was 9 days, and the average follow-up period was 15 months. The fracture was fixed with a dorsal plate and screws in 10 patients and with only screws in eight patients. All patients had PRTS. All patients returned to their original occupation and the fractures united in good alignment. The average grip strength was 86% of that of the unaffected side. The average active PIPJ motion was 85° (range: 50°-106°), and the average active distal interphalangeal joint (DIPJ) motion was 48° (range: 10°-90°). Conclusions: Our results show that a combination of PRTS and open reduction and fixation with plate and/or screws achieved a good range of motion and articular reduction. Level of Evidence: Level IV (Therapeutic).

G protein-coupled receptor 30 contributes to improved remyelination after cuprizone-induced demyelination.

Estrogen exerts neuroprotective and promyelinating actions. The therapeutic effect has been shown in animal models of multiple sclerosis, in which the myelin sheath is specifically destroyed in the central nervous system. However, it remains unproven whether estrogen is directly involved in remyelination via the myelin producing cells, oligodendrocytes, or which estrogen receptors are involved. In this study, we found that the membrane-associated estrogen receptor, the G protein-coupled receptor 30 (GPR30), also known as GPER, was expressed in oligodendrocytes in rat spinal cord and corpus callosum. Moreover, GPR30 was expressed throughout oligodendrocyte differentiation and promyelinating stages in primary oligodendrocyte cultures derived from rat spinal cords and brains. To evaluate the role of signaling via GPR30 in promyelination, a specific agonist for GPR30, G1, was administered to a rat model of demyelination induced by cuprizone treatment. Histological examination of the corpus callosum with oligodendrocyte differentiation stage-specific markers showed that G1 enhanced oligodendrocyte maturation in corpus callosum of cuprizone-treated animals. It also enhanced oligodendrocyte ensheathment of dorsal root ganglion (DRG) neurons in co-culture and myelination in cuprizone-treated animals. This study is the first evidence that GPR30 signaling promotes remyelination by oligodendrocytes after demyelination. GPR30 ligands may provide a novel therapy for the treatment of multiple sclerosis.

Long-term results of vascularized bone graft for stage III Kienböck disease.

PURPOSE: Vascularized bone grafting (VBG) is one of the therapeutic approaches for treating advanced Kienböck disease; however, few reports on long-term outcomes are available for this technique. The purpose of this study is to evaluate long-term results by following up patients with stage III Kienböck disease for more than 10 years after VBG. METHODS: The study included 18 patients with advanced Kienböck disease (Lichtman stage IIIA, n = 10; stage IIIB, n = 8) who received VBG between 1996 and 2001 and were followed up for at least 10 years. Eleven patients received transplantation from the metacarpal base and 7 patients from the distal radius. Radial shortening and capitate shortening were performed in 5 and 2 stage IIIB patients, respectively. RESULTS: The mean follow-up period was 12 years, 3 months. Based on the Mayo Modified Wrist Score, clinical results were excellent in 8 patients, good in 7 patients, and fair in 3 patients. The Stahl index and carpal height ratio were not improved in stage IIIA patients who received bone graft alone, whereas significant improvement was observed in stage IIIB patients who received shortening, as well. CONCLUSIONS: Vascularized bone grafting for stage III Kienböck disease demonstrated favorable long-term results and is recommended as a surgical treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Spontaneous tendon rupture of the extensor digitrum communis in systemic lupus erythematosus.

We present a rare case of spontaneous tendon rupture of the extensor digitorum communis (EDC) in a patient with systemic lupus erythematosus (SLE). Inflammation in SLE presents as periarthritis, which may develop into Jaccoud's arthropathy. We bridged the ruptured tendon of the EDC (III) at the metacarpophalangeal (MP) joint of this patient with a tendon graft. This case demonstrates that this portion of the MP joint can be a site of tendon rupture of fingers in SLE patients.

Acute compartment syndrome caused by hematoma with minor trauma in hemodialysis patients: Two case reports.

INTRODUCTION: Acute compartment syndrome is a condition that requires an immediate diagnosis and surgical management. Compartment syndrome related to hematoma caused by minor trauma in hemodialysis patients is rarely reported. CASE PRESENTATION: We present two cases of hemodialysis patients diagnosed with compartment syndrome of the forearm due to hematoma caused by the disruption of blood vessels after a minor trauma. The removal of the hematoma and fasciotomy with adequate skin care significantly improved soft tissue heeling with no functional impairment. DISCUSSION: A long-term history of hemodialysis may increase the vascular vulnerability and have the potential risk of disruption by minor trauma. When the blood vessel is disrupted, a hematoma is formed and necessitating emergent surgical intervention. CONCLUSION: Surgeons should be aware of the potential risk of damage to blood vessels with minor trauma that results in the formation of a hematoma and compartment syndrome in hemodialysis patients.

The role of preoperative glycemic control in decreasing surgical site infections in lower extremity fractures.

BACKGROUND: Postoperative surgical site infections (SSIs) are an important complication to prevent in surgical treatment. Patients with diabetes mellitus (DM) have a higher risk of SSIs. Preoperative glycemic control is required. For patients with orthopedic trauma, the duration of preoperative glycemic control is limited because delaying operative treatment is difficult. However, whether preoperative glycemic control would decrease the risk of SSIs in diabetic patients with lower extremity fractures is unclear. The first aim of this study was to investigate the rate of SSIs among patients with DM who had undergone preoperative glycemic control, compared with that of patients without DM. As the secondary aim, we sought to demonstrate among patients with DM whether preoperative glycemic control would affect the development of SSIs between patients with controlled DM and patients with poorly controlled DM. METHODS: In this retrospective cohort study, 1510 patients treated surgically for lower extremity fractures were enrolled. Data collected were patient age, sex, body mass index, history of DM, development of SSIs, tobacco use, the presence of an open fracture, the period between the day of injury and the operation, the length of surgery, and blood glucose levels on admission and on the day before surgery. RESULTS: The rate of total SSIs was 6.0% among patients with DM and 4.4% among patients without DM (p = 0.31). Multivariate logistic regression revealed a significant association between the development of SSIs and the presence of DM (odds ratio, 1.79; 95% confidence interval 1.01-3.19; p = 0.047). The results of the secondary study revealed that the rate of early SSIs was significantly higher in the poorly controlled DM group than in the controlled DM group (5.9% vs. 1.5%; p = 0.032). However, multivariate logistic regression revealed that control levels of DM were not significantly associated with the development of SSIs. CONCLUSIONS: Even though patients with DM had undergone preoperative glycemic control, SSIs were significantly associated with DM, especially when the patients had poorly controlled DM. This finding suggested that continuous glycemic control is important preoperatively and postoperatively to prevent SSIs.

Factors associated with maintaining walking ability postoperation for hip fractures and the predictive value of the CGA7 score for postoperative walking ability.

AIM: Patients with hip fractures have a high rate of mortality or decreased mobility, despite early operative treatment and rehabilitation. The first aim of this study was to investigate the factors of decreased walking ability after hip fracture based on whether walking ability was or was not maintained postoperatively. The second aim was to examine the usefulness of the Comprehensive Geriatric Assessment 7 (CGA7), modified from the conventional Comprehensive Geriatric Assessment, for predicting postoperative walking ability. METHODS: This study included patients who were treated surgically for hip fractures. We divided patients by whether they did or did not maintain their walking ability postoperatively. We registered the following demographic data: walking ability preadmission and at discharge, CGA7 score, cognitive impairment, the patient's prefracture status, fracture type, surgical waiting time, hospital stay duration, limitation of weight-bearing, postoperative complications, transfer to rehabilitation hospital, final living place, and follow-up period. The characteristics of the two groups were compared using Wilcoxon's rank-sum test, the chi-squared test, or Fisher's exact test. RESULTS: Among 855 patients, 616 (73.0%) patients maintained walking ability and 239 (27.0%) patients did not. Multivariate logistic regression revealed that the factors of age, sex, preoperative walking ability, and postoperative complications were significantly associated with maintaining postoperative walking ability. Furthermore, the higher the CGA7 score, the more likely were patients to maintain their walking ability (odds ratio, 0.72; 95% confidence interval, 0.61-0.85; P < 0.001). CONCLUSIONS: Patients who had a low CGA7 score had the potential risk of decreased walking ability. Geriatr Gerontol Int 2023; 23: 830-835.

Conservative treatment of ulnar styloid fractures following volar-plate fixation of distal radius fractures: incidence of nonunion evaluated by computed tomography.

PURPOSE: The first aim of this study was to investigate the incidence of ulnar styloid fractures (USFs) accompanied by distal radius fractures (DRFs), treated with volar locking plates. The fracture type of DRFs was evaluated by the classifications, based on computed tomography (CT) scan findings. The second aim was to investigate the bone union rate of USFs, depending on the fracture type of DRFs, by comparing union and nonunion groups in the USFs groups. METHODS: Between May 2012 and December 2019, 239 consecutive patients with DRFs were treated. Of these patients, 177 DRFs met inclusion criteria. The fracture patterns of the DRFs, based on the classification, using CT scans, which included the AO classification, sagittal angulation, and axial fracture patterns of the articular surface of the distal radius in two-part intra-articular fractures were evaluated. The size of USFs, classified as a tip or base fracture was also investigated. RESULTS: The incidence of USFs was significantly higher for AO types A and C than for type B. Analysis of the sagittal angulation of DRFs showed that the incidence of USFs was higher for the extension type than for the flexion type. Axial CT classification of two-part fractures revealed that DRFs with a dorsal fracture line was more frequent than the volar type of DRFs. These results suggested that dorsal displacement of DRFs was associated with a higher incidence of USFs. Finally, the analysis of the bone union rate of USFs revealed that AO classification and sagittal angulation were not correlated with bone union in USFs. However, it was found that a fracture line on the radial side of the radius had a significantly low rate of bone union, compared to a fracture line on the dorsal side. The size of USFs was also not correlated with the bone union rate. CONCLUSIONS: The incidence and the bone union rate of USFs have different patterns. The incidence of USFs was higher in the dorsal displacement type of DRFs. However, the bone union rate of USFs was lower for a fracture line on the radial side. Therefore, USFs with DRFs that have a fracture line on the radial side is a candidate for fixation to prevent nonunion.

In vivo assessment of peripheral nerve regeneration by diffusion tensor imaging.

PURPOSE: To evaluate the sensitivity of diffusion tensor imaging (DTI) in assessing peripheral nerve regeneration in vivo. We assessed the changes in the DTI parameters and histological analyses after nerve injury to examine degeneration and regeneration in the rat sciatic nerves. MATERIALS AND METHODS: For magnetic resonance imaging (MRI), 16 rats were randomly divided into two groups: group P (permanently crushed; n = 7) and group T (temporally crushed; n = 9). Serial MRI of the right leg was performed before the operation, and then performed at the timepoints of 1, 2, 3, and 4 weeks after the crush injury. The changes in fractional anisotropy (FA), axial diffusivity (λ(∥)), and radial diffusivity (λ(⟂)) were quantified. For histological analyses, the number of axons and the myelinated axon areas were quantified. RESULTS: Decreased FA and increased λ(⟂) were observed in the degenerative phase, and increased FA and decreased λ(⟂) were observed in the regenerative phase. The changes in FA and λ(⟂) were strongly correlated with histological changes, including axonal and myelin regeneration. CONCLUSION: DTI parameters, especially λ(⟂) , can be good indicators for peripheral nerve regeneration and can be applied as noninvasive diagnostic tools for a variety of neurological diseases.

Use of an iliac bone graft with the tensor fasciae latae for the reconstruction of capitellum and radial collateral ligament in wind swept elbow.

Traumatic elbow injuries often result in wounds and exposure of the nerves, tendons, and bone with defects in the soft tissue. A severe type of wind swept injury causes loss of the capitellum and radial collateral ligament (RCL), which leads to severe instability of the elbow. For reconstructing a defect of the capitellum and RCL, we applied an autogenous iliac bone graft with the fascia of the tensor fasciae latae muscle, which has never been reported with successful results. This bone-tendon unit may be a strong candidate for the reconstruction of defects of the radiocapitellar joint in a wind swept injury.

Use of the Extensor Carpi Ulnaris Half-Slip for Treating Chronic Neglected Volar Dislocation of the Distal Radioulnar Joint.

Volar dislocation of the distal radioulnar joint (DRUJ) is a rare injury. Furthermore, few reports exist regarding DRUJ dislocation with simultaneous elbow dislocation. Elbow dislocation is easily diagnosed and reduced, whereas a DRUJ dislocation is easily missed because of an inaccurate or missed examination of the wrist, which results in a chronic condition. We experienced a case of simultaneous elbow and volar DRUJ dislocation; the latter was found 2 months postinjury. To treat chronic volar dislocation of the DRUJ, surgical methods should include reconstruction of the triangle fibrocartilage complex because of scar tissue and severe instability. In this paper, we describe triangle fibrocartilage complex reconstruction by using the extensor carpi ulnaris half-slip. It is the first report of applying this technique for chronic volar DRUJ dislocation. This technique has a role in creating strong stabilization of the DRUJ and can be an effective treatment option.

Localized Immunoglobulin Light-Chain Amyloidosis of the Ulnar Nerve.

Amyloidosis is a disorder caused by extracellular tissue deposition of insoluble fibrils. Amyloidosis can be divided into systemic or localized disease. Primary systemic amyloidosis is a multisystem disease caused by the deposition of amyloid in various tissues. Localized amyloidosis has different characteristics than those of systemic amyloidosis. In this paper, we present the case of a middle-aged woman who presented with worsening ulnar nerve palsy. Electrophysiological examination and MRI indicated a tumor surrounding the ulnar nerve in the forearm. However, the operative findings revealed that ulnar nerve fascicles were replaced with a yellow tissue, which was diagnosed as amyloid light-chain λ amyloidosis, based on histopathological examination. Systemic amyloidosis was ruled out after the screening examinations. This paper is the first report of the ulnar nerve as the sole site of localized immunoglobulin light-chain amyloidosis manifestation.

Endogenous glucocorticoids improve myelination via Schwann cells after peripheral nerve injury: An in vivo study using a crush injury model.

Glucocorticoids improve the symptoms of peripheral nerve disorders, such as carpal tunnel syndrome and peripheral neuropathy. The effects of glucocorticoids are mainly anti-inflammatory, but the mechanisms of their effects in peripheral nerve disorders remain unclear. Schwann cells of the peripheral nerves express glucocorticoid receptors (GR), and glucocorticoids enhance the rate of myelin formation in vitro. Therefore, it is possible that the clinical improvement of peripheral nerve disorders by glucocorticoids is due, at least in part, to the modulation of myelination. In this study, an adrenalectomy (ADX) was performed, and followed by a daily injection of either low dose (1 mg/kg) or high dose (10 mg/kg) corticosterone (CORT). We then simulated a crush injury of the sciatic nerves. A sham ADX operation, followed by a simulated crush injury, was conducted as a control. Immunohistochemistry showed that the nuclei of in vivo Schwann cells expressed GR and that glucocorticoids impacted the GR immunoreactivity of the Schwann cells. The mRNA and protein expression of myelin basic protein was significantly lower in the animals given ADX with vehicle than in the sham operation group. However, the expression was restored in the low-dose CORT replacement group. Morphological analyses showed that the ADX with vehicle group had a significantly lower myelin thickness than did the low-dose CORT replacement group and the sham operation group. These results suggest that endogenous glucocorticoids have an important role in myelination through the GR in Schwann cells after an in vivo peripheral nerve injury.

Carpal tunnel syndrome caused by a vascular malformation in a 48-year-old woman.

INTRODUCTION: Vascular malformation can present as nerve compression syndrome in middle age due to slow lesion growth, after first appearing in childhood. In a case of vascular malformation involving the peripheral nerve, surgical resection may cause uncontrollable hemorrhage and further nerve compression. Therefore, a more conservative approach is needed in such cases. CASE PRESENTATION: A 48-year-old woman complained of pain and paresthesia of the fingers, and was diagnosed with a large vascular malformation expanding from the proximal forearm to the palm on MRI. Because of the size of the lesion and involvement of soft tissue, resection had a risk of major hemorrhage and incomplete removal. Thus, carpal tunnel release was performed as a less invasive procedure, and was effective for reducing pain while avoiding the risks associated with resection. DISCUSSION: Our case indicates that a vascular lesion is a possible cause of nerve compression in the carpal tunnel. Finger numbness and pain were caused by this nerve compression, but the lesion itself was not painful. The median nerve was separate from the venous structure, and the case was diagnosed as an extraneural type. CONCLUSION: Symptoms that develop in middle age due to an extraneural vascular malformation in the carpal tunnel can be treated successfully using carpal tunnel release, instead of more invasive resection of the lesion.

The expression pattern of PKCtheta in satellite cells of normal and regenerating muscle in the rat.

Protein kinase C (PKC) is a key enzyme in regulating a variety of cellular functions. PKCtheta is the most abundant PKC isoform expressed in skeletal muscle. However, the functional role of PKCtheta linked to muscle regeneration has not yet been identified. Using reverse transcription (RT)-PCR and immunofluorescence analysis, we investigated the expression patterns of PKCtheta in normal and regenerating tibialis anterior (TA) muscles in the rat. The amount of PKCtheta mRNA in the muscle increased from the 4th to 6th post-surgical day. Immunofluorescence revealed PKCtheta protein in quiescent satellite cells identified by c-Met. PKCtheta immunoreactivity was not observed in many proliferating satellite cells by labeling with BrdU in the regenerating muscle. At 4, 6 and 10 days postsurgery, PKCtheta immunoreactivity was observed in half the differentiating satellite cells labeling with myogenin. After 4 and 6 days, the localization of PKCtheta coincided with those of Pax7 and TGF-beta. Thus, PKCtheta may play an important role in inhibiting differentiation and maintaining the quiescent satellite cells in muscle regeneration.

In vivo evaluation of rabbit sciatic nerve regeneration with diffusion tensor imaging (DTI): correlations with histology and behavior.

Diffusion tensor imaging (DTI) is widely used in the study of the central nervous system. DTI represents a potential diagnostic tool for the peripheral nerve. However, more detailed information is needed for application of DTI in the clinical setting. In this study, peripheral degeneration and regeneration were evaluated using DTI-based analyses in a rabbit model. The changes in DTI parameters were compared to histological and functional changes after nerve injury. We used a high magnetic field (7.04T) MRI system. Japanese white male rabbits were used as the model of sciatic nerve crush injury. MR images were obtained before injury and at 2, 4, 6 and 8 weeks post-injury. The DTI parameters of fractional anisotropy (FA), axial diffusivity (λ||), and radial diffusivity (λ⊥) were calculated. Our results showed decreased FA and increased λ⊥ during the degenerative phase after sciatic nerve injury. In contrast, increased FA and decreased λ⊥ were observed during the regenerative phase. FA changes were correlated with axon number and with motor function recovery, assessed with the toe-spreading index. This study clearly demonstrates the validity of applying DTI parameters to the in vivo evaluation of peripheral nerve regeneration. Furthermore, results suggest that DTI can be a potent tool for predicting the extent of functional recovery after peripheral nerve injury.

Application of Raman spectroscopy for visualizing biochemical changes during peripheral nerve injury in vitro and in vivo.

Raman spectroscopy can be used for analysis of objects by detecting the vibrational spectrum using label-free methods. This imaging method was applied to analysis of peripheral nerve regeneration by examining the sciatic nerve in vitro and in vivo. Raman spectra of intact nerve tissue had three particularly important peaks in the range 2800-3000 cm-1. Spectra of injured sciatic nerves showed significant changes in the ratio of these peaks. Analysis of cellular spectra suggested that the spectrum for sciatic nerve tissue reflects the axon and myelin components of this tissue. Immunohistochemical analysis showed that the number of axons and the myelinated area were reduced at 7 days after injury and then increased by 28 days. The relative change in the axon to myelin ratio showed a similar initial increase, followed by a decrease at 28 days after injury. These changes correlated with the band intensity ratio and the changes in distribution of axon and myelin in Raman spectral analysis. Thus, our results suggest that label-free biochemical imaging with Raman spectroscopy can be used to detect turnover of axon and myelin in peripheral nerve regeneration.