Ultrasound-guided gradual reduction using flexion and abduction continuous traction for developmental dysplasia of the hip: a new method of treatment.

We describe our experience in the reduction of dislocation of the hip secondary to developmental dysplasia using ultrasound-guided gradual reduction using flexion and abduction continuous traction (FACT-R). During a period of 13 years we treated 208 Suzuki type B or C complete dislocations of the hip in 202 children with a mean age of four months (0 to 11). The mean follow-up was 9.1 years (five to 16). The rate of reduction was 99.0%. There were no recurrent dislocations, and the rate of avascular necrosis of the femoral head was 1.0%. The rate of secondary surgery for residual acetabular dysplasia was 19.2%, and this was significantly higher in those children in whom the initial treatment was delayed or if other previous treatments had failed (p = 0.00045). The duration of FACT-R was significantly longer in severe dislocations (p = 0.001) or if previous treatments had failed (p = 0.018). This new method of treatment is effective and safe in these difficult cases and offers outcomes comparable to or better than those of standard methods.

Upregulation of H(+)-peptide cotransporter PEPT2 in rat remnant kidney.

The progression of renal damage resulting from reduced nephron mass has been extensively studied in the 5/6 nephrectomized rat. However, reabsorption of small peptides and D-glucose across the renal proximal tubule in this model remains poorly understood. In this study, we examined the alterations of H(+)-peptide cotransporters (PEPT1 and PEPT2) and Na(+)-D-glucose cotransporters (SGLT1 and SGLT2) in chronic renal failure. Two weeks after surgery, H(+)-dependent [(14)C]glycylsarcosine uptake by the renal brush-border membrane vesicles isolated from 5/6 nephrectomized rats was significantly increased compared with that from sham-operated controls. Kinetic analysis revealed that the maximum velocity value for [(14)C]glycylsarcosine uptake by the high-affinity-type of peptide transporter was increased threefold by 5/6 nephrectomy, without significant changes in the apparent Michaelis-Menten constant value. Competitive PCR analyses indicated that the expression of PEPT2 mRNA was markedly increased in the remnant kidney, but PEPT1, SGLT1, and SGLT2 mRNA levels showed no significant changes. These findings indicated that the high-affinity-type H(+)-peptide cotransport activity is upregulated by 5/6 nephrectomy, accompanied by the increased expression of PEPT2. The upregulation of PEPT2 expression would result in an increase in reabsorption of small peptides and peptide-like drugs across the brush-border membranes in chronic renal failure.

Bilateral humeral lengthening in achondroplasia.

Twenty humeral lengthenings were done on 10 achondroplastic dwarfs using the Ilizarov circular fixator. There were five female and five male patients from 6 years 11 months to 17 years 8 months of age (mean, 12 years 10 months) at the time of the operation. Mean length obtained was 7.8 cm (range, 3.5 cm-10 cm). External fixation time ranged from 105 days to 368 days (mean, 221 days). Healing index averaged 30 days/cm (27 days/cm when two patients with radial nerve palsy were excluded). Two half pins in one patient required replacement. Two humeral fractures occurred, one while in the fixator and the other after removal of the apparatus. Transient radial nerve palsy developed during lengthening in two patients, and lengthening was discontinued. Symptoms of radial nerve palsy resolved completely in both patients, but one patient required an additional surgery to explore the radial nerve for persistent paresthesia of the forearm. Although preexisting loose shoulders deteriorate during lengthening and sometimes cause pain and discomfort, they always resolve spontaneously as lengthening proceeds. Bilateral humeral lengthening was very effective for improving function and overall proportion in patients with achondroplasia.

Magnetic resonance imaging of growth plate injuries: the efficacy and indications for surgical procedures.

In 23 patients with growth plate injuries, magnetic resonance imaging (MRI) studies were performed a total of 31 times to evaluate the physis which showed plain radiographic evidence of possible damage. Fourteen patients clinically showed growth arrest, and 10 patients required a Langenskiold operation. In 3 patients who underwent this operation, subsequent premature total fusion of the physis adversely affected the postoperative results. We propose that the merging shape of the arrest line with calcification of the provisional zone of the metaphysis shown by MRI indicates poor viability of the physis. MRI provided useful information on the appearance of the growth plate and changes in the metaphysis, both of which affected the prognosis and the results of the surgical procedures.

A histochemical investigation of the bone formation process by guided bone regeneration in rat jaws. Effect of PTFE membrane application periods on newly formed bone.

BACKGROUND: Guided bone regeneration (GBR) has been widely utilized for the promotion of bone augmentation in bone loss areas. However, little information has been available regarding chronological changes in newly formed bone and alterations in the nature of newly formed bone after removal of a barrier membrane. The present study attempted to establish a GBR model for rat maxillae. We also examined the effects of membrane application periods on newly formed bone and its remodeling process after removal of the membrane in this experimental model. METHODS: Thirty-five Wistar rats were divided into 2 groups: a membrane application group and a membrane removal group. The chronological changes of newly formed bone were evaluated histologically and statistically. RESULTS: At 2 weeks after the GBR procedure, bony cavities had completely filled the newly formed bone in the experimental side. In the control side, corticalization on the surface of the newly formed bone proceeded with a decrease in the bone marrow cavity, whereas the bone marrow space had enlarged by 12 weeks post-surgery in the experimental side. In the membrane removal group, the osteoblasts appeared on newly formed bone at 1 week after membrane removal. Comparatively thick compact bone had formed on the surface of the newly formed bone at 4 weeks after membrane removal, and corticalization proceeded later. CONCLUSIONS: The long-term application of a barrier membrane induces the enlargement of the bone marrow spaces. We suggest that PTFE membrane removal in adequate time promotes the corticalization and maturation of the newly formed bone by the GBR technique.

Preliminary traction and the use of under-thigh pillows to prevent avascular necrosis of the femoral head in Pavlik harness treatment of developmental dysplasia of the hip.

One hundred and sixty-one hips of 145 patients were treated with the Pavlik harness for developmental dysplasia of the hip. The patients were divided into two groups. Group A consisted of 65 patients (70 hips) who were treated between 1980 and 1987. The harness was applied immediately after the diagnosis. Group B consisted of 80 patients (91 hips) who were treated between 1988 and 1992. These patients received preliminary traction, and small pillows supported the lower extremities from just above the knee to the foot to prevent extreme abduction when the harness was applied. When the distance from the middle point of the proximal metaphyseal border of the femur to the Y-line (distance "a") was 8 mm or more on the initial X-ray picture, the rate of avascular necrosis in group A was 11% and that in group B was 0%; the difference was significant. However, when distance "a" was less than 8 mm, the rate of avascular necrosis in group A was 13% and that in group B was 12%, and there was no significant difference. Thus, we suggest that the Pavlik harness is indicated for developmental dysplasia of the hip in which distance "a" is 8 mm or more. Traction should precede application of the harness, and pillows placed under the thigh must be used during application.

Functional outcomes of "floating elbow" injuries in adult patients.

OBJECTIVES: To assess elbow function, complications, and problems of floating elbow fractures in adults receiving surgical treatment. DESIGN: Retrospective clinical review. SETTING: Level I trauma center in Kanagawa, Japan. PATIENTS: Fourteen patients with fifteen floating elbow injuries, excluding one immediate amputation, seen at the Kitasato University Hospital from January 1, 1984, to April 30, 1995. INTERVENTION: All fractures were managed surgically by various methods. In ten cases, the humeral and forearm fractures were treated simultaneously with immediate fixation. In three cases, both the humeral and forearm fractures were treated with delayed fixation on Day 1, 4, or 7. In the remaining two cases, the open forearm fracture was managed with immediate fixation and the humerus fracture with delayed fixation on Day 10 or 25. MAIN OUTCOME MEASUREMENTS: All subjects underwent standardized elbow evaluations, and results were compared with an elbow score based on a 100-point scale. The parameters evaluated were pain, motion, elbow and grip strength, and function during daily activities. Complications such as infections, nonunions, malunions, and refractures were investigated. RESULTS: Mean follow-up was forty-three months (range 13 to 112 months). At final follow-up, the mean elbow function score was 79 points, with 67 percent (ten of fifteen) of the subjects having good or excellent results. The functional outcome did not correlate with the Injury Severity Score of the individual patients, the existence of open injuries or neurovascular injuries, or the timing of surgery. There were one deep infection, two nonunions of the humerus, two nonunions of the forearm, one varus deformity of the humerus, and one forearm refracture. CONCLUSION: Based on the present data, we could not clarify the factors influencing the final functional outcome after floating elbow injury. These injuries, however, potentially have many complications, such as infection or nonunion, especially when there is associated brachial plexus injury. We consider that floating elbow injuries are severe injuries and that surgical stabilization is needed; beyond that, there are no specific forms of surgical treatment to reliably guarantee excellent results.

Different methods of treatment related to the bilateral occurrence of Perthes' disease.

We treated 98 consecutive patients with Perthes' disease by a unilateral brace in external rotation, flexion and abduction and a further consecutive 110 by a bilateral cast with the hips in internal rotation and abduction. During treatment in the unilateral brace, six (6.1%) hips on the opposite side developed evidence of Perthes' disease and one developed this after the brace had been removed. In children managed in bilateral casts, no contralateral Perthes' disease was seen. Adequate containment of the femoral head may prevent subsequent changes in the opposite hip.

Bellini duct carcinoma: a case report.

We report a rare case of Bellini duct carcinoma, which is an unusual variant of renal cell carcinoma. The patient, a 56-year-old man, was admitted to our hospital for detailed examination of a renal mass on the left side. He had no clinical symptoms such as gross hematuria or flank pain. Abdominal ultrasonography, computed tomography and magnetic resonance imaging revealed a tumor 4 cm in diameter at the lower pole of the left kidney. Selective renal angiography showed an avascular mass lesion. We performed left transperitoneal radical nephrectomy with a preoperative diagnosis of left renal tumor, T2N0M0. The histopathological diagnosis was Bellini duct carcinoma of papillary tubular type. Lectin histochemistry demonstrated positive staining with soyabean agglutinin and peanut agglutinin. These findings supported our conclusion that the tumor might have originated from the Bellini duct epithelium. The patient currently remains disease-free. The pathogenesis and management of this rare condition are discussed.

[Retroperitoneal ganglioneuroma: a case report].

We experienced a case of ganglioneuroma. A 37-year-old man was admitted to our hospital for right flank pain. Computed tomography (CT) showed a low density mass near the upper pole of the right kidney. Selective renal arteriography did not demonstrate any tumor vessels in the right kidney. An endocrinological study revealed high values of noradrenaline and dopamine in urine. Under the preoperative diagnosis of a retroperitoneal tumor or right adrenal tumor, tumor resection was performed. The tumor was found in the retroperitoneal space on surgical exploration. The histopathological diagnosis was ganglioneuroma.

Avascular necrosis and the Pavlik harness. The incidence of avascular necrosis in three types of congenital dislocation of the hip as classified by ultrasound.

We analysed the incidence of avascular necrosis in 101 hips of 90 infants with congenital dislocation treated with Pavlik harness and followed up for more than one year. Using ultrasonography in the flexed-abducted position the hips were classified as type A when the femora head was displaced posteriorly, but within the socket and making contact with the posterior inner wall of the acetabulum; type B when it was in contact with the posterior margin of the acetabulum, with its centre at this level or anterior to it; and type C when it was displaced out of the socket, with its centre posterior to the posterior rim of the acetabulum. Eighty-seven hips were reduced by the harness (86%), and seven of these developed avascular necrosis (8%). All 69 hips with type-A dislocation were reduced and only one (1.4%) showed slight avascular necrosis. Eighteen (78.3%) of 23 hips with type-B dislocation were reduced, and six developed avascular necrosis (33.3%). In one hip, the femoral head was severely damaged. None of the nine hips with type-C dislocation was reduced in the harness. We concluded that the Pavlik harness is indicated for type-A but not for type-B or type-C dislocations.

Percutaneous reduction of displaced radial neck fractures.

Twenty patients with acute, displaced, radial neck fractures were treated by percutaneous reduction with a periosteal elevator. In all cases acceptable radiographic reduction was achieved, and the reduction position was maintained on serial x-ray examinations with a mean observation period of 3 years. Clinical results were satisfactory in all but one case with slightly limited elbow extension.

Surgery for bilateral carpal tunnel syndrome. Endoscopic and open release compared in 10 patients.

In 10 patients with bilateral carpal tunnel syndrome, endoscopic release was performed in one hand, while a conventional open release was done in the other hand. No postoperative differences were noted in the remission of symptoms and grip strength. However, endoscopic surgery was preferred by all patients because of the small skin incision with no painful scar, the short operation time, the reduced postoperative pain, early return to daily activities or occupation, and the short hospital stay after surgery.

Basic fibroblast growth factor as a candidate tumor marker for renal cell carcinoma.

The present investigation was conducted to determine serum levels of basic fibroblast growth factor (FGF) by enzyme immunoassay in patients with various urogenital tumors. Renal cell carcinoma had a higher tendency (28 of 52, 53.8%) toward increased serum levels of basic FGF than any of the other urogenital tumors, and increased serum basic FGF was detected more frequently in patients with advanced renal cell carcinoma. Analysis of histological pattern indicated that renal cell carcinoma with a solid or tubular component is more likely to produce basic FGF. However, no significant difference was seen between the percentage of clear cell type tumor patients with increased serum basic FGF (50.0%) and the percentage of granular cell type tumor patients with increased serum basic FGF (66.7%). Five of 8 patients with renal cell carcinoma who underwent selective renal venous sampling before nephrectomy showed increased serum basic FGF in the renal vein from the affected kidney. After resection of the affected kidney to remove the cancer, serum basic FGF disappeared within 2 weeks. However, residual huge tumor or postoperative disease prolonged the increased levels of basic FGF in 2 patients, indicating that basic FGF is produced from and secreted by tumor tissue itself. These findings suggest that serum basic FGF can be useful in the diagnosis, and in evaluating the prognosis, of patients with renal cell carcinoma.

Arthroscopy in 19 children with Perthes' disease. Pathologic changes of the synovium and the joint surface.

Arthroscopy of the hip joint was performed in 19 children with Legg-Calvé-Perthes' disease. Proliferation of the synovium was pronounced both in the acetabular fossa and over the inner wall of the capsule. Hypervascularity was seen on the acetabular labrum in every stage of the disease. Microscopically, hyperplasia of the synovial lining cells was observed, but inflammatory changes in the synovial tissue were inconspicuous in the early stage of the disease. Although hypertrophy of the endothelial cells of the vessels was seen in the late stage of the disease, it was not distinct in the initial or fragmentation stages. Joint pain improved after irrigation during arthroscopy.

Dislocation and subluxation during femoral lengthening.

Femoral lengthening by callus distraction was performed on 26 femurs of 18 patients with various disorders between 1988 and 1992. Age at surgery ranged from 6 to 17 years (13 years on average). The amount of lengthening varied from 2 to 7.5 cm (mean 5 cm). Follow-up evaluation of femoral-head displacement was based on the change of center-edge (CE) angle. The hips were divided into two groups based on the preoperative CE angle; one group consisted of 14 hips with a CE angle > 20 degrees and the other group consisted of 12 hips with an angle of < or = 20 degrees. In the first group, none of the hips deteriorated; however, five of 12 hips in the second group did deteriorate. One hip developed complete dislocation and the other four showed a decrease in the CE angle. Four of five deteriorated hips had a history of congenital dislocation of the hip and the other had multiple epiphyseal dysplasia. In cases in which the CE angle is < or = 20 degrees preoperatively, bony procedures such as innominate osteotomy should precede femoral elongation.

[The effects of rhodamine 123 on the cell growth of the cultured cells derived from urogenital carcinoma].

Rhodamine 123 (Rh123) is a red fluorescence dye, which is accumulated more and retained longer in the mitochondria of malignant transformed cells. In this study, the suppressive effects on the growth of cultured urogenital carcinoma cells (PC-3 and LNCaP from prostate carcinoma, T-24 from bladder cancer, and SV-HUC-1 human ureteral transitional cell transformed by SV virus in vitro, ACHN, YCR-1 and RCF213 from renal cell carcinoma) were examined. The cell growth of PC-3, LNCaP, T-24 and SV-HUC-1 was suppressed significantly in a dose dependent manner, but that of cells derived from renal cell carcinoma was not suppressed. The uptake and elimination of Rh123 in PC-3, ACHN and YCR-1 were not significantly different. When administered with verapamil and buthionine sulfoximine, which are reported to be chemical modulators of anticancer agents, Rh123 suppressed the growth of ACHN and YCR-1 significantly. Rh123 seems to have an anticancer effect against the urogenital carcinomas, and the role of Rh123 with hyperthermia, photodynamic therapy and chemotherapy requires further investigation.

Arthroscopy for slipped capital femoral epiphysis.

Arthroscopy was performed in five hips with slipped capital femoral epiphysis (SCFE) before pinning in situ. Arthroscopy disclosed erosion of acetabular cartilage in the anterosuperior region and damage to the posterolateral aspect of the acetabular labrum. Cartilaginous erosion and transverse cleft were identified on the anterior surface of the femoral head. These findings support the hypothesis that all pathomechanisms of SCFE are caused by traumatic factors. Arthroscopy for SCFE is also clinically useful in reducing hip pain. Arthroscopy performed simultaneously with pinning in situ can permit early exercise of the joint.