Idiopathic anterior dislocation of the radial head: symptoms, radiographic findings, and management of 8 patients.

BACKGROUND: Radial head dislocation may occur during trauma or in association with congenital diseases, or it may be developmental or idiopathic. Reports of idiopathic dislocation of the radial head have been scarce. The symptoms, radiographic findings, and management of idiopathic dislocation of the radial head have not been well described in the literature. METHODS: During the past 28 years, we have encountered 8 cases of idiopathic anterior dislocation of the radial head (mean patient age, 12.5 years). In only 1 case did the patient and/or the patient's parents recall any preceding trauma or injury to the affected limb. Patients' complaints included a bulging mass, pain, and limited elbow flexion. Radiographically, the shape of the radial head was flat or slightly convex. Seven of the patients were treated with open reduction of the radial head and angulation osteotomy of the ulna. The other patient's radial head was stabilized without osteotomy. RESULTS: The mean postoperative follow-up period was 4.5 years. In patients whose elbow flexion was limited before surgery, improvement to more than 125° occurred. The bulging mass in the cubital fossa disappeared. None of the patients complained of disability during activities of daily living or sports participation. Radiographically, the radial head remained in the reduced position in all patients in whom open reduction of the radial head with angulation osteotomy of the ulna was performed. CONCLUSIONS: We have described the symptoms, radiographic characteristics, and treatment of idiopathic anterior dislocation of the radial head. Open reduction of the radial head combined with angulation osteotomy of the ulna yielded favorable results both clinically and radiographically.

Acute Compartment Syndrome of the Forearm Secondary to Hematoma after Playing Golf.

Acute compartment syndrome of the forearm secondary to hematoma without direct trauma has been reported rarely. We report a case of acute compartment syndrome of the forearm following a hematoma after playing golf. A 55-year-old man felt pain in his left forearm while playing golf that gradually worsened. He could not continue to play and visited the emergency department of our hospital. The radial side of his left forearm was markedly swollen on presentation, and he suffered severe pain that worsened with ulnar flexion of the wrist; no paralysis or hypesthesia was observed. A hematoma in the brachioradialis was seen on magnetic resonance imaging, and radial compartment pressure was 120 mmHg. A diagnosis of acute compartment syndrome was made, and urgent fasciotomy was performed. The patient recovered with no dysfunction of the arm.

A comparative study of the effects of bucillamine and salazosulfapyridine in the treatment of rheumatoid arthritis.

Bucillamine (Buc), developed in Japan, is a disease-modifying antirheumatic drug (DMARD) which has been used to treat numerous patients with rheumatoid arthritis (RA) in Japan and Korea with favorable results. However, it has not been used globally. In the present study, we compared the timing of onset of efficacy and the usefulness of this drug with that of the globally accepted agent salazosulfapyridine (SASP). There were 26 patients in the Buc group and 23 in the SASP group. We compared changes in the number of swollen joints, number of painful joints, duration of morning stiffness, grip strength, levels of inflammatory marker [erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)], rheumatoid factor (RF), physician's rating by visual analogue scale (VAS), patient's rating of pain, patient's overall rating (VAS), and improvement according to European League against Rheumatism (EULAR) criteria (DAS28-CRP, DAS28-ESR) in these two groups of patients. Both Buc and SASP were shown to be efficacious within 3 months after the start of treatment. Both drugs were found to be suitable as first-line treatment of early RA. Signs of efficacy tended to occur earlier with Buc than with SASP, and Buc also tended to have higher efficacy than SASP.

Biomechanical comparison of different fixation methods on the tibial side in anterior cruciate ligament reconstruction: a biomechanical study in porcine tibial bone.

BACKGROUND: The fixation strength of the hamstring tendon graft on the tibial side is considered the weak point in anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare the biomechanical characteristics of four types of ACL reconstruction methods on the tibial side. METHODS: Extensor digitorum tendons harvested from fresh bovine forelimbs were used as the graft materials in this study. Twenty-eight porcine tibias were divided into four groups based on different fixation methods. Group D was fixed using a double spike plate (DSP), group I was fixed using an interference screw, group DI-80 was fixed using both an interference screw and DSP (80 N tension was applied to DSP), and group DI-150 was fixed using both an interference screw and DSP (150 N tension was applied to DSP). RESULTS: The displacement of the grafts in response to 500 cycles of 0-150 N loading was significantly greater in groups D (10.3 +/- 15 mm) and I (5.5 +/- 1.7 mm) than that in groups DI-80 (2.1 +/- 0.3 mm) and DI-150 (1.2 +/- 0.4 mm), with no significant differences between groups DI-80 and DI-150. The ultimate failure load and stiffness were significantly higher in groups DI-80 (745 +/- 156 N, 103 +/- 17 N/mm) and DI-150 (801 +/- 129 N, 151 +/- 35 N/mm) than those in groups D (374 +/- 53 N, 70 +/- 13 N/mm), and I (520 +/- 76 N, 78 +/- 18 N/mm). The stiffness of group DI-150 was significantly greater than that of group DI-80. CONCLUSIONS: Our results indicate that the initial fixation strength of the hamstring tendon can be increased by using an interference screw combined with DSP on the tibial side.

Response of rabbit skeletal muscle to tibial lengthening.

BACKGROUND: Experimental and clinical studies have provided knowledge regarding osteogenesis during limb lengthening. However, response of skeletal muscle to limb lengthening is not fully understood, especially as concerns histogenesis. We studied the morphological response of rabbit skeletal muscle to limb lengthening. In this study, we investigated proliferation of satellite cells, responsible for generation of new myonuclei, during limb lengthening. METHODS: Tibialis anterior muscles of young and adult rabbits were subjected to lengthening at a rate of 0.5 mm twice per day for 20 days. After lengthening, muscle wet weight was measured to assess skeletal muscle growth, then proliferating cell nuclear antigen was measured. Immunostaining was performed to analyze proliferating cells in the proximal, middle, and distal portions of the muscle belly and the musculotendinous junction. RESULTS: Muscle wet weight increased significantly after lengthening both in adult (0.4 g) and young (0.1 g) rabbits. Satellite cells showed proliferation in response to lengthening. In adult rabbits, satellite cell proliferation increased along the entire lengthened muscle to a similar degree (from 7.1% in the middle portion to 8.6% in the musculotendinous junction). In young rabbits, proliferation was greater in the musculotendinous junction (4.8%) than that in other muscle portions (2.3% in the middle and distal portions, and 2.4% in the proximal portion). In adult rabbits, the rate of increase in satellite cell proliferation was 1780% in the middle portion to 2860% in the musculotendinous junction, whereas the rate was between 210% in the middle portion and 290% in the distal portion in young rabbit. The rate of increase in cell proliferation by lengthening was higher in adult muscle than that in young muscles as well as satellite cell proliferation. CONCLUSION: These findings indicate that limb lengthening promotes muscle growth in both young and adult rabbits.

Tarsal tunnel syndrome in athletes.

BACKGROUND: The details of the occurrence of tarsal tunnel syndrome in athletes have not been well documented in the literature, and more data on tarsal tunnel syndrome related to sporting activity are necessary to enable better recognition of this condition. HYPOTHESIS: Sporting activities make athletes vulnerable to the occurrence of tarsal tunnel syndrome under specific conditions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 1986 and 2002, 18 patients with tarsal tunnel syndrome related to sporting activities were surgically treated, of whom 15 patients (21 feet; mean age, 17.8 years) were competitive athletes and 3 were recreational sports amateurs (4 feet; mean age, 52.7 years). To assess the role of physical factors and sporting activities in making athletes vulnerable to the occurrence of tarsal tunnel syndrome, the authors reviewed the medical charts and evaluated the results of treatment. The mean duration of follow-up was 58.6 months. RESULTS: Activities that triggered tarsal tunnel syndrome were those that applied a heavy burden on the ankle joint such as sprinting, jumping, and performing ashibarai in judo under specific physical conditions. Predisposing underlying physical factors were flatfoot deformity and an existence of talocalcaneal coalition, accessory muscles, and bony fragments around the tarsal tunnel. The majority of patients were able to return to the same sport after treatment. CONCLUSION: Tarsal tunnel syndrome occurs in athletes involved in strenuous sporting activities, especially when predisposing physical factors are present.

Pathogenesis of tendinous xanthoma: histopathological study of the extremities of Watanabe heritable hyperlipidemic rabbits.

BACKGROUND: Tendinous xanthomas associated with heritable hyperlipidemia are clinically well known. Nevertheless, there have been few basic investigations of the pathogenesis of these xanthomas. To clarify the pathogenesis of these xanthomas, we examined the localization and histopathological features of xanthomatous tissues in the extremities of Watanabe heritable hyperlipidemic (WHHL) rabbits. METHODS: Twenty-six WHHL rabbits at 1-31 months of age were dissected to observe the localization of xanthomas. In the histopathological study, tendons and ligaments that included xanthomatous tissues were sectioned and stained with hematoxylin and eosin, Masson's trichrome, and toluidine blue. Immunohistochemical staining was performed with RAM-11, a monoclonal antibody specific for rabbit macrophages, and CD31, a monoclonal antibody specific for endothelial cells. RESULTS: At necropsy examination, spontaneous development of xanthomas was observed in the plantar side of the plantaris tendon, the flexor retinaculum of the carpus, and around the digital flexor tendons of each joint level. Xanthoma formation was observed from 10 months of age and progressed with advancing age. The histomorphological study revealed that xanthomas had developed in superficial paratenon of the tendons that wrap around bony or fibrous pulleys. Many fibrocartilage cells were observed in the deep side of affected tendons. A large number of blood vessels were seen in the xanthomatous tissues of these WHHL rabbits. Immunohistochemical evaluation revealed that the xanthoma plaques contained endothelial cells and macrophages. CONCLUSIONS: It is likely that mechanical stress and extensive vascularization are essential factors for xanthoma formation. Moreover, endothelial cells and macrophages cells are principal contributors to the pathogenesis of tendinous xanthomas and to atherogenesis.

Efficacy of rhBMP-2 during distraction osteogenesis.

BACKGROUND: Osteoinductive ability of bone morphogenetic protein-2 (BMP-2) has been studied in recent reports. In this study, we evaluated the efficacy of BMP-2 during distraction osteogenesis. METHODS: A group of 24 Japanese white rabbits were divided into four groups randomly and underwent lengthening of the right femur. Distraction was performed for 2 weeks (1.0 mm/day). Group A began distraction following a 7-day waiting period after surgery. For all other groups (B-D), distraction was started immediately after surgery. Groups A and B did not undergo any surgical intervention at the osteotomy site, as a control. The delivery system for rhBMP-2 used a polymer-coated gelatin sponge (PGS). Buffer/PGS was implanted into the osteotomy site in group C, and group D received rhBMP-2/PGS. Callus was evaluated radiographically at 1, 2, 4, and 6 weeks after the surgery, and all rabbits were killed at 6 weeks. One rabbit from each group was examined histologically; the remaining five rabbits underwent biomechanical testing. RESULTS: A significant increase in callus formation was evident in group D compared with that in other groups. In group D, regenerative changes were evident during the earlier phase. Formation of bone cortex and bone marrow cavity was almost complete in group D, and the cortex was thicker than that in the other groups. Torsional strength values (10(-2) Nm) of each group were as follows: A, 118.7 +/- 52.4; B, 160.0 +/- 40.7; C, 106.8 +/- 8.1; D, 266.1 +/- 93.1. Stiffness values (10(-3) Nm/degree) were as follows: A, 390.2 +/- 137.2; B, 391.8 +/- 158.4; C, 183.1 +/- 78.5; D, 624.4 +/- 214.2. Group D exhibited the highest values for both torsional strength and stiffness. CONCLUSIONS: Acceleration of the regenerative changes during the early phase occurred in the BMP-2-treated group. The efficacy of BMP-2 in distraction osteogenesis was recognized radiographically, histologically, and by biomechanical testing (torsional strength and stiffness).

Proximal metatarsal osteotomy: relation between 1- to greater than 3-years results.

UNLABELLED: We analyzed the relationship between the 1-year and greater than 3-years results of a distal soft tissue procedure with a proximal osteotomy for hallux valgus in the same patient population. The series consisted of 55 feet treated with this procedure. The results at 1 year and greater than 3 years were evaluated. The final followup was greater than 3 years. Patients with pain in the first metatarsophalangeal joint at the 1-year followup had a greater risk of having pain at the final followup than did patients without pain at the 1-year followup. Patients with metatarsalgia at the 1-year followup had a greater risk of having metatarsalgia at the final followup than did patients without metatarsalgia at the 1-year followup. The extension of the first metatarsophalangeal joint at the final followup was greater than extension at the 1-year followup. In 48 feet (87%), radiologic evaluation showed no or minimal changes in the hallux valgus and intermetatarsal angles between 1 year and greater than 3 years followup. The data suggest the 1-year results predict those beyond 3 years, although the extension of the first metatarsophalangeal joint may increase 1 year after surgery. LEVEL OF EVIDENCE: Prognostic study, Level III. See the Guidelines for Authors for a complete description of levels of evidence.

Type II SLAP lesions: a new scoring system--the sulcus score.

A new scoring system-the sulcus score-was developed to differentiate between a large superior labral sulcus and a type II superior labrum anterior-posterior (SLAP) lesion. The sulcus scoring system permits quantification of the size of the superior labral sulcus and the severity of a type II SLAP lesion. Specifically, the depth of the superior labral sulcus was classified into 4 grades, and the length was recorded by clock position. The sulcus score was then calculated by multiplying the depth (grade) by the length (the number of "hours" from the clock position). After stretching of the anterior capsule into excessive humeral external rotation at 60 degrees glenohumeral abduction, the sulcus score of cadaveric shoulders increased significantly (before, 3.4; after, 6.8), indicating the extension of the superior labral sulcus and resulting in a pathologically created type II SLAP lesion. The intraclass correlation coefficient and mean difference were 0.77 and 0.8 +/- 0.7, respectively, for intraobserver repeatability and 0.72 and 0.9 +/- 0.6, respectively, for interobserver reproducibility. The sulcus score provided a consistent and objective means for quantitatively describing the size and severity of type II SLAP lesions. Clinical assessment of the superior labral sulcus by use of the sulcus score may be useful for the diagnosis and treatment of type II SLAP lesions.

Efficacy of novel-concept pedicle screw fixation augmented with calcium phosphate cement in the osteoporotic spine.

Pedicle screw instrumentation has become increasingly popular for rigid internal stabilization of the thoracolumbar spine. However, when pedicle screws are used in elderly osteoporotic patients, the screw-bone interface is stripped easily. Therefore, the risk of screw loosening and backing-out after surgery has increased. The purpose of this study was to evaluate the efficacy of the novel-concept pedicle screw fixation augmented with calcium phosphate cement (CPC) in the osteoporotic spine. The novel-concept screw has the same shape as the ordinary screw, but it is hollow and fabricated with 20 small holes (1.3 mm in diameter) leading to the hollow part on the bottom of the thread. Fifteen embalmed cadaveric lumbar vertebrae were instrumented with two types of pedicle screw (the ordinary screw and the novel-concept screw) in each pedicle. Only the novel-concept screws were augmented with CPC after insertion. Seven days later, axial pull-out testing was performed at a crosshead speed of 10 mm/min. The mean maximal pull-out strength of the ordinary screws was 258 N, and that of the novel concept screws was 637 N. These results suggest that the novel-concept screw augmented with CPC can be useful for pedicle screw fixation of the osteoporotic spine.

Arthroscopic findings in chronic lateral ankle instability: do focal chondral lesions influence the results of ligament reconstruction?

BACKGROUND: There are few studies that have assessed the influence of focal chondral lesions on the results of ligament reconstruction for chronic lateral ankle instability. HYPOTHESIS: Focal chondral lesions do not influence the results of ligament reconstruction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Arthroscopic examination of the ankle was performed on 30 consecutive patients immediately before ligament reconstruction using the palmaris longus tendon. Clinical assessment was performed using the Karlsson scoring scale. A radiologic assessment was performed on stress radiographs of the ankle. Preoperative anteroposterior and lateral weightbearing radiographs of the ankle did not show any joint space narrowing in any ankle. The mean duration of follow-up was 38 months. RESULTS: On arthroscopy, focal chondral lesions were found in 19 ankles (63%). Chondral lesions were located on the medial side of the tibial plafond in 13 ankles (43%), on the lateral side in 2 ankles (7%), on the lateral side of the talar dome in 3 ankles (10%), and on the medial side in 9 ankles (30%). Postoperative mean Karlsson scores in patients without chondral lesions and in those with chondral lesions were 99.1 and 98.4 points, respectively. Postoperative mean talar tilt angles in patients without chondral lesions and in those with chondral lesions were 5.9 degrees and 4.7 degrees , respectively. There were no significant differences in the clinical and radiologic results between patients with chondral lesions and those without chondral lesions. CONCLUSIONS: Reconstruction of the lateral ligament can be successful regardless of the presence of focal chondral lesions in patients with chronic lateral ankle instability when preoperative weightbearing radiographs of the ankle do not show any joint space narrowing.

Inhibition of induction of myofibroblasts by interferon gamma in a human fibroblast cell line.

Interferon gamma (IFNgamma) has been reported as a possible therapeutic agent for contractile diseases in clinical trials and in vitro studies. It is not yet clear, however, whether IFNgamma simply inhibits myofibroblast generation or downregulates alpha smooth muscle actin (alphaSMA) production in myofibroblasts. In this study, we attempted to clarify how IFNgamma acts in the generation of myofibroblasts, and the production of alphaSMA by myofibroblasts, using immunofluorescence staining, cell capture enzyme immunoassay (CC-EIA) and the reverse transcription polymerase chain reaction (RT-PCR) for alphaSMA. We examined whether IFNgamma could block the TGFbeta1-promoted changes in myofibroblasts or the generation of myofibroblasts by TGFbeta1. IFNgamma strongly blocked the generation of myofibroblasts and moderately inhibited the production of alphaSMA in TGFbeta1-promoted myofibrobasts. These findings indicate that IFNgamma may be effective in the early stage of contractile diseases to prevent the progression of contractile lesions.

Tibialis spastic varus foot caused by osteoid osteoma of the calcaneus.

Tibialis spastic varus foot is an extremely rare condition. A 30-year-old man had tibialis spastic varus foot caused by juxtaarticular osteoid osteoma of the calcaneus. The correct diagnosis was delayed because the symptoms were similar to arthritis and the nidus was difficult to detect on plain radiographs. Curettage of the tumor was done, and the osseous defect was filled with interporous hydroxyapatite. The pain was relieved immediately after surgery. The varus deformity of the foot and spasm of the tibialis anterior muscle gradually improved. Three years 10 months after surgery, the patient was pain-free and the spasm of the tibialis anterior muscle had disappeared. The varus deformity and motion of the foot improved, but a restricted range of motion remained. To the authors' knowledge, there have been no published descriptions of tibialis spastic varus foot caused by juxtaarticular osteoid osteoma of the calcaneus.

Macrophage apoptosis in rat skeletal muscle treated with bupivacaine hydrochloride: possible role of MCP-1.

The fate of macrophages infiltrating damaged rat skeletal muscle fibers after intramuscular injection of the anesthetic bupivacaine hydrochloride (BPVC) and the possible roles of monocyte chemoattractant protein-1 (MCP-1) were investigated. The number of macrophages reached a maximum level at 2 days after the injection and then gradually decreased. The number of apoptotic cells detected by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay was elevated at 2-4 days and decreased thereafter. In serial sections, TUNEL-positive cells were also immunopositive for RM-4, an antibody specific for identification of macrophages. Electron microscopy further confirmed that it was the macrophages themselves that were undergoing apoptosis. As assessed by reverse transcriptase-polymerase chain reaction (RT-PCR), high levels of MCP-1 mRNA in BPVC-treated muscles were observed and positively correlated with maximum macrophage infiltration. However, the levels of MCP-1 mRNA returned to normal low values coincident with decrease of inflammation and healing of damaged muscle fiber. Local apoptosis of macrophages, under the control of MCP-1, may be involved in healing of BPVC-treated muscles.

Proximal dome-shaped osteotomy for symptomatic bunionette.

The results of a dome-shaped osteotomy of the proximal third of the fifth metatarsal in patients with symptomatic bunionette deformity were reviewed. The series was comprised of eight patients (10 feet; mean age of patients, 21 years). The average followup was 30 months. All patients were free from pain at the fifth metatarsophalangeal joint and were satisfied with the results of this procedure. The mean angle between the longitudinal axes of the fifth metatarsal and the proximal phalanx was 18.9 degrees before surgery and 2.6 degrees after surgery. The mean angle between the longitudinal axes of the fourth and fifth metatarsals was 12.2 degrees before surgery and 4.8 degrees after surgery. The overall results were good in all 10 feet. Three feet had delayed union at the osteotomy site, but union was obtained in all feet. The osteotomy site of the fifth metatarsal in feet with delayed union was more proximal than that of the other feet. Therefore, proximal osteotomy of the fifth metatarsal should be done not at the base, but at the proximal site of the diaphysis to prevent delayed union. A proximal dome-shaped osteotomy corrects the deformity and relieves the symptoms, but careful attention should be paid to the osteotomy site.