An anterolateral dislocated monteggia lesion with plastic lateral bowing of the ulna associated with ipsilateral epiphyseal fracture of the distal radius: a case report with 4 years of follow-up.

We encountered a rare presentation of anterolateral dislocation of the radial head with plastic lateral bowing of the ulna associated with ipsilateral epiphyseal fracture of the distal radius in a child. The patient was treated surgically and reached skeletal maturity 4 years later with no functional or growth deficiency.

Insufficient Postoperative Rehabilitation in Patients with Both Proximal Femoral Fracture and Antecedent Mental Illness.

INTRODUCTION: Though a combination of proximal femoral fracture and mental illness is likely, the management of this combination is not well established. The aim of this study was to clarify the current disposition of acute care and rehabilitation for patients with this combination of conditions at our institution. METHODS: We retrospectively analyzed the records of 192 patients hospitalized in the psychiatric ward who present with a proximal femoral fracture and an antecedent mental illness. We investigated walking ability prior to injury and after surgery, at discharge from our institution, using the Functional Independence Measure (FIM) score. RESULTS: Although patients in the psychiatric ward demonstrated postoperative hospital stays approximately 10 days longer than those in the orthopedic ward, more than half of the patients in the psychiatric ward were discharged from our institution with a functional level of complete dependence for walking ability. In addition, nearly 90% of the patients studied were transferred to a psychiatric hospital where no physical therapy or rehabilitation was provided to the inpatients. CONCLUSIONS: At our institution, patients with proximal femoral fracture and antecedent mental illness tended to be discharged with complete dependence in walking ability, often to a psychiatric hospital without physical therapy or rehabilitation. We hope this paper will draw attention to the need for rehabilitation in these patients.

Gustilo Type III Open and Comminuted Tibial Fractures Managed by Simultaneous Combination of a Free Latissimus Dorsi Muscle Flap and Ilizarov External Fixation: A Case Report.

CASE: A 70-year-old woman who sustained Gustilo type III open and comminuted tibial fractures presented with extensive soft-tissue defect. Definitive surgery was performed using a free latissimus dorsi muscle flap for the extensive soft-tissue defect and Ilizarov external fixation (IEF) to stabilize the fractures and arthrodese the ankle. Ankle arthrodesis was accomplished by the wires penetrating the implanted muscle flap. CONCLUSION: The combined free flap and IEF management protocol described in this report was effective in achieving early weight-bearing and prompt bone healing in an elderly patient with poor bone quality and extensive open and comminuted fractures.

MicroRNA-130b functions as an oncomiRNA in non-small cell lung cancer by targeting tissue inhibitor of metalloproteinase-2.

Non-small cell lung cancer (NSCLC) is the most frequent cause of cancer-related death worldwide. Although many molecular-targeted drugs for NSCLC have been developed in recent years, the 5-year survival rate of patients with NSCLC remains low. Therefore, an improved understanding of the molecular mechanisms underlying the biology of NSCLC is essential for developing novel therapeutic strategies for the treatment of NSCLC. In this study, we examined the role of miR-130b in NSCLC. Our results showed that high expression of miR-130b in clinical specimens was significantly associated with poor overall survival in patients with NSCLC. Moreover, miR-130b expression was significantly increased in NSCLC clinical specimens from patients with vascular and lymphatic invasion. Consistent with this, overexpression of miR-130b promoted invasion and matrix metalloproteinase-2 (MMP-2) activity in A549 cells. Argonaute2 immunoprecipitation and gene array analysis identified tissue inhibitor of metalloproteinase-2 (TIMP-2) as a target of miR-130b. Invasion activity promoted by miR-130b was attenuated by TIMP-2 overexpression in A549 cells. Furthermore, TIMP-2 concentrations in serum were inversely correlated with relative miR-130b expression in tumor tissues from the same patients with NSCLC. Overall, miR-130b was found to act as an oncomiR, promoting metastasis by downregulating TIMP-2 and invasion activities in NSCLC cells.

The miR-130 family promotes cell migration and invasion in bladder cancer through FAK and Akt phosphorylation by regulating PTEN.

Bladder cancer causes an estimated 150,000 deaths per year worldwide. Although 15% of the recurrent bladder cancer becomes an invasive type, currently used targeted therapy for malignant bladder cancer is still not efficient. We focused on the miR-130 family (miR-130b, miR-301a, and miR-301b) that was significantly upregulated in bladder cancer specimens than that of the normal urothelial specimens. We analyzed the functional significance of miR-130 family using a 5637 bladder cancer cell line and revealed that miR-130 family of inhibitors suppressed cell migration and invasion by downregulating focal adhesion kinase (FAK) and Akt phosphorylation. Mechanistic analyses indicate that the miR-130 family directly targets phosphatase and tensin homolog deleted from chromosome 10 (PTEN), resulting in the upregulation of FAK and Akt phosphorylation. In clinical bladder cancer specimens, downregulation of PTEN was found to be closely correlated with miR-130 family expression levels. Overall, the miR-130 family has a crucial role in malignant progression of bladder cancer and thus the miR-130 family could be a promising therapeutic target for invasive bladder cancer.

miR-629 Targets TRIM33 to Promote TGFß/Smad Signaling and Metastatic Phenotypes in ccRCC.

UNLABELLED: Renal cell carcinoma (RCC) is the most common neoplasm of the adult kidney, and clear cell RCC (ccRCC) represents its most common histological subtype. To identify a therapeutic target for ccRCC, miRNA expression signatures from ccRCC clinical specimens were analyzed. miRNA microarray and real-time PCR analyses revealed that miR-629 expression was significantly upregulated in human ccRCC compared with adjacent noncancerous renal tissue. Functional inhibition of miR-629 by a hairpin miRNA inhibitor suppressed ccRCC cell motility and invasion. Mechanistically, miR-629 directly targeted tripartite motif-containing 33 (TRIM33), which inhibits the TGFß/Smad signaling pathway. In clinical ccRCC specimens, downregulation of TRIM33 was observed with the association of both pathologic stages and grades. The miR-629 inhibitor significantly suppressed TGFß-induced Smad activation by upregulating TRIM33 expression and subsequently inhibited the association of Smad2/3 and Smad4. Moreover, a miR-629 mimic enhanced the effect of TGFß on the expression of epithelial-mesenchymal transition-related factors as well as on the motility and invasion in ccRCC cells. These findings identify miR-629 as a potent regulator of the TGFß/Smad signaling pathway via TRIM33 in ccRCC. IMPLICATIONS: This study suggests that miR-629 has biomarker potential through its ability to regulate TGFß/Smad signaling and accelerate ccRCC cell motility and invasion.

State of the art: Transforaminal approach for percutaneous endoscopic lumbar discectomy under local anesthesia.

Minimally invasive percutaneous endoscopic discectomy (PED) with a transforaminal approach under local anesthesia was started in the late 20th century. As the procedure requires a skin incision of only 8 mm, it is the least invasive disc surgery procedure at present, and owing to advances in instruments and optics, the use of this technique has gradually spread. In Japan, Dr. Dezawa from Teikyo University Mizonokuchi Hospital introduced this technique in 2003. Thanks to his efforts, the number of surgeons who can perform PED has increased, although the number of active PED surgeons is still only around 20. The first author (K.S.) started PED in 2010. In this review article, we explain the state-of-the-art PED transforaminal technique for minimally invasive disc surgery and present three successful cases.

The state of the art in arthroscopic hip surgery.

Hip arthroscopy is among the most rapidly evolving arthroscopic techniques in the last decade and offers the benefits of being both a minimally invasive procedure and an excellent diagnostic tool. Improvements in instrumentation and surgical skills have advanced our ability to accurately diagnose and treat various conditions of the hip joint, and hip arthroscopy has elucidated several pathologies that cause disabling symptoms. Many of these conditions were previously unrecognized and left untreated. The indications for hip arthroscopy include the management of early osteoarthritis, synovial disorders (e. g., synovial osteochondromatosis), labral tears, chondral lesions, and femoroacetabular impingement (FAI), which is increasingly recognized as a disorder that can lead to the development of early cartilage and labral injury. A better understanding of hip arthroscopy, including the anatomy, improved surgical techniques, indications, and complications of the procedure, is essential for its success. This review article discusses the state of the art of arthroscopic hip surgery.

State of the art: Elbow arthroscopy: review of the literature and application for osteochondritis dissecans of the capitellum.

Elbow arthroscopy has become a safe and effective treatment option for a number of elbow disorders. The most rewarding and successful indication is the removal of loose bodies. Loose bodies are often a result of osteochondritis dissecans (OCD) of the capitellum, and arthroscopy in this case is useful for performing debridement, thereby eliminating the need for a more extensive open procedure associated with complications. In this review, we describe our arthroscopic technique for OCD of the capitellum. We usually conduct arthroscopy in the supine position, and use 2.9-mm arthroscopes of 30° and 70°. The 70° arthroscope provides a greater operative field than the 30° arthroscope. Arthroscopic treatment for OCD may require 2 anterior and 2 posterior portals. Loose bodies are commonly found in the radial fossa, coronoid fossa, and in the olecranon fossa. Once the loose bodies are removed, all unstable cartilage of the capitellum lesion is removed to create a stable bed. If any sclerotic changes to the lesion bed are observed, we create microfractures in the lesion bed. The most significant complication in arthroplasty is neurovascular injury. However, we have never experienced this devastating complication, which can be avoided by paying careful attention to detail.

LOXL2 status correlates with tumor stage and regulates integrin levels to promote tumor progression in ccRCC.

UNLABELLED: Clear cell renal cell carcinoma (ccRCC) is the most common histologically defined subtype of renal cell carcinoma (RCC). To define the molecular mechanism in the progression of ccRCC, we focused on LOX-like protein 2 (LOXL2), which is critical for the first step in collagen and elastin cross-linking. Using exon array analysis and quantitative validation, LOXL2 was shown to be significantly upregulated in clinical specimens of human ccRCC tumor tissues, compared with adjacent noncancerous renal tissues, and this elevated expression correlated with the pathologic stages of ccRCC. RNAi-mediated knockdown of LOXL2 resulted in marked suppression of stress-fiber and focal adhesion formation in ccRCC cells. Moreover, LOXL2 siRNA knockdown significantly inhibited cell growth, migration, and invasion. Mechanistically, LOXL2 regulated the degradation of both integrins α5 (ITGAV5) and ß1 (ITGB1) via protease- and proteasome-dependent systems. In clinical ccRCC specimens, the expression levels of LOXL2 and integrin α5 correlated with the pathologic tumor grades. In conclusion, LOXL2 is a potent regulator of integrin α5 and integrin ß1 protein levels and functions in a tumor-promoting capacity in ccRCC. IMPLICATIONS: This is the first report demonstrating that LOXL2 is highly expressed and involved in ccRCC progression by regulating the levels of integrins α5 and ß1.

Bilateral atypical femoral fractures in a patient with multiple myeloma treated with intravenous bisphosphonate therapy.

Bisphosphonates are currently the standard approach to managing bone disease in multiple myeloma. Bisphosphonates have high bone affinity that inhibits osteoclastic activity and additionally reduces the growth factors released from malignant or osteoblastic cells, thereby impairing abnormal bone remodeling which leads to osteolysis. However, patients of multiple myeloma may be at a higher risk of atypical femoral fractures because the treatment for malignant myeloma requires notably higher cumulative doses of bisphosphonates. Here we present a patient with bilateral atypical femoral fractures and multiple myeloma treated with intravenous bisphosphonate therapy.

Massive femoral osteolysis secondary to loosening of a cemented roughened long stem: a case report.

The surface finish of a femoral stem plays an important role in the longevity of cemented total hip arthroplasty. In efforts to decrease the rate of aseptic loosening, some prostheses have been designed to have a roughened surface that enhances bonding between the prosthesis and cement, but clinical outcomes remain controversial. We present a rare case of massive osteolysis with extreme femoral expansion that developed after cemented revision total hip arthroplasty. The destructive changes in the femur were attributable to abnormal motion of the stem and were aggravated by the roughened precoated surface of the long femoral component. Revision surgery using a total femur prosthesis was performed because there was insufficient remaining bone to fix the new prosthesis. The surgical technique involved wrapping polypropylene meshes around the prosthesis to create an insertion for the soft tissue, which proved useful for preventing muscular weakness and subsequent dislocation of the hip.

Navigation-Assisted Total Knee Arthroplasty for Osteoarthritis with Extra-Articular Femoral Deformity and/or Retained Hardware.

Total knee arthroplasty (TKA) for osteoarthritis (OA) patients with extra-articular deformity is still challenging because angular deformity, canal sclerosis, or the retained hardware that precludes the use of the traditional intramedullary guide. In addition, atypical bone cut for intra-articular correction leads to imbalanced soft tissue gap. Furthermore, corrective osteotomy should be considered for severe deformity or para-articular deformity cases. Recently, navigation-assisted TKA has been reported to increase the accuracy of prosthetic positioning and limb alignment. This system can calculate mechanical axis regardless of extra-articular deformity, canal sclerosis, or retained hardware. Accordingly, navigation surgery has been considered to be a powerful option especially in TKAs with extra-articular deformity cases. Here, we report 3 successful navigation-assisted TKAs for osteoarthritis with extra-articular deformities and/or retained hardware. Navigation-assisted TKA is an effective and reliable alternative for patients with extra-articular deformities.

Subchondral cysts in dysplastic osteoarthritic hips communicate with the joint space: analysis using three-dimensional computed tomography.

INTRODUCTION: Bone cyst formation in hips increases as osteoarthritis worsens. Although bone cysts in hips have been described in many studies, their etiology remains unclear and under debate. The purpose of this study was to investigate the communication between a bone cyst and the joint space, as well as the relationship between the severity of osteoarthritis and the formation of subchondral bone cysts in dysplastic hips. METHOD: We studied bone cysts from 150 dysplastic hips in 97 patients by computed tomography (CT) and plain radiography. We investigated the distribution of the bone cysts and the presence or absence of a communication path between the cysts and the joint space by three-dimensional (3D) CT. RESULT: Of the 150 hips, 94 acetabula and 55 femoral heads were found to contain cysts. Of the 94 hips containing acetabular cysts, 89 and 5 hips showed black lines and gray lines connecting the cyst and the joint space, respectively, on 3D-CT. The rate of cyst presentation in the hip increased as the joint space became narrower. The number of hips that possessed cysts in the anterior and/or middle portion was significantly higher than that in the posterior portions. CONCLUSION: Bone cysts in dysplastic osteoarthritic hips were found to communicate with the joint space in all cases. This suggests that the formation and enlargement of the cysts in dysplastic hips may be greatly influenced by the joint fluid. Cyst formation was initially observed in the anterior acetabulum, gradually progressing to involve the entire joint, including the posterior acetabulum and the femoral head, with worsening of the osteoarthritis.

A three-dimensional method for evaluating changes in acetabular osteolytic lesions in response to treatment.

UNLABELLED: The treatment of asymptomatic osteolysis among well-fixed cementless cups remains controversial. To compare the effectiveness of different treatment strategies, an objective technique for evaluating bone remodeling would be useful. By matching and comparing serial CT images with the aid of a computer-assisted imaging program, we developed a method to evaluate three-dimensional mineralization changes within osteolytic defects. Preoperative, immediate postoperative, and followup CT images were normalized based on a phantom with known densities and matched using image registration so that the same region could be analyzed on each image. New bone mineralization within the preoperative osteolytic lesion volume was quantified based on a patient-specific trabecular bone density threshold. As a pilot study, we applied this technique in 10 patients treated by polyethylene liner exchange with débridement and grafting of periacetabular osteolytic lesions using a calcium sulfate bone graft substitute. Relative to the preoperative osteolytic lesion volume, an average of 43% (range, 8%-72%) of each defect was filled with graft at revision. After resorption of the graft, an average of 24% (range, 9%-44%) of the original defect volume demonstrated evidence of new mineralization at 1-year followup. The amount of new mineralization was directly proportional (r(2) = 0.70) to the defect filling achieved at revision. CT-based image analysis offers an objective method for quantifying three-dimensional bone remodeling and can be used to evaluate the effectiveness of osteolysis treatment strategies. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Percutaneous opening wedge varus osteotomy with a multidrilling guide in Perthes' disease: a technical note on two cases.

We report a technique of percutaneous opening wedge intertrochanteric femoral osteotomy using a multidrilling guide with application of an Ilizarov external fixator in the management of Perthes' disease, and describe the early results obtained in two children. The average operative time was 96.5 min and the duration of external fixation was 51.5 days. Intraoperative blood loss was less than 20 ml. There were no significant complications. This percutaneous technique offers several advantages over currently available methods for surgical containment of Perthes' disease. These include a small incision, soft tissue preservation, sufficient stability, easy procedure, and short time in fixator.

Arthroplasty using a custom-made cemented total hip prosthesis for an extensive giant cell tumor of the proximal femur: report of a patient followed up for over 30 years.

We report the case of a 26-year-old man who had a pathologic transtrochanteric fracture of the left femur due to a grade II giant cell tumor affecting the neck and the trochanteric area. This patient underwent complete resection of the tumor and arthroplasty using a custom-made cemented total hip prosthesis. The good radiologic and functional results of the surgery have been maintained for over 30 years without local recurrence or lung metastasis. Moreover, new bone formation was observed at the reattachment sites of abductors, iliopsoas tendons and vastus lateralis to the femoral component of the prosthesis although local bone resorption was detected at the upper lateral part of the femoral stem and zone I of the cup side.

Computed tomography assessment of pelvic osteolysis and cup-lesion interface involvement with a press-fit porous-coated acetabular cup.

We used computed tomography to investigate the 3-dimensional pattern of expansile osteolysis that occurs with a modular cementless acetabular component incorporating a central hole. We measured pelvic osteolysis volume and evaluated how much of the porous-coated surface area was involved with osteolytic defects. Among the 34 total hip arthroplasties we studied, osteolysis almost always originated from the dome hole and typically expanded inferiorly or superiorly without involving the anterior or posterior surfaces of the cup. Larger-volume lesions generally involved greater amounts of the cup surface area, but the cup-lesion interface involvement plateaued at 40% for radiographically stable cups without clinical complications. We hypothesize that the plateauing surface area involvement may explain the absence of cup loosening among these cases despite the presence of large osteolytic lesions.

Can the volume of pelvic osteolysis be calculated without using computed tomography?

UNLABELLED: The most common method to diagnose and monitor osteolysis is the standard anteroposterior radiograph. Unfortunately, plain radiographs underestimate the incidence and extent of osteolysis. CT scans are more sensitive and accurate but also more expensive and subject patients to more radiation. To determine whether the volume of pelvic osteolysis could be accurately estimated without a CT scan, we evaluated the relationships between CT volume measurements and other variables that may be related to the size of pelvic osteolytic lesions in 78 THAs. Only the area of pelvic osteolysis measured on radiographs, heavy patient activity level, and total volume of wear were associated with the pelvic osteolysis volume measured on CT in the context of the multivariate regression analysis. Despite a strong correlation (r = 0.93, r(2) = 0.87) between these three variables and the volume of pelvic osteolysis measured on CT, estimates of pelvic osteolysis volume deviated from the actual volume measured on CT by more than 10 cm(3) among eight of the 78 THAs in this study. CT images remain our preferred modality when accurate assessments of pelvic osteolysis volume are required. LEVEL OF EVIDENCE: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Life expectancies of Japanese patients with rheumatoid arthritis: a review of deaths over a 20-year period.

We investigated trends in life expectancy in rheumatoid arthritis (RA) patients, reviewing records for 286 patients (204 female, 82 male) who had died over the past 20 years. The average age at death was 68.8 years before 1990, increasing to 72.1 years after 2001. Trends in disease modifying anti-rheumatic drugs (DMARDs) saw gold preparations (45.2%) predominate before 1990, sulphydryl donor agents (53.6%) from 1991 to 2000, then methotrexate (43.0%) after 2001. The most common causes of death were infectious diseases up to 1995, rheumatic disease 1996-2000, and cardiovascular events and malignancies after 2001. Major advances in surgical interventions, such as joint replacement surgery, occurred after 1990. Surgical intervention followed by a period of rehabilitation maintained a favourable level of activities of daily living (ADLs), The requirements for favourable life expectancy are control of RA inflammation and maintenance of a favourable level of ADLs. Although recently developed DMARDs and biological agents show promise, caution is required to avoid serious adverse reactions. Optimum care of patients with RA will require preventive measures and early intervention for infections and rheumatic diseases, as well as for lifestyle diseases, osteoporosis and malignancies.