Ulnar Nerve Injury Following Distal Radius Fracture Assessed by Ultrasonography: Management of an Ulnar Nerve Lesion.

A fracture of the distal radius with an associated injury to the ulnar nerve is rare. The management of the ulnar nerve lesion is unclear. We present a patient with a closed distal radius fracture related to an injury to the ulnar nerve associated with diminished sensation and a claw deformity. This was assessed by ultrasonography (US) that showed the nerve to be in continuity without any evidence of compression. The nerve was deviated towards the volar side at the distal end of the ulna and was enlarged at the same point. Open reduction and internal fixation was performed for the fracture. Emergent nerve exploration was not performed. The function of the ulnar nerve was completely restored at 16 weeks after injury. In cases presenting with ulnar nerve injury, we recommend US to evaluate the condition of the ulnar nerve. Nerve exploration should be performed when neurological deficits were found on US or symptoms did not recover over 4 months observation. Level of Evidence: Level V (Therapeutic).

Impact of orthogeriatric care management by orthopedic surgeons and physicians on in-hospital clinical outcomes: A difference-in-difference analysis.

AIM: The orthopedic surgery unit in our suburb serves a large elderly trauma population in addition to providing elective surgeries. As patients with hip fractures have become older and at higher risk of medical complications, our hospital has initiated integrated co-management of these patients by orthopedic surgeons and geriatricians from the point of hospital admission. The aim of this study was to evaluate the impact of the hospital policy change on hip fracture management and clinical outcome indicators. METHODS: Using the difference-in-difference approach, in total, 288 consecutive patients with hip fractures treated during the 1 year before and 2 years after transition to orthogeriatric care from a geriatric consultation model to integrated orthogeriatric care model were compared with 576 patients from other local hospitals. RESULTS: Despite a seasonal trend toward increased length of hospital stay in winter, the intervention significantly reduced the change in mean length of stay (mean difference [95% confidence interval], -12.9 days [-21.5 to -4.3]; P = 0.007) and discharge to home tended to change less frequently (-12.6%; P = 0.10). There was no significant reduction in mean time to surgery (-0.2 days; P = 0.83), mortality (-0.8%; P = 0.62), or complications (-1.0%; P = 0.85). CONCLUSIONS: Changing our hip fracture service from a geriatric consultation model of care to an integrated orthogeriatric model significantly reduced length of hospital stay probably due to a lower chance of discharge to home. To our knowledge, this is the first study in Japan to compare two orthogeriatric care models considering the nationwide improvement in hip fracture management. Geriatr Gerontol Int 2022; 22: 138-144.

Early recovery of basic mobility under femoral nerve block after hip fracture surgery - A propensity score matched pilot study.

BACKGROUND: Previous studies have shown better pain reduction utilizing femoral nerve block (FNB) in patients who underwent hip fracture surgery. However, few studies have focused on the recovery of physical function after FNB, and most studies excluded patients with dementia. We investigated the association between FNB performed in the operating room and the recovery of physical function after hip fracture surgery, including patients with dementia. METHODS: A total of 103 patients with a mean age of 87.4 years who underwent hip fracture surgery under spinal anesthesia between July 2015 and December 2017 (46 patients receiving a single injection of FNB and 57 standard care) were enrolled. Patients with FNB versus standard care were matched by a propensity score to adjust for patient characteristics. An anesthesiologist performed FNB with 20ml of 0.2% ropivacaine, and the standard care group received intravenous 1000 mg acetaminophen or 50mg flurbiprofen once after surgery. After matching, 78 patients were analyzed. Our primary outcome was 3-day cumulated ambulation score (CAS, 0-18 points) and secondary outcomes were 1-day CAS on postoperative day 1-3 and length of hospital stay. We also stratified patient groups based on the presence of dementia and fracture type. RESULTS: Patients undergoing FNB had significantly better 3-day CAS compared to standard care (mean [SD], 8.72 [3.42] vs 7.33 [2.62]; mean difference, 1.38 [95%CI; 0.03 - 2.74]; p = 0.048) and 1-day CAS on postoperative day two (mean [SD], 3.10 [1.39] vs 2.56 [0.94]; mean difference, 0.54 [0.01 - 1.07]; p = 0.049). Length of hospital stay did not significantly differ among the two groups (p = 0.65). Larger positive effect was likely to be seen for patients with a femoral neck fractures and for those without dementia. CONCLUSIONS: Patients who underwent surgery with spinal anesthesia plus FNB had better ambulatory status early after hip fracture surgery compared to patients not offered FNB. The beneficial association between FNB and ambulatory status was likely to be observed especially in patients with femoral neck fracture and without dementia.

Effect of hip fracture surgery within 24 hours on short-term mobility.

BACKGROUND: Hip fracture constitutes a high-mortality injury in elderly patients. In addition, caregiver burden is also a relevant issue, as patients after hip fracture surgery lose ambulation and require support in the perioperative period and after discharge. Early surgery is recommended to improve mortality. However the positive effect of early surgery on the short-term postoperative ambulatory function is unknown. The objective of this study was to determine whether a shorter waiting time for hip fracture surgery improves short-term postoperative mobility in elderly patients. We used the cumulated ambulation score (CAS), a feasible function scoring system using low-demand activities, to measure short-term postoperative mobility. METHODS: In this retrospective, observational study of 175 hip fracture patients at a single hospital, the patients were divided based on the waiting period for surgery (within 24 hours of arrival, early group; after 24 hours of arrival, delayed group). The primary outcome was postoperative mobility, assessed using the CAS. Multivariable linear regression analysis with adjustment for covariates, age, sex, mobility before injury, comorbidity, presence of dementia and type of fracture. As a subgroup analysis, cognitive function and the interaction between the surgical waiting time and the presence of dementia were considered. RESULTS: The early group had a significantly better CAS (adjusted beta = 1.36; 95% confidence interval [95% CI]: 0.24-2.48, p = 0.02) than the delayed group. Significant CAS improvement was observed among cognitively intact patients (adjusted beta = 2.66; 95% CI: 0.62-4.69, p = 0.01), but not among those with dementia (adjusted beta = 0.43; 95% CI: -0.93 to 1.79, p = 0.53). However, the interaction between the surgical waiting time and the presence of dementia in the entire population did not reach statistical significance (p for interaction = 0.15). CONCLUSIONS: Hip fracture surgery within 24 hours could improve the recovery of postoperative ambulatory function faster. The postoperative caregiver burden would be reduced by early surgery.

Conservative treatment in displaced fractures of the humeral capitellum: a reduction technique under local anaesthesia.

We report the case of a 46-year-old woman who struck her right elbow on the ground after a fall on ice. Radiography showed a right humeral capitellar fracture, and CT further confirmed a Dubberley type 1A fracture. Closed reduction was performed under local anaesthesia, and an anatomical position was obtained. After the reduction, her right elbow was casted for 18 days. Three months after the injury, bone union was achieved without displacement, and the active range of motion of her right elbow recovered similar to the unaffected side. At 1 year postinjury, the Grantham score was excellent, and she obtained a two-point score on the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire. Although surgical treatment is recommended for a displaced humeral capitellar fracture, a Dubberley type 1A (no posterior column fracture of a distal humerus) can be effectively treated by early closed reduction.

Endoscopic Stalk Resection of a Toe Ganglion With Color-aided Visualization.

Ganglion cysts are common cystic lesions filled with a jelly-like substance and originate from a joint capsule or tendon sheath through a stalk. Ganglion cysts mostly occur in the hand region, for which surgical excision usually results in good outcomes. In contrast, toe ganglions are relatively rare, and surgical treatment is associated with a high recurrence rate because of unidentifiable ganglion stalks, requiring large skin incisions. We have treated toe ganglion cysts using endoscopy in the ganglion cyst by injecting methylene blue into the tendon sheath that connects to the ganglion stalk. The result has been favorable, without recurrence. The advantages of our technique include the following: (1) Endoscopy using a color aid can show the location of a ganglion stalk, and removing the stalk can prevent recurrence. (2) Endoscopic stalk-only resection is minimally invasive, allowing early mobilization and reducing surgical-site complications. The purpose of this Technical Note is to describe our endoscopic stalk resection technique with color-aided visualization, and we have included a video presentation.

Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction.

PURPOSE: The recently developed 2-bundle anterior cruciate ligament (ACL) reconstruction lacks sufficient anatomic background. The purpose of this anatomic study was to describe functional anteromedial (AM) and posterolateral (PL) portions of the natural ACL and to provide a reproducible description of the graft placement. Our hypothesis was that the core functional area of the femoral ACL attachment will be revealed by removing the surface fibrous membranous tissue of the ACL midsubstance and the attachment area. METHODS: The natural ACL was divided into 2 portions of AM and PL bundles in a flexion position; those bundles were most clearly defined when the knee was in flexion. The surface membrane of the ACL was removed and the margin was marked. The attachment site was removed after documenting its measurements. The knee position was corrected by digital photographs with the femoral bone in the correct lateral position. RESULTS: The length of the major axis of the AM and PL bundles averaged 9.2 +/- 0.7 mm and 6.0 +/-0.8 mm, respectively. Both lengths of the minor axis of AM and PL bundles averaged 4.7 +/-0.6 mm. The distance from the attachment center of each AM and PL bundle to the posterior bone and articular surface border averaged 6.3 +/- 0.6 mm and 8.6 +/- 0.6 mm, respectively. The center of the AM and PL bundles was described as 1:40 and 3:10 clock positions, respectively, as left knee when the point was defined on the "lateral wall clock" of the intercondylar notch. CONCLUSIONS: The study described the position and area of each 2-bundle of AM and PL portions of the natural ACL by describing its central structure with the surface membrane removed. CLINICAL RELEVANCE: The detailed anatomic description of the natural ACL femoral attachment might suggest to surgeons where to make femoral tunnels during 2-bundle reconstruction.

In vitro chondrogenesis of human synovium-derived mesenchymal stem cells: optimal condition and comparison with bone marrow-derived cells.

There are increasing reports that mesenchymal stem cells (MSCs) are present in various tissues other than bone marrow, including synovium. Here we investigated the optimal conditions for in vitro chondrogenesis of human synovium-derived MSCs and compared these cells with bone marrow-derived MSCs, especially in terms of their chondrogenesis potential. Synovium and bone marrow were harvested from six donors during knee operations for ligament injuries. Digested synovium cells or nucleated cells from bone marrow were expanded clonally. A pellet culture system was used for chondrogenesis, and the best combination of up to three cytokines of the seven assessed. Synovium-derived MSCs plated at a lower density expanded more rapidly. Contrary to previous reports, a combination of TGFbeta and dexamethasone was not sufficient to induce chondrogenesis. However, addition of BMP2 to TGFbeta and dexamethasone dramatically increased cartilage pellet size and the synthesis of cartilage matrix. The cartilage pellets were also analyzed by electron microscopy and immunohistology. DNA content per pellet decreased during chondrogenesis, indicating the pellet increased its size through the accumulation of newly synthesized extracellular matrix. Sequential chondrogenic gene expression was demonstrated by RT-PCR. Synovium-derived MSCs looked similar to the bone marrow-derived MSCs in their surface epitopes and proliferation potential; however, cartilage pellets from synovium were significantly larger than those from bone marrow in patient-matched comparisons. We demonstrated that the combination of TGFbeta, dexamethasone, and BMP2 was optimal for in vitro chondrogenesis of synovium-derived MSCs and that the synovium-derived MSCs have a greater chondrogenesis potential than bone marrow-derived MSCs.

Gene trap screening for cell surface and extracellular matrix molecules produced by chondrocytes.

We have developed a simple and unique strategy for identifying cell surface and extracellular matrix molecules produced by chondrocytes. Our strategy comprises two methods, retrovirus-based signal sequence gene trapping and culturing of Swarm rat chondrosarcoma chondrocytes. After infection with a retrovirus vector and isolation of hygromycin-resistant clones, trapped genes could be easily identified by the 5' rapid amplification of cDNA ends (5' RACE) method. Furthermore, the treatment of isolated clones with gadolinium chloride enabled us to determine whether the trapped gene expression was dependent on the state of chondrogenic differentiation.