Surgical Treatment of Distal Radius Fractures under the Ultrasound-Guided Brachial Plexus Block Performed by Surgeons.

Background: The upper limb surgery under the ultrasound-guided brachial plexus block is becoming popular due to its safety, effectiveness, and convenience. However, the uneven distribution of anesthesiologists become a social problem. Ultrasound-guided brachial plexus block by surgeons has been widespread especially in hand surgeons. We report the surgical treatment of distal radius fractures under the ultrasound-guided brachial plexus block performed by surgeons in our hospital. Methods: The subjects were 101 patients (41 males and 60 females, average age 61.6 years) who underwent surgery for distal radius fractures under ultrasound-guided brachial plexus block administered by orthopedists at our university or related facilities between January 2014 and June 2016. Brachial plexus block was administered through the supraclavicular approach. The time from initiation of anesthesia to initiation of surgery, mean operative time, the presence or absence of additional anesthesia (local infiltration anesthesia, intravenous anesthesia, and general anesthesia), and complications were evaluated. Results: The mean time from brachial plexus block to initiation of surgery was 35.7 (20-68) minutes, and the mean operative time was 90.5 (35-217) minutes. Surgery was completed with brachial plexus block alone in 62 patients (61.4%), and additional anesthesia was necessary in 39 patients (38.6%). Furthermore, general anesthesia was employed in 6 patients (5.9%). No serious complications occurred. Conclusions: According to our results, the operation could be completed with brachial plexus block alone and additional local infiltration anesthesia or intravenous anesthesia in 94.1% (95 cases). However, 6 cases (5.9%) shifted to general anesthesia. Although it needs training, we consider that hand surgery including distal radius fractures treatment under the ultrasound-guided brachial plexus block is possible. On the other hand, cooperation or a cooperative system with anesthesiologists is necessary for surgeons to administer this anesthesia.

Association between leg bowing and serum alkaline phosphatase level regardless of the presence of a radiographic growth plate abnormality in pediatric patients with genu varum.

When children around 2 years of age show leg bowing and diseases are ruled out based on radiographic findings without conducting blood tests, they are classified as "physiologic" genu varum. Since whether or not physiologic genu varum is associated with bone metabolism is unclear, this study was conducted to clarify the association between genu varum and bone metabolism in children. Thirty-five pediatric patients with genu varm who visited our out-patient clinic were enrolled. While two of the 35 children had nutritional rickets, showing abnormalities on both blood test (ALP, ≥1000 IU/L; iPTH, >65 pg/mL and 25(OH)D, ≤20 ng/mL) and radiographs (such as cupping, fraying or splaying), five of 35 children showed abnormalities on blood tests but not radiographs. While metaphyseal-diaphyseal angle (MDA) correlated with serum 25-hydroxy vitamin D (r = -0.35, p = 0.04) and magnesium (r = -0.36, p = 0.04), MDA and femorotibial angle (FTA) correlated with alkaline phosphatase (r = 0.43, p = 0.01 and r = 0.51, p = 0.006, respectively). A ridge regression analysis adjusted for age and body mass index indicated that ALP was associated with MDA and FTA. A logistic regression analysis adjusted for age and BMI indicated that higher ALP influenced an MDA >11°, which indicates the risk for the progression of genu varum (odds ratio 1.002, 95% confidence interval 1.0003-1.003, p = 0.021). The higher ALP (+100 IU), the higher risk of an MDA >11° (odds ratio 1.22). In conclusion, genu varum is associated with the alkaline phosphatase level regardless of the presence of radiographic abnormalities in the growth plate in children.

An eggshell-like mineralized recurrent lesion in the popliteal region after treatment of giant cell tumor of the bone with denosumab.

We report a case of recurrent giant cell tumor of the bone (GCTB) in which treatment with denosumab gradually enhanced the eggshell-like mineralization at the periphery of the tumor. A 28-year-old male presented with a mass on his left distal femur that had enlarged within the past few months. Before curettage, GCTB of the distal femur was diagnosed based on histological analysis of a biopsy specimen; the tumor consisted of a proliferation of ovoid mononuclear stromal cells with evenly scattered multinucleated osteoclast-like giant cells. The tumor recurred three times after the initial diagnosis; at the time of the third relapse, the patient underwent en bloc resection and reconstruction with a knee joint prosthesis. He was also treated with denosumab postoperatively because some studies have recently shown the benefits of the receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor denosumab as adjuvant therapy in patients with GCTB. Six months after starting adjuvant treatment with denosumab, radiography revealed a mineralized nodule >2 cm in diameter at the popliteal region; this lesion was considered a soft tissue recurrence of GCTB. Treatment with denosumab was continued for another 1.5 years, and the lesion was resected. Histological examination showed residual mononuclear stromal cells expressing RANKL without multinucleated giant cells surrounded by the peripheral mineralization. The patient was successfully treated by complete resection with the support of adjuvant treatment with denosumab.