Efficacy of Hand Therapy After Volar Locking Plate Fixation of Distal Radius Fracture in Middle-Aged to Elderly Women: A Randomized Controlled Trial.

PURPOSE: This study aimed to evaluate the efficacy of hand therapy after volar locking plate fixation of distal radius fractures in middle-aged to elderly women. METHODS: Fifty-seven patients diagnosed with distal radius fractures who had undergone volar plate fixation were enrolled in a prospective, randomized controlled trial. Patients were randomized into the hand therapy and independent exercise (IE) groups, in which they exercised independently under the surgeon's direction with and without hand therapy, respectively. The primary outcome was the functional outcome measured using the Disability of Arm, Shoulder, and Hand questionnaire after 6 weeks. The secondary outcomes were functional outcomes measured using the Patient-Rated Wrist Evaluation questionnaire, active and passive ranges of motion (ROMs), grip strength, key pinch strength, and pain measured on a visual analog scale. Patients were followed up in the outpatient department at 2, 4, 6, and 8 weeks and at 3 and 6 months. RESULTS: The Disability of Arm, Shoulder, and Hand scores were significantly lower in the hand therapy group at 6 weeks after surgery (12.5 vs 19.4 in the IE group). The postoperative visual analog scale pain scores were significantly lower in the hand therapy group at 2, 4, and 6 weeks (10.2 vs 17.6 in the IE group). The active ROM of the wrist flexion-extension arc at 2, 4, 6, and 8 weeks; active ROM of the pronation-supination arc at 6 and 8 weeks; and passive ROM of the wrist flexion-extension arc at 2, 4, and 8 weeks were significantly greater in the hand therapy group. CONCLUSIONS: Hand therapy improved the outcomes after volar locking plate fixation for distal radius fracture in middle-aged to elderly women at 8 weeks after surgery. No significant between-group differences were observed in any functional outcome measure at 6 months after surgery, as previously reported. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

BNCT for primary synovial sarcoma.

Synovial sarcoma is a rare tumor requiring new treatment methods. A 46-year-old woman with primary monophasic synovial sarcoma in the left thigh involving the sciatic nerve, declining surgery because of potential dysfunction of the affected limbs, received two courses of BNCT. The tumor thus reduced was completely resected with no subsequent recurrence. The patient is now able to walk unassisted, and no local recurrence has been observed, demonstrating the applicability of BNCT as adjuvant therapy for synovial sarcoma. Further study and analysis with more experience accumulation are needed to confirm the real impact of BNCT efficacy for its application to synovial sarcoma.

Two case reports of intra-articular nodular fasciitis of the knee confirmed by MYH9-USP6 gene fusion expression.

AIM: To describe two cases of intra-articular nodular fasciitis (NF) which developed within the knee joint and were associated with the expression of the MYH9-USP6 gene fusion. PATIENTS AND METHODS: Two women, 30 and 56 years of age, with no history of joint disease or knee joint trauma, are presented in our cases. We report these cases describing the clinical presentation, assessment, histopathological examination, gene expression, and clinical management. RESULTS: Both patients presented with knee pain and limitation in the range of flexion. We diagnosed our two cases as intraarticular nodular fasciitis based on histological findings and by the detection of the MYH9-USP6 gene fusion. The transcript of MYH9-USP6 gene fusion was identified by RT-PCR and direct sequencing in both cases. CONCLUSION: We report the first cases of intra-articular NF involving the knee joint, with identification of a MYH9-USP6 gene fusion by RT-PCR. NF should be considered in the differential diagnosis of intra-articular lesions.

Endoprosthetic Reconstruction for a Displaced Atypical Femoral Fracture in a Cancer Patient with Poor Prognosis.

Zoledronate or denosumab treatment is beneficial for cancer patients with bone metastasis. However, each agent may trigger atypical femoral fractures. Incomplete atypical femoral fractures can be successfully treated with prophylactic intramedullary nailing. On the other hand, intramedullary nailing for displaced atypical femoral fractures occasionally causes problems with regard to bone healing, resulting in long-term treatment. In cancer patients with poor prognosis who experience atypical femoral fractures, improvement in activities of daily living should be the priority. Thus, we performed endoprosthetic reconstruction for a displaced atypical femoral fracture in a breast cancer patient with poor prognosis to enable walking in the early stage after the operation. Two weeks after the operation, she could successfully walk. The postoperative Musculoskeletal Tumor Society score was 47%, and it had improved to almost the preoperative level before injury (50%). In conclusion, endoprosthetic reconstruction for displaced atypical femoral fractures may be a first-line treatment approach to acquire early postoperative walking ability for improving activities of daily living in cancer patients with poor prognosis.

Calcific myonecrosis mimicking soft tissue sarcoma: A case report.

Calcific myonecrosis is a rare soft tissue condition. The first case was reported in 1960, however, the precise pathophysiology of calcific myonecrosis remains unclear. The disease was thought to arise from compartment syndrome within a confined space resulting in necrosis and fibrosis, subsequent repeated intralesional hemorrhage, mass enlargement and calcification. Several previous reports have described calcific myonecrosis, which include the formation of calcific myonecrosis after a prolonged period of post trauma. Notably, calcific myonecrosis has typically been described in the lower legs and characteristic imaging findings have been indicated. Furthermore, surgical intervention carries a high risk of complications. In the present case report 2 cases of calcific myonecrosis that occurred after a prolonged period of time following a traumatic event that impacted the lower leg were reported. CT images revealed disruption of calcified fascia and disease expansion into the outside of the fascia. Previous reports have implied that there is late focal enlargement of calcific myonecrosis following earlier enlargement, which may be caused by herniation through muscle fascia. However, no previous publications have focused on images for evidence of late local enlargement. To the best of our knowledge, this is the first report focusing on fascial herniation of calcific myonecrosis using images. Analysis of this feature using images may aid clinicians to differentiate calcific myonecrosis from malignancies.

Neurogenic Shock Immediately following Posterior Lumbar Interbody Fusion: Report of Two Cases.

Study Design Case report. Objective To present two cases of neurogenic shock that occurred immediately following posterior lumbar interbody fusion (PLIF) and that appeared to have been caused by the vasovagal reflex after dural injury and incarceration of the cauda equina. Case Report We present two cases of neurogenic shock that occurred immediately following PLIF. One patient had bradycardia, and the other developed cardiac arrest just after closing the surgical incision and opening the drainage tube. Cardiopulmonary resuscitation was performed immediately, and the patients recovered successfully, but they showed severe motor loss after awakening. The results of laboratory data, chest X-ray, electrocardiogram, computed tomography, and echocardiography ruled out pulmonary embolism, hemorrhagic shock, and cardiogenic shock. Although the reasons for the postoperative shock were obscure, reoperation was performed to explore the cause of paralysis. At reoperation, a cerebrospinal fluid collection and the incarceration of multiple cauda equina rootlets through a small dural tear were observed. The incarcerated cauda equina rootlets were reduced, and the dural defect was closed. In both cases, the reoperation was uneventful. From the intraoperative findings at reoperation, it was thought that the pathology was neurogenic shock via the vasovagal reflex. Conclusion Incarceration of multiple cauda equina rootlets following the accidental dural tear by suction drainage caused a sudden decrease of cerebrospinal fluid pressure and traction of the cauda equina, which may have led to the vasovagal reflex.

Venous thromboembolism after total joint arthroplasty: results from a Japanese multicenter cohort study.

INTRODUCTION: Real-world evidence of the effectiveness of pharmacological thromboprophylaxis for venous thromboembolism (VTE) is limited. Our objective was to assess the effectiveness and safety of thromboprophylactic regimens in Japanese patients undergoing joint replacement in a real-world setting. METHOD: Overall, 1,294 patients (1,073 females and 221 males) who underwent total knee arthroplasty (TKA) and 868 patients (740 females and 128 males) who underwent total hip arthroplasty (THA) in 34 Japanese national hospital organization (NHO) hospitals were enrolled. The primary efficacy outcome was the incidence of deep vein thrombosis (DVT) detected by mandatory bilateral ultrasonography up to post-operative day (POD) 10 and pulmonary embolism (PE) up to POD28. The main safety outcomes were bleeding (major or minor) and death from any cause up to POD28. RESULTS: Patients undergoing TKA (n = 1,294) received fondaparinux (n = 360), enoxaparin (n = 223), unfractionated heparin (n = 72), anti-platelet agents (n = 45), or no medication (n = 594). Patients undergoing THA (n = 868) received fondaparinux (n = 261), enoxaparin (n = 148), unfractionated heparin (n = 32), anti-platelet agents (n = 44), or no medication (n = 383). The incidence rates of sonographically diagnosed DVTs up to POD10 were 24.3% in patients undergoing TKA and 12.6% in patients undergoing THA, and the incidence rates of major bleeding up to POD28 were 1.2% and 2.3%, respectively. Neither fatal bleeding nor fatal pulmonary embolism occurred. Significant risk factors for postoperative VTE identified by multivariate analysis included gender (female) in both TKA and THA groups and use of a foot pump in the TKA group. Only prophylaxis with fondaparinux reduced the occurrence of VTE significantly in both groups. Propensity score matching analysis (fondaparinux versus enoxaparin) showed that the incidence of DVT was lower (relative risk 0.70, 95% confidence interval (CI) 0.58 to 0.85, P = 0.002 in TKA and relative risk 0.73, 95% CI 0.53 to 0.99, P = 0.134 in THA) but that the incidence of major bleeding was higher in the fondaparinux than in the enoxaparin group (3.4% versus 0.5%, P = 0.062 in TKA and 4.9% versus 0%, P = 0.022 in THA). CONCLUSIONS: These findings indicate that prophylaxis with fondaparinux, not enoxaparin, reduces the risk of DVT but increases bleeding tendency in patients undergoing TKA and THA. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry: UMIN000001366. Registered 11 September 2008.

Rates of serious intracellular infections in autoimmune disease patients receiving initial glucocorticoid therapy.

BACKGROUND/AIMS: The Japanese National Hospital Organization evidence-based medicine (EBM) Study group for Adverse effects of Corticosteroid therapy (J-NHOSAC) is a Japanese hospital-based cohort study investigating the safety of the initial use of glucocorticoids (GCs) in patients with newly diagnosed autoimmune diseases. Using the J-NHOSAC registry, the purpose of this observational study is to analyse the rates, characteristics and associated risk factors of intracellular infections in patients with newly diagnosed autoimmune diseases who were initially treated with GCs. METHODOLOGY/PRINCIPAL FINDINGS: A total 604 patients with newly diagnosed autoimmune diseases treated with GCs were enrolled in this registry between April 2007 and March 2009. Cox proportional-hazards regression was used to determine independent risk factors for serious intracellular infections with covariates including sex, age, co-morbidity, laboratory data, use of immunosuppressants and dose of GCs. Survival was analysed according to the Kaplan-Meier method and was assessed by the log-rank test. There were 127 serious infections, including 43 intracellular infections, during 1105.8 patient-years of follow-up. The 43 serious intracellular infections resulted in 8 deaths. After adjustment for covariates, diabetes (Odds ratio [OR]: 2.5, 95% confidence interval [95% CI] 1.1-5.9), lymphocytopenia (≦1000/µl, OR: 2.5, 95% CI 1.2-5.2) and use of high-dose (≧30 mg/day) GCs (OR: 2.4, 95% CI 1.1-5.3) increased the risk of intracellular infections. Survival curves showed lower intracellular infection-free survival rate in patients with diabetes, lymphocytopaenia and high-dose GCs treatments. CONCLUSIONS/SIGNIFICANCE: Patients with newly diagnosed autoimmune diseases were at high risk of developing intracellular infection during initial treatment with GCs. Our findings provide background data on the risk of intracellular infections of patients with autoimmune diseases. Clinicians showed remain vigilant for intracellular infections in patients with autoimmune diseases who are treated with GCs.

Neoadjuvant and adjuvant chemotherapy with high-dose ifosfamide, doxorubicin, cisplatin and high-dose methotrexate in non-metastatic osteosarcoma of the extremities: a phase II trial in Japan.

From 1997 to 2003, 40 patients (all <40 years of age) with non-metastatic osteosarcoma of the extremities were treated with OOS-D and definitive surgery. Two cycles of doxorubicin 90 mg/m(2) plus cisplatin 120 mg/m(2) and ifosfamide 15 g/m(2) were given as neoadjuvant chemotherapy, and two cycles of doxorubicin/cisplatin and ifosfamide, and two cycles of high-dose methotrexate (10-12 g/m(2)) were given post-operatively. All patients underwent limb salvage surgeries, and 66% showed good response to neoadjuvant chemotherapy. With a median follow-up period of 117 months, 31 of the evaluable 40 patients were continuously disease-free, 7 were currently alive with no evidence of disease, and 2 died of disease. There was no local recurrence. The 5-year event-free and overall survival rates were 83 and 98%, respectively. The 10-year event-free and overall survival rates were 80 and 95%, respectively. The major form of toxicity was haematological one.

Retrospective multicenter study of surgical treatments for osteoporotic vertebral fractures.

BACKGROUND: Although many surgical procedures are available for treating osteoporotic vertebral fractures, there have been no comprehensive multicenter surveys in Japan focusing on surgical treatments for these fractures. This study aimed at (1) conducting a retrospective multicenter study to survey surgical treatments performed at referral center hospitals in various regions in Japan and (2) analyzing situations and problems related to the surgical treatments of osteoporotic vertebral fractures in Japanese hospitals. METHODS: Among 738 patients who were hospitalized in 13 hospitals in various regions in Japan between 2005 and 2006 for osteoporotic vertebral fractures, 84 patients (11.4%) who underwent spinal surgery were enrolled. These patients were retrospectively analyzed regarding cause of injury, preoperative symptoms, preoperative neurological function, surgical procedures, periods of bed rest, length of hospital stay, and ambulatory status at discharge from hospital. RESULTS: As to the cause of spinal fracture, 38 patients (45% of the surgical patients) could not identify a specific cause of their spinal fracture. Preoperative neurological motor weakness in legs was observed in 41 (49%). With regard to surgical treatment, posterior spinal reconstruction surgery was performed in 50 patients (60%), vertebroplasty in 26 (31%), anterior reconstruction surgery in 6 (7%), anterior and posterior combined reconstruction surgery in 1, and posterior decompression alone in 1 patient. In all, 70 patients (83.3%), whose periods of hospital stay averaged 52.8 days, could walk by themselves at the time of discharge; 14 (16.7%), whose periods of hospital stay averaged 44.7 days, could not walk by themselves at the time of discharge. CONCLUSIONS: Even after a large variety of surgical procedures were tried to treat osteoporotic vertebral fractures and long hospital stays, about 17% of the patients were unable to walk by themselves at the time of discharge from hospital.

Nationwide survey of current medical practices for hospitalized elderly with spine fractures in Japan.

BACKGROUND: The status of hip fracture incidence and treatment is well known through nationwide surveys in Japan. However, there have been no similar studies on spine fractures. Therefore, we investigated current medical practices for them. METHODS: Altogether, 1200 hospitals were randomly selected for the survey with consideration of region and hospital characteristics. Questionnaire items included the number of hospitalized spine patients, imaging test implementation, type of conservative treatment, use of open surgery and vertebroplasty, and the number of these procedures performed in 2005. RESULTS: Responses were received from 473 hospitals. On the day of response, there were 14 372 hospitalized orthopedic patients (average 32.8/hospital). Among them were 1403 spine fracture patients (3.1/hospital), accounting for 13.5% of orthopedic patients. Of them, 91.9% received conservative treatment. The mean percentage of spine fracture patients who were hospitalized was 39.5%. The most reliable imaging test was said to be magnetic resonance imaging. Casting or bracing was used in most of the institutions. The most common analgesic treatment was oral nonsteroidal antiinflammatory drugs. Open surgery and vertebroplasty were conducted for spine fractures in the elderly at 26.5% and 16.3% of hospitals, respectively. In these hospitals, 624 and 257 patients underwent open surgery and vertebroplasty, respectively, in 2005. CONCLUSIONS: In Japan, more than 90% of elderly patients hospitalized with spine fractures received conservative treatment. Surgical treatment, either open surgery or vertebroplasty, was performed at 30% of the hospitals. This study provides basic data that will contribute to planning improvements in spinal fracture treatment in the elderly.

Usefulness of limb salvage surgery for bone and soft tissue sarcomas of the distal lower leg.

PURPOSE: The usefulness of limb salvage surgery for distal lower leg sarcoma remains controversial. We analyzed the long-term prognosis, limb function, and complications after limb salvage treatment of patients with distal lower leg sarcoma. METHODS: Ten patients treated with limb salvage surgery for primary distal lower leg sarcoma were retrospectively reviewed. The median follow-up period after the first operation was 9.0 years. We performed three types of reconstructive techniques for the skeletal defect after a wide resection, including (1) arthrodesis with a combination of autograft and intraoperative autoclaved tumor bone graft in two patients, or allograft in one patient, (2) ankle joint preserving surgery using intraoperative extracorporeal irradiated tumor bone graft in five patients, and (3) prosthesis in two patients. RESULTS: The overall survival rate was 80%. The 5-year disease-free survival was 80%. The rate of limb preservation at the final follow-up was 90%. The mean functional score according to the scoring system of the Musculoskeletal Tumor Society was 88% at the final follow-up. Postoperative complications occurred in seven patients. Skin trouble occurred in three patients, infectious non-union in one patient, fracture in three patients, and loosening of prosthesis in one patient. CONCLUSIONS: Despite the high rate of complications, patients treated with limb salvage surgery for the distal lower leg sarcoma revealed excellent final functional results without impairing the oncologic results. Limb salvage surgery is therefore considered to be an effective treatment option for distal lower leg sarcoma when adequate informed consent can be obtained from the patient.

Acute arm paresis with cervical spondylosis: three case reports.

BACKGROUND: The mild type of anterior spinal artery syndrome (ASAS) is characterized by motor loss with an absent or insignificant sensory deficit due to a disturbance in the blood supply to the anterior horn of the spinal cord. The clinical symptoms of cervical spondylotic amyotrophy (CSA) are motor loss or atrophy with an absent or insignificant sensory deficit or a long tract sign; however, the pathophysiology has not been clarified. METHODS: Three patients who suffered from palsy of the deltoid and biceps brachii are presented. Magnetic resonance imaging confirmed the intrinsic cord disease as the cause of the paresis. We measured the central motor conduction time (CMCT) and the latencies of the tendon reflex (T waves) of the biceps and triceps and those of the F waves of the abductor pollicis brevis and abductor digiti minimi before, 2 weeks after, and 3 months after starting intravenous injections of prostaglandin E(1) (PGE(1)). RESULTS: In these 3 cases, restoration of muscle strength began after starting injection of PGE(1). The electrophysiologic diagnosis revealed a disturbance of the motor conduction, in the CMCT and the latencies of the T waves, in the paretic muscle, which is more severe than that in other muscles. The radiological diagnosis suggested damage in the spinal cord. Improvements in the disturbance of the motor conduction and those of symptoms were parallel. CONCLUSION: From symptomatologic or radiological viewpoints, it is difficult to differentiate CSA from ASAS with cervical spondylosis. This suggests that there have been patients with ASAS whom we have diagnosed as CSA, and we may add administration of PGE(1) to the treatment for the patients with CSA. The present 3 patients showed improvement of muscle strength after starting injections of PGE(1). Although this improvement was measured by an electrophysiologic method, the mechanisms of PGE(1) require further study.

Skeletal metastasis in patients with gastric cancer.

To clarify metastatic patterns, and histologic and radiologic features in skeletal metastases from gastric cancer, 48 patients were retrospectively analyzed. The mean age of the patients at the time of diagnosis of gastric cancer was 59 years. In 31 patients with a history of the radical surgery, the mean interval between surgery and diagnosis of skeletal metastasis was 14 months. The mean duration between diagnosis of skeletal metastasis and death was 60 days. Scintigraphic assessment showed that solitary osseous lesions were found in four patients, whereas the remaining 44 had multiple skeletal lesions. In 28 patients with bone-only metastases with absence of visceral metastases, a higher incidence of thoracolumbar metastases at the level nearest the stomach was found. The incidence of skeletal metastasis in each histologic type was intestinal in 19 and diffuse in 29. Radiologic examination revealed that the ratio between the presence and the absence of osteosclerosis was 1:2. Osteosclerosis was seen in three of 19 patients with intestinal type metastasis, whereas with the diffuse type 13 of 29 patients had osteosclerosis.

Analysis of organ selectivity in the metastatic behavior of Dunn osteosarcoma.

In the current study, the authors established a novel metastatic model to analyze organ selective metastasis by osteosarcoma, using a murine cell line, Dunn osteosarcoma. The lung, liver, kidney, and spleen were resected from syngeneic donor mice, and a tissue fragment of the respective organs was transplanted subcutaneously into a recipient mouse. Two weeks later, tumor cells were injected intravenously and the formation of metastatic deposits in the ectopic transplants was examined. Ectopic lung transplants had a significantly higher incidence of metastasis than either liver or kidney transplants. When enzymatically dispersed organ cells that were embedded in agar gel were transplanted, intravenous injection of tumor cells also resulted in a higher metastatic rate in lung transplants than in either liver or kidney transplants. Photomicrographs and microangiographs of the transplants showed equivalent revascularization of the different organs. Radiolabeled tumor cells were deposited in equivalent amounts in the ectopic transplants of the different organs after intravenous injection. In addition, in vitro growth of tumor cells was stimulated by medium conditioned with lung tissue in a dose-dependent manner. These results suggest that organ selective metastasis by osteosarcoma is not defined anatomically or hemodynamically, but may be caused by tumor cells responding to possible paracrine factors emanating from the lung.

Clinical implications of serum C-reactive protein levels in malignant fibrous histiocytoma.

Paraneoplastic syndromes (PNSs) associated with mesenchymal tumors are uncommon. Previous reports sporadically described inflammatory PNSs with elevated serum C-reactive protein (CRP) levels and leukocytosis in patients with inflammatory malignant fibrous histiocytoma (MFH) of soft tissue; however, the relationship between other subtypes of MFH and PNS has not been extensively investigated. Forty-six patients with primary MFH of soft tissues who underwent radical surgery were retrospectively analyzed. These patients were divided into 2 groups according to preoperative serum CRP level: normal (<1.0 mg/dl) and elevated (> or = 1.0 mg/dl). The correlation between serum CRP level and several clinicopathologic factors was analyzed. Correlation between preoperative serum CRP level and metastasis-free and overall survival was also investigated by univariate and multivariate analyses. Elevated preoperative serum CRP levels were found in 65% of patients with a mean of 3.7 mg/dl. There were statistically significant relationships regarding tumor size, depth, histologic subtypes, grade, stage and metastatic rate among normal and elevated CRP groups (p < 0.001, p < 0.02, p < 0.005, p < 0.001, p < 0.001 and p < 0.05, respectively). When the tumor was removed, the elevated CRP level subsided into the normal range and other abnormal laboratory findings diminished in all cases. In 11/14 relapsed cases that showed elevated CRP preoperatively, the serum CRP level re-elevated with tumor relapse. The normal CRP group showed significantly more favorable prognosis than the elevated CRP group in metastasis-free and overall survival on univariate analysis (p < 0.02, p < 0.05, respectively). Patients with MFH frequently present with an inflammatory PNS, such as elevated serum CRP level, which can be a useful marker of disease activity and a valuable prognostic indicator.