Comparative clinical outcomes and radiological images of clavicle hook plate versus Scorpion Plate® for unstable distal clavicle fractures.

BACKGROUND: Although various surgical methods are available for unstable distal clavicle fractures, consensus remains lacking on the optimal technique. Therefore, the present retrospective study aimed to compare the clavicle hook plate and Scorpion Plate® in terms of clinical outcomes and radiological findings for unstable distal clavicle fractures. METHODS: Fifty-seven patients with unstable distal clavicle fractures who underwent treatment using a clavicle hook plate (Group H; 28 patients) or Scorpion Plate® (Group S; 29 patients) were included in the present study. No patients received additional augmentation and all were followed-up for >1 year (mean follow-up, 28 months). Clinical outcomes were operation time, bleeding volume, complications, range of motion (ROM) at 6 months after surgery and final follow-up, and clinical scores (Constant-Murley score and University of California, Los Angeles (UCLA) shoulder score). Radiological outcomes assessed were coracoclavicular distance (CCD), difference in CCD between affected and non-affected sides (ΔCCD), and acromioclavicular subluxation ratio (%ACS) from plain X-rays. The χ2 test and Mann-Whitney U test were used to compare each outcome. RESULTS: Complications were seen in 3 shoulders (10.7%) in Group H. ROM was significantly worse in Group H at 6 months postoperatively, but no significant differences between groups were evident at final follow-up. Moreover, no significant differences in clinical outcomes were seen between groups. In terms of radiological results, Group H showed greater improvement in CCD and ΔCCD than Group S. Further, %ACS was significantly worse in Group S. CONCLUSIONS: The clavicle hook plate allows reconstruction of a more anatomical position than the Scorpion Plate®, but carries a greater risk of complications. Conversely, the Scorpion Plate® has a low risk of complications, but acromioclavicular subluxation remains. However, no significant differences in ROM or clinical outcomes were apparent at final follow-up.

Functional reconstruction of elbow flexion with latissimus dorsi muscle rotational transfer: two case reports.

BACKGROUND: We report two cases of biceps brachii and brachialis paralysis due to musculocutaneous nerve injury in which elbow joint flexion was reconstructed using rotational transfer of the latissimus dorsi muscle with sutures to the radial and ulnar tuberosities, thereby enabling flexion by simultaneous activation of the humeroradial and humeroulnar joints. In cases of associated brachialis paralysis, weaker flexion strength can be expected when the forearm is in a pronated position than when it is in a supinated state. To the best of our knowledge, no previous study has reported the rotational position of the forearm during elbow joint flexion reconstruction. CASE PRESENTATION: Case 1 involved a 30-year-old Asian male who presented with a rupture of the musculocutaneous, median, radial, and ulnar nerves. Reconstruction was performed by rotational transfer of the latissimus dorsi muscle. In this case, the supination and pronation flexion forces were equal. Case 2 involved a 50-year-old Asian man who presented with partial loss of the musculocutaneous nerve, biceps brachii, and pectoralis major due to debridement. Reconstruction was performed by rotational transfer of the latissimus dorsi muscle. In this case, supination and pronation flexion strengths were demonstrated to be equal. Our reconstruction method used the rotational transfer of the latissimus dorsi muscle; the distal muscle flap was divided into radial and ulnar sides to allow elbow joint flexion by simultaneously activating the humeroradial and humeroulnar joints. These sides were then fixed to the anchors at the radial and ulnar tuberosities. Finally, they were wrapped around the myotendinous junction of the biceps brachii or brachialis and secured using sutures. CONCLUSIONS: Although larger studies are required to verify these methods, this case study successfully demonstrates the following: (1) the flexion strength in the supinated position was equal to that in the pronated position; (2) the stability of the humeroradial and humeroulnar joints was unaffected by the forearm's rotational position; and (3) a satisfactory range of motion of the elbow joint was obtained, with no complications.

Comparison of the clinical outcomes of intramedullary nailing between impending and completed pathological fractures caused by metastatic femoral tumors from solid cancers.

BACKGROUND: We examined the treatment outcomes following intramedullary nailing in patients with metastatic femoral tumors, excluding those from hematological malignancies. METHODS: We retrospectively evaluated treatment outcomes following intramedullary nailing between patients who underwent preventative surgery compared with those who had surgery following pathological fracture. Patients who underwent preventative surgery (Mirels' score ≥8) were allocated to the impending fracture group (n = 11) and those who underwent surgery after pathological fracture were allocated to the completed fracture group (n = 20). RESULTS: Duration of surgery was significantly shorter in the impending fracture group than in the completed fracture group. Median blood loss was significantly less, and the median duration of hospital stay was significantly shorter in the impending fracture group than in the completed fracture group. Among patients who died following surgery, the median postoperative survival duration was significantly longer in the impending fracture group than in the completed fracture group. Significantly more patients regained walking function in the impending fracture group than in the completed fracture group. Regarding complications, infection occurred in one patient in the completed fracture group. No implant damage was observed in either group. CONCLUSIONS: Patients with metastatic femoral tumors who underwent intramedullary nailing in the impending fracture group had better postoperative survival and gait function, less blood loss, and shorter durations of surgery and hospital stay than those in the completed fracture group. These findings indicate the importance of early diagnosis and treatment and value of treatment prior to fracture occurrence.

Differentiation Capacity of Porcine Skeletal Muscle-Derived Stem Cells as Intermediate Species between Mice and Humans.

Large animal experiments are important for preclinical studies of regenerative stem cell transplantation therapy. Therefore, we investigated the differentiation capacity of pig skeletal muscle-derived stem cells (Sk-MSCs) as an intermediate model between mice and humans for nerve muscle regenerative therapy. Enzymatically extracted cells were obtained from green-fluorescence transgenic micro-mini pigs (GFP-Tg MMP) and sorted as CD34+/45- (Sk-34) and CD34-/45-/29+ (Sk-DN) fractions. The ability to differentiate into skeletal muscle, peripheral nerve, and vascular cell lineages was examined via in vitro cell culture and in vivo cell transplantation into the damaged tibialis anterior muscle and sciatic nerves of nude mice and rats. Protein and mRNA levels were analyzed using RT-PCR, immunohistochemistry, and immunoelectron microscopy. The myogenic potential, which was tested by Pax7 and MyoD expression and the formation of muscle fibers, was higher in Sk-DN cells than in Sk-34 cells but remained weak in the latter. In contrast, the capacity to differentiate into peripheral nerve and vascular cell lineages was significantly stronger in Sk-34 cells. In particular, Sk-DN cells did not engraft to the damaged nerve, whereas Sk-34 cells showed active engraftment and differentiation into perineurial/endoneurial cells, endothelial cells, and vascular smooth muscle cells, similar to the human case, as previously reported. Therefore, we concluded that Sk-34 and Sk-DN cells in pigs are closer to those in humans than to those in mice.

Relationship Between Subacromial Bone Erosion and Hook Position of Clavicular Plate in Distal Clavicle Fractures.

OBJECTIVES: To evaluate the influence of posterior hook position on subacromial bone erosion during surgical treatment of distal clavicle fractures with locking compression plate clavicle hook plate (CHP). DESIGN: Single-center retrospective study. SETTING: Level V trauma center (university hospital). PATIENTS: Twenty-one patients (mean age, 45.8 years) treated with CHP were included. One, 3, 15, and 2 patients had Neer type I, IIa, IIb, and V fractures, respectively. INTERVENTION: Open reduction and internal fixation were performed with locking compression plate CHP. All implants were removed after a mean of 6.1 months postoperatively. MAIN OUTCOME MEASUREMENTS: Japanese Orthopaedic Association shoulder scores were used to assess recovery. Radiographically, the coracoclavicular distance was measured as the distance between the tip of the coracoid process and the undersurface of the clavicle. Three-dimensional computed tomography was performed to identify bone erosion at the hook tips after implant removal. The distance from the acromioclavicular joint center to the bone erosion was divided into 5 areas at 5-mm intervals, and the position and depth of bone erosion were measured in each area. RESULTS: The mean follow-up period was 17.4 months; mean ± SD Japanese Orthopaedic Association score was 75.9 ± 4.7 at the final follow-up, whereas the mean duration of bony union was 4.4 ± 1.0 (SD) months. Delayed bony union was observed in one patient, whereas a second surgery was required in another due to acromion cut-out. Radiography showed overreduction in 95% of cases. The correlation coefficient showed a difference between coracoclavicular distance and the position of bone erosion measured by CT (Rs = 0.32, P = 0.006). Erosion under the acromion surface was found in all patients. The depth of erosion correlated with the posterior hook position (Rs = 0.29, P = 0.023). CONCLUSIONS: Posterior hook tip placement increased the likelihood of bone erosion and complications due to overreduction. CHP should be set more anteriorly beneath the acromion to prevent complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-term outcomes of open modified inferior capsular shift for traumatic anterior shoulder instability: over 20 years of follow-up.

BACKGROUND: This study aimed to assess the long-term outcomes of the open modified inferior capsular shift procedure across more than 20 years in patients with traumatic anterior shoulder instability. METHODS: Participants in this study comprised 84 patients (86 shoulders; 67 men, 17 women). Mean follow-up was 28.0 years. We compared the recurrent instability rate after surgery, apprehension, revision rate, satisfaction, return to preinjury sporting activity, and patient background characteristics between recurrent and nonrecurrent groups. Twenty-seven patients who were examined directly were evaluated for differences in range of motion and muscle strength between affected and nonaffected sides. Clinical outcome scores used for this study were the Western Ontario Shoulder Instability Index and the Rowe score. RESULTS: Nine shoulders (10.5%) showed recurrent instability, as dislocation in 3 shoulders and subluxation in 6 shoulders, but no revisions were required. All patients with recurrent instability were males with new trauma. Three shoulders developed recurrent instability ≤5 years after surgery, and the remaining 6 shoulders showed recurrent instability >5 years after surgery. No significant differences in any patient characteristic were identified between the recurrent and nonrecurrent groups. Significant differences between affected and nonaffected sides were seen in the mean active range of motion or muscle strength for external rotation in the anatomic position or in 90° of abduction. Western Ontario Shoulder Instability Index and Rowe score were significantly worse in the recurrent group than in the nonrecurrent group. Patients reported that 84 shoulders (97.7%) were "much better." Most athletes (88.4%) had returned to sports activity at a level >70%. CONCLUSION: We investigated long-term outcomes of the open modified inferior capsular shift procedure for traumatic anterior shoulder instability. Our data suggest that recurrent instability might result from new trauma even if a long time has passed since the open modified inferior capsular shift procedure, so follow-up should be continued as long as possible after surgery. As in other reports, satisfaction was high and clinical scores were good. We thus believe this surgical method offers good results even after more than 20 years.

Using blood glucose and lactate levels for early detection of venous congestion following a free flap procedure for lower extremity open fractures.

PURPOSE: Gustilo-Anderson type IIIB and IIIC open fractures of the lower extremities require reconstruction of extensively injured soft tissues using a free flap; however, impaired blood flow through the flap is an early postoperative complication. To detect flap congestion due to venous thrombosis, blood glucose and lactate level measurements within the flap are taken to determine variations in these levels. We aimed to detect early-stage venous congestion and to perform salvage operations. METHODS: We included 22 limbs with lower leg and foot open fractures, with fracture sites covered using a free flap. A pinprick test was used to measure blood glucose and lactate levels. RESULTS: Of 7 and 15 congested and non-congested limbs, respectively, the 7 congested limbs had a mean flap blood glucose level immediately before salvage surgery of 3.8 ± 2.0 (7.4-1.8) mmol/L. The ratio to blood glucose levels in healthy fingertips was 0.6 ± 0.2 (0.8-0.3). Lactate levels increased to 13.3 ± 5.1 (9.4-22.8) mmol/L. The ratio of blood glucose levels in congested flaps and in healthy fingertips was significantly lower than that in non-congested flaps and in healthy fingertips (p = 0.0016). Lactate levels were significantly higher in patients with congestion (p = 0.0013). Salvage surgery was performed, thrombi were removed, and six limb flaps were viable. CONCLUSION: Flap blood glucose and lactate levels provide a quantitative method of evaluating blood flow and detecting flow abnormalities postoperatively, and are useful in detecting early congestion due to venous thrombosis.

Peripheral Nerve Regeneration Using a Cytokine Cocktail Secreted by Skeletal Muscle-Derived Stem Cells in a Mouse Model.

Severe peripheral nerve injury, which does not promise natural healing, inevitably requires clinical treatment. Here, we demonstrated the facilitation effect of peripheral nerve regeneration using a cytokine cocktail secreted by skeletal muscle-derived stem cells (Sk-MSCs). Mouse sciatic nerve was transected with a 6 mm gap and bridged collagen tube, and the culture supernatant of Sk-MSCs with 20% adult mouse serum (AMS)/Iscove's modified Dulbecco's medium (IMDM) was administered into the tube immediately after the operation, followed by an injection once a week for six weeks through the skin to the surrounding tube of the cytokine (CT) group. Similarly, 20% AMS/IMDM without cytokines was administered to the non-cytokine control (NT) group. Tension recovery in the plantar flexor muscles via electrical stimulation at the upper portion of the damaged nerve site, as well as the numerical recovery of axons and myelinated fibers at the damaged site, were evaluated as an index of nerve regeneration. Specific cytokines secreted by Sk-MSCs were compared with damaged sciatic nerve-derived cytokines. Six weeks after operation, significantly higher tension output and numerical recovery of the axon and myelinated fibers were consistently observed in the CT group, showing that the present cytokine cocktail may be a useful nerve regeneration acceleration agent. We also determined 17 candidate factors, which are likely included in the cocktail.

Locking versus nonlocking superior plate fixations for displaced midshaft clavicle fractures: A prospective randomized trial comparing clinical and radiografic results.

BACKGROUND: It is unknown whether locking or nonlocking superior plate fixation is better for managing displaced midshaft clavicle fractures. Therefore, we aimed to compare the clinical and radiographic outcomes of locking and nonlocking superior plate fixation of displaced midshaft clavicle fractures. METHODS: A total of 102 consecutive patients with displaced midshaft clavicle fractures (2B1 and 2B2 in Robinson classification) participated in this randomized controlled trial; 12 patients were excluded. Surgeries were performed using a 3.5-mm Locking Compression Plate (LCP) between 2007 and 2015. Patients were treated either with a locking plate (group L, n = 45) or a nonlocking plate (group N, n = 45). In both groups, the plates were fixed to the proximal and distal clavicle with two and/or three screws, respectively. The main outcome measures were complication rates, time to bone union, and Constant score. RESULTS: Forty-two patients in group L (mean age, 45.9 years) and 41 in group N (mean age, 43.6 years) were followed. The overall complication rates in groups L and N were 7.2% (three peri-implant fractures) and 7.3% (non-union, deformed plate, and peri-implant fracture), respectively (p = .98). The average time to union significantly differed between groups (L vs. N: 13.0 ± 4.1 vs. 17.5 ± 6.3 weeks; p < .01). However, the Constant score at the final follow-up was not significantly different between groups (L vs. N: 87.0 ± 12.3 vs. 89.8 ± 9.1). CONCLUSIONS: Similar complication rates and clinical results were found for locking and nonlocking superior plate fixation for displaced midshaft clavicle fractures. However, the time to bone union was shorter with the locking plate. This study suggests that both plating systems are effective for treating displaced midshaft clavicle fractures. LEVEL OF EVIDENCE: Therapeutic, level I.

Clinical Features and Outcomes of Bilateral Atypical Femoral Fractures.

Bilateral atypical femoral fractures (AFFs) are relatively rare. In this report, we retrospectively researched clinical features and outcomes of bilateral AFFs treated at our institution. We previously treated 4 patients (8 limbs) with intramedullary nailing for complete AFFs (6 limbs) and incomplete AFFs (2 limbs). The mean age at the first operation was 53.3 years, and all patients were female. Of the 4 patients, two had breast cancer, and another two had systemic lupus erythematosus. Three of them received bisphosphonates, and 2 received denosumab, proton pump inhibitor, or glucocorticoid therapy. Only 2 of 6 cases of incomplete AFFs had prodromal pain before progressing to complete fracture. The mean interval from the first surgery to contralateral fracture or prophylactic surgery was 16 months. Radiographically, complete bone union was achieved in 6 limbs. However, a small gap at the lateral cortex of fracture site remained in 2 limbs. Finally, all of the patients were pain-free and able to walk without a cane. It is absolutely necessary to confirm contralateral femoral conditions; however, prediction of progression to complete fracture based solely on prodromal pain was difficult. Therefore, we should advise patients about the danger of progression to complete AFFs even if they are asymptomatic, and a prophylactic surgery should be performed after obtaining informed consent.

Retrospective analysis of risk factors for deep infection in lower limb Gustilo-Anderson type III fractures.

BACKGROUND: Open fractures are among the most severe injuries observed in orthopedic patients. Treating open fractures is difficult because such patients with infections may require multiple operations and amputations. Furthermore, only a few studies have focused on antibiotic prophylaxis in open fractures and evaluated how to cover lost soft tissue to increase the success rate of reconstruction. We evaluated the risk factors for deep infection in lower limb Gustilo-Anderson (G-A) type III fractures. MATERIALS AND METHODS: This retrospective study investigated patients who underwent surgical procedures for lower limb G-A type III fractures between January 2007 and January 2017 at our institution. We enrolled 110 patients with 114 lower limb G-A type III fractures (77 G-A type IIIA fractures and 37 G-A type IIIB fractures) who were followed up for at least 2 years. We compared patients presenting infections with those without infections by assessing the following factors: severe contamination, diabetes, smoking, Injury Severity Scale, segmental fracture, location of fracture, G-A classification, damage control surgery, methods of surgery, timing of fixation, combination of antibiotics used, duration of antibiotic prophylaxis, timing of wound closure, and soft-tissue reconstruction failure. RESULTS: Eighteen fractures presented deep infections. Compared with patients without infections, patients developing infections differed significantly in terms of severe contamination (P < 0.01), G-A classification (P < 0.01), duration of antibiotic prophylaxis (P < 0.01), timing of wound closure (P < 0.01), and incidence of soft-tissue reconstruction failure (P < 0.01). Skin grafting was associated with significantly higher failure rates than muscle and free flap reconstructions (P = 0.04). Treatment with antibiotics was significantly longer in patients with drug-resistant bacterial infections than in those without infections (P < 0.01). CONCLUSION: Early flaps rather than skin grafting should be used to cover G-A type IIIB fractures, because skin grafting resulted in the highest failure rate among soft-tissue reconstructions in open fractures. Longer duration of antibiotic use had a significant impact not only on deep infection rates but also on the presence of drug-resistant bacteria. These findings suggest that prolonged use of antibiotics should be avoided in cases of open fractures. LEVEL OF EVIDENCE: Level IV retrospective observational study.

Clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments: a retrospective analysis of risk factors for delayed union.

BACKGROUND: This study retrospectively evaluated the clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments and analyzed the risk factors for delayed union. METHODS: Retrospective analyses involving 51 patients who underwent intramedullary nailing of femoral shaft fractures with third fragments (AO classification type B, 35 cases; type C, 16 cases) were conducted. Delayed union was defined as either more than 10 months required for callus formation in more than three of the four cortical bone surfaces observed in the frontal and lateral radiographic views or the requirement for additional surgery such as nail conversion or bone transplantation. Seventeen patients developed delayed union (D group). Thirty-four patients achieved bony union within 9 months (U group). The following background variables were compared between groups: age at the time of the injury; AO classification; ratio of open fracture; waiting period before surgery; rate of the infraisthmal fracture; diameter of the intramedullary nail; ratio of the intramedullary nail to the femur; length and displacement of the third fragment; and use of open reduction, poller screws, or dynamization. RESULTS: Significant differences were found between the D and U groups for age (32.2±14.1 vs. 25.3±9.6 years), open fracture ratio (35.3% vs. 11.8%), and displacement of the third fragment (13.7±6.4 vs. 9±6.3 mm). Multiple logistic regression analysis only identified displacement of the third fragment as a risk factor for delayed union (p=0.03; OR 1.13; 95% CI 1.01 to 1.26). DISCUSSION: Delayed union was observed in 17 cases (33.3%) after intramedullary nailing of femoral shaft fractures with third fragments. Displacement of the third fragment influenced delayed union. LEVEL OF EVIDENCE: Level III.

Comparison of three plain radiography methods for evaluating proximal humerus bone strength in women.

BACKGROUND: We assessed the correlation between three methods for measuring cortical thickness of the humerus on a plain radiograph and bone mineral density measured by dual-energy X-ray absorptiometry in order to establish a simple bone strength evaluation method in patients at risk of proximal humerus fragility fracture. METHODS: In this retrospective study, 1732 patients underwent screening of the distal third radius, proximal femur, and lumbar spine by dual-energy X-ray absorptiometry. We identified 224 patients who also underwent anteroposterior shoulder radiography. Patients with fractures or who had undergone surgery in the region of interest were excluded. The study consisted of 80 women with a mean age of 76 years (range: 39-94 years). Cortical thickness, cortical index, and deltoid tuberosity index were determined to assess the proximal humerus. Correlation between bone mineral density measured by dual-energy X-ray absorptiometry and cortical thickness determined using these three methods was examined. We defined the osteoporosis group as patients satisfying both the World Health Organization criteria and the diagnostic criteria for primary osteoporosis (2012 revision) and compared values between the osteoporotic and non-osteoporotic groups. RESULTS: BMD correlated positively with cortical thickness, cortical index, and deltoid tuberosity index values, but the strength of correlation differed. These values were significantly lower in the osteoporotic group than in the non-osteoporotic group. Receiver operating characteristic curve analysis revealed that only the distal third radius had an area under the curve of 0.7 or more for all methods. CONCLUSIONS: All three methods yielded values that correlated with the dual-energy X-ray absorptiometry bone mineral density measured at the distal third radius, the proximal femur, and the lumbar spine. The correlation coefficient in the radius was high and differed significantly from those of weight-bearing bones (proximal femur, lumbar spine).

Regeneration of Transected Recurrent Laryngeal Nerve Using Hybrid-Transplantation of Skeletal Muscle-Derived Stem Cells and Bioabsorbable Scaffold.

Hybrid transplantation of skeletal muscle-derived multipotent stem cells (Sk-MSCs) and bioabsorbable polyglyconate (PGA) felt was studied as a novel regeneration therapy for the transected recurrent laryngeal nerve (RLN). Sk-MSCs were isolated from green fluorescence protein transgenic mice and then expanded and transplanted with PGA felt for the hybrid transplantation (HY group) into the RLN transected mouse model. Transplantation of culture medium (M group) and PGA + medium (PGA group) were examined as controls. After eight weeks, trans-oral video laryngoscopy demonstrated 80% recovery of spontaneous vocal-fold movement during breathing in the HY group, whereas the M and PGA groups showed wholly no recoveries. The Sk-MSCs showed active engraftment confined to the damaged RLN portion, representing favorable prevention of cell diffusion on PGA, with an enhanced expression of nerve growth factor mRNAs. Axonal re-connection in the HY group was confirmed by histological serial sections. Immunohistochemical analysis revealed the differentiation of Sk-MSCs into Schwann cells and perineurial/endoneurial cells and axonal growth supportive of perineurium/endoneurium. The number of axons recovered was over 86%. These results showed that the stem cell and cytokine delivery system using hybrid transplantation of Sk-MSCs/PGA-felt is a potentially practical and useful approach for the recovery of transected RLN.

Voluntary Exercise Positively Affects the Recovery of Long-Nerve Gap Injury Following Tube-Bridging with Human Skeletal Muscle-Derived Stem Cell Transplantation.

The therapeutic effects of voluntary exercise on the recovery of long-gap nerve injury following the bridging of an acellular conduit filled with human skeletal muscle-derived stem cells (Sk-SCs) have been described. Human Sk-SCs were sorted as CD34⁺/45- (Sk-34) cells, then cultured/expanded under optimal conditions for 2 weeks. Surgery to generate a long-gap sciatic nerve injury was performed in athymic nude mice, after which the mice were divided into exercise (E) and non-exercise (NE) groups. The mice were housed in standard individual cages, and voluntary exercise wheels were introduced to the cages of the E group one week after surgery. After 8 weeks, the human Sk-34 cells were actively engrafted, and showed differentiation into Schwann cells and perineurial cells, in both groups. The recovery in the number of axons and myelin in the conduit and downstream tibial nerve branches, and the lower hindlimb muscle mass and their tension output, was consistently higher by 15-25% in the E group. Moreover, a significantly higher innervation ratio of muscle spindles, reduced pathological muscle fiber area, and acceleration of blood vessel formation in the conduit were each observed in the E group. These results showed that the combined therapy of tube-bridging, Sk-34 cell transplantation, and voluntary exercise is a potentially practical approach for recovery following long-gap nerve injury.

Open Bankart repair plus inferior capsular shift versus arthroscopic Bankart repair without augmentations for traumatic anterior shoulder instability: A prospective study.

PURPOSE: Arthroscopic treatment of shoulder instability has some advantages (including short surgical time, less morbidity, less postoperative pain, reduced hospitalization time, and decreased risk of complications) compared with open procedures. We performed a prospective study comparing open repair with arthroscopic repair for recurrent anterior shoulder instability. The aim was to clarify the relative effectiveness of open Bankart repair plus inferior capsular shift (OBRICS) and arthroscopic Bankart (AB) repair without augmentations with approximately 5 years of follow-up. METHODS: We investigated 32 shoulders of 30 patients (24 men and 6 women) undergoing OBRICS (15 shoulders of 17 patients; two patients were bilateral) and AB (15 shoulders of 15 patients). The average follow-up was 5 years and 2.5 months (range: 60-66 months). The clinical evaluation included recurrent instability rate, range of motion, and postoperative rehabilitation. All patients were assessed using the scoring systems of Rowe and the University of California at Los Angeles (UCLA) preoperatively and during the final evaluation. RESULTS: Recurrent instability rates were significantly different between the OBRICS (0%) and AB (26.6%) groups ( p = 0.022). There were fewer limitations of external rotation (ER), ER at 90° abduction, and horizontal extension for AB than for OBRICS postoperatively ( p < 0.05). The mean Rowe and UCLA scores for both methods were not significantly different at final follow-up. CONCLUSION: Our data suggest that OBRICS leads to a lower rate of recurrent instability. However, those with AB had fewer ER and horizontal extension limitations.

An Examination of the Factors Related to a Reduction in the Use of Low-Intensity Pulsed Ultrasound (LIPUS).

OBJECTIVE: We examined the factors related to a reduction in the use of low-intensity pulsed ultrasound (LIPUS) for patients at both our hospital and other affiliated institutions. MATERIALS AND METHODS: Of 350 patients who used LIPUS at our and other affiliated institutions from May 2010 to April 2015, 279 (168 males, 111 females) were evaluated, after excluding mortalities and those with unexplained bone adhesion. Those patients with LIPUS compliance [calculated as: (number of days LIPUS was used/number of days LIPUS was available) × 100] below 80% were defined as the non-compliant group (170 patients), and those patients with a compliance rate of 80% or above were defined as the compliant group (109 patients). Factors related to a reduction in compliance were examined and included duration of use, age, sex, fracture side (right or left), and fracture site. RESULTS: The duration of use was longer in the non-compliant group compared with that in the compliant group (mean ± SD: 160 ± 118 days vs. 126 ± 81 days; P = 0.01), and the mean age was younger in the non-compliant group (42 ± 20 years vs. 50 ± 21 years; P = 0.002). Additionally, there was a higher ratio of females/males in the compliant group (60/49 vs. 120/50; P = 0.008). However, the side of the fracture was not significantly different between the groups (P = 0.449). Fractures of the forearm were more frequent in the non-compliant group than that in the compliant group (25/170 vs. 7/109; P = 0.003). DISCUSSION: The results suggest that the factors predictive of a reduction in the use of LIPUS are a long period of use, younger age, male gender, and use on fractures of the forearm.

Delayed methicillin-resistant Staphylococcus aureus-induced osteomyelitis of the tibia after pin tract infection: two case reports.

BACKGROUND: Pin tract infection is a common complication of external fixation. It usually heals after treatment with debridement, antibiotics, and/or pin removal, only rarely developing into delayed osteomyelitis. We treated two patients with delayed methicillin-resistant Staphylococcus aureus-induced osteomyelitis of the tibia following pin tract infection. CASE PRESENTATION: One patient, a diabetic 60-year-old Japanese man, underwent definitive external fixation using an Ilizarov fixator for postoperative osteomyelitis of an open fracture of his left ankle. One year after removing the external fixator, he developed methicillin-resistant Staphylococcus aureus-induced osteomyelitis of the tibial pin site. He underwent surgical debridement four times. No recurrence was seen 2 years 8 months after the last debridement. Another patient, a healthy 38-year-old Japanese man, underwent bilateral temporary external fixation for a right ankle open fracture and a comminuted fracture of the left tibial plateau. Three months after removal of the external fixator, he was diagnosed with methicillin-resistant Staphylococcus aureus-induced osteomyelitis of the bilateral tibial pin sites. He underwent surgical debridement three times, but the infection of his right tibia persisted. Finally, a gastrocnemius muscle flap was placed. No recurrence was seen 2 years after this last surgery. CONCLUSIONS: Pin tract infection should not be considered a minor complication because osteomyelitis may develop, requiring treatment that is more aggressive than curettage of the pin tract. A gastrocnemius flap is a useful treatment option for refractory osteomyelitis because flap harvest causes less functional disturbance and is a relatively easy surgical technique.