An operative case of gastric cancer with ectopic bile duct drainage in the lesser curvature of the stomach.

BACKGROUND: Among the various anomalies of the biliary system, a double common bile duct with ectopic drainage in the stomach is rare. Furthermore, ectopic bile ducts are extremely rare in gastric cancers. CASE PRESENTATION: A 67-year-old man was admitted to our hospital with gastric cancer and ectopic left extrahepatic bile duct drainage in the stomach. Pre-operative testing revealed no communication between the intrahepatic bile ducts. Distal gastrectomy and bile duct jejunostomy were performed. The post-operative course was uneventful, and the patient did not exhibit recurrence for 39 mo. CONCLUSIONS: Although it is uncertain whether sustained bile exposure from an ectopic bile duct is related to gastric cancer, short-term follow-up might be necessary because of the possibility of gastric cancer.

The Combined Suture Bridge With Mason-Allen Technique Is Superior to the Conventional Suture Bridge Technique for Arthroscopic Rotator Cuff Repair.

PURPOSE: To compare clinical results and retear rates between the combined suture bridge with Mason-Allen (SBMA) technique and the conventional suture bridge (SB) technique in patients with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff repair. METHODS: One hundred two patients who underwent arthroscopic rotator cuff repair using the SB technique (n = 50) or SBMA technique (n = 52) for a full-thickness rotator cuff tear and had at least 2 years of follow-up were retrospectively analyzed. Magnetic resonance imaging was performed before surgery and 2 years after to determine preoperative tear size, Goutallier stage, and presence of retear after surgery. Patients were clinically evaluated using the Japanese Orthopaedic Association (JOA) score. RESULTS: The groups did not significantly differ in terms of follow-up period, age, sex, tear size, Goutallier stage, or number of suture anchors. The retear rate was significantly lower in the SBMA group (7.7% vs 28.0%; P < .01). The JOA score was significantly higher at last follow-up than before surgery in both groups (P <.01). The JOA score at last follow-up was significantly higher in the SBMA group (P = .02). CONCLUSIONS: Arthroscopic rotator cuff repair using the SBMA technique may provide better clinical and anatomical outcomes than the conventional SB technique. LEVEL OF EVIDENCE: Level III, retrospective cohort design; treatment study).

Shear wave elastography correlates to degeneration and stiffness of the long head of the biceps tendon in patients undergoing tenodesis with arthroscopic shoulder surgery.

BACKGROUND: Tendinopathy of the long head of the biceps (LHB) tendon causes degeneration and changes its stiffness. However, a reliable means of diagnosis has not been established. Shear wave elastography (SWE) provides quantitative tissue elasticity measurements. In this study, the relationship of preoperative SWE values with biomechanically measured stiffness and degeneration of the LHB tendon tissue was investigated. METHODS: LHB tendons were obtained from 18 patients who underwent arthroscopic tenodesis. SWE values were measured preoperatively at 2 sites, proximal to and within the bicipital groove of the LHB tendon. The LHB tendons were detached immediately proximal to the fixed sites and at their superior labrum insertion. Tissue degeneration was histologically quantified using the modified Bonar score. Tendon stiffness was determined using a tensile testing machine. RESULTS: The SWE values of the LHB tendon were 502.1 ± 113.6 kPa proximal to the groove and 439.4 ± 123.3 kPa within the groove. The stiffness was 39.3 ± 19.2 N/mm. The SWE values displayed a moderate positive correlation with the stiffness proximal to the groove (r = 0.80) and within it (r = 0.72). The SWE value of the LHB tendon within the groove showed a moderate negative correlation with the modified Bonar score (r = -0.74). CONCLUSIONS: These findings suggest that preoperative SWE values of the LHB tendon correlate moderately positively with stiffness and moderately negatively with tissue degeneration. Therefore, SWE may predict LHB tendon tissue degeneration and changes in stiffness caused by tendinopathy.

Potential of an artificial nerve graft containing Schwann cells for the treatment of a 20-mm nerve defect in rats.

OBJECTIVE: In a previous study, the authors showed that the migration of Schwann cells (SCs) through end-to-side (ETS) neurorrhaphy promotes axonal regrowth within an acellular nerve graft. In the present study, the authors investigated whether a similar strategy using an artificial nerve (AN) would allow reconstruction of a long nerve gap (20 mm) in rats. METHODS: Forty-eight 8- to 12-week-old Sprague Dawley rats were divided into control (AN) and experimental (SC migration-induced AN [SCiAN]) groups. Prior to the experiment, the ANs used in the SCiAN group were populated in vivo with SCs over a 4-week period by ETS neurorrhaphy onto the sciatic nerve. In both groups, a 20-mm sciatic nerve defect was reconstructed in an end-to-end fashion using 20-mm ANs. Sections from the nerve graft and distal sciatic nerve in both groups underwent assessments at 4 weeks for SC migration by immunohistochemical analysis and quantitative reverse transcription-polymerase chain reaction. At 16 weeks, axonal elongation was assessed by immunohistochemical analysis, histomorphometry, and electron microscopy. The number of myelinated fibers was counted, the g-ratio was calculated, and myelin sheath thickness and axon diameter were measured. Furthermore, functional recovery was evaluated at 16 weeks using the Von Frey filament test for sensory recovery and by calculating the muscle fiber area for motor recovery. RESULTS: The area occupied by SCs at 4 weeks and by axons at 16 weeks was significantly larger in the SCiAN group than in the AN group. Histomorphometric evaluation of the distal sciatic nerve revealed a significantly greater number of axons. At 16 weeks, plantar perception in the SCiAN group was significantly better, demonstrating improvement in sensory function. However, no tibialis anterior muscle motor improvement was observed in either group. CONCLUSIONS: The induction of SC migration into an AN by ETS neurorrhaphy is a useful technique for repairing 20-mm nerve defects in rats, with better nerve regeneration and sensory recovery. No motor recovery was observed in either group; however, motor recovery might require a longer period of time than the lifespan of the AN used in this study. Future studies should investigate whether structural and material reinforcement of the AN, to lower its decomposition rate, can improve functional recovery.

The Effect of Vitamin C and N-Acetylcysteine on Tendon-to-Bone Healing in a Rodent Model of Rotator Cuff Repair.

BACKGROUND: Oxidative stress inhibits tendon-to-bone healing after rotator cuff repair. Regulation of oxidative stress has the potential to accelerate this healing, but its mechanism remains unclear. PURPOSE: To investigate the effects of reducing oxidative stress by applying antioxidants, such as N-acetylcysteine (NAC) and vitamin C (VC), on rotator cuff repair in a rat rotator cuff repair model. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 48 Sprague Dawley rats underwent bilateral surgery to repair the infraspinatus tendon to its insertion site 1 week after detachment. Rats were assigned to either the NAC group, the VC group, or a control group. Histological evaluation was performed via hematoxylin-eosin or toluidine blue staining, and oxidative stress was assessed via dihydroethidium intensity and protein carbonyl concentration at 3 and 6 weeks. Superoxide dismutase 1 (SOD1), SOD2, SOD3, peroxiredoxin 5, collagen type I (COL1), COL3, matrix metalloproteinase 1 (MMP-1), MMP-3, and MMP-13 expression and SOD activity were determined at 3 and 6 weeks. Biomechanical tests were performed at 6 and 12 weeks. RESULTS: Histological evaluation showed that the number of chondrocytes in the NAC group at 6 weeks and in the VC group at 3 and 6 weeks, the area of fibrocartilage at 6 weeks in the VC group, and collagen fibers at 6 weeks in the NAC and VC groups were significantly increased compared with those in the control group. Dihydroethidium intensity at 3 and 6 weeks and protein carbonyls at 6 weeks in the NAC and VC groups were significantly decreased. SOD1 expression and SOD activity at 3 weeks in the VC group and peroxiredoxin 5 expression at 6 weeks in the NAC group were significantly upregulated compared with that in the control group. COL3 expression was significantly upregulated at 6 weeks in the VC group, and MMP-13 expression was significantly decreased at 6 weeks in the NAC and VC groups. The biomechanical strength showed no significant difference. CONCLUSION: Antioxidant treatment, via NAC or VC administration, reduced oxidative stress in the rotator cuff repair site and accelerated healing. CLINICAL RELEVANCE: These findings provide essential indications to develop clinical strategies for improved healing after rotator cuff surgical repair in patients.

Chronologic Changes in the Elastic Modulus of a Healing Achilles Tendon Rupture Measured Using Shear Wave Elastography.

BACKGROUND: Shear wave elastography (SWE) has been used to examine the elasticity of a ruptured Achilles tendon; however, the healing process of a ruptured tendon has not been studied yet. This study aimed to detail the change in mechanical properties of a healing Achilles tendon rupture managed conservatively or surgically using SWE. METHODS: Using a prospective cohort study design, we evaluated the patients treated conservatively (conservative group) and surgically (surgical group) with the "gift-box" technique for an isolated index acute Achilles tendon rupture during their healing process. SWE measurements were taken of both the injured and uninjured sides every 4 weeks up to 24, 36, and 48 weeks after treatment. Additionally, tendon thickness and power Doppler (PD) grade were measured at the same time points as SWE measurements. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot rating system score and Achilles tendon Total Rupture Score (ATRS) were compared at 24 and 48 weeks. RESULTS: The ruptured Achilles tendon obtained an SWE value comparable with the unruptured side at 12 weeks in the conservative group and at 4 weeks with surgical group. The surgical group had significantly higher SWE values up to 24 weeks compared with the conservative group. Additionally, this group had a significantly larger increase in tendon thickness in nearly all periods. Both treatment groups were comparable regarding the PD grade, AOFAS score, and ATRS. CONCLUSION: SWE is a convenient noninvasive method to determine the progress of the healing process after tendon injury. Our analysis using SWE has revealed the detailed chronologic changes in SWE values and related mechanical properties of a healing Achilles tendon rupture, which can be used for devising appropriate rehabilitation protocols. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Effect of limited range of motion of the hip joint and leg-length discrepancy on gait trajectory: an experiment to reproduce the asymmetric gait that occurs in patients with osteoarthritis of the hip joint.

PURPOSE: Although some symptoms that often occur with hip joint osteoarthritis (OA) may be involved in the appearance of gait disturbance, the main cause has not been identified. We hypothesised that the abnormalities in gait trajectory of patients with hip joint OA are mainly caused by limited range of motion of the hip joint or the presence of leg-length discrepancy, or both. To investigate this hypothesis, we examined whether the abnormal gait trajectory in patients with hip joint OA can be reproduced in healthy individuals by asking them to wear a hip orthosis and shoe orthotic (insole). METHODS: We recruited 2 groups of participants: patients with hip joint OA (OA group, 38 patients) and healthy individuals who imitated patients with OA of the hip joint by wearing a hip orthosis or shoe orthotic (10-mm or 20-mm insole) or both (simulated OA group, 6 individuals). For gait analysis, we used a portable, wearable gait analyser with inertial sensors to evaluate 3-dimensional (3D) changes in gait trajectory. RESULTS: In the OA group, the patterns of gait trajectories that were drawn on the 3 planes (coronal, sagittal, and horizontal planes) could be roughly divided into 3 types. The gait trajectories that were drawn when wearing a hip orthosis in the simulated OA group were very similar to 1 of the 3 patterns of gait trajectory that occurs in the OA group. CONCLUSIONS: We were able to reproduce the abnormal gait trajectory that is observed in ⅓ of patients with hip OA in healthy individuals, so we propose that an extreme reduction in hip joint ROM is 1 of the causes of abnormal gait pattern in patients with OA of the hip joint. A difference in leg length of 20 mm alone has little effect on gait trajectory.

Posterior shoulder stiffness was associated with shoulder pain during throwing in college baseball players: assessment of shear wave elastography.

PURPOSE: To investigate shoulder stiffness on the throwing and non-throwing sides in college baseball players using ultrasound shear wave elastography (SWE), and investigate the relationship between stiffness and shoulder pain during throwing. METHODS: Forty-nine college baseball players (98 shoulders) were recruited. Shoulder range of motion was evaluated. SWE was used to measure stiffness of the bilateral supraspinatus tendons, infraspinatus tendons, subscapularis tendons, supraspinatus muscles, infraspinatus muscles (ISPM), and posterior capsules. Participants were divided into pain and no pain groups based on the presence or absence of shoulder pain during throwing within 1 month before measurements on the throwing side. Items were compared between the throwing and non-throwing sides, and between the pain and no pain groups. Factors affecting shoulder pain during throwing were also investigated via multiple logistic regression analysis. RESULTS: Compared with the non-throwing side, the throwing side had significantly greater external rotation at 90° abduction, significantly lesser internal rotation at 0° abduction and internal rotation at 90° abduction (AbdIR), significantly higher SWE values of the infraspinatus tendon, ISPM, and posterior capsule, and significantly lower SWE values of the subscapularis tendon. Compared with the no pain group, the pain group had a significantly higher SWE value of the ISPM, and significantly lesser AbdIR. Increased ISPM SWE values and decreased AbdIR were significantly correlated with shoulder pain during throwing. CONCLUSIONS: The posterior tissue was stiffer than the anterior tissue on the throwing side. Decreased AbdIR and increased ISPM stiffness may be correlated with shoulder pain during throwing.

Comparison of anemia, renal function, and nutritional status in older women with femoral neck fracture and older women with osteoarthritis of the hip joint.

BACKGROUND: Several studies in older patients with femoral neck fracture found that preoperative anemia and malnutrition were associated with higher mortality and poorer physical function. Therefore, we compared nutritional status, Hb level, and renal function in women with femoral neck fracture and women of the same age with osteoarthritis of the hip joint. METHODS: We enrolled 257 women aged 70 years and older who suffered femoral neck fracture (F group) or who were scheduled to undergo total hip arthroplasty for osteoarthritis of the hip joint (OA group). The F and OA groups were further divided into 2 groups on the basis of age, ie, 74 years old and younger (F70 and OA70) and 75 years old and older (F75 and OA75). To assess whether patients had undernutrition, mortality risk, anemia, and renal dysfunction, we assessed Geriatric Nutritional Risk Index (GNRI), Hb, and eGFR. RESULTS: We found a significant difference in the mean Hb levels and GNRI scores between the F75 and OA75 and F70 and OA70. Moreover, we found a moderate correlation between Hb level and GNRI score in the F75 and OA75. With respect to the GNRI category, the percentage of patients at moderate or major risk was 42.1% in the F70 group and 57.6% in the F75 group but only 1.9% in the OA70 group and 4.3% in the OA75 group. CONCLUSION: We found that women with femoral neck fracture had significantly lower Hb levels and lower GNRI scores than women with hip OA in the same age and that anemia and undernutrition were closely linked in women aged 75 and above. Moreover, we found that more than 40% of patients with a femoral neck fracture had a moderate to major risk on the basis of their GNRI scores.

Effects of social isolation associated with the COVID-19 pandemic on hip muscle strength, hip joint pain, and walking ability in patients with osteoarthritis of the hip joint.

To reduce the spread of the Sars-CoV-2 virus, governments in many countries adopted a social isolation strategy. However, social isolation may adversely affect people's health, e.g., by decreasing the muscle function of lower limbs. We recruited 118 patients who had undergone total hip arthroplasty (THA) and 87 patients with moderate to severe hip joint osteoarthritis (OA) and measured hip muscle strength, hip joint pain, and walking ability from before to one year after the start of the COVID-19 pandemic. During the pandemic, hip flexion (straight leg raise, SLR) strength decreased in 13.1% of patients in the post-THA group and 25.6% in the severe-OA group; in the severe-OA group, the decrease in SLR strength was mainly in patients aged 65 years and older. In addition, pain increased to mild or moderate and walkable distance decreased in more patients in the severe-OA group.

Predictive factors for early recurrence after pancreaticoduodenectomy in patients with resectable pancreatic head cancer: A multicenter retrospective study.

BACKGROUND: Patients diagnosed with resectable pancreatic ductal adenocarcinoma often experience early recurrence even after upfront R0 resection. This study aimed to define early recurrence and identify preoperative risk factors for early recurrence after upfront pancreaticoduodenectomy in patients with resectable pancreatic ductal adenocarcinoma of the pancreatic head. METHODS: This multicenter, retrospective study involved 500 patients who underwent pancreaticoduodenectomy resectable pancreatic ductal adenocarcinoma of the pancreatic head at 10 institutions between 2007 and 2016. Preoperative, intraoperative, and postoperative clinicopathological results were compared between early and non-early recurrence groups. Predictors of early recurrence were determined using statistical analyses. RESULTS: Log-rank tests revealed a significant difference (P < .001) between recurrence within 3 to 6 months and 6 to 9 months. Early recurrence was subsequently defined as recurrence within 6 months. Patients were categorized into early recurrence (n = 104) and non-early recurrence groups (n = 389). The median overall survival of the early and non-early recurrence groups was 8.6 months and 42.6 months (P < .001), respectively. Preoperatively, high carbohydrate antigen 19-9 levels ≥120 U/mL, retroperitoneal invasion, and diabetes mellitus were identified as independent predictive risk factors for early recurrence according to multivariate analysis. Comparing survival rates among patients with 3, 2, 1, or none of these factors, the median overall survival was 17.6 (n = 90), 21.2 (n = 184), 47 (n = 141), and 61.5 (n = 73) months, respectively. CONCLUSION: The optimal period that defines the early recurrence for resectable pancreatic ductal adenocarcinoma of the pancreatic head is 6 months. Tumor size ≥20 mm, preoperative carbohydrate antigen 19-9 levels ≥120 U/mL, retroperitoneal invasion of the tumor, and the presence of diabetes mellitus are independently associated with early recurrence.

Arthroscopic Bankart repair with additional footprint fixation using the double-row technique at the 4 o'clock position anatomically restored the capsulolabral complex and showed good clinical results.

PURPOSE: To investigate the clinical outcome and magnetic resonance imaging (MRI) findings after arthroscopic Bankart repair with additional double anchor footprint fixation (DAFF) at the 4 o'clock position, where the native footprint is widest anatomically, for recurrent anterior shoulder instability. METHODS: Forty-two patients (mean age 27.0 years) with recurrent anterior shoulder instability and without severe glenoid bone defects underwent arthroscopic Bankart repair with additional DAFF at the 4 o'clock position. Using three standard portals, single-row repair was performed at the 2, 3, and 5 o'clock positions, and DAFF with the suture bridging technique was conducted at the 4 o'clock position. MRI was performed preoperatively and at 6 months postoperatively. Patients with follow-up periods of ≥1 year were included in the present study and clinically evaluated at the final follow-up. The morphology at the 2 and 4 o'clock positions on radial MRI slices was compared between the preoperative and 6-month postoperative scans, and the footprint of the repaired capsulolabral complex at 6 months postoperatively was compared between the 2 and 4 o'clock positions. RESULTS: The average follow-up period was 19.5 ± 6.2 months. The rates of dislocation recurrence and positive apprehension test results were 2.4 and 4.8%, respectively. External rotation was restricted by 3.5°. The University of California at Los Angeles and Rowe scores at the final follow-up were 34.5 ± 1.0 points and 97.2 ± 5.7 points, respectively, representing significant improvements over the preoperative scores (p < 0.01). Although the capsulolabral complex at 6 months postoperatively was firmly repaired at both the 2 and 4 o'clock positions compared to its preoperative state, the footprint of the restored capsulolabral complex was wider at the 4 o'clock position than at the 2 o'clock position (p < 0.01). CONCLUSIONS: Additional DAFF at the 4 o'clock position improved the glenohumeral stability and function of the shoulder joint. This study suggests that this technique is a reliable and useful treatment for shoulder instability. LEVEL OF EVIDENCE: IV.

Simple surgical technique for minimizing the risk of extensor pollicis longus rupture following volar plate fixation of distal radial fracture: A case report.

INTRODUCTION AND IMPORTANCE: Extensor pollicis longus (EPL) tendon injury is a major complication in distal radial fracture repair. The risk factors for EPL tendon injury are prominent dorsal screws, direct intraoperative damage through drilling, and/or dorsal roof fragments. Herein, we introduce a simple technique to minimize the risk of EPL tendon rupture after volar plate fixation of distal radial fracture. CASE PRESENTATION: The patient was a 67-year-old woman with an intra-articular unstable distal radial fracture treated by volar locking plate fixation. Intraoperatively, we opened the third compartment after screw fixation. Because the screw had penetrated the floor of the third compartment, we moved the EPL tendon out of its groove and closed the third compartment by suturing the retinaculum. We confirmed that the EPL tendon was intact 7 years postoperatively, even though the screw was prominent in the third compartment. CLINICAL DISCUSSION: After volar plate fixation of the distal radial fracture, we partially open the third compartment through an approximately 2-cm-long incision on the ulnar side of Lister's tubercle. If the screw is prominent in the third compartment, we completely open the third compartment, take the EPL tendon out of its groove, and close the compartment by suturing the retinaculum. Our method was proved useful because the EPL tendon has remained intact for 7 years with the screw protruding into the third compartment. CONCLUSION: Our surgical technique is useful to prevent secondary EPL tendon rupture after distal radial plate fixation.

Relationship of superoxide dismutase to rotator cuff injury/tear in a rat model.

Rotator cuff degeneration is one of the several factors that lead to rotator cuff tears. Oxidative stress and superoxide dismutase have been reported to be related to rotator cuff degeneration; however, the precise mechanism still remains unclear. In this study, we investigated the relationship of oxidative stress and superoxide dismutase to the degeneration of the rotator cuff using rat models. Eighty-four rats were used to create a collagenase-induced rotator cuff injury model (injury model) and a rotator cuff tear model (tear model). The controls were administered saline and had only a deltoid incision, respectively. We evaluated degeneration morphology of the rotator cuff using a degeneration score; dihydroethidium fluorescence intensity, which detects oxidative stress; gene expression; and superoxide dismutase activity. The rotator cuffs in the injury and tear models significantly increased degeneration scores and dihydroethidium fluorescence intensity. On the other hand, gene expression of superoxide dismutase isoform, superoxide dismutase 1, and superoxide dismutase activity were significantly decreased in the injury model but showed no significant difference in the tear model. These findings suggested that superoxide dismutase might not be associated with rotator cuff degeneration after tear but may be involved in degenerative rotator cuff without tear. However, we found that rotator cuff degeneration involves oxidative stress both with and without tear. Based on these findings, it is presumed that different treatments may be appropriate, depending on the state of rotator cuff degeneration, because the mechanisms of the degeneration may be different.

Anatomical position of the corona mortis relative to the anteroposterior and inlet views.

PURPOSE: Although pubic ramus fractures are common in the elderly, resultant hemodynamic instability is a rare complication. The corona mortis, a vascular anastomosis between the obturator vessels and the external iliac vessels in the retropubic space, is occasionally damaged by fractures of the pubic ramus, causing significant hemorrhage. The purpose of this study was to evaluate the incidence and anatomical position of the corona mortis on the anteroposterior and inlet views. METHODS: Sixty-one cadavers (122 hemipelvizes) were dissected and the incidence of the corona mortis was evaluated. Photographs were then taken simulating anteroposterior and inlet radiographs, and labeled as the anteroposterior and inlet views. The distance from the pubic symphysis to the corona mortis was measured on each of the two views. RESULTS: The corona mortis was present in 76.1% of hemipelvizes. The corona mortis traverses along the periosteum of the dorsal surface of the pubis. The incidence of arterial corona mortis was 28.3% and that of venous corona mortis was 76.1%. The distance from the superior margin of the symphysis pubis to the corona mortis measured 47.7 ± 9.9 (45.9-49.6) mm on the anteroposterior view, and 59.4 ± 9.2 (57.3-61.5) mm on the inlet view. CONCLUSIONS: In order to predict possible hemodynamic instability of the corona mortis following pubic ramus fractures, it is of clinical significance to precisely establish the anatomical position of the corona mortis on the anteroposterior and inlet views.

Changes in serum creatine kinase and C-reactive protein after posterior and direct anterior approaches in total hip arthroplasty.

PURPOSE: Some studies reported that measuring serum creatine kinase (CK) level is an objective method with which to determine the relative invasiveness of surgery. The purpose of this study was to evaluate the change in postoperative serum CK levels as a measure of whether the direct anterior approach (DAA) is less invasive than the posterior approach (PA) regarding postoperative rehabilitation. MATERIALS AND METHODS: We prospectively recruited 71 women who were undergoing total hip arthroplasty, 47 were treated by the PA and 24 by the DAA. Serum CK and C-reactive protein (CRP) levels were measured preoperatively and 3 hours and 1, 4, 7, 10, and 14 days after the operation. RESULTS: The serum CK levels were significantly higher in the DAA group than in the PA group on postoperative days 1, 4, 7, 10, and 14. On postoperative day 4 and 7, the percentage of patients whose serum CK levels were above the normal range was 46.8% and 8.5% in the PA group and 95.2% and 45.5% in the DAA group. CONCLUSIONS: CK levels were significantly higher in the 2 weeks after THA by a DAA than after the same procedure by a PA indicating that DAA causes prolonged muscle damage. Although the DAA is considered to be a muscle-sparing approach this may not be the case and DAA may not actually be a minimally-invasive approach.

New Linked-Wire-Type External Fixator (the Ichi-Fixator System) for Metacarpal Fractures: Case Series and Literature Review.

Background: External fixator is an effective treatment option in the comminuted or unstable metacarpal fractures. The new linked-wire type of external fixator (the Ichi-Fixator System) developed for hand and wrist fractures enables fine adjustment of the fixation under fluoroscopic inspection through small screws inside the fixator fitted externally. This technique is designed to reinforce the stability and rigidity of conventional percutaneous Kirchner wire fixation. The aim of this study is to assess the effectiveness of the fixator for comminuted or unstable metacarpal fractures through the evaluation of short-term results in ten cases. Methods: Patients were fixated with fixator pins and metal clamps using the Ichi-Fixator System. All patients were then examined for post-operative complications, functional recovery, visual analogue scale (VAS) score, and the Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH) score at the end of the final follow-up consultation. Results: Operative treatment using the Ichi-Fixator System facilitates anatomical reduction and allows immediate full mobilization, producing good outcomes. No infections were observed in all cases, including those at pin insertion sites. There were no implant failure and nonunion. Patients could perform all routine activities with normal grip strength and retained a full range of hand motion without pain. This treatment method with improved postoperative comfort would allow immediate return to work, which would clearly boost patient satisfaction. Conclusions: Ichi-Fixator System is considered to be useful for the treatment of metacarpal fractures, and this will provide a new surgical option for all hand fractures.

Hepatocellular adenoma initially diagnosed as hepatocellular carcinoma with resistance to proton beam radiotherapy - A case report.

INTRODUCTION AND IMPORTANCE: Hepatocellular adenoma (HCA) is a rare liver tumor. We report a case of a radio-resistant liver tumor that was removed surgically and found to be HCA. CASE PRESENTATION: A 37-year-old Japanese man was incidentally diagnosed with a liver tumor. He had no history of viral hepatitis nor metabolic disorders. MRI revealed a tumor enhancing in arterial phase, followed by washout in late phase, and hypointensity in hepatobiliary phase. A diagnosis of hepatocellular carcinoma (HCC) was made and surgery was advised. However, the patient chose proton beam radiotherapy. Although the tumor initially shrunk, it increased in size thereafter. Therefore, anterior sectionectomy was performed. Histology revealed proliferation of hepatocytes without cytologic atypia. On immunohistochemistry, CRP, SAA, GS, L-FABP, and nuclear expression of ß-catenin were positive. A final diagnosis of mixed inflammatory and ß-catenin activated HCA was made. CLINICAL DISCUSSION: HCA is associated with obesity. The present case was a slightly obese man without history of viral hepatitis. In such cases, HCA should be considered. In the present case, proton beam radiotherapy was performed for a diagnosis of HCC. However, the tumor was radio-resistant. CONCLUSION: HCA shows an almost equal male to female ratio in the Asian population. Molecular classification is vital in the management of HCA. HCC and HCA are often difficult to differentiate; tumor biopsy is necessary for patients with atypical imaging findings and in younger patients without underlying liver disease. Since the effectiveness of radiation therapy on HCA has not been reported, surgery should be preferred.

Association of Recurrent Tear After Arthroscopic Rotator Cuff Repair and Superoxide-Induced Oxidative Stress.

BACKGROUND: Recurrent tears after arthroscopic rotator cuff repair (ARCR) remain a significant clinical problem. Oxidative stress contributes to the degeneration of the rotator cuff, and a degenerative rotator cuff can lead to recurrent tear after ARCR. However, the correlation between oxidative stress and retear after ARCR is unclear. PURPOSE: To investigate the correlation between superoxide-induced oxidative stress and recurrent tear after ARCR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 68 patients who underwent ARCR using a suture-bridge technique participated in this study. Specimens were collected from the edge of the torn tendon during surgery. The modified Bonar score was used to evaluate degeneration of the rotator cuff on histological specimens, and fluorescence intensity on dihydroethidium (DHE) staining was used to detect oxidative stress. Superoxide dismutase (SOD) enzyme activity was also measured. The following were used for clinical evaluation: age, tear size on magnetic resonance imaging (MRI) before surgery, Goutallier classification on MRI before surgery, and Japanese Orthopaedic Association score before and 6 months after surgery. After the repaired rotator cuffs were evaluated on MRI 6 months after surgery, the patients were divided into groups: those with a healed rotator cuff (healed group; n = 46) and those with a recurrent tear (retear group; n = 22). The significant differences between the groups were determined with regard to clinical evaluation, modified Bonar score, DHE intensity, and SOD activity. In addition, multivariate logistic regression analysis was performed to investigate risk factors for recurrent tear. RESULTS: Age, tear size, Goutallier classification, modified Bonar score, DHE intensity, and SOD activity were significantly greater in the retear group than in the healed group, although the Japanese Orthopaedic Association score was not significantly different. Multiple logistic regression analysis demonstrated that age, tear size, and SOD activity were significantly correlated with recurrent tear. CONCLUSION: In addition to tear size and age, superoxide-induced oxidative stress may be an exacerbating factor for retear after ARCR.

Stiffness change of the supraspinatus muscle can be detected by magnetic resonance elastography.

Magnetic resonance elastography (MRE) and ultrasound shear wave elastography (SWE) are imaging techniques to measure stiffness of the soft tissue using magnetic resonance imaging (MRI) and ultrasound images, respectively. The purpose of this study was to explore the feasibility of the MRE measurement to evaluate the change in supraspinatus (SSP) muscle stiffness before and after rotator cuff tear, and to compare the result with those of SWE. Six swine shoulders were used. The skin and subcutaneous fat were removed, and the stiffness value of the SSP muscle was measured by MRE and SWE. The MRE measurement was performed with 0.3 T open MRI and the vibration from a pneumatic driver system with active driver to a passive driver to create the shear wave in the tissue. The passive driver was placed on the center of the SSP muscle. The stiffness was estimated from the wave images using local frequency estimation methods. In the SWE measurement, the probe of the ultrasound was placed on the center of the SSP muscle. The shear wave propagation speed was measured at a depth of 1 cm from the surface, and the stiffness was calculated. After those measurements, the rotator cuff tendon was detached from the greater tuberosity, and MRE and SWE measurements were then performed in the same manner again. The differences in the stiffness values were compared between before and after the rotator cuff tendon tear on both the MRE and SWE measurements. The results indicated that stiffness values on MRE and SWE were 9.3 ± 1.8 and 10.0 ± 1.2 kPa respectively before the rotator cuff tear, and 7.3 ± 1.3 and 8.0 ± 0.8 kPa respectively after the tendon detachment. Stiffness values were significantly lower after the tendon detachment on both the MRE and SWE measurements (p < 0.05). Our results demonstrated that stiffness values of the SSP muscle on MRE and SWE were lower after rotator cuff detachment. From this result, MRE may be a feasible method for quantification of the change in rotator cuff muscle stiffness.