Autophagy in an extruded disc compared to the remaining disc after lumbar disc herniation in the same patient.

PURPOSE: The purpose of this study was to investigate autophagy in an extruded disc and to compare this activity with the activity in the remaining disc after lumbar disc herniation in the same patient. METHODS: In total, 12 patients (females 4, males 8) with the extruded type of lumbar disc herniation (LDH) were surgically treated. Their mean age was 54.3 ± 15.8 years (range: 29 ~ 78 years). The mean interval from the occurrence of symptoms to the operation was 9.8 ± 9.4 weeks (range: 2 ~ 24 weeks). The extruded discs were excised, and the remaining disc material removed, to prevent recurrence of herniation. Immediately after specimen collection, all tissues were stored at -70 °C prior to analysis. Autophagy was assessed immunohistochemically and via Western blotting for Atg5, Atg7, Atg12, Atg12L1, and Beclin-1. And the relationship between autophagy and apoptosis was investigated by correlation analysis of caspase-3 with autophagy proteins. RESULTS: The expression levels of autophagic markers were significantly increased in the extruded discs compared to the remaining discs within the same patients. The mean expression levels of Atg5, Atg7, Atg12, and Beclin-1 in extruded discs were statistically significantly higher than those in the remaining discs (P < 0.01, P < 0.001, P < 0.01, and P < 0.001 respectively). CONCLUSIONS: The autophagic pathway was more active in extruded disc material than in remaining disc material within the same patient. This may explain spontaneous resorption of the extruded disc after LDH.

10-Year Clinical Follow-Up after Decompression of Lipofibromatous Hamartoma of the Median Nerve in a 3-Year-Old Patient: Case Report and Review of the Literature.

Lipofibromatous hamartoma, first reported in 1953, is a rare, slowly progressive soft tissue tumor, the characteristics of which include the enlargement of the affected nerve via the epineurial and perineurial proliferation of adipose and fibrous tissues. Out of 200 previously reported cases of lipofibromatous hamartoma of the median nerve, there have been approximately 25 pediatric cases under the age of 18. Herein, we report a case of lipofibromatous hamatoma of the median nerve in a 3-year-old female patient who was surgically decompressed via carpal tunnel release and epineurolysis. The patient was followed-up on an outpatient clinic basis annually with sonographic evaluations, and the postoperative 10th-year follow-up did not show recurrence or any deficits in motor and sensory functions.

Osteoid Osteoma of the Proximal Phalanx of the Great Toe in a 13-Year-Old Female Patient.

Osteoid osteoma (OO) is a benign osteoblastic bone tumor typically involving the diaphysis or metaphysis in long tubular bones. OO in phalanges of the great toe has been rarely reported, and it is often challenging to differentiate with subacute osteomyelitis, bone abscess, or osteoblastoma. This case report describes an uncommon case of a 13-year-old female patient with subperiosteal OO in the proximal phalanx of the great toe. The atypical location of OO should be familiarized to include appropriate differential diagnosis and to ensure accurate diagnosis by radiologic evaluations. Surgical excision remains the benchmark for the treatment of OO with its advantages on direct visualization and histologic confirmation for the diagnosis.

The first case report of thorn-induced Alternaria alternata infection of the hand in an immunocompetent host.

BACKGROUND: Fungal infection secondary to a penetrating plant thorn injury in upper extremities is infrequently reported especially in immunocompetent hosts. Alternaria is a dematicaceous hyphomycete, commonly found in decay and plant pathogens, and Alternaria alternata has been regarded as the most frequent species among more than 400 s of its species. This case is the first report of thorn-induced Alternaria alternata infection of the hand in an immunocompetent host. CASE PRESENTATION: A 47-year-old male patient was admitted to our institution with persistent pain and swelling of the right hand even after a prior surgical removal of a previous thorn injury. Upon impression of abscess, chronic extensor tenosynovitis, and septic arthritis at the 3rd metacarpophalangeal joint based on advanced imaging, the patient underwent surgical incision and drainage. Intraoperative culture, biopsy, and gene molecular sequencing results revealed fungal infection with Alternaria alternata. Postoperatively, the patient was treated with oral itraconazole (200 mg q 12 h) for nine consecutive months. CONCLUSIONS: We report the first case of chronic extensor tenosynovitis and septic arthritis of the hand with Alternaria alternata after a thorn injury in an immunocompetent host. Despite rare incidences of fungal extensor tenosynovitis and septic arthritis, the current case strongly suggests a careful examination of social history and surgical debridement along with a prolonged use of appropriate anti-fungal agents in thorn injuries.

Associations between hand function and electrophysiological measurements in hand osteoarthritis patients of different ages with or without carpal tunnel syndrome.

Osteoarthritis is a common degenerative disease that most frequently involves the hand. The objective was to compare clinical functional outcome measures including hand grip, pinch strength, and dexterity with various electrophysiological measures in patients of different ages with hand osteoarthritis with or without the presence of carpal tunnel syndrome (CTS). Patients with hand osteoarthritis (208 patients, 404 hands) who underwent hand-function tests and motor and sensory nerve conduction studies (NCS) between June 2015 and June 2016 were enrolled. The patients' hands were assigned to carpal tunnel syndrome (CTS) (206 hands; mean age, 56.37 ± 10.52; male:female, 46:160) or control groups (198 hands; mean age, 57.88 ± 9.68; male:female, 55:143). The strength of hand grip and lateral pinch, the time required to complete the nine-hole pegboard test (9HPT), and motor and sensory nerve conduction parameters were measured and compared across age groups and between hands with or without CTS. The CTS group showed significantly lower hand grip and lateral pinch strength, and a longer time to complete the 9HPT in comparison with the control group. Female patients showed significantly lower hand grip and lateral pinch strength than male patients. However, there was no difference in the 9HPT completion time between genders. Multivariate regression analysis identified the amplitude of the median compound muscle action potential (CMAP), age, and male gender as independent predictors of grip strength (adjusted R2 = 0.679), and amplitude of median CMAP and male gender as independent predictors of KP strength (adjusted R2 = 0.603). Velocity of median CMAP, amplitude of median sensory nerve action potential, and age were identified as independent predictors of 9HPT time (adjusted R2 = 0.329). Nerve conduction measurements were significantly related to hand-function test results, and CTS induced significant deficits in strength and performance of the affected hand.

Reverse digital artery cross-finger flap for reconstruction of failed finger replantation.

PURPOSE: This study aimed to describe the reverse digital artery cross-finger flap (RDAC flap) in the treatment of failed finger replantation. METHODS: This study retrospectively reviewed the records of patients who underwent modified RDAC flap reconstructions for failed finger replantation and assessed their outcomes. Of the patients who underwent soft tissue reconstructions for finger injuries between March 2011 and February 2015, we enrolled 11 patients in whom RDAC flap reconstruction procedures were performed to treat the failed replantations. RESULTS: The flaps survived in all cases, with a mean static, two-point discrimination value of 5.3 mm (range, 4-7 mm) in the healed flaps. The sizes of the flaps ranged from 2 × 1 cm2 to 2.3 × 1.5 cm2. CONCLUSION: The RDAC flap was introduced by Lai et al., and it is a mixed form with the advantages of both cross-finger flap and heterodigital island flap. Our results suggest that it could provide reliable coverage of the sensate soft tissue of fingers with failed replantation.

Serial stab incision venous drainage technique for simple artery-only fingertip replantation.

PURPOSE: Fingertip replantation is a challenging and technically demanding procedure. A variety of venous drainage techniques have been attempted for successful fingertip replantation. We present a new venous drainage technique, known as serial multifocal incision for fingertip replantation. METHODS: Between 2006 and 2014, we performed 94 fingertip replantations without vein anastomosis. Eighty of the patients were male, and 14 were female, with an overall mean age of 42 years (range: 8-67 years). All patients suffered amputations distal to the distal phalanx joint (Ishikawa subzone I, II, or III). We performed only artery anastomosis. To relieve venous congestion, we incised the fingertip 2-3 mm using a number 11 scalpel blade and allowed the vein to drain naturally. We made small serial incisions every 2-3 days for 1 week. RESULTS: The overall success rate for this procedure was 90%, with 85 surviving digits. Two patients with partial necrosis and nine patients with complete loss needed a second operation. Two patients received blood transfusions with an average of 1.5 units, but both had an accompanying injury at another site. No one complained of nail deformity or wound infection. CONCLUSIONS: Various external bleeding techniques have been reported to yield good results. The serial stab incision venous drainage technique is a modified fish-mouth external bleeding technique that overcomes the disadvantages of published methods. This technique is simple, allows for easy control of venous drainage, and reduces the need for blood transfusions compared to other venous drainage techniques that cause large amounts of bleeding. We propose a new method, the serial stab incision venous drainage technique, which is effective and associated with high rates of survival.

Early and Delayed Postoperative Rehabilitation after Arthroscopic Rotator Cuff Repair: A Comparative Study of Clinical Outcomes.

BACKGROUND: The duration of immobilization after arthroscopic rotator cuff repair and the optimal time to commence rehabilitation are still the subject of ongoing debates. This study was undertaken to evaluate the functional outcome and rotator cuff healing status after arthroscopic rotator cuff repair by comparing early and delayed rehabilitation. METHODS: Totally, 76 patients with small, medium, and large sized rotator cuff tears underwent arthroscopic repair using the suture-bridge technique. In early rehabilitation group, 38 patients commenced passive range of motion at postoperative day 2 whereas 38 patients assigned to the delayed rehabilitation group commenced passive range of motion at postoperative week 3. At the end of the study period, clinical and functional evaluations (Constant score, the University of California, Los Angeles [UCLA] shoulder score) were carried out, subsequent to measuring the range of motion, visual analogue scale for pain, and isokinetic dynamometer test. Rotator cuff healing was confirmed by magnetic resonance imaging at least 6 months after surgery. RESULTS: No significant difference was obtained in range of motion and visual analogue scale between both groups. Functional outcomes showed similar improvements in the Constant score (early: 67.0-88.0; delayed: 66.9-91.0; p<0.001) and the UCLA shoulder score (early: 20.3-32.3; delayed: 20.4-32.4; p<0.001). Furthermore, rotator cuff healing showed no significant differences between the groups (range, 6-15 months; average, 10.4 months). CONCLUSIONS: Delayed passive rehabilitation does not bring about superior outcomes. Therefore, early rehabilitation would be useful to help patients resume their daily lives.

Dual plate for comminuted proximal humerus fractures.

The purpose of this study is to evaluate radiological, clinical results and complication rates of dual plate fixation for severe metaphyseal comminuted fracture of proximal humerus. 21 patients who have proximal humerus fractures with impaired posteromedial buttress were enrolled. Fractures were treated with dual plate technique using Proximal Humeral Locking plate and Variable Angle Plate. Radiographic results were analyzed based on duration of union. For evaluation of the degree of anatomical reduction, neck shaft angle on the anteroposterior view was measured by simple plain radiography using the Paavolainen method, while anterior-posterior angulation was measured on the axial view. Degree of anatomic reduction was good in 17 patients (80.95%), fair in 3 patients (14.28%), and poor in 1 patient (4.77%). One case of impingement, and one case of avascular necrosis were noted. The dual plate technique provides stable fixation and satisfactory clinical and radiological results for severely comminuted metaphyseal fracture of the proximal humerus.

Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable intertrochanteric fractures: A modified candy-package wiring technique.

INTRODUCTION: The purpose of this study was to introduce a new surgical technique, that involves modified Candy-package wiring followed by IM nailing fixation and to determine the clinical and radiological results obtained in patients with unstable intertrochanteric fractures with a lesser trochanter fragment. MATERIALS AND METHODS: This study included 22 patients who were undergone proximal IM nailing with lesser trochanter wiring between January 2014 to June 2015. All patients were treated with minimally invasive technique of candy-package wiring for lesser trochanter fragments. The mean age was 75.8 years (range, 53-88) and average follow-up period was 15.1 months (range, 12-24). Each patient was followed up for a minimum of 12 months and their clinical and radiological results were analyzed. RESULTS: The mean period required for fracture union was 16.6 weeks. (range, 8-25) and union was successfully completed in all cases. The WOMAC scores at the last F/U visit (average; 45.4, range; 21-75) were not significantly different to pre-trauma status (average; 36.5, range; 19-59) (p=0.087). In comparison of ambulatory capacity prior to trauma, ambulatory aggravation was noted in four cases (18.2%), and eighteen cases (81.8%) was sustained walking ability of prior of trauma. Wiring breakage was found in two cases and heterotrophic ossification in one case. There were no functional deficeit related to the radiologic finding in these patients. With regard to postoperative complications, were no cut-outs, breakage, or pullout of screws. CONCLUSION: When surgically repairing unstable intertrochanteric fractures with lesser trochanter comminution using proximal IM nailing method, the modified Candy-packaging wiring technique increases the fixation force at the fracture site. Thus, through this technique, both firm fixation of the lesser trochanter and more stable bony union were obtained.

Osteochondroma of the Radial Tuberosity in Child.

Osteochondromas are common benign bone tumors. They may occur on any bone preformed in cartilage, but usually are found on the metaphysis of a long bone near the physis. In this article, we report a case of the subluxation of the radial head caused by osteochondroma on the radial tuberosity. A 9-year-old female patient presented with a hard palpable mass and pain in her posterior aspect of left elbow joint. Preoperative radiography and MRI demonstrated an expansile bone lesion arising in the left radial tuberosity of the proximal radius. Resection of the bone tumor was done without any complications. Biopsy confirmed the diagnosis of osteochondroma without malignant degeneration. A one year after surgery, the elbow had full range of motion without any discomfort and complication.

Emphysematous Cystitis Found Incidentally in a Patient Undergoing Hip Arthroplasty: A Case Report.

CASE: Emphysematous cystitis is a rare, complicated urinary tract infection that is potentially life-threatening if left untreated. We present the case of an eighty-one-year-old woman with left hip pain from a low-energy fall with no associated urinary symptoms. Pelvic computed tomography revealed a left femoral neck fracture and an air-fluid level in the bladder. Bipolar hemiarthroplasty was delayed for three weeks to allow for the potentially serious urinary tract infection to resolve. CONCLUSION: Increased awareness is required for early diagnosis and treatment of asymptomatic emphysematous cystitis in a patient presenting with musculoskeletal symptoms.

Comparison of the osteogenic potential of bone dust and iliac bone chip.

BACKGROUND CONTEXT: There is no comparative study of the in vitro and in vivo osteogenic potential of iliac bone chips (autogenous iliac cancellous bone chips) compared with bone dusts generated during the decortication process with a high-speed burr in spine fracture or fusion surgery. PURPOSE: To compare the osteogenic potential of three sizes of bone dusts with iliac bone chips and to determine whether bone dusts can be used as a bone graft substitute. STUDY DESIGN: In vitro and in vivo study. METHODS: Bone chips were harvested from the posterior superior iliac spine and bone dusts from the vertebrae of 15 patients who underwent spinal fracture surgery. Bone dust was divided into three groups: small (3 mm), middle (4 mm), and large (5 mm) according to the size of the burr tip. A comparison was made using a cell proliferation assay, alkaline phosphatase (ALP) activity, the degree of mineralization in an in vitro model, and radiographic and histologic studies (the change of absorbable area and tissue density) after implantation of the various materials into back muscles of nude mice. RESULTS: Although all three bone dust groups were less active with regard to cell proliferation, ALP activity, and the degree of mineralization, than were bone chips, they still exhibited osteogenic potential. Furthermore, there was no significant difference among the three bone dust groups. The three bone dust groups did show greater absorbable area and change of the tissue density than did the iliac bone chip group. Again, there was no significant difference among the three bone dust groups in this regard. Histologically, specimens from the bone dust groups had a higher osteoclast cell number than specimens from the iliac bone chip group. CONCLUSIONS: The osteogenic potential of bone dusts is lower than that of iliac bone chips, and the absorption speed of bone dusts in vivo is faster than that of iliac bone chips. The increased resorption speed appeared to result from an increase in osteoclast cell number. Therefore, caution needs to be used when surgeons employ bone dust as a bone graft substitute.

Giant extra-articular synovial osteochondromatosis of the sinus tarsi: a case report.

A 32-year-old male presented with painful swelling of the sinus tarsi that occurred during daily activities. Diagnostic imaging suggested the presence of a large synovial osteochondromatosis that blocked subtalar motion with deformity of the adjacent bone. The large bony mass was excised, and normal subtalar motion was achieved.

Primary Ewing sarcoma of lumbar spine in an 8-year-old boy: a case report.

Primary Ewing's sarcoma of the mobile spine is rare, but nevertheless, is the second most common primary malignant bone neoplasm in children. Furthermore, in contrast to long bone involvement, delays may occur because symptoms may not be present until neurological deficits occur. Here, we report a case of an 8-year-old boy with lower back pain and radicular pain on the posterior lower extremities with tingling and progressively reduced sensation in both feet. The patient initially seemed to have muscle sprain but was eventually diagnosed with Ewing's sarcoma of the L5 vertebra with intraspinal extension.

Treatment for symptomatic os subtibiale in a preadolescent athlete: a report of 3 cases in preadolescence.

The os subtibiale is a rare accessory bone, which should be distinguished from fracture of the medial malleolus because misinterpretation leads to the unnecessary surgery and immobilization. Herein, we report 3 cases of a symptomatic os subtibiale in preadolescent athlete with a review of the relevant literature.