Forearm nonunion caused by hyperparathyroidism with 7 years follow up: A case report.

INTRODUCTION: We report a patient who developed nonunion of both bones of the forearm associated with hyperparathyroidism (HPT). PRESENTATION OF CASE: The patient was a 71-year-old female who previously fell and hit her left hand on the ground. At 2 years after injury the patient visited our hospital, since she became aware of instability of the left forearm without an inducer due to nonunion of the radioulnar diaphysis. The patient was surgically treated to acquire forearm support. Surgery for nonunion was applied only to the ulna. To acquire an elbow joint flexion angle, an about 30° angle was added to the false joint region. At one year after surgery, blood testing suggested HPT, however, the parathyroid mass was not excised following the current guidelines for management of HPT. At 7 years after surgery, the elbow range of motion, VAS and the Q-DASH score were improved. Weight-bearing by the forearm became possible, and the patient can perform pronation and supination at the radial nonunion. DISCUSSION: We learned from this case that it is necessary to immediately perform close examination to identify the presence or absence of primary disease causing insufficiency fracture, such as HPT. For treatment of nonunion of the 2 forearm bones in this elderly female, osteosynthesis of the ulna alone achieved sufficient osteal support without osteosynthesis of the radius, and the postoperative course was favorable. CONCLUSION: We presented here a rare case of nonunion of both bones of the forearm associated with HPT.

A survey of extensor pollicis longus tendon injury at the time of distal radius fractures.

BACKGROUND: The purpose of this study is to investigate the presence or absence, incidence, and degree of extensor pollicis longus (EPL) tendon injury by visual confirmation of the EPL at the time of osteosynthesis for distal radius fractures. METHODS: The subjects were 25 patients (5 males and 20 females; mean age: 56 years) with distal radius fracture that had a dorsal roof fragment. During osteosynthesis using a volar locking plate, the third compartment was exposed in order to determine the EPL injury. The survey items in this study were: incidences of the forms of EPL injury (1: absent, 2: tendon floor fibrillation, and 3: laceration), and the presence or absence of periosteal rupture on the EPL tendon floor. In addition, on the final follow-up, the presence or absence of EPL rupture, the range of wrist motion, grip strength, Visual Analog Scale (VAS) score, Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and the Mayo wrist score were investigated. RESULTS: During the operation, EPL injury was classified as: 1) absent (12%), 2) tendon floor fibrillation (52%), or 3) laceration (36%). In the EPL tendon floor, periosteal rupture was observed in all patients. The mean postoperative follow-up period was 8 months (6-12 months) and no EPL rupture was observed in any patient. The wrist range of motion was 71° for flexion, 75° for extension, 84° for pronation, and 85° for supination, and the grip (% compared with the unaffected side) was 79%. The VAS, Q-DASH and Mayo scores were 1, 10 and 93 respectively. CONCLUSION: This study showed a high incidence of EPL tendon injury at the time of distal radius fractures (88%). To improve the ambient environment of the damaged tendon may be useful in terms of the prevention of tendon injury.

Devising for a distal radius fracture fixation focus on the intra-articular volar dislocated fragment.

INTRODUCTION: Distal radius fracture (DRF) accompanied by intra-articular volar displaced fragment is difficult to reduce. This volar fragment remains when treated with a simple buttress effect alone, and V-shaped deformity may remain on the articular surface. We attempted to improve dorsal rotational deviation of volar fragment by osteosynthesis applying the condylar stabilizing technique. We report the surgical procedure and results. MATERIALS AND METHODS: The subjects were 10 cases of DRF accompanied by intra-articular volar displaced fragments surgically treated (mean age: 69 years old). The fracture type based on the AO classification was B3 in 1 case, C1 in 4, C2 in 2, and C3 in 3 cases. All cases were treated with a volar locking plate. Reduction was applied utilizing the angle stability of the volar locking plate, similarly to the condylar stabilizing technique. On the final follow-up, we evaluated clinical and radiologic evaluation. To evaluate V-shaped valley deformity of the articular surface, the depth of the lunate fossa of the radius was measured using computed tomography (CT). RESULTS: The duration of postoperative follow-up was 11 (6-24) months. Mayo wrist score was 93 (Excellent in 10 cases). No general complication associated with a volar locking plate was noted in any case. Volar tilt on radiography were 11° (4-14). The depth of the lunate fossa on CT was 3.9 ± 0.7 mm in the patients. CONCLUSION: This procedure may be useful for osteosynthesis of distal radius fracture accompanied by intra-articular volar displaced fragments.

Assessment of dorsal instability of the ulnar head in the distal radioulnar joint: comparison between normal wrist joints and cases of ruptured extensor tendons.

In the present study, the adaptability of the distal radioulnar joint (DRUJ) was evaluated using conventional computed tomography (CT) evaluation methods. In addition, we investigated/compared a new method to evaluate dorsal displacement of the ulnar head. Our subjects consisted of 32 healthy volunteers (64 wrists) and 11 patients (13 wrists) with extensor tendon injuries related to dorsal displacement of the ulnar head. To diagnose instability in the DRUJ based on CT scans, the radioulnar line method and the modified radioulnar line method were measured. Instability was evaluated by the new method that the ulnar head was located on the dorsal side from a line involving the peak of Lister's tubercle in parallel to this baseline was regarded as showing abnormal dorsal displacement of the ulnar head. The diagnostic accuracy of each method was calculated. The sensitivities, specificities, false-positive rates, positive predictive values and the negative predictive value of new methods were better than other two methods. The new method that we recommend is simple. Based on the results of this study, an evaluation of normal/abnormal dorsal displacement of the ulnar head in the DRUJ using the new method may be useful for determining the timing of surgery.

Distal radius fracture after proximal row carpectomy.

INTRODUCTION: We encountered a patient with distal radius fracture (DRF) after proximal row carpectomy (PRC). The mechanism of the DRF after PRC is discussed in this report. PRESENTATION OF CASE: The patient was a 73-year-old female who had undergone PRC due to Kienböck disease before. The wrist range of motion was: 45° on dorsiflexion and 20° on flexion. DRF has occurred at 3 years after PRC. The fracture type was extra-articular fracture. Osteosynthesis was performed using a volar locking plate. No postoperative complication developed, the Mayo score was excellent at 6 months after surgery, and the daily living activity level recovered to that before injury. DISCUSSION: Since the wrist range of motion decreased and the lunate fitted into the joint surface after PRC, making the forearm join with the hand like a single structure, pressure may have been loaded on the weak distal end of the radius from the dorsal side, causing volar displacement and fracture. CONCLUSION: The pressure distribution and range of motion of the radiocarpal joint after PRC are different from those of a normal joint, and the mechanism of fracture also changes due to PRC.

Atypical Subtrochanteric Femoral Fracture Below an Arthritic Hip: A Case Report.

CASE: We present a case of a sixty-nine-year-old woman with an atypical subtrochanteric femoral fracture below an arthritic hip; the patient had a history of long-term bisphosphonate treatment. We performed a one-stage total hip arthroplasty with a plate and cables because the healing of atypical femoral fractures in patients with a history of bisphosphonate use can be prolonged. CONCLUSION: The combined use of a plate and total hip arthroplasty is a potential intervention for atypical proximal femoral fractures associated with hip arthritis.

Is urinary incontinence the hidden secret complications after total hip arthroplasty?

INTRODUCTION: We hypothesized that posterior approach (PA) dissecting the short external rotators and anterior approach (AA) not dissecting these have different influences on the pelvic floor muscles and subsequently affect urinary incontinence. The objective of this study was to investigate whether AA advantageously influences symptoms of urinary incontinence. PATIENTS AND METHODS: The subjects were 76 female patients who underwent their primary total hip arthroplasty. The presence or absence of urinary incontinence before and after surgery was surveyed by a direct interview at the time of outpatient examination within a period from 1.5 year after surgery using the international consultation on incontinence questionnaire-short form. RESULTS: Urinary incontinence improved after surgery in eight patients (22.2%), slightly improved in one (2.8%), remained unchanged in 26 (72.2%), slightly aggravated in one (2.8%) in the AA group. In the PA group, urinary incontinence improved after surgery in one (2.5%), remained unchanged in 30 (75%), slightly aggravated in four (10%), and aggravated in five (12.5%). Symptoms of urinary incontinence were significantly improved in the AA group and aggravated in the PA group (Mann-Whitney U test, P = 0.0057). CONCLUSIONS: As the anatomical characteristic of the short external rotators, the root of the internal obturator muscle is connected to the levator ani muscle. Among the pelvic floor muscles, this levator ani muscle is closely involved in supporting the pelvic organs. Since the short external rotators may have been atrophied due to hip joint dysfunction before surgery, if the strength of this muscle group recovers, support of the pelvic organs and urinary incontinence may be improved. It was assumed that surgery through AA improved external rotation contracture of the hip joint and leg length, which increased tension of the internal obturator muscle, with which tension of the pelvic floor muscle also increased and improved urinary incontinence.

Mid-term clinical results of total hip arthroplasty using a Wagner standard cup for dysplastic hip.

BACKGROUND: The outcome of cementless total hip arthroplasty depends on many factors. We must not forget fundamental things those are design of outer surface of the component, that leads bone ingrowth into the prosthesis, better initial stability, and better insertional techniques. The purpose of this study was to review our experience with metal-on-metal total hip arthroplasty with a Wagner standard cup for patients who had acetabular dysplasia. PATIENTS AND METHODS: Fifty-four patients with 55 hips underwent primary metal-on-metal total hip arthroplasty (Metasul prosthesis) with a Wagner standard cup (44-48 mm in outer diameter) and were followed for a minimum of 10 years. All patients received the same type of cementless femoral component (Natural hip stem) and femoral head (28 mm in diameter). RESULTS: Seventeen of the 55 Wagner standard cups (30.9%) showed aseptic loosening over a mean period of 3.6 years after surgery, and there were no bone anchors on the outer surface of the 16 retrieved cups. CONCLUSION: From our experience, the small Wagner standard cup does not achieve sufficient osteointegration and we do not recommend the use of this cup, especially for patients with acetabular dysplasia and/or those with a small stature.

Chromium level of salvaged blood in patients undergoing revision hip arthroplasty.

PURPOSE. To evaluate the chromium level of the salvaged blood in patients undergoing revision total hip arthroplasty (THA). METHODS. Records of 7 women and one man aged 54 to 83 (mean, 64.3) years who underwent revision THA for aseptic loosening of the acetabular component (n=6), osteolysis of the acetabulum (n=1), or migration of the outer head (n=1) were reviewed, as were 2 controls who underwent primary THA. The initial THA entailed a metal-on-metal prosthesis (n=4), a metal-on-polyethylene prosthesis (n=3), and a bipolar head prosthesis (n=1). Chromium levels in the preoperative peripheral blood and intraoperative salvaged blood were measured using atomic absorption analysis. RESULTS. For controls and the patient with a bipolar head prosthesis, the mean chromium level in salvaged blood was 0.4 (range, 0.2-0.6) micrograms/l, which was significantly lower than that in the remaining 7 patients undergoing revision THA (mean, 5.6 micrograms/l; range, 1.2-9.8 micrograms/l). CONCLUSION. Salvaged blood of patients with a metal-on-metal prosthesis undergoing revision THA contained higher levels of chromium.

Pedicle freezing with liquid nitrogen for malignant bone tumour in the radius: a new technique of osteotomy of the ulna.

We describe a new technique of pedicle freezing of the distal radius with malignant bone tumour and osteotomy of the normal ulna. The distal radius was sufficiently elevated to enable freezing without damaging adjacent tissues by releasing the distal radio-ulnar and radio-carpal joint and cutting the middle third of the ulna. The distal radius (including the tumour) was soaked in liquid nitrogen and the defect filled with iliac grafts. The ulna was repaired with plate and screws and was united at month 2. There was no local recurrence and the postoperative function score was 93%. This technique decreases the risk of non-union of the osteotomy site of the tumorous bone.

Altered antibody production and helper T cell function in mice lacking chemokines CCL19 and CCL21-Ser.

The roles of chemokines CCL19 and CCL21 in Ab production were investigated using plt mutant mice, which lack expression of CCL19 and CCL21-ser in their lymphoid organs. In these mice, the Th response has been shown to tend towards the Th1 type because of accumulation of inflammatory dendritic cells. When plt mice were immunized with 100 µg OVA in CFA, the number of Ab-forming cells in the draining LN, and serum concentrations of OVA-specific IgM and IgG Ab, were very close to those of the control, yet IgG2a Ab in plt mice was increased. In vitro IFN-γ production by the draining LN cells of plt mice was increased. In addition, the ability of helper T cells from plt mice to stimulate Ab production in vitro was prolonged. Also, in the plt mice, in vivo challenge with OVA in incomplete Freund's adjuvant elicited a stronger IgG2a response and a weaker IgG1 response, which is suggestive of a Th1-dominant response. Similar findings were obtained when mice were immunized with 100 µg OVA in alum, except that with alum the increases observed in plt mice were IgG1 produced in vivo and IL-4 produced in vitro by draining LN cells. Furthermore, immunization with alum adjuvant also induced a prolonged in vitro recall response of IFN-γ and IL-4. These findings indicate that plt mice mount an anti-OVA Ab response, and suggest that CCL19 and CCL21 induce prompt Ab responses to antigen, and negatively regulate helper T cell responses in vivo.

Seven years of chronological changes of serum chromium levels after Metasul metal-on-metal total hip arthroplasty.

Although many authors have reported the serum concentrations of metal ions in patients who had metal-on-metal coupling prostheses, most of the studies were not longitudinal, and the follow-up periods were short. We evaluated the longitudinal changes of serum chromium levels in 44 patients who had undergone unilateral metal-on-metal total hip arthroplasty for a minimum of 7 years postoperatively. Although there was a consistent increase in the mean serum chromium level until 3 years after implantation, there was little difference in the levels from years 3 to 7 postoperatively. Although the serum chromium concentration was low throughout postoperative follow-up for 7 years in about 25% of patients, the serum chromium level stayed high or showed gradual elevation in 16.3% of our patients.

CCR7 ligands are required for development of experimental autoimmune encephalomyelitis through generating IL-23-dependent Th17 cells.

CCL19 and CCL21 are thought to be critical for experimental autoimmune encephalomyelitis (EAE) induction, but their precise role is unknown. We examined the role of these chemokines in inducing EAE. C57BL/6 mice lacking expression of these chemokines (plt/plt mice) or their receptor CCR7 were resistant to EAE induced with myelin oligodendrocyte glycoprotein peptide 35-55 (MOG(35-55)) and pertussis toxin. However, passive transfer of pathogenic T cells from wild-type mice induced EAE in plt/plt mice, suggesting a defect independent of the role of CCR7 ligands in the migration of immune cells. Examination of draining lymph node (DLN) cells from MOG(35-55)-immunized plt/plt mice found decreased IL-23 and IL-12 production by plt/plt dendritic cells (DCs) and a concomitant defect in Th17 cell and Th1 cell generation. In contrast, production of the Th17 lineage commitment factors IL-6 and TGF-beta were unaffected by loss of CCR7 ligands. The adoptive transfer of in vitro-generated Th17 cells from DLN cells of MOG(35-55)-immunized plt/plt mice developed EAE in wild-type recipient mice, whereas that of Th1 cells did not. Pathogenic Th17 cell generation was restored in plt/plt DLNs with the addition of exogenous IL-23 or CCL19/CCL21 and could be reversed by inclusion of anti-IL-23 mAb in cultures. Exogenous CCL19/CCL21 induced IL-23p19 expression and IL-23 production by plt/plt or wild-type DCs. Therefore, CCR7 ligands have a novel function in stimulating DCs to produce IL-23 and are important in the IL-23-dependent generation of pathogenic Th17 cells in EAE induction.

Rotational acetabular osteotomy for osteonecrosis of the femoral head after intracapsular fracture of the neck of the femur.

The treatment of osteonecrosis of the femoral head in younger patients varies among orthopaedic surgeons. In particular, the optimal treatment of extensive osteonecrosis associated with femoral head collapse remains controversial. Since 1995, we have performed rotational acetabular osteotomy on 70 hips, including those of 3 patients with extensive osteonecrosis of the femoral head after intracapsular fracture of the neck of the femur. In all 3 patients, adequate coverage of the femoral head by the osteotomized acetabulum was obtained, and their symptoms (especially pain) showed marked improvement at latest follow-up.

Changes of D-dimer after total hip arthroplasty in patients with and without intraoperative heparin.

INTRODUCTION: Marked activation of thrombosis is common in patients undergoing total hip arthroplasty, especially during reaming of the femur and after insertion of the femoral prosthesis. This suggests that management designed to minimize deep vein thrombosis and fatal pulmonary embolism after total hip arthroplasty should be focused on the period during insertion of the femoral component. In some previous studies, a low dose of heparin administered intraoperatively was shown to suppress the formation of fibrin. OBJECTIVE: The present study was performed to evaluate the influence of intraoperative heparin administration on the D-dimer level and on the prevention of pulmonary embolism after total hip arthroplasty. MATERIAL/METHODS: A total of 22 and 26 consecutive patients respectively underwent total hip arthroplasty with and without intraoperative administration of unfractionated heparin. Postoperatively, all patients wore knee-high elastic stockings and were fitted with calf-to-thigh intermittent pneumatic compression devices. Active ankle flexion and extension exercises were commenced as soon as motor function recovered. None of the 48 patients received prophylactic anticoagulants postoperatively. RESULTS: There was a significant difference of the mean D-dimer level on the 1st day between the patients with and without intraoperative administration of heparin (8.9 +/- 6.6 vs. 15.7 +/- 12.7, P < 0.05). Although there were no patients with symptomatic deep venous thrombosis and pulmonary embolism, asymptomatic pulmonary embolism was detected by pulmonary perfusion scintigraphy in three patients who did not receive intraoperative heparin. The operative blood loss and postoperative drainage were similar in both groups and no bleeding complications were observed. In conclusion, we recommend a safe and inexpensive regimen comprising 1,000 U of intravenous unfractionated heparin intraoperatively, postoperative pneumatic compression, and early active mobilization for prevention of thoromboembolic complications after total hip arthroplasty.

Chemokines CCL19 and CCL21 promote activation-induced cell death of antigen-responding T cells.

Secondary lymphoid organs (SLOs) provide a niche for the initiation and regulation of T-cell responses, but the mechanisms have been poorly understood. We investigated the influence of chemokines CCL19 and CCL21 constitutively expressed in SLOs on activation-induced cell death (AICD) of CD4+ T cells. When paucity of lymph node T cells (plt) mutant mice lacking expression of CCL19/CCL21 were primed with OVA/CFA, both expansion of OVA-responding CD4+ T cells in the draining lymph nodes and an in vitro recall response were prolonged as compared with responses in wild-type (WT) mice. The apoptotic cell frequency among OVA-responding CD4+ T cells was similarly low in plt/plt and WT mice during the clonal expansion phase. However, during the clonal contraction phase, the frequency never increased in plt/plt mice, whereas in WT mice it continuously increased to a peak 18 days after immunization. The presence of CCL19/CCL21 during the in vitro stimulation of CD4+ T cells with anti-CD3 plus anti-CD28 significantly enhanced in vitro AICD induction of the restimulated T cells, partially through enhancing expression of Fas ligand. Our results suggest that CCL19/CCL21 produced by stromal cells and antigen-presenting cells regulate CD4+ T-cell immune responses in SLOs by promoting AICD.

Original methods to move femoral head medially and caudally after rotational acetabular osteotomy: especially to use ceramic spacer.

The operative procedures chosen to treat arthrosis in patients with severe acetabular dysplasia vary among orthopaedic surgeons, particularly in younger patients. We operated on 450 hips with acetabular dysplasia by using the rotational acetabular osteotomy (RAO) method of Ninomiya and Tagawa by Ninomiya (Clin Orthop 247:127-137, 1989). In this report, we describe our technique of performing RAO with hydroxyapatite tricalcium phosphate-composite (HAP-TCP) blocks to achieve good acetabular coverage and the results of this procedure in 16 hips with severe dysplasia, including nine with advanced arthrosis. Adequate coverage of the osteotomized acetabulum was maintained and symptoms, especially pain, showed marked improvement at the latest follow up.