Postoperative Rotation Deformity of Head-Neck Fragments in Unstable Intertrochanteric Fractures Fixed with Intramedullary Nails

BACKGROUND

Our purpose was to quantify the postoperative rotation deformity (RD) after osteosynthesis of unstable intertrochanteric fractures (ITFx) using 3D-CT / image processing software, and to clarify the clinical meaning of RD.

METHODS

Forty-six consecutive patients with unstable intertrochanteric fractures were enrolled in this study. All were fixed with Gamma 3 Trochanteric nail and RC Lag Screw® (Stryker). We performed 3D-CT evaluations for the rotational deformity of head-neck fragments, the medial cortex support (MCS) between main fragments and bone healing at 3 months postoperatively.

RESULTS

The RD was significantly larger in the patients without the MCS (5.1 ± 4.0°, N = 9) than those with the MCS (2.4 ± 2.6°, N = 37) (P = 0.006*). Delayed healing (N=3) was observed in patients without the MCS, and the association between RD and delayed healing was significant (P = 0.003*, cut-off value 6.4°, sensitivity 100% and specificity 90.7%, AUC 0.91).

CONCLUSIONS

This study proposed a novel method of measuring postoperative RD. Lack of MCS may lead to RD and consequent delayed healing in unstable ITFx fixed with intramedullary nails.

Saphenous Nerve Entrapment Neuropathy After Closed Tibial Fracture: A Case Report

CASE

A 43-year-old man who underwent intramedullary nailing for a closed tibial fracture developed saphenous nerve entrapment neuropathy. He developed severe medial leg pain, which was worse on walking or standing, 2 years postoperatively. Surgical neurolysis resulted in complete pain relief and functional recovery of the limb without recurrence of symptoms.

CONCLUSION

Clinicians should consider several etiologies in the diagnostic evaluation of a patient with chronic pain after limb trauma. If a patient complains of lower extremity pain after intramedullary fixation of closed fractures of the tibial shaft, the possibility of saphenous nerve entrapment neuropathy should be considered.

Treatment of Capitellum and Trochlea Fractures Using Headless Compression Screws and a Combination of Dorsolateral Locking Plates

Introduction

This study aimed to evaluate the clinical outcomes of 16 patients with capitellum and trochlea fractures that were treated using isolated headless compression screws or a combination of dorsolateral locking plates and anterior-to-posterior screws. We also investigated the presence of lateral epicondyle fragments because this fragment is especially important when making decisions regarding the surgical approach and implants.

Materials and methods

We conducted a retrospective analysis of 16 patients with capitellum and trochlea fractures. Clinical, radiographic (based on CT scans), and elbow-specific outcomes, including the Mayo Elbow Performance Index (MEPI), were evaluated at a mean of 23.5 months postoperatively.

Results

The average MEPI scores in patients with Dubberley type A (non-posterior comminution) and type B (posterior comminution) fractures were 88 and 78, respectively (p=0.08). Headless compression screws were used in 10 cases of type A fracture and one case of type B fracture. A combination of dorsolateral locking plates and anterior-to-posterior screws was used in five cases of type B fracture. Hardware loosening was seen in one case of type B fracture with isolated screw fixation. The presence of a lateral epicondyle fragment was significantly associated with the type B group (6/6 patients; 100%). In contrast, patients in the type A group rarely had posterior comminution of the lateral epicondyle fragment (2/10 patients; 20%).

Conclusions

Capitellum and trochlea fractures with posterior comminution, which typically presented with lateral epicondylar fragments, were safely and effectively treated with a combination of dorsolateral locking plates and anterior-to-posterior screws through lateral approaches. Cases without posterior comminution were treated with headless compression screws with no complications. The Dubberley classification system provides helpful information to determine the fixation strategy.

Primary treatment of atlantoaxial rotatory fixation in children: a multicenter, retrospective series of 125 cases

OBJECTIVE

The primary treatment for atlantoaxial rotatory fixation (AARF) remains controversial. The aim of this study was to investigate the primary treatment for AARF and create an algorithm for primary treatment.

METHODS

The authors analyzed the data of 125 pediatric patients at four medical institutions from April 1989 to December 2018. The patients were reported to have neck pain, torticollis, and restricted neck range of motion and were diagnosed according to the Fielding classification as type I or II. As a primary treatment, 88 patients received neck collar fixation, and 28 of these patients did not show symptom relief and required Glisson traction. Thirty-seven patients were primarily treated with Glisson traction. In total, 65 patients, including neck collar treatment failure patients, underwent Glisson traction in hospitals.

RESULTS

The success rate of treatment was significantly higher in the Glisson traction group (97.3%) than in the neck collar fixation group (68.2%) (p = 0.0001, Wilcoxon test). In the neck collar effective group, Fielding type I was more predominant (p = 0.0002, Wilcoxon test) and the duration from onset to the first visit was shorter (p = 0.02, Wilcoxon test) than that in the neck collar ineffective group. Using multivariate logistic regression analysis with the above items, the authors generalized from the estimated formula: logit [p(success group by neck collar fixation group)|duration from onset to the first visit (x1), Fielding type (x2)] = 0.4(intercept) - 0.15x1 + 1.06x2, where x1 is the number of days and x2 = 1 (for Fielding type I) or -1 (for Fielding type II). In cases for which the score is a positive value, the neck collar should be chosen. Conversely, in cases for which the score is a negative value, Glisson traction should be the first choice.

CONCLUSIONS

According to this formula, in patients with Fielding type I AARF, neck collar fixation should be allowed only if the duration from onset is ≤ 10 days. In patients with Fielding type II, because the score would be a negative value, Glisson traction should be performed as the primary treatment.

Risk of breast cancer among Japanese women with a positive family history

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Background: Most breast cancer cases are sporadic, rather than associated with inherited gene mutations, such as BRCA1 and BRCA2. However, women with a family history of breast cancer are at increased risk of developing breast cancer compared to those women without any family history, even if they lack these gene mutations.

Methods: We analyzed 10892 patients including bilateral breast cancer cases (total of 11398 breast cancers) who underwent surgery at our hospital between 1962 and 2009. We excluded 295 cases whose family history data were not available. Clinical and pathological differences between following patient groups were tested; 9528 patients or 9955 cancers (88%) with negative family history (FH-), 896 patients or 951 cancers (8%) who had at least one first-degree relative with breast cancer (1FH+), 468 patients or 492 cancers (4%) who had second-degree relative with breast cancer (2FH+), and 1364 patients or 1443 cancers (12%) with family history regardless of first- or second-degree relative (FH+). Significance was established at a p-value of < 0.05.

Results: Among the family members, sisters were more likely to have treated for breast cancer (38% in FH+ group), followed by mothers (27%), aunts (26%), grandmothers (7%), and daughters (2%). The incidence of developing contralateral breast cancer was significantly higher in 1FH+ group, compared to patients in FH- and 2FH+ groups. No other factors showed any significant difference, including the incidence of cancer in other organs, pathological characteristics, and age of onset, although BRCA1 and BRCA2 mutation may be associated with increased risk of developing breast cancer at younger age. Outcome studies with available data did not show any significant difference in overall survival between FH+ and FH- patients.

Conclusions: A Japanese woman with a positive family history has a higher risk of developing breast cancer than women without any close relatives with breast cancer, similar to the results reported in Western countries where prevalence of breast cancer is higher. Regular checkup of contralateral breast is important for those patients whose first-degree relatives have also been diagnosed with breast cancer.

Study of sentinel lymph node biopsy after preoperative chemotherapy in patients with breast cancer

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Background: Despite the increasing use of both sentinel lymph node biopsy (SLNB) and preoperative chemotherapy (PST) in patients with operable breast cancer, there is still limited information on the feasibility and accuracy of SLNB following PST. In this study, the feasibility and accuracy of SLNB for breast cancer patients with clinically negative lymph nodes after PST were investigated. In addition, conditions that may affect SLN biopsy detection and false-negative rates with respect to clinical tumor response and clinical tumor/nodal status before PST were analyzed.

Methods: Between 2003 and 2008, 200 patients with stage II and III breast cancer previously treated with PST were enrolled in this study. The eligible criteria for PST were (a) primary tumor > 3cm or (b) positive axillary lymph node status on initial examination. FNA biopsy was performed for clinically or ultrasonographically suspicious axillary lymph nodes. The patients then underwent SLNB, which involved a combination of intradermal injection over the tumor of radiocolloid and subareolar injection of blue dye. This was followed by Level I/II axillary lymph node dissection (ALND).

Results: The median patient age was 49 years, and the median primary tumor size was 4.9 cm. The overall SLN identification rate was 94.5% (189 of 200). In 178/189 patients (94%) the SLN accurately predicted the axillary status. Eleven patients had a false-negative SLN biopsies, yielding a false-negative rate of 12.9%. There were no significant differences in the SLN identification rate according to tumor classifications before PST, the clinical nodal status before PST, the clinical tumor response after PST, or pathological response of the tumor after PST, although the SLN identification rate tended to be lower in patients with a T4 primary tumor.

Conclusions: Our data and some reports suggested that SLNB was feasible method for axillary staging in breast cancer patients who received PST even in patients who initially with lymph node positive disease. However, false-negative rate of SLNB in patients with clinical and pathological complete tumor response tended to be higher than other group.

Effect of a nonprotein bioactive agent on the reduction of cyclooxygenase-2 and tumor necrosis factor–α in human intervertebral disc cells in vitro

Object

Neurotropin is a nonprotein extract from the inflamed skin of rabbits inoculated with vaccinia virus. In the present study the authors sought to clarify the focal antiinflammatory effects of Neurotropin in intervertebral disc cells, and these effects were compared with those induced by the selective cyclooxygenase (COX)–2 inhibitor 6-methoxy-2-naphthylacetic acid (nabumetone).

Methods

Six human intervertebral disc specimens were harvested during spinal surgery for lumbar disc herniation. Cells were stimulated with 500 pg/ml of interleukin (IL)–1β in the presence of various concentrations of Neurotropin (0, 10−5, 10−4, and 10−3Neurotropin Units/ml) or 50 μg/ml of nabumetone for 3 hours. The mRNA was extracted for polymerase chain reaction (PCR), and real-time PCR was used to quantify the mRNA levels of COX- 2, tumor necrosis factor (TNF)–α, and phospholipase A2. Cyclooxygenase-2, TNFα, and prostaglandin E2 (PGE2) protein concentrations were each determined by enzyme-linked immunosorbent assay.

Results

Neurotropin was found to significantly suppress the expression of COX-2 and TNFα at mRNA levels as well as the concentration of COX-2 at protein levels in a dose-dependent manner. Nabumetone was found to significantly increase COX-2 at mRNA levels but directly suppress the concentration of PGE2 in culture medium.

Conclusions

Results in this study suggest that Neurotropin has an analgesic effect through the suppression of COX-2 and TNFα in a focal area, and nabumetone shows this same effect through the suppression of PGE2 production. Thus, Neurotropin could decrease pain by blocking the central pain pathway or increasing focal antiinflammatory effects.

Immunohistochemical demonstration of advanced glycation end products and the effects of advanced glycation end products in ossified ligament tissues in vitro

STUDY DESIGN

This study correlates advanced glycation end products with ossified ligament tissues of the cervical spine in vitro.

OBJECTIVE

To investigate the effect of advanced glycation end products on ossification of the spinal ligaments in vitro.

SUMMARY OF BACKGROUND DATA

We have hypothesized that an accumulation of advanced glycation end products in the spinal ligament might result in some observable change in specific growth factors responsible for ossification in the spinal ligaments.

METHODS

Samples of the posterior longitudinal and yellow ligaments were harvested from patients (n = 5) with ossification of the posterior longitudinal ligament, and analyzed for the presence of advanced glycation end products and their receptor advanced glycation end product receptor by immunohistochemistry. Real-time polymerase chain reaction (PCR) was used to quantify the messenger ribonucleic acid (mRNA) levels of bone morphogenetic protein (BMP)-2, BMP-7, alkaline phosphatase, an osteoblast-specific transcription factor 1 (Cbfa1), and osteocalcin from yellow ligament cells treated with advanced glycation end products.

RESULTS

Immunohistochemical analysis revealed that advanced glycation end products and advanced glycation end product receptor were localized to within the posterior longitudinal and yellow ligaments. Advanced glycation end products were found to increase significantly the expression of BMP-2, BMP-7, Cbfa1, and osteocalcin at the mRNA levels after treatment with advanced glycation end products (1 microg/mL).

CONCLUSIONS

This is the first report to investigate the correlation, if any, between the ossified spinal ligament and advanced glycation end products. These results suggested that accumulation in advanced glycation end products and their interaction with advanced glycation end product receptor were 1 of the important risk factors in the process of ossification in the spinal ligaments.

Advanced glycation end-products downregulating intervertebral disc cell production of proteoglycans in vitro

Object

The authors sought to clarify the role, if any, of advanced glycation end-products (AGEs) in disc degeneration.

Methods

Intervertebral discs were analyzed for the presence of AGEs and of their receptor (RAGE) by immunohistochemical analysis. Reverse transcriptase polymerase chain reaction (RT-PCR) was performed to detect any RAGE gene expression, and real-time PCR was used to quantify messenger RNA (mRNA) levels of aggrecan and collagen types I and II in nucleus pulposus cells treated with AGEs. Aggrecan protein concentration was determined by enzyme-linked immunosorbent assay.

Immunohistochemical analysis revealed that AGEs and RAGE were localized in the nucleus pulposus of the intervertebral disc. Advanced glycation end-products were found to significantly suppress the expression of aggrecan at both mRNA and protein levels in a dose- and time-dependent manner. The levels of collagen types I and II remained unchanged after treatments with AGEs.

Conclusions

These results suggest that the accumulation of AGEs and their interaction with their receptor in the nucleus pulposus might result in the downregulation of aggrecan production responsible for disc degeneration.

Positive feedback loop of interleukin-1beta upregulating production of inflammatory mediators in human intervertebral disc cells in vitro

OBJECT

Interleukin-1beta (IL-1beta) induces neurological symptoms in intervertebral disc herniation (IDH). Recently, the existence of a positive feedback loop of IL-1beta, which encourages an inflammatory reaction or degeneration in the cells of tendon, has been reported. The authors hypothesized that there is a positive feedback loop of IL-1beta in the cells of IDH.

METHODS

Eight human intervertebral disc specimens were harvested during spinal surgery for lumbar disc herniation. The cells were stimulated in serum-free medium with or without exogenous IL-1beta. The messenger RNA (mRNA) was extracted for reverse-transcription polymerase chain reaction (PCR) and real-time PCR to quantify the mRNA of endogenous IL-1beta, IL-6, cyclooxygenase-2 (COX-2), and matrix metalloproteinases (MMPs). The cells were then stimulated in serum-free medium with or without exogenous IL-1beta, and then exogenous IL-1beta was removed. After 2, 4, and 6 days, the medium was collected, and enzyme-linked immunosorbent assay was used to measure the protein concentration of endogenous IL-1beta. The mRNA expressions of endogenous IL-1beta, IL-6, COX-2, and MMPs were increased significantly depending on the concentration of exogenous IL-1beta. The protein concentration of endogenous IL-1beta was increased over time.

CONCLUSIONS

There was a positive feedback loop of IL-1beta in the cells of IDH. Furthermore, the productions of IL-6, COX-2, MMP-1, and MMP-3 were upregulated as a result of the increasing concentration of IL-1beta in a positive feedback loop of IL-1beta. The authors concluded that this positive feedback loop of IL-1beta upregulated the production of mediators and thus can cause cessation of symptoms in IDH.

Separation of a process from the neuronal cell body using a thin aluminum foil separator

A new technique using a simple-structured separator is described to separate the end of the process from the cell body (soma) of cultured cells. By this method, stimulation limited to neuronal processes is experimentally possible. The separator is of an oblong shape and consists of two parts: a square bracket-shaped frame made of Teflon and a thin aluminum foil which is stuck on both free ends of frame (bracket) coated with epoxy-resin. The separator is horizontally placed on the dish under microscope to divide the process on the way, so that the free end of the process is outside the oblong separator. This separator is simple and low cost, and does not need a long process, unlike other methods requiring a special culture dish with a micro-groove for growth of the neuronal process (neurite). The new technique could be useful in basic pain research and neurophysiology.

Suppressive effects of low-power laser irradiation on bradykinin evoked action potentials in cultured murine dorsal root ganglion cells

The effects of Ga-Al-As diode laser (830 nm, 16.2 mW) irradiation on the distal portion of the processes of cultured murine dorsal root ganglion (DRG) neurons associated with C-fibers were studied by patch-clamp whole-cell recording of membrane potentials at the cell body. The chemical as well as laser light stimulations were limited to the processes of the neuron isolated from the cell body with a separator. The action potentials elicited by bradykinin (BK) in the cell body were reversibly suppressed by the irradiation of laser light. The laser irradiation may block the conduction of nociceptive signals in primary afferent neurons. The present experimental method offers a simple and easy to use procedure for studying the pain relief effects by laser irradiation.