Comparison of early clinical outcome in carpal tunnel release - mini-open technique with palmar incision vs. endoscopic technique with wrist crease incision

BACKGROUND

The purpose of this study was to examine two techniques for Carpal Tunnel Syndrome, mini-Open Carpal Tunnel Release (mini-OCTR) and Endoscopic Carpal Tunnel Release (ECTR), to compare their therapeutic efficacy.

METHODS

Sixteen patients who underwent mini-OCTR in palmar incision and 17 patients who underwent ECTR in the wrist crease incision were included in the study. All patients presented preoperatively and at 1, 3, and 6 months postoperatively and were assessed with the Visual Analogue Scale (VAS) and the Disabilities of Arm, Shoulder and Hand Score (DASH). We also assessed the pain and cosmetic VAS of the entire affected hand or surgical wound, and the patient's satisfaction with the surgery.

RESULTS

In the objective evaluation, both surgical techniques showed improvement at 6 months postoperatively. The DASH score was significantly lower in the ECTR group (average = 3 months: 13.6, 6 months: 11.9) than in the mini-OCTR group (average = 3 months: 27.3, 6 months: 20.6) at 3 and 6 months postoperatively. Also, the pain VAS score was significantly lower in the ECTR group (average = 17.1) than in the mini-OCTR group (average = 36.6) at 3 months postoperatively. The cosmetic VAS was significantly lower in the ECTR group (average = 1 month: 15.3, 3 months: 12.2, 6 months: 5.41) than in the mini-OCTR group (average = 1 month: 33.3, 3 months: 31.2, 6 months: 24.8) at all time points postoperatively. Patient satisfaction scores tended to be higher in the ECTR group (average = 3.3) compared to the mini-OCTR group (average = 2.7).

CONCLUSIONS

ECTR in wrist increase incision resulted in better pain and cosmetic recovery in an early postoperative phase compared with mini-OCTR in palmar incision. Our findings suggest that ECTR is an effective technique for patient satisfaction.

Minimally Invasive Surgery for Trapezoid Nonunion: Case Report and Review of the Literature

We report a case of trapezoid nonunion diagnosed 3 months post injury. A 25-year-old male patient felt continuous wrist pain after being injured. His radiograph showed non-union with sclerotic change and bone resorption. He was planned for surgery, and this was done using a minimally invasive technique. Via a dorsal approach, we percutaneously drilled to the nonunion site and freshened the fracture ends. Bone plugs were harvested from the iliac crest using a bone marrow biopsy needle and packed into the nonunion site. The fracture was then fixed with a cannulated headless compression screw. This procedure could be performed without injuring the ligaments around the trapezoid. The patient was immobilised for 4 weeks, and bone union was achieved 6 months after surgery. He had full range of finger and wrist motion and no pain at the final follow-up. Level of Evidence: Level V (Therapeutic).

Fracture Line Distributions of Undisplaced Distal Radius Fractures in Relation to Rupture of the Extensor Pollicis Longus Tendon

Rupture of the extensor pollicis longus (EPL) tendon is a known complication after undisplaced distal radius fracture (DRF). However, no report has revealed the relationship between EPL tendon rupture and the fracture pattern. Thus, this study aimed to investigate the characteristics of fractures at risk of EPL tendon rupture using fracture line mapping of undisplaced DRFs. This study used computed tomography imaging data of undisplaced DRFs with (n=18) and without EPL tendon rupture (n=52). Fracture lines obtained from 3D reconstruction data were drawn manually after matching with a 2D template wrist model. Fracture maps represented the fracture line distribution by superimposing the fracture lines of all 70 patients. Heat maps showed the relative frequency of the fracture lines as a gradual color change. Fracture lines of cases with EPL tendon rupture were concentrated in the proximal border of Lister's tubercle. By contrast, fracture lines of cases without EPL tendon rupture were relatively dispersed.

A114 UNIFIED MAGNIFYING ENDOSCOPIC CLASSIFICATION (UMEC) FOR GASTROINTESTINAL LESIONS: A NORTH AMERICAN EDUCATION STUDY

Background

Magnification endoscopy and magnification narrow-band imaging are image enhanced endoscopy technologies that may allow for the diagnosis of advanced neoplasia in the GI tract on the basis of imaging characteristics. Recently, the Unified Magnifying Endoscopic Classification (UMEC) has been developed, which unified the criteria for the esophagus, stomach, and colon. UMEC divides optical diagnosis into one of the three categories: non-neoplastic, intramucosal neoplasia, and deep submucosal invasive cancer.

Purpose

The objective of this study is to educate North American endoscopists on the use of the UMEC schema, and to ascertain performance of the UMEC framework among North American endoscopists.

Method

Using UMEC, five North American endoscopists (>1000 procedures) without prior training in magnifying endoscopy independently diagnosed previously collected endoscopic image set of the esophagus, stomach, and colon. The endoscopists were trained on the use of UMEC via an eleven-minute training video with exemplars of each element of UMEC from esophagus, stomach, and colon. All endoscopists were blinded to white-light and non-magnifying NBI findings as well as histopathological diagnosis. The diagnostic performance of UMEC was assessed while using the gold standard histopathology as a reference.

Result(s)

A total of 299 gastrointestinal lesions (77 esophagus, 92 stomach, and 130 colon) were assessed using UMEC. For esophageal squamous cell carcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 65.2% (95% CI: 50.9–77.9) to 87.0% (95% CI: 75.3–94.6), 77.4% (95% CI: 60.9–89.6) to 96.8% (95% CI: 86.8–99.8), and 75.3% to 87.0%, respectively. For gastric adenocarcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 94.9% (95% CI: 85.0–99.1) to 100%, 52.9% (95% CI: 39.4–66.2) to 92.2% (95% CI: 82.7–97.5), and 73.3% to 93.3%, respectively. For colorectal adenocarcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 76.2% (95% CI: 62.0–87.3) to 83.3% (95% CI: 70.3–92.5), 89.7% (95% CI: 82.1–94.9) to 97.7% (95% CI: 93.1–99.6), and 86.8% to 90.7%, respectively.

Image

Conclusion(s)

UMEC is a simple and practical classification that can be used to introduce and educate endoscopists to magnification narrow-band imaging and optical diagnosis.

Please acknowledge all funding agencies by checking the applicable boxes below

CAG

Disclosure of Interest

M. R. A. Fujiyoshi Grant / Research support from: 2022 CAG/AbbVie Education Research Grant, Y. Fujiyoshi: None Declared, N. Gimpaya: None Declared, R. Bechara: None Declared, T. Jeyalingam: None Declared, N. Calo: None Declared, N. Forbes: None Declared, R. Khan: None Declared, M. Atalla: None Declared, A. Toshimori: None Declared, Y. Shimamura: None Declared, M. Tanabe: None Declared, J. Mosko: None Declared, H. Inoue: None Declared, S. Grover: None Declared

The effect of mechanical stress on enthesis homeostasis in a rat Achilles enthesis organ culture model

Tendons and ligaments are jointed to bones via an enthesis that is essential to the proper function of the muscular and skeletal structures. The aim of the study is to investigate the effect of mechanical stress on the enthesis. We used ex vivo models in organ cultures of rat Achilles tendons with calcaneus including the enthesis. The organ was attached to a mechanical stretching apparatus that can conduct cyclic tensile strain. We made the models of 1-mm elongation (0.5 Hz, 3% elongation), 2-mm elongation (0.5 Hz, 5% elongation), and no stress. Histological evaluation by Safranin O staining and Toluidin Blue and Picro Sirius red staining was conducted. Expression of sex-determining region Y-box 9 (Sox9), scleraxis (Scx), Runt-related transcription factor 2 (Runx2), and matrix metalloproteinase 13 (Mmp13) were examined by real-time polymerase chain reaction and immunocytochemistry. Terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate biotin nick end-labeling and live/dead staining and was conducted for evaluation of the apoptosis and cell viability. The structure of the enthesis was most maintained in the model of 1-mm elongation. The electronic microscope showed that the enthesis of the no stress model had ill-defined borders between fibrocartilage and mineralized fibrocartilage, and that calcification of mineralized fibrocartilage occurred in the model of 2-mm elongation. Sox9 and Scx was upregulated by 1-mm elongation, whereas Runx2 and Mmp13 were upregulated by 2-mm elongation. Apoptosis was inhibited by low stress. The results of this study suggested that 1-mm elongation can maintain the structure of the enthesis, while 2-mm elongation promotes degenerative changes.

Effect of difference in fixation methods of tendon graft and the microfracture procedure on tendon-bone junction healing

Background

There are generally two methods of fixation for tendon grafts used in ligament reconstruction: bone tunnel fixation and anchor fixation. The microfracture (Mf) procedure is a technique to induce bleeding from the bone marrow, and the bleeding may contain cells with differentiation potential. However, few studies have compared the effects of the Mf procedure with those of the fixation methods. This study aimed to evaluate the effectiveness of the Mf procedure on two tendon graft fixation methods: histological, gene expression, tendon graft thickness, and mechanical. We especially focused our investigation on junction healing of tendon grafts and bone in the two fixation methods.

Methods

We used 20 rabbits to evaluate tendon and bone healing in a peroneal tendon graft model. The rabbit models were divided into five groups according to the combination of peroneal tendon graft fixation method and Mf technique as follows: control group (C, n = 4), bone tunnel fixation without Mf procedure group (BT − Mf, n = 4), bone tunnel fixation with Mf procedure group (BT + Mf, n = 4), anchor fixation without Mf procedure group (A − Mf, n = 4), and anchor fixation with Mf procedure group (A + Mf, n = 4). All animals were sacrificed at 4 weeks postoperatively. The specimens underwent histological evaluation, mRNA analysis, tendon graft thickness at the tendon-bone junction, and biomechanical testing.

Results

Histological evaluation of the BT + Mf and A + Mf groups showed healing with fibrocartilage formation at the tendon graft-bone junction. The mRNA expression showed significant increase in type 2 collagen, Scleraxis, and SRY-box9 in the BT + Mf and A + Mf groups. In biomechanical tests, the BT + Mf and A + Mf groups showed significantly increased tensile strength compared with the BT − Mf and A − Mf groups (BT + Mf group, 21.6 ± 1.7 N; A + Mf group, 22.5 ± 2.3 N vs. BT − Mf group, 12.3 ± 2.4 N; A − Mf group, 11 ± 2.3 N).

Conclusion

The Mf procedure resulted in fibrocartilage formation at the tendon-bone junction in the BT and anchor fixation and improved the fixation strength at 4 weeks.

Fracture patterns in midshaft clavicle fractures

Current classifications of midshaft clavicle fractures are based on radiography. The aim of the study was to evaluate the fracture pattern of clavicle fractures using 3-dimensional computed tomography (3D CT). A retrospective analysis was performed on CT scans of 65 acute clavicle fractures. Using quantitative 3D CT reconstruction techniques, the fracture of the clavicle was virtually reduced. Based on these reconstructions, a group-based fracture heat map and small fragment heat map, and the location of the most common fracture line were determined. Also, the direction and amount of displacement were evaluated. Three fracture patterns could be distinguished. The primary fracture line in type 1 is going from posteromedial to anterolateral and located between 50% and 68% of the clavicle’s length. In type 2, a transverse fracture line is located around 55%, and in type 3, a superolateral to inferomedial line is located between 47% and 56%. Wedged fracture fragments can be seen in types 1 and 2 and are mainly situated inferiorly. The displacement is similar in all types, but the main direction of displacement is specific for the different types (posterior, anterior, inferior). We can conclude that several fracture patterns can be seen in clavicle fractures. Most fractures are located laterally at the midshaft of the clavicle. Wedged segments are mainly located inferiorly, and at the posterior part of the clavicle, no comminution is ever seen. The direction of displacement depends on the fracture pattern.

Relationship between clinical outcomes and nerve conduction studies before and after surgery in patients with carpal tunnel syndrome

Background

Nerve conduction study (NCS) is the only useful test for objective assessment of carpal tunnel syndrome (CTS). However, the relationship between pre- and postoperative NCS and clinical outcomes was unclear. This study aimed to determine whether pre- and postoperative (6 months) NCS could predict patient-oriented and motor outcomes (6 and 12 months postoperatively) in patients with CTS.

Method

Of the 85 patients with CTS, 107 hands were analyzed from March 2011 to March 2020. All patients underwent open carpal tunnel release and were examined using the disabilities of the arm, shoulder and hand (DASH) questionnaire and grip strength (GS) preoperatively and 6 and 12 months postoperatively. Moreover, NCS was examined preoperatively and 6 months postoperatively. Distal motor latency (DML) and sensory conduction velocity (SCV) were the parameters used for NCS. The correlation coefficient between NCS and DASH or GS was calculated. A receiver operating characteristic curve was utilized to determine the NCS threshold value to predict DASH and GS improvement.

Results

The average scores of GS preoperatively and 6 and 12 months postoperatively were 21.3, 22.3, and 22.8, respectively. On the other hand, the average scores of DASH preoperatively and 6 and 12 months postoperatively were 28.8, 18.3, and 12.2, respectively. The average NCS scores (DML and SCV) preoperatively/6 months postoperatively were 7.3/5.4 and 27.8/36.7, respectively. Preoperative NCS did not correlate with DASH and GS. Postoperative SCV correlated with the change in grip strength (6–12 months, r = 0.67; 0–12 months, r = 0.60) and DASH (0–12 months, r = 0.77). Moreover, postoperative DML correlated with the change in DASH (6–12 months, r = − 0.33; 0–12 months, r = − 0.59). The prediction for the improvement of GS/DASH achieved a sensitivity of 50.0%/66.7% and a specificity of 100%/100%, at an SCV cutoff score of 38.5/45.0 or above. The prediction for improvement of GS/DASH achieved a sensitivity of 83.3%/66.7% and a specificity of 100%/66.7% at a DML cutoff score of 4.4/4.4 or below.

Conclusion

NCS at 6 months postoperatively can be used to predict the improvement of clinical outcome after 6 months postoperatively in patients with CTS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04771-y.

Fracture patterns in midshaft clavicle fractures

Current classifications of midshaft clavicle fractures are based on radiography. The aim of the study was to evaluate the fracture pattern of clavicle fractures using 3-dimensional computed tomography (3D CT). A retrospective analysis was performed on CT scans of 65 acute clavicle fractures. Using quantitative 3D CT reconstruction techniques, the fracture of the clavicle was virtually reduced. Based on these reconstructions, a group-based fracture heat map and small fragment heat map, and the location of the most common fracture line were determined. Also, the direction and amount of displacement were evaluated. Three fracture patterns could be distinguished. The primary fracture line in type 1 is going from posteromedial to anterolateral and located between 50% and 68% of the clavicle's length. In type 2, a transverse fracture line is located around 55%, and in type 3, a superolateral to inferomedial line is located between 47% and 56%. Wedged fracture fragments can be seen in types 1 and 2 and are mainly situated inferiorly. The displacement is similar in all types, but the main direction of displacement is specific for the different types (posterior, anterior, inferior). We can conclude that several fracture patterns can be seen in clavicle fractures. Most fractures are located laterally at the midshaft of the clavicle. Wedged segments are mainly located inferiorly, and at the posterior part of the clavicle, no comminution is ever seen. The direction of displacement depends on the fracture pattern.

The trend of treatment and conveyance system for upper extremity replantation in Japan: A nationwide population-based study from the Japan trauma data bank

BACKGROUND

In Japan, microsurgical skill development and a system to transfer patients to an appropriate hospital for upper extremity amputation have been promoted; however, information about trends of replantation is limited. Therefore, the aim of this study was to clarify the trends in the treatment for upper extremity amputation using the Japan Trauma Data Bank (JTDB).

METHODS

Data derived from JTDB (2004-2015) were used to quantify trends in the volume of replantation for upper extremity amputation including finger amputation. Trauma was diagnosed based on the Abbreviated Injury Scale code; a subgroup of patients who underwent replantation was delineated. We investigated patient demographics, infection rate, and characteristics of treating facilities.

RESULTS

A total of 1240 patients underwent upper extremity amputation. Among these, 510 (41.1%) underwent replantation, and the rate of replantation did not change over the study period. The average age of patients who underwent or did not undergo replantation was 45.5 and 47.2 years, respectively. The proportion of the patients who were transferred to another hospital for treatment significantly decreased between 2004 (28.5%) and 2015 (16.3%) (P < 0.01). Time taken for transfer from the accident site to hospitals increased. The rate of patients who underwent replantation differed among different hospitals; however, higher-volume hospitals were more likely to perform replantation.

CONCLUSION

The rate of patients transferred to another hospital decreased between 2004 and 2015; however, the rate of patients who underwent replantation remained unchanged. This suggests that the number of patients who were transported directly from the accident site to an appropriate hospital has increased, whereas the indication for care in each hospital remains unchanged. Common criteria for amputations are needed to address the differing rates of replantation among hospitals.

AB1050 CLINICAL IMPLICATIONS OF ULTRASONOGRAPHY (US) IN DIAGNOSIS AND MONITORING DISEASE ACTIVITY OF RELAPSING POLYCHONDRITIS (RP) AND COMPARATIVE INVESTIGATION BY US BETWEEN AURICLE OF RP, REPEATED TRAUMA, CELLULITIS AND HEALTHY SUBJECT

Objectives:

To assess the clinical implications of ultrasonography (US) in monitoring disease activity and diagnosis of relapsing polychondritis (RP).

Methods:

Firstly, auricular (n=5) and nasal (n=1) chondritis of six patients with RP were assessed by US before and after treatments. The relationship between US findings and serum markers were evaluated. Moreover, the comparisons of US findings between the auricle of patients with RP (n=5), repeated trauma (n=5), cellulitis (n=2) and healthy subjects (n=5) were also assessed.

Results:

US finding before treatment showed low-echoic swollen auricular and nasal cartilage with increased power Doppler signals (PDS) in all cases of RP. US findings corresponded to biopsy findings. After treatment, the swollen ear and nose completely resolved. Then, US findings also showed dramatic reductions in swollen cartilage with the decrease in PDS. Although serum markers completely improved, US finding remained in 1 of 6 cases, and this case showed flare due to PSL tapering. Finally, RP could be differentiated from the damage of repeated trauma and cellulitis by the presence or absence of PDS and subperichondrial serous effusion.

Conclusion:

US of auricular and nasal cartilage in RP possibly facilitates evaluation of auricular lesions and monitoring of disease activity, especially when we consider the treatment response and the timing of drug tapering.

Disclosure of Interests:

None declared

The Masquelet technique for septic arthritis of the small joint in the hands: Case reports

Septic arthritis in distal interphalangeal (DIP) joints sometimes occurs in association with mucous cysts or after the surgical treatment of mallet fingers. Recently, several studies have demonstrated the effectiveness of the Masquelet technique in the treatment of bone defects caused by trauma or infection. However, only few studies have reported the use of this technique for septic arthritis in small joints of the hand, and its effectiveness in treating septic arthritis in DIP joints remains unclear. We report the clinical and radiological outcomes of three patients who were treated with the Masquelet technique for septic arthritis in DIP joints. One patient had uncontrolled diabetes and another had rheumatoid arthritis treated with methotrexate and prednisolone. The first surgical stage involved thorough debridement of the infection site, including the middle and distal phalanx. We placed an external fixator from the middle to the distal phalanx and then packed the cavity of the DIP joint with antibiotic cement bead of polymethylmethacrylate (40 g) including 2 g of vancomycin and 200 mg of minocycline. At 4-6 weeks after the first surgical stage, the infection had cleared, and the second surgical stage was performed. The external fixator and cement bead were carefully removed while carefully preserving the surrounding osteo-induced membrane. The membrane was smooth and nonadherent to the cement block. In the second surgical stage, an autogenous bone graft was harvested from the iliac bone and inserted into the joint space, within the membrane. The bone graft, distal phalanx, and middle phalanx were fixed with Kirschner wires and/or a soft wire. Despite the high risk of infection, bone union was achieved in all patients without recurrence of infection. Although the Masquelet technique requires two surgeries, it can lead to favorable clinical and radiological outcomes for infected small joints of the hand.

Clinical outcomes of treatment with locking compression plates for distal femoral fractures in a retrospective cohort

Background

Plate fixation is one of the standard surgical treatments for distal femoral fractures. There are few reports on the relationship between the screw position and bone union when fixing by the bridging plate (relative stability) method.

Methods

This retrospective study included 71 distal femoral fractures of 70 patients who were treated with the locking compression plate for distal femur (DePuy Synthes Co., Ltd, New Brunswick, CA, USA). The following measurements were evaluated and analyzed: (1) bone union rate, (2) bridge span length (distance between screws across the fracture), (3) plate span ratio (plate length/bone fracture length), (4) number of empty holes (number of screw holes not inserted around the fracture), and (5) medial fracture distance (bone fracture distance on the medial side of the distal femur). Patient demographics (age), comorbidities (smoking, diabetes, chronic steroid use, dialysis), and injury characteristics (AO type, open fracture, infection) were obtained for all participants. Univariate analysis was performed on them.

Results

Of 71 fractures, 26 fractures were simple fractures, 45 fractures were comminuted fractures, and 7 fractures resulted in non-union. Non-union rate was significantly higher in comminuted fractures with bone medial fracture distance exceeding 5 mm.

Non-union was founded in simple fractures with bone medial fracture distance exceeding 2 mm, but not significant (p = 0.06). In cases with simple fractures, one non-union case had one empty hole and one non-union case had four empty holes, whereas in cases with comminuted fractures, five non-union cases had two more empty holes.

Conclusions

We concluded that bone fragment distance between fracture fragments is more important than bridge span length of the fracture site and the number of empty holes. Smoking and medial fracture distance are prognostic risk factors of nonunion in distal femoral fractures treated with LCP as bridging plate.

Nonunion fragility fracture of the pelvis with complication from bladder rupture: A case report

The incidence rate of bladder rupture associated with pelvic ring fractures is reported to be about 5–10%, mostly occurring at the time of injury. Fragility pelvic ring fractures are reported to increase fracture displacement or become nonunion if they are treated inadequately. Few case reports on bladder rupture associated with fragility pelvic ring fracture have been published. We report a rare case of delayed bladder rupture associated with a fragility fracture of the pelvis.

A 65-year-old female felt right hip pain without sustaining any trauma. She was diagnosed with a right pubic rami fracture. However, her pain deteriorated, and a sacral fracture was identified one month later. She was prescribed teriparatide, but her pain worsened and she was referred to our hospital. She was diagnosed with fragility fracture of the pelvis (Rommens classification type IVb) and was treated operatively. During the surgery, her thin bladder wall, which was compressed by a displaced pubic fragment, was torn and repaired.

This is the first report describing a fragility fracture of the pelvis associated with a bladder rupture. Our treatment led to a successful result.

Role of video capsule endoscopy in patients with constitutional mismatch repair deficiency (CMMRD) syndrome: report from the International CMMRD Consortium

BACKGROUND AND STUDY AIMS

Constitutional mismatch repair deficiency (CMMRD) syndrome, also known as biallelic mismatch repair deficiency (BMMRD) syndrome is a rare autosomal-recessive genetic disorder that has a high mortality due to malignancy in childhood and early adulthood. The small bowel phenotype in CMMRD is not well described and surveillance protocols for small bowel cancer have not been well established. This study was conducted to evaluate the usefulness and clinical impact of video capsule endoscopy (VCE) for small bowel surveillance.

PATIENTS AND METHODS

We retrospectively reviewed the prospectively maintained International CMMRD Consortium database. Treating physicians were contacted and VCE report data were extracted using a standardized template.

RESULTS

Among 58 patients included in the database, 38 VCE reports were collected from 17 patients. Polypoid lesions were first detected on VCE at a median age of 14 years (range: 4 - 17). Of these, 39 % in 7 patients (15/38) showed large polypoid lesions (> 10 mm) or multiple polyps that prompted further investigations. Consequently, three patients were diagnosed with small bowel neoplasia including one patient with adenocarcinoma. Small bowel neoplasia and/or cancer were confirmed histologically in 35 % of the patients (6/17) who had capsule surveillance and the lesions in half of these patients were initially visualized on VCE. Multiple polyps were identified on eight VCEs that were completed on three patients. Ten VCEs (28 %) were incomplete due to slow bowel transit; none required capsule removal.

CONCLUSIONS

Small bowel surveillance in patients with CMMRD should be initiated early in life. VCE has the potential to detect polyps; however, small bowel neoplasias are often proximal and can be missed, emphasizing the importance of concurrent surveillance with other modalities.

MEETING PRESENTATIONS

 Digestive Disease Week 2017 and World Congress of Pediatric Gastroenterology, Hepatology and Nutrition 2016.

Results of Total Elbow Arthroplasty with Cementless Implantation of an Alumina Ceramic Elbow Prosthesis for Patients with Rheumatoid Arthritis

We investigated the long-term clinical results of total elbow arthroplasty (TEA) by cementless fixation of alumina ceramic unlinked elbow prostheses (J-alumina ceramic elbows: JACE) for the reconstruction of elbow joints with rheumatoid arthritis (RA). Seventeen elbows in 17 patients (aged 44-72 years, average 54.8) replaced by JACE TEA without bone cement were investigated. The average follow-up period was 10.7 (range, 1.0-19.3) years. Clinical conditions of each elbow before and after surgery were assessed according to the Mayo Elbow Performance Index (MEPI). Radiographic loosening was defined as a progressive radiolucent line of more than 1 mm that was completely circumferential around the intramedullary stem. The average MEPI significantly improved from 46.8 points preoperatively to 66.8 points at final follow-up (p=0.0226). However, aseptic loosening was noted in 10 of 17 elbows (58.8%) and revision surgery was required in 7 (41.2%). Most loosening was observed on the humeral side. With radiographic loosening and revision surgery defined as the end points, the likelihoods of prosthesis survival were 41.2% and 51.8%, respectively, up to 15 years by Kaplan-Meier analysis. The clinical results of JACE implantation without bone cement were disappointing, with high revision and loosening rates of the humeral component.

First results of electron temperature measurements by the use of multi-pass Thomson scattering system in GAMMA 10

A multi-pass Thomson scattering (TS) has the advantage of enhancing scattered signals. We constructed a multi-pass TS system for a polarisation-based system and an image relaying system modelled on the GAMMA 10 TS system. We undertook Raman scattering experiments both for the multi-pass setting and for checking the optical components. Moreover, we applied the system to the electron temperature measurements in the GAMMA 10 plasma for the first time. The integrated scattering signal was magnified by approximately three times by using the multi-pass TS system with four passes. The electron temperature measurement accuracy is improved by using this multi-pass system.

Occult Compression Fracture of Metacarpal Head without Evidence of Avascular Necrosis

We report a case of 4th metacarpal head collapse of a 19-year-old healthy man. MRI revealed T1 low and T2 high regions in the collapsed 4th metacarpal head, as well as in the right 3rd and left 4th metacarpal head. Our initial diagnosis was occult compression fracture due to avascular necrosis, known as Dieterich's disease. However, pathological findings of surgically resected right 4th metacarpal head were compatible with transient osteoporosis and metacarpal head fracture followed by active tissue repair. The autologous osteochondral transplants from costchondral junction survived and maintained their size and shape even at 10-year follow-up.

Recurrent Stenotrophomonas maltophilia bacteremia after iliac crest bone graft harvest

We describe a rare case of recurrent Stenotrophomonas maltophilia bacteremia in a previously healthy 45-year-old man. The infection was caused by osteomyelitis at the site of an iliac crest bone graft harvest. A genetic analysis using enterobacterial repetitive intergenic consensus polymerase chain reaction (ERIC-PCR) revealed that the blood isolates and pathogens obtained from the surgical wound were identical. Initial treatment with levofloxacin and cefozopran was ineffective, but the patient's infection was successfully treated by long-term administration of latamoxef and trimethoprim-sulfamethoxazole. The present case suggests that attention should be given to the possibility of S. maltophilia infection in any situations.

Variability of parvovirus B19 genotype 2 in plasma products with different compositions in the inactivation sensitivity by liquid-heating

BACKGROUND AND OBJECTIVES

Our previous report showed that parvovirus B19 genotype 1 in different solutions derived from plasma preparations showed different heat-sensitivity patterns during liquid-heating. In this study, we similarly examined B19 genotype 2.

MATERIALS AND METHODS

Two plasma samples one containing B19 genotype 1 and the other genotype 2 DNA were used. Four process samples collected immediately before the heat treatment step in the manufacture of albumin, immunoglobulin, haptoglobin and antithrombin preparations were spiked with B19 and subsequently treated at 60°C for 10 h. A low pH immunoglobulin solution was also spiked with B19 and treated at room temperature for 14 days. Infectivity was then measured.

RESULTS

B19 genotype 2, similar to genotype 1, showed three patterns of inactivation: (i) a rapid inactivation in the albumin and immunoglobulin preparations, (ii) a slow inactivation in the haptoglobin preparation and (iii) only limited inactivation in the antithrombin preparation. Its sensitivity in the low pH immunoglobulin solutions also resembled that of genotype 1.

CONCLUSION

Both genotypes 1 and 2 of B19 varied in sensitivity to liquid-heating and low pH among different plasma preparations.

Biomechanical evaluation of the fixation methods for transcondylar fracture of the humerus:ONI plate versus conventional plates and screws

We biomechanically evaluated the bone fixation rigidity of an ONI plate (Group I) during fixation of experimentally created transcondylar humerus fractures in cadaveric elbows, which are the most frequently observed humeral fractures in the elderly, and compared it with the rigidity achieved by 3 conventional fixation methods:an LCP reconstruction plate 3.5 using a locking mechanism (Group II), a conventional reconstruction plate 3.5 (CRP) with a cannulated cancellous screw (Group III), and a CRP with 2 cannulated cancellous screws (CS) in a crisscross orientation (Group IV). In the axial loading test, the mean failure loads were:Group I, 98.9+/-32.6;Group II, 108.5+/-27.2;Group III, 50.0+/-7.5;and Group IV, 34.5+/-12.2 (N). Group I fixations failed at a significantly higher load than those of Groups III and IV (p<0.05). In the extension loading test, the mean failure loads were:Group I, 34.0+/-12.4;Group II, 51.0+/-14.8;Group III, 19.3+/-6.0;and Group IV, 14.7+/-3.1 (N). Group IV fixations showed a significantly lower failure load than those of Group I (p<0.05). The fixation rigidities against mechanical loading by the ONI plate and LCP plate were comparable. These results suggested that an ONI system might be superior to the CRP and CS method, and comparable to the LCP method in terms of fixation rigidity for distal humerus fractures.

An Asian variant of intravascular lymphoma: unique clinical and pathological manifestation in the gallbladder

We here present a rare case of intravascular lymphoma (IVL) in a Japanese man. 4 months after cholecystectomy due to cholecystitis, a diagnosis of intravascular lymphoma (IVL) was strongly suspected. Lymphoma cells were diffusely observed in the bone marrow parenchyma, but were absent in the vascular spaces. The patient died of respiratory failure and at autopsy a small number of lymphoma cells in the extravascular parenchyma of the adrenal gland and bone marrow were seen. Serial sections of the surgically resected gallbladder retrospectively confirmed the diagnosis of IVL. In addition, congestion and edema were observed in the connective tissue layer. It is possible that edema or ischemia in the gallbladder wall or at other anatomic sites due to the circulation disturbance induced by the intravascular obstruction of lymphoma cells may have caused the initial symptoms. In conclusion, clinicians and pathologists should keep in mind that the gallbladder may be initially involved in IVL.

Bridging necrosis and reticulin bridging fibrosis induced by intrahepatic involvement of acute biphenotypic leukemia

A 47-year-old Japanese woman was diagnosed as having acute biphenotypic leukemia with association of t(9;22)(q34;q11). Cholestatic liver dysfunction arose, and she died of cachexia and intracranial hemorrhage. Autopsy showed unusual hepatic fibrosis. In the liver, bridging infiltration, bridging necrosis and bridging fibrosis by leukemic cells were seen. It seemed that the degree of fibrosis was associated with the number of aggregates of infiltrating leukemic cells. The fibrotic foci were predominantly composed of reticulin and collagen fibers, and distortion of the lobules was observed. Immunohistochemically, dense bundles of alpha-smooth muscle actin (ASMA)-positive stromal cells, namely activated hepatic stellate cells (HSCs), were observed in the immature fibrotic foci as well as along the sinusoids densely infiltrated by leukemic cells. No cells positive for TGF-beta1 or PDGF-BB were identified. In conclusion, extensive intrahepatic involvement by neoplastic cells in adult acute biphenotypic leukemia may cause the unusual "disorganized" hepatic fibrosis.

[Mitral valve repair of valve insuffficiency with broad and complex lesions due to infective endocarditis; report of a case]

Surgical intervention is necessary for the treatment of infective endocarditis, although antibiotic therapy has been shown to be effective for treatment of this disorder. Mitral valve infective endocarditis frequently presents with broad and complex lesions, and thus a variety of valve repair is needed. A 40-year-old woman with mitral valve insufficiency due to infective endocarditis underwent mitral valve repair. During the operation, torn chordae, aneurysm with perforation of the anterior leaflet, and torn chordae of the posterior leaflet were found. The chordae of the anterior leaflet were reconstructed and the aneurysm was excised, and autopericardial patch repair was performed. Then, resection and suturing of the prolapsing lesion of posterior leaflet were performed. Mitral valve repair preserves the left ventricular apparatus and function. Therefore, mitral repair results in better prognosis than valve replacement. The repair of the mitral valve should be attempted for the treatment of valve insufficiency due to infective endocarditis.

[Infarct exclusion for postinfarction left ventricular free wall rupture with severe congestive heart failure]

A 70-year-old man was transferred to our hospital with severe congestive heart failure and ventricular arrhythmia due to acute myocardial infarction. He had experienced chest pain 3 weeks previously and was admitted to another hospital for dyspnea, where he required assist ventilation, 1 week prior to the transfer. An echocardiogram revealed a broad anteroseptal infarction and very poor left ventricular function with an ejection fraction (EF) of 22%. He remained in a severe congestive heart failure condition despite a full administration of catecholamines. Coronary angiogram findings revealed an occlusion of the proximal left anterior descending coronary artery and 1 week later severe hypotension was suddenly presented. An echocardiogram showed pericardial effusion with signs of cardiac tamponade. A pericardiocentesis was performed and hemodynamic improvement was obtained for a short time, after which the patient underwent urgent open heart surgery. During the operation, exclusion of the anteroseptal akinetic area using an oval patch was performed under a cardiopulmonary bypass and ventricular fibrillation. Severe cardiac failure remained postoperatively and the patient could not be weaned from cardiopulmonary bypass, therefore, we implanted a percutaneous cardiopulmonary support (PCPS) and started intraaortic balloon pumping (IABP). The patient was weaned from PCPS at 26 days after surgery and from IABP at 30 days. Following hospital release, he has continued to do well without heart failure for 39 months after the operation.

[Critical hypertrophic obstructive cardiomyopathy patient with improved hemodynamics following mitral valve replacement: report of a case]

A 75-year-old man with dyspnea was admitted to our hospital in critical condition. Catheterization showed normal coronary arteries and good left ventricular function. Transesophageal echocardiography showed left ventricular hypertrophy and severe mitral regurgitation. We decided to perform mitral valve replacement because the patient was in critical condition and it was necessary to complete the operation smoothly. During the operation, we could see the dilated mitral valve annulus and hypertrophic mitral valve, which was restricted. The patient's hemodynamics showed improvement after mitral valve replacement with a mechanical prosthesis, and he was discharged on postoperative day 21. In conclusion, mitral valve replacement is a beneficial method for the treatment of patients with critical hypertrophic obstructive cardiomyopathy.

[Mitral valve plasty and coronary artery bypass grafting under beating heart cardiopulmonary bypass for severe left ventricular dysfunction; report of a case]

A 54-year-old man with ischemic mitral regurgitation and severe heart failure due to broad myocardial infarction successfully underwent mitral valve plasty and coronary artery bypass grafting under beating heart. He had an old anterior myocardial infarction and was admitted to our hospital with acute inferior myocardial infarction. Two weeks later, the cathetelization revealed moderate mitral regurgitation and triple vessel coronary artery disease. We selected antegrade continuous blood perfusion for myocardial protection on operation. He recovered uneventfully and discharged on postoperative day 31. We could perform this procedure safety and satisfactorily, we could this procedure for heart valve operation with other complications.

[The efficiency of nifekalant hydrochloride for the prevention of ventricular tachycardia during cardiac surgery]

Many cases have been successfully treated by us with experimented nifekalant hydrocholoride to prevent ventricular tachycardia (VT) during cardiac surgery. The 13 patients who underwent cardiac surgery at our hospital from 1999 to 2002 were retroactively given nifekalant hydrocholoride against VT. Lidocaine hydrochloride was not effective for VT, and it was difficult for 3 patients to be weaned for cardio-pulmonary bypass, while 6 patients needed aortic balloon pumping or percutaneous cardio-pulmonary support. Nifekalant hydrochloride suppressed VT induction in 9 patients (69.2%). Blood pressure and heart rate did not change, but QTc intervals were significantly increased with nifekalant hydrochloride (p < 0.005). Proarrhythmic events (Torsades de pointes) occurred in 2 patients, but none of the cases showed drug-induced worsening of cardiac function. Nifekalant hydrochloride is a class III antiarrhythmic drug that has been found to be effective against VT and ventricular fibrillation. While class I antiarrhythmic drugs are usually ineffective and induce severe heart failure, nifekalant hydrochloride can be effective.

[Apico-aortic conduit for severe aortic stenosis in elderly]

We described a case of an 84-year-old woman with end stage aortic stenosis in whom favorable results were obtained after constructing apico-aortic conduit bypass. The patient admitted due to complete atrio ventricular(AV) block and respiratory insufficiency. Although a permanent pacemaker was implanted, heart failure did not improve. Echocardiograms showed small aortic annulus and severe calcific aortic stenosis with a measured trans valve gradient of 100 mmHg. Since cardiac failure deteriorated and she lapsed into hypotension and acute renal failure, an emergency operation was performed. The left lateral thoracotomy was performed with cardiopulmonary bypass. A bioprosthetic valved conduit was anastmosed to the left ventricle apex. Another graft was anastomosed to the discending thoracic aorta. The operation was completed by anastomosing the tailored ends of the grafts together. Although the patient required hemodialysis for 2 weeks after operation, she was discharged on 57th day after operation without any complications. Apico-aortic conduit is considered to be an useful procedure for elderly patients who were not good candidates for conventional valve replacement.

[Usefulness of silicone blake drains after cardiac surgery]

In the present study, the drainage system consisting of a silicon blake drain and a portable suction reservoir (J-vac system) was applied to the patients who received cardiac surgery (SD group). Postoperative drainage volume, postoperative pericardial effusion volume, and postoperative length of hospital stay in SD group were compared with those in the patients who received cardiac surgery and were applied a conventional chloroethlene drain (CD group). There were no significant differences in postoperative drainage volume, postoperative pericardial effusion volume, or postoperative length of hospital stay between SD and CD groups. Therefore, its was thought that a silicon back drain could be safely used as a drainage system after heart surgery. Recently the development of less-invasive cardiac surgery made the early hospital discharge possible, and J-vac system might be very useful in view of its portability under such clinical settings.

[Economic evaluation of off-pump coronary artery bypass grafting; compared to conventional coronary artery bypass grafting]

This study was undertaken to compare economic outcomes of off-pump coronary artery bypass grafting (off-pump CABG: OPCAB) and conventional CABG (CCABG). We reviewed the medical records of 5 patients with ischemic coronary disease (IHD) who underwent OPCAB and 5 patients with IHD who underwent CCABG. A hospital income which was based on a current Japanese health insurance system was indicated. There were significant differences in total cost (OPCAB = 208,200 +/- 7,383 yen versus CCABG = 324,300 +/- 10,290 yen, 35.8% decreased), costs of medical materials and transfusions (OPCAB = 14,760 +/- 3,270 yen versus CCABG = 87,540 +/- 3,326, 81.3% decreased) and charges of surgery and anesthesia (OPCAB = 130,400 +/- 1,853 yen versus CCABG = 147,650 +/- 4,167 yen, 12% decreased) OPCAB markedly reduces the cost of hospitalization. But charges of surgery and anesthesia of OPCAB seems to be valued properly in a current Japanese health insurance system.

[Clinical outcome of emergency off-pump coronary artery bypass grafting]

From January 2001 to January 2003, we performed 25 emergency off-pump coronary artery bypass grafting (CABG) procedures for patients with acute myocardial infarction (AMI) or unstable angina pectoris. During the same period, we also performed 2 emergency on-pump beating CABG procedures for patients with left main coronary trunk (LMT) shock syndrome. For the present study, we evaluated the operative results of the 25 cases of emergency or urgent off-pump CABG. The patients were divided into 3 groups, those with acute AMI with cardiogenic shock (group 1; n = 8), acute myocardial infarction without shock (group 2; n = 8), and unstable angina (group 3; n = 9). There were no differences between groups 1 and 2 with regard to age, number of diseased vessels, and preoperative use of an intraaortic balloon pump, however, patients in group 1 had a higher number of completely obstructed coronary arteries. Patients in groups 1 and 2 underwent off-pump CABG within 3.5 hours after a coronary angiography or coronary intervention procedure, while those in group 3 underwent off-pump CABG within 2 days of coronary angiography. The mean number of grafts per patient was 1.8, 2.1, and 2.3 in groups 1, 2, and 3, respectively. One group 1 patient with an LMT lesion was transferred to on-pump beating CABG because of hemodynamic instability. The 30-day mortality rate was 38% (3 of 8) in group 1, whereas it was 0% in groups 2 and 3. Intubation time, ICU stay, and postoperative stay were similar among the 3 groups. An early angiographic study was undertaken in all surviving patients and the results demonstrated patency in all of the examined grafts. Although our results are limited, emergency off-pump CABG was found to be safe and feasible for AMI without cardiogenic shock or unstable myocardial ischemia. However, the outcome of this procedure for patients with preoperative cardiogenic shock was not satisfactory, therefore, a combination therapy of appropriate mechanical circulatory support, prior revascularization by catheter intervention, and emergency surgical revascularization are considered to improve survival of those patients.

[Aortic valve replacement with a freestyle stentless valve using the modified subcoronary technique and hemiarch replacement for bicuspid aortic valve and ascending aortic aneurysma; report of a case]

An association between bicuspid aortic valve disease and ascending aortic aneurysma has long been recognized. Root replacement with a composite valve graft for such disease is a well-established technique. But it may involve serious technical difficulties, and may be a more time-consuming procedure than separate valve replacement and graft replacement. We performed an aortic valve replacement with Freestyle stentless valve using the modified subcoronary technique and hemiarch replacement for a 72-year-old man with severe aortic stenosis and ascending aortic aneurysma. Angiographic studies after surgery showed no residual aortic regurgitation (AR) and no deformity of aorta. This technique is an acceptable option for an aortic disease and ascending aneurysma in elderly patients.

[Graft holding system; a new device for coronary artery bypass grafting]

A new graft holding system for coronary artery bypass grafting was described. This system was an application of a memo-clip, which was composed of a flexible arm and 2 paper clips at both ends. A graft was wrapped by a piece of sponge and pinched indirectly by one of the clips. The other clip was fixed at an edge of the sternal retractor. Regardless of the size of the graft or the amount of the surrounding tissue, the graft can be fixed securely at one's pleased position due to a flexible arm of the device. Intimal injury can be avoided referring to the gentle holding of a piece of sponge. It enables us to place precise stitches and to minimize handling, anastomosis time, and leakage.

Recurrent palmar dislocation of the distal radioulnar joint. A case report

Recurrent palmar dislocation of the distal radioulnar joint is not a common injury. We report one case in a 73-year-old female. This injury was incorrectly diagnosed at the first presentation because there has been no distinct deformity at the wrist and extension-flexion was normal. The need for proper physical examination and accurate radiographic positioning is stressed. Distal diaphysis resection combined with distal radioulnar arthrodesis (modified Sauve-Kapandji procedure) was the preferred method of treatment in an old patient. Two years after the injury, the patient was asymptomatic.

Hamatometacarpal fracture-dislocation: distinctive three dimensional computed tomographic appearance

We report here two fully documented cases of hamatometacarpal fracture-dislocation following trauma and treated in our hospital. In our cases, the patients suffered hamate fracture in association with metacarpal dislocation. In the first case, a dorsal oblique fracture of the hamate was associated with a dorsal dislocation of the base of the fourth metacarpal. In the second case, a dorsal oblique fracture of the hamate was not associated with a dorsal dislocation of the base of the fifth metacarpal. This diagnosis should be suspected on initial review of plain radiographs, which must include an oblique view because of diagnostic difficulty for this injury. We recommend three dimensional computed tomography (3D-CT) in any patient presenting with pain after blunt trauma to the hand to prevent in diagnosis. Open reduction and internal fixation of the fracture is indicated and relevant for displaced fracture.

Cervical fracture of the anterior and posterior elements without evidence of neurological deficit. A report of three cases

We present three cases of cervical spinal fracture, involving two columns without an obvious neurological deficit. Usually if two of three columns are fractured, the injury is considered unstable structurally and clinically. Fortunately our cases did not involve sensory or motor impairment because of an enlargement of the spinal canal.

Methods for determination of milt protein and epsilon-polylysine in food additive preparations and processed foods by capillary zone electrophoresis

A simple and rapid method using capillary zone electrophoresis (CZE) for the determination of milt protein (MP), which contains mainly protamine, and polylysine (PL) in food additive preparations and processed foods was developed. CZE separation was performed on poly(vinyl alcohol)-coated capillaries at a column temperature of 20 degrees C with 120 mmol/L phosphate buffer (pH 2.5) as the running buffer. The influence of various components in food additive preparations on CZE analysis of MP and PL was examined. Egg white lysozyme, glycine, sodium acetate, glycerol, fumaric acid, calcium carbonate, dextrin, emulsifiers and sodium polyphosphate and pyrophosphate had no effect. No peak of protamine was detected in preparations containing metaphosphate. The analysis method for processed foods was composed of extraction with 4% formic acid, precipitation of macromolecular compounds with ethanol, concentration in a water bath and determination by CZE. The average recoveries were 108.4% for protamine sulfate (PS) in red bean sticky rice, and 81.3% for PL in white rice, 118% in egg sandwiches, and 115% in shiraae. The limits of detection of PS in red bean sticky rice and PL in white rice were both 50 ppm.

[Daily intake of isoflavones based on the market basket method]

Daily intake of isoflavones (daidzin, glycitin, genistin, daidzein, glycitein, and genistein) was determined quantitatively, based on the market basket method. Acid hydrolysis during extraction of foods was chosen to convert phytoestrogenes into the respective aglycons, facilitating HPLC analysis and allowing quantitation of total isoflavones as aglycones including both originally present glycosides and "free" aglycones. The isoflavones were extracted from samples with methanol and determined by reversed-phase HPLC analysis using a linear gradient of methanol-water as the eluent. From the results of hydrolysis, the daily intake of total isoflavon was 38.1 mg/adult Japanese. The values obtained by the market basket method and the National Nutrition Survey method were similar.