Feasibility of using a magnetic tracking device for measuring carpal kinematics

While several different methods have been used to measure carpal kinematics, biplanar radiography is generally considered to be the most accurate and popular one. However, biplanar radiography is tedious and so only pseudo-dynamic kinematics can be measured. Recently, magnetic tracking system has been developed for the measurement of joint kinematics which is versatile and easy to use and so the possibility of measuring motions dynamically. In this study, the capability of a magnetic tracking device to accurately measure carpal kinematics was investigated by comparing it with biplanar radiography. The kinematics of the third metacarpal, scaphoid, and lunate in five fresh cadaveric specimens were measured using both methods as the wrists were placed in eight positions. The finite screw rotation of each bone with respect to the distal radius during selecting the seven wrist motions was calculated for both measuring techniques and compared. In general, the kinematics for all three bones measured by using either magnetic tracking device or biplanar radiography was identical and showed no statistical difference. The averaged differences ranged from 0.0 to 2.0 degrees. These differences were due to the potential effect of the weight of the sensors and the interference of the attaching rod to the surrounding tissue. It is concluded that the application of the magnetic tracking device to carpal kinematics is warranted, if proper technical procedures as suggested are followed.

Treatment of flexor tendon sheath ganglions using ultrasound imaging

Forty-one patients with a symptomatic digital mass or swelling of suspected ganglionic origin were examined by ultrasound. Findings were classified into 4 groups: group 1, solitary cyst appearing as a well-defined solitary oval anechoic mass (27 digits); group 2, multiple cysts having multiple oval anechoic masses (3 digits); group 3, solid tumor indicating a heterogeneous hypoechoic mass (6 digits); and group 4, tenosynovitis with no abnormal echoic mass (5 digits). Treatment was determined by lesion classification. In group 1, 26 of the 27 solitary cysts were punctured, and a jellylike material was aspirated from 24 cysts. Postaspiration ultrasound examination revealed that a cyst was still present in 2 cases, and these were excised surgically. In group 2, all the cysts were surgically removed. A ganglion with multiple cysts was confirmed on pathological examination. In group 3, the lesions were removed surgically; among the diagnoses were tendon sheath ganglion, giant-cell tumor of tendon sheath, neurilemmoma, and hemangioma. In group 4, no abnormal masses had appeared at follow-up examination. The 24 patients whose ganglions were treated by aspiration, as well as the 8 patients whose ganglions were excised, were monitored for more than 12 months. None of these 32 patients experienced residual pain or lesion recurrence. These results indicate that ultrasound is useful, in cases in which flexor tendon sheath ganglion are suspected, for assisting in diagnosis and determining whether patients should undergo aspiration or surgical excision.

Endoscopic lithotomy of common bile duct stones with sublingual nitroglycerin and guidewire

OBJECTIVE

In 21 patients, our objective was the endoscopic removal of common bile duct stones by sphincter dilation with the application of sublingual nitroglycerin.

METHODS

Nitroglycerin 0.3-0.6 mg was needed for proper dilation of the orifice and for successful cannulation of the Dormia basket into the bile duct. Cannulation of the Dormia basket was simplified by placing the guidewire in the common bile duct beforehand. Because of possible stone impaction, a mechanical lithotriptor was applied smoothly in two patients.

RESULTS

Complete stone removal was successful in 18 of the 21 (86%) patients. One patient who developed a mild form of acute pancreatitis recovered in a few days by conservative management with drip infusion of protease inhibitor. Blood pressure dropped transiently in a patient receiving nitroglycerin, but the general condition of the patient was stable.

CONCLUSIONS

This procedure was found to be safe, easy, and effective in extracting common bile duct stones.

Occurrence of neuropathic osteoarthropathy of the elbow joint after fixation of the radius nonunion in a patient with syringomyelia

A case of syringomyelia with Chiari malformation is reported that showed neuropathic osteoarthropathy of the elbow joint after fixation of the ipsilateral radius nonunion. No similar case has been reported in the literature.

FREE VASCULARISED FIBULAR STRUT GRAFT FOR ANTERIOR SPINAL FUSION

A vascularised fibular strut graft was used for anterior spinal fusion in 16 patients with spinal kyphosis. The procedure was abandoned in three because of difficulty in establishing a vascular anastomosis and in one because the grafted fibula dislodged two days after operation. One patient died after five days. Of the 11 remaining patients, there were seven males and four females. Their ages at the time of operation averaged 30.9 years (12 to 71). The number of vertebrae fused averaged 6.7 (5 to 9) and the length of fibula grafted averaged 10.9 cm (6.5 to 18).

Average follow-up was 54 months (27 to 84). Bone union occurred at both ends of the grafted fibula in all 11 patients, with an average time to union of 5.5 months (3 to 8). We did not see a fracture of the grafted fibula. Two patients had postoperative complications; the graft dislodged in one and laryngeal oedema occurred two days after operation in the other.

A vascularised fibular strut graft provides a biomechanically stable and long-standing support in spinal fusion because the weak phase of creeping substitution does not take place in the graft.

Left brachial approach for transcatheter arterial embolization therapy in patients with hepatocellular carcinoma

We evaluated the efficacy of the lipiodol-transcatheter arterial embolization (L-TAE) technique for hepatocellular carcinoma (HCC) performed using a left brachial approach. A total of 64 procedures were performed using the brachial route in 53 patients with HCC between 1989 and 1996 using a 4-French catheter and these patients were retrospectively studied. The technical success rate was 95.3%. The overall complication rate was 31.3%: fever of over 38.0 degrees C lasting longer than three days (18.8%), transient neurologic complications (4.7%), and pancreatitis (1.6%). Complications such as lumbago, back pain, and dissection of the celiac artery or its branches, which frequently complicated femoral approaches, were avoided. These data indicate that L-TAE using the left brachial approach may be a safe and effective alternative to the transfemoral approach in patients with HCC.

Free vascularised fibular strut graft for anterior spinal fusion

A vascularised fibular strut graft was used for anterior spinal fusion in 16 patients with spinal kyphosis. The procedure was abandoned in three because of difficulty in establishing a vascular anastomosis and in one because the grafted fibula dislodged two days after operation. One patient died after five days. Of the 11 remaining patients, there were seven males and four females. Their ages at the time of operation averaged 30.9 years (12 to 71). The number of vertebrae fused averaged 6.7 (5 to 9) and the length of fibula grafted averaged 10.9 cm (6.5 to 18). Average follow-up was 54 months (27 to 84). Bone union occurred at both ends of the grafted fibula in all 11 patients, with an average time to union of 5.5 months (3 to 8). We did not see a fracture of the grafted fibula. Two patients had postoperative complications; the graft dislodged in one and laryngeal oedema occurred two days after operation in the other. A vascularised fibular strut graft provides a biomechanically stable and long-standing support in spinal fusion because the weak phase of creeping substitution does not take place in the graft.

Increased expression of cytokines in liver and serum in patients with extrahepatic diseases

To determine whether the liver plays an immunological role in certain extrahepatic disorders, we investigated the expression of interleukin (IL)-1 beta, IL-6, interferon (IFN)-gamma, and tumor necrosis factor (TNF)-alpha in 11 patients who had recovered from cholecystolithiasis, 12 patients with gastric cancer, 20 patients with chronic hepatitis, and 6 healthy controls. Cytokine mRNAs in the liver were detected by semiquantitative reverse transcribed-polymerase chain reaction. Serum cytokines and soluble IL-2 receptor (sIL-2R) were investigated by enzyme-linked immunosorbent assays. Increases in TNF-alpha, IL-6, IL-1 beta, and IFN-gamma mRNAs were found in the livers of patients with extrahepatic diseases. TNF-alpha and IL-6 peptides were increased in the sera of patients with gastric cancer. TNF-alpha in the sera and TNF-alpha mRNA in the liver were correlated in gastric cancer patients. Surprisingly, sIL-2R in the serum of gastric cancer patients was significantly higher than the level in healthy controls. Our findings suggest that the liver produces cytokines in reaction to extrahepatic lesions. Further, the increase in sIL-2R in gastric cancer patients indicates that malignancy may affect the immune network in vivo.

Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement

In order to determine indications for arthroscopic debridement and the management of triangular fibrocartilage complex (TFCC) tears, we reviewed 16 wrists retrospectively. The mean patient age was 30 years, with a range of 20 to 53 years. The follow-up period averaged 35 months. Two groups were identified: post-traumatic tears (n = 11) and degenerative tears (n = 5). The results of arthroscopic debridement were compared and analyzed based on the preoperative and postoperative evaluation of pain, range of motion, grip strength, return to work, patient acceptance, and complications. Failures were further evaluated to determine identifiable lesions or anatomic defects associated with poor results. Patients with positive ulnar variance and lunotriquentral interosseous ligament tears had a poor clinical outcome. Good results correlated with grip strength; all patients with post-traumatic TFCC tears had excellent results, while those with degenerative TFCC tears did poorly.

Scanning of polypoid gallbladder lesions by ultrasonic microprobes using transpapillary catheterization

BACKGROUND AND STUDY AIMS

Polypoid lesions of the gallbladder can be diagnosed by transabdominal ultrasonography and endoscopic ultrasonography. However, the image resolution is limited, and the histopathology of these lesions is difficult to determine. We report here on our preliminary results in four patients using a high-frequency (20 MHz) ultrasonic microprobe introduced into the gallbladder via the transpapillary approach.

PATIENTS AND METHODS

Insertion of the microprobe into the gallbladder through the papilla of Vater was attempted in four patients with gallbladder diseases without preceding endoscopic sphincterotomy.

RESULTS

The lesions in the gallbladder were clearly visualized in three of the four patients. We tried to correlate the characteristic ultrasound findings with the histopathology of the lesions, which were found to be early cancer, adenoma, and adenomyomatosis on histopathology of the specimens after cholecystectomy. No complications occurred.

CONCLUSIONS

High-resolution endoscopic transpapillary ultrasonography of the gallbladder is feasible and safe, and may contribute to the diagnosis of gallbladder diseases, particularly of small polypoid lesions.

Transient and specific expression of a cysteine endopeptidase associated with autolysis during differentiation of Zinnia mesophyll cells into tracheary elements

Endopeptidase activities during the differentiation of Zinnia cells into tracheary elements (TEs) were examined with several peptidyl 4-methyl-7-coumarylamido (MCA) as substrates. The activity that hydrolysed carbobenzoxy-Phe-Arg-MCA (Z-Phe-Arg-MCA) at pH 5 increased in a differentiation-related manner: this activity, which was not observed in freshly isolated mesophyll cells was induced by the combination of alpha-naphthaleneacetic acid (NAA) and 6-benzyladenine (BA) that is necessary for differentiation of TEs, but not by NAA or BA alone. The activity in cells cultured in TE-inductive medium that contained both NAA and BA increased very rapidly between the 48th and 60th hours of culture, when the number of TE increased rapidly. A protease responsible for this activity with a molecular mass of 30 kDa was partially purified from cells which had been cultured in the TE-inductive medium and included many immature TEs. Strong inhibition by [L-3-trans-carboxyoxiran-2-carbonyl]-L-Leu- -agmatin (E-64), and activation by dithiothreitol (DTT) indicated that this protease belongs to a family of cysteine endopeptidases (EC 3.4.22).

Papillary dilation vs sphincterotomy in endoscopic removal of bile duct stones. A randomized trial with manometric function

To circumvent the long-term effects of papillary ablation for extracting common bile duct stones (< 12 mm in diameter) in endoscopic sphincterotomy (EST), endoscopic papillary dilation (EPD) was attempted in 20 patients. To evaluate papillary function before and after the procedures, manometry of the sphincter of Oddi was carried out in 13 with EPD and 10 of 20 patients with EST. Extraction of all stones was successful (100%) in both groups at an equal rate. Repeated numbers of procedures were common in both groups. However, the mean duration of the procedure was high in EPD compared to EST (63 min vs 42 min, P < NS). Adjunctive therapies like mechanical lithotripsy (ML), nasobiliary drainage, and choledochoscopy were included in EPD, while EST required a basket catheter and ML. There was no significant difference on manometry before and after the procedures (P = NS), although papillary function was found to have decreased after the EPD. In contrast, all patients in the EST group lost papillary function after the procedure. Thirty-day morbidity and mortality rate were absent in both groups. Immediate and 2.5-year follow up complications were uncommon in both groups. As a simple method, EPD may be an effective and safe alternative to EST in the management of patients with bile duct stones who require maintenance of papillary function.

[Endoscopic lithotomy using sublingual nitroglycerin]

After medical sphincter dilation using sud-lingual nitroglycerin, endoscopic removal of common bile duct stones in 15 patients was carried out. Complete stone removal was obtained in 14 of 15 patients. Only 0.3 mg to 0.6 mg nitroglycerin was needed to give an enough dilation of the orifice for cannulating the basket catheter into the bile duct. Mechanical lithotriptor was smoothly cannulated in one patient because of possible impaction. Blood pressure was dropped transiently in one patient by nitroglycerin, however, the general condition of the patient was stable. This procedure is safe, easy and effective in preserving sphincter function. Acute cholecystitis, a common complication of persistent gallbladder stone after endoscopic sphincterotomy, may be avoided by employing this method. More clinical studies, on long term and in a large scale of patients, are necessary to reduce complications that usually occur after sphincterotomy.

The Sauvé-Kapandji procedure for osteoarthritis of the distal radioulnar joint

The Sauvé-Kapandji procedure has been performed in 15 patients with primary and secondary osteoarthritis of the distal radioulnar joint. The average age of the patients was 45 years (range, 31-63 years). There were 12 men and 3 women. The follow-up period averaged 2 years and 11 months. Postoperative pain relief was good in all wrists. The preoperative range of motion of the wrist joint averaged 50 degrees extension and 44 degrees flexion. Forearm motion averaged 66 degrees pronation and 64 degrees supination. Postoperatively, the range of motion improved to 55 degrees extension and 51 degrees flexion at the wrist and forearm motion improved to 78 degrees pronation and 82 degrees supination. Although all wrists also showed an increased grip strength and improved range of motion over preoperative values, these did not have statistical significance. Postoperative x-ray evaluation showed an unstable proximal stump and radioulnar convergence in 12 wrists. Our clinical and x-ray film findings suggest that the Sauvé-Kapandji procedure is a satisfactory procedure for patients with osteoarthritis of the distal radioulnar joint.

Hemiresection-interposition arthroplasty for osteoarthritis of the distal radioulnar joint

Hemiresection-interposition arthroplasty of the distal radioulnar joint has been carried out in 12 men. The indication was osteoarthritis with an intact triangular fibrocartilage, or when the fibrocartilage could be reconstructed. The average age was 41 years and average follow up for 53 months. In all the patients, there was relief of pain and a significant increase in movement and in grip strength.

Vascularized fibular graft for bone reconstruction of the extremities after tumor resection in limb-saving procedures

We treated 18 patients (8 males and 10 females) with bone or soft tissue tumors in the extremities by vascularized fibular grafts (VFGs). The average age was 29 years. Two had malignant soft tissue tumors in the forearm (angiosarcoma and synovial sarcoma) and the other 16 had bone tumors [osteosarcoma (8), chondrosarcoma (3), angiosarcoma (1), adamantinoma (1), and giant cell tumor (3)]. Affected sites of the bone tumor cases were tibia (5), femur (5), humerus (3), radius (2), and ulna (1). According to the surgical staging system of Enneking et al. 1 patient was in stage III, 12 in IIB, 2 in IB, and 3 in IA. The surgical margin was curative in 5 patients, wide in 9, marginal in 2, and intralesional in 2. One patient died due to lung metastasis although bone union was obtained by the VFGs. Functional results of the bone reconstruction in the remaining 17 patients were evaluated according to the modified scale of Enneking et al. The VFGs resulted in substantial bone unions in all patients except 1. Bone unions in all 17 patients occurred in less than 10 months. Overall clinical results were satisfactory. Based on a 30-point scale overall clinical results ranged from 10 to 30 points with an average of 21 points. Functional evaluation in the upper extremity were, generally, superior to those in the lower extremity. Postoperative complications were 5 metastases (4 in the lung and 1 in the mediastinum) in 4 patients, 1 recurrence, and 2 fractures after obtaining bone union. One patient died from metastasis.(ABSTRACT TRUNCATED AT 250 WORDS)

Ileal lymphoma in swine

Eleven cases of alimentary lymphoma affecting the ileum were observed among 26 cases of swine lymphoma detected by meat inspection in Kochi, Japan. The ileal lymphomas were located in the Peyer's patches, along with early involvement of regional lymph nodes, and showed a characteristic pattern of follicular invasion leading to diffuse growth. Following the National Cancer Institute Working Formulation, 10 neoplasms were classified as diffuse, large, noncleaved cell lymphomas and one neoplasm was a diffuse, mixed, small to large cell lymphoma. Both types of lymphoma featured numerous intermingled "starry sky" histiocytes. The lymphoma cells tended to infiltrate into the muscular layer of the ileum in an "Indian file" pattern. Two cases also showed transserosal metastasis into the abdomen and leukemic change. The lymphoma cells showed membrane positivity for alkaline phosphatase and diffuse cytoplasmic staining for acid phosphatase and non-specific esterase. Monoclonal intracytoplasmic immunoglobulins were demonstrated in nine neoplasms (IgM-lambda in seven, IgG-lambda in one, and IgG-kappa in one). In the areas of follicular invasion, an attenuated network of follicular dendritic cells was visualized via an antiserum against the beta subunit of S-100 protein. Ultrastructurally, strands of dilatated rough endoplasmic reticulum and scattered or clustered dense bodies were noted. When compared with feline and human alimentary lymphoma, including Burkitt's lymphoma, the present neoplasms possessed distinctive features, such as originating in Peyer's patches, transserosal metastasis, and predominantly large B cell type with IgM-lambda type immunoglobulin expression, although some features were similar.

Extensive subcutaneous calcification of the forearm in systemic lupus erythematosus

We report two cases with long-standing systemic lupus erythematosus (SLE) who developed widespread calcification in subcutaneous tissue and peri-articular structures. To our knowledge only 26 case reports have appeared concerning this abnormality in SLE. However, there has been no report of calcification in an SLE patient in the literature of orthopaedic surgery. The calcifications of the forearm were marginally removed because of pain surrounding them. X-ray analysis revealed that the calcification was made of pure calcium phosphate.

Direct dissolution of gallstones with methyl tert-butyl ether (MTBE) via endoscopic transpapillary catheterization in the gallbladder (ETCG)

In a pilot study of direct dissolution therapy of gallstones with methyl tert-butyl ether (MTBE), endoscopic transpapillary catheterization in the gallbladder (ETCG) was performed. Complete dissolution was seen in 8 out of 12 (66%) patients and partial dissolution was seen in 2 (16%) patients. In one of the 8 complete dissolution patients, combined extracorporeal shock wave lithotripsy (ESWL) and dissolution therapy was carried out successfully. These 8 patients were followed up for 12-20 months with regular ultrasonography. During this period, 1 patient underwent laparoscopic cholecystectomy due to stone recurrence. Thickening of the gallbladder wall was seen in 2 patients, but there were no other complications. Using Tsuchiya's classification based on ultrasound, complete dissolution was seen in type Ia stones. This pilot study suggests that the direct dissolution of gallstones with MTBE via ETCG might be a useful and safe non-invasive treatment in patients with cholesterol stones in preserved gallbladders.

Long-term results of Kienböck's disease treated by triscaphe arthrodesis and excisional arthroplasty with a coiled palmaris longus tendon

Fifteen patients with Kienböck's disease were treated with scaphotrapeziotrapezoidal arthrodesis and lunate excisional arthroplasty with a coiled palmaris longus tendon replacement. Patients were classified into five groups preoperatively according to Lichtman's classification: stage IIIA, 1 patient; stage IIIB, 11; and stage IV, 3. After an average follow-up period of 57 months, the clinical results were evaluated by the method described by Lichtman et al. Twelve patients were rated as satisfactory, and three patients were rated as unsatisfactory. Clinical results were good with regard to pain relief and grip strength, but poor with regard to range of motion of the wrist. Five patients revealed postoperative progression of osteoarthritic changes at the radioscaphoid joint, and this appeared to be a main factor influencing clinical results. Two of these five patients had subsequent wrist arthrodesis. We conclude that stage IIIB is a specific indication for scaphotrapeziotrapezoidal arthrodesis.

Repair and/or reconstruction of scapholunate interosseous ligament in lunate and perilunate dislocations

This study was undertaken to ascertain whether repair and/or reconstruction of the scapholunate interosseous ligament can prevent or reduce the occurrence of carpal instability and improve the clinical results. Thirty-two patients with lunate and perilunate dislocations were treated in the last 12 years. Of the 32, only 2 patients were seen within 4 weeks of injury, and the remaining 30 patients were seen and treated more than 4 weeks after the dislocation. Patients were followed for an average of 5 years. The scapholunate interosseous ligament was repaired and reconstructed in 12 patients (group 1). In 20 patients the ligament was not repaired or reconstructed (group 2). Clinical results were expressed by a modification of the point score method of Green and O'Brien. The scapholunate angles were measured on the lateral x-ray films with the wrist in neutral position. In group 1 clinical results averaged 82 points, while in group 2 they averaged 59 points. The scapholunate angles in group 1 averaged 50 degrees whereas in group 2 they averaged 69 degrees. These clinical and x-ray film results suggest that scapholunate interosseous ligament repair and/or reconstruction can prevent or reduce the occurrence of carpal instability and improve clinical results.