Development of synchronous bilateral lung cancers after esophagectomy for esophageal cancer: report of a case

It is well known that squamous cell carcinoma of the esophagus can be associated with carcinoma of other organs. We report herein the rare case of a 60-year-old man who developed synchronous bilateral lung cancers after undergoing esophagectomy for esophageal cancer. Staged bilateral lobectomy was successfully performed to minimize respiratory complications 3 years after his esophagectomy. This case report serves to demonstrate that aggressive and careful surgical approach with adequate followup offers the chance of long-term survival for patients with multiple primary cancers.

Comparison of new approaches to estimate mechanical output of individual joints in vertical jumps

Conventional calculation of joint power is not effective in order to assess translational motions of human body. Two new approaches were developed in this study to estimate translational mechanical outputs from individual joints. They were applied to the analysis of vertical jump motions of six male subjects. In both cases, body of subjects were modeled with a four mass-points system model, and joints were regarded as motion generators. In one approach, increase of vertical component of ground reaction force (GRF) was decomposed into push-off force of three joints (ankle, knee, and hip joints). This procedure gave an estimation of impulse exerted per leg, as 83-92 N s (95% confidential interval) for squat jump, which was similar to half of the impulse provided to mass center of the body calculated from GRF, 82-88 N s. In the other approach, amount of the power exerted by each joint vertically was estimated by calculating the scalar product of joint reaction force and relative velocity vectors of adjacent segments. This approach gave estimation of vertical work provision per leg, as 201-226 and 141-181 J for squat and counter movement jumps, which were not so different from half of the work provided to mass center of the body calculated from GRF, 209-227 and 137-175 J, respectively. As these approaches make it possible to calculate translational mechanical outputs specifically, they are useful and consistent concerning the analysis of translational motion of human body.

In vitro sorption and desorption of basic fibroblast growth factor from biodegradable hydrogels

In vitro interaction of basic fibroblast growth factor (bFGF) with biodegradable gelatin hydrogels was investigated, focusing on its sorption into the hydrogels and desorption from them. Basic bFGF was sorbed to the hydrogel of acidic gelatin with an isoelectric point (IEP) of 5.0 over time at 4 degrees C, in contrast to that of basic gelatin with an IEP of 9.0 and type I collagen. The bFGF sorption was almost independent of the sorption temperature except for 4 degrees C and the hydrogel water content. Fluorescent microscopic observation revealed that bFGF was sorbed into the interior of the acidic gelatin hydrogel. The binding molar ratio of bFGF to the acidic gelatin was around 1.0. The bFGF sorption to the acidic gelatin hydrogel increased when gelatin was further carboxylated. bFGF was sorbed into the acidic gelatin hydrogel more slowly than into the poly(acrylic acid) (PAAc) hydrogel, probably because of the lower density of negative charge of gelatin. The bFGF sorption decreased with an increase in solution ionic strength, indicating that an electrostatic interaction was the main driving force for bFGF sorption to the acidic gelatin hydrogel. However, even at higher ionic strengths of solution, the sorbed bFGF was not desorbed from the acidic gelatin hydrogel, in contrast to the PAAc hydrogel.

Treatment of brachial plexus injury

A brachial plexus injury is the most severe nerve injury of the extremities. To achieve good results from treatment, correct diagnosis and early nerve repair are mandatory. The brachial plexus should be explored as early as possible if there is an incised wound, if clinical findings or diagnostic imaging indicate that at least one root is avulsed, if there is damage to the subclavian artery, and if there is total-type injury. With an upper-type injury with no clinical signs of a preganglionic lesion, the patient should be treated conservatively for 3 months and if there are no signs of recovery, then the brachial plexus should be explored. During this exploration, recording of the spinal cord evoked potential (ESCP) or the somatosensory evoked potential (SEP) is mandatory to determine the site of injury. Nerve grafting is indicated for a rupture in the root demonstrating a positive ESCP or SEP potential, in the trunk or in the cord. Exploration of the brachial plexus should be extended distally as far as possible to achieve good results after nerve grafting; when this was done more than M3 (MRC grading) power of the infraspinatus, deltoid, and biceps was achieved in more than 70% of our 32, 30, 33 patients, respectively. Results of nerve grafting for the forearm muscles have been very poor. Intercostal nerve transfer is recommended to restore elbow flexion in root avulsion type of injury, with elbow flexion to more than M3 being regained in 70% of our 221 patients. The best results of intercostal nerve transfer were achieved in patients younger than 30 years who received the operation within 6 months after injury. Motor recovery of hand function after intercostal nerve transfer was poor but protective sensation was restored in fingers innervated by the median nerve. The recommended treatment for each type of injury is described according to the results achieved.

Different modes of cell death induced by 5-fluoro-2'-deoxyuridine in two clones of the mouse mammary tumor FM3A cell line

The mode of cell death induced by 1 microM 5-fluoro-2'-deoxyuridine (FdUrd) changed in a wild-type F28-7 clone of mouse mammary tumor FM3A cells after a six-month culture. In the original stocked F28-7 clone, FdUrd-induced cell death was accompanied by necrosis-like cell swelling and DNA fragmentation to 100-200 kbp. In subclone F28-7-A isolated from F28-7 cells, which had been cultured for six months, apoptotic bodies and nucleosomal DNA-ladder fragments were observed with the treatment. Furthermore, we investigated the differences in FdUrd-induced intracellular signals between these clones. In F28-7 cells, FdUrd induced increases in caspase-3-like activity, and the mRNA levels of the c-jun, c-fos and c-myc genes, which were greater and earlier than those in F28-7-A cells. Moreover, intracellular acidification occurred in F28-7-A cells treated with FdUrd, though it was not observed in F28-7 cells. These findings suggest that FdUrd-induced cell death occurred through the death program to cell lysis (necrosis) without apoptosis when the induction of these intracellular signals was very high and when intracellular acidification was deficient. Investigation of the differences in the mode of FdUrd-induced cell death between these clones would be important for elucidating the molecular mechanism of pivotal events guiding cells toward either apoptosis or necrosis.

The molecular mechanisms of 5-fluoro-2'-deoxyuridine induced cell death

The molecular mechanism of cell death induced by 5-Fluoro-2'-deoxyuridine (FUdR) was investigated. FUdR caused cell death to induce dNTP pool imbalance and following DNA double strand breaks in mouse mammary tumor FM3A cells. We isolated a new endonuclease from FUdR-treated cells, named endonuclease S, that played an important role in FUdR-induced cell death. Cells treated with FUdR showed intracellular acidification before cell death formation. We observed that the endonuclease S in acidic cells may lead the DNA fragmentation. On the other hand, we observed that protease inhibitors (such as TLCK, TPCK, PMSF, p-APMSF, Pefabloc SC and Z-Asp-CH2-DCB) blocked intracellular acidification, DNA fragmentation and FUdR-induced cell death. But the inhibitors did not affect dNTP pool imbalance in the cells. These results suggest that proteases act at the point of downstream of dNTP pool imbalance and upstream of the intracellular acidification.

Avulsion injury of cervical nerve roots: enhanced intradural nerve roots at MR imaging

PURPOSE

To study the magnetic resonance (MR) imaging features of intradural nerve roots in avulsion injury of the cervical nerve roots.

MATERIALS AND METHODS

Presurgical gadolinium-enhanced MR imaging was performed in 27 consecutive patients. The images were evaluated for enhancement of the intradural nerve roots and enhancement of the spinal cord surface at the root entry zone ("root stump" enhancement) by two radiologists, who were blinded to the clinical information. Intradural nerve roots were classified as enhanced, normal, or not visible. Root stumps were classified as enhanced or normal. The results were compared with the results of nerve root continuity studies (exploratory surgery with intraoperative recording of somatosensory evoked potentials or neurologic examination).

RESULTS

At the 250 nerve levels (500 nerve roots) studied, 12 enhanced nerve roots and 42 enhanced root stumps were found. Seven enhanced nerve roots and 38 enhanced root stumps were related to preganglionic injury. Results of the kappa test for interobserver concordance on findings of intradural nerve roots and root stumps were 0.55 and 0.93, respectively.

CONCLUSION

Although visualization of nerve roots is a problem, enhanced MR imaging is a noninvasive means of obtaining anatomic information and unique physiologic information on injured intradural nerve roots.

Familial occurrence of hyperplastic callus in osteogenesis imperfecta

There is a hypothesis that hyperplastic callus (HC) in osteogenesis imperfecta (OI) is not merely a rare complication but could actually be inherited, although this idea has not yet been investigated. We described two cases, a mother and son, with mild OI, normal scleral colour and no dentinogenesis imperfecta, who repeatedly had HC in their femur. Familial occurrence of HC was found in 13 cases in 5 families among 21 cases in 7 families with a familial background of OI in the literature (including this report). This is higher than the reported incidence of HC, 1.5% (5 cases of 333), and the mode of transmission is concomitant with autosomal dominant inheritance in all these families. Since a review of 47 cases in the literature shows that HC occurs independently of scleral colour and the degree of bone fragility, it may be an additional criterion for subdivision within each type of the Sillence classification.

Dyggve-Melchior-Clausen syndrome without mental retardation (Smith-McCort dysplasia): morphological findings in the growth plate of the iliac crest

Dyggve-Melchior-Clausen syndrome without mental retardation (Smith-McCort dysplasia) (SM) has clinical and radiographic findings similar to those of Dyggve-Melchior-Clausen syndrome (DMC) except for mental retardation. Iliac crest biopsies from two patients with SM were examined. The lace-like appearance of the iliac crests, which is a characteristic radiological sign of SM and DMC, was caused by bone tissue deposited in a wavy pattern at the osteochondral junction. The growth plate showed abnormal enchondral ossification with no columnarization of chondrocytes. Electron microscopy demonstrated chondrocytes with dilated cisternae of rough endoplasmic reticulum containing fine granular or amorphous material, similar to those reported in cases of DMC. Thus, SM has pathologic changes in common with DMC as a rough endoplasmic reticulum storage disorder, even though the mental condition is different.

Full exposure of the axillary and suprascapular nerves

We describe a method of exposing the whole length of the axillary and suprascapular nerves through a sabre-cut incision. The coracoid process is osteotomised and part of trapezius is detached from its insertions. The posterior deltoid is freed from its scapular origin to expose infraspinatus. We have used this approach to explore combined injuries of the axillary and suprascapular nerves with good results, and no serious complications. Its success depends on a meticulous surgical technique.

RESULTS OF NERVE GRAFTING FOR INJURIES OF THE AXILLARY AND SUPRASCAPULAR NERVES

We report the results in 33 patients who had nerve grafting of the axillary or the suprascapular nerve or of both. There were 32 men and one woman; their mean age was 21 years and the average interval between injury and operation was three months.

At a mean follow-up of 27 months, the deltoid had recovered to M3 or better in 23 of 30 patients (77%) and the infraspinatus in 18 of 25 patients (72%). Shoulder elevation had reached 120° or more in 27 patients (82%), with external rotation of 30° or more in 27 (82%). Twenty-six patients (79%) could reach to the top of their head with their hand.

Recovery of muscle strength, range of movement and shoulder function were satisfactory when surgery was performed within four months of the injury. Early exploration and nerve grafting can lead to a good functional recovery, but thorough exploration and careful repair of both nerves are essential.

Results of nerve grafting for injuries of the axillary and suprascapular nerves

We report the results in 33 patients who had nerve grafting of the axillary or the suprascapular nerve or of both. There were 32 men and one woman; their mean age was 21 years and the average interval between injury and operation was three months. At a mean follow-up of 27 months, the deltoid had recovered to M3 or better in 23 of 30 patients (77%) and the infraspinatus in 18 of 25 patients (72%). Shoulder elevation had reached 120 degrees or more in 27 patients (82%), with external rotation of 30 degrees or more in 27 (82%). Twenty-six patients (79%) could reach to the top of their head with their hand. Recovery of muscle strength, range of movement and shoulder function were satisfactory when surgery was performed within four months of the injury. Early exploration and nerve grafting can lead to a good functional recovery, but thorough exploration and careful repair of both nerves are essential.

[A case of postbulbar duodenal ulcer due to adjuvant chemotherapy after gastrectomy for gastric cancer]

We encountered a rare case of postbulbar ulcer caused by adjuvant chemotherapy after gastrectomy. A 64 year-old woman, who received chemotherapy with CDDP-5-FU after gastrectomy, developed severe hematemesis. Endoscopic examination revealed a gigantic ulcer at the anal site of Vater's papilla. The ulcer was healed with PPI and soft diet.

Arc osteotomy of the humerus to correct cubitus varus

The appearance of the elbow after corrective osteotomy for cubitus varus often is different from that of the unaffected side, even if the carrying angle of the affected side is corrected to match that of the unaffected side. Not only must the carrying angle formed by the humerus and the ulna be corrected, but the lateral shift between the humeral axis and the ulnar axis also should be corrected to achieve a matching appearance after corrective osteotomy. Based on this concept, a technique of arc osteotomy was developed to correct simultaneously both the angle and the lateral shift of the affected elbow joint to match those of the unaffected side. This new method has been used to treat 12 patients. The length of followup averaged 28 months, with a range of 8 to 70 months. The carrying angle was corrected from 22 degrees varus on average to 6 degrees valgus on average, with a difference between the right and left side of 2 degrees on average. No complication was observed during the treatment. The average range of motion of the elbow joint was from 0 degrees extension to 125 degrees flexion preoperatively and from 6 degrees hyperextension to 134 degrees flexion postoperatively.

Nerve grafting in brachial plexus injuries. Results of free grafts in 90 patients

We have assessed the efficacy of free nerve grafts in 90 cases of brachial plexus injury. Relatively good recovery of the elbow flexor and extensor muscles and of those of the shoulder girdle was found but recovery of the flexors and extensors of the forearm and of the intrinsic muscles of the hand was extremely poor. Poor results were found when spinal nerve roots seemed normal to the touch and appeared intact but had abnormal somatosensory evoked potentials or myelography. Recovery of the deltoid and infraspinatus muscles was better when injury had occurred to the circumflex and suprascapular nerves rather than to the plexus itself, perhaps because these nerves were explored in their entirety to determine the presence of multiple lesions. It is important to visualise the entire nerve thoroughly to assess the overall condition. Thorough exploration of the plexus and the use of intraoperative recording of somatosensory evoked potentials are essential.

NERVE GRAFTING IN BRACHIAL PLEXUS INJURIES

We have assessed the efficacy of free nerve grafts in 90 cases of brachial plexus injury. Relatively good recovery of the elbow flexor and extensor muscles and of those of the shoulder girdle was found but recovery of the flexors and extensors of the forearm and of the intrinsic muscles of the hand was extremely poor.

Poor results were found when spinal nerve roots seemed normal to the touch and appeared intact but had abnormal somatosensory evoked potentials or myelography. Recovery of the deltoid and infraspinatus muscles was better when injury had occurred to the circumflex and suprascapular nerves rather than to the plexus itself, perhaps because these nerves were explored in their entirety to determine the presence of multiple lesions.

It is important to visualise the entire nerve thoroughly to assess the overall condition. Thorough exploration of the plexus and the use of intraoperative recording of somatosensory evoked potentials are essential.

Spontaneous anterior interosseous nerve palsy with hourglass-like fascicular constriction within the main trunk of the median nerve

Interfascicular neurolysis was performed in nine patients with spontaneous anterior interosseous nerve palsy. In eight of these patients, an hourglass-like constriction in the fascicles forming the anterior interosseous nerve was found within the main trunk of the median nerve at 2-7.5 cm above the medial epicondyle. The clinical signs and symptoms of these eight patients were similar to those that have been described to isolated neuritis. While the etiology remains unknown, when spontaneous anterior interosseous nerve palsy is suspected to be caused by isolated neuritis, interfascicular neurolysis should be performed to confirm the lesion and to discover whether fascicular constriction is present.

Emerin deficiency at the nuclear membrane in patients with Emery-Dreifuss muscular dystrophy

Mutations in the STA gene at the Xq28 locus have been found in patients with X-linked Emery-Dreifuss muscular dystrophy (EDMD). This gene encodes a hitherto unknown protein named 'emerin'. To elucidate the subcellular localization of emerin, we raised two antisera against synthetic peptide fragments predicted from emerin cDNA. Using both antisera, we found positive nuclear membrane staining in skeletal, cardiac and smooth muscles in the normal controls and in patients with neuromuscular diseases other than EDMD. In contrast, a deficiency in immunofluorescent staining of skeletal and cardiac muscle from EDMD patients was observed. A 34 kD protein is immunoreactive with the antisera--the protein is equivalent to that predicted for emerin. Together, our findings suggest the specific deficiency of emerin in the nuclear membrane of muscle cells in patients with EDMD.

Tenodesis of extensor digitorum in treatment of brachial plexus injuries involving C5, 6, 7 and 8 nerve roots

Restoration of motor function in the hand is difficult in brachial plexus injuries in which the C5, 6, 7 and 8 roots are involved, because there are insufficient motors available for transfer to restore the extensors of the fingers and wrist. We have used extensor digitorum tenodesis in 11 cases and found it effective and simple.

Intercostal nerve transfer to restore upper extremity functions after brachial plexus injury

We report the efficacy of intercostal nerve transfer to restore elbow flexion, shoulder functions, and hand functions. One hundred and twelve patients with loss of elbow flexion were treated with intercostal nerve transfer to the musculocutaneous nerve and 97 (87%) of them regained grade 3 or 4 elbow flexion. Seven patients with loss of shoulder functions were treated with combined intercostal nerve transfer to the axillary nerve and phrenic nerve transfer to the suprascapular nerve, and 4 (57%) of them regained more than 80 degrees abduction and 5 (71%) regained more than 50 degrees external rotation starting with the forearm against the chest. To restore hand functions, intercostal nerves were sutured to the radial nerve or one of its branches in 40 patients and to the median nerve in 10 patients. Motor recovery was poor in both nerve transfers, but protective sensation was regained in the fingers innervated by the median nerve in 9 (90%) of the 10 patients. We conclude that intercostal nerve transfer after brachial plexus injury was a useful procedure to restore elbow flexion and shoulder functions, and for restoring a protective sensation in the fingers.

Brachyolmia: a report of two cases

Brachyolmia is a rare form of skeletal dysplasia characterized by generalized platyspondyly without significant epiphyseal, metaphyseal, or diaphyseal changes in the long bones. Two cases of brachyolmia are reported: one of the Hobaek type, and another of the dominant type. One patient developed linear densities in the femoral necks: The manifestation is thought to be specific to the Hobaek type. Another patient had atlantoaxial instability and failure of ossification of the dens. These complications of brachyolmia have not been previously reported.

Skeletal abnormalities in Satoyoshi's syndrome: a radiographic study of eight cases

Skeletal abnormalities of eight patients with Satoyoshi's syndrome, a rare condition of unknown etiology characterized by progressive muscle spasms, alopecia, and diarrhea, were studied radiographically. Various skeletal changes were observed including metaphyseal lesions, slipping of multiple epiphyses, cystic lesions, acroosteolysis and osteolysis, bone fragmentation at tendinous insertions, fatigue fractures, and early osteoarthrosis. This wide range of lesions is likely to be due to repeated injuries to the growth plates, epiphyses, and tendon attachments in the growing skeleton caused by recurrent vigorous muscle spasms.

A new technique for mismatched nerve suture in direct intercostal nerve transfers

We introduce a new suturing technique for intercostal nerve transfer in brachial plexus injuries. This method allows the anastomosis of nerves of unequal diameter.

Hemolysis of normal human erythrocytes by autologous serum complement

Unsensitized normal human erythrocytes (E) were shown to be lysed when incubated with autologous serum in the presence of zymosan (Zy). The hemolysis proceeded slowly with a relatively constant rate for at least 24 h at 37 degrees C. It was shown that the hemolytic reaction is antibody independent and mediated by complement activation through the alternative pathway and that hemolysis is not due to the decay or inactivation of complement regulators present on the E membrane. The mechanism of the phenomenon was studied by use of several kinds of sera genetically deficient in C3, C5, C7 or C9. The reaction was found to be divided into two stages: in the first step, neither E, C5, C7 nor C9 but Zy, serum factors containing C3 and metal ions are necessary, and in the second step, neither C3 nor metal ions but E, C5, C7 and C9 are necessary. Thus, E seem to be lysed by reactive lysis induced by C5 convertase formed on Zy through alternative complement pathway activation.

Disproportionate short stature, type E brachydactyly and exostoses of tibiae in a patient with an XYY karyotype. A 'new' syndrome?

An 18-year-old male with an XYY karyotype is reported with short stature, normal intelligence and normal personality, in contrast to the XYY syndrome which can be characterized by tall stature, mental subnormality and aggressive behaviour. The patient, in addition, had exostoses of the tibiae bilaterally and type E brachydactyly; this association has not previously been described in patients with the XYY karyotype.

A new tendon transfer for ulnar clawhand: use of the palmaris longus extended with the palmar aponeurosis

A new tendon transfer for ulnar paralytic clawhand, in which the palmaris longus with distal extensions of the palmar aponeurosis is passed under the transverse carpal ligament and fixed to the A-1 pulley of the small and ring fingers, is described. Advantages of the procedure are that there is no loss of function and free tendon grafts are not needed.

Restoration of elbow flexion in root lesions of brachial plexus injuries

A retrospective review of 87 patients with loss of elbow flexion secondary to root injuries of the brachial plexus was carried out. Results of nerve grafting, direct nerve transfer with the intercostal nerve, or tendon transfer were analyzed, and treatment recommendations were developed. Nerve transfer provided good or excellent results for injuries that included avulsion of the C5 and/or C6 roots. Nerve grafts were used successfully in cases of single or combined ruptures of C5 and C6. Tendon transfers provided good or excellent results in C5-C6 or C5-C7 avulsions, where nerve grafting was not possible and transferable muscles had good strength. Somatosensory evoked potentials were necessary to demonstrate nerve root avulsions in cases in which the roots appeared ruptured on visual inspection.

Metachondromatosis: a report of two cases in a family

We have described a 10-year-old Japanese boy and his father with metachondromatosis characterized by multiple exostoses, enchondromas, and periarticular calcification or ossification and reviewed the literature on this condition. The boy developed bilateral epiphyseal changes in the hips mimicking Perthes' disease. These cases are the first Japanese individuals with this disorder. The natural history and the associated disorders of metachondromatosis are also discussed in this paper. Metachondromatosis is an inherited skeletal dysplasia characterized by multiple cartilaginous exostoses, multiple enchondromas, and periarticular calcification or ossification. The mode of inheritance of the disease is autosomal dominant. In 1971, Maroteaux first described the disorder in 6 patients of 2 kindreds. Since then, 22 cases have been reported. However, no Japanese patient with this disorder has been described to date. We herein report a Japanese boy and his father with this rare bone dysplasia. The boy developed bilateral epiphyseal lesions in the femoral heads mimicking Perthes' disease.

Attempted limb lengthening by physeal distraction. Continuous monitoring of an applied force in immature rabbits

The effectiveness of physeal distraction in stimulating bone growth in animals was investigated by force applied to the distal femoral growth plate of immature rabbits. The system was continuously monitored to detect physeal separation. A distraction of 0.25 mm every 12 hours led to physeal separation in five animals. One animal given a 6-kg force and two of seven given a 4-kg force showed physeal separation. All four rabbits given a 2-kg force and five of seven given a 4-kg force did not show a greater increase in length than the control femurs. Bone growth was not stimulated by physeal distraction. Any increase in length of more than the normal growth is attributable to physeal separation.

Developmental changes in the bark lectin of Sophora japonica L

Lectin is the major protein in the phloem tissue of S. japonica. By immunohistochemistry using anti-seed lectin antibody it was demonstrated that the lectin was localized in the ray and the axial parenchyma. Neither lectin nor other cross-reactive materials were observed in the cambium, sieve tubes and companion cells. The distribution and localization changed in relation to tissue development. Lectin content in the bark changed during the year, the average in summer being about 50% of that in winter. The distribution of lectin in the bark in winter was similar from the innermost (youngest) to the outermost (oldest) region. In contrast, in summer the innermost region hardly contained any lectin, and the outermost region contained less lectin than the middle. Lectin localization in tissues and cells differed also depending on tissue age. In new tissue, produced in the current year, lectip was absent in summer, was located in the cytoplasmic layer between cell wall and vacuole in autumn, and sequestered in the vacuoles in winter. On the other hand, lectin in old tissue (formed in the previous year) was located throughout the year mainly within the vacuoles, with only very small contents in the cytoplasmic layer in autumn. Within the outermost (oldest) region, in which the lectin content was low in summer, the cells which bordered the outer bark never contained any lectin in summer. The intracellular localization in autumn in new tissue, determined by immunogold electron microscopy, was in the lumen of the endoplasmic reticulum and vesicles, with gold particles hardly present in the cytoplasm. From these findings we conclude that lectin is synthesized on the endoplasmic reticulum and most vigorously in the new tissue in autumn, and that it is mainly consumed in the outermost bark regions, where dilatation occurs and-or where cork cambium is differentiated.

Direct nerve crossing with the intercostal nerve to treat avulsion injuries of the brachial plexus

One hundred seventy-nine patients with root avulsion brachial plexus injuries were treated with direct nerve crossing with the intercostal nerve and 159 cases were followed more than 1 1/2 years after the operation. When suture was done to the musculocutaneous nerve, 90% of 10 children who had operation within 7 months of injury and 81.8% of 110 adults, younger than 40 years with operation within 6 months of injury regained grade 3 or 4 elbow flexion power. This direct method seems to produce better results than those of nerve crossing, which uses intermediary nerve grafts.

Shoulder arthrodesis by external fixation

The choice of pin site in shoulder arthrodesis after brachial plexus injury is important for efficient external fixation. The pins are inserted into the coracoid process from the anterior aspect and the scapular spine from the acromion. This insertion method holds the scapula more rigid and allows the patient to lie supine. Moreover, it makes it possible to correct the fixation angle after the operation. In 11 cases of brachial plexus injury, solid bony arthrodesis was obtained within three months.

Usefulness of myelography in brachial plexus injuries

Ninety brachial plexus lesions have been examined by myelography and the results classified into six types. These were compared against the level of lesion found at exploration of the brachial plexus with electrophysiological investigations carried out during the operation. The results show that myelography can be a reliable and useful pre-exploratory measure to assess the level of the lesion of each injured root.

Tibial lengthening by epiphyseal distraction

Tibial lengthening by slow distraction of the distal epiphysis using the dynamic axial fixator was performed in 3 patients near to skeletal maturity, in 2 patients with congenital origin and in one with achondroplasia. The obtained lengths were 4.4 cm (17% of the tibial length), 3.7 cm (12%) and 3.6 cm (19%). There were no serious complications. Bone formation at the site of distraction was thought to be periosteal in origin when assessed using X-rays and computerized tomography. There was no radiological evidence that bone at the distracted sites was formed by an apposition from the metaphyseal side which is expected in cases of stimulation of endochondral ossification in the growth plate. There was no further measurable growth at the distracted growth plates after lengthening. This method is useful for limb lengthening near the time of epiphyseal closure.

Brachial plexus injuries. Prognosis of postganglionic lesions

One hundred ninety-eight cases of postganglionic brachial plexus injury with no signs of combined damage to preganglionic sites were treated conservatively. Among them, 50 whole, 32 upper and 13 lower type injuries were followed up for at least 2 years and the course of the progression of the individual muscle was observed. In the whole type, 44% showed good functional recovery, although some of them needed reconstructive surgery. Thirty-eight percent recovered usefully only in the muscles innervated by upper roots. Three out of 50 cases did not recover at all. There were no particular differences between the whole and upper types with regard to the recovery rate of the arm muscles. However, the upper type showed better functional recovery than the whole type. If the muscles innervated by upper roots could gain a strength of M1 before 9 months after injury, and muscles innervated by lower roots reached M1 before 12 months, their final results were more than M3. But muscles with a strength of less than M2 at 18 months did not recover to more than M3. The muscular power at 24 months was almost the same as the final results. About half of the postganglionic brachial plexus injuries which did not combine preganglionic lesions showed favorable spontaneous recovery with conservative treatment. At the exploration of the brachial plexus, if the somatosensory evoked potential test is positive, which negates the possibility of root avulsion, and also if there is no definite discontinuity of the postganglionic nerves, it should be treated conservatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Investigation of brachial plexus injuries by intraoperative cortical somatosensory evoked potentials

With the intention of estimating the extent and site of damage in brachial plexus injuries which involve close to the root outlet and also the distal portion, cortical somatosensory evoked potentials (SEP) were recorded in 21 patients by directly stimulating the exposed brachial plexus. In 38 avulsed nerve roots which showed positive sensory action potentials (SNAP)/nerve action potentials (NAP) in their peripheral part, 15 roots (nine patients) were apparently in continuity and confirmed as root avulsion injury by the absence of cortical SEP. However, 11 roots (ten patients) which showed neither SNAP nor SEP would suggest either extensive lesions involving root and more distal segment or a combination of root avulsion and postganglionic injury. Fourteen patients who showed a positive Tinel's sign had at least one root with a postganglionic type lesion, but cortical SEP evoked by stimulation of the most proximal root zone sometimes revealed a reduced amplitude and prolonged latency. This would indicate the retrograde extension of damage. To confirm the extent and degree of the nerve lesions in brachial plexus injuries, an intraoperative SEP and NAP recording is very useful, practical, and also indispensable.

[An experimental study on the functional recovery of denervated muscles--effects of stump rotation in nerve suture (author's transl)]

There are many factors which affect the end result of nerve suture. Clinically it is said tht rotation of the stumps at suture site has an unfavorable effect upon functional recovery, owing to discrepancies of funicular patterns and inappropriate funicular approximation. In order to evaluate the effect of rotation of the stumps at suture sites, tibial nerves of thirty-three full grown rabbits were used. After the tibial nerve was cut at a point three cm proximal to the popliteal fossa, in one group (20 rabbits) the nerve was sutured without rotation (0 degrees group) and in another group (19 rabbits) with 180 degrees rotation of the proximal stump (180 degrees groups), using epineural technique under operating microscope. Six months later return of nerve function was evaluated electrophysiologically and histologically. Electrophysiological measurements included electromyography, motor conduction velocity and muscle strength stimulating proximal stump. Histological evaluation following weighing included H-E stain, DPN diaphorase stain for muscle and Cajal stain for axon. There were no significant differences between the two groups with regard to the passage rate of axons at the suture site, motor conduction velocity or recovery rate of muscle weight. But muscle strength of the plantaris in the 180 degrees group was significantly weaker than that of 0 degrees group, and in the 180 degrees group, recovery rate of muscle strength was lower than that of muscle weight, though they were the same in the 0 degrees group. Histochemically there was marked fibre type grouping of the reinnervated muscle in both groups. The author concluded that in the rabbits, the rotation of nerve stumps at suture site does not affect the passage rate of axons at the suture site nor maturation of the axon. However, it does impose unfavorable influence upon functional recovery. Further problems may arise for the recovery of complex functions when reconstitution of proprioceptive feed-back system is considered.

Meitens' syndrome

This paper reports on Mietens' syndrome which is characterized by mental retardation, growth failure, flexion contracture of the elbows, dislocation of the radius, abnormally short ulna and radius, bilateral corneal opacity, horizontal and rotational nystagmus, strabismus and a small pointed nose with depressed root. This is the second on the Mietens' syndrome.