Extensive rib resection followed by thoracic wall reconstruction using polytetrafluoroethylene mesh and titanium plates for refractory intercostal artery bleeding induced by severe blunt thoracic injury: report of a case.

Massive hemothorax due to multiple rib fractures and intercostal artery (ICA) injuries is one of the most lethal forms of chest trauma. Urgent thoracotomy is required; however, suturing is sometimes difficult owing to the limited operative field in the thoracic cavity and because the transected ICA retracts between the surrounding intercostal muscles. We present a patient with refractory ICA bleeding induced by severe blunt thoracic injury successfully treated with extensive rib resection followed by thoracic wall reconstruction using GORE® DUALMESH® and titanium plates. A 66-year-old woman attempted suicide by diving into the path of a train. She incurred massive left hemothorax associated with multiple rib fractures and severe trauma to her extremities; both upper limbs and left leg at the thigh were nearly disconnected. Initially, she underwent urgent left anterolateral thoracotomy followed by partial lung resection and suture hemostasis of the thoracic wall. Subsequently, interventional radiology was performed for the ICA bleeding, and her extremities except her right leg were amputated. However, because hemothorax persisted, and because of the comminuted fractures, we removed the fifth to eighth ribs, and the ICA vascular sheath was ligated. Resecting multiple ribs caused deformities and lung herniations, although hemostasis was achieved. On the third postoperative day, thoracic reconstruction using Gore-Tex® Dual Mesh and titanium plates was performed. Although a small empyema occurred, it was controlled with antibiotics and drainage. Paradoxical respiration and atelectasis did not occur, and the patient was moved to the hospital for continued care in a lucid state.

Freshly isolated retinal capillaries to determine efflux transporter function at the inner BRB.

Since it has been known that in vitro cell lines for analyzing drug transport at the inner blood-retinal barrier (BRB) do not completely retain several in vivo functions, new ex vivo/in vitro methods to evaluate drug transport across the inner BRB help us understand the role of this barrier in maintaining the homeostasis of vision and regulating drug distribution to the retina. To expand the limitations of existing in vitro approaches, we established a protocol to isolate fresh rat retinal capillaries as ex vivo model of the inner BRB. Fresh retinal capillaries were prepared by applying serial filtration steps and using density gradient centrifugation. We performed mRNA and protein analyses by reverse transcription-polymerase chain reaction and immunostaining that indicated expression of marker proteins such as facilitative glucose transporter 1 and claudin-5 in freshly isolated rat retinal capillaries. We also used fluorescent transporter substrates to characterize functional activity of organic anion transporter (Oat) 3, P-glycoprotein (P-gp), breast cancer resistance protein (Bcrp), and multidrug resistance-associated protein (Mrp) 4 in isolated retinal capillaries. Capillary luminal accumulation of fluorescent substrates of P-glycoprotein and Bcrp was decreased in the presence of transporter inhibitors. Moreover, luminal accumulation of the Oat3 and Mrp4 substrate, 8-(2-[fluoresceinyl]aminoethylthio) adenosine-3',5'-cyclic monophosphate (8-[fluo]-cAMP), was reduced by substrates/inhibitors of Oat3 and Mrp4. In conclusion, our study shows that freshly isolated retinal capillaries retain marker protein expression and transporter functional activity. It is suggested that isolated retinal capillaries are a useful tool to study transport across the inner BRB. Using freshly isolated retinal capillaries, we anticipate applying this approach to determine the role of transporters at the inner BRB during pathophysiological states of the eye and evaluate the drug delivery to the retina.

Mobility and mortality of 340 patients with fragility fracture of the pelvis.

PURPOSE: To investigate prognosis of patients with fragility fracture of the pelvis (FFP) treated in a single trauma unit in Japan. METHODS: We retrospectively investigated 340 consecutive patients with FFP (40 men, 300 women; average age, 82.5 years) treated in our facility from April 2012 to April 2019. Fractures were categorized according to the Rommens classification. Patients' mechanism of injury, existence of hip implant, standing and walking abilities (using the Majeed score), and 1-year mortality rate were evaluated. RESULTS: According to the Rommens classification, there were 84 type Ia, 2 type Ib, 24 type IIa, 78 type IIb, 51 type IIc, 40 type IIIa, 1 type IIIb, 4 type IIIc, 1 type IVa, 51 type IVb, and 3 type IVc fractures. Sixteen patients (4.7%) received surgical treatments. Twenty-eight patients (8.2%) had no memory of a traumatic event, and 61 (18%) had implants from a previous hip surgery. A total of 176 patients (52%) were followed up for ≥ 1 year, and 70 (39.8%) and 67 (38.1%) patients had recovery of standing and walking abilities, similar to those before the injury. The operative group (7/9 = 77.8%) had a higher proportion of patients who regained their standing and walking abilities at the 1-year follow-up than the conservative group. The 1-year mortality rate of the patients who could be followed for ≥ 1 year was 6.7%. CONCLUSION: According to our data, 4.7% of patients were indicated for surgery, and only < 40% of patients were able to regain their pre-injury standing and walking abilities at 1 year after the injury. FFP may greatly affect an elderly's activities of daily living and may lead to prognosis similar to patients with proximal hip fractures. To regain the walking ability of patients with FFP, more aggressive indication of surgical treatment may be considered depending on the patient's background. Further examinations are necessary to determine the surgical indications and treatment protocol for FFP.

Involvement of sodium-coupled neutral amino acid transporters (system A) in l-proline transport in the rat retinal pericytes.

The retinal pericytes contribute to the supply of collagen to the basement membrane, and thus, form the structural support of the blood-retinal barrier. Since l-proline (L-Pro) is a major component of collagen, the uptake of L-Pro is an important process for the synthesis of collagen. This study was aimed to elucidate L-Pro transport mechanism(s) in the retinal pericytes. The transport of [3H]L-Pro was evaluated in the conditionally immortalized rat retinal pericyte cell line, TR-rPCT1 cells. The expression of the candidate transporter was examined by qualitative/quantitative reverse transcription-polymerase chain reaction, immunoblot analysis, and immunostaining. The [3H]L-Pro uptake by TR-rPCT1 cells showed Na+-dependence, Cl--independence, and concentration-dependence with a Km of 810 µM. The substrates for system A, such as 2-(methylamino)isobutyric acid (MeAIB), significantly inhibited the L-Pro uptake, suggesting the involvement of system A in the uptake of L-Pro. Among the subtypes of system A, the mRNA expression levels of ATA2 were the highest in TR-rPCT1 cells. Immunostaining analysis of the isolated rat retinal capillaries containing pericytes indicated the protein expression of ATA2 in retinal pericytes. In conclusion, it is suggested that ATA2, at least in part, is involved in the transport of L-Pro in the retinal pericytes.

Multiple limb compartment syndrome as a manifestation of capillary leak syndrome secondary to metformin and dipeptidyl peptidase IV inhibitor overdose: A case report.

RATIONALE: Capillary leak syndrome is a condition that increases systemic capillary permeability and causes characteristic manifestations such as recurrent hypovolemia, systemic edema, and hemoconcentration. Acute limb compartment syndrome is a possible complication of severe capillary leak syndrome. However, timely diagnosis and prompt treatment are challenging because of atypical presentation. PATIENT CONCERNS: An 18-year-old woman with a history of clinical depression was admitted to our intensive care unit (ICU) because of metformin and vildagliptin overdose. She developed marked vasodilatory shock with recurrent severe hypovolemia and disseminated intravascular coagulation. After urgent hemodialysis and plasma exchange, she started to stabilize hemodynamically. However, her limbs became stone-hard with massive edema. Her serum creatinine kinase level increased to an extremely high level. DIAGNOSIS: Extremities were distended, and her skin developed pallor with blistering. Intramuscular pressure in both forearms and lower legs was significantly elevated. INTERVENTIONS: Decompressive fasciotomy was performed. Hemodialysis was continued because of rhabdomyolyses-induced acute kidney injury. OUTCOMES: The patient was finally able to walk by herself at the time of hospital discharge on day 109. LESSONS: The possibility of acute compartment syndrome should be considered in patients with marked capillary leakage, especially after aggressive fluid resuscitation. It is important to be aware of the compartment syndrome in an ICU setting because communication barriers often mask typical symptoms and make diagnosis difficult.

Primary bipolar hemiarthroplasty as a treatment option for unstable intertrochanteric fractures.

OBJECTIVES: Management of unstable intertrochanteric fractures is challenging, especially in patients with osteoporosis. Comminuted unstable intertrochanteric fractures require postoperative immobilization. Several recent reports have recommended hemiarthroplasty for treatment of unstable intertrochanteric fractures to avoid various immobilization-associated complications. The purpose of this study was to evaluate the functional and clinical outcomes of bipolar hemiarthroplasty for unstable intertrochanteric fractures in older persons. METHODS: Sixty patients aged over 75 years underwent hemiarthroplasty to treat unstable intertrochanteric fractures and were followed up over 12 months. All surgeries were performed by the same surgical team using the standard posterolateral approach. Wires, cables, and plates were used as required. Use of cemented protheses was considered when the lesser trochanter had been displaced. All patients were allowed full weight-bearing as tolerated. Clinical evaluation was based on Harris Hip Scores. RESULTS: The cohort comprised 16 men and 44 women (aged 75-96 years). According to the Jensen classification, 24 fractures were type III, 14 type IV, and 22 type V. Cement was used in 24 patients. At 12 months follow-up, Harris Hip Scores were excellent in 18%, good in 42%, fair in 25%, and poor in 15%. No radiological abnormalities were detected. CONCLUSIONS: Primary bipolar hemiarthroplasty for treating unstable intertrochanteric fractures eliminates the need for prolonged immobilization and permits early ambulation. As reported by others, hip hemiarthroplasty is an effective treatment choice for unstable intertrochanteric femoral fracture in older patients.

Fragility fracture of pelvis caused by amenorrheic osteoporosis operated upon using computed-tomography-3D-fluoroscopy matching navigation system: a case report.

INTRODUCTION: Low-energy trauma fractures of older people cause fragility fractures of the pelvis (FFPs), and secondary amenorrhea triggers osteoporosis that might lead to FFPs. Anorexia nervosa is a major causative factor in secondary amenorrhea, thus, FFPs might be a problem for young anorexia nervosa patients as well as older people. Here, we report a rare case of a young woman with anorexia nervosa who had an FFP, followed by gradual progression of severe sacral deformity. CASE: A 49-year-old woman with hypothalamic amenorrhea (a subtype of secondary amenorrhea) caused by anorexia nervosa fell from a chair. She visited a nearby hospital and was diagnosed with an undisplaced sacral fracture; however, she chose to stay at home since the pain was slight and she could still walk. She fell to the floor several times while injured, and 3 months later, she had walking difficulty accompanied with severe pain, and was admitted to our facility. On radiological examination, she was diagnosed with FFP with severe sacral deformity, and was treated surgically. Because of the severe sacral deformity, a computed tomography (CT)-3D-fluoroscopy matching navigation system was used during surgery to support appropriate placement of percutaneous iliosacral (IS) and transiliac-trans-sacral (TITS) screws. DISCUSSION: To our knowledge, this is the first report of FFP caused by amenorrheic osteoporosis, treated by matching navigation. This matching navigation could be a supportive tool in inserting IS and TITS screws during surgery for FFPs, especially in cases with severe deformity.

A Heart-shaped Sleeve Simplifies Intramedullary Tibial Nail Insertion when Using the Suprapatellar Approach.

The suprapatellar approach for intramedullary tibial nailing has become widely accepted over the past decade. A round sleeve is passed beneath the patella to protect the surface of the patellofemoral joint (PFJ). However, the round sleeve cannot be easily stabilized in the PFJ because it does not conform to the shape of the patellar apex. Consequently, we produced a heart-shaped sleeve to simplify the insertion of the entry sleeve during the suprapatellar approach. Using the new sleeve, the following procedure is used: (1) make a longitudinal 4 cm skin incision proximal to the patella to reach the PFJ, (2) insert the guide pin manually to the ventral edge of the tibial plateau, (3) insert the cannulated trocar along the guide pin, (4) insert the heart-shaped sleeve along the cannulated trocar, (5) remove the cannulated trocar, (6) ream the entry point through the heart-shaped sleeve. Then, continue insertion of the nail in the standard manner. Among 44 patients (29 men, mean age 45.6 years, range 26-87 years) with tibial fractures treated between 2010 and 2015, the first 18 consecutive cases were performed using a round sleeve and the rest were performed using the heart-shaped sleeve. The surgery time until entry reaming commenced was 8.9 min (range 6-12 min) using the round sleeve and 6.2 min (range 3-12 min) using the heart-shaped sleeve (P < 0.05). The heart-shaped sleeve is easily stabilized in the PFJ and greatly simplifies the intramedullary nailing of tibial shaft fractures using the suprapatellar approach.

Effect of Retroperitoneal Pelvic Packing on Pelvic Cavity Pressure: A Cadaveric Study.

Limited clinical evidence demonstrates the effectiveness of direct retroperitoneal pelvic packing for hemorrhage control in pelvic fractures due to the difficulty in measuring pressure on the pelvic walls within the pelvic cavity after retroperitoneal pelvic packing. Using a cadaver model, the authors aimed to assess whether retroperitoneal pelvic packing generates pressure that exceeds the venous return and arterial pressure in the pelvis. The pressure on the pelvic wall was measured in 5 fresh Japanese cadavers. Sensors were placed at 4 points on the pelvic wall, and the pressure at each point was measured after the insertion of each of 3 sponges, per the procedure originally described for direct retroperitoneal pelvic packing. In each specimen, the average pressure across all 4 points on the pelvic wall increased with the addition of each sponge, reaching 12.3±4.5 mm Hg when all 3 sponges were inserted. Furthermore, the pressure at the pelvic floor and posterior pelvic brim increased significantly, whereas the pressure at the anterior and middle pelvic brim increased nonsignificantly. The results of this study suggest that retroperitoneal pelvic packing provides pressure on the pelvic wall that exceeds the venous pressure and is thus effective for the control of venous hemorrhage in pelvic fractures. Currently, the recommended procedure combines external fixation for venous bleeding, transcatheter arterial embolization, and pelvic packing; however, the authors' results suggest that pelvic packing alone may be effective for controlling venous hemorrhage in pelvic fracture. [Orthopedics. 2017; 40(6);e947-e951.].

Crowned dens syndrome: reports of six cases and review of the literature.

Case: We have reported six cases of Crowned dens syndrome (CDS) diagnosed by computed tomography (CT). Presenting cases were three male and three female, aged from 45 to 89 (averaged in 72). Outcome: All cases showed calcification around the dens of axis in CTs. Neck pain in all cases relieved within at least 10 days, treated by non-steroidal anti-inflammatory drugs (NSAIDs) in five cases, and one by acetaminophens. Conclusion: Bouvet et al. first reported CDS in 1985, as acute pseudogout of the neck, which causes neck pain. CDS is a radioclinical syndrome defined by the radiographic calcifications in a crown-like configuration around the odontoid process, accompanied clinically by acute neck pain, often with neck stiffness, fevers and raised inflammatory markers. CDS is thought to be a rare condition; however, it is frequently misdiagnosed. CDS is an important differential diagnosis in patients presenting with acute neck pain.

Double traction method-an easy and safe reduction method for anterior shoulder dislocations, even for non-orthopedic surgeons.

Cases: Forty-three male and 27 female patients with anterior shoulder dislocation, with an average age of 45 years, were treated with the "double traction method". The reduction is carried out by two operators, with the patient in a supine position. The first operator holds the patient's wrist and pulls gently longitudinally. After the patient's muscle spasm adequately subsides, the second operator tows the humerus head laterally by using a towel wrapped around the proximal arm. Outcome: Reduction was successful in 63 patients (90%). No iatrogenic fracture or neurovascular deficit occurred. Conclusion: Movement of the patient's arm position causes pain-related muscle spasm. The double traction method is distinctive compared to other manual relocation maneuvers in that the patient's arm is kept at the same position throughout the whole procedure. This maneuver is an easy and safe reduction method for anterior shoulder dislocations, even for non-orthopedic surgeons. It should be an option worth considering for closed reduction in shoulder dislocations.

A simple reduction technique in intramedullary nailing (MICRONAIL) of distal radius fracture - intrafocal elastic-spring pinning method.

On treating distal radius fracture with intramedullary nailing (MICRONAIL, Wright Medical), completed anatomical reduction is indispensable before inserting the nail. However, complete reduction in percutaneous pinning or in Kapandji intrafocal pinning is troublesome. Thus, majority of the operation time is usually spent on reducing the fracture appropriately. We have commenced the "intrafocal elastic-spring pinning" as a reduction technique and have simplified the reduction prior to nailing. First, curve the 1.5 mm Kirschner wire properly. Next, pins are introduced percutaneously and intrafocally into the marrow cavity. The nail is then inserted in a standard manner. With this technique, an average of 16 consecutive intraoperative surgical times was 32.1 minutes (range, 16-55); apparently shorter than other previous reports. The bending-induced tension in the pins counteracts the postero-lateral displacing forces, and is especially efficient in comminuted or osteoporotic fractures. The nail will just brush aside the elastic pins when the pins interfere with the nail insertion.

Vertical locking of the metacarpophalangeal joint in young adults.

Locking of the metacarpophalangeal joints has been occasionally reported in older adults, but reports of this problem are rare in younger individuals. We report 8 young adult patients with a metacarpophalangeal joint locked in 90° flexion after minor trauma. The cases included 6 little fingers and 2 thumbs in 1 male and 7 female patients aged 16 to 39 years. All were easily reduced closed. We postulate the mechanism of injury.

Inhibition of STAT1 accelerates bone fracture healing.

Skeletal fracture healing involves a variety of cellular and molecular events; however, the mechanisms behind these processes are not fully understood. In the current study, we investigated the potential involvement of the signal transducer and activator of transcription 1 (STAT1), a critical regulator for both osteoclastogenesis and osteoblast differentiation, in skeletal fracture healing. We used a fracture model and a cortical defect model in mice, and found that fracture callus remodeling and membranous ossification are highly accelerated in STAT1-deficient mice. Additionally, we found that STAT1 suppresses Osterix transcript levels and Osterix promoter activity in vitro, indicating the suppression of Osterix transcription as one of the mechanisms behind the inhibitory effect of STAT1 on osteoblast differentiation. Furthermore, we found that fludarabine, a potent STAT1 inhibitor, significantly increases bone formation in a heterotopic ossification model. These results reveal previously unknown functions of STAT1 in skeletal homeostasis and may have important clinical implications for the treatment of skeletal bone fracture.

Vertical locking of the metacarpophalangeal joint of the thumb.

Locking of the metacarpophalangeal (MP) joint of the fingers, though reported infrequently, is not rare in the literature. We will report two rare cases of the MP joint of the thumb locked in 90 degrees of flexion (vertical locking). The first case is a 21-year-old man, punched on his right thumb by his friend, who arrived with his thumb fixed in a flexed position. The X-ray images of the right thumb showed the proximal phalanx subluxation in the palmer side in a vertical position. The second case is a 35-year-old woman with her right thumb accidentally caught in the chain of a key-holder. The locking was easily reduced without anaesthesia in both cases. We assume the mechanism was that the flexion force on the MP joint led to subluxation and the locking occurred due to the tension of the collateral ligament caused by the volar prominence of the radial condyle.