Methicillin-resistant Staphylococcus aureus arthritis of the wrist treated with arthrodesis using vascularized fibular transfer: a case report.

There have been few reports of vascularized fibular transfer for septic arthritis of the wrist. We report on a 52-year-old male who presented with methicillin-resistant Staphylococcus aureus (MRSA) arthritis of the wrist following a severe crush injury. We performed on this patient wrist arthrodesis using curettage of the lesion and vascularized fibular transfer with comparatively good results. Arthrodesis of the wrist using vascularized fibular transfer is useful for reconstructing bone destruction or defects accompanying intractable arthritis of the wrist such as caused by MRSA arthritis.

Treatment of subungual glomus tumour.

We reviewed 30 patients with subungual glomus tumours of the hand operated on between 1964 and 1997. Seven patients were male and 23 were female. Their age ranged from 16 to 78 years. A transungual approach was selected in 27 patients, and a periungual approach in three. Pre-operative pain subsided in all of the patients, but recurrence of the pain was observed in nine. Nail deformities were observed in nine patients before surgery. After surgery, it disappeared in three patients, persisted in six, and new deformities developed in five. To avoid recurrence of pain, it is important that the accurate pre-operative localisation of the tumour and a complete extirpation should be performed. To avoid nail deformity, it is better to apply a periungual approach for tumours developing in the peripheral region, and a transungual approach followed by meticulous repair of the nail bed for tumours developing in the central region.

Blood flow and blood volume in the femoral heads of healthy adults according to age: measurement with positron emission tomography (PET).

OBJECTIVE: To deepen understanding of hemodynamics in the femoral head, i.e., the essential factor in clarifying pathogenesis of hip disorders, this study examined blood flow and blood volume in the femoral heads of healthy adults, and their changes with age, by using positron emission tomography (PET). METHODS: In 16 healthy adult males (age: 20-78 years old, mean age: 42 years), blood flow was measured by means of the H2(15)O dynamic study method, and blood volume was measured by means of the (15)O-labeled carbon monoxide bolus inhalation method. RESULTS: Blood flow was 1.68-6.47 ml/min/100 g (mean +/- SD: 3.52 +/- 1.2), and blood volume was 1.67-6.03 ml/100 g (mean +/- SD: 3.00 +/- 1.27). Blood flow significantly decreased (p < 0.01) with age, and blood volume significantly increased (p < 0.05). CONCLUSION: PET was useful in the measurement of blood flow and blood volume in the femoral heads. With age, physiological hemodynamic changes also increased in femoral heads.

Free vascularized toe joint transfer to the hand. A technique for simultaneous reconstruction of the soft tissue.

Twelve patients underwent reconstruction of injured finger joints using our technique of a vascularized transfer of the second toe proximal interphalangeal joint. The age of the patients at operation ranged from 7 to 47 years and the postoperative follow-up was 9 to 48 months. All the joint transfers survived and united with resolution of the preoperative joint pain, deformity and instability. The average range of motion of the reconstructed joints was 59 degrees in the proximal interphalangeal and 54 degrees in the metacarpophalangeal joints. No patient complained of pain or functional deficits in the donor foot.

Double-toe transplantation following temporary insertion of a block of silicone for reconstruction of a traumatic metacarpal defect.

The treatment of the mutilated hand with more than one digit missing and a metacarpal defect is challenging. We used double-toe transfer after temporary insertion of a block of silicone to fill the bony defect.

Microcirculatory hemodynamics during the acute phase of free vascularized muscle allograft rejection.

This study investigated the microcirculatory pattern during acute rejection of a vascularized free muscle graft. Using a new rat cremaster muscle free flap model, isograft transplantation was done between genetically identical Lewis rats (N = 23) and allograft transplantation across a major histocompatibility barrier (Lewis Brown Norway [RT-11 + n] to Lewis [RT-11] rats; N = 24). At days 1, 3, 5, and 7 posttransplantation, microcirculatory measurements were taken of vessel diameter, red blood cell velocity, endothelial edema index, leukocytic-endothelial interaction (rolling, adhering, and transmigrating leukocytes), and capillary perfusion. In the allografts at 5 days the lumen obstruction was 27% greater (p < 0.05) than onset. The number of perfused capillaries decreased by 36% compared with isografts at day 5 (p < 0.05). The number of adhering leukocytes increased significantly in allografts both at day 1 (71%; p < 0.05) and at day 3 (77%; p < 0.05). At day 3, transmigrating leukocytes rose significantly (p < 0.05). Allograft histology showed myocytic destruction and lymphocytic infiltration at day 5. Our results suggest that the microcirculatory signs of acute muscle allograft rejection occurred 24 hours after transplantation, and preceded histological signs of rejection. The critical time for microvascular survival of muscle allografts was 3 days. This procedure allows us to distinguish events related to transplantation trauma from rejection phenomena.

Epidural hematoma of the lumbar spine, simulating extruded lumbar disk herniation: clinical, discographic, and enhanced magnetic resonance imaging features. A case report.

STUDY DESIGN: This case report describes a patient with epidural hematoma of the lumbar spine and progressive intermittent claudication whose imaging findings were similar to those of a patient with extruded disk herniation. OBJECTIVES: To highlight the diagnosis and cause of the lumbar epidural hematoma. SUMMARY OF BACKGROUND DATA: The characteristics of imaging of lumbar epidural hematomas have been reported. To the authors' knowledge, a case of epidural hematoma with leakage of the contrast medium into the mass at discogram has never been reported. METHODS: A case of a lumbar epidural hematoma with 10-15 minutes of intermittent claudication was described. There was no history of major trauma or coagulation disorders. Diagnosis was made using magnetic resonance imaging, myelography, discography, and computed tomography. The magnetic resonance image demonstrated a relatively large, rounded mass posterior to the S1 vertebral body with L5-S1 disc protrusion. A gadolinium-enhanced magnetic resonance image showed a rim-enhancing lesion. A discogram revealed leakage of the contrast medium into the mass. The mass was diagnosed as extruded disk herniation, and surgery was performed. RESULTS: At surgery no evidence of obvious disk herniation was detected, but the encapsulated hematoma was found. CONCLUSIONS: A case of chronic lumbar epidural hematoma in which clinical and imaging findings were similar to those of an extruded lumbar disk herniation was reported. Clinical information and results of imaging studies should be analyzed carefully because the imaging findings of contained epidural hematomas are often quite specific to this condition and can be differentiated from those of extruded disc herniations. Management of chronic lumbar epidural hematoma may be altered by a specific diagnosis.

Delay of the denervation process in skeletal muscle by sensory ganglion graft and its clinical application.

We examined the effects of dorsal root ganglion isografts on the denervation process of skeletal muscle. A segment of sciatic nerve was removed from each of 25 inbred Wistar-Kyoto rats. Fifteen were set aside as controls. In the remaining 10 rats, isogeneic cervical dorsal root ganglia were grafted to the severed distal stump of the common peroneal nerve. Between day 72 and day 286 postoperatively, both controls and recipients were killed after twitch and tetanic tension recording of the extensor digitorum longus was performed. The wet muscle weight and the twitch and tetanic tensions of the denervated extensor digitorum longus in the graft group were significantly greater than those in the control group. The mean area of the denervated tibialis anterior muscle fibers in the graft group also was significantly larger than that in the control group. In electron and light microscopic images, nerve cells along the periphery of each dorsal root ganglion were found surviving with regenerating axons throughout the experimental period. Numerous myelinated axons were observed in the common peroneal nerve of the graft group, and there were significantly more axonal branches in the extensor digitorum longus of the graft group than in the extensor digitorum longus of the control group. Thus sensory nerve fibers from the grafted dorsal root ganglia had certain beneficial effects to slow the denervation process, presumably secreting trophic factors into the denervated muscle. Clinically, we have transferred avulsed dorsal root ganglia in cases of total brachial plexus avulsion directly into denervated skeletal muscle. This procedure, accompanied by nerve crossing procedures, will probably keep denervated skeletal muscle in a better condition until regenerating motor axons from the repair site reach their target muscle.

Flap reconstruction in the upper limb.

The introduction of the free flap and the regional fasciocutaneous flap has added to the methods of skin defect coverage in the upper limb and avoids the disadvantages of conventional flaps. This paper describes the features and indications of regional axial pattern flaps and free flaps for upper limb skin defects. They can be categorised into flaps in the ipsilateral upper limb and flaps from out of the upper limb. Flaps in the upper limb include the lateral arm flap, the radial forearm flap, the posterior interosseous artery flap, the dorsal metacarpal artery flap, and the digital artery flap. Flaps from out of the upper limb comprise the latissimus dorsi myocutaneous flap, the scapular flap, the groin flap and the hemipulp flap. Criteria for flap selection include the patient's age and health, the condition of the skin defects, the location and size of the defects and damage of the deep structure, the patient's cosmetic demand, the surgeon's technical skill and the facilities in the operating room.

A case of steroid-induced osteonecrosis of femoral condyle treated surgically.

The clinical course and the established treatment for steroid-induced osteonecrosis of the femoral condyle have not been clarified yet, mainly because of the limited number of reports. Conservative treatment for steroid-induced osteonecrosis of the femoral condyle has been advocated, because the underlying disease tends to be serious and multiple joints are usually involved. Conservative treatment usually is continued until osteonecrosis becomes extensive and osteoarthritis has progressed enough to justify total knee arthroplasty. Reported here is a case of steroid-induced osteonecrosis of the lateral femoral condyle that, according to preliminary results, was treated successfully with a vascularized bone and periosteal graft.

The diagnostic value of MRI in traumatic brachial plexus injury.

Findings in 34 patients with traumatic brachial plexus injury documented by surgical exploration and intra-operative somatosensory-evoked potentials were correlated with findings on myelography and magnetic resonance imaging (MRI) to determine whether MRI can identify nerve root avulsion. The coronal and sagittal planes were not able to demonstrate avulsion of the individual nerve roots. The axial and axial oblique planes did provide useful information to determine which nerve root was avulsed in the upper plexus, although it was difficult to clearly delineate the lower cervical rootlets. The accuracy of MRI was 73% for C5 and 64% for C6 and that of myelography 63% for C5 and 64% for C6. Thus, the diagnostic accuracy of MRI for upper nerve roots was slightly superior to myelography. Although its primary diagnostic value is limited to the upper nerve roots whose avulsion is relatively difficult to diagnose by myelography, MRI can provide useful guidance in the waiting period prior to surgical exploration after brachial plexus injury.

Experimental challenge for the treatment of Duchenne muscular dystrophy using a vascularized free muscle graft.

Following free vascularized normal muscle graft in mice, a study was made to determine whether dystrophin expression is possible in dystrophin-deficient muscles. In this study, dystrophic C57BL/10 ScSn-mdx mice were used as recipients and normal C57BL/10 ScSn mice as donors. A free vascularized quadriceps muscle 8.0 x 6.0 x 6.0 mm in size was orthotopically transplanted into a muscle defect produced in the recipient mouse. The diameter of the sutured vessels was about 0.4 mm. Transplantation was successful in 7 of 20 mice. At 12 weeks after the transplantation, the grafted muscle was examined by immunocytochemical stain using anti-dystrophin antibody. This study showed that dystrophin was expressed in the transplanted muscle but not in the adjacent recipient quadriceps muscle, suggesting that grafted donor cells with dystrophin failed to migrate into dystrophic muscle cells and fuse together. However, since the grafted normal skeletal muscle successfully survived and normal dystrophin was expressed in almost all the grafted muscle fibers, the possibility was suggested that the function of muscular dystrophy muscle can be compensated by complete replacement with a larger muscle.

Reinnervation of denervated skeletal muscles by grafted dorsal root ganglion.

We examined whether or not the cervical dorsal root ganglion (DRG) of the rat, when isografted and connected to the distal stump of the severed common peroneal nerve, could survive, project axons to the denervated leg muscles, and exert beneficial influences to delay the degeneration of the denervated muscles. Rats in which the muscles were similarly denervated but no DRG was grafted served as the control. After a postoperative period of 72 to 286 days, histological study showed that nerve cells at the superficial part of the grafted DRG survived. Indirect electrical stimulation via the distal stump of the common peroneal nerve produced no contraction of the muscles, indicating that no functional neuromuscular contacts had been reestablished. Direct stimulation of the denervated muscles did elicit contraction, and the isometric twitch and tetanic tensions were significantly much higher in the experimental rats with a grafted DRG than in the control rats. Cholinesterase-silver staining indicated the presence of axons in the denervated muscles, but the axons did not terminate on endplates. Compared with the control muscles, the experimental muscles had significantly more axons, and had atrophied less as indicated by muscle wet weight and histological appearance. These results indicate that the sensory axons can delay the weakening and atrophy of muscles after denervation. We suggest that the sensory axons may exert certain trophic influence on the denervated muscle fibers, though the actual mechanism is unknown.

Experimental irradiation of femoral arteries by carbon dioxide (CO2) laser: morphologic changes under transmission electron microscope (T.E.M.) examination.

In order to study the morphologic changes after CO2 laser irradiation, 42 rat femoral arteries were irradiated under various conditions at different time intervals from zero to three weeks. The arteries were examined under transmission electron microscope (T.E.M.), and 30 mW power and 0.3 to 0.5 mm/sec velocity were considered to be the most suitable for a CO2 anastomosis of small femoral arteries.

Evaluation of arthrography and arthroscopy for lesions of the posteromedial corner of the knee.

Injuries of the posteromedial corner of the knee joint were evaluated using the results of clinical, arthrographic, and arthroscopic examinations in 137 surgically treated patients (137 knees) with injuries of the ACL (acute in 61, chronic in 76). The accuracy of each diagnosis was confirmed by determining the site of the injury during the arthrotomy. A tear of the posteromedial corner of the medial meniscus was present in 40 patients, and an accurate diagnosis was made in 29 patients by clinical examination, in all 40 patients by arthrography, and in 38 patients by arthroscopy. Injury of the posterior oblique ligament was noted in 37 patients, and an accurate diagnosis was made in 15 patients by clinical examination, in 35 patients by arthrography, and in 8 patients by arthroscopy. Lesions of the posterior oblique ligament which were not detected in the arthroscopic examination alone were either rupture at the attachment to the femur or longitudinal tears in the meniscofemoral or meniscotibial portion. The results revealed that arthrography is an important means of evaluation in the diagnosis of injuries of the posteromedial corner of the knee joint.