Hiroaki Ueba

Ultrasound-Assisted Closed Reduction of Distal Radius Fractures

PURPOSE To assess the accuracy and ability of ultrasound for monitoring closed reduction for distal radius fractures. METHODS Consecutive patients undergoing ultrasound-guided closed reduction of acute, displaced distal radius fractures between January 2003 and December 2006 at our department were enrolled. The control group was extracted from patients who underwent a closed reduction for similar fractures under fluoroscopy or without any imaging assistance. To confirm the accuracy of the ultrasonography measurements, displacement distance values were compared with those on radiographic imaging before and after reduction. X-ray parameters for pre- and postreduction, reduction time, total cost, and success rate were compared between the ultrasound-guided and the control groups. RESULTS The ultrasound-guided group consisted of 43 patients (mean age, 68 y) and the control group consisted of 57 patients, which included 35 patients (mean age, 74 y) with fluoroscopic reduction and of 22 patients (mean age, 72 y) with reduction unaided by imaging. There were no significant displacement differences between radiographic and ultrasound measurements. In x-ray parameters for pre- and postreduction, there were no significant differences between the 2 groups. Ultrasound-guided reduction took longer than the other 2 methods. The success rate of the ultrasound and the fluoroscopic groups were similar (95% and 94%, respectively). CONCLUSIONS Our data suggest that ultrasound assistance can aid reduction of distal radius fractures as well as fluoroscopy. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.

Improved quality of cartilage repair by bone marrow mesenchymal stem cells for treatment of an osteochondral defect in a cynomolgus macaque model

Background and purpose — Integration of repaired cartilage with surrounding native cartilage is a major challenge for successful tissue-engineering strategies of cartilage repair. We investigated whether incorporation of mesenchymal stem cells (MSCs) into the collagen scaffold improves integration and repair of cartilage defects in a cynomolgus macaque model. Methods — Cynomolgus macaque bone marrow-derived MSCs were isolated and incorporated into type-I collagen gel. Full-thickness osteochondral defects (3 mm in diameter, 5 mm in depth) were created in the patellar groove of 36 knees of 18 macaques and were either left untreated (null group, n = 12), had collagen gel alone inserted (gel group, n = 12), or had collagen gel incorporating MSCs inserted (MSC group, n = 12). After 6, 12, and 24 weeks, the cartilage integration and tissue response were evaluated macroscopically and histologically (4 null, 4 gel, and 4 MSC knees at each time point). Results — The gel group showed most cartilage-rich reparative tissue covering the defect, owing to formation of excessive cartilage extruding though the insufficient subchondral bone. Despite the fact that a lower amount of new cartilage was produced, the MSC group had better-quality cartilage with regular surface, seamless integration with neighboring naïve cartilage, and reconstruction of trabecular subchondral bone. Interpretation — Even with intensive investigation, MSC-based cell therapy has not yet been established in experimental cartilage repair. Our model using cynomolgus macaques had optimized conditions, and the method using MSCs is superior to other experimental settings, allowing the possibility that the procedure might be introduced to future clinical practice.

Spatiotemporal control of proliferation and differentiation of bone marrow–derived mesenchymal stem cells recruited using collagen hydrogel for repair of articular cartilage defects

Articular cartilage has a poor healing capacity, and cartilage regeneration is not always warranted to achieve healing. On the other hand, collagen scaffolds have been shown to support regeneration of articular cartilage defects in animal models, whereas bone morphogenetic protein-2 (BMP-2) is known to cause chondrogenic differentiation of marrow-derived mesenchymal stem cells (MSCs). The purpose of this study was to evaluate the effectiveness of intra-articular administration of BMP-2 into bone marrow-derived MSCs recruited to defects using original collagen hydrogel in rabbits at various time points. Full-thickness defects were created in both knees, then collagen hydrogels were transplanted, and BMP-2 was supplied for 1-week periods, as follows. BMP-2 was administered immediately after the operation for 1 week (BMP0-1 group), and BMP-2 was administered between weeks 1 and 2 after the operation (BMP1-2 group). BMP2 was administered between weeks 2 and 3 (BMP2-3 group). Specimens were then obtained, and bromodeoxyuridine (BrdU)-positive cells were enumerated and histologic grading was also performed. In addition, the gene expression analysis was performed using quantitative real-time reverse transcription polymerase chain reaction (RT-PCR) assays. Enumeration of BrdU-positive cells showed a significant increase in the BMP0-1 group compared with the other groups. Similarly, histologic scores in the BMP0-1 group were superior for up to 8 weeks. Finally, RT-PCR findings revealed that immediate BMP-2 administration enhanced chondrogenic differentiation.

A new form of surgical treatment for patients with avascular necrosis of the talus and secondary osteoarthritis of the ankle

A new method of vascularised tibial grafting has been developed for the treatment of avascular necrosis (AVN) of the talus and secondary osteoarthritis (OA) of the ankle. We used 40 cadavers to identify the vascular anatomy of the distal tibia in order to establish how to elevate a vascularised tibial graft safely. Between 2008 and 2012, eight patients (three male, five female, mean age 50 years; 26 to 68) with isolated AVN of the talus and 12 patients (four male, eight female, mean age 58 years; 23 to 76) with secondary OA underwent vascularised bone grafting from the distal tibia either to revascularise the talus or for arthrodesis. The radiological and clinical outcomes were evaluated at a mean follow-up of 31 months (24 to 62). The peri-malleolar arterial arch was confirmed in the cadaveric study. A vascularised bone graft could be elevated safely using the peri-malleolar pedicle. The clinical outcomes for the group with AVN of the talus assessed with the mean Mazur ankle grading scores, improved significantly from 39 points (21 to 48) pre-operatively to 81 points (73 to 90) at the final follow-up (p = 0.01). In all eight revascularisations, bone healing was obtained without progression to talar collapse, and union was established in 11 of 12 vascularised arthrodeses at a mean follow-up of 34 months (24 to 58). MRI showed revascularisation of the talus in all patients. We conclude that a vascularised tibial graft can be used both for revascularisation of the talus and for the arthrodesis of the ankle in patients with OA secondary to AVN of the talus.

Florid reactive periostitis of the forearm with pronation and supination contracture.

Extraskeletal bone lesions are occasionally encountered in the upper extremities. The differential diagnosis for these lesions includes myositis ossificans and related nonneoplastic, heterotopic ossifications, fibrodysplasia ossificans progressiva, and extraskeletal osteosarcoma [1]. Florid reactive periostitis (FRP), one of the heterotopic ossifications, is a benign bone-forming lesion that is frequently encountered in the hands and feet [2–6]. Typically, the lesion affects adolescents and young adults and presents as a swollen and painful finger or toe. However, FRP involving the forearm is rare, and the etiology is unclear. We report the case of a 53-year-old woman who was followed clinically and radiographically after the diagnosis of FRP with pronation and supination contracture in the forearm. We also discuss the surgical treatment with use of a pedicled fascio-fat flap after marginal resection of the lesion.

Physeal Bar Resection Under Guidance With a Navigation System and Endoscopy for Correction of Distal Radial Deformities After Partial Growth Plate Arrest

Partial growth plate arrest caused by trauma may lead to severe deformity and dysfunction. The Langenskiöld method is a surgical technique that involves resection of the physeal bar causing partial growth plate arrest. However, it is a technically demanding procedure. We used the Langenskiöld method under guidance with a navigation system and endoscopy and obtained good results in 2 cases. We consider that use of these tools can be a helpful adjunct to the carrying out this procedure.

Tumor-Induced Osteomalacia Caused by a Bone Tumor in the Ulna

Hypophosphatemic osteomalacia induced by overproduction of fibroblast growth factor 23 (FGF23) by a tumor is a relatively rare paraneoplastic syndrome that recently has been recognized. During the course of the disease, termed “tumor-induced osteomalacia” (TIO), the level of phosphorus in the blood becomes reduced as a result of accelerated diuresis due to excessive FGF23 production by the tumor, resulting in bone calcification dysfunction in the entire body, which leads to osteomalacia1-4. TIO most commonly develops in middle-aged adults, with no differences between men and women. Clinically, it is characterized by general bone pain, muscular weakness, and pathological fractures. A TIO-like syndrome can also be seen in association with other diseases such as prostate cancer, small-cell carcinoma (oat cell cancer), hematologic malignancies, neurofibromatosis, epidermal nevus syndrome, and polyostotic fibrous dysplasia of bone5-15. We describe a tumor resection and ulnar bone reconstruction in a patient with an ulnar tumor that caused TIO. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A forty-nine-year-old left-handed man presented to our department with pain in the left forearm. There was no appreciable family or previous medical history. He worked as a delivery person. Plain radiographic findings revealed a cystic lesion of the bone and a pathological fracture in the diaphysis of the left ulna. Moreover, a Looser zone, which is a lucent band adjacent to the periosteum representing an unhealed insufficiency-type stress fracture commonly associated with osteomalacia, was seen in the diaphysis of the left radius (Fig. 1). Systemic bone disease was suspected. The patient initially had noticed bone pain throughout the entire body about two years prior, but did not seek treatment. Fig. 1 Anteroposterior (top) and lateral (bottom) radiographs show a cystic lesion and pathological fracture in the …