Makoto Motomiya

Arthroscopic-Assisted Repair of Avulsed Triangular Fibrocartilage Complex to the Fovea of the Ulnar Head: A 2- to 4-Year Follow-up Study

PURPOSE The objective of this study was to conduct a follow-up evaluation of an arthroscopic reattachment technique using an avulsed deep component of the triangular fibrocartilage complex (dc-TFCC) from the fovea of the distal ulna (ulnar fovea). METHODS A retrospective study was performed on a consecutive cohort of 12 patients who underwent arthroscopic reattachment of the avulsed dc-TFCC into the ulnar fovea over a 24-month period. The mean age was 31 years (range, 20 to 50 years). There were 6 men and 6 women. This technique anchors the avulsed portion of the dc-TFCC to the ulnar fovea by means of a repair suture passed through the created osseous tunnel from the ulnar neck to the foveal surface. Postoperative clinical and functional outcomes were quantitatively evaluated with the Modified Mayo Wrist Score. The Disabilities of the Arm, Shoulder and Hand questionnaire served to assess each patients subjective outcome. A questionnaire regarding each patients return to his or her previous job was also completed. Radiographic evaluation was based on computed tomography and magnetic resonance imaging examinations. RESULTS At the mean follow-up of 30 months, all patients had significant reduction of wrist pain. The mean Modified Mayo Wrist Score was 92.5 ± 7.5, and all patients were rated as having excellent or good clinical results. The Disabilities of the Arm, Shoulder and Hand score significantly improved from 59.5 ± 18.5 to 7.7 ± 11.9 postoperatively (P < .0001). Of the 9 working patients, 7 returned to their previous work. Two patients had occasional extensor carpi ulnaris tendinitis after surgery. Magnetic resonance images at 12 weeks postoperatively showed findings indicating attachment of the triangular fibrocartilage complex (TFCC) to the fovea. CONCLUSIONS Arthroscopic reattachment of the avulsed TFCC to the ulnar fovea by the described technique is a valid alternative for treating avulsion of the foveal TFCC insertion.

Analysis of the Expression and Function of BRINP Family Genes During Neuronal Differentiation in Mouse Embryonic Stem Cell-Derived Neural Stem Cells

We previously identified a novel family of genes, BRINP1, 2, and 3, that are predominantly and widely expressed in both the central nervous system (CNS) and peripheral nervous system (PNS). In the present study, we analyzed the expression pattern of three BRINP genes during differentiation of mouse embryonic stem (ES) cell‐derived neural stem cells (NSCs) and their effects on the cell‐cycle regulation of NSCs. While there was no significant expression of any BRINP‐mRNA expressed in mouse ES cells, BRINP 1 and 2‐mRNAs was expressed at high levels in the ES cell‐derived neural stem cells. Upon differentiation into neuronal cells in the presence of retinoic acid and BDNF, all three types of BRINP‐mRNA were induced with a similar time course peaking at day three of treatment. Upon differentiation into astroglial cells in the presence of serum, BRINP1‐mRNA was slightly up‐regulated, while BRINP2‐ and BRINP3‐mRNAs were almost abolished in the astrocytes. While 69.2, 26.1, and 7.7% of cells in a population of NSCs in the exponentially growing phase were in the G1, S and G2 phases, respectively, over‐expression of any one of the three BRINP genes completely abolished cells in the G2 phase and significantly reduced the cells in S phase to 11.8–13.8%. Based on these results, the physiological roles of induced BRINP genes in the cell‐cycle suppression of terminally differentiated post‐mitotic neurons are discussed.

In Vivo Vascularity Alterations in Repaired Rotator Cuffs Determined by Contrast-Enhanced Ultrasound

Background: The alterations in blood flow after rotator cuff repair remain unclear. Visualization of vascular patterns could clarify basic and clinical investigations. Purpose: To assess longitudinal blood flow inside the repaired cuff and the surrounding tissue after rotator cuff repair, using contrast-enhanced ultrasonography. Study Design: Descriptive laboratory study. Methods: Fifteen patients (7 men and 8 women; mean age, 65.0 ± 9.8 years) consented to participate. The patients underwent an ultrasound scan before and 1, 2, and 3 months after surgery. Enhanced ultrasound images were recorded for 1 minute after intravenous injection of contrast reagent. Four regions of interest inside the cuff and 2 regions in the anchor hole and subacromial bursa were superimposed on the obtained images. Calculated areas under the time-intensity curves were expressed in acoustic units (AU). Results: We found area-dependent differences in patterns of alteration and magnitude of blood flow inside the repaired cuff and peritendinous tissues. Vascularity in the articular distal and bursal distal region of the repaired cuff at 1 month postoperatively increased significantly compared with that at the preoperative baseline (76 vs 5 AU, P = .0037; 92 vs 7 AU, P = .043). The vascularity peaked at 1 month after surgery in the bursal area within the cuff but at 2 months in the articular area. The vascularity in the articular proximal region of the repaired cuff was significantly lower than that in the bursal proximal (P = .0046), bursal distal (P = .0183), and articular distal regions (P = .0163) 1 month after surgery. Conclusion: Enhancement patterns in intratendinous tissue increased at 1 or 2 months postoperatively and decreased at 3 months. We found area-dependent differences in enhancement patterns inside the repaired cuff and peritendinous tissue. Clinical Relevance: Visualization of vascularization using contrast-enhanced ultrasound could help in deciding on an appropriate repair technique or on the form of postoperative rehabilitation after rotator cuff repair.

Clinical and Radiological Results of Radiolunate Arthrodesis for Rheumatoid Arthritis: 22 Wrists Followed for an Average of 7 Years

PURPOSE To evaluate the clinical and radiological results of radiolunate (RL) arthrodesis for rheumatoid arthritis (RA) patients treated with disease-modifying antirheumatic drugs and/or biologicals with an average of 7 years of follow-up. In addition, we compared the results in advanced stages with those in less advanced stages in patients with comparatively low disease activity of RA. METHODS This study included RL arthrodesis for 22 wrists in 19 patients with comparatively low disease activity of RA. The mean follow-up period was 7 years (range, 2-16 y). Fourteen wrists with Larsen classification grade III and 8 wrists with grade IV were included in this study. The range of motion was calculated, and clinical scores were graded using the Mayo wrist score and the Stanley classification. The carpal height ratio (CHR) and ulnar translation (UT) were determined from the radiographs. RESULTS All wrists achieved radiographic fusion. Clinical scores were markedly improved, although there was a decrease in flexion. The Larsen grade did not deteriorate during follow-up. CHR and UT improved immediately after operation and remained good through the final follow-up. Although the flexion/extension range of motion of the grade IV wrists was smaller than that of the grade III wrists at follow-up, both groups obtained good clinical results. CONCLUSIONS Our results for RL arthrodesis were clinically and radiologically better than those of previous reports. Control of the disease activity of RA could theoretically be a factor in obtaining good long-term clinical and radiographic outcomes. RL arthrodesis is our recommended procedure for the RA wrist even in the advanced stage. LEVEL OF EVIDENCE Therapeutic IV.

Brachial artery perforator-based propeller flap coverage for prevention of readhesion after ulnar nerve neurolysis

It is difficult for most plastic and orthopaedic surgeons to treat nerve dysfunction related to neural adhesion because the pathophysiology and suitable treatment have not been clarified. In the current report, we describe our experience of surgical treatment for adhesive ulnar neuropathy. A 58‐year‐old male complained of pain radiating to the ulnar nerve‐innervated area during elbow and wrist motion caused by adhesive ulnar neuropathy after complex open trauma of the elbow joint. The patient obtained a good clinical outcome by surgical neurolysis of the ulnar nerve combined with a brachial artery perforator‐based propeller flap to cover the soft tissue defect after resection of the scar tissue and to prevent readhesion of the ulnar nerve. This flap may be a useful option for ulnar nerve coverage after neurolysis without microvascular anastomosis in specific cases.

Application of free temporoparietal fascial flap for recurrent neural adhesion of superficial radial nerve—A case report

Because of its anatomical location, the superficial radial nerve is vulnerable to trauma as well as injury during various surgical procedures. Once the nerve adheres to surrounding scar tissue, radiating pain often occurs due to nerve traction caused by loss of smooth gliding. Since it has been reported that the success rate with neurolysis only is lower, additional preventive procedures for recurrent neural readhesion are recommended. In the current report, we describe our experience performing neurolysis followed by nerve coverage using a free temporoparietal fascial flap for recurrent neural adhesion of the superficial radial nerve. A 45‐year‐old male complained of motion pain of the left wrist and thumb joints caused by recurrent neural adhesion of the superficial radial nerve after a chain saw trauma and following multiple reconstructive procedures. The radiating pain completely disappeared after neurolysis performed by a previous surgeon; however, it recurred 4 weeks later. Four months after the previous neurolysis the patient underwent external neurolysis and covering of the nerve with a free temporoparietal fascial flap to prevent neural readhesion because local soft tissue could not be used due to the massive scar tissues on the forearm. One year after the secondary neurolysis, the symptoms of radiating pain during wrist and thumb motion were drastically improved. A free adipofascial flap such as a temporoparietal flap may be an option for prevention of neural readhesion after neurolysis of the superficial radial nerve in cases where a local flap cannot be used on the forearm.

Reliability of peripheral intraneural microhemodynamics evaluation by using contrast-enhanced ultrasonography

PurposeThe purpose of the study was to validate the reliability of quantitative intraneural enhancement patterns by using contrast-enhanced ultrasonography (CEUS).MethodsNine asymptomatic wrists underwent a total of three CEUS examinations each conducted at 1-month intervals. The CEUS enhancement pattern of median nerves was quantitatively evaluated. The area under the time–intensity curve was calculated by placing the regions of interest at the proximal, center, and distal regions of the median nerve. An intra-class correlation coefficient for intra-observer, inter-observer, and inter-examination reproducibility was calculated.ResultsThe intra- and inter-observer reproducibility was almost perfect. Inter-examination reproducibility of the proximal, center, and distal regions was 0.891, 0.614, and 0.535, respectively. In this study, we found that the reproducibility of the distal and center regions of the median nerve in the carpal tunnel was lower than that of the proximal region.ConclusionHigh intra-observer, inter-observer, and inter-examination reproducibility of CEUS was obtained in the evaluation of the intraneural enhancement pattern when the region of interest was placed in the proximal region of the median nerve.

Giant-Cell Tumor of the Distal Ulna Treated by Wide Resection and Ulnar Support Reconstruction: A Case Report

Giant-cell tumor of bone occurred in the distal end of the ulna is extremely uncommon. A 23-year-old male had a giant-cell tumor occurred in the distal end of the ulna. After wide resection of the distal segment of the ulna including giant-cell tumor, ulnar components of the wrist joint were reconstructed with modified Sauvé-Kapandji procedure using the iliac bone graft, preserving the triangular fibrocartilage complex and ulnar collateral ligament in order to maintain ulnar support of the wrist, and the proximal stump of the resected ulna was stabilized by tenodesis using the extensor carpi ulnaris tendon. One year after operation, the patients wrist was pain-free and had a full range of motion. Postoperative X-rays showed no abnormal findings including recurrence of the giant-cell tumor and ulnar translation of the entire carpus. The stability of the proximal stump of the distal ulna was also maintained.

Intraneural microvascular patterns of the median nerve assessed using contrast-enhanced ultrasonography in carpal tunnel syndrome

We carried out an unblinded comparison of intraneural blood flow in the median nerve of 13 patients with a moderate to severe carpal tunnel syndrome (CTS) and 15 unmatched control subjects using contrast enhanced ultrasound (CEUS) imaging. Table 1 shows their demographic data. The diagnosis of CTS was indicated by the following criteria: nocturnal hand pain and paraesthesia of the median nerve-innervated area, a positive Phalen test, and prolonged motor nerve distal latency (>5 ms). Table 2 shows disease severity of the patients. All ultrasound (US) examinations were performed by a certified sonographer in a blinded manner. US images were corrected using an ultrasound unit (AplioTM 500, Toshiba Medical Systems Corp., Tochigi, Japan) with an 8.0 MHz centre frequency linear transducer (PLT-805AT) as previously reported (Ishizaka et al., 2014). The forearm and hand were fixed on an arm stand with the wrist in full supination and without any radial/ulnar deviation or flexion/extension (Figure 1(A)). The scaphoid tubercle, pisiform and hook of hamate were marked on the skin surface by palpation and US. Sagittal views of the median nerve were obtained at the midpoint between the scaphoid tubercle-pisiform line and hook of hamate (Figure 1(B)). B-mode images with a 5.5 MHz frequency linear transducer were obtained initially to confirm optimum visualization of the median nerve and to place an oval region of interest with a size of 2.26 × 1.41 mm in the median nerve proximal to the carpal tunnel (Figure 1 (C) and (F). CEUS provides high reproducibility in evaluation of intraneural blood flow of the median nerve proximal to the carpal tunnel, though it is difficult to evaluate the intraneural blood flow just within, and distal to, the carpal tunnel because of the artefacts and attenuation (Ishizaka et al., 2014). An intravenous catheter was placed in the left arm of each volunteer and in the arm of each patient corresponding to the intact or less severe hand. A microbubble contrast agent (Sonazoid, GE Healthcare, Waukesha,

PREVENTION OF INSTABILITY OF THE PROXIMAL END OF THE RADIUS AFTER RADIAL HEAD RESECTION USING AN ANCONEUS MUSCLE FLAP

Resection of the radial head frequently causes instability of the proximal end of the radius. To prevent this instability, we performed a stabilization technique using an anconeus muscle flap. Since 2003, six patients with radiocapitellar joint dysfunction have been treated with radial head resection combined with stabilizing its proximal end using an anconeus muscle flap. At a mean follow-up of 51 months, all patients were free from elbow pain and the mean Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder and Hand score significantly improved. Radiographic findings showed no apparent instability of the proximal radius. The anconeus is useful as a reliable muscle flap for preventing instability of the proximal radius after a radial head resection. This procedure does not require any microvascular techniques and makes it possible to apply a pedicled muscle flap using a relatively simple technique without any considerable risks of elbow dysfunction.