Michio Minami

Satisfactory elbow flexion in complete (preganglionic) brachial plexus injuries: Produced by suture of third and fourth intercostal nerves to musculocutaneous nerve

The third and fourth intercostal nerves were sutured to the musculocutaneous nerve to restore flexion of the elbow joint in complete (preganglionic) brachial plexus injuries. Seventeen patients were followed on the average for 5 years and 7 months after surgery. The results were evaluated by means of manual muscle tests and electrical diagnostic tests. Good (grade IV), or better, flexion of the elbow joint occurred in 12 patients over 3 years after the operation.

Outerbridge-Kashiwagi's method for arthroplasty of osteoarthritis of the elbow — 44 elbows followed for 8–16 years

Primary osteoarthritis of the elbow is usually caused by repetitive and hard usage of the arm. In the early stage, the growing osteophytes in the olecranon, olecranon fossa, coronoid, and coronoid fossa cause pain and impair the function of the elbow. Outerbridge-Kashiwagis method (OKM) is a simple and palliative, but not radical, arthroplasty procedure for osteoarthritis of the elbow. Forty-four elbows were reviwed at a mean follow up of 10 years 7 months (range of follow-up period, 8–16 years 4 months). Twenty-seven elbows had good relief of pain. Elbow extension had improved by an average of 6° and elbow flexion by 11°. However, it was shown that osteoarthritic changes progressed for more than 10 years after OKM.

Maintenance treatment using abatacept with dose reduction after achievement of low disease activity in patients with rheumatoid arthritis (MATADOR) – A prospective, multicenter, single arm pilot clinical trial

Abstract Objectives: To preliminarily evaluate the feasibility of maintenance therapy with reduced dose of intravenous abatacept (ABT) to 250u2009mg/body/month after achieving remission or low disease activity (LDA). Patients and methods: RA patients treated with ABT at 13 sites were enrolled in this prospective interventional pilot study during the period between March 2013 and March 2015. Inclusion criteria were (1) age at 20 years or older, (2) under treatment with monthly intravenous ABT at approved doses, (3) DAS28-CRP lower than 2.7 at least for 6 months, (4) agreed to join this trial with written informed consent and (5) body weight under 125u2009kg. Enrolled patients were maintained with intravenous monthly ABT at a reduced dose of 250u2009mg/body (MATADOR protocol). The primary end point was the proportion of the patients continued with MATADOR protocol at week 48. MATADOR protocol was discontinued upon disease flare or other reasons such as patients’ request or severe adverse event (AE). Disease activities and structural changes were also evaluated. Results: Fifty-three patients fulfilled the entry criteria and were followed for 1-year. MATADOR protocol was continued for 1-year in 43 (81%) of the evaluated patients. Three patients experienced severe AEs. Mean DAS28-CRP and remission rate were 1.56 and 88% when ABT reduced and 1.80 and 81% at 1-year, respectively. Structural remission was achieved in 34 out of 42 evaluated patients. Conclusions: Reduced dose of intravenous ABT was proposed as a feasible choice for maintenance therapy for RA after achievement of remission/LDA, although further randomized trials would be awaited.

Postoperative Infection Related with the Total Elbow Arthroplasty (Kudo’s Prosthesis) in Rheumatoid Arthritis

BACKGROUNDnTotal Elbow Arthroplasty (TEA) for the rheumatoid arthritis (RA) has been popularized since 1980s. The outcomes of TEA using any type of implant design for RA has been satisfactory. On the other hand, many orthopedicians experience several postoperative complications. Among them, postoperative infection has still being the most troublesome and difficult to treat. This study is to clarify the causes of postoperative infection of TEA using Kudos prosthesis for RA and discuss how to manage and prevent infection.nnnMETHODSn421 TEAs were performed for 405 cases with RA at the authors institute during the period between 1982 and 2007. They were followed up for 1~25 years (Av. 12.3 years). The authors examined pain, the range of motion, roentgenograms and complications postoperatively. We were able to start treatment within 4 weeks after occurrence of infection. For surgical management of infected TEAs, debridement of the synovium and removal of the prosthesis with loosening were performed for all cases. In addition, all cases have been regularly and strictly followed-up with the elbow protector to prevent recurrence of infection since 2008.nnnRESULTSnThere were 98 TEAs with the postoperative complications (23.3%). Eight out of 98 TEAs were infected (1.9%). Five of eight infected TEAs were primarily at the surgical scar site infection (SSSI) (60%), unknown causes in two, hematogenous course in 1. Its obvious that surgical scar site infection (SSSI) was the leading cause of postoperative infection in this study. Thus, the authors made the elbow proctor to avoid injuries of the skin around surgical scar site (SSS). Since 2008, all of the TEAs and revised TEAs have been applied with this protector.nnnCONCLUSIONSnThe authors reported 8 infected TEAs: 5 cases were revised, 2 with the brace, 1 had above the elbow amputated. The regular and meticulous follow up and application of the elbow protector were useful to prevent infection of post-TEAs using Kudos prosthesis in RA. Since 2008, there have been no infection of post TEAs and revised TEAs.

A Case Report of Familial Mediterranean Fever Diagnosed Following the Total Knee Arthroplasty

Postoperative fever following orthopedic surgical procedures is common, but the cause of fever and its relation to infections is often unclear. Periprosthetic joint infection is a devastating complication following the total joint arthroplasty [8]. In the USA, periprosthetic joint infection is currently the most common indication for revision total knee arthroplasty and the third most common indication for revision total hip arthroplasty [2, 8]. Since no highly accurate diagnostic method exists, the diagnosis of infection is based on a combination of clinical suspicion, serological tests, culture results, histology, and basic molecular techniques. n nWe present the case of a 62-year-old female who presented to our clinic with a fever of unknown origin following a total knee replacement. She was suspected to have a periprosthetic joint infection. Because of her recurrent febrile episodes associated with peritonitis, pleuritis, and synovitis, familial mediterranean fever (FMF) was suspected based on the Tel-Hashomer criteria, if two major or one major + two minor criteria are met (Major criteria are (1) recurrent febrile episodes associated with peritonitis, pleuritis, or synovitis; (2) amyloidosis of AA-type without a predisposing disease; and (3) favorable response to daily colchicine. Minor criteria are (1) recurrent febrile episodes, (2) erysipelas-like erythema, and (3) positive history of familial mediterranean fever in a first degree relative) [5]. As part of the workup for her fever, a genomic search for the mediterranean fever gene (MEFV) was performed, and heterozygous L110P, E148Q, and M694I mutations were found in the patient. FMF was confirmed by the mutation in the hot spot of MEFV. The patient’s symptoms were successfully controlled by administration of colchicine.