Shingo Nobuta

Clinical Outcome of Fragment Fixation for Osteochondritis Dissecans of the Elbow

Background: The choice of surgical or non-surgical treatments for osteochondritis dissecans (OCD) of the humeral capitellum is still controversial. The purpose of this study was to assess the efficacy of fragment fixation for OCD of the humeral capitellum. Methods: We reviewed 28 patients with OCD of the humeral capitellum after a mean follow up of 17 months. All patients were men and mean age was 14 years. Twenty-seven patients had a history of repetitive overuse of the elbow with baseball pitching, one with tennis. Mean duration of overuse of the elbow was four years. All patients had elbow pain and difficulty in throwing, with a mean duration of symptoms for 17 months. The mean arc of flexion before surgery ranged from 11 degrees to 126 degrees. Radiographs of the elbow showed a radiolucent cystic area of the humeral capitellum in one patient, a non-displaced split type fragment in 12 patients, and a slightly displaced split type fragment in 15 patients. Fragment fixation surgery was performed in all patients by lateral arthrotomy including drilling and fixation of the fragment with a double wiring technique using flexible wire or thread under direct vision. Sport activities using upper extremities were restricted for four to six months until the lesion healed in radiograph. Results: Post-operatively, 25 patients had no pain and three decreased pain. Average arc of flexion was one to 132 degrees, an improvement of 16 degrees compared with the pre-operative arc. Radiographic findings showed complete healing of the lesion in 11 patients, partial healing in 12, unchanged in three, and loose body formation in two. By Tivnons evaluation of the elbow function, results were excellent in 19 patients, good in five, fair in two, and poor in two. The ratio of complete or partial healing of the lesion was 100 percent in 16 patients in whom the thickness of the lesion was less than 9 mm on pre-operative radiograph, and 58 percent in 12 patients in whom the lesion thickness was 9 mm or more, which showed a significant difference (p<0.01). Conclusions: Fragment fixation for OCD of the humeral capitellum was effective in patients whose lesion thickness was less than 9 mm. Fixation by flexible wire or thread and revascularization by drilling for the fragment were considered to be insufficient for large lesions with a thickness of 9 mm or more.

Open Elbow Arthrolysis for Post-traumatic Elbow Contracture

Background: Post-traumatic contracture is a common complication after elbow trauma. If conservative therapy fails to restore adequate elbow motion, arthrolysis is indicated. The purposes of this study were to evaluate the clinical outcome of open arthrolysis for post-traumatic elbow contracture and to determine factors influencing the outcome. Methods: Twenty-seven patients with post-traumatic elbow contracture were followed-up after open arthrolysis for at least 12 months. Before surgery, the mean limitation in extension was 30 ° and the mean maximum flexion was 83 °. A posterior surgical approach was used in 18 patients, and a lateral approach was employed in nine patients. Using the posterior approach, the fibrotic posterior capsule was excised and the ulnar collateral ligament was split. Both the anterior and posterior capsules were released with a lateral approach. Results: The mean flexion increased from 83 ° to 121 °, but the mean extension improved little from –30 ° to –26 °. The mean flexion-extension arc increased from 53 ° to 95 °. According to the elbow evaluation score by the Japanese Orthopaedic Association, both pain and function scales improved significantly. By Hertels subjective evaluation, the results were good in 13 patients, fair in ten patients, and poor in four patients. Twenty-three patients (85 percent) were satisfied with the results, but four were not satisfied because of residual contracture. These poor results were related to severe soft tissue trauma, residual displacement of intra-articular fragments, and recurrence of heterotopic bone formation. Conclusions: Tendon lengthening of stiff triceps, accurate reduction of intra-articular fragmens, and sharp epiperiosteal resection around the heterotopic bones are essential procedures of open arthrolysis to restore adequate motion in post-traumatic elbow contracture.

Effects of Wrist Splinting for Carpal Tunnel Syndrome and Motor Nerve Conduction Measurements

Background. Carpal tunnel syndrome (CTS) is one of the most common disease among the entrapment neuropathies. Wrist splinting has been conventionally used for the CTS treatment. The purposes of this study were to assess the efficacy of wrist splinting for CTS, and to evaluate the value of the motor nerve conduction measurement as a prognostic indicator for CTS. Methods. Two hundred and fourteen hands with CTS were treated by wrist splinting, and reviewed after a mean follow up of seven months. Severity of symptoms were minimal lesions in 177 hands, intermediate lesions in 33 hands, and severe lesions in four hands. Motor nerve conduction measurement was performed in all cases before and after treatment, and distal latency (DL) and amplitude on compound muscle action potential (CMAP) from the abductor pollicis brevis (APB) muscle were analyzed. Results. According to Kellys grading of outcome, results were excellent in 41 hands, good in 110 hands, fair in 45 hands, and poor in 18 hands. Excellent or good results were obtained in 131 hands (74 percent) with minimal lesions, 20 hands (61 percent) with intermediate lesions, and in no cases with severe lesions. The ratio of excellent or good results was 79 percent in patients in whom DL of pre-treatment APB-CMAP was less than 8 milliseconds (ms), and 62 percent in patients whose DL was 8 ms or more, which showed a significant difference. In nine hands whose pre-treatment APB-CMAP was unrecordable, the results were good in one hand, fair in five, and poor in three. Conclusions. Wrist splinting is most effective in cases of minimal or intermediate lesions with DL of APB-CMAP less than 8 ms. If relief of symptoms is not obtained after five months of treatment by splinting, that would be the limit of splinting. Surgical release is recommended for cases with severe lesions and with unrecordable APB-CMAP.

Radial nerve palsy at the elbow.

We studied the clinical features and images along with surgical findings of 8 cages of radial nerve palsy due to a space-occupying lesion (SOL) at the elbow. Based on image findings, we examined compressing masses and their extent, we contrasted them with operative findings of the radial nerve, and we surmised the site of impairment. Compressing masses were ganglions in 6 cages, an old radial head dislocation in 1 case, and engorged radial recurrent vessels in 1 case. The extent of the SOLs was roughly 15–40 mm from the interepicondylar line and 0–30 mm from the radiohumeral joint. In operative findings, only the posterior interosseous nerve (PIN) was compressed in 5 cases, while both the PIN and superficial branch were compressed in 3 cases. No apparent correlation between operative findings and the type of palsy was found. The radial tunnel has yet to be defined clearly, but the radial nerve palsy is readily understandable in cases of SOLs via the definition of the radial tunnel as the tubular structure from the radiohumeral joint to the outlet of the supinator muscle.

Long-term Results of Ulnohumeral Arthroplasty for Symptomatic Elbow Osteoarthritis

Objective: Symptomatic elbow osteoarthritis with painful limitation of motion requires surgical treatment. The purpose of this retrospective study was to assess the long-term results of open ulnohumeral arthroplasty (UHA) and to investigate the factors influencing results. Methods: Twenty-two elbows from 20 patients were evaluated after a mean follow-up of 82 months. The patients included 19 men and a woman with a mean age of 56 years. All patients had been complaining of motion pain and loss of flexion-extension arc of the elbow before surgery. The preoperative radiographs were graded with a point system, and preoperative evaluations and the outcomes at follow-up were assessed using the Mayo Elbow Performance Score (MEPS). Results: At the final follow-up evaluation, ten elbows had no motion pain and 11 others had decreased pain. The average preoperative flexion-extension arc improved from 89 to 104 postoperatively (p<0.001). MEPS improved from 69 to 85 (p<0.001). The results were excellent in 10 elbows, good in 10, fair in two and there were no poor cases. Patients’ satisfaction showed that 17 elbows had a satisfactory result, and 5 had an unsatisfactory result. The preoperative radiographic score and flexion-extension arc were factors for predicting postoperative results. Conclusions: The UHA was effective in reducing pain and increasing the range of motion for symptomatic elbow osteoarthritis after a mean follow-up of 82 months.

Effects of tendon transfer to restore index finger abduction for severe cubital tunnel syndrome

Background. Severe cases of cubital tunnel syndrome do not always result in functional recovery after surgical decompression of the ulnar nerve. A combined operation of tendon transfer to restore index finger abduction and decompression of the ulnar nerve was performed for patients with severe cubital tunnel syndrome who required powerful pinch strength and whose preoperative compound muscle action potential of the abductor digiti minimi muscle was not recordable or almost non-recordable. The purpose of this study was to assess the efficacy of tendon transfer to restore index finger abduction for severe cubital tunnel syndrome. Methods. Sixteen hands in 15 patients with severe cubital tunnel syndrome were operated on with extensor pollicis brevis tendon transfer to the first dorsal interosseous muscle to restore index finger abduction and ulnar nerve decompression. They were reviewed after a mean follow-up of 16 months. All 16 hands had preoperatively severe lesions with paralysis of ulnar intrinsics, marked anaesthesia, or hypaesthesia. Results. Postoperative results were excellent in 2 hands, good in 10, fair in 4, and no cases with poor results according to Akahoris criteria. Four hands with fair results had a residual Froment sign or annoying hypaesthesia in the ring and little fingers. All patients were relieved of preoperative discomfort and showed recovery of motor and sensory function. The mean pre- and postoperative pinch strength was 3.3 kg and 5.6 kg, respectively, which showed a significant difference (P<0.01). Mean time of showing a negative Froment sign after surgery was 5 months in 13 cases. Conclusions. The extensor pollicis brevis tendon transfer is simple and useful to restore index finger abduction and pinch strength for severe cubital tunnel syndrome.

Remitting seronegative symmetrical synovitis with pitting oedema syndrome-like symptoms associated with periodontitis: a case report

Abstract Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) is a rare inflammatory condition characterised by symmetrical synovitis of the hands and feet with pitting oedema. The etiology of RS3PE remains unclear. Although previous studies have reported associations between RS3PE and other diseases, none have described a possible association between RS3PE and periodontitis. The authors report a case of RS3PE syndrome-like symptoms improved by minocycline and oral care, including extraction of teeth.

Influence of Remained Medial Osteophyte on the Outcome after Ulnohumeral Arthroplasty

Objective: The authors reported the long-term results of ulnohumeral arthroplasty (UHA) for symptomatic elbow osteoarthritis. UHA does not allow access to the medial ulnohumeral osteophyte and to the radiohumeral joint, and the influence of remained medial ulnohumeral osteophyte on the outcome is still unclear. The purpose of the present study was to determine the influence of remained medial osteophyte on the outcome in a much larger sample size. Methods: Fifty-eight elbows in 51 patients with elbow osteoarthritis underwent UHA and were evaluated. Before surgery, all patients complained of motion pain and loss of flexion-extension arc of the elbow. Preoperative evaluation and the outcome at follow-up were assessed using Mayo Elbow Performance Score (MEPS), and medial ulnohumeral osteophyte was assessed in anteroposterior radiograph. Results: Forty-one elbows had no pain and 17 decreased pain. The average flexion-extension arc improved from 93° preoperatively to 107°postoperatively. Total MEPS improved from 69 to 91. The result was excellent for 40 elbows (69%), good for 14 (24%), fair for four (7%) and no poor case. Patients’ satisfaction showed that fifty (86%) were satisfactory subjective result and eight (14%) were unsatisfactory result. The preoperative flexion-extension arc was factors for predicting postoperative results. Remained medial ulnohumeral osteophyte was related to decreased arc of the flexion-extension but not patients’ satisfaction and pain scale. Conclusions: Remained medial ulnohumeral osteophyte was related to decreased arc of the flexion-extension but not patients’ satisfaction and pain scale after UHA.

Lumbar radicular symptom caused by the cauda equina in ankylosing spondylitis: a case report

Abstract Lumbar radicular symptom is an unusual manifestation of neurological complications in patients with ankylosing spondylitis. Here, we report a case of lumbar radicular symptom caused by the cauda equina in ankylosing spondylitis.

Retrospective Analysis of Anterior Interosseous Nerve Lesions and MotorNerve Conduction Measurements

Objective: Anterior interosseous nerve (AIN) lesions are rare and a few nerve conduction measurements have been reported. The purpose of this retrospective study was to assess the diagnostic value of the motor nerve conduction measurements for the AIN lesion and to investigate its electrodiagnostic features. Methods: Twenty-three patients with AIN lesion were reviewed after a mean follow-up of 13 months. Of these 23 cases, a complete palsy of flexor pollicis longus (FPL) and flexor digitorum profundus to the index finger (FDP1) was seen in five, and an isolated palsy of FPL in three and that of FDP1 in two, while pronator quadratus (PQ) was weak in twelve. The compound muscle action potential (CMAP) from the PQ muscle and the FPL muscle were recorded and analyzed. Twenty-two patients were treated conservatively and one underwent surgery. Results: Both PQ-CMAP and FPL-CMAP were recorded in all of the patients initially, and they all showed abnormality in PQ- and/or FPL-CMAP. Delayed latency and / or low amplitude were seen in 21 for PQ-CMAP and in 17 for FPL-CMAP. At the time of final follow-up, an improvement in the muscle strength of FPL, FDP1 and PQ was seen in 11 with the British Medical Research Council (MRC) grade 4 or better (complete recovery), whereas, partial recovery in 11 and unchanged in one. The decrease of amplitude in PQ-CMAP showed a significant difference between the normal PQ strength group and the weak PQ strength group. Conclusion: Recording and analysis of PQ- and FPL-CMAP are simple and safe and are important for the definite electrodiagnosis of AIN lesions. The data suggest that an axonal degeneration is main pathology.