Yi-Shiong Hang

A Clinical and Roentgenographic Study of Little League Elbow

Background Comparisons of medial elbow injury rate and the incidence of clinical and radiographic findings among Little League baseball players have not been documented. Hypothesis Injury rate and clinical and radiographic findings in Little Leaguers of different positions may be similar. Study Design Survey and retrospective review. Methods Altogether, 343 Little Leaguers (120 pitchers, 40 catchers, and 183 fielders) participated in the study. The survey (including age, playing position, playing experience, and symptoms), clinical examination, and roentgenogram of both elbows were obtained for analysis using Pearsons chi-square test. Results Clinically, 58% of the pitchers presented with soreness compared to 63% in catchers and 47% in fielders. Radiographic examination revealed hypertrophy of the medial humeral epicondyle in all pitchers and catchers and 90% of the fielders. Separation of the medial epicondyle was found in 63% of pitchers, 70% of catchers, and 50% of fielders, while fragmentation was found in 19% of pitchers, 40% of catchers, and 15% of fielders. In subjects with separation or fragmentation, 49% and 56% complained of elbow soreness, respectively. Conclusion Similar rates of medial elbow changes in Little Leaguers may imply that the roentgenological changes of the medial epicondyle could be an adaptive yet physiological reaction to the excessive valgus stress of throwing. The higher incidence of medial epicondylar separation and fragmentation in catchers that has not been reported before may be secondary to the increased stress placed on the elbow when throwing from the squatting position.

An ultra-weak chemiluminescence study on oxidative stress in rabbits following acute thermal injury

It is not easy to detect oxygen free radicals directly because of their very short half-life. In the present study, a sensitive ultra-weak chemiluminescence detector was used to detect the generation of oxygen free radicals following thermal injury. Twelve New Zealand white rabbits were used in this study. After anesthesia, the bilateral hind-limbs were exposed to 100 degrees C water for 30 s. Six control animals were exposed to 22 degrees C water to act as a control. The chemiluminescence of whole blood and visceral organs were measured with both luminol-amplified t-butyl hydroperoxide-initiated and lucigenin-initiated methods. The results showed that chemiluminescence of blood was affected significantly by acute thermal injury. The chemiluminescence of blood increased significantly at 1 h following acute thermal injury, reached a peak at 2 h, then decreased but still remained above the control level at 4 h following thermal injury. The results for TBHP-initiated chemiluminescence from visceral organs following acute thermal injury were much higher than that of the control rabbits. The effects of lucigenin-initiated tissue chemiluminescence following acute thermal injury were not statistically significant. It is suggested that the decreased vascular antioxidant activity following local thermal injury is partially contributed by the superoxide pathway; while, the remote pathophysiologic events are mediated by the defective scavenging defenses.

Locked nailing for displaced surgical neck fractures of the humerus

OBJECTIVE To report experience with a newly devised humeral locked nail for treating surgical neck fractures of the humerus. This device has the advantages of a small diameter for minimal tissue trauma and transfixing locking screws for reliable fixation. METHODS From 1993 to 1996, 21 consecutive severely displaced surgical neck fractures of the humerus were antegrade nailed with humeral locked nails; 2 fractures were associated with dislocation and 1 fracture was a comminuted metaphyseal fracture with a failed plating. The average age of patients was 65.8 years; average follow-up time was 19.2 months. The proximal screws were applied upward in 5 patients and downward in 16 patients. Static locking was performed in 8 patients, dynamic locking in 13 others. RESULTS The average operation time was 55 minutes. No patients needed blood transfusion. All fractures eventually achieved union with an average time to union of 14.8 weeks. On the basis of Neer criteria for outcome analysis, excellent or satisfactory results were obtained for 86% of the patients (18 of 21 patients). No patients had deep infection, implant failure, malunion, osteonecrosis, or nail migration that interfered with joint motion. Due to technique errors, one patient had shoulder joint impingement caused by protrusion of the proximal nail tip. CONCLUSION The operative method reported here has the advantages of minimal tissue trauma, minimal hardware application, sufficient fixation, and easy operative technique, and it can be a worthy alternative for the treatment of severely displaced surgical neck fractures of the humerus.

In vitro and in vivo mechanical evaluations of plasma-sprayed hydroxyapatite coatings on titanium implants: The effect of coating characteristics

This study was undertaken to evaluate the effect of coating characteristics on the mechanical strengths of the plasma-sprayed HA-coated Ti-6Al-4V implant system both in vitro and in vivo. Two types of HA coatings (HACs) with quite different microstructures, concentrations of impurity-phases, and indices-of-crystallinity were used. In vitro testings were done by measuring the bonding-strength at the Ti-6Al-4V-HAC interface, with HACs that had and had not been immersed in a pH-buffered, serum-added simulated body fluid (SBF). The shear-strength at the HAC-bone interface was investigated in a canine transcortical femoral model after 12 and 24 weeks of implantation. The results showed a bonding degradation of approximately 32% or higher of the original strength after 4 weeks of immersion in SBF, and this predominantly depended on the constructed microstructure of the HACs. After the push-out measurements, it was demonstrated that the HACs with higher bonding-strength in vitro would correspondingly result in significantly higher shear-strength at each implant period in vivo. Nevertheless, there were no substantial histological variations between the two types of HACs evaluated. The most important point elucidated in this study was that, among coating characteristics, the microstructure was the key factor in influencing the mechanical stability of the HACs both in vitro and in vivo. As a consequence, a denser HAC was needed to ensure mechanical stability at both interfaces.

Traumatic dislocation of the hip.

Of 125 patients with traumatic dislocation of the hips treated, 96 were reviewed retrospectively; 80 were males and 16 females with an age range from seven to 81 years (mean, 33.5 years). Motorcycle accidents were the leading cause of traumatic dislocation in this series (40 cases, 42%). Associated injuries were found in 68 cases (70.8%). Seventy-seven hips (80%) were reduced within 24 hours. In follow-up periods ranging from 15 months to 18 years (mean, 7.5 years), 56 patients had excellent or good results (58.3%). Statistical analysis of the clinical results showed that those patients with simple dislocations had better functional recovery. The earlier the reduction, the better the results. Associated injuries affected prognoses. Good results were obtained in patients with early, stable, and accurate reductions by either closed or open methods.

Treatment of humeral shaft delayed unions and nonunions with humeral locked nails.

OBJECTIVE To report experience with use of humeral locked nails in treating humeral delayed unions and nonunions. The following techniques yielded encouragingly good results: static locking, short-to-long segment nailing, bone grafting, fracture compression, and minimal surgical trauma. DESIGN AND METHODS A total of 41 consecutive patients with 13 delayed unions and 28 nonunions were treated with humeral locked nails. Delay from trauma to surgery averaged 4.2 months for delayed union and 15.5 months for nonunion. The average age of patients was 50.2 years; average follow-up time was 23.2 months. There were 7 proximal-third fractures, 21 middle-third fractures, and 13 distal-third fractures. The antegrade approach was used for 13 fractures and retrograde for 28. Open nailing was performed in 39 fractures and closed nailing in 2. If the fracture motion was still present after nail insertion, axial compression of the fracture site was specially applied. Bone grafting was performed in the fractures with open nailing. Thirty-four fractures were nailed with 8-mm nails, and 7 fractures were nailed with 7-mm nails. RESULTS With a single operation, all but two patients achieved osseous union in, on average, 5.6 months. One of these two patients eventually gained union after another surgery with fracture compression along the original nail and concurrent bone grafting. The second patient, undergoing hemodialysis for chronic renal failure, had persistent nonunion. At follow-up, for patients with antegrade nailing, all but four patients had less than 20 degrees limitation of shoulder abduction. For patients with retrograde nailing, all but two had less than 10 degrees limitation of elbow motion. Only the patient with persistent nonunion had continual pain and significant impairment of arm function. CONCLUSIONS Humeral locked nailing seems to be effective for humeral delayed unions or nonunions. It may be an acceptable alternative for fractures unsuited for plate fixation, such as those with comminution, osteoporosis, or a severely adhered radial nerve.

Anatomic considerations of locked humeral nailing

To investigate the risk of axillary nerve injury by the proximal locking screws in antegrade nailing of humeral fractures, the anatomy of the axillary nerve was examined in 20 fresh anatomic specimen humeri, which subsequently were nailed antegrade with specially designed humeral locked nails. The axillary nerve was found to be on average 45.6 mm below the tip of the greater tuberosity; it was jeopardized by insertion of the lower proximal locking screw in one of the 20 specimens. Short humeri, humeri with small heads, or too deeply inserted nails may increase the risk of nerve injury; likewise, a lower location and more horizontal direction of the locking screws and a greater curvature of the nail can heighten the risk. In addition to the examination of the axillary nerve, a geometric study of these anatomic specimen was performed and was aimed at improving retrograde nailing technique and thus treatment results. The humeral geometry indicated that for the best linearity in the sagittal plane, an entry portal incorporating the superior margin of the olecranon fossa would be recommended for the 14 humeri with a distal humeral offset less than 4 mm, whereas a supracondylar entry portal would be recommended for the six humeri with an offset larger than 4 mm. For best linearity in the coronal plane, the entry portal and nailing direction should be more lateral in humeri with a smaller humeral elbow angle.

Menadione-induced cytotoxicity to rat osteoblasts

Abstract. Oxygen-derived free radical injury has been associated with several cytopathic conditions. Oxygen radicals produced by chondrocytes is an important mechanism by which chondrocytes induce matrix degradation. In the present study, we extend these observations by studying oxidative processes against osteoblasts. Osteoblasts were mixed in in vitro culture with 200 μM menadione. The cytotoxic effect of menadione-induced oxidative stress was monitored by lucigenin- or luminol-amplified chemiluminescence, tetrazolium assay and immunocytochemical study. Results showed that adding menadione induces an oxidative stress on osteoblasts, via superoxide and hydrogen peroxide production, that can be eradicated by superoxide dismutase (SOD) and catalase in a dose-dependent manner. Catalase and the appropriate concentration of dimethyl sulfoxide have a protective effect on cytotoxicity induced by menadione, whereas SOD does not. Menadione-treated osteoblasts have a strong affinity for annexin V, and the nuclei are strongly stained by TUNEL (TdT-mediated dUTP nick-end labelling). The results suggest that menadione-triggered production of reactive oxygen species leads to apoptosis of osteoblasts.

A SIMPLE CHEMILUMINESCENCE ASSAY FOR DETECTING OXIDATIVE STRESS IN ISCHEMIC LIMB INJURY

This study was designed to evaluate a simple, sensitive, nonstimulated chemiluminescence assay to measure the oxidative stress production in the whole blood of rabbits after an ischemic insult. By using an ultra-sensitive chemiluminescence (CL) analyzer and lucigenin amplification, the assay system can be performed without leukocyte isolation and stimulant administration. The blood CL levels of healthy rabbits were 122 +/- 18 counts/10 s. After 8 h of ischemia, the CL levels of whole blood immediately after reperfusion, 1 h, 2 h, 24 h, 48 h, 7 days, and 14 days of reperfusion were 409 +/- 78 counts/10 s, 283 +/- 55 counts/10 s, 256 +/- 43 counts/10 s, 228 +/- 33 counts/10 s, 185 +/- 32 counts/10 s, 160 +/- 16 counts/10 s, and 119 +/- 15 counts/10 s. The differences were statistically significant between the control and samples obtained up to 24 h after reperfusion. The corresponding creatine phosphate kinase (CPK) levels of the rabbits in this study were 938 +/- 43 U/l for the control blood sample and 5921 +/- 498 U/l, 6948 +/- 427 U/l, 6860 +/- 1115 U/l, 5763 +/- 516 U/l, 1545 +/- 291 U/l, 478 +/- 60 U/l, and 458 +/- 48 U/l for the experimental blood samples. The CPK levels of the blood samples before 24 h and after 7 days of reperfusion were significantly different to that of the control blood sample. The changes in the CL and CPK levels were quite similar before 48 h reperfusion. This assay has proved to be valuable in the quantitative measurement of ischemic insults of skeletal muscles.

Ununited femoral neck fractures by open reduction and vascularized iliac bone graft.

Neglected femoral neck fractures are frequently complicated with nonunion and avascular necrosis of the femoral head. The treatment is especially difficult in young adults because arthroplasty is not indicated. Five cases of neglected femoral neck fractures in young patients were treated by open reduction and internal fixation with pins. The defect of the femoral neck was filled with a block of vascularized iliac bone graft. After at least two years, the fractures were healed without avascular necrosis of the femoral head. The leg-length discrepancy was corrected in all but one case. The pedicled iliac graft provided a viable bone graft, which maintained the viability of the head and hastened fracture healing.