Search

The causes of ulnar neuropathy at the elbow are unclear. The authors hypothesized that the humeral trochlea protrudes into the cubital tunnel during elbow flexion and causes a dynamic morphologic change of the ulnar nerve in the cubital tunnel.An ultrasonic probe was fixed to the ulnar shafts of 10 fresh cadavers with an external fixator, and dynamic morphology of the cubital tunnel and ulnar nerve was observed. The distance from the Osborne band to the trochlea (OTD), distance from ulnar nerve center to the trochlea (UTD), and the short- and long-axis diameters of the nerve at 30°, 60°, 90°, and 120° of elbow flexion were recorded. We compared the OTD, UTD, and the flattening of the ulnar nerve at the different angles of flexion using single-factor analysis of variance. Correlation between the ulnar nerve flattering, OTD, and UTD was examined using Spearman correlation coefficient. A P value less than .05 was used to denote statistical significance.Flattening of the ulnar nerve progressed with increasing elbow flexion and was significantly different between 0° and 60°, 90°, and 120° (P = .03 at 60°, P .01 at 90° and 120°). OTD decreased with elbow flexion, and there was a significant difference at all elbow flexion angles (all P .01). UTD decreased significantly from 0° flexion to 90° flexion (P = .03). Flattening of the nerve was significantly correlated with the OTD (r = 0.66, P .01).A positive correlation was found between the protrusion of the humeral trochlea into the cubital tunnel during elbow flexion and ulnar nerve flattening using cadaveric elbow and ultrasonography.

Purpose To examine the clinical outcomes of arthroscopic lunate excisions for advanced Kienbock's disease. Methods Fifteen patients (six men and nine women; mean age: 65 years; range: 48-83 years) with advanced Kienbock's disease, who underwent arthroscopic lunate resection between April 2008 and March 2016, were reviewed clinically and radiographically after a follow-up of >2 years (mean: 29 months; range: 24-60 months). Clinical parameters, such as wrist range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and patient-rated wrist evaluation (PRWE) score were evaluated. Radiographic parameters included radioscaphoid angle, scaphocapitate angle, carpal height ratio, ulnar-triquetrum distance, and the scaphoid-triquetrum distance. Wilcoxon's signed-rank test was used to compare measurement results. Results During the final follow-up, patients exhibited significant improvements, such as 42.9° in wrist range of motion (P = .009), 24.5% of the contralateral side in grip strength (P = .001), 26.2 points in DASH score (P = .002), and 37.8 points in PRWE score (P < .001), compared with the preoperative values. The radioscaphoid and scaphocapitate angles significantly increased by 4.8° (P = .0027) and 3.7° (P = .0012), respectively. The carpal height ratio, ulnar-triquetrum distance, and scaphoid-triquetrum distance significantly decreased by 0.05 (P < .001), 2.6 mm (P < .001), and 1.3 mm (P = .0012), respectively. Conclusions Our results suggest that arthroscopic lunate excisions provided excellent postoperative pain relief and functional recovery within 2 years of follow-up. Changes in carpal alignment and stress concentration on the radial side of the carpal bones could occur in the long term; however, arthroscopic lunate excision can be a good surgical option for treating low-demand patients with advanced Kienbock's disease. Level of Evidence Level IV, therapeutic case series.

Background Of the anatomical reduction and fixation methods used to treat distal radius fracture, non-bridging external fixation has the advantage of enabling early wrist motion. The surgical technique relies on successful placement of the pin in individual fracture fragments. The present study aimed to identify the safe zone of pin insertion for a non-bridging external fixator into the distal radius that avoids metal impingement of extensor tendons. Methods The width and length of the septal attachments of the extensor retinaculum were measured on axial MR images of 62 wrists. Results The 2–3 septum was the widest and longest, with a width of 2–7 mm and a location 0–36 mm proximal to the wrist joint. The width of the 1–2 septum was 2–6 mm, and was widest at 10 mm proximal to the joint. The 1–2 septum was triangular-shaped, while the 2–3 septum was oval-shaped. The 3–4 and 4–5 septa had narrow attachments and were adequate for pin insertion (with a pin 1–2 mm in width) at a position less than 8 mm proximal to the wrist. The width of the 1 R septum (radial to the 1st septum) was 2–6 mm at the radiovolar aspect of the wrist. Conclusions There were two safe pin insertion sites; the first was safe at the distal aspect only (8–10 mm proximal to the wrist) and included the 1–2, 3–4, and 4–5 septa, while the second was safe from 0 mm to 32–38 mm proximal to the wrist and included the 1 R and the 2–3 septa. The 1 R septum had adequate size for use as a new pin insertion site that aligns in the internervous plane and has minimal risk of superficial radial nerve injury.

There is a lack of data on how ulnar nerve strain varies according to the location around the elbow joint. Therefore, we measured the longitudinal movement of the ulnar nerve around the elbow joint. Four fresh-frozen cadaveric upper extremities were used. A linear displacement sensor was attached to the ulnar nerve at eight measurement points at 20-mm intervals. At each point, the longitudinal movement of the ulnar nerve was measured during elbow flexion. We calculated the strain on the ulnar nerve based on the change in movement between neighboring points. Ulnar nerve movement with elbow flexion had a maximum value (mean, 10.5 mm, p &lt, 0.001) at 2 cm proximal to the medial epicondyle. In the site distal to the medial epicondyle, the movement was small and demonstrated no significant difference between points (p = 0.1). The change in strain between mild flexion (0–60°) and deep flexion (60–120°) significantly differed at 2–4 cm and 6–8 cm proximal to the medial epicondyle (15% versus 3%, p &lt, 0.01, 5% versus 9%, p &lt, 0.05, respectively). The longitudinal movement of the ulnar nerve during elbow flexion occurred mainly at the site proximal to the medial epicondyle and became smaller away from the medial epicondyle.

A few treatment options for radial neck non-union have been reported, including radial head excision, radial head replacement, and internal fixation with a bone graft. We describe a new treatment for radial neck non-union using a reverse vascularized bone graft of the lateral distal humerus. In the anatomical study, the posterior radial collateral artery (PRCA) was dissected in eight fresh-frozen cadaver arms. The number of branches from the PRCA to the humerus was determined, and the distances from these branches to the lateral epicondyle of the humerus were measured. We then used this information to create a reverse vascularizedhumeral bone graft, which was used to treat non-union of a radial neck fracture in a 73-year-old female. There were two to four PRCA branches (mean: 3.3) entering the bone. The distance from the branches to the lateral epicondyle of the humerus ranged from 2.5 to 10.8 cm. The mean distances from the most proximal and distal PRCA branches to the lateral epicondyle of the humerus were 7.6 cm and 3.4 cm, respectively. The case of non-union of a radial neck fracture was successfully treated with a reverse vascularized humeral bone graft. There were no major complications, and radiographs showed bony union at 8 weeks postoperatively. This procedure may become a new option for the treatment of non-union of fractures of the radial head and neck, as it enables preservation of the radial head, which is an important structure in the elbow and proximal radioulnar joints.

The most common procedure for the treatment of painful median nerve neuroma is coverage with vascularized soft tissue following external neurolysis. However, the ideal treatment should include reconnecting the proximal and distal stumps of the damaged nerve to allow the growth of regenerating axons to their proper targets for a functional recovery. We developed a useful technique employing radial artery perforator adipofascial flap including the lateral antebrachial cutaneous nerve (LABCN) to repair the median nerve by vascularized nerve grafting and to achieve coverage of the nerve with vascularized soft tissue. In an anatomical study of 10 fresh-frozen cadaver upper extremities, LABCN was constantly bifurcated into two branches at the proximal forearm (mean: 8.2 cm distal to the elbow) and two branches that run in a parallel manner toward the wrist. The mean length of the LABCN branches between the bifurcating point and the wrist was 18.2 cm, which enabled inclusion of adequate length of the LABCN branches into the radial artery perforator adipofascial flap. The diameters of the LABCN branches (mean: 1.7 mm) were considered suitable to bridge the funiculus of the median nerve defect after microsurgical internal neurolysis. In all cadaver upper extremities, the 3-cm median nerve defect at the wrist level could be repaired using the LABCN branches and covered with the radial artery perforator adipofascial flap. On the basis of this anatomical study, the median nerve neuroma was successfully treated with radial artery perforator adipofascial flap including vascularized LABCN branches.

Purpose Trapeziometacarpal (TMC) joint arthrodesis is an effective treatment for stage III osteoarthritis . Although this procedure alleviates thumb pain and restores grip power and pinch strength, persistent limitation of thumb movement is inevitable. This biomechanical study aimed to investigate the altered kinematics of thumb circumduction motion after TMC joint arthrodesis and subsequent excision of the trapeziotrapezoid (TT) and trapezio-second metacarpal (T-2MC) joint spaces. Methods Eight cadaver upper extremities were mounted on a custom testing apparatus. The hand and carpal bones were fixed to the apparatus, except for the first metacarpal bone , trapezium, and trapezoid. A 50-g load was applied at the tip of the first metacarpal head to generate passive thumb circumduction. An electromagnetic tracking system measured the angular and rotational displacement of the first metacarpal. All specimens were tested in 4 conditions: intact, after simulated TMC joint fusion, after subsequent excision of 3 mm of bone at the TT joint space, and after additional 3 mm resection at the T-2MC joint space. Results After simulated TMC arthrodesis, the range of angular motion of thumb circumduction decreased to 25% that of the intact thumb. Subsequent resections at the TT and T-2MC joint spaces increased circumduction ranges to 49% (TT joint) and 73% (TT plus T-2MC joints) that of the intact thumb. The range of thumb rotational motion showed a similar trend. Conclusions Trapeziometacarpal arthrodesis decreased the range of both angular and rotational motion during thumb circumduction. Subsequent resections at the paratrapezial space increased the range of thumb motion, suggesting that hypermobility of the paratrapezial joints increases thumb mobility after TMC joint fusion. Clinical relevance Patients with hypermobile paratrapezial joints may have larger thumb movement after TMC joint fusion. Additional resections of the TT and T-2MC joint spaces may further mobilize the thumb in patients who complain of stiffness after TMC fusion.

Continuous infusions (CI) of factor (F)VIII are preferable to the conventional bolus injections for the maintenance of consistent FVIII levels during surgery in patients with severe hemophilia A. A third generation, B domain-truncated recombinant FVIII (turoctocog alfa, Novo Nordisk, NovoEight®), was approved for clinical use in 2014. The hemostatic efficacy and safety of bolus injections of turoctocog alfa in patients undergoing surgery have been reported, but no reports on CI therapy have been published. We describe a 43-year-old patient with severe hemophilia A who required arthroscopic synovectomy of the right elbow and arthrodesis of the right ankle. He was treated with a bolus injection of turoctocog alfa (36 IU/kg) immediately before operation, followed by CI (infusion rate; 2.9 IU/kg/h) to maintain FVIII activity > 80 IU/dl throughout the perioperative period. Surgery was completed successfully with uncomplicated hemostatic control. CIs were continued until post-operative day (POD) 4. Further bolus injections were given from POD5. No anti-FVIII inhibitor has been detected post-operation. This case provides important information on CI therapy using turoctocog alfa during surgery for patients with severe hemophilia A.

Background The peroneal artery perforator-based flap has been widely used as a pedicled propeller flap for soft tissue reconstruction in the lower extremity; however, its application as a free flap has been rarely reported. We report on the utility of the free peroneal artery perforator-based flap for finger soft tissue reconstruction. Methods Twelve patients underwent reconstructions of soft tissue defects of the finger with free peroneal artery perforator-based flaps. The soft tissue defects were located either dorsally and/or laterally on the fingers. The size of the flaps ranged from 5 × 2 to 8 × 3 cm. The length of the vascular pedicles ranged from 4 to 5 cm. The artery and vein of the perforator vessels were anastomosed in the finger to the digital artery and subcutaneous vein, respectively. Results All twelve flaps survived completely, and the donor site in the lower leg was closed primarily in all cases. Secondary defatting was performed in six cases, while in the remaining cases, thinning of the flap was performed when the flap was transferred. Conclusion The advantages of the free peroneal artery perforator-based flap for finger soft tissue reconstruction include the following: the flap is flexible and can be thinned to match the texture of the finger; elevation of the flap is easy; the donor site can be closed primarily; there is no need to sacrifice any main arteries in the lower leg; and the diameter of the perforator vessels is suitable for anastomosis to the digital artery and subcutaneous vein in the finger.

Background The purpose of this article was to review the anatomy, kinematics of the distal radioulnar joint (DRUJ), and to discuss definition, classification, and diagnosis of DRUJ instability. Methods A biomechanical perspective on physical examination of DRUJ ballottement test was documented. Physiological dynamic DRUJ translation and differences of the translation following sequential ligament sectioning and changes in different forearm and wrist positions were demonstrated. The clinical significance of each ligament's contribution to joint stability in specific wrist positions was addressed. Conclusion Each ligament stabilizing the DRUJ contributed to joint stability depending on the direction (palmer or dorsal) and different positions of the wrist and forearm. DRUJ ballottement test in each wrist and forearm position may detect tears of specific ligament stabilizing the DRUJ.

Purpose Distal scaphoid and triquetrum excisions can improve the range of wrist motion after radioscapholunate (RSL) fusion, but little is known about the kinematics of dart-throwing and global circumduction motions. We hypothesized that these excisions could increase the range of motion without causing midcarpal instability. Methods Seven fresh-frozen cadaver upper extremities were mounted on a testing apparatus after isolation and preloading of the tendons of the flexor carpi radialis, flexor carpi ulnaris, extensor carpi radialis, and extensor carpi ulnaris. Sequential loadings of the flexor carpi ulnaris and extensor carpi radialis simulated active dart-throwing motion. Passive circumferential loading produced the wrist circumduction motion. We measured the range of wrist motions with an electromagnetic tracking system in 4 experiments: intact, simulated RSL fusion, RSL fusion with distal scaphoid excision, and RSL fusion with distal scaphoid and total triquetrum excisions. To evaluate midcarpal stability, we conducted passive mobility testing of the distal carpal row in the radial, volar, ulnar, and dorsal directions. Results Radioscapholunate fusion decreased the dart-throwing motion to a mean of 46% of the baseline value; distal scaphoid and triquetrum excisions increased the mean arc to 50% and 62%, respectively. Radioscapholunate fusion diminished the wrist circumduction to a mean of 43% of the baseline value, which increased to a mean of 58% and 74% after distal scaphoid and triquetrum excision, respectively. A significant increase in radial deviation was noted after distal scaphoid excision, and subsequent triquetrum excision significantly increased motion in the ulnar-palmar direction. Regarding midcarpal stability, dorsal translation significantly increased after distal scaphoid and triquetrum excisions. Conclusions Distal scaphoid and triquetrum excision after RSL fusion improved both dart-throwing and circumduction motions, but dorsal midcarpal instability occurred. Clinical relevance Subsequent carpal excisions may improve short-term outcome by increasing motions in a RSL-fused wrist; however, a potential risk of midcarpal instability should be considered.

We investigated the reliability and accuracy of the distal radioulnar joint (DRUJ) ballottement test using five fresh-frozen cadaver specimens in triangular fibrocartilage complex (TFCC)-intact, and TFCC-sectioned wrists. The humerus and proximal ulna were fixed. The ulna was allowed to translate in dorsopalmar directions without rotation, and the radius was allowed to move freely. Four sensors of a magnetic tracking system were attached to the radius and ulna, and the nails of each examiner's thumbs. Five examiners conducted the DRUJ ballottement test before and after TFCC sectioning. We used two techniques: With holding and without holding the carpal bones to the radius (holding and non-holding tests, respectively). We compared the magnitudes of bone-to-bone (absolute DRUJ) movement with that of the examiner's nail-to-nail (relative DRUJ) movement. The intrarater intraclass correlation coefficients (ICCs) were 0.92 (holding) and 0.94 (non-holding). The interrater ICCs were 0.84 (holding) and 0.75 (non-holding). Magnitudes of absolute and relative movements averaged 11.5 and 11.8 mm, respectively (p

Septic arthritis of the wrist is rare entity, especially; atypical mycobacterial infection of the wrist is extremely rare. We report a case of septic arthritis of the wrist caused by Mycobacterium intracellulare, which was successfully treated by radical debridement followed by wrist arthrodesis using vascularised fibular grafting.

BACKGROUND Bone marrow stromal cells can be applied therapeutically to enhance angiogenesis; however, the use of bone marrow stromal cell suspensions reduces efficiency because of low-level attachment. The authors hypothesized that bone marrow stromal cell sheets would facilitate cell fixation, thus enhancing angiogenesis. The authors investigated flap survival area and enhancement of angiogenic factors in a rat random-pattern skin flap model after application of bone marrow stromal cell sheets. METHODS Bone marrow stromal cell sheets (prepared from 7-week-old rat femurs) were cultured under four different hypoxic conditions. Sheets with the highest angiogenic potential, determined by an in vitro pilot study, were injected into subcutaneous layers of the rat dorsum (bone marrow stromal cell sheet group). A control group (phosphate-buffered saline only) was included. On day 2 after injection, caudally based random-pattern skin flaps (12 × 3 cm) were elevated. On day 7 after elevation, surviving skin flap areas were measured. Skin samples were harvested from each flap and gene expression levels of vascular endothelial growth factor and basic fibroblast growth factor were measured by quantitative real-time polymerase chain reaction. RESULTS Skin flap survival area (71.6 ± 2.3 percent versus 51.5 ± 3.3 percent) and levels of vascular endothelial growth factor and basic fibroblast growth factor were significantly higher in the bone marrow stromal cell sheet group than in the control group (p < 0.05). CONCLUSIONS Implantation of bone marrow stromal cell sheets increased the survival area of random-pattern skin flaps. Expression of angiogenic factors may have contributed to the increased flap survival.

Wide-awake surgery has potential advantages for treating extensor or flexor tendon injury. We present a case of chronic extensor hallucis longus injury treated with turn-down reconstruction using wide-awake surgery with a selective nerve block. To the best of our knowledge, this is the first such case reported. The patient had dropped a knife proximal to the right hallux metatarsophalangeal joint. Because direct suturing was thought to be difficult, turn-down reconstruction was performed under a selective nerve block. At 8 months postoperatively, the hallux had 75° of extension in the metatarsophalangeal joint and -5° of extension in the interphalangeal joint, similar to those of the healthy foot. The Japanese Society for Surgery of the foot objective hallux scale score had improved from 87 to 100, and the subjective scores in the subcategories of pain and pain-related, physical functioning and daily living, and shoe-related in the self-administered foot evaluation questionnaire had improved from 82.8 to 94.4, 97.7 to 100, and 50 to 83.3, respectively. Turn-down reconstruction using wide-awake surgery with a selective nerve block can be used for chronic extensor hallucis longus rupture and can be expected to provide good results.

We investigated the dynamics of the ulnar nerve during elbow flexion and the relationships between these dynamics and the morphology of the ulnar nerve groove in healthy individuals.Twenty healthy volunteers (40 elbows) underwent ultrasonographic examination of the ulnar nerve at the elbow. We measured the breadth and depth of the ulnar nerve groove at 90° of elbow flexion and calculated the depth-to-breadth ratio. We recorded the distance from the trochlea of the humerus to the nerve and the short-axis diameter of the nerve at 30°, 60°, 90°, and 120° of elbow flexion. We calculated the medial shift and flattening of the ulnar nerve at each angle relative to 30° of flexion, compared the values among the different angles, and compared the depth-to-breadth ratio with the location, medial shift, and flattening ratio of the ulnar nerve.The medial shift was significantly greater at 120° than at other angles (P.001). Flattening increased with increasing elbow flexion and was significantly different at 60°, 90°, and 120° (all P.001). The flattening ratios were significantly correlated with the depth-to-breadth ratio at 120° (r = -0.43, P = .005).The ulnar nerve moves medially and is flattened with the elbow flexed between 90° and 120°. When the ulnar nerve groove is shallow, high degrees of elbow flexion result in flattening of the ulnar nerve in the groove.

Anterior dislocation of the ulnar nerve is occasionally encountered after simple decompression of the nerve for treatment of cubital tunnel syndrome. The purpose of this study was to determine whether the incidence of dislocation of the nerve following simple decompression of the nerve is correlated with the patient's preoperative characteristics and/or elbow morphology. We studied 51 patients with cubital tunnel syndrome who underwent surgery at our institution. Intraoperatively, we simulated dislocation of the nerve after simple decompression by flexing the elbow after releasing the nerve in each patient. Univariate and multiple logistic regression analysis showed that young age and a small ulnar nerve groove angle are positively correlated with dislocation of the nerve. Our results suggest that patients who are young and/or have a sharply angled ulnar nerve groove identified radiographically have a high probability of experiencing anterior dislocation of the ulnar nerve after simple decompression.

We investigated the reliability and accuracy of the distal radioulnar joint (DRUJ) ballottement test using five fresh-frozen cadaver specimens in triangular fibrocartilage complex (TFCC)-intact, and TFCC-sectioned wrists. The humerus and proximal ulna were fixed. The ulna was allowed to translate in dorsopalmar directions without rotation, and the radius was allowed to move freely. Four sensors of a magnetic tracking system were attached to the radius and ulna, and the nails of each examiner's thumbs. Five examiners conducted the DRUJ ballottement test before and after TFCC sectioning. We used two techniques: With holding and without holding the carpal bones to the radius (holding and non-holding tests, respectively). We compared the magnitudes of bone-to-bone (absolute DRUJ) movement with that of the examiner's nail-to-nail (relative DRUJ) movement. The intrarater intraclass correlation coefficients (ICCs) were 0.92 (holding) and 0.94 (non-holding). The interrater ICCs were 0.84 (holding) and 0.75 (non-holding). Magnitudes of absolute and relative movements averaged 11.5 and 11.8 mm, respectively (p 0.05). Before TFCC sectioning, the DRUJ movement during the holding and non-holding techniques averaged 9.8 and 10.8 mm, respectively (p 0.05). The increase in DRUJ movement after TFCC sectioning was greater with the holding technique (average 2.3 mm) than with the non-holding technique (average 1.6 mm). The DRUJ ballottement test with magnetic markers is relatively accurate and reliable for detecting unstable joints. We recommend the holding technique for assessing DRUJ instability in clinical practice. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1123-1127, 2017.

An 11-year-old girl with Kienböck disease (stage IIIA) was treated by temporary scaphotrapeziotrapezoidal fixation. It was fixed in a cast for four weeks and wires removed after eight weeks. Follow up examinations showed that movement of the wrist and grip strength were improved, and she had no pain while revascularisation of the lunate could be seen on magnetic resonance imaging.

Two cDNAs that encode asparagine synthetase were cloned from root nodules of Astragalus sinicus cv. Japan (Renge-sou). The expression of the transcripts was nodule-enhanced. The expression of both genes was reduced in nodules when (NH4)2SO4 was added to the culture medium. This is the first report of the inhibition of asparagine synthetase gene expression by ammonium in root nodules.

A system for the Agrobacterium rhizogenes-mediated transformation and root and then shoot regeneration of the legume species Astragalus sinicus (Chinese milk vetch) has been developed. A. rhizogenes DC-AR2 strain harboring the binary vector pBI121, carrying the uidA gene encoding GUS activity, was used to transform seedlings in wound sites. Transformation was monitored by detection of mikimopine and histochemical β-glucuronidase (GUS) activity. GUS expression was found in approximately 44% of the seedlings 15 days after infection and 46% of the aerial roots tested were GUS positive while all of the GUS positive roots also contained mikimopine, which is a characteristic of strain DC-AR2. When the transformed roots were cultured in vitro, sporadic shoot development occurred after culture periods ranging from 1 to 2 months and transgenic A. sinicus plantlets were established. The transformation of the regenerated plantlets was further confirmed by histochemical GUS activity and by Southern blot analysis. The resulting plants exhibited the ‘Ri plasmid’ syndrome such as small thin leaves and short internodes while cultured roots grew rapidly and were plagiotropic. This transformation and plant regeneration system will be useful as a model system for testing the expression of genes and their effect on a leguminous plant.

A novel nodulin gene, AsNODc22, was isolated from Astragalus sinicus cv. Japan (Renge-sou) by differential screening. The transcript of AsNODc22 was nodule specific, and its size was approximately 0.8 knt. AsNODc22 encoded an unknown ORF containing a putative signal peptide and a pair of similar hepta-peptides (CSAQVSC, CSAQLSC). For immunological study, antiserum against AsNODc22 protein was prepared in mice. By immunoblot analysis, the antiserum detected a nodule specific band at approximately 18 kDa. Immunofluorescence microscopy was used to observe localization of the gene product in the nodule. The signals were seen along the cell wall of bacteria-infected cells, but no significant signals were seen on uninfected cells.

The purpose of this study was to analyze fracture patterns and the magnitude of displacement in the distal radioulnar joint (DRUJ), by three-dimensional (3D) computed tomography (CT), for distal radius fractures with intra-articular displacement of the radiocarpal joint.We reconstructed 3D images for 72 consecutive patients with displaced intra-articular distal radius fracture on the basis of fine-cut axial CT data. The fracture patterns involving the DRUJ were classified on the basis of the location and direction of fracture lines, and the extent of fracture comminution. We measured the maximum spatial distance of the gap and the step between the fragments in each 3D image, and the magnitudes of displacement between the groups were compared by analysis of variance followed by post-hoc analysis by use of Tukey's test.Sixty wrists had a fracture involving the DRUJ. We classified the 60 wrists into 3 types of fracture pattern. Type 1 was a transverse fracture with minimum displacement. Type 2, in which fracture lines extended into the distal margin of the sigmoid notch, was the most common longitudinal fracture. Type 3 was a fracture with multiple fragments. The step and gap in Type 3 was significantly larger than that in the other types.Eighty-three percent of intra-articular distal radius fractures had DRUJ involvement, and 28% of the wrists had multiple fragments. For Type 3 fractures with dorsal or proximal comminution displacement was significantly larger than for simple Type 1 and 2 fractures. Surgical intervention for the DRUJ fragment may be beneficial when there is remarkable intra-articular displacement.

The usefulness of wide-awake surgery with infiltration of local anesthetics has been widely reported.1,2 The ability of the hand surgeon to observe active movement of the fingers intraoperatively is a great advantage in terms of predicting the postsurgical function of the hand. The most frequently reported technique of wide-awake surgery involves subcutaneous infiltration of a local anesthetic based on anatomical landmarks, and the surgical site is usually limited to the area distal to the wrist joint. A large amount of local anesthetic may be required when the surgical site extends to the forearm, as in tendon reconstruction surgery. Lalonde and Wong1 described that wide-awake surgery at the forearm requires up to 500 mg (200 mL) of epinephrine-containing lidocaine. The use of a large amount of local anesthetics is associated with a substantial risk of local anesthetic systemic toxicity. Cardiac arrest because of local anesthetic toxicity is a rare but serious complication.3,4 The maximum dose of epinephrine-containing lidocaine for local anesthesia is usually 4–7 mg/kg. The maximum dose of ropivacaine in healthy adults is 3 mg/kg. Regional anesthesia under ultrasound guidance is effective because of the ability to observe the nerves, needles, and spread of the local anesthetic in real time.5,6 Barrington and Kluger7 reported that ultrasound-guided regional anesthesia is associated with a lower risk of local anesthetic systemic toxicity based on an analysis of approximately 20,000 cases. Real-time observation is considered to be useful for avoidance of nerve injury and intravascular injection of the local anesthetic, making regional anesthesia a safer procedure.5 Ultrasonography allows for identification of the location of the branching site of the superficial branch of the radial nerve and dorsal sensory branch of the ulnar nerve in the forearm. We hypothesized that sufficient analgesia for wide-awake forearm tendon surgery can be obtained without local anesthetic toxicity with the use of accurate ultrasound-guided injection into each sensory nerve to the skin, interosseous membrane, and fascia of the upper extremity. The purpose of this study was to evaluate the effectiveness of ultrasound-guided selective sensory nerve block for wide-awake forearm tendon reconstruction.

Astragalus sinicus (renge-sou) is a winter growing green manure legume, and its divergent strains have been widely used to fertilize rice field in China and Japan and has been used for 2,000 years. The plant forms nitrogen-fixing root nodules by Rhizobium huakuii or R. huakuii bv. renge (Y. Murooka et al., 1993). Formation of adventitious shoots and plant regeneration by culture of cotyledon segment in A. sinicus were established (H-J. Cho et al., 1995). We also developed transformation and regeneration of A. sinicus with Agrobacterium rhizogenes DC-AR2 harboring pBI12l. Transformation frequencies of up to 90% was obtained. Mikimopine formation and GUS activity were observed in these transformants (H-J. Cho et al., unpublished). Shoots were spontaneously formed on hairy root cultures and thus transgenic A. sinicus plantlets were established.