Journal of Orthopaedic Science

Published by Springer Verlag
Online ISSN: 1436-2023
Print ISSN: 0949-2658
The concept of day surgery is becoming an increasingly important part of elective surgery worldwide. Relentless pressure to cut costs may constrain clinical judgment regarding the most appropriate location for a patient's surgical care. The aim of this study was to determine clinical and quality indicators relating to our experience in orthopedic day durgery, mainly in relation to unplanned overnight admission and readmission rates. Additionally, we focused on describing the main characteristics of the patients that experienced complications, and compared the patient satisfaction rates following ambulatory and non-ambulatory procedures. We evaluated 10,032 patients who underwent surgical orthopedic procedures according to the protocols of our Ambulatory Surgery Unit. All complications that occurred were noted. A quality-of-life assessment (SF-36 test) was carried out both pre- and postoperatively. Ambulatory substitution rates and quality indicators for orthopedic procedures were also determined. The major complication rate was minimal, with no mortal cases, and there was a high rate of ambulatory substitution for the procedures studied. Outcomes of the SF-36 questionnaire showed significant improvement postoperatively. An unplanned overnight admission rate of 0.14 % was achieved. Our institution has shown that it is possible to provide good-quality ambulatory orthopedic surgery. There still appears to be the potential to increase the proportion of these procedures. Surgeons and anesthesiologists must strongly adhere to strict patient selection criteria for ambulatory orthopedic surgery in order to reduce complications in the immediate postoperative term.
The Exeter stem was introduced to the Japanese market in 1996. Since then, owing to excellent clinical results, the number of stems used has increased year by year and more than 2000 stems were implanted in 2009. The objective of this study was to prove the efficacy of the Exeter stem for Japanese patients by evaluating the short-term results of four major dedicated hip centers. We performed a retrospective study of clinical and radiographic results of 1000 primary total hip arthroplasties (THA) performed using the Exeter stem on 881 patients who were followed-up for at least 2 years after surgery. The average age of the patients at operation was 62.3 years (range 23-89 years). Mean postoperative follow-up period was 4.0 (range 2-9) years. Thirty postoperative complications were observed, including 9 infections, 14 dislocations, 5 cases of deep vein thrombosis, and 2 cases of sciatic nerve palsy. No symptomatic pulmonary embolization or femoral fractures were observed. Re-operations for infection and dislocation were performed in 8 and 6 hips, respectively. According to Barrack's classification, the postoperative cementing grade was judged as A for 735 hips, B for 246 hips, and C for 4 hips. At final follow-up, no radiolucent line was observed at the bone-cement interface. Cortical hypertrophy was observed in 9.5 % of cases in Gruen zones 2-6. Kaplan-Meier survival analysis predicted 100 % survival at 5 years when a radiolucent line at the bone-cement interface of the femur was used as the endpoint, 98.8 % when re-operation was required for any reason. This study revealed that excellent short-term results were achieved by fixing the Exeter stem with modern cementing techniques for primary THA in Japanese patients.
Lumbar surgery and associated complications are increasing as society is aging. However, definitions of complications after lumbar surgery have not been established and previous reports have varied in the definition of, and focus on, intraoperative or major postoperative complications. We analyzed the frequency and severity of perioperative complications and all minor adverse events in lumbar surgery at a single center. We retrospectively reviewed all lumbar surgery, including decompression surgery with or without fusion, at Meijo Hospital over a 10-year period. Perioperative complications and all surgery-related adverse events until 1 month postoperatively were reviewed for 1012 operations on 918 patients (average age 54 years old). The incidence of intraoperative complications was compared between junior (<10 years experience of spine surgery) and senior (≥10 years experience) surgeons. Perioperative complications and adverse events occurred in 159 operations (15.7%) on 127 patients (13.8%). There were a variety of perioperative adverse events, including digestive problems. Of the 159 complications and events, 24 (2.4%) were intraoperative and 135 (13.3%) were postoperative. Incidence of intraoperative complications was not significantly higher for junior surgeons; however, the operations performed by senior surgeons were significantly more invasive. Complications were more frequent in elderly patients (p < 0.01) and in operations that were longer (p < 0.0001), had greater estimated blood loss (p < 0.0001), and involved use of spinal instrumentation (p < 0.0001). Psychotic symptoms occurred significantly more often in older patients (p < 0.001). The absence of a relationship between the experience of the surgeon and incidence of intraoperative complications may be because of the greater effect of invasive surgery. Although age and invasiveness were associated with more perioperative adverse events, we do not conclude that major surgery should be avoided for elderly patients. In contrast, careful focus on the surgical indication and procedure is required for these patients.
The purpose of this study was to evaluate the minimum 10-year results of primary total hip arthroplasty using an uncemented, hydroxyapatite-coated tapered stem. Radiological signs of bone remodeling are also presented. We followed a consecutive series of 105 patients (115 hips), who had had an uncemented, proximally hydroxyapatite-coated Bi-Metric femoral component for a mean of 12.2 years (range 10.0-14.9 years). The average age at operation was 52 years. Detailed clinical and radiological analyses were performed after a minimum of 5 and 10 years. Eight patients (10 hips) had died, and one patient was lost to follow-up, leaving 104 hips for final evaluation. The clinical result was evaluated by the Harris Hip Score, complications, and thigh pain. All patients still had their femoral components in place at the final follow-up. The average Harris Hip Score after 10 years was 92 (range 50-100) with no deterioration over time. Radiologically, several signs of progressive remodeling were identified, but no stem showed signs of loosening. The intermediate clinical and radiological results with this stem are encouraging. In the hands of various surgeons, the stem has performed well in a young, high-risk population.
Intra-focal fixation for a displaced distal radius fracture is a surgical option that achieves early functional recovery. We report a retrospective evaluation of the results with various types of distal radius fracture, using various fixation materials in 104 patients (69 women and 35 men; average age, 51.4 years; range, 4-91 years). Fracture types classified according to Frykman were: 14 type I, 15 type II, 6 type III, 16 type IV, 10 type V, 16 type VI, 9 type VII, and 18 type VIII. Fixation materials used were: conventional Kirschner wire in 6 patients, threaded Kirschner wire in 38, arum pins in 38, and conehead wedging screws in 22. The results for patients with Frykman types V-VIII fractures were not as good as those for patients with types I-IV. The arum pin and conehead wedging screw were each superior to either Kirschner wire or threaded Kirschner wire in reducing the fracture and in maintaining fixation. Our evaluation suggested that intra-focal fixation was also suitable for treatment of an intra-articular fracture. In elderly patients, we recommend the arum pin and conehead wedging screw as fixation materials, and suggest short-term postoperative immobilization.
It is well known that carpal tunnel syndrome (CTS) can occur in a wide range of time periods after distal radius fracture (DRF). Few studies have evaluated in detail the relationship between fracture and electrophysiological finding characteristics and time to onset of CTS after DRF. To clarify the characteristics of CTS after DRF, we classified a large number of clinical cases based on the period from the injury to onset of CTS. These cases were analyzed retrospectively. We reviewed 105 wrists with CTS following DRF. Patients' ages ranged from 13 to 89 years. These 105 wrists were divided into three groups according to the period of post-fracture onset of CTS. Twenty-eight wrists were classified into the acute onset group (when the symptoms of CTS occurred within 1 week after fracture). Forty-seven wrists were classified into the subacute onset group (when symptoms of CTS occurred from 1 to 12 weeks after fracture). The remaining 30 wrists were classified into the delayed onset group (when symptoms of CTS occurred more than 12 weeks after fracture). Deformity of the distal radius on X-ray films was evaluated and distal motor latency (DML) of the median nerve was recorded to compare values among these three groups. In the acute onset group, 68% had an AO C-type fracture and 46% were caused by a high-energy injury. The percentage of this fracture pattern and mechanism was significantly higher in the acute onset group than in the other groups (P < 0.05; Kruskal-Wallis test). In the subacute onset and delayed onset groups, 79% and 63% had an A-type fracture and more than 90% were caused by a low-energy injury. In the delayed onset group, the incidence of prolonged DML in the contralateral wrists was 71%, which was significantly higher than in the other two onset groups (P < 0.05; Kruskal- Wallis test). There were three onset patterns of CTS after DRF, and each CTS onset pattern had different etiologic mechanisms and different clinical features of CTS. In the acute onset group, a high-energy fracture pattern was associated with CTS. In the subacute and the delayed onset groups, lowenergy injury in elderly women was associated with CTS. Both deformity of the fracture and preexisting median nerve dysfunction were suggested as predisposing factor for CTS.
We report long-term results of the first clinical trial of hydroxyapatite-coated total hip arthroplasty conducted in Japan. The hemispherical cup and the straight-tapered stem were made of titanium alloy with a grit-blasted, hydroxyapatite-coated surface. The surface roughness before and after hydroxyapatite coating was 1.4 microm and 3.4 microm, respectively. Thirty-three patients (35 hips) were followed prospectively; of these, 1 patient was lost to follow-up, 5 were deceased at the latest follow-up, and 27 were followed for 11 to 14 years. Two cups and one stem (two patients) were revised. Survivorship, with radiological acetabular loosening as the endpoint, was 62.3% at 14 years. At the latest radiological follow-up, stable fixation with bone ongrowth was achieved in 46% of the acetabular cups and 89% of the femoral stems. Acetabular cups with host bone coverage of less than 60% had a high rate of failure. The suboptimal result of the hydroxyapatite-coated smooth cup indicates that porous coatings under the hydroxyapatite coating would be beneficial for hydroxyapatite-coated total hip implants, especially for the acetabular components.
Background: This study investigated the radiological factors that correlated with progression of collapse and joint space narrowing after transtrochanteric posterior rotational osteotomy (PRO) for osteonecrosis of the femoral head. Methods: This study reviewed 51 hips in 47 patients with a mean follow-up of 11 years (5-20). The subjects included 29 males and 18 females with a mean age of 34 years (12-54) at the time of surgery. The 51 hips were divided into two groups based on the radiological outcome (group I: evidence of progression of collapse and/or joint space narrowing, group II: no evidence of either progression of collapse or joint space narrowing). Both clinical and radiological factors were analyzed by both univariate and multivariable analyses. Results: Six hips were categorized as group I and 45 hips were categorized as group II. The postoperative intact ratio and preoperative stage were significantly correlated with the radiological outcome in both univariate (P < 0.0001, P = 0.006) and multivariate (P = 0.0014, P = 0.0039) analysis. The cutoff point for the postoperative intact ratio (the minimum ratio required to prevent both progression of collapse and joint space narrowing) was 36.8 %. Conclusions: The results of this study indicate that the postoperative intact ratio is one of the main influences on progression of collapse and/or joint space narrowing after PRO, and should be at least 36.8 %. An increased awareness of this critical ratio would be useful for planning the optimal use of this procedure.
Total hip replacement in developmental dysplasia of the hip is a demanding procedure and usually requires dedicated devices and special surgical techniques. Nevertheless, the described techniques have shown variable outcomes. The aim of this study was to assess the 11-year outcomes of an off-the-shelf modular neck prosthesis in dysplastic patients and to evaluate the ability of the modular neck system to adequately restore femoral offset, abductor muscles lever arm and leg length. We retrospectively evaluated 61 modular neck prostheses implanted in 47 patients between June 1995 and March 2004. The preoperative diagnosis was developmental dysplasia of the hip in all cases. The clinical outcomes were assessed using the Harris hip score and the Western Ontario and McMaster Universities score. The femoral offset, abductor muscles lever arm, height and medialization of the hip center of rotation, and differences in leg length were evaluated on postoperative radiographs. Prosthesis survival was calculated according to the Kaplan-Meier method considering any reason for revision as failure. The average follow-up was 117.2 months (range 57-162 months). The cumulative survival at 11 years was 97.5%. One prosthesis failed 5 years after surgery because of a ceramic liner fracture due to an inappropriate obstetric maneuver during labour. At the latest follow-up the mean Harris hip score was 74.7 (range 23-91). Leg length discrepancy was avoided in the majority of cases; femoral offset was almost always restored. The results of this series support the use of modular neck prostheses as an effective alternative in the treatment of developmental dysplasia of the hip. The modularity was very efficient in restoring offset, leg length and maintaining stability with a good mid-long-term follow-up. Unlike other proposed surgical techniques, these good results are achievable by a standard surgical technique and with an off-the-shelf prosthesis.
Split lesions of the peroneus brevis tendon are believed to be rare and have received little attention in populations of Asian countries. The purpose of this study was to investigate the incidence of split lesions in the Japanese population. The peroneus tendons of 112 ankles from 30 male and 26 female adult human embalmed cadavers with an average age of 76.9 years (range, 55-93) were dissected. The presence of split lesions, determined by either thinning or longitudinal splitting of the peroneus brevis tendon, was examined. Forty-two ankles (37.5%) had split lesions, of which 21 (50%) showed a thinning appearance without splitting, and 12 (28.6%) had well-defined, full-thickness longitudinal tears. The incidence of split lesions of the peroneus brevis tendon in the Japanese population was similar to that in studies of the U.S. population, but the condition of the lesions was less severe. Although the clinical presence is expected to be extremely rare, we must consider a neglected split lesion of the peroneus brevis tendon when residual pain is observed in the retrofibular location.
The aim of this study was to investigate the pain patterns in patients with end-stage hip disease and to assess the response after total hip arthroplasty (THA). The pain patterns of patients undergoing THA for end-stage hip diseases were prospectively evaluated by requesting them to mark a map of body areas before and after surgery. Patients were excluded if they had coexisting pathology of the knee or spine. The pain measurements were quantified using visual analog scales, and factors that may contribute to different pain patterns were also evaluated. Among 113 patients (113 hips) enrolled in the study, the groin, anterior thigh, buttock, anterior knee, and greater trochanter were the most common pain locations before THA. Pain over the lower back, shin, and calf areas, which were not generally considered referral pain areas from hip diseases, was present in 21.2, 7.1, and 2.7% patients, respectively. The presence of lower back pain (LBP) was statistically more common in patients with longer duration of hip symptoms. Regardless of the different pain patterns, 97.3% (110 of 113) of patients reported complete pain relief within 12 weeks after THA. The distribution of pain from end-stage hip diseases is versatile, and presence of pain in areas other than around the hip is not uncommon. LBP was more common in patients with longer duration of symptoms. THA satisfactorily resolves the pain in all areas soon after surgery.
The prevalence of obesity and previous knee injury was assessed in a retrospective study of 115 patients under-going total knee replacement due to osteoarthritis. Obesity was considered a contributing factor in the development of osteoarthritis in 37% of the patients, and 33% of the patients had had an injury to the knee in question. Unilateral osteoarthritis was significantly more frequent than bilateral osteoarthritis among patients with a history of previous knee injury. The association of previous injury to the knee and unilateral osteoarthritis was stronger in men than women. Aggressive treatment of patients with knee injuries seems warranted.
The joint gap is set rectangular at 90 degrees flexion during total knee arthroplasty (TKA). However, the condition of the joint gap in deep knee flexion is obscure. The method for obtaining a posteroanterior view radiograph of the knee at 90 degrees flexion (the epicondylar view) was modified, and a method to obtain an anteroposterior view radiograph at 120 degrees flexion (deep flexion view) was established. With this method, subjects lie on the radiography table with their thighs placed on a device so their lower legs hang down in neutral rotation with a 1.5-kg weight attached to the ankle. The joint gap angle and medial and lateral joint space widths were measured on epicondylar view and deep flexion view radiographs in 20 normal male subjects, 20 normal female subjects, and 20 subjects after TKA. The joint gap was almost rectangular at two flexion angles in normal subjects. In the implanted knees, the gap angle was 1.4 degrees varus +/- 3.3 degrees (mean +/- standard deviation), and no significant difference was found between medial and lateral joint space widths at 90 degrees flexion. In contrast, the gap angle was 2.5 degrees varus +/- 2.5 degrees and the lateral joint space width was significantly wider than the medial joint space width at 120 degrees flexion (P < 0.001). The gap angle was more varus with a significant difference in the implanted knees than that in the normal subjects at 120 degrees flexion (P < 0.001). The joint gap was trapezoidal with a wider lateral side at 120 degrees flexion even though it was almost rectangular at 90 degrees flexion after TKA.
Gender, decade, and total number of subjects 
Average number of 10-s grip and release tests (weaker side) in each gender and decade 
Average number of 10-s step test in each gender and decade
Average of grip power (weaker side) in each gender and decade
Purpose: The 10-s grip and release (G&R) test and 10-s step test were reported to be useful tools to evaluate the severity of cervical myelopathy quantitatively. The purpose of this study is to establish the standard values of the 10-s G&R test and 10-s step test as quantitative tests for cervical myelopathy and to elucidate the aging variation and gender difference of those values in a large cohort of normal subjects. Methods: A total of 1230 healthy volunteers were enrolled. They included at least 100 men and 100 women in each decade from the 20s to 70s. Three tests were performed: the number of finger grips and releases in 10 s, number of steps in 10 s, and gripping power. Results: The average number of G&Rs on the weaker side was 21.5 ± 5.5, whereas the average number of steps was 19.7 ± 3.4. The average gripping power on the weaker side was 29.5 ± 9.6 kg. The number of G&Rs and steps in 10 s decreased significantly with age (r = -0.58, -0.43, respectively). The average number of G&Rs on the weaker side was <20 in the 60s and 70s. The number of G&Rs was significantly correlated with the number of steps and gripping power. A significant difference was seen between the genders in all three tests. Conclusion: The standard values of the 10-s G&R test, 10-s step test, and gripping power were established in this study. When these quantifiable tests are used as screening tests of cervical myelopathy, aging variation and gender difference should be considered.
Long-term clinical results of Harris-Galante type prosthesis in total hip arthroplasty (THA) were evaluated in 27 hip joints of 25 patients (2 men and 23 women). Seventeen joints also received bone grafting on the acetabulum. Mean follow-up period was 11 years and 3 months. Clinical out-come was evaluated using the hip score of the Japanese Orthopaedic Association, and the score was good and stable during the monitoring period. Implant stability, bone changes around the implant, and the occupancy rate of the stem in the medullary space were radiologically examined. As a result of stem, there was subsidence in 3 joints and loosening in 6. There were no cases of cup loosening. A pedestal was found in 12 joints, and 4 of them which were associated with a radiopaque line had stem loosening. Among the 21 joints without loosening, 8 had a pedestal but they were not associated with a radiopaque line. The 2 joints which developed osteolysis did not have loosening. Stem loosening was related to the stem occupancy rate in the distal part of the medullary cavity. Postoperative stem occupancy rate could be an important indicator for long-term clinical results. Stems for cementless THA should be designed to have a high occupancy rate in the distal part, and stems should also be carefully chosen to meet individual differences.
a In the LF from DM (?) LSCS patients, elastic fibers were disorganized and focally lost, accompanied by a proliferation of collagen fibers. The elastic fibers also had low volumes and uneven diameters. H&E staining 9200. b LF from DM (?) LSCS patients. H&E staining 940. c In the LF from DM (-) LSCS patients, a large area was stained pink with a regular arrangement, indicating a normal, non-fibrotic condition. H&E staining 9200. d LF from DM (-) LSCS patients. H&E staining 940. e In the LF from DM (?) LSCS patients,  
Demographic data of the patients
Paraffin specimens of yellow ligament from individuals with DM [DM (?)] or non-DM [DM (-)] were stained with rabbit anti- MMP13 antibody followed by Alexa488-conjugated goat anti-rabbit  
Lumbar spinal canal stenosis (LSCS) is one of the most common spinal disorders in the elderly, and ligamentum flavum (LF) hypertrophy is an important cause of LSCS. Matrix metalloproteinase 13 (MMP13) can degrade fibrillar collagens and elastic microfibrils, and is involved in inflammation and fibrosis. The purpose of this study was to compare the expression of MMP13 in the LF from LSCS patients with diabetes mellitus [DM (+)] with that in the LF from patients without DM [DM (-)] and to analyze the relationship among DM, MMP13 expression, and LF hypertrophy. LFs from 11 DM (+) and 24 DM (-) LSCS patients were analyzed in this study. Histology analysis using hematoxylin and eosin and Masson's trichrome stain was performed for each LF. The expression of MMP13 was analyzed by quantitative real-time PCR. The thickness of LF was measured by CT. In the LF from DM (+) LSCS patients, the elastic fibers were more disorganized and had lower volumes than in the LF from DM (-) LSCS patients, while more fibrotic tissue was observed in the LF from DM (+) than from DM (-) LSCS patients. MMP13 expression was significantly higher in the LF from DM (+) LSCS patients (0.46 ± 0.61 vs. 0.05 ± 0.09, P = 0.002). The LF from the DM (+) LSCS patients was significantly thicker than that from the DM (-) LSCS patients (5.0 ± 0.9 vs. 3.1 ± 0.8 mm, P < 0.01), and the thickness was correlated with the expression of MMP13 (correlation coefficient = 0.43, P = 0.01, Pearson's correlation test). DM-related MMP13 expression can be one of the factors contributing to fibrosis and hypertrophy of the LF. Further research on the mechanism of this process may lead to new therapies for LF hypertrophy.
The aim of this study was to clarify the significance of subchondral bone in the pathology of osteoarthritis (OA) by investigating the expression of inflammatory cytokines, proteases, and receptor activator of NF-kappaB ligand (RANKL)/receptor activator of NF-kappaB (RANK)/osteoprotegerin (OPG) involved in cartilage degeneration. Subchondral bone was obtained from 19 patients diagnosed with knee OA and 4 patients diagnosed with femoral neck fracture. Subchondral bone osteoblasts (SBOs) were isolated, and total RNA was extracted. Messenger RNA expression of inflammatory cytokines, proteases, and RANKL/RANK/OPG were analyzed using a real-time reverse transcription-polymerase chain reaction (RT-PCR). Real-time RT-PCR showed that mRNA expressions of interleukin-6 (IL-6), matrix metalloproteinase-13 (MMP-13), and RANKL were significantly enhanced in OA SBOs compared to SBOs without OA. The expressions of these genes was greater in patients with severe cartilage damage than in those with mild cartilage damage. A high correlation between mRNA expression of IL-6 and that of MMP-13 was found in OA SBOs. The increases in IL-6, MMP-13, and RANKL expression in OA SBOs suggest that in subchondral bone OA progression involves abnormal osseous tissue remodeling, which induces mechanical property changes. Cartilage degeneration in OA may also be due, at least in part, to IL-6 and MMP-13 produced by SBOs. Comprehensive research on these pathological features may lead to the development of more effective therapies for OA by administration of molecules that affect bone remodeling and metabolism.
Morphological differences of dysplastic hips exist not only on the acetabular side but also on the femoral side. Therefore, for reconstructing the hip joint of these patients, the shape of the proximal femur is problematic for getting adequate "fit and fill" by cementless stems. The purpose of this study was to investigate the clinical and radiological outcomes of anatomically designed prostheses for the treatment of osteoarthritis due to developmental dysplasia of the hip. A total of 81 consecutive primary cementless total hip arthroplasties using an anatomic hip system were performed in 75 patients (10 men, 65 women). The mean age at the time of the surgery was 59.0 years (range 41-84 years). The average duration of follow-up was 101.4 months (range 72-157 months). Clinical performance was evaluated using the Harris hip score (HHS), and radiographic findings were assessed using the fixation and stability score according to Engh et al. The average preoperative HHS was 44.5 points, and the most recent average HHS was 87.5 points. Altogether, 66 hips (81%) were deemed excellent (>or=90 points) or good (80-89 points). The mean fixation and stability score was 19.6 +/- 5.2 points. In total, 75 (93%) of the femoral components had bone-ingrown fixation, and 6 (7%) indicated possible ingrowth. There was osteolysis around five femoral components and three acetabular components. No femoral component was revised; however, five cups were revised because of breakage of the polyethylene or massive osteolysis. Dislocation of the hip implant was seen in one hip, but there was no recurrent dislocation. There was no deep infection, deep vein thrombosis, or nerve palsy. The anatomic stem showed acceptable clinical and radiological results in cases with mild or moderate subluxation of the hip at the intermediate-term follow-up.
Clinical features of upper cervical spinal cord tumors are not clear because there have been too few published reports. The purpose of this study was to review the clinical features of these tumors. We reviewed 13 patients who underwent surgery for an upper cervical spinal cord tumor. Data regarding age, sex, duration and type of symptoms, levels, topographical locations, surgical results, and histological features were investigated retrospectively. Of the 13 tumors, 5 were at C1/2, 7 at C2/3 and 1 at C1-3. Topographically, 9 of the 13 tumors were dumbbell shaped, and all 5 at C1/2 had this shape. The initial symptom was occipital pain in three patients, numbness or pain of the extremity in nine, and clumsiness of the upper extremity in one. The average duration from initial symptom to surgery was 14.9 months. There were no major surgical complications, but there were three cases of postoperative cervical kyphosis. These three patients underwent tumorectomy with total laminectomy of C2. Tumor recurrence was seen in three patients for reasons thought to be the same as tumors at other levels, being residual meningiomas lying ventral to the cord and extraforaminal neurinomas. Spinal cord tumors in the upper cervical region tend to progress as dumbbell tumors. As all the neurinomas had this shape (Eden type 2 or 3) at C1/2, this anatomy might favor progression to the extradural and extraforaminal spaces.However, it also allows total removal of the tumor via a posterior approach. To maintain postoperative cervical alignment, the surgeon should select the least invasive approach to the paraspinal muscles attached to the spinous process of C2.
Summary of studies reporting the management of Vancouver type-B1 periprosthetic fractures of the proximal femur treated with locking plate fixation 
Purpose: The overall incidence of periprosthetic femoral fractures (PPF) is between 0.1 and 6 % of all total hip arthroplasties. Locking compression plates (LCP) have been used for the treatment of Vancouver B1 PPFs with variable results. The aim of this study is to examine the literature on locking plate failure rates, mode and reasons for failure. Methodology: A literature search was conducted for studies reporting the management of PPF of the femur with LCP fixation. The primary medical search engines used for the study were Ovid MEDLINE and EMBASE databases up to August 2012. Results: Twelve studies were identified, reporting overall union rates of 91 % in 135 fractures. Only 7 (5 %) fractures required revision surgery due to plate fracture (5) or pull out (2). Important trends in plate complications included: stress riser at the end of the plate, stress concentration in the fracture area due to rigid fixation, early loading and absence of cortical strut grafting for biological support when needed. Conclusion: LCP has been used successfully in the management of Vancouver B1 PPF. However, potential areas of improvement include, leaving the fracture site free of locking screws, therefore, not disturbing the soft tissue envelope around the fracture and also reducing plate stiffness. Adding cortical strut allografts to improve stability and bone quality, if needed, may also improve outcome. Limitations in the use of strut grafts or transverse fractures below the tip of the stem that cannot be controlled with single or double plating may require long stem revision to achieve axial stability.
Giant cell tumour of bone (GCT) is a benign but locally aggressive lesion. We analysed a series of GCTs of bone to determine whether there was any variation in the incidence and distribution in an Indian population compared to other populations reported in the literature, as well as treatment options applicable in developing countries, and we report the results here. A total of 139 patients with histologically proven GCT of bone were treated in our referral centre. Of these, 124 cases had a follow-up of more than 2 years (mean 8.3 years). Demographically, 72 were male, 67 were female, and they had a mean age of 29 years (range 15-59 years). The majority of the cases were of Campanacci grade III (n = 72, 51.1%). A total of 157 oncological procedures were performed. Incidence of GCT of bone was found to be 20.3% (n = 139/685) among all primary bone tumours. The distal radial involvement amounted to 22.7% (n = 28). There were 14 recurrences (11.1%) and 3 re-recurrences. Functional outcome was evaluated using the MSTS-93 scoring system. Average rating was 89.6% (avg. score 26.9) for upper extremities and 84% (avg. score 25.2) for lower extremities. The incidence of GCT of bone was found to be high in our population, with surprisingly high involvement of the distal radius. Nonvascularised autogenous fibular graft was found to be an effective option for reconstruction. The Indian population, like their South East Asian neighbours, has a higher incidence of GCT compared to Western populations described in the literature.
High tibial osteotomy (HTO) is an established surgical treatment for medial knee osteoarthritis (OA). Several studies have reported the deterioration of clinical results with time, especially after more than 10 years. The purpose of this study was to evaluate the long-term results after HTO using our originally developed fixation method and to clarify the factors affecting the long-term clinical outcome. Sixty-eight HTO treatments in 55 patients were evaluated. Eighteen patients were unable to be analyzed, thus reducing the study to 48 knees in 37 patients. The follow-up rate of the knee joint was 70.6% and the mean follow-up period was 17.1 years. The first evaluation was performed at a mean of 6.5 years postoperatively, and the most recent evaluation was done at more than 10 years postoperative follow-up. A closing-wedge osteotomy was performed, and the osteotomy site was fixed with two threaded pins and a figure-of-eight wiring technique. The Japanese Orthopaedic Association knee rating score (JOA score) was used for the clinical assessment. The change of the femorotibial angle (FTA) and progression of knee OA were radiographically analyzed. The whole knees were subsequently divided into two groups, satisfactory group and unsatisfactory group, according to the JOA score at the most recent follow-up. The mean JOA score was 59.1 before HTO and 83.1 at the most recent evaluation. In comparing the satisfactory and unsatisfactory groups, the JOA score before HTO was the same, but the JOA score of the unsatisfactory group was significantly lower at the first evaluation. The FTA in the unsatisfactory group was the same as in the satisfactory group preoperatively, but it was significantly larger after HTO. The radiographic OA was significantly progressed at the most recent evaluation, but no difference was observed in the distribution of the preoperative OA grade between the two groups. HTO with two threaded pins and figure-of-eight wiring fixation showed an acceptable clinical outcome, but careful attention was needed for correction loss in early postoperative periods. In addition, the proper correction angle is necessary in order to achieve satisfactory long-term results.
Radiation therapy (RT) is commonly used to treat malignant tumors, but it leads to side effects and complications. Postradiation sarcomas developing from a previously irradiated area are especially vicious to deal with, though their occurrence is rare. This article focuses on the clinical manifestations, pathological characteristics, and therapeutic effects concerning postradiation soft tissue sarcomas (PRSTSs). A series of 14 PRSTSs treated between 1979 and 2000 in five hospitals in Japan were analyzed. Their histological types were malignant fibrous histiocytoma (eight cases), extraskeletal osteosarcoma (four cases), fibrosarcoma (one case), and leiomyosarcoma (one case). The primary diagnoses, RT history, latent period, and outcome of treatment were studied retrospectively. The original tumors included uterine cancer (seven cases), breast cancer (four cases), synovial sarcoma (one case), squamous cell carcinoma (one case), and Hodgkin's disease (one case). There were 13 women and 1 man, with ages ranging from 23 to 77 years (mean 58 years) at the time of the appearance of the PRSTS. RT doses ranged from 48 to 91 Gy (mean 62 Gy). The latent period from RT to the occurrence of the PRSTS varied from 4 to 27 years (mean 12.6 years). Altogether, 4 of 13 patients (31%) had recurrence of the sarcoma after resection. Of the 10 patients whose tumors were removed with a wide margin, one had a local recurrence; 3 cases were performed with a marginal margin and all 3 had a local recurrence. One of three who underwent RT and one of five who underwent chemotherapy (CT) responded. Of the 14 patients, 6 (42.9 %) survived continuously disease free, 2 (14.3%) died from other causes, 2 (14.3%) has an unknown outcome, and 4 (28.6 %) died of the disease during the follow-up period of 16-36 months (mean 24 months). The deaths due to other causes included an esophageal cancer and a wound infection. The prognosis of the PRSTS patients was not poor if the tumor could be removed with a wide surgical margin. Because adjuvant therapies including RT and CT had a poor effect on PRSTSs, the primary treatment of PRSTSs should be radical resection with a wide margin.
Studies examining the reference values of bone mineral density (BMD) and their patterns at different ages are largely based on data generated from developed countries. The objective of this study was to estimate reference values of BMD, along with their correlates, for women living in urban and suburban areas of Bangladesh. Dual-energy X-ray absorptiometry scans were performed on 500 women 16-65 years of age. Reference values at the lumbar spine (LS) and femoral neck (FN) were estimated after adjusting for height and weight. In addition, multiple linear regression analysis was used to examine correlates of BMD at the LS and FN. Mean BMD was highest at the LS and FN in women 16-19 (1.001-1.007 g/cm(2)) and 16-22 years of age (0.880-0.888 g/cm(2)), respectively, and gradually declined with increasing age thereafter. BMD decreased at an annual rate of 0.0027 g/cm(2) at the LS and 0.0046 g/cm(2) at the FN among women aged 16-45 years. For women 46-65 years of age, the respective figures were 0.0073 and 0.0083 g/cm(2). In both age groups, body weight was positively associated with BMD at both sites, and with height only at the LS. In addition, years of pill use was positively associated with BMD at the LS among women aged 16-45 years. BMD levels at both sites began to decline during the early twenties among Bangladeshi women. Age-specific BMD data generated in this study could be useful for interpreting bone densitometry data among women in Bangladesh and other South Asian countries.
We present a rare case of malignant transformation of desmoplastic fibroma in a 37-year-old man. In 1984 we performed curettage and bone grafting for a bone tumor of the left distal femur. Histologically, we obtained a final diagnosis of desmoplastic fibroma. After this treatment, the patient had no particular symptoms but felt tension in the left knee in 2000 and consulted our department. We performed tumor curettage and bone grafting although malignant findings were recognized by imaging. The last pathology diagnosis was an osteosarcoma (in view of the formation of an osteoid). We performed caffeine-assisted chemotherapy and an additional wide excision. In the literature, two reports of a high-grade sarcoma developing in a desmoplastic fibroma have appeared. It is sometimes difficult to distinguish desmoplastic fibroma from low-grade fibrosarcoma or intraosseous-type osteosarcoma, although the radiographic findings and aspects of the resected specimen in 1984 were typical of a desmoplastic fibroma. Moreover, from a clinical standpoint, because the recurrence came 16 years after the initial operation, and lung metastasis was not seen, it is difficult to believe this case was malignant originally. This extremely rare lesion is believed to be a desmoplastic fibroma transformed to osteosarcoma.
Giant cell tumor (GCT) of the bone is a unique bone tumor that can behave in locally aggressive fashion despite its benign histological appearance, and the local recurrence rate is approximately 25-35% following curettage, supplemented with bone grafting, cementation, cryosurgery, or instillation of phenol or ethanol [1, 2]. Pulmonary metastases, or so-called pulmonary implants, are also a well-documented phenomenon in conventional GCT of the bone, with an incidence of from 1 to 9% of patients with GCT in the literature [3-7]. They have generally self-limited growth potential and a relatively good prognosis; thus, surgical resection of pulmonary metastatic lesions as much as feasible is the treatment of choice. However, approximately 25% of patients with unresectable metastasis eventually die of the disease [1]. Much more unusually, GCT of the bone can metastasize to extrapulmonary sites, including the bone (actually indistinguishable from multicentric GCT of the bone), scalp, prepuce, brain, and mediastinal and regional lymph nodes, especially in the presence of simultaneous pulmonary metastatic lesions [8, 9]. However, intramedullary spinal cord metastasis is an extremely rare event, even in cases of malignant tumors, such as lung and breast cancers [10, 11]. As far as we know, there have been no reports documenting intramedullary spinal cord metastasis from GCT of the bone with or without malignant transformation. The present report describes a patient presenting with an intramedullary spinal cord metastasis following spontaneous malignant transformation from conventional GCT of the bone 16 years after pulmonary metastasis. The patient was informed that data from the case would be submitted for publication and gave her consent during her lifetime.
Background: Reported revision of internal fixation for undisplaced intracapsular hip fractures is between 12 and 17% at 1 year. This risk is greater for elderly patients, for whom mortality after such a fracture is also higher. Our purpose was to identify predictors of fixation failure and mortality for elderly patients sustaining undisplaced intracapsular hip fractures, and to assess whether their socioeconomic status affected their outcome. Methods: During a 3-year period we prospectively compiled a consecutive series of 162 elderly (≥65 years old) patients who underwent internal fixation for an undisplaced (Garden stage I or II) intracapsular hip fracture. Patient demographics, American Society of Anesthesiologists (ASA) grade, and posterior tilt (measured on the lateral radiograph) were recorded pre-operatively. All patients were followed up for a minimum of 1 year. Each patient's socioeconomic status was assigned by use of the Scottish Index of Multiple Deprivation. Patient mortality was established by use of the General Register Office for Scotland. Results: There were 28 failures of fixation during the study period. In Cox regression analysis, ASA grade and the presence of posterior tilt (p < 0.0001) were significant independent predictors of fixation failure. Overall unadjusted mortality at 1 year was 19% (n = 30/162). Cox regression analysis also affirmed ASA grade to be the only significant independent predictor of 1-year mortality (p = 0.003). The standardised mortality rate for the cohort was 2.3 (p < 0.001), and was significantly greater for patients less than 80 years of age (p = 0.004). Socioeconomic status did not affect outcome, but the most deprived patients sustain their fracture at a significantly younger age (p = 0.001). Conclusion: We have demonstrated that ASA grade and posterior tilt of the femoral neck are independent predictors of fixation failure of undisplaced intracapsular hip fractures in elderly patients, and ASA grade was also an independent predictor of mortality.
IntroductionIntracranial meningeal hemangiopericytoma (HPC) tumors are rare, accounting for only 0.2 % of all primary brain tumors, and are found mostly in middle-aged adults. The tumor usually occurs in contact with the dura or the dural arteriovenous structures of a cerebral hemisphere, [1, 2] and is generally best treated by microsurgical excision. The local recurrence rate is relatively high and extracranial metastases have been reported [3]. We report a case of HPC metastasizing to the thoracic spine 17 years after the intracranial lesion was surgically excised. The patient was informed that data, radiographs, and photographs from the case would be submitted for publication and gave his written consent.Case reportA 36-year-old man presented with a 3-month history of back pain. The patient was referred to our hospital after magnetic resonance imaging (MRI) revealed a tumor in the thoracic spine. A neurological examination at the initial visit revealed that the patient’s deep tendon ...
Background When the neck is flexed in patients with Chiari I malformation, herniated tonsils descend, impacting the spinal canal, and the clivus-canal angle changes and compresses the ventral spinal cord. Therefore, we speculated that the existence of tonsillar herniation might have some influence on the cervical spine, such as changes in range of motion, sagittal alignment, and spondylosis. The purpose of this radiological study was to clarify quantitatively the relation between tonsillar herniation and the cervical spine regarding range of motion, sagittal alignment, and cervical spondylotic change. Methods We examined the cervical spine of 609 outpatients with magnetic resonance imaging, and the cerebral tonsils being located below the foramen magnum was defined as tonsillar herniation. Of the 609 patients, 88 (14.4%) had tonsillar herniation. Two of the 88 patients who had complicating osseous anomalies were excluded from this study, and the remaining 86 patients with tonsillar herniation were the subject group (TH group). Of the remaining 521 patients without tonsillar herniation, 86 patients whose age and sex matched those of the TH group were selected at random to be in the control group (Non-TH group). The range of motion, sagittal alignment, and the diameter of the intersegmental dura in the cervical spine in the TH group were compared by age with those in the Non-TH group using a roentgenograph or magnetic resonance imaging. Results The range of motion at C1-C2 was significantly smaller in the TH group (5.4°) than in the Non-TH group (8.4°) in patients over 70 years of age. The level of narrowing of the dura diameter at C5/C6 was significantly higher (P = 0.029) in the TH group (23.3%) than in the Non-TH group (13.4%) in patients over 70 years of age. The cervical alignment was similar in both groups for all age groups.
We studied the long-term results of bipolar endoprosthetic replacement in 12 patients (12 hips) 12 to 18 years after surgery. These patients had Ficat stage III nontraumatic osteonecrosis of the femoral head. The original Bateman universal proximal femoral endoprosthesis, which did not have a self-centering mechanism, was inserted without cement as a primary surgical intervention. Three patients underwent revision surgery, 3, 17, and 17 years after surgery, respectively. The reasons for revision surgery were migration of the stem in 2 patients and migration of both the stem and the outer cup in 1. In the remaining 9 patients, the total Merle d'Aubigné and Postel score was 16.1 +/-1.3 at the time of follow-up. Radiographs showed migration of the endoprosthesis in 1 of these 9 patients. Thus, 11 of the 12 patients retained the endoprosthesis 12 years or more after implantation. We concluded that the original Bateman endoprosthesis was effective in delaying the need for total hip replacement for more than 10 years in patients with Ficat stage III nontraumatic osteonecrosis of the femoral head.
18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) has been used to examine muscle activity during running. The dash is a basic activity in various kinds of sports but differs from running in terms of intensity and severity. The purpose of this study was to evaluate muscle activity during running at full speed using FDG PET. Six healthy men were investigated during a dash for 10 min after intravenous injection of FDG (37 MBq). Another six healthy men were studied as controls. PET images were obtained 45 min after the FDG injection. Regions of interest were drawn on the anterior and posterior thighs and the anterior and posterior legs. The standardized uptake value (SUV) was calculated to examine the FDG uptake of muscle tissue per unit volume according to an equation. In the control group, the mean SUVs of the anterior thigh, posterior thigh, anterior leg, and posterior leg were 0.49 +/- 0.04, 0.44 +/- 0.02, 0.46 +/- 0.05, and 0.44 +/- 0.07, respectively. In the dash group, the mean SUVs of the anterior thigh, posterior thigh, anterior leg, and posterior leg were 0.74 +/- 0.20, 0.79 +/- 0.08, 0.61 +/- 0.07, and 0.60 +/- 0.08, respectively. FDG accumulation of every one of the four compartments in the dash group was significantly higher than that in the control. FDG accumulation of the posterior thigh was significantly higher than that of the anterior and the posterior leg in the dash group (P < 0.02). Based on the results of our investigation, posterior thigh muscles were especially active during a dash.
We studied the effects of denervation on the energy metabolism and peripheral circulation dynamics of rat hindlimb muscles during and after exercise. The sciatic nerves of male Wistar rats were cut to produce denervation. Energy metabolism was assessed by phosphorus-31 magnetic resonance spectroscopy (MRS), and circulation by fluorine-19 MRS. Exercise of rat hindlimb muscles was induced by electrical stimulation at 40 Hz. The inorganic phosphate (Pi) / ¿Pi + phosphocreatine (PCr)¿ ratio, an indicator of the energy level, was 0.795 immediately after denervation. The ratios 4 and 8 weeks after denervation were 0.870 and 0.853, respectively. The intracellular pH during the 4 min after initiation of stimulation was significantly reduced 4 and 8 weeks after denervation compared with the value immediately after denervation. The signal strength of the research perfluoro-carbon (FC-43; perfluorotributylamine) a measure of circulation dynamics, increased to 167% in controls during exercise, but an increase of only 134% was seen in rats 8 weeks after denervation. These results showed that the energy supply and circulation dynamics in denervated atrophic muscles decreased during exercise compared with findings in control muscles.
The purpose of this study was to investigate the association of stress fractures with age, sex, sport level, sporting activity, and skeletal site in athletes seen at our sports medicine clinic between September 1991 and May 2001. During these 10 years, 10 726 patients (6415 males, 3861 females) visited our clinic because of sport-related injuries, and 196 patients [125 males (1.9%), 71 females (1.8%)] sustained stress fractures. The average age of the patients with stress fractures was 20.1 years (range 10-46 years); 84 patients (42.6%) were 15-19 years of age, and 68 (34.7%) were 20-24 years of age. Altogether, 74 patients (37.8%) were active at the high recreational level and 122 (62.2%) at the competitive level. The sites of the stress fractures varied from sport to sport. The ulnar olecranon was the most common stress fracture site among baseball athletes and the rib among the rowing athletes. Classical ballet, aerobics, tennis, and volleyball athletes predominantly sustained stress fractures of the tibial shaft. Basketball athletes predominantly sustained stress fractures of the tibial shaft and medial malleolus and the metatarsal bone, whereas track and field and soccer athletes predominantly sustained stress fractures of the tibial shaft and pubic bone. Our results show that stress fractures are seen even in high-level adolescent athletes, with similar proportions for males and females, and that particular sports are associated with specific sites for stress fractures.
It has already been more than 50 years since the Pavlik harness was introduced in Japan, and today the Pavlik harness is widely recognized as the standard initial treatment modality for developmental dysplasia of the hip. We performed a multicenter nationwide questionnaire study concerning the results of Pavlik harness treatment twice in 1994 and 2008. In 1994 and in 2008, we sent questionnaires to 12 institutes in Japan specializing mainly in pediatric orthopedics. We compare the results of these two studies and discuss differences in reduction rates, incidence of avascular necrosis in the femoral epiphysis and the percentage of joints with acceptable morphology (Severin grade I + II/total) at skeletal maturity. We statistically assessed these results to see whether there were changes in the treatment outcomes over this 14-year period. Reduction of the dislocated hips was obtained by the Pavlik harness in 80.2 % (1990/2481 hips; 1994) and 81.9 % (1248/1523 hips; 2008). The incidences of avascular necrosis of the proximal femoral epiphysis in the dysplastic hips were 14.3 % (119/835 hips; 1994) and 11.5 % (76/663 hips; 2008). The type of avascular necrosis in hips from the 2008 study was determined according to the classification of Kalamchi and MacEwen: 24/69 hips (34.8 %) were classified as group I; 20/69 hips (29.0 %) as group II; 11/69 hips (15.9 %) as group Ill; 14/69 hips (20.3 %) as group IV. The percentages of hips with acceptable outcomes at skeletal maturity discerned from Severin X-ray changes (grade I + II/total) were 72.3 % (604/835 hips; 1994) and 77.7 % (488/628 hips; 2008). Reduction rates and the incidence of avascular necrosis in 2008 were statistically similar to the results in 1994. The rate of acceptable outcome (Severin grade I + II/total) in 2008 was statistically higher than that of 1994.
To determine whether MTNR1B rs4753426 and rs10830963 polymorphisms are correlated with AIS. Adolescent idiopathic scoliosis (AIS) is the most common form of spinal deformity, while its etiology remains uncertain. Melatonin receptor 1B (MTNR1B) gene polymorphisms have been found to be significantly associated with AIS risk; however, some of these results are controversial. An systematic online search was performed using PubMed, EMBASE, Web of Science and the Cochrane Library to identify case-control studies investigating the relationship between MTNR1B rs4753426 and rs10830963 polymorphisms and the susceptibility of AIS. The pooled odds ratio (OR) with 95 % confidence interval (95 % CI) was calculated to assess the associations, and subgroup meta-analyses were performed according to the ethnicity of the study populations. A total of five studies involving 2395 cases and 3645 controls met the inclusion criteria after assessment by two reviewers. Overall, no significant associations were found between MTNR1B rs4753426 polymorphism and AIS risk (C vs. T: OR = 1.11, 95 % CI 0.94-1.30, P = 0.21; CC vs. TT: OR = 1.15, 95 % CI 0.97-1.36, P = 0.12; CT vs. TT: OR = 1.14, 95 % CI 0.97-1.35, P = 0.10; CC/CT vs. TT: OR = 1.14, 95 % CI 0.98-1.33, P = 0.09; CC vs. OR = 1.10, 95 % CI 0.84-1.45, P = 0.48), as well as the MTNR1B rs10830963 polymorphism (G vs. C: OR = 0.99, 95 % CI 0.88-1.12, P = 0.91; GG vs. CC: OR = 0.99, 95 % CI 0.74-1.33, P = 0.96; CG vs. CC: OR = 1.00, 95 % CI 0.84-1.18, P = 0.88; GG/CG vs. CC: OR = 0.99, 95 % CI 0.84-1.17, P = 0.93; GG vs. OR = 0.99, 95 % CI 0.75-1.30, P = 0.92). When stratified by ethnicity, there were no significant associations between MTNR1B rs4753426 and MTNR1B rs10830963 polymorphisms and AIS risk in either Asian or Caucasian populations. MTNR1B rs4753426 and MTNR1B rs10830963 polymorphisms are not obviously associated with risk of AIS in either Asian populations or Caucasian populations.
Background: Controversy still exists around surgical strategies for Lenke type 1C and 2C curves with primary thoracic and compensatory lumbar curves in adolescent idiopathic scoliosis (AIS). The benefit of selective thoracic fusion (STF) for these curve types is spontaneous lumbar curve correction while saving more mobile lumbar segments. However, a risk of postoperative coronal decompensation after STF has also been reported. This multicenter retrospective study was conducted to evaluate postoperative behavior of thoracolumbar/lumbar (TLL) curve and coronal balance after posterior thoracic fusion for Lenke 1C and 2C AIS. Methods: Twenty-four Lenke 1C and 2C AIS patients who underwent posterior thoracic fusion were included. The mean age of patients was 15.7 years old at time of surgery. Constructs used for surgery in all cases were pedicle screw constructs ending at L3 or above. Radiographic measurements were performed on Cobb angles of the main thoracic and TLL curves and coronal balance. Factors related to final Cobb angle of TLL curve and postoperative change of coronal balance were investigated. Results: Mean Cobb angles for main thoracic and TLL curves were 59.0° and 43.9° preoperatively, and were corrected to 21.5° and 22.0° at final follow-up, respectively. Mean coronal balance was -5.6 mm preoperatively and was corrected to -14.6 mm at final follow-up. Final Cobb angle of TLL curve was significantly correlated with immediate postoperative Cobb angle of main thoracic curve and tilt of lowest instrumented vertebra (LIV). Postoperative change of coronal balance was significantly correlated with selection of LIV relative to stable vertebra. Conclusion: Spontaneous correction of TLL curve occurred consistently by correcting the main thoracic curve and making the LIV more horizontal after posterior thoracic fusion for Lenke 1C and 2C AIS. The more distal fixation to stable vertebra resulted in coronal balance shifting more to the left postoperatively.
More and more attention has been focused on the inflammation or degeneration caused by biochemical factors in radiculopathy during lumbar facet joint degeneration. This study was designed to examine the expression and relationship of MMP-1/TIMP-1 and interleukin-1β (IL-1β), and to analyze the possible mechanism in degenerative lumbar facet joint disease. Lumbar facet joint cartilage and synovial tissues in 36 cases of posterior lumbar surgery were harvested to investigate IL-1β and MMP-1/TIMP-1 by immunohistochemistry and Western blot analysis. Double labeling immunofluorescence and real-time PCR, respectively, were used to assess the relationship between IL-1β and MMP-1. IL-1β and MMP-1 were low in the lumbar disc herniation (LDH) group, and increased markedly in the lumbar spinal canal stenosis (LSCS) group (P < 0.05). However, there is no significant difference of TIMP-1 between LDH group and LSCS group (P > 0.05). Double staining results indicated that IL-1β overlapped with MMP-1 in the LSCS group. Moreover, real-time PCR results showed that MMP-1 mRNA in chondrocytes in vitro was affected in a dose- and time-dependent manner in response to IL-1β stimulation. Overexpression of MMP-1, induced by IL-1β, plays an important role in the inflammatory process of lumbar facet joint degeneration.
Osteoarthritis is recognized as a noninflammatory, progressive condition, the principal cause of which is regressive changes associated with aging and which pursues a chronic course. Recently, the involvement of genetic factors has been widely reported. The purpose of this study was to identify polymorphisms at particular risk of osteoarthritis of the knee for community-living middle-aged and elderly people. Focusing on 359 participants (ages 44-86 years) of the comprehensive health examination program (CHEP), we investigated the presence/absence of radiographic osteoarthritis (ROA) of the knee, and 11 types of gene polymorphisms and their association with ROA. Interleukin-1beta (IL1B) T-31C polymorphism was found to be associated with ROA. In the case of IL1B T-31C polymorphism in the ROA group, a significant difference was found between the groups combining the C/C genotype, the C/T genotype, and the T/T genotype. In particular, the genotypes with the C allele differed from the T/T genotype, with the morbidity rate being higher in the T/T group (odds ratio (OR) 2.04, 95% confidence interval (95%CI) 1.05-3.98, P = 0.036). Our results confirm that in IL1B T-31C with the T/T genotype, the rate of ROA was significantly higher than that with the C/C and C/T genotypes. It might be possible to implement active preventative measures, such as avoidance of obesity and excessive exercise loads, for carriers of IL1B T/T.
Definitions of prevalent psychiatric disorders and incident orthopedic injuries 
Comparison of the percentage of co-morbid osteoporosis (identified using ICD-9-CM diagnostic codes 733.0, 733.0X (i.e., 733.01-733.09) in 2000) between psychiatric patients and the nonpsychiatric disorder population. Trends of increased osteoporosis with age and more prevalent osteoporosis among the psychiatric population were noted 
Characteristics of the subjects with prevalent psychiatric disorders enrolled in 2000 
Treatment incidences of different orthopedic injuries in the psychiatric cohort group, 2000-2005 
Background The relationship between psychiatric disorders and musculoskeletal injuries is interesting but has not been investigated in depth. Study design A retrospective cohort study, based on a large-sample nationwide database, was performed during 2000–2005 in Taiwan. Methods All subjects matching the inclusion criteria of psychiatric-associated ICD9-CM diagnostic codes in 2000 were selected as the inception cohort population. Another cohort-based case–control study was designed, and one sex-matched and age-matched (1:1) control group randomly selected from the population without any prevalent psychiatric disorder in 2000 and incident psychiatric disorder in 2001–2005 was used for comparison. Results 64,662 Taiwanese people with any prevalent psychiatric disorder were enrolled in this study in 2000. The 6-year cumulative incidences of orthopedic injuries were 13.61/10,000 for femoral neck/femur fracture and 4.64/10,000, 3.40/10,000, 3.25/10,000, and 3.09/10,000 for radius/ulna or hand fracture, tibia/fibula or patella fracture, ankle or foot fracture, and humeral fracture, respectively. Compared with the control group, this Taiwanese population with prevalent psychiatric disorders had fewer incidences of all orthopedic injuries during the 6 years since 2000, and their cumulative incidence ratios ranged from 0.04 to 0.4 for the different injury sites. For lower-limb fractures, compared with the age stratum of less than 20-years-old, the odds ratios (OR) for the age strata 80-years-old or more and 60–79-years-old were 15.84 (95 % CI 4.55–55.20) and 6.11 (95 % CI 1.92–19.49), respectively. The people with organic psychotic conditions had a significantly greater tendency to suffer upper-limb and lower-limb fractures than those with other psychiatric diagnoses (the ranges of ORs were 3.23–16.67 and 2.13–25.00, respectively). Conclusion Subjects with prevalent psychiatric disorders had fewer occurrences of orthopedic injuries than the general population. Among this specific population, an organic psychotic condition and old age were risk factors for suffering fracture of a limb.
The Japanese Orthopaedic Association Committee on Tissue Transplantation and Regenerative Medicine has conducted a nationwide survey of the status of bone grafting in Japan every 5 years from 1985. We report here the status of bone grafting from 2000 to 2004, show the trends in bone grafting from 1985 to 2004, and draw attention to the issues affecting banked bone allografts. Questionnaires devised by the Committee were sent to all educational and training hospitals (2239 institutions) approved by the Japanese Orthopaedic Association. Survey responses were obtained from 1263 institutions (56%). Of these, 875 institutions performed tissue transplantation during this period. A total of 163 564 tissue transplantations were performed, and 134 782 (82.4%) of them were bone grafts. Of the bone grafts, 76 015 (56.4%) were autografts, 53 735 (40%) used a synthetic bone substitute, and 4886 (3.6%) were banked bone allografts. The proportion of synthetic bone substitutes increased, and the proportion of autografts decreased year by year. Synthetic bone substitutes were most frequently used for replacement arthroplasty (31%). Fifty percent of banked bone allografts were performed for joint disorders requiring replacement arthroplasty. During this period, 271 institutions performed banked bone allografts, with 210 preserving allografts in their own institutions. Donor selection criteria, processing and preservation methods, and management of the bone bank were not the same in all banks. Most bone grafts performed in Japan during the four surveys were still autografts. However, the proportion of autografts decreased, and the proportion of synthetic bone substitutes increased. The number of synthetic bone substitutes and banked bone allografts used for replacement arthroplasty increased significantly. However, the total number of banked bone allografts reported in the fourth survey was still low. Quality control of banked bone allografts and management of bone banks were not satisfactory, although they were improved.
The 2001 revised criteria for the diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head were proposed in June 2001, by the working group of the Specific Disease Investigation Committee under the auspices of the Japanese Ministry of Health, Labor and Welfare, to establish criteria for diagnosis and management of idiopathic osteonecrosis of the femoral head. Five criteria that showed high specificity were selected for diagnosis: collapse of the femoral head (including crescent sign) without joint-space narrowing or acetabular abnormality on x-ray images; demarcating sclerosis in the femoral head without joint-space narrowing or acetabular abnormality; "cold in hot" on bone scans; low-intensity band on T1-weighted MRI (bandlike pattern); and trabecular and marrow necrosis on histology. Idiopathic osteonecrosis of the femoral head is diagnosed if the patient fulfills two of these five criteria and does not have bone tumors or dysplasias. Necrotic lesions are classified into four types, based on their location on T1-weighted images or x-ray images. Type A lesions occupy the medial one-third or less of the weight-bearing portion. Type B lesions occupy the medial two-thirds or less of the weight-bearing portion. Type C1 lesions occupy more than the medial two-thirds of the weight-bearing portion but do not extend laterally to the acetabular edge. Type C2 lesions occupy more than the medial two-thirds of the weight-bearing portion and extend laterally to the acetabular edge. Staging is based on anteroposterior and lateral views of the femoral head on x-ray images. Stage 1 is defined as the period when there are no specific findings of osteonecrosis on x-ray images, although specific findings are observed on MRI, bone scintigram, or histology. Stage 2 is the period when demarcating sclerosis is observed without collapse of the femoral head. Stage 3 is the period when collapse of the femoral head, including crescent sign, is observed without joint-space narrowing. Mild osteophyte formation in the femoral head or acetabulum may be observed in stage 3. Stage 3 is divided into two substages. In stage 3A, collapse of the femoral head is less than 3 mm. In stage 3B, collapse of the femoral head is 3 mm or greater. Stage 4 is the period when osteoarthritic changes are observed.
Top-cited authors
Hiroyuki Tsuchiya
  • Kanazawa University
Masaya Nakamura
  • Keio University
Shinichi Konno
  • Fukushima Medical University
Naoki Ishiguro
  • Nagoya University
Toshiharu Shirai
  • Kyoto Prefectural University of Medicine