The five year outcome of a clinical feasibility study using a biphasic construct with minced autologous cartilage to repair osteochondral defects in the knee.

PURPOSE: Autologous minced cartilage has been used to repair cartilage defects. We have developed a biphasic cylindrical osteochondral construct for such use in human knees, and report the five year post-operative outcomes. METHODS: Ten patients with symptomatic osteochondral lesion at femoral condyles were treated by replacing pathological tissue with the osteochondral composites, each consisted a DL-poly-lactide-co-glycolide chondral phase and a DL-poly-lactide-co-glycolide/ß-tricalcium phosphate osseous phase. A flat chamber between the two phases served as a reservoir to house double-minced (mechanical pulverization and enzymatical dissociation) autologous cartilage graft. The osteochondral lesion was drill-fashioned a pit of identical dimensions as the construct. Graft-laden construct was press fit to the pit. Post-operative outcome was evaluated using Knee Injury and Osteoarthritis Outcome Score (KOOS) up to five years. Regenerated tissue was sampled with arthroscopic needle biopsy for histology at one year, and imaged with magnetic resonance at one, three, and five years to evaluate the neocartilage with MOCART chart. Subchondral bone integration was evaluated with computed tomography at three and five years. RESULTS: Nine patients completed the five-year follow-up. Post-operative mean KOOS, except that of the "symptom" subscale, had been significantly higher than pre-operation from one year and maintained to five years. The change of MOCRAT scores of the regenerated cartilage paralleled the change of KOOS. The osseous phase remained mineralized during the five-year period, yet did not fully integrate with the host bone. CONCLUSIONS: This novel construct for chondrocyte implantation yielded promising mid-term outcome. It repaired the osteochondral lesion with hyaline-like cartilage durable for at least five years.

Clinical practice recommendations for the use of imaging in the diagnosis and management of axial spondyloarthritis in Taiwan.

OBJECTIVE: Axial spondyloarthritis (axSpA) is a chronic inflammatory disease bearing challenges in early diagnosis. To improve clinical diagnosis and management of axSpA, recommendations were developed with current axSpA classification criteria and recent advances in medical imaging applications. METHODS: A systematic literature review was conducted by 10 rheumatologists and radiologists in Taiwan to retrieve research evidence on the utilization of imaging modalities, including conventional radiography (CR), magnetic resonance imaging (MRI), computed tomography (CT), ultrasound (US), quantitative sacroiliac scintigraphy (QSS), and dual-energy X-ray absorptiometry (DXA). The panel of experts proposed six key issues on the role of imaging in early diagnosis of axSpA, monitoring of disease activity and structural changes, predicting treatment effects, and assessing complications such as osteoporosis and spinal fracture. The consensus was established on the basis of research evidence, clinical experiences and expert opinions. For each recommendation statement, the level of evidence was evaluated, the strength of recommendation was graded and the final level of agreement was determined through voting. RESULTS: In total, four overarching principles and 13 recommendations were formulated. These recommendations outlined different imaging approaches in the diagnosis and management of axSpA disease progression. Considering CT is easy to perform when MRI is less available in Taiwan, the expert panel proposed a concise and practical diagnostic scheme to strengthen the valuable role of MRI and CT in the diagnostic evaluation of axSpA without evident radiographic features. CONCLUSION: These modified recommendations provide guidance for rheumatologists, radiologists and healthcare professionals on timely diagnosis of axSpA and disease management with appropriate imaging modalities.

BCOR-CCNB3-positive soft tissue sarcoma with round-cell and spindle-cell histology: a series of four cases highlighting the pitfall of mimicking poorly differentiated synovial sarcoma.

AIMS: BCOR-CCNB3 sarcoma is a genetically defined undifferentiated malignancy with Ewing sarcoma (ES)-like round cells, and preferentially affects the bones of male adolescents. Sarcomas harbouring BCOR-CCNB3 rarely arise from soft tissues; therefore, we aimed to report four cases to expand the clinicopathological spectrum. METHODS AND RESULTS: By reverse transcription polymerase chain reaction and confirmatory sequencing, we detected a BCOR-CCNB3 transcript in primary undifferentiated sarcomas of the deep musculature of four male patients, comprising two teenagers (aged 14 and 17 years) and two adults (aged 34 and 44 years). The tumours originated in the back (n = 2), pelvis (n = 1), and thigh (n = 1), and were 70-140 mm in size (mean, 107 mm). All tumours showed sheets of primitive round or ovoid cells with vesicular nuclei, active mitosis (28-41/10 high-power fields), variably prominent nucleoli, and geographical necrosis. This major component transformed into fascicles of elongated spindle cells with staghorn vessels and a myxoid reticular stroma, accounting for 10-50% of areas. All cases were positive for CD99, three were positive for TLE1, and one was positive for EMA, indicating poorly differentiated synovial sarcomas (PDSSs). Nuclear cyclin B3 reactivity was present in all cases, but not in molecularly confirmed atypical ESs and PDSSs. At the last follow-up (median, 13.5 months), one patient had died of lung metastasis, two were alive with tumours, and one was tumour-free. CONCLUSIONS: BCOR-CCNB3-positive sarcomas may primarily occur in soft tissues of adults and show PDSS-mimicking round-cell and spindle-cell histology with aggressive behaviour. Cyclin B3 is useful for selecting candidates for BCOR-CCNB3 molecular testing.

Effects of chronic treatment with diosgenin on bone loss in a D-galactose-induced aging rat model.

D-galactose is known to cause oxidative stress and induce aging-related diseases. Our previous study demonstrated that diosgenin can prevent osteoporosis in menopausal rats. The aim of the present study was to determine the effects of oral administration of diosgenin on bone loss in a D-galactose-induced aging rat model. Three groups of twelve-week-old male Wistar rats received a daily injection of D-galactose (150 mg/kg/day, i.p.) and orally administered diosgenin (0, 10, or 50 mg/kg/day) for eight weeks, while a control group received saline injection (1 ml/kg/day, i.p.), then the femurs were taken to measure mechanical and morphological properties. The results showed that frame volume and femur volume decreased and porosity and frame density increased in the D-galactose-induced aging rats compared to controls and that these effects were prevented by co-administration of diosgenin. This suggests that diosgenin might prevent bone loss during aging and provide beneficial effects in osteoporosis in the elderly.

Ultrasound-guided facet joint injection to treat a spinal cyst.

Lumbar spinal cysts often present with backache and may be accompanied by lower extremity weakness as well as radiation pain if root compression occurs. The treatment regimens include anti-inflammatory drugs, physical therapy, procedures guided by fluoroscopy or computed tomography, and surgery. We report the case of a patient with a symptomatic lumbar spinal cyst at the L4-L5 facet joint. The symptoms immediately remitted after ultrasound-guided steroid-lidocaine injection into the L4-L5 facet joint. Magnetic resonance imaging follow up 4 months after injection showed complete resolution of the cyst.

Predicting cortical bone strength from DXA and dental cone-beam CT.

OBJECTIVE: This study compared the capabilities of dual-energy X-ray absorptiometry (DXA) and dental cone-beam computed tomography (CBCT) for predicting the cortical bone strength of rat femurs and tibias. MATERIALS AND METHODS: Specimens of femurs and tibias obtained from 14 rats were first scanned with DXA to obtain the areal bone mineral density (BMD) of the midshaft cortical portion of the bones. The bones were then scanned using dental CBCT to measure the volumetric cortical bone mineral density (vCtBMD) and the cross-sectional moment of inertia (CSMI) for calculating the bone strength index (BSI). A three-point bending test was conducted to measure the fracture load of each femur and tibia. Bivariate linear Pearson analysis was used to calculate the correlation coefficients (r values) among the CBCT measurements, DXA measurements, and three-point bending parameters. RESULTS: The correlation coefficients for the associations of the fracture load with areal BMD (measured using DXA), vCtBMD (measured using CBCT), CSMI (measured using CBCT), and BSI were 0.585 (p = 0.028) and 0.532 (p = 0.050) (for the femur and tibia, respectively), 0.638 (p = 0.014) and 0.762 (p = 0.002), 0.778 (p = 0.001) and 0.792 (p<0.001), and 0.822 (p<0.001) and 0.842 (p<0.001), respectively. CONCLUSIONS: CBCT was found to be superior to DXA for predicting cortical bone fracture loads in rat femurs and tibias. The BSI, which is a combined index of densitometric and geometric parameters, was especially useful. Further clinical studies are needed to validate the predictive value of BSI obtained from CBCT and should include testing on human cadaver specimens.

Association of ultrasonographic findings of synovitis with anti-cyclic citrullinated Peptide antibodies and rheumatoid factor in patients with palindromic rheumatism during active episodes.

OBJECTIVE: The purpose of this study was to investigate whether the presence of ultrasonographic findings of synovitis is associated with the presence of anti-cyclic citrullinated peptide (CCP) antibodies and rheumatoid factor (RF) in patients with palindromic rheumatism (PR) during active episodes. METHODS: Clinically involved regions of 84 patients with PR during active episodes were examined with high-resolution ultrasonography. Serum levels of anti-CCP antibodies were determined by an enzyme-linked immunosorbent assay, and RF levels were measured by nephelometry. RESULTS: Thirty patients (36%) had ultrasonographic findings of synovitis during active episodes. Significantly higher positive rates of anti-CCP antibodies and RF were observed in patients with PR who had ultrasonographic findings of synovitis compared with those who had no ultrasonographic findings of synovitis (26.7% versus 5.6%; odds ratio, 6.18; P < .05; and 30.0% versus 5.6%; odds ratio, 7.29; P < .01, respectively). The intraobserver and interobserver agreement for the detection of synovitis and Doppler signals by ultrasonographic assessment was excellent. CONCLUSIONS: Ultrasonography is a reliable method for assessing the presence of synovitis in patients with PR during active episodes. The ultrasonographic findings of synovitis are associated with the presence of anti-CCP antibodies and RF in patients with PR.

Combination of transverse myelitis and arachnoiditis in cauda equina syndrome of long-standing ankylosing spondylitis: MRI features and its role in clinical management.

The cauda equina syndrome (CES) is a rare neurological complication of ankylosing spondylitis (AS). Imaging diagnosis of CES in long-standing AS patients (CES-AS) using myelography, computed tomography (CT), and magnetic resonance imaging (MRI) were reported in the literature. They, however, demonstrate only the chronic abnormalities of CES-AS, i.e., dural ectasia, dorsal dural diverticula, and selective bone erosion at the posterior elements of the vertebrae. To our knowledge, imaging features of acute intradural inflammation in CES-AS were not described. We report a patient of CES-AS in whom MRI disclosed acute transverse myelitis and arachnoiditis along the lower spinal cord, and discuss the pathogenesis of CES-AS and the role of MRI in clinical management.

Establishing a popliteal portal using the METRx system under ultrasound guidance.

This report describes a special technique for safe establishment of a popliteal portal with the METRx system (Medtronic Sofamor Danek, Memphis, TN) under ultrasound guidance with the patient in the awake state. Herbert screws located at the posterior tibial plateau were removed via this portal in a minimally invasive way. Before surgery, we performed surface mapping of the screw tract with an image intensifier and target needling under ultrasound guidance. The METRx system was used to establish the soft-tissue corridor along the guide pin. Screw removal and tibial plateau resurfacing were performed with the Acufex Mosaicplasty system (Smith & Nephew Endoscopy, Andover, MA). In our review of the literature, no similar method establishing the knee popliteal portal was found. The method is recommended especially for minimally invasive surgery in regions rich with neurovascular structures.

Effects of alendronate combined with hormone replacement therapy on osteoporotic postmenopausal Chinese women.

To evaluate the effect of alendronate combined with hormone replacement therapy (HRT) on postmenopausal osteoporotic Chinese women living in Taiwan, we treated 151 women (age range, 47-70 years; mean, 61 years) with conjugated equine estrogen (0.625 mg), medroxyprogesterone 5 mg, and elemental calcium 500 mg daily with either alendronate 10 mg (n = 79) or placebo (n = 72), and measured their bone mineral density (BMD) at the lumbar spine and hip every 6 months for 3 years. Urine N-telopeptide of type I collagen corrected by concentration of urine creatinine (NTx/Cr) and serum osteocalcin (OC) concentration was also measured at weeks 2, 4, and every 3 months from month 3 for 2 years. Significantly higher percentage increases in BMD at the lumbar spine (P < .0001, 2-way analysis of variance) throughout the 36-month treatment period were found in the alendronate plus HRT group than in the HRT-only group. However, there was no difference in BMD at the femoral neck and trochanter between these 2 groups. Treatment with alendronate plus HRT resulted in a 10.1% increase at the L-spine BMD and a 7.7% increase at the trochanter BMD at the end of the 3-year study period (P < .01, compared with baseline at both sites). A significant decline in urine NTx/Cr was observed at week 4 in the alendronate plus HRT group, whereas in the HRT-only group, a significant decline in urine NTx/Cr occurred at month 9. By the end of 24 months, urine NTx/Cr decreased by 49.7% in the alendronate plus HRT group (P = .001 compared with a 20.4% increase in the HRT group). A significant decline in serum OC level occurred at month 3 in the alendronate plus HRT group, whereas a similar decline was observed at month 6 in the HRT-only group. By the end of 24 months, serum OC decreased by 52.2% in the alendronate plus HRT group (P < .001 compared with a 1.5% increase in the HRT-only group). Subjects treated with alendronate plus HRT had a significantly greater percentage decrease in urine NTx/Cr (P = .0001) and serum OC (P = .0007) than subjects treated with HRT only throughout the 24-month treatment period by 2-way analysis of variance comparison. There was no difference in upper gastrointestinal or drug-related side effects between groups. In conclusion, our data suggest that the use of alendronate combined with HRT for 3 years was well tolerated and it significantly increased BMD at the L-spine and hip in postmenopausal Chinese women with osteoporosis. This regimen is safe and can be used in subjects who have no satisfactory response to a single agent or who have very low BMD with multiple risks. However, this study does not indicate whether HRT plus alendronate has any greater effect on BMD than alendronate alone.

A mucolipidosis III patient presenting characteristic sonographic and magnetic resonance imaging findings of claw hand deformity.

Mucolipidosis III (ML-III), or pseudo-Hurler polydystrophy, is an autosomal recessive Hurler-like disorder without mucopolysacchariduria. The diagnosis is challenging for rheumatologists since the musculoskeletal presentation is similar to some rheumatic diseases. We report a case of ML-III in a 16-year-old Taiwanese boy. The characteristic findings of sonography and magnetic resonance imaging (MRI) of claw hand deformity are described. A 16-year-old boy was referred to our rheumatologic clinic because of progressive claw hand deformity, multiple joint stiffness and tightness of the skin over the fingers at the age of 6 years. Sonography and MRI examination disclosed tendon sheath thickening over extensor tendons of both wrists and fingers without features of active inflammation over tendons or joints nor thickening of skin. Urinary glycosaminoglycans were normal. The diagnosis of ML-III was confirmed by the presence of elevated activities of beta-glucuronidase (2141.99 nmol/mg protein/hour), arylsulfatase A (1237.7 nmol/mg protein/hour) and alpha-fucosidase (52.95 nmol/mg protein/hour) in his plasma and decreased activity of these lysosomal enzymes in cultured skin fibroblasts. Sonography and MRI screening for claw hand deformity may offer important clues enabling early diagnosis of ML-III.