Single-stage posterior resection of the transversal process combined with an intervertebral foraminal approach for debridement, interbody fusion, internal fixation for the treatment of lumbar tuberculosis and psoas major abscess.

PURPOSES: To investigate the feasibility and clinical efficacy of the treatment for lumbar tuberculosis with psoas major abscess with single-stage posterior resection of the transversal process combined with an intervertebral foraminal approach for debridement, interbody fusion, internal fixation. METHODS: This retrospective study evaluated the clinical data of 24 patients (14 males and 10 females) with lumbar tuberculosis and psoas major abscess admitted to the Comprehensive Surgery from June 2016 to June 2019. All patients were treated with the single-stage posterior approach to remove the transverse process combined with the intervertebral foramina approach for debridement, interbody fusion, internal fixation. The quadruple anti-tuberculosis drug therapy was given both pre-operatively and post-operatively. Clinical symptoms and complications were investigated and recorded. The visual analogue scale (VAS), American Spinal Injury Association (ASIA), degree of lesion fusion C-reactive protein (CRP) levels, and erythrocyte sedimentation rate (ESR) were evaluated. RESULTS: The average follow-up period was 16. 5 months (from 12 to 36 months). The average VAS score at three months post-operation was significantly declined than the pre-operative VAS score [(2.17 ± 0.87) points vs (5.46 ± 1.22) points, t = - 11.534, P < 0.01)]. At the last follow-up, the neurological function of 20 patients recovered to grade E, whereas four patients were still in grade D. The ESR and CRP returned to normal levels in all patients. Bone fusion was achieved in nine cases at six months, 11 cases at nine months, and four cases at 12 months. The incisions of 23 patients had healed nicely without chronic sinus. Poor incision healing only happened in one case at the day 12 post-operation. The bone grafts among the lesions obtained bony fusion. Besides, there was no recurrence of tuberculosis, loosening or fracture of internal fixation during the follow-up. CONCLUSION: Single-stage posterior resection of the transversal process combined with an intervertebral foramina approach for debridement, interbody fusion, internal fixation is probably an effective and safe approach of the treatment for lumbar tuberculosis combined with psoas major abscess, producing few complications. This technique provides an alternative method for the surgical treatment of lumbar tuberculosis combined with psoas major abscess.

Mycobacterium culturing and drug resistance of osteoarticular tuberculosis in Xinjiang, China.

This study aims to elucidate the strains and drug resistance of mycobacterium isolated from osteoarticular tuberculosis (OATB) patients and provide a reference for the diagnosis and treatment of OATB.Sixty-nine clinically diagnosed and surgically treated OATB patients were collected in time period of January 2017 to December 2018 at the First Affiliated Hospital of Xinjiang Medical University. The BACTEC MGIT 960 system was used for mycobacteria culturing, strain identification, and drug susceptibility testing, and the mycobacteria culture positive rate, species distribution, and drug resistance were analyzed.Within 4 weeks, 24 (34.78%) isolates of mycobacteria culture were positive; 40 (57.97%) isolates were positive, when culturing time was expanded to 8 weeks, and the difference was statistically significant (P < .05). Among the 40 isolates, 24 (60%) were identified as mycobacterium tuberculosis (MTB), 10 (25%) were Mycobacterium bovis, and 6 (15%) were non-tuberculous mycobacteria (NTM). Among total 69 isolates, 40 were enrolled in drug sensitivity test, and 15 (37.5%) isolates were confirmed drug resistant strains, in which 5 isolates were MTB, 4 isolates were M. bovis, and 6 isolates of NTM.The pathogen of clinically diagnosed OATB was mainly MTB. However, M. bovis and NTM also accounted for a considerable proportion, and their drug resistance rate was higher. Extending the culturing time appropriately could improve the culture positive rate. NTM was a drug resistant strain, and mycobacteria culturing, strain identification, and drug resistance analysis should be carried out to serve as a guide for individual treatment.

Synovial Fluid HMGB-1 Levels are Associated with Osteoarthritis Severity.

BACKGROUND: Recent data have shown that enhanced cytokine production in knee osteoarthritis (OA) synovium are believed to promote pathological OA. High-mobility group box 1 (HMGB-1) as a well-known pro-inflammatory cytokine may influence the development of knee OA. The purpose of this study is to analyze the amount of and location of HMGB-1 in OA synovium and to compare it with controls who are afflicted with acute meniscal or cruciate ligament tears. We also evaluated the relationship between the level of HMGB-1 in synovial fluid with the severity of synovitis, clinical symptoms (pain, stiffness, daily activity), and radiological changes in patients with knee OA. METHODS: Synovium and synovial fluid were harvested from seventy-four knee OA patients and thirty-four controls afflicted with acute meniscal or cruciate ligament tears. Kellgren-Lawrence (KL) grading system and Western Ontario McMaster University Osteoarthritis Index (WOMAC) assessment scale were applied to evaluate the radiological and clinic severity of OA patients. Additionally, for all patients, the microscopic synovitis was graded to evaluate the severity of synovium pathology. The location of HMGB-1 was determined in the synovium by immunohistochemistry. Synovium and synovial fluid HMGB-1 levels were measured by western blotting and enzyme-linked immunosorbent assay (ELISA), respectively. RESULTS: Synovium immunohistochemical analysis revealed that HMGB-1 displayed a strictly nuclear localization in controls; however, both nuclear and cytoplasmic distributions were present in OA patients. The percentage of HMGB-1 positive cells as well as cytoplasmic HMGB-1 cell population in OA patients were higher than those of controls (42.5% vs. 39.7% and 24.0% vs. 5.7%). Both synovium and synovial fluid HMGB-1 levels in OA patients were significantly higher than controls. In OA patients, HMGB-1 in the KL2/3 group was higher than in the KL4 group. Additionally, synovial fluid HMGB-1 levels in OA patients were positively associated with the severity of synovitis, pain, and daily activities. CONCLUSIONS: Our results demonstrated that HMGB-1 is overexpressed and relocated in synovial membranes of patients with knee OA. The increased synovial fluid HMGB-1 levels were associated with the severity of synovitis, pain, and daily activities in knee OA patients. These results suggested that HMGB-1, as a pro-inflammatory cytokine, may play a crucial role in the progression of knee OA.

Research of osteoblastic induced rat bone marrow mesenchymal stem cells cultured on ß-TCP/PLLA porous scaffold.

BACKGROUND: Ceramic and polymer composite scaffolds are widely used in tissue engineering for bone tissue regeneration. Composite of ß-tricalcium phosphate (ß-TCP) and poly L-lactic acid (PLLA), due to its biocompatibility and biodegradability, is widely used in bioengineering. However, optimal ratio, porosity and pore size of this kind of scaffolds were not very clear yet. MATERIALS AND METHODS: We cultured osteoblastic induced rMSCs on ß-TCP/PLLA scaffolds to investigate the optimum construction, which owned better properties for supporting cells growth, proliferation and differentiation. A total of 24 mice were divided into three groups: rMSCs + ß-TCP/PLLA, osteoblastic rMSCs + ß-TCP/PLLA and ß-TCP/PLLA without cells. 8 rude mice were implanted with rMSCs + ß-TCP/PLLA in the left thighs and ß-TCP/PLLA without cells in the right thighs. 8 rude mice were implanted with osteoblastic rMSCs + ß-TCP/PLLA in the left thighs and the same treatments in the right thighs as the above. After 8 and 12 weeks, the mice were sacrificed and implants with the surrounding tissues were harvested together. Paraffin sections were got and HE stain and Masson-Goldner stain were employed to observe the ectopic bone formation. RESULTS: The scaffolds of ß-TCP/PLLA = 2:1 significantly increased osteocalcin production of the cells. In addition, scaffolds with NaCl = 70 wt%, pore size 200~450 µm showed better compatibility to these seeding cells. A significantly larger area of bone formation in the osteoblastic rMSCs and ß-TCP/PLLA composite than that in rMSCs/scaffold and in the scaffold without cells in vivo. CONCLUSION: compounds of osteoblastic induced rMSCs and the scaffold with ß-TCP/PLLA = 2:1, NaCl = 70 wt%, pore size = 200-450 µm had good properties as a kind of bone substitute.

In vitro evaluation of rhBMP-2-induced expression of VEGF in human adipose-derived stromal cells.

Bone Morphogenetic Protein 2 (BMP-2) plays a key role in skeletal development, repair and regeneration. Our previous studies indicate that recombinant human BMP-2 (rhBMP-2) can stimulate osteogenic differentiation and promote angiogenesis through the up-regulation of Vascular Endothelial Growth Factor (VEGF), while the underlying mechanism of the BMP-2 effect on human cells is not well understood. To gain a better understanding of BMP-2-induced angiogenesis, we further characterized the effect of rhBMP-2 on VEGF expression in human adipose-derived stromal cells (hASCs) by RT-PCR and ELISA. VEGF expression was induced by rhBMP-2 in a dose- and time-dependent manner, with the highest induction observed using 100 ng/ml of rhBMP-2 at 18-24 h post stimulation. In addition, Western blot analyses revealed that the phosphorylation of p38 was closely related to the expression of VEGF, and blocking the p38MAPK pathway with the specific inhibitor sb203580 resulted in the decreased VEGF expression. Our data suggest that p38 activation may be required for rhBMP-2-induced VEGF expression and angiogenesis. Information derived from this study may shed light on understanding the effect of rhBMP-2 in the angiogenesis of hASCs, which is important for designing new strategies to increase the angiogenesis of tissue engineering bone.

Enhanced osteogenic activity of mesenchymal stem cells and co-modified BMP-2 and bFGF genes.

BACKGROUND: We co-modified rat mesenchymal stem cells (rMSCs) with bone morphogenetic protein-2 (BMP-2) and basic fibroblast growth factor (bFGF) genes, and then evaluated their osteogenic activity in vitro and evaluated ectopic bone formation in vivo. MATERIAL/METHODS: Nude mice (male, 20±2 g) were randomly divided into 2 groups: a control group (n=30) and a transfection group (n=30). In the control group, rMSCs+scaffold was implanted into the intramuscular pocket in the left femur, and BMP-2 gene modified rMSCs+scaffold was implanted into the intramuscular pocket in the right femur. In the transfection group, bFGF gene modified rMSCs+scaffold was implanted into the left femur, and BMP-2+bFGF gene modified rMSCs+scaffold was implanted into the right femur. Under anesthesia, an 8-mm incision was made over the lateral aspect of each femur and cell-scaffold composite was implanted into an intramuscular pocket created by blunt dissection. Samples taken at 3 months were stained. Sections were counterstained with hematoxylin. The relative capillary density was estimated by counting the capillary number and measuring the length of the capillaries in the defined area after image digitization. RESULTS: Comparison with the BMP-2 group and bFGF group, the proliferation of the BMP-2+bFGF group was obviously enhanced (p<0.01). The modification could promote alkaline phosphatase activity in endochylema of MSCs in BMP-2+bFGF group. Osteocalcin secretion had obviously improved in the BMP-2+bFGF group compared with the BMP-2 group and the bFGF group (p<0.01). Histologic analysis of the stages of bone formation showed a more obvious scaffold substitution progress in the BMP-2+bFGF group. CONCLUSIONS: Co-modification of rMSCs with BMP-2 and bFGF genes can promote the in vitro osteogenic activity of rMSCs and in vivo ectopic bone formation.

[Concentration- or time-dependent manner of recombinant bone morphogenetic protein 2 in regulating expression of vascular endothelial growth factor].

OBJECTIVE: To study biological rule of recombinant human bone morphogenetic protein 2 (rhBMP-2) in regulating the expression of vascular endothelial growth factor (VEGF) of adipose-derived stem cells (ADSCs) at different induced concentrations and time points at gene level and protein level. METHODS: ADSCs were separated from adult human adipose tissues and cultured until passage 3. After ADSCs were induced by rhBMP-2 in concentrations of 0, 50, 100, and 200 ng/mL respectively for 24 hours, and by 100 ng/mL rhBMP-2 for 3, 6, 12, 18, 24, 36, and 48 hours (ADSCs were not induced at corresponding time point as controls) respectively, the VEGF mRNA and protein expressions were detected by RT-PCR and ELISA. RESULTS: The VEGF mRNA and protein expressions induced by rhBMP-2 were concentration-dependent; the expressions were highest in a concentration of 100 ng/mL. The VEGF mRNA expression in concentrations of 50, 100, and 200 ng/mL were significantly higher than that in a concentration of 0 ng/mL (P < 0.05); and the expression in concentration of 100 ng/mL was significantly higher than that in concentrations of 50 and 200 ng/mL (P < 0.05). The VEGF protein expression in a concentration of 100 ng/mL was significantly higher than that in the other concentrations (P < 0.05). The VEGF mRNA and protein expressions induced by rhBMP-2 were time-dependent. The VEGF mRNA and protein expressions at 3 and 6 hours after induction were significantly lower than those of non-induced ADSCs (P < 0.05); the expressions were lower at 12 hours after induction, showing no significant difference when compared with those of non-induced ADSCs (P > 0.05); the expressions reached peak at 18 and 24 hours after induction, and were significantly higher than those of non-induced ADSCs (P < 0.05); the expressions decreased in induced and non-induced ADSCs at 36 and 48 hours, showing no significant difference between induced and non-induced ADSCs (P > 0.05). CONCLUSION: rhBMP-2 adjusts VEGF expression of ADSCs in a concentration- and time-dependent manner. The optimum inductive concentration of rhBMP-2 is 100 ng/mL, induced to 18-24 hours is a key period when rhBMP-2 is used to promote tissue engineering bone vascularization.

[Clinical characteristics and treatment for patients with low back and leg pain caused by lumbar annular tears].

OBJECTIVE: To investigate whether annular tears is a cause of low back and radiating leg pain and explore the clinical characteristics and treatment for patients with this condition. METHODS: A total of 34 patients with low back and radiating leg pain, but without lumbar disc herniation on CT (computed tomography) or MRI (magnetic resonance imaging), were examined by electrophysiological studies and discography to identify whether there were or not annular tears and nerve root injury and decipher the relations between them. The series included 15 males and 19 females with an average age of 45.6 years old and the average duration of symptoms was 25.8 months. All patients with annular tears and positive pain provocation test were treated by local windowing decompression and debridement of nucleus pulposus after failed conservative treatment. The pre- and post-operative functions and pain were evaluated by JOA (Japanese Orthopedic Association) and VAS (visual analog scale) scores respectively. The average follow-up was 17.4 months. RESULTS: The clinical manifestations included low back and radiating leg pain, intermittent claudication and nerve root injury. No significant abnormalities were discovered on X-ray and CT scan. T2W images of magnetic resonance demonstrated a low intensity or black disc in all patients and high-intensity zone (HIZ) (n = 21). Electromyography showed nerve root injury (n = 27). Abnormality of conduction velocities of common peroneal nerve (n = 7) and tibial nerve (n = 3) were found. Thirty-four patients with 38 discs displayed pain reproduction on contrast injection during discography and the sites of annular tears were confirmed on CT scan after discography. Pre- and post-operative average JOA scale score was 8.7 points and 13.5 points, the recovery ratio 76.2% and the excellent and good outcomes 88.2%. Pre- and post-operative average VAS score was 8.6 points and 2.8 points. And the recovery rate was 80.5%. CONCLUSION: The annular tears result in low back and radiating leg pain. And the typical characteristics are low back and radiating leg pain, intermittent claudication and nerve root injury. MRI and electrophysiological studies play an important role in diagnosing this condition. Lumbar discography is the decisive method and prerequisite of selecting surgery. Local windowing decompression and debridement of nucleus pulposus is a simple and effective method.

[Intraobserver and interobserver reliability of the King, Lenke, and PUMC classification systems for idiopathic scoliosis].

OBJECTIVE: To evaluate the intraobserver and interobserver reliability and main influencing factors of the King, Lenke, and PUMC classification systems for idiopathic scoliosis (IS) using radiographs that had not been premeasured. METHODS: Fifty-six patients with IS, 9 male and 47 female, aged 15.4 (11 - 18), underwent preoperative X-ray photography of spine standing full-length posteroanterior and lateral films and left and right supine side-bending radiographs. The films were read by four orthopedic surgeons independently to do measurement and typing according to the King, Lenke, and PUMC classification systems respectively. Two weeks later, the sequence of the X-ray films was re-ordered and the 4 surgeons read them and did measurement and typing once more. The average percentage of intraobserver and interobserver agreement was calculated. Kappa coefficients were used to determine the intraobserver and interobserver reliability. RESULTS: King classification demonstrated fair interobserver reliability and excellent intraobserver reliability. The mean interobserver reliability was 65.8% (Kappa coefficient = 0.542), while the intraobserver reliability was 82.6% (Kappa coefficient = 0.767). The main reason of disagreement was distinguishment of the King type II and type III. Another reason was assessment of King type V. The complete Lenke classification demonstrated poor reliability. The mean interobserver reliability was 50.0% (Kappa coefficient = 0.438), and the intraobserver reliability was 47.0% (Kappa coefficient = 0.402). The 3 components of Lenke classification had fair interobserver and intraobserver reliability when they were examined separately. The main reasons for disagreement arose from judging whether there was a structural upper thoracic curve and assigning sagittal thoracic modifier. The PUMC type demonstrated excellent intraobserver and interobserver reliability with a mean interobserver reliability of 87.8% (Kappa coefficient = 0.757), and a mean intraobserver reliability of 92.9% (Kappa coefficient = 0.958). Its subtypes demonstrated fair agreement with the mean interobserver reliability of 70.2% (Kappa coefficient = 0.629), and a mean intraobserver reliability of 74.1% (Kappa coefficient = 0.674). The main reasons for disagreement were definition of a curvature and Cobb angle measurement. CONCLUSION: King and PUMC classification systems have higher interobserver and intraobserver reliability than Lenke classification. The reliability levels of the 3 classification systems are all influenced by many factors. Judgment of an upper thoracic curve, variable of Cobb angle measurement, and relationship of the central vertical sagittal line to apex of curve are the common reasons for disagreement in these 3 classifications.

Treatment of tibial defect and bone nonunion with limb shortening with external fixator and reconstituted bone xenograft.

OBJECTIVE: To explore the effect of external fixator and reconstituted bone xenograft (RBX) in the treatment of tibial bone defect, tibial bone nonunion and congenital pseudarthrosis of the tibia with limb shortening. METHODS: Twenty patients (13 males and 7 females) with tibial bone defect, tibial bone nonunion or congenital pseudarthrosis of the tibia with limb shortening were treated with external fixation. Two kinds of external fixators were used: a half ring sulcated external fixator used in 13 patients and a combined external fixator in 7 patients. Foot-drop was corrected at the same time with external fixation in 4 patients. The shortened length of the tibia was in the range of 2-9 cm, with an average of 4.8 cm. For bone grafting, RBX was used in 12 patients, autogenous ilium was used in 3 patients and autogenous fibula was implanted as a bone plug into the medullary canal in 1 case, and no bone graft was used in 4 patients. RESULTS: All the 20 patients were followed-up for 8 months to 7 years, averaging 51 months. Satisfactory function of the affected extremities was obtained. All the shortened extremities were lengthened to the expected length. For all the lengthening area and the fracture sites, bone union was obtained at the last. The average healing time of 12 patients treated with RBX was 4.8 months. CONCLUSIONS: Both the half ring sulcated external fixator and the combined external fixator have the advantages of small trauma, simple operation, elastic fixation without stress shielding and non-limitation from local soft tissue conditions, and there is satisfactory functional recovery of affected extremities in the treatment of tibial bone defects, tibial bone nonunion and congenital pseudarthrosis of the tibia combined with limb shortening. RBX has good biocompatibility and does not cause immunological rejections. It can also be safely used in treatment of bone nonunion and has reliable effect to promote bone healing.