Evaluation of osteochondral-like tissues using human freeze-dried cancellous bone and chondrocyte sheets to treat osteochondral defects in rabbits.

Human freeze-dried cancellous bone combined with human chondrocyte sheets have recently been used to construct an osteochondral-like tissue, which resembled a cartilage layer on a subchondral bone layer. Nevertheless, the efficacy of these human tissues in a xenogeneic model has been rarely reported. Therefore, this study aimed to evaluate the potential of human freeze-dried cancellous bones combined with human chondrocyte sheets for the treatment of osteochondral defects in rabbits. The key roles of the extracellular matrix (ECM) and released cytokines in these tissues in osteochondral repair were also assessed. Triple-layered chondrocyte sheets were constructed using a temperature-responsive culture surface. Then, they were placed onto cancellous bone to form chondrocyte sheet-cancellous bone tissues. The immunostaining of collagen type II (COL2) and the proteomic analysis of the human tissues were carried out before the transplantation. In our in vitro study, the triple-layered chondrocyte sheets adhered well on the cancellous bone, and the COL2 expression was apparent throughout the tissue structures. From the proteomic analysis results, it was found that the major function of the secreted proteins found in these tissues was protein binding. The distinct pathways were focal adhesion and the ECM-receptor interaction pathways. Among the highly expressed proteins, laminin-alpha 5 (LAMA5) and fibronectin (FN) not only played roles in the protein binding and ECM-receptor interaction, but also were involved in the cytokine-mediated signaling pathway. At 12 weeks after xenogeneic transplantation, compared to the control group, the defects treated with the chondrocyte sheets showed more hyaline-like cartilage tissue, as indicated by the abundance of safranin-O and COL2 with a partial collagen type I (COL1) expression. At 4, 8, and 12 weeks, compared to the defects treated with the cancellous bone, the staining of safranin-O and COL2 was more apparent in the defects treated with the chondrocyte sheet-cancellous bone tissues. Therefore, the human chondrocyte sheets and chondrocyte sheet-cancellous bone tissues provide a potential treatment for rabbit femoral condyle defect. LAMA5 and FN found in these human xenografts and their culture media might play key roles in the ECM-receptor interaction and might be involved in the cytokine-mediated signaling pathway during tissue repair.

Construction and Evaluation of Osteochondral-Like Tissue Using Chondrocyte Sheet and Cancellous Bone.

The manipulation of human chondrocyte sheets in target areas frequently results in their tearing because they are thin and fragile. In this study, human cancellous bones were used as a supporting material to create chondrocyte sheet-cancellous bone tissues, and their properties were evaluated. Using cell sheet technology, human chondrocytes were constructed into triple-layered chondrocyte sheets that displayed chondrogenic properties. After transferring the chondrocyte sheets onto cancellous bones, the top area of the chondrocyte sheet-cancellous bone tissues exhibited a smooth surface topography without cell sheet floating within 7 days of culture. The immunofluorescence staining of collagen type II (COL2A1) and fibronectin (FN1) was also performed and examined. Using the shotgun proteomic analysis, the proteins associated with cell adhesion, extracellular matrix (ECM) organization, cell-substrate junction assembly, and cell adhesion mediated by integrin were observed in the chondrocyte sheets, cancellous bones, and chondrocyte sheet-cancellous bone tissues. Three integrin members, including integrin ß4 (ITGB4), ITGB6, and ITGB8, were found in the chondrocyte sheets. Only ITGB8 was found in the chondrocyte sheets and chondrocyte sheet-cancellous bone tissues. During 48 h, the mean velocity of the individual cell migration was low, which did not affect the structure and chondrogenic properties of the chondrocyte sheets. Staining of the filamentous actin (F-actin) cytoskeleton in the migratory cells also provided a better understanding of the dynamic communication between the cell cytoskeleton and adhesion molecules through ITGB8, which may play a key role in the attachment of the chondrocyte sheets and the synthesis of the cartilage ECM. Therefore, we suggest that cancellous bone could be used as a supporting material to construct chondrocyte sheet-cancellous bone tissues for potential treatment of osteochondral lesions. Impact Statement We proposed a method to construct an osteochondral-like tissue by placing human chondrocyte sheets onto cancellous bone. The stationary chondrocyte sheets and the low mean velocity of the individual cell migration on the cancellous bone with the expression of COL2A1 indicated that the cancellous bone served as an appropriate supporting material. Moreover, the cellular mechanism for the adhesion of the chondrocyte sheets on the cancellous bone based on ITGB8-mediated adhesion through the rearrangement of filamentous actin provided a better understanding to improve the construction of osteochondral-like tissues, and to predict the repair mechanism in osteoarthritis therapy.

Invalid freeze-dried platelet gel promotes wound healing.

Wound healing is the curative process of tissue injury, composed of three phases: the inflammatory phase, proliferative phase, followed by the maturation cum remodeling phase. Various treatment options were previously depicted for wound healing, however a treatment that accelerates these phases would be highly valuable. Platelet aggregation at the bleeding vessels and release of various growth factors are the most promising factors that stimulates the wound healing progress. In the present study, we hypothesized that the freeze-dried platelet which were normally discarded from the blood banks due to invalidity, might be promising to accelerate the phases of wound healing. The invalid freeze-dried platelets were prepared to a gel form called invalid freeze-dried platelet gel (IF-PG), which was tested for its efficacy in a cutaneous punch wound model in rats. Mupirocin antibiotic gel was used as a bio-equivalent formulation. The wound healing phases and changes in the wound sites were determined by assessing the wound sizes, histopathological analysis, immunohistochemical staining. The re-epithelialization at the wound sites at different time intervals till the wound closure was also determined. Our results suggest the beneficial effects of IF-PG; in reducing the wound area and accelerating wound closure in the cutaneous punch wound in rats. Histopathology and immunostaining results support the improvements in the wound when treated with IF-PG, which were similar to that of mupirocin antibiotic gel. Our preliminary findings also warrant the competency of IF-PG in modulating the different phases of wound healing process. In conclusion, IF-PG might be a resourceful alternative for the wound care management, however further studies are required to validate its impact on various growth factors before proceeding to clinical studies.

Differentiation of patented crystalline glucosamine sulfate from other glucosamine preparations will optimize osteoarthritis treatment.

Symptomatic slow-acting drugs for osteoarthritis (SYSADOAs) are recommended for the medium- to long-term management of knee osteoarthritis (OA) due to their abilities to control pain, improve function and delay joint structural changes. Among SYSADOAs, evidence is greatest for the patented crystalline glucosamine sulfate (pCGS) formulation (Mylan). Glucosamine is widely available as glucosamine sulfate (GS) and glucosamine hydrochloride (GH) preparations that vary substantially in molecular form, pharmaceutical formulation and dose regimen. Only pCGS is given as a highly bioavailable once-daily dose (1500 mg), which consistently delivers the plasma levels of around 10 µmol/L required to inhibit interleukin-1-induced expression of genes involved in the pathophysiology of joint inflammation and tissue destruction. Careful consideration of the evidence base reveals that only pCGS reliably provides a moderate effect size on pain that is higher than paracetamol and equivalent to non-steroidal anti-inflammatory drugs (NSAIDs), while non-crystalline GS and GH fail to reach statistical significance for pain reduction. Chronic administration of pCGS has disease-modifying effects, with a reduction in need for total joint replacement lasting for 5 years after treatment cessation. Pharmacoeconomic studies of pCGS demonstrate long-term reduction in additional pain analgesia and NSAIDs, with a 50% reduction in costs of other OA medication and healthcare consultations. Consequently, pCGS is the logical choice, with demonstrated medium-term control of pain and lasting impact on disease progression. Physician and patient education on the differentiation of pCGS from other glucosamine formulations will help to improve treatment selection, increase treatment adherence, and optimize clinical benefit in OA.

Maintenance of human chondrogenic phenotype on a dendrimer-immobilized surface for an application of cell sheet engineering.

BACKGROUND: Dedifferentiation of chondrocytes during cell expansion is one of the barriers in tissue construction for cartilage repair. To understand chondrocyte behavior and improve cell expansion in monolayer culture, this study investigated the effects of morphological changes and cellular aggregation on the maintenance of chondrogenic capacity by observing the expression patterns of chondrogenic (collagen type II and aggrecan) and dedifferentiation (collagen type I) markers. Primary human chondrocytes were cultured on either a polystyrene surface (PS) or a polyamidoamine dendrimer surface with a fifth-generation (G5) dendron structure to create a one-step process of cell expansion and the maintenance of chondrogenic activities prior to the construction of cell sheets. RESULTS: During the first two passages (P0 - P2), the relative mRNA level of collagen type II decreased in all cultures, while that of collagen type I increased. Remarkably, the level of collagen type II was higher and aggrecan was retained in the chondrocytes, forming cell aggregates and showing some round-shaped cells with less production of stress fibers on the G5 surface compared to fibroblast-like chondrocytes with abundant stress fibers on the PS surface. The numbers of P2 chondrocytes on the G5 and PS surfaces were nearly the same and sufficient for construction of chondrocyte sheets using a temperature-responsive plate. Without a supporting material during cell sheet manipulation, chondrocyte sheets spontaneously detached and exhibited a honeycomb-like structure of stress fibers. Unlike the chondrocyte sheets constructed from cells on the PS surface, the chondrocyte sheets from cells on the G5 surface had higher chondrogenic activities, as evidenced by the high expression of chondrogenic markers and the low expression of dedifferentiation markers. CONCLUSIONS: The one-step process of cell expansion and maintenance of chondrogenic activity could be obtained using the G5 surface. Human chondrocyte sheets were successfully constructed with high chondrogenic activity. These findings may lead to an alternative cultivation technique for human chondrocytes that offers high clinical potential in autologous chondrocyte implantation.

Effect of Cell Sheet Manipulation Techniques on the Expression of Collagen Type II and Stress Fiber Formation in Human Chondrocyte Sheets.

Cell sheet technology is applied to human articular chondrocytes to construct a tissue-like structure as an alternative treatment for cartilage defect. The effect of a gelatin manipulator, as a cell sheet transfer system, on the quality of the chondrocyte sheets was investigated. The changes of important chondrogenic markers and stress fibers, resulting from the cell sheet manipulation, were also studied. The chondrocyte cell sheets were constructed with patient-derived chondrocytes using a temperature-responsive polymer and a gelatin manipulator as a transfer carrier. The properties of the cell sheets, including sizes, expression levels of collagen type II and I, and the localization of the stress fibers, were assessed and compared with those of the cell sheets harvested without the gelatin manipulator. Using the gelatin manipulator, the original size of the chondrocyte cell sheets was retained with abundant stress fibers, but with a decrease in the expression of collagen type II. Without the gelatin manipulator, although the cell shrinkage occurred, the cell sheet with suppressed stress fiber formation showed significantly higher levels of collagen type II. These results support our observations that stress fiber formation in chondrocyte cell sheets affected the production of chondrogenic markers. These densely packed tissue-like structures possessed a good chondrogenic activity, indicating their potential for use in autologous chondrocyte implantation to treat cartilage defects.

Pain Perception in Buddhism Perspective.

Dhamma, which Lord Buddha has presented to people after his enlightenment, analyzes every phenomenon and objects into their ultimate elements. The explanation of sensory system is also found in a part of Dhamma named Abhidhammapitaka, the Book of the Higher Doctrine in Buddhism. To find out the relationship between explanation of pain in the present neuroscience and the explanation of pain in Abhidhamma, the study was carried out by the use of a comprehensive review. The comparisons were in terms of peripheral stimulation, signal transmission, modulation, perception, suffering, determination and decision making for the responding to pain. We found that details of the explanation on pain mechanism and perception in Abhidhamma could associate well with our present scientific knowledge. Furthermore, more refinement information about the process and its function in particular aspects of pain perception were provided in Abhidhammapitaka.

Use of warm Ringer's lactate solution in the management of locally advanced giant cell tumor of bone.

BACKGROUND: This study was conducted to discover the effectiveness and safety of using warm Ringer's lactate solution (RLS) as a local treatment in the management of locally advanced giant cell tumor of bone with marked soft tissue invasion, including nearby neurovascular bundles. PATIENTS AND METHODS: This was a longitudinal cohort study with an average follow-up period of 4.6 ± 0.3 years, ranging from 4.2 to 5.9 years. There were 21 patients (9 male and 12 female), with the ages of subjects ranging from 12 to 64 years. Eight patients (38 %) were tumor recurrence cases. Pathological fracture was found in 15 patients (71 %). After extended curettage, warm RLS (50 °C) was locally applied for 20 min. Bone stabilization and reconstruction were then performed. RESULTS: All patients survived the operation. No additional neurovascular injury resulting from the use of warm RLS was found. Patients who had neurological deficit before the operation experienced significant improvement in motor and sensory function during the follow-up period. Complication was found in one patient (5 %). Two patients (9.5 %), had tumor recurrence and 19 patients (90.5 %) were tumor-free with good to acceptable function. CONCLUSION: Use of warm Ringer's lactate solution as an adjunctive local treatment during intra-lesional curettage of giant cell tumor with locally soft tissue extension was found to be safe with relatively low recurrence rate. However, additional studies to identify the optimum thermoablation dose at each part of the body should be undertaken before this technique can be used as a standard treatment.

A New Recommendation for Handling and Care of Human Allogenic Bone Graft (at Siriraj Hospital) to Reduce Post-Operative Complication

Background: Bangkok Biomaterial Center is the only allogenic bone bank in Thailand, supplying the bones to all medical centers. From a report, a certain number of post-operative complications were found. Objective: To compare pre-protocol revision and post-protocol revision success rates and complications associated with the use of allogenic bone grafts relative to perioperative handling and care of allogenic bone. Material and Method: This retrospective comparative study was conducted at the Bangkok Biomaterial Center, Faculty of Medicine Siriraj Hospital, Mahidol University. All registration forms and surgical follow-up reports relating to the use allogenic bones procured from our bone bank between 2005 and 2015 were reviewed. New recommendations for the use of our allogenic bones were established in 2009. Results and complications after allogenic bone transplantation between 2005 and 2008 were compared with results and complications after transplantation to a new protocol between 2009 and 2015. Descriptive analysis and analysis of variance were used to evaluate the data. Results: Data of 825 patients who underwent deep frozen allogenic bone transplantation and 1,541 patients who underwent freeze-dried allogenic bone transplantation were retrospectively reviewed. Overall, the complication rate was reduced from 14.83% in the pre-protocol revision period to 5.15% in the period after the new recommendations for perioperative graft handling were established and implemented. Conclusion: New recommendations for the handling and care of allogenic bone during the perioperative period significantly reduced post-operative complications in patients who received transplantation with deep frozen allogenic bone. The infection rate in patients who received allogenic bone graft was very low.

Plate Fixation Technique for Reducing Osteoarticular Allograft Fracture: A Preliminary Report.

Background: Osteoarticular allograft is now commonly used as a reconstructive biomaterial to replace bone defect following removal of aggressive bone tumors and for revision of failed arthroplasty. Good long-term clinical result of allograft replacement has been demonstrated. However, the rate of complications is high, including deep infection, allograft fracture, delayed union or non-union, and joint instability. Prevalence of allograft fracture ranges from 12-54 percent. Many studies recommend avoiding plate and screw fixation, or they advise the use of a modified screw fixation technique that minimizes the number of screws and changes screw alignment. Objective: The objective of this study was to compare the efficacy of the conventional technique with a new method of plate and screw fixation in osteochondral allograft following removal of aggressive bone tumors. Material and Method: From September 1988 to February 2015, 52 patients with primary aggressive benign or malignant bone tumor underwent massive bone allograft reconstruction. There were 25 males and 27 females with a mean age of 27-years. Giant cell tumor and osteosarcoma comprised most of the diagnoses. Thirty-five of the tumors were located around the knee. Average length of allograft was 12.9 cm. Twenty-nine patients were reconstructed using standard technique and 23 patients were fixed using only one dynamic compression plate with limited and 15-degree divergent-angle screw fixation at the allograft. Results: Mean follow-up time in the group treated by conventional fixation was 84.5 months. There were 13 fractures (44.8%) in the conventional fixation group, with a median time to graft fracture of 4.9 months. The 23 patients with new technique fixation were followed-up for a mean duration of 60.5 months. Six fractures (26.1%) occurred in this group, with a median time to graft fracture of 10.40 months. Differences between groups for incidence of allograft fracture and median time to fracture were not statistically significant (p = 0.163 and p = 0.244, respectively). Most patients with allograft fracture were treated surgically using autogenous bone grafting and revision of internal fixation. Conclusion: The new method of osteochondral allograft fixation using single plate, fewer screws, and divergent screw fixation yielded a lower fracture rate and a longer median time to fracture than the conventional method; however the differences between groups did not achieve statistical significance. The results of this preliminary study should be confirmed in a larger group of allografts over a longer follow-up period.

Effect of a Short-Term Treatment with Once-A-Week Medication of Alendronate 70 Mg on Bone Turnover Markers in Postmenopausal Women with Osteoporosis.

OBJECTIVE: The study was carried out to evaluate safety and efficacy of once-a-week medication of Kasparalendronate for inhibiting high bone turnover rate. MATERIAL AND METHOD: Forty-nine postmenopausal osteoporotic participants were included in the study. This investigation was carried out as an open study. The participants received the drug every weekfor 12 weeks. Pain, drugside effects and bone turnover markers were evaluated at the 6"' week and 12' week after the first visit. RESULTS: None had significant complication and all could complete the trial. Thirteen participants, (26.3%), had minimal side ffects, which the trial drug could be administered until the end ofstudy. At the 12th week follow-up, 42/49 participants (85.7%) had normal serum Beta-crosslab and 45/49 participants (91.8%) had normal serum N-MID osteocalcin. None showed any decrease in serum P1NP All participants had slight reduction in serum alkaline phosphatase. CONCLUSION: The trial drug could inhibit high bone turnover in about 85% of post-menopausalparticipants within 12 weeks of drug administration and no severe side effect took place.

Effects of thermoablation with or without caffeine on giant cell tumour of bone.

PURPOSE: To evaluate the effect of caffeine on the apoptosis rate of giant cell tumour of bone cells during thermoablation. METHODS: Giant cell tumour of bone tissue (2 cm3) was collected from 10 patients. Cells were incubated at 37ºC, 40ºC, 45ºC, 50ºC, 52.5ºC, and 55ºC for 20 minutes (3 tubes for each temperature). Caffeine was added to the tubes in amounts of 0 µg/ml (control), 50 µg/ml, and 100 µg/ml. The apoptotic effect of thermoablation with or without caffeine was evaluated. RESULTS: In all test conditions, the apoptotic rate of tumour cells increased when the temperature increased. Compared with controls (no caffeine), adding 50 or 100 µg/ml of caffeine did not increase the apoptotic rate significantly at 40ºC to 52.5ºC. Caffeine had no enhancing effect at any temperature. Conversely, at 55ºC, the apoptotic rate was lower when 100 µg/ml of caffeine was added than when no or 50 µg/ml of caffeine added (p=0.045). CONCLUSION: Thermoablation at 40ºC to 52.5ºC for 20 minutes increased the apoptosis rate of giant cell tumour of bone cells. Caffeine had no enhancing effect at any temperature. Conversely, at 55ºC, caffeine had cytoprotective effects on the tumour cells against thermoablation.

Prevalence of neuropathic pain after radical sacral chordoma resection: an observational cohort study with 10-year follow-up.

This study was carried out to discover the prevalence, characteristics and severity of neuropathic pain after wide resection of chordoma of the sacrum by the use of posterior approach. Patients who had chordoma of their sacrums and underwent wide resection via posterior approach, during 1990-2002, were followed up as a prospective cohort. Pain assessment was carried out in terms of onset, characteristics, intensity (numerical rating scale), response to pain medication and associated symptoms. The correlation between patients' biographic data, preoperative neuropathic pain, type and levels of surgery and pain were analyzed. There were 21 patients; 14 male and 7 female patients. Their ages ranged between 29 and 75 years. Subtotal sacrectomy was carried out in 9 patients and total sacrectomy was carried out in 12 patients. All patients survived the operation. Neuropathic pain was found in 11 patients (52.4%). Male patients and presentation of preoperative neuropathic pain were significantly related to postoperative neuropathic pain. The other factors were not related to the postoperative pain. Recurrent of severe pain with different characteristics after the operation might indicate tumor recurrent. Early detection of the pain and proper treatment could minimize pain intensity and improved pain management satisfaction.

Modification of human cancellous bone using Thai silk fibroin and gelatin for enhanced osteoconductive potential.

The modification of human cancellous bone (hBONE) with silk fibroin/gelatin (SF/G) using 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide hydrochloride (EDC)/N-hydroxysuccini-mide (NHS) crosslinking was established. The SF/G solutions at a weight ratio of 50/50 and the solution concentrations of 1, 2, and 4 wt % were studied. SF/G sub-matrix was formed on the surface and inside pore structure of hBONE. All hBONE scaffolds modified with SF/G showed smaller pore sizes, less porosity, and slightly lower compressive modulus than unmodified hBONE. SF/G sub-matrix was gradually biodegraded in collagenase solution along 4 days. The hBONE scaffolds modified with SF/G, particularly at 2 and 4 wt % solution concentrations, promoted attachment, proliferation, and osteogenic differentiation of bone marrow-derived mesenchymal stem cells (MSC), comparing to the original hBONE. The highest cell number, ALP activity and calcium production were observed for MSC cultured on the hBONE scaffolds modified with 4 wt % SF/G. The mineralization was also remarkably induced in the cases of modified hBONE scaffolds as observed from the deposited calcium phosphate by EDS. The modification of hBONE with SF/G was, therefore, the promising method to enhance the osteoconductive potential of human bone graft for bone tissue engineering.

Use of Beach Shoes for Foot Protection during the Bangkok Flood of 2011.

BACKGROUND: Foot injury was common as a result of the Bangkok flood of 2011. In the future, this type of injury should be prevented to lessen the burden during a disaster. OBJECTIVES: The study was performed to ascertain what type of footwear is appropriate for volunteer rescue workers during a flood. MATERIAL AND METHODS: The study was carried out during the flood in November 2011 at Siriraj Hospital. There were 15 volunteers enrolled in the study. None of the volunteers had any foot deformity or injury before the study. Participants were divided into 3 groups of 5 volunteers: group A, the barefoot group; group B, the high top shoe group; and group C, the beach shoe group. All volunteers worked in the areas close to Siriraj Hospital and were followed up after 5 days of rescue work. Prevalence of foot and ankle injuries, satisfaction regarding work conditions and willingness to use the shoes were subjectively evaluated. Wearing of beach shoes during rescue was satisfactory during the early phase of the flood. RESULTS: The age range of volunteers was 20-28. In the group A, most volunteers were barely satisfied with conducting rescue work in water with bare feet, that bare feet were good for working on a wet surface and were 'just satisfied' to not satisfied that bare feet were good for work on dry surfaces. In group B, most of the volunteers had opinions similar to group A with the exception that they felt better while they were working on dry surfaces. In group C, most volunteers were significantly more satisfied under all three conditions. Foot injury occurred in 2 volunteers from group A. CONCLUSION: Beach shoes offer adequate foot protection during flood rescue.

Using polypropylene mesh graft for soft-tissue reconstruction in internal hemipelvectomy: a case report.

We report the case of a patient with chondrosarcoma involving the right pelvis and contralateral pubic area in a 45-year-old male who underwent an extensive internal hemipelvectomy without bony reconstruction. We demonstrate the technique of using polypropylene mesh graft for soft-tissue reconstruction. Follow-up at 7.5 years showed a good oncological and functional outcome.

Serum 25-hydroxy-calciferol level and failed back surgery syndrome.

PURPOSE: To assess the association of serum 25-hydroxy-calciferol levels with pain and low back function in patients with failed back surgery syndrome. METHODS: Records of 6 men and 3 women aged 25 to 54 (mean, 39.2) years who had failed back surgery syndrome after pedicular screw and rod instrumentation for lower lumbar degenerative diseases were reviewed. They had moderate-to-severe pain (visual analogue scale [VAS] score of >6) and low back function disability (Japanese Orthopaedic Association [JOA] back score of <10). In all patients, the serum 25-hydroxy-calciferol level was <30 ng/ ml, indicating vitamin D deficiency. Vitamin D2 (20 000 IU per day) was given for 10 days, and vitamin D3 (600 IU per day) was given for maintenance. Patients were followed up at months 3 and 6. Three men and 4 women aged 27 to 55 (mean, 41.3) years who were age- and disease-matched but achieved good outcomes (VAS score of 0-1 and mean JOA low back score of 14.7) were used as indirect referents. All 7 matched patients except one had a normal serum 25-hydroxy-calciferol level (mean, 40.6 ng/ml). RESULTS: In the 9 patients with failed back surgery syndrome, the mean duration of chronic pain was 2.6 years; the mean VAS score for pain was 7.7; the mean JOA low back score was 7.6; the mean number of reoperations was 2.2; and the mean serum 25-hydroxy-calciferol level was 17.0 ng/ml. Two male patients had grade-IV motor weakness and decreased sensory function based on the pin prick test. One patient had a history of prolonged (>3 months) antibiotic use after primary surgery, but had no evidence of infection. Six months after vitamin D2 and vitamin D3 supplementation, the mean serum 25-hydroxy-calciferol level improved significantly (17.0 vs. 42.5 ng/ml), as did the mean pain score (7.7 vs. 4.2) and mean JOA back score (7.6 vs. 11.1). Seven of the patients had a pain score of <6 and a JOA back score of >10, the remaining 2 patients had neurological deficits and only slight improvement. CONCLUSION: Vitamin D supplementation may be used as an adjuvant treatment for patients with failed back surgery syndrome.

A randomized control trial between fosfomycin and cefuroxime as the antibiotic prophylaxis in knee arthroplasty.

BACKGROUND: Antibiotic prophylaxis is used in all patient underwent total knee arthroplasty to prevent post operative infection which produced poor outcome. The suitable drug should be safe and good efficacy. OBJECTIVE: To study safety and efficacy of fosfomicin and cefuroxime as antibiotic prophylaxis for total knee arthroplasty. MATERIAL AND METHOD: The control trial was performed to find out efficacy and safety of fosfomycin as an antibiotic prophylaxis comparing to cefuroxime. There were 112 patients, 14 male and 98 female, with their ages ranged between 57 and 86 years. They were randomly divided into two groups, the fosfomycin group, 56 patients and the cefuroxime group, 56 patients. All patients underwent elective knee arthroplasty by the authors. The scheduled antibiotics were given perioperatively for 24 hours and all patients were followed-up for 6 months. Physical examination, skin temperature of the operated knee, radiograph and blood tests were carried out in the patients to monitor post operative infection, renal and liver disturbance. RESULTS: One patient in the cefuroxime group had local wound infection which responded well to local treatment and administration of antibiotics. No patients had post operative infection at the 6 months follow-up. No patients had any complication and none had renal and liver function disturbance during the follow-up. CONCLUSION: Comparing to cefuroxime,fosfomycin is safe and effective for the use as antibiotic prophylaxis in knee arthroplasty.

The outcomes of treatment of giant cell tumor of bone around the knee.

BACKGROUND: Giant cell tumor of bone has been characterized as an aggressive benign bone tumor and commonly occurs at the distal femur and the proximal tibia. The recommended treatment has ranged from intralesional curettage to wide excision and the decision depends on severity of the tumor extent, rate of local recurrence,functional and morbidity outcomes. OBJECTIVE: To compare extended curettage and wide excision in Grade II-III giant cell tumor of bone around the knee with regard to their effectiveness in tumor control and complication. MATERIAL AND METHOD: There were 54 patients with a giant cell tumor which involved the distal femur or proximal tibia who had been managed consecutively at Siriraj Hospital between 1994-2009. The lesion of all patients were staged according to the system of Campanacci et al. There were 21 males and 33 females with mean age of 34 years. Thirty-five tumors located at distal femur and 19 located at proximal tibia. Fourteen patients had a Grade II lesion and 40 had a Grade III lesion. Thirty patients received extended curettage whereas other 24 patients had a wide excision. Fisher's exact analysis was used for statistical analysis for the outcome of tumor recurrence in each surgery. RESULTS: The mean follow-up time was 59 months. There were 7 (23.3 percent) local recurrences in the extended curettage group and 2 (8.3 percent) in the wide excision group. Most recurrences occurred within one year postoperatively. There was no statistical difference for the outcome of tumor recurrence in each group (p = 0.270). All patients with tumor recurrence were successfully treated with re-curettage, except for 3 patients who was treated by above-knee amputation. The functional analysis was excellence in the extended curettage group (94 percent) and good in the wide excision group (77.6 percent) according to the Musculoskeletal Tumor Society functional classification. CONCLUSION: The authors believe that using extended curettage was not significantly different in percentage of local recurrence when compared with wide excision for Campanacci's Grade II-III of giant cell tumor of bone. Even better function was found in extended curettage group, the choice of surgical treatment should be considered in individual patient which depends on the extent of bone destruction and risk of tumor recurrence.