Barthel Index and Age as Predictors of Discharge Destination in Patients with Glioblastoma.

This study aimed to investigate the predictive factors of transfer of glioblastoma multiforme (GBM) patients who underwent rehabilitation in acute care hospitals. We retrospectively identified 85 patients with GBM who underwent rehabilitation at our hospital. Multivariable logistic regression analysis showed that age and Barthel index (BI) at rehabilitation initiation significantly influenced the discharge destination. Cut-off values for these factors were 76 years of age and 30 BI points. These findings could help predict the discharge destination and the choice of rehabilitation strategies of newly diagnosed patients with GBM admitted to an acute care hospital.

Subcutaneous Anterior Transposition With Modified Procedures to Prevent Recurrence Associated With the Transposed Ulnar Nerve.

Subcutaneous anterior transposition of the ulnar nerve is a common surgical treatment for cubital tunnel syndrome. However, there are surgical failures associated with the new compressive sites at the edge of flexor carpi ulnaris (FCU) and resubluxation posterior to the medial epicondyle of the transposed nerve. To reduce the muscle volume at the edge of FCU, we approach the ulnar nerve by dividing the muscle belly of the FCU humeral heads. This procedure can reduce repeated traction forces on the transposed nerve at the edge of the FCU. To keep the transposed ulnar nerve anteriorly, we use a fat flap including the membranous superficial fascia. This flap can softly stabilize the ulnar nerve and act as a pliable cover to prevent perineural scarring or further constriction around the flap. Ninety-three elbows in 90 patients who had undergone this procedure for cubital tunnel syndrome were evaluated. According to Messina's criteria, the numbers of patients showing excellent, good, fair, and poor recovery were 41 (44%), 47 (51%), 5 (5%), and 0 (0%), respectively. Most patients experience resolution of symptoms and good functional outcomes. None of the patients suffered recurrence, infection, or nerve injury.

Predicting anterior cruciate ligament degeneration using magnetic resonance imaging: Insights from histological evaluation.

BACKGROUND: Mucoid degeneration of the anterior cruciate ligament is a pathological condition that may impair knee mechanics and contribute to the symptomatology of osteoarthritis. This study aimed to evaluate whether preoperative magnetic resonance imaging can predict anterior cruciate ligament degeneration, specifically mucoid degeneration, and to elucidate the histopathological characteristics of mucoid degeneration in knee osteoarthritis patients. METHODS: We evaluated a total of 95 knees of osteoarthritis patients (23 males, 72 females; mean age: 72.7 ± 7.5) scheduled for total knee arthroplasty. The relationship between preoperative magnetic resonance imaging findings and the histopathological evidence of anterior cruciate ligament mucoid degeneration was examined. Immunohistochemical analysis was employed for collagen types (COL-I, COL-II), chondrogenesis (SOX9), and vascularity (CD31). RESULTS: High signal intensity on magnetic resonance imaging showed a positive correlation with Alcian Blue staining areas (rs = 0.59, p < 0.01) and the swelling index (rs = 0.62, p < 0.01), indicating advanced mucoid degeneration. The absence of synovial lining around the anterior cruciate ligament was associated with more severe degeneration. In the histological evaluations, advanced degeneration was characterized by an increase in chondroid metaplasia and collagen disorientation. The Alcian Blue and SOX9 correlation was positive (rs = 0.69, p < 0.01), but negative with COL-I (rs = -0.38, p = 0.03) and vascularity (CD31) (rs = -0.60, p < 0.01). CONCLUSIONS: Preoperative magnetic resonance imaging is an effective tool in assessing the severity of anterior cruciate ligament degeneration; it influences surgical decisions. High signal intensity on magnetic resonance images denotes advanced mucoid degeneration. The absence of synovial lining around the anterior cruciate ligament is associated with more severe degeneration and may accelerate degenerative changes. Chondroid metaplasia and collagen disorientation mark advanced degeneration. Magnetic resonance imaging can be used to gauge the degree of anterior cruciate ligament degeneration in osteoarthritis.

Endoscopically assisted transaxillary release of the scalene muscles for thoracic outlet syndromes: a comparison with or without first rib resection.

OBJECTIVES: There are several surgical techniques for thoracic outlet syndrome (TOS). However, there have been no reports of endoscopically assisted transaxillary release of the anterior and middle scalene muscles (EATRS), leaving the first rib intact for TOS. We hypothesized that EATRS would achieve a good Quick Disability of the Arm, Shoulder and Hand score. This study aims to present our experience with a new technique for TOS using endoscopy. METHODS: We chose two surgeries depending on the patient's TOS condition. If the costoclavicular space was under 12 mm, we selected endoscopically assisted transaxillary first rib resection (EAFRR). If the costoclavicular space was over 12 mm, we selected EATRS. Between January 2021 and December 2022, 31 consecutive surgeries for TOS were performed in our institution. Twenty-five patients underwent EAFRR, and six (19%) underwent EATRS. Since July 2022, EAFRR has been performed under differential lung ventilation. RESULTS: Complete and almost complete relief was achieved in 24 patients (77%), and partial relief was conducted in seven patients (23%) at a mean of 19.7 months after surgery. The symptoms improved in all cases. Intraoperative pneumothorax did not occur, and no other complications were observed. Both EAFRR and EATRS were effective and safe surgeries for TOS. Operative time was significantly shorter in EATRS than in EAFRR. CONCLUSIONS: We first report EATRS surgery for TOS. EATRS is indicated for patients whose costoclavicular space is preserved before surgery. Good surgical results were obtained after surgery for this indication.

Life Course Epidemiology of Hip Osteoarthritis in Japan: A Multicenter, Cross-Sectional Study.

BACKGROUND: The incidence of developmental dysplasia of the hip (DDH) in Japanese newborns has reduced drastically following a primary prevention campaign initiated around 1972 to 1973; this perinatal education campaign promoted maintaining the hips of newborns in the naturally flexed-leg position. The purpose of the present study was to describe the life course epidemiology of hip osteoarthritis (OA) in adolescent and adult patients and to assess its association with exposure to the primary prevention campaign for DDH. METHODS: We included new patients with hip OA diagnosed from January 1, 2022, to December 31, 2022, at 12 core hospitals (8 special-function hospitals and 4 regional medical care support hospitals). The trend in the percentage of hips with a history of DDH treatment in childhood was estimated with use of a centered moving average using the birth year of the patient. We compared the prevalence of severe subluxation (Crowe type II, III, or IV) between patients with secondary hip OA due to hip dysplasia who were born in or before 1972 and those who were born in or after 1973. RESULTS: Overall, 1,095 patients (1,381 hips) were included. The mean age at the time of the survey was 63.5 years (range, 15 to 95 years). A total of 795 patients (1,019 hips; 73.8% of hips) were diagnosed with secondary OA due to hip dysplasia. Approximately 13% to 15% of hips among patients born from 1963 to 1972 had a history of DDH treatment in childhood; however, the percentage decreased among patients born in or after 1973. The prevalence of severe subluxation (Crowe type II, III, or IV) among patients born in or after 1973 was 2.4%, which was significantly less than that among patients born in or before 1972 (11.1%; odds ratio, 0.20; p < 0.001). CONCLUSIONS: As of 2022, secondary hip OA due to hip dysplasia is still responsible for most new cases of adolescent and adult hip OA seen in core hospitals in Japan. However, the perinatal education campaign initiated 50 years ago, which utilized a population approach and advocated for maintaining the hips of newborns in the naturally flexed-leg position, may have improved the environmental factors of DDH, as indicated by the apparently reduced need for treatment of DDH in childhood and the associated severe subluxation. This may result in a reduced need for challenging hip surgery later in life. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The effect of continuous interscalene brachial plexus block for arthroscopic rotator cuff repair.

Background: Arthroscopic rotator cuff repair (ARCR) is a minimally invasive surgical technique. However, it is challenging to control postoperative pain. This study aimed to investigate the difference between a single-shot interscalene block and a combined continuous block for ARCR. Methods: Ninety-four patients who underwent ARCR were included in this study. In the preceding period, 43 patients received a single-shot interscalene block and continuous postoperative intravenous opioid infusion (Single group). In the posterior period, 51 patients received a single-shot interscalene block preoperatively and a continuous block postoperatively (Continuous group). Their mean age at surgery was 64.9 years (range, 43-83 years). The mean follow-up period was 25.4 months (range, 24-54 months). The numerical rating scale (NRS) of pain was evaluated immediately after the surgery, at rest, and at night for 1-4 days after the surgery. One day postoperatively, the amount of food taken was assessed from 0 % (no food intake) to 100 % (all food taken). The University of California at Los Angeles (UCLA) shoulder score, range of motion (ROM), and isometric shoulder strength were evaluated. Results: NRS at rest in the Continuous group on the day of surgery was 3.7 ± 2.5. This was significantly lower than in the Single group (5.2 ± 1.8) (P = 0.002). NRS at rest in the Continuous group on the second day after surgery was 3.0 ± 2.1, significantly lower than in the Single group (3.9 ± 1.8) (P = 0.04). The amount of food taken in the morning in the Continuous group was 61 % ± 37 %, which was significantly greater than in the Single group (35 % ± 41 %) (P = 0.004). The ROM of extension at 6 months postoperatively in the Continuous group was 47 ± 7°, which was significantly greater than in the Single group (43 ± 6°) (P = 0.02). The postoperative strength of the external rotator at 6 months in the Continuous group was 95 ± 33 N, significantly greater than in the Single group (78 ± 28 N) (P = 0.01). There was no significant difference in UCLA score at any time. Conclusion: The continuous interscalene block with ultrasound guidance in ARCR effectively relieved pain. The recovery of ROM for extension and the strength of the external rotator was better in the Continuous group.

Six-month safety and effectiveness of tofacitinib in patients with rheumatoid arthritis in Japan: Interim analysis of post-marketing surveillance.

OBJECTIVES: We evaluated the real-world safety/effectiveness of tofacitinib, an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA), in patients with RA in Japan registered in a post-marketing surveillance study. METHODS: This interim analysis included data from July 2013 to December 2018. Adverse events (AEs), serious AEs (SAEs), Simplified Disease Activity Index (SDAI)/Clinical Disease Activity Index (CDAI)/Disease Activity Score in 28 joints, erythrocyte sedimentation rate [DAS28-4(ESR)] scores, and rates of SDAI/CDAI/DAS28-4(ESR)-defined remission and low disease activity were analysed using 6 months of data. Risk factors for serious infections were assessed by multivariable analyses. RESULTS: Safety and disease activity were evaluated in 6866 and 6649 patients, respectively. Overall, 32.73%/7.37% of patients reported AEs/SAEs. Clinically important AEs with tofacitinib included serious infections/infestations [3.13% of patients; incidence rate (IR; patients with events) 6.91/100 patient-years (PY)], herpes zoster (3.63%; IR 8.02/100 PY), and malignancies (0.68%; IR 1.45/100 PY). SDAI/CDAI/DAS28-4(ESR) scores and remission/low disease activity rates improved over 6 months. Male sex, older age, Steinbrocker's stage IV, history of infection, and diabetes mellitus at baseline were independent risk factors for serious infection. CONCLUSIONS: In patients with RA receiving tofacitinib in Japan, safety was consistent with the reported profile, and disease activity improved over 6 months. STUDY IDENTIFIER: NCT01932372.

Feasibility of methotrexate discontinuation following tocilizumab and methotrexate combination therapy in patients with long-standing and advanced rheumatoid arthritis: a 3-year observational cohort study.

OBJECTIVES: Methotrexate (MTX) is associated with extensive side effects, including myelosuppression, interstitial pneumonia, and infection. It is, therefore, critical to establish whether its administration is required after achieving remission with tocilizumab (TCZ) and MTX combination therapy in patients with rheumatoid arthritis (RA). Therefore, the aim of this multicenter, observational, cohort study was to evaluate the feasibility of MTX discontinuation for the safety of these patients. METHODS: Patients with RA were administered TCZ, with or without MTX, for 3 years; those who received TCZ+MTX combination therapy were selected. After remission was achieved, MTX was discontinued without flare development in one group (discontinued [DISC] group, n = 33) and continued without flare development in another group (maintain [MAIN] group, n = 37). The clinical efficacy of TCZ+MTX therapy, patient background characteristics, and adverse events were compared between groups. RESULTS: The disease activity score in 28 joints-erythrocyte sedimentation rate (DAS28-ESR) at 3, 6, and 9 months was significantly lower in the DISC group (P < .05, P < .01, and P < .01, respectively). Further, the DAS28-ESR remission rate at 6 and 9 months and Boolean remission rate at 6 months were significantly higher in the DISC group (P < .01 for all). Disease duration was significantly longer in the DISC group (P < .05). Furthermore, the number of patients with stage 4 RA was significantly higher in the DISC group (P < .01). CONCLUSIONS: Once remission was achieved, MTX was discontinued in patients who responded favorably to TCZ+MTX therapy, despite the prolonged disease duration and stage progression.

Lower limb alignment in healthy Japanese adults.

BACKGROUND: Knowledge regarding the normal alignment of the lower limb is important when considering alignment for total knee arthroplasty. However, few studies have explored the lower limb alignment of healthy Japanese subjects. METHODS: Between July and October 2020, we performed whole leg standing radiography of 120 legs of 60 healthy adult Japanese volunteers aged <50 years in the closed-leg stance. The measurement parameters were hip knee ankle angle (positive for varus), percentage of constitutional varus (hip knee ankle angle ≥ 3°), mechanical axis deviation ratio, mechanical lateral distal femoral angle, medial proximal tibial angle, joint line convergence angle (positive for lateral opening), and tibial joint line angle (positive for medial inclination). RESULTS: The mean measured values for all volunteers, men and women, were as follows: hip knee ankle angle (°), 2.3, 2.6, and 2.0; mechanical axis deviation ratio, 35.8, 35.6, and 36.9; mechanical lateral distal femoral angle (°), 86.7, 87.0, and 86.7; medial proximal tibial angle (°), 85.6, 85.0, and 86.2; joint line convergence angle (°), 0.6, 0.3, and 0.8; and tibial joint line angle (°), -1.0, -0.7, -1.4, respectively. The percentage of constitutional varus was 35.8% overall, 35.8% in men and 35.3% in women. Only the medial proximal tibial angle was smaller in men than that in women (p = 0.003). CONCLUSIONS: The mechanical lateral distal femoral and medial proximal tibial angles were smaller, hip knee ankle angle was larger, and percentage of constitutional varus was higher in Japanese subjects than those reported for subjects in other countries. Our findings improve the understanding of Japanese-specific alignments when considering alignment for lower limb surgery, especially, total knee arthroplasty.

Decennial trends in hip fractures over 20 years in Yamagata Prefecture, Japan.

BACKGROUND: Hip fracture is among the most common injuries in elderly people. We aimed to investigate the decennial trends in hip fractures in patients ≥65 years of age. METHODS: A questionnaire was distributed to all hospitals with a Department of Orthopaedic Surgery in Yamagata Prefecture to collect data on hip fractures occurring in 1996, 2006 and 2016. RESULTS: The response rate was 100%. The total numbers of hip fractures in 1996, 2006 and 2016 were 665, 1169 and 1,728, respectively (crude incidence: 258, 373 and 494 per 100,000 person-year, respectively). Injuries frequently occurred in the early morning and daytime morning in 1996. In contrast, they frequently occurred in activity times (e.g., morning and afternoon) in 2006 and 2016. Among the patients, 80-90% were injured by simple falls, and 70-80% were injured indoors. The incidence of trochanteric fractures was approximately 1.8-1.9 times greater than incidence of neck fractures in all years. Especially, trochanteric fractures in females of ≥90 years of age markedly increased. The rate of surgical treatment was the same in 1996 and 2006, but was lower in 2016. In 1996, the percentage of independent walkers at discharge and 1 year later was almost the same. In 2006 and 2016, the rate of independent walkers was low at discharge, but increased 1 year later. The rate of discharge to home decreased gradually. The combined percentage of patients discharged to home and to rehabilitation institutions in 2006 and the percentage of patients who entered the regional referral clinical pathway in 2016 were both approximately 70%, with no marked changes observed. CONCLUSIONS: Hip fractures, especially trochanteric fractures in super-aged females, increased. Discharge to home decreased, and the use of the regional referral clinical pathway was widespread. Ambulation ability was reduced at discharge, but improved after 1 year.

Safety and effectiveness of baricitinib for rheumatoid arthritis in Japanese clinical practice: 24-week results of all-case post-marketing surveillance.

OBJECTIVES: To assess the safety and effectiveness of baricitinib treatment for rheumatoid arthritis (RA) in real-world clinical practice. METHODS: This ongoing all-case post-marketing surveillance study (starting September 2017) includes all patients with RA treated with baricitinib in Japan. Safety and effectiveness (disease activity) were assessed for 24 weeks. RESULTS: Safety analyses to February 2021 included 4731 patients (initial baricitinib dose: 4 mg/day, n = 3058; 2 mg/day, n = 1661; other, n = 12); 1059 (22.38%) were ≥75 years and 3362 (71.06%) previously received biologic therapy. The overall observational period was 1863.14 patient-years; 1174 (24.82%) patients discontinued baricitinib before Week 24, mostly for lack of effectiveness (n = 478; 10.10%). Adverse events occurred in 1271 (26.87%) patients [serious: 203 (4.29%); death: 18 (0.38%)]. The incidence of herpes zoster, hepatic function disorder, and serious infection was 3.09%, 2.77%, and 1.90%, respectively. Malignancy occurred in 17 patients (0.36%) and major adverse cardiovascular events in seven patients (0.15%). Among patients with effectiveness data, at least 26.57% (Boolean) achieved remission at Week 24. CONCLUSIONS: This large nationwide surveillance study evaluated the safety and effectiveness of 24 weeks of baricitinib for RA in real-world clinical practice. Continued surveillance of long-term safety is ongoing.

Combining Cylindrical Bone Graft and Headless Screw Fixation for Nonunion of the Medial Trochlea of the Elbow: A Case Report.

CASE: A 19-year-old handballer presented with elbow pain and nonunion of the medial trochlea of the elbow. He had undergone earlier surgery for an elbow injury at 6 years of age. Revision surgery for nonunion was performed using an extra-articular method combining cylindrical bone graft and headless screw fixation. Partial union was observed, and he resumed sports after 3 months, with his limb largely pain-free and functional. At the 21-month follow-up, bone healing was complete. CONCLUSIONS: Combining cylindrical bone graft and headless screw fixation using the extra-articular technique is an option for managing nonunion of the medial trochlea of the elbow.

Midterm results of endoscopically assisted first rib resection in the zero position for thoracic outlet syndrome.

OBJECTIVES: We have hypothesized that an endoscopically assisted transaxillary approach in the zero position would be able to improve visualization and allow safe surgery for thoracic outlet syndrome. METHODS: We performed surgery only for patients with certain objective findings, including blood flow disruption, low blood flow and accelerated blood flow in the subclavian artery demonstrated using Doppler sonography, narrowing of the scalene interval width between the anterior and middle interscalene muscles (interscalene base) or costoclavicular space demonstrated using Duplex ultrasonography or computed tomography angiography. The present study included 45 consecutive patients (50 limbs) who underwent endoscopic transaxillary first rib resection with scalenotomy and brachial plexus neurolysis. We assessed the intraoperative parameters, including the interscalene base, blood loss, operation time, patient satisfaction, preoperative and postoperative Quick Disability of the Arm, Shoulder and Hand and complications. RESULTS: The mean intraoperatively measured interscalene base width was 6.4 mm. All patients showed improvement after surgery. The outcome was excellent in 40% of cases, good in 48%, fair in 12% and poor in none. Pneumothorax was present in 6%. There were no other complications and no recurrences. Among patients who had been followed up for at least 2 years, the Quick Disability of the Arm, Shoulder and Hand score was significantly improved (42 before surgery vs 12 at final follow-up), especially in athletes relative to non-athletes (0.2 vs 16). The present approach achieved complete relief in 43% of cases overall (91% in athletes and 16% in non-athletes). CONCLUSIONS: Endoscopically assisted transaxillary first rib resection and brachial plexus neurolysis in the zero position are useful and safe for thoracic outlet syndrome, especially in athletes.

Evaluation of hindfoot and knee alignment by the hip-to-calcaneus view in patients with knee osteoarthritis and healthy individuals.

BACKGROUND: Hip-to-calcaneus (HC) view is a whole-leg standing view that can visualize the hindfoot in detail. The aim of this study was to investigate the reliability and validity of tibiocalcaneal angle in HC view (H-TCA) by comparing it with that in long axial view (L-TCA). We also verified whether periarticular knee alignment parameters, measured conventionally in whole-leg standing radiography, could be measured in HC view. METHOD: Sixty healthy volunteers and 61 patients with medial knee osteoarthritis were included. H-TCA was measured by two examiners in the healthy group, and intra-class correlation coefficients (ICCs) were evaluated. H-TCA and L-TCA were then measured in the healthy and osteoarthritis groups and correlated. Finally, we measured hip-knee-ankle angle, mechanical axis deviation ratio, mechanical lateral distal femoral angle, medial proximal tibial angle, and joint-line convergence angle in HC view and conventional whole-leg standing radiography to evaluate statistical differences and correlations. RESULTS: The intra-observer and inter-observer ICCs were 0.86 and 0.76, respectively. Correlation coefficients (r) between H-TCA and L-TCA were r = 0.87 in healthy group and r = 0.81 in osteoarthritis group, indicating a strong positive correlation in both groups. There was no significant difference in periarticular knee alignment parameters between HC view and conventional whole-leg radiography. CONCLUSIONS: Hindfoot evaluation in HC view showed high intra-observer and inter-observer reliabilities and strong positive correlation with TCA in long axial view. By using HC view before knee surgery, such as total knee arthroplasty, other necessary alignments can be evaluated simultaneously.

The Effect of Elbow and Forearm Position on the Resisted Wrist Extension Test and Incidence of Sensory Disturbance of the Superficial Radial Nerve in Patients with Lateral Epicondylitis.

Background: The aim of this study is to determine the effect of elbow and forearm position on the resisted wrist extension test (RWET) in patients with lateral epicondylitis. We also looked at the incidence of associated sensory disturbance of the superficial radial nerve (SRN) and the effect of treatment of lateral epicondylitis on sensory disturbance. Methods: Sixty-three consecutive patients (68 limbs) with lateral epicondylitis and an equal number of age and gender matched volunteers were investigated. Patients with lateral epicondylitis were subdivided into two groups based on history of corticosteroid injection. We performed the RWET in four limb positions namely elbow extended and forearm pronated (EP), elbow flexed and forearm pronated (FP), elbow extended and forearm supinated (ES), elbow flexed and forearm supinated (FS). Sensory disturbance in the SRN was assessed using a Wartenberg pin wheel. Results: The positivity rate of the RWET was significantly higher in the EP position (100%) compared to the FP (66%), ES (62%) and the FS (24%) positions in limbs with lateral epicondylitis. The RWET was positive only in one subject in the EP position in the control group (1.5%). Sensory disturbance in the SRN territory was present in 63.2% of limbs and only two subjects (2.9%) in the control group. The incidence of sensory disturbance was significantly higher (74.5% vs. 48.3%, p < 0.05) in patients who did not have a corticosteroid injection. Conclusions: The sensitivity and specificity of the RWET is better when it is performed with the elbow in extension with the forearm pronated (EP); 63.2% of limbs with lateral epicondylitis were noted to have an associated sensory disturbance of the SRN and a corticosteroid injection seems to decrease the incidence of sensory disturbances. Level of Evidence: Level II (Diagnostic).

Effectiveness of Bone Marrow-Derived Platelet-Rich Fibrin on Rotator Cuff Healing in a Rabbit Degenerative Model.

BACKGROUND: Platelet-rich fibrin (PRF) is a second-generation platelet concentrate. Although peripheral blood-derived PRF (P-PRF) is commonly applied in biological augmentation, there is no report about the therapeutic effect of bone marrow-derived PRF (BM-PRF) for degenerative rotator cuff tears (RCTs). PURPOSE/HYPOTHESIS: To examine the effects of platelet-rich plasma (PRP), P-PRF, and BM-PRF during rotator cuff repair (RCR) in degenerative RCTs in rabbits. We hypothesized that BM-PRF would accelerate the bone-tendon healing after RCR. STUDY DESIGN: Controlled laboratory study. METHODS: Degenerative RCT models were created 2 weeks before beginning the study, and 68 juvenile rabbits were divided into 4 groups: the control, PRP, P-PRF, and BM-PRF groups. RCR without augmentation was done in the control group. PRP was prepared by centrifuging peripheral blood twice using a plastic tube. P-PRF and BM-PRF were prepared by centrifuging peripheral blood and bone marrow, respectively, using a glass tube. Rabbits from PRP, P-PRF, and BM-PRF groups were administered the augmentation in a similar fashion for RCR, between the rotator cuff and the footprint of the humerus. At 4, 8, and 12 weeks, rabbits were euthanized and histologically assessed using hematoxylin and eosin staining, Alcian blue staining, and immunohistochemical staining for type I and III collagen. The sections were also evaluated with immunofluorescence staining of vascular endothelial growth factor (VEGF) at 4 weeks. RESULTS: The continuity was significantly better in the BM-PRF group at 4 weeks (P < .05). Immunofluorescence staining demonstrated that VEGF-positive stained cells were significantly greater in the BM-PRF group than in the control group (P < .01). The modified tendon maturing score was significantly greater in the BM-PRF group than in the control and PRP groups at 12 weeks (P < .05). There was no significant difference in the modified tendon maturing score of the P-PRF group compared with the control group. CONCLUSION: The rabbit model of degenerative RCTs demonstrated that RCR combined with BM-PRF enhanced tendon-bone continuity and increased the VEGF-positive cells at 4 weeks and obtained preferable tendon-bone maturation at 12 weeks. CLINICAL RELEVANCE: RCR augmented with BM-PRF has the potential to improve clinical outcomes for RCTs.

MRI Grading Scale Predicts Ambulatory Function After Radiotherapy for Metastatic Spinal Cord Compression: A Prospective Single-Institution Observational Study.

INTRODUCTION: Although magnetic resonance imaging (MRI) is an important modality for the diagnosis of metastatic spinal cord compression (MSCC), there are only a few reports on MSCC findings and symptoms after radiotherapy. We aimed to reveal the factors related to ambulatory function after treatment, including the MRI findings, in a prospective observational study. METHODS: Patients with suspected MSCC who were treated with radiotherapy were included in this study. Orthopedic surgeons evaluated the neurological function according to the Frankel grade. All patients underwent spinal MRI, and the degree of spinal cord compression was assessed by a radiologist and a radiation oncologist using an MRI grading scale. One month after treatment, orthopedic surgeons reassessed the Frankel grade. Twenty-three patients who were evaluated 1 month after radiotherapy were included in the analysis. RESULTS: Before radiotherapy, 17 patients were ambulatory and six were unable to walk. Furthermore, 13 patients were diagnosed with grade 3 compression on MRI (spinal cord compression with no cerebrospinal fluid seen on axial T2-weighted imaging). Patients with grade 3 MSCC were significantly more likely to be non-ambulatory at 1 month. CONCLUSIONS: The MRI grading scale for MSCC may be a prognostic factor for ambulatory function after radiotherapy. MRI findings could aid in determining the indication for radiotherapy.

Conservative treatment for stable osteochondritis dissecans of the elbow before epiphyseal closure: effectiveness of elbow immobilization for healing.

BACKGROUND AND HYPOTHESIS: Stable lesions of osteochondritis dissecans (OCD) of the capitellum have been treated with activity restriction (AR), and the complete healing requires 1 or 2 years. Little is known about the effectiveness of elbow immobilization. We hypothesized that elbow immobilization would have positive effects on healing of stable OCD. METHODS: The study subjects were 43 patients (mean age: 12.2 years) with 43 stable OCD lesions of the prematured elbow (mean skeletal age score: 17.1 points of 0-27 points system). The subjects were divided into 3 groups: group A, AR without elbow immobilization, 22 cases; group B, splint (mean: 8.8 weeks) followed by AR, 9 cases; and group C, cast (mean: 3.7 weeks) followed by splint (mean: 7.3 weeks) and AR, 12 cases. The mean nonoperative observation period was 17.5 months (minimum three months). On anteroposterior radiographs of the elbow at 45 degrees of flexion, 5 observers independently assessed the healing of the capitellum, and the interobserver and intraobserver reliabilities were examined. The differences in outcomes among 3 groups were also examined. RESULTS: The interobserver and intraobserver reliabilities of the radiographic assessment were almost perfect (Cohen kappa value: 0.82 and 0.91, respectively). There were no significant differences in age, sports played, or stage of the lesion before the treatment. The proportion of patients returning to sports and the mean period required were 77% and 8.2 months in group A, 78% and 5.7 months in group B, and 83% and 4.4 months in group C, respectively. The proportion of patients showing ossification in the central aspect of the capitellum and the mean period required were 67% and 8.2 months in group A, 63% and 4.9 months in group B, and 91% and 1.9 months in group C, respectively. The proportion of patients showing complete healing and the mean period required were 41% and 16.4 months in group A, 67% and 7.0 months in group B, and 92% and 5.5 months in group C, respectively. Compared to group A, group C showed a significantly earlier return to sports (P = .034), a significantly shorter period required for ossification (P < .001), and significantly higher proportion of patients with complete healing (P = .012) within a significantly shorter period (P = .009). CONCLUSION: Elbow immobilization had positive effects on healing and enabled both an early return to sports and complete healing. Cast immobilization is recommended as a first choice of nonoperative treatment for stable OCD lesions of the elbow before epiphyseal closure.

Pathogenesis of follicular thymic hyperplasia associated with rheumatoid arthritis.

Lymphoproliferative disorders may occur in patients with rheumatoid arthritis (RA) who are treated with methotrexate. However, follicular thymic hyperplasia (FTH) associated with RA (FTH-RA) is generally not considered a lymphoproliferative disorder. To investigate the pathogenesis of FTH-RA, we examined 12 cases of FTH involving thymic enlargement, four of FTH involving RA and eight of FTH involving myasthenia gravis (MG). Increased numbers and larger germinal center (GC) size were observed in FTH-RA group. The percentage of distorted GCs was 13.3% in FTH-RA group and 3.25% in FTH associated with MG (FTH-MG) group. A greater meshwork of follicular dendritic cells was observed in the GCs of FTH-RA group. Positive indices of CD27+ cells and PD-1+ cells per GC in FTH-RA group were significantly higher than those in FTH-MG group, though positive indices of CD68+ cells and CD163+ cells were similar. Myoid cell proliferation, as evaluated by α-SMA, tenascin-C, and l-caldesmon expression, was significantly increased in the FTH-RA group compared with the FTH-MG group. These results suggest that FTH should be considered in patients with RA treated with methotrexate. The pathogenesis of FTH-RA includes GC expansion and increased numbers of memory B cells, follicular helper T cells, and myoid cells, indicating humoral immunity activation.