Does vacuum phenomenon at non-fused discs affect the postoperative course after transforaminal lumbar interbody fusion in patients showing a positive value of difference in lumbar lordosis?

INTRODUCTION: Preoperative difference in lumbar lordosis (DiLL) was associated with surgical outcomes after single-level transforaminal lumbar interbody fusion (TLIF). Patients with DiLL>0 (DiLL (+)) tended to show worse clinical outcomes and postoperative greater restoration of lumbar lordosis (LL). However, some patients with DiLL (+) showed relatively good outcomes and no postoperative LL restration. This study aimed to elucidate whether the lumbar intervertebral disc vacuum phenomenon (VP) influences clinical course after single-level TLIF in patients with DiLL (+) and DiLL (-). METHODS: Patients with lumbar spinal stenosis and degenerative spondylolisthesis treated with single-level TLIF were included. Pre- and postoperative LL were measured, and postoperative LL improvement was calculated. Preoperative DiLL was calculated as preoperative supine LL minus standing LL. Severity of VP at the non-fused discs (SVP (non-FS)) was evaluated using preoperative reconstructed computed tomography imaging. Clinical outcomes were assessed using the Oswestry disability index, visual analogue scale (VAS; low back pain (LBP), lower-extremity pain, numbness, and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Patients were stratified by the median preoperative SVP (non-FS) score into severe and mild VP groups in patients with DiLL (+) or DiLL (-), and their surgical outcomes were compared. RESULTS: Overall, 89 patients were included. In patients with DiLL (+) (n = 37), patients with severe VP showed worse clinical outcomes, particulary for LBP and DiLL (+) patients with mild VP showed greater LL improvement (6.5° ± 10.0°). In patients with DiLL(-) (n = 52), patients with severe VP showed worse clinical outcomes, particularly for LBP and no differences in preoperative, postoperative, and improvement of LL were observed between two groups. CONCLUSION: Patients with DiLL (+) and DiLL (-) showed different clinical courses depending on VP severity at the non-fused discs after single-level TLIF.

Postoperative change in lumbopelvic alignment after short-segment transforaminal lumbar interbody fusion is related to preoperative postural difference in lumbar lordosis.

BACKGROUND: Postoperative changes in lumbar lordosis (LL) after transforaminal lumbar interbody fusion (TLIF) and the related factors are not well-understood. Recently, the preoperative difference in LL between standing and supine positions (DiLL) was proposed as a factor for predicting postoperative radiologic outcomes after short-segment TLIF. This study investigated the influence of DiLL on mid-term radiological outcomes after short-segment TLIF. METHODS: Sixty-six patients with lumbar degenerative disease treated with short-segment TLIF (1-2 levels) who underwent lumbar spine standing radiographs at 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years postoperatively were divided into DiLL (+) and DiLL (-) groups (preoperative DiLL ≥0° and <0°, respectively). Associations between the postoperative change in LL and DiLL and clinical outcomes (Oswestry disability index (ODI) and Nakai score) were evaluated. RESULTS: Temporary restoration of LL (+4.5°) until 1 year postoperatively and a subsequent decrease in LL from 1 to 5 years postoperatively (-5.3°) was observed in the DiLL (+) group. No postoperative change in LL was observed in the DiLL (-) group. Postoperative changes in LL were mainly observed in non-fused segments. The postoperative change in LL (ΔLL) until 1 year postoperatively had a significant positive association with DiLL (p = 0.00028), whereas ΔLL from 1 to 5 years postoperatively showed a significant negative association with DiLL (p = 0.010) and a positive association with Nakai score (p = 0.028). ΔLL until 5 years postoperatively showed a significant positive association with postoperative ODI improvement (p = 0.011). CONCLUSIONS: DiLL (+) patients showed a specific time course with temporary LL restoration until 1 year postoperatively and a subsequent decrease in LL from 1 to 5 years postoperatively. Patients with larger postoperative increase in LL until 5 years postoperatively and lesser decrease in LL from 1 to 5 years postoperatively tended to show better mid-term clinical outcomes.

The influence of COVID-19 epidemic on the number of orthopaedic surgeries in Japan.

BACKGROUND: There is limited data on the impact of COVID-19 epidemic on the number of orthopaedic surgeries in Japan. METHODS: We conducted a nationwide hospital survey asking for the monthly number of orthopaedic surgeries performed at each facility from January 2019 to June 2021. Those facilities that had performed at least 100 surgeries in 2019 were included for analyses. The facilities were further grouped by prefecture and by hospital characteristics. A brief health economic evaluation was also performed. Risk ratios were compared using univariate analyses with P < 0.05 considered statistically significant. RESULTS: Questionnaire was sent to 1988 hospitals with 1671 hospitals (84%) responding. The survey data indicated a total number of orthopaedic surgeries decreased in 2020 compared to 2019 (1,061,541 vs 1,119,955 P < 0.01), and also for the first six months of 2021 compared to the same period in 2019 (530,388 vs 550,378 P < 0.01). In 2020, over 50% of all facilities in nearly all of the prefectures saw a decline in surgical procedures. The risk of incurring more than a 25% decease in the number of surgeries was significantly higher in 2020 for class I designated medical institutions compared to those that were not designated for any types of infectious diseases among the institutions with a tertiary emergency medical center in 2020 (crude risk ratio 2.9: 95% CI 1.2-7.4, p = 0.02) and in 2021 (crude risk ratio 4.7: 95% CI 1 0.9-12.1, p < 0.01). The estimated total nationwide decrease of revenue were in the range of approximately ¥29.2 to ¥116.8 billion per year for orthopaedic surgeries alone. CONCLUSION: There was a statistically significant decrease in the number of orthopaedic surgeries in Japan. The magnitude of the decline varied by prefectures and hospital characteristics, with the greater impact imposed on medical institutions with higher classification functions. The estimated immediate health economic impact was sizable.

Feasibility of the fat-suppression image-subtraction method using deep learning for abnormality detection on knee MRI.

Purpose: To evaluate the feasibility of using a deep learning (DL) model to generate fat-suppression images and detect abnormalities on knee magnetic resonance imaging (MRI) through the fat-suppression image-subtraction method. Material and methods: A total of 45 knee MRI studies in patients with knee disorders and 12 knee MRI studies in healthy volunteers were enrolled. The DL model was developed using 2-dimensional convolutional neural networks for generating fat-suppression images and subtracting generated fat-suppression images without any abnormal findings from those with normal/abnormal findings and detecting/classifying abnormalities on knee MRI. The image qualities of the generated fat-suppression images and subtraction-images were assessed. The accuracy, average precision, average recall, F-measure, sensitivity, and area under the receiver operator characteristic curve (AUROC) of DL for each abnormality were calculated. Results: A total of 2472 image datasets, each consisting of one slice of original T1WI, original intermediate-weighted images, generated fat-suppression (FS)-intermediate-weighted images without any abnormal findings, generated FS-intermediate-weighted images with normal/abnormal findings, and subtraction images between the generated FS-intermediate-weighted images at the same cross-section, were created. The generated fat-suppression images were of adequate image quality. Of the 2472 subtraction-images, 2203 (89.1%) were judged to be of adequate image quality. The accuracies for overall abnormalities, anterior cruciate ligament, bone marrow, cartilage, meniscus, and others were 89.5-95.1%. The average precision, average recall, and F-measure were 73.4-90.6%, 77.5-89.4%, and 78.4-89.4%, respectively. The sensitivity was 57.4-90.5%. The AUROCs were 0.910-0.979. Conclusions: The DL model was able to generate fat-suppression images of sufficient quality to detect abnormalities on knee MRI through the fat-suppression image-subtraction method.

Sweat-gland carcinoma with neuroendocrine differentiation (SCAND): a clinicopathologic study of 13 cases with genetic analysis.

Low-grade neuroendocrine carcinoma of the skin (LGNECS) was proposed in 2017 as a new primary cutaneous neoplasm with neuroendocrine differentiation; however, it is not yet well known due to its rarity. Herein, we perform a detailed clinicopathologic analysis of 13 cases as well as panel DNA sequencing in three cases. The study included 12 males and 1 female with a median age of 71 (43-85) years. All lesions occurred on the ventral trunk. The mean tumor size was 2.2 (0.8-11.0) cm. The histopathology resembled that of well-differentiated neuroendocrine tumors (NETs) in other organs, but intraepidermal pagetoid spreading was seen in 8 (61.5%) cases and stromal mucin deposits in 4 (30.8%). Immunoreactivity for CK7, CK19, EMA, BerEP4, CEA, chromogranin A, synaptophysin, INSM1, GCDFP15, GATA3, ER, and bcl-2 were present in varying degrees in all tested cases. PTEN c.165-1G>A splice site mutation was detected by panel sequencing in one case, and GATA3 P409fs*99 and SETD2 R1708fs*4 in another case. Lymph node metastasis was seen significantly in cases with tumor size >2.0 cm [8/8 (100%) vs. 1/5 (20%)]. All three cases with size >3.0 cm were in unresectable advanced-stage [3/3 (100%) vs. 1/10 (10%)], and two of the three patients succumbed to the disease. The two cases of death revealed mild nuclear atypia (mitosis: 1/10 HPFs) and moderate nuclear atypia (2/10 HPFs). Thus, tumor size would be a better prognostic factor than nuclear atypia, mitotic count, and Ki67 index, unlike in NETs. These clinicopathologic and immunohistochemical features would represent the characteristics as skin adnexal tumors with apocrine/eccrine differentiation rather than NETs; therefore, we rename it as sweat-gland carcinoma with neuroendocrine differentiation (SCAND).

Diagnostic Value of Advanced Metal Artifact Reduction Magnetic Resonance Imaging for Periprosthetic Joint Infection.

MATERIALS AND METHODS: Magnetic resonance imaging around metal joint prostheses including multiacquisition variable-resonance image combination selective at 1.5 T (from April 2014 to August 2020) was retrospectively evaluated by 2 radiologists for detection of abnormal findings (joint effusion, capsular thickening, pericapsular edema, soft-tissue fluid collection, soft-tissue edema, bone marrow edema pattern around the implant [BME pattern], lymphadenopathy, and others) and overall image impression for PJI. Regarding the soft-tissue fluid collection, presence of communication to the joint or capsular-like structure was evaluated. Clinical assessments were recorded. Positive predictive values (PPVs), negative predictive values (NPVs), and odds ratios (ORs) for PJI were calculated for the abnormal findings. Overall image impression for PJI was evaluated. χ2, Fisher exact, t, and Mann-Whitney U tests and receiver operating characteristic analysis were used. Interobserver agreement was assessed with κ statistics. RESULTS: Forty-three joints in 36 patients (mean ± SD age, 75.4 ± 8.8 years; 30 women; hip [n = 29], knee [n = 12], and elbow [n = 2]) were evaluated. Eighteen joints (42%) were clinically diagnosed as PJI. The findings suggesting PJI were capsular thickening (PPV, 70%; NPV, 90%; OR, 20.6), soft-tissue fluid collection (PPV, 81%; NPV, 81%; OR, 19.1), soft-tissue edema (PPV, 67%; NPV, 89%; OR, 17), pericapsular edema (PPV, 76%; NPV, 81%; OR, 13.7), and joint effusion (PPV, 55%; NPV, 100%; OR, 12). Soft-tissue fluid collection without capsular-like structure (PPV, 83%; NPV, 74%; OR, 14.4) or with communication to the joint (PPV, 75%; NPV, 71%; OR, 7.3) suggested PJI. The combinations of joint effusion, capsular thickening, pericapsular edema, soft-tissue fluid collection, and soft-tissue edema highly suggested PJI. Regarding the BME pattern, the combination with soft-tissue edema raised the possibility of PJI (PPV, 73%; NPV, 69%; OR, 5.9). Regarding the interobserver agreements for each abnormal finding, κ values were 0.60 to 0.77. Regarding the overall image impression, weighted κ value was 0.97 and areas under the receiver operating characteristic curve were 0.949 (95% confidence interval, 0.893-1.005) and 0.926 (95% confidence interval, 0.860-0.991) with no significant difference (P = 0.534). CONCLUSIONS: The findings suggesting PJI were capsular thickening, soft-tissue fluid collection, soft-tissue edema, pericapsular edema, and joint effusion. The combinations of them highly suggested PJI. Regarding the BME pattern, the combination with soft-tissue edema raised the possibility of PJI.

Brain Diseases and Fall-Related Surgery in Older Persons.

BACKGROUND: It is known that age-related brain symptoms (gait difficulty and dementia) increase the likelihood of fall-related surgery. In contrast, it is not known which types of brain disease underlie such symptoms most. OBJECTIVE: The aim of this study was to correlate brain diseases with the types of surgeries performed at our hospital for patients who had fallen. METHODS: This was a retrospective study at a multifaculty university hospital in Japan, with a 12-month recruiting period, a follow-up period of 3.0 ± 2.5 weeks, and ≥1×/week visits. We assembled a neurogeriatric team to diagnose brain diseases with the use of brain imaging to the extent possible and correlated the diagnoses with types of fall-related surgery. RESULTS: Fall-related surgery was conducted by the orthopedics (OP) and neurosurgery (NS) faculties (total n = 124) at a ratio of about 2 to 1. The underlying brain diseases differed by faculty; for OP, surgery was most commonly performed in patients with a combination of white matter disease (WMD) and Alzheimer's disease (AD) (79%) followed by dementia with Lewy bodies. In contrast, for NS, the most common surgery was for patients with alcoholism (50%) followed by a combination of WMD and AD. CONCLUSION: Fall-related surgery was performed by the OP and NS faculties at a 2 to 1 ratio. The major underlying brain diseases were a combination of WMD and AD (79%) for OP and alcoholism (50%) for NS.

Three-year clinical and radiological results of a cruciate-retaining type of the knee prosthesis with anatomical geometry developed in Japan.

BACKGROUND: The FINE total knee was developed in Japan and clinical use began in 2001. It has unique design features, including an oblique 3o femorotibial joint line that reproduces anatomical geometry. Although 20 years have passed since the FINE knee was clinically used for the first time in Japan, a formal clinical evaluation including patient-reported and radiographic outcomes has not been undertaken. METHODS: A total of 175 consecutive primary cruciate-retaining (CR)-FINE total knee arthroplasties (TKAs) at our hospital between February 2015 and March 2017 were included in this study. Three years postoperatively, range of motion (ROM), Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Forgotten Joint Score (FJS) were recorded and compared with preoperative scores. Radiographic analyses including mechanical alignment, component alignment, and incidence of radiolucent lines also were undertaken based on the radiographs 3 years postoperatively. RESULTS: One-hundred twenty-two knees (70%) were available for 3-year follow-up data using KOOS, except for the sports subscale. Postoperative KOOS-symptom, -pain and -ADL were > 85 points, but KOOS-sports, -QOL and FJS were less satisfactory. ROM, KSS and all the subscales of KOOS were significantly improved compared with preoperative scores. Postoperative mean FJS was 66 and was significantly correlated with all the subscales of KOOS, but not with postoperative ROM. Radiolucent lines ≧1 mm wide were detected in five knees (4.1%). There were no major complications needing revision surgeries. CONCLUSIONS: Patient-reported outcomes (PROs) for symptoms, pain and ADL after the CR-FINE TKA were generally improved, but those for sports, QOL and FJS were improved less. The incidence of radiolucent lines was rare but detected around the femoral components. With the mid- to long-term follow-up, improvements of surgical technique will be necessary to achieve better PROs from patients receiving the FINE knee.

Characteristics of relief and residual low back pain after discectomy in patients with lumbar disc herniation: analysis using a detailed visual analog scale.

BACKGROUND: Several authors have reported favorable results in low back pain (LBP) for patients with lumbar disc herniation (LDH) treated with discectomy. However, detailed changes over time in the characteristics and location of LBP before and after discectomy for LDH remain unclear. To clarify these points, we conducted an observational study to determine the detailed characteristics and location of LBP before and after discectomy for LDH, using a detailed visual analog scale (VAS) bilaterally. METHODS: We included 65 patients with LDH treated by discectomy in this study. A detailed VAS for LBP was administered with the patient under 3 different conditions: in motion, standing, and sitting. Bilateral VAS was also administered (affected versus opposite side) for LBP, lower extremity pain (LEP), and lower extremity numbness (LEN). The Oswestry Disability Index (ODI) was used to quantify clinical status. Changes over time in these VAS and ODI were investigated. Pfirrmann grading and Modic change as seen by magnetic resonance imaging (MRI) were reviewed before and 1 year after discectomy to determine disc and endplate condition. RESULTS: Before surgery, LBP on the affected side while the patients were in motion was significantly higher than LBP while they were sitting (p = 0.025). This increased LBP on the affected side in motion was improved significantly after discectomy (p < 0.001). By contrast, the residual LBP while sitting at 1 year after surgery was significantly higher than the LBP while they were in motion or standing (p = 0.015). At 1 year following discectomy, residual LBP while sitting was significantly greater in cases showing changes in Pfirrmann grade (p = 0.002) or Modic type (p = 0.025). CONCLUSIONS: Improvement of LBP on the affected side while the patient is in motion suggests that radicular LBP is improved following discectomy by nerve root decompression. Furthermore, residual LBP may reflect increased load and pressure on the disc and endplate in the sitting position.

Good response to methotrexate is associated with a decrease in the gene expression of ABCG2, a drug transporter, in patients with rheumatoid arthritis.

OBJECTIVES: Methotrexate (MTX) is used as an anchor drug in the treatment of rheumatoid arthritis (RA), although more than a half of the patients with RA require additional treatments. We designed a prospective study involving two medical centers in Japan to examine the association between the expression of MTX-related genes including a drug transporter ATP-binding cassette sub-family G member 2 (ABCG2) gene and the clinical response to MTX in MTX-naive patients with RA. METHODS: The primary endpoint of this study was good response based on the European League Against Rheumatism (EULAR) response criteria by Disease Activity Score using 28-joint count (DAS28). We evaluated the association between the baseline expression of six genes involved in the intracellular pharmacokinetics of MTX, including ABCG2, as well as their temporal changes, and the clinical response at week 12 from the initiation of MTX. RESULTS: Based on the clinical response at 12 weeks after the initiation of MTX, 24 patients were classified into good responders (n = 9) and non-good responders (n = 15; 10 moderate responders and 5 non-responders) groups. A univariate logistic regression analysis of the baseline gene expression levels to predict the EULAR good response at week 12 showed a significant association with ABCG2 expression alone. Furthermore, the rate of baseline expression of ABCG2 mRNA above the cut-off value determined using a receiver operating characteristic curve was higher in good responders than in non-good responders (p = .012). Moreover, ABCG2 expression decreased in almost all good responders, but not in non-good responders, after MTX treatment for 12 weeks (median -76% vs. +41% from baseline, respectively; p = .011). The ABCG2 expression level did not correlate with DAS28 at baseline or week 12. CONCLUSIONS: Our study revealed that good response to MTX is associated with a decrease in the expression of ABCG2 in patients with RA.

Predicting clinical outcomes after total knee arthroplasty from preoperative radiographic factors of the knee osteoarthritis.

BACKGROUND: Total knee arthroplasty (TKA) is the major surgical treatment for end-stage osteoarthritis (OA). Despite its effectiveness, there are about 20% of patients who are dissatisfied with the outcome. Predicting the surgical outcome preoperatively could be beneficial in order to guide clinical decisions. METHODS: One-hundred and ten knees of 110 consecutive patients who underwent TKAs for varus knees resulting from OA were included in this study. Preoperative varus deformities were evaluated by femorotibial angle (FTA), medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA), and classified as a severe varus (SV) or a mild varus (MV) group. The osteophyte score (OS), which we developed originally, was also calculated based on the size of the osteophytes and classified as groups with more or less osteophytes. We compared preoperative and 1-year postoperative range of motion, the Knee Society Score, and Japanese Knee injury Osteoarthritis Outcome Score (KOOS) between SV and MV groups (varus defined by FTA, MPTA, or LDFA), in each group with more or less osteophytes. RESULTS: When varus deformities were defined by FTA, regardless of OS, postoperative KOOS subscales and/or the improvement rates were significantly higher in the SV group than in the MV group. When varus defined by MPTA, regardless of OS, there were no significant differences in postoperative KOOS subscales between groups. However, when varus defined by LDFA, scores for pain, activities of daily living (ADL), and quality of life (QOL) on postoperative KOOS and/or the improvement rates were significantly higher in the SV group than in the MV group only in patients with less osteophytes. No significant differences were found between groups in patients with more osteophytes. CONCLUSIONS: We classified OA types by radiographic measurements of femur and tibia in combination with OS. Postoperative patient-reported outcomes were better in patients with SV knees but were poor in patients with knees with MV deformity and less osteophytes.

Serum oxidative stress influences neurological recovery after surgery to treat acutely worsening symptoms of compression myelopathy: a cross-sectional human study.

BACKGROUND: Recent reports indicate that oxidative stress induced by reactive oxygen species is associated with the pathobiology of neurodegenerative disorders that involve neuronal cell apoptosis. Here we conducted a cross-sectional study to evaluate serum levels of oxidative stress in cervical compression myelopathy. METHODS: Thirty-six serum samples were collected preoperatively from patients treated for acutely worsening compression myelopathy (AM) and chronic compression myelopathy (CM). Serum levels of oxidative stress markers were evaluated by measuring derivatives of reactive oxygen metabolites (ROM), which reflect concentrations of hydroperoxides. ROM in healthy individuals range from 250 to 300 (U. CARR), whereas ROM >340-400 and > 400 define moderate and severe levels of oxidative stress, respectively. Difference of ROM by the cause of disorders whether cervical spondylotic myelopathy (CSM) or cervical ossification of longitudinal ligament (OPLL), correlations between ROM and patient age, body mass index (BMI), history of smoking, existence of diabetes were examined. Neurological evaluations according to Japanese Orthopaedic Association (JOA) scores were performed and correlated with ROM. RESULTS: ROM increased to 349.5 ± 54.8, representing a moderate oxidative stress, in CM samples. ROM increased to 409.2 ± 77.9 in AM samples, reflecting severe oxidative stress which were significantly higher than for CM samples (p < 0.05). There was no significant difference by the cause of disorders (CSM or OPLL). ROM were significantly increased in AM serum samples from female patients versus AM male and CM patients (p < 0.05). There were no correlations between ROM and age, BMI, history of smoking, and existence of diabetes. A negative correlation between ROM and recovery rate of JOA score (R2 = 0.454, p = 0.047) was observed in the AM group. CONCLUSIONS: Although moderate oxidative stress was present in patients with CM, levels of oxidative stress increased in severity in patients with AM. These results suggest that postsurgical neurological recovery is influenced by severe oxidative stress in AM.

Unilateral laminectomy for bilateral decompression improves low back pain while standing equally on both sides in patients with lumbar canal stenosis: analysis using a detailed visual analogue scale.

BACKGROUND: Unilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis (LSS) is a less invasive technique compared to conventional laminectomy. Recently, several authors have reported favorable results of low back pain (LBP) in patients of LSS treated with ULBD. However, the detailed changes and localization of LBP before and after ULBD for LSS remain unclear. Furthermore, unsymmetrical invasion to para-spinal muscle and facet joint may result in the residual unsymmetrical symptoms. To clarify these points, we conducted an observational study and used detailed visual analog scale (VAS) scores to evaluate the characteristics and bilateral changes of LBP and lower extremity symptoms. METHODS: We included 50 patients with LSS treated with ULBD. A detailed visual analogue scale (VAS; 100 mm) score of LBP in three different postural positions: motion, standing, and sitting, and bilateral VAS score (approached side versus opposite side) of LBP, lower extremity pain (LEP), and lower extremity numbness (LEN) were measured. Oswestry Disability Index (ODI) was used to quantify the clinical improvement. RESULTS: Detailed LBP VAS score before surgery was 51.5 ± 32.5 in motion, 63.0 ± 30.1 while standing, and 37.8 ± 31.8 while sitting; and showed LBP while standing was significantly greater than LBP while sitting (p < 0.01). After surgery, LBP while standing was significantly improved relative to that while sitting (p < 0.05), and levels of LBP in the three postures became almost the same with ODI improvement. Bilateral VAS scores showed significant improvement equally on both sides (p < 0.01). CONCLUSIONS: ULBD improves LBP while standing equally on both sides in patients with LCS. The improvement of LBP by the ULBD surgery suggests radicular LBP improved because of decompression surgery. Furthermore, the symmetric improvement of LBP by the ULBD surgery suggests unsymmetrical invasion of the paraspinal muscles and facet joints is unrelated to residual LBP.

Superior graft maturation after anatomical double-bundle anterior cruciate ligament reconstruction using the transtibial drilling technique compared to the transportal technique.

PURPOSE: To evaluate and compare the femoral tunnel aperture position, graft bending angle and the magnetic resonance imaging (MRI) graft signal intensity after anatomical double-bundle anterior cruciate ligament (ACL) reconstruction between transtibial and transportal drilling techniques of the femoral tunnel. METHODS: Eighty-seven patients who underwent anatomic double-bundle ACL reconstruction with hamstring tendon autograft between January 2012 and December 2014 were included in this retrospective study. Forty-one patients underwent reconstruction using a transportal technique (TP group) and 46 patients underwent reconstruction using a transtibial technique (TT group). The anteromedial (AM) femoral aperture position and the graft bending angle were assessed using transparent three-dimensional CT 2 weeks postoperatively. MRI assessment was performed with proton density-weighted images in an oblique coronal plane 6 and 12 months postoperatively. Signal/noise quotient was calculated for two specific graft sites (femoral tunnel site and mid-substance site). Femoral aperture position, the graft bending angle and signal/noise quotient were compared between the TP and TT groups. RESULTS: There was no significant difference in the aperture position between the two groups. The graft bending angle of the AM tunnel in the axial plane was significantly greater in the TP group (p < 0.001). On the other hand, the TP group had a significantly more acute angle in the coronal plane (p < 0.001). There was no significant difference at either site in the signal/noise quotient of the graft between the two groups at 6 months. However, the TT group had a lower signal/noise quotient at 12 months at both sites (femoral aperture: p = 0.04, mid-substance: p = 0.004). CONCLUSION: There was a significant difference in signal/noise quotient between the two drilling techniques 12 months postoperatively. There was no significant difference in femoral tunnel aperture position between the two groups. However, graft bending angle at the femoral tunnel aperture was significantly different between the two groups, indicating the possibility that graft bending angle is a factor that influences graft maturation. This indicates that the TT technique has an advantage over the TP technique in terms of graft maturation.

Predictive factors for radiographic progression of large joint damage in patients with rheumatoid arthritis treated with biological disease-modifying antirheumatic drugs (bDMARDs): Results of 3 to 4 years of follow-up.

Objectives: Little information is available regarding long-term follow-up of radiographic progression of damage (RPD) to large joints during treatment of rheumatoid arthritis (RA) with biological disease-modifying antirheumatic drugs (bDMARDs). We evaluated 3- to 4-year follow-up results and the associations between RPD and patient background and Larsen grade (LG) of joints.Methods: Seventy-one RA patients receiving bDMARDs for 3 to 4 years or who achieved bDMARD-free status were included. The mean age and disease duration at the start of bDMARDs were 62.4 years and 10.8 years, respectively. A total of 314 joints, including shoulders, elbows, hips, knees, and ankles, were evaluated to determine whether RPD was present by comparing radiographs before and after treatment.Results: RPD was observed in 24 patients (33.8%) and 34 joints (10.8%). Joints with an LG of III or higher had significantly higher rates of RPD than those with LGs I and II. Multivariate logistic regression analysis revealed that stage and health assessment questionnaire (HAQ) score at 18-months were independent risk factors for RPD (cut-off value: 2.5, odds ratio: 7.222 for stage; cut-off value: 0.9375, odds ratio: 6.278 for HAQ at 18-months).Conclusion: Stage, HAQ at 18-months, and LG at the start of bDMARDs were predictive of RPD after 3 to 4 years. bDMARDs should be started before both stage and LG exceed III and the therapeutic strategy should be determined so that HAQ does not exceed 1.0 during treatment.

Extracorporeal shock wave treatment can selectively destroy end plates in neuromuscular junctions.

INTRODUCTION: This study assesses the effect of radial extracorporeal shock wave (rESW) exposure on neuromuscular transmission and neuromuscular junction (NMJ) morphology. METHODS: We applied 2,000 rESWs at 0.18 mJ/mm2 and a frequency of 15 Hz to the right calf of male rats, measured the compound muscle action potential (CMAP), and examined NMJ morphology using electron microscopy. Left calf muscles were used as controls. RESULTS: rESW exposure significantly reduced CMAP amplitude without delayed latency in exposed muscles compared with controls. All rESW-exposed muscles exhibited NMJs with irregular end plates. Mean interjunctional fold interval was significantly increased compared with controls. However, axon terminals and muscle fibers surrounding NMJs with irregular end plates were unchanged. DISCUSSION: This localized destruction of end plates may be caused by differences in acoustic impedance induced by the density of acetylcholine receptors. These results provide a possible mechanism for the effectiveness of rESW treatment for spasticity and dystonia. Muscle Nerve 57: 466-472, 2018.

Axonal damage is remarkable in patients with acutely worsening symptoms of compression myelopathy: biomarkers in cerebrospinal fluid samples.

PURPOSE: To determine levels of biomarkers reflecting damage to axon, myelin, astrocytes, and neuron in cerebrospinal fluid (CSF) of patients with cervical compression myelopathy. METHODS: We collected 69 CSF samples from patients before spinal surgery for acutely worsening compression myelopathy (AM, 20), chronic compression myelopathy (CM, 20), and lumbar canal stenosis (LCS 29; control). We measured levels of phosphorylated neurofilament subunit H (pNF-H), tau (reflecting axonal damage), myelin basic protein (MBP) (reflecting demyelination), S100b (reflecting astrocyte damage), and neuron-specific enolase (NSE) (reflecting neuronal damage). Change of neurological function by surgery was determined using a Japanese Orthopaedic Association (JOA) score for cervical myelopathy. RESULTS: Significantly higher levels of pNF-H were detected in AM compared with those in either CM or LCS (P < 0.01). Significantly higher levels of tau were detected in AM compared with those in CM (P < 0.05). Levels of MBP were undetectable in almost all the patients. Levels of S100b were equivalent in the three groups. Levels of NSE in AM and CM were significantly lower than those in LCS (P < 0.01). The recovery rate of JOA score was significantly greater for patients with AM than CM. We found a positive correlation between pNF-H and recovery of JOA score (r = 0.381, P = 0.018). CONCLUSION: The present results suggest that axonal damage is remarkable compared with demyelination, astrocytic, and neuronal damage in AM. Better clinical outcome in AM with high CSF levels of pNF-H indicates that axonal compensatory plasticity in spinal cord is preserved, and pNF-H can be predictive of good surgical outcome for AM. These slides can be retrieved under Electronic Supplementary Material.

Health assessment questionnaire-disability index (HAQ-DI) score at the start of biological disease-modifying antirheumatic drug (bDMARD) therapy is associated with radiographic progression of large joint damage in patients with rheumatoid arthritis.

OBJECTIVES: Radiographic progression of damage (RPD) to large joints in patients with rheumatoid arthritis (RA) has not been fully studied. We previously demonstrated that Larsen grade of the large joints was associated with RPD of large joints in patients treated with biological disease-modifying anti-rheumatic drugs (bDMARDs); however, no factors associated with background characteristics of patients were identified. METHODS: A total of 400 large joints in the upper and lower extremities, including the shoulder, elbow, knee, and ankle, of 88 patients with RA treated with bDMARDs for 1-3 years were investigated. Radiographs of tender and/or swollen large joints were acquired at least twice during the study period (mean, 16.4 months), and the RPD was evaluated. RESULTS: A multivariate analysis revealed that health assessment questionnaire-disability index (HAQ-DI) score at the start of bDMARD treatment was associated with RPD. The cutoff value that discriminated progression from non-progression, determined by a receiver operating characteristic (ROC) curve, was 1.4375 (sensitivity: 0.778, specificity: 0.894). CONCLUSIONS: HAQ-DI score at the start of bDMARD treatment was associated with RPD to large joints during a therapeutic period of 1-3 years. Progressive damage is expected to increase when functional disability exceeds an HAQ-DI score of 1.5.

Identification of genes required for the spontaneous repair of partial-thickness cartilage defects in immature rats.

PURPOSE: Our previous study showed that partial-thickness articular cartilage defects (PTCDs) created in immature rats spontaneously healed to resemble normal hyaline cartilage, but that of mature rats did not. To identify molecules involved in the spontaneous cartilage repair observed in this model, gene expression was compared between PTCD and sham-operated cartilage of immature and mature rats. MATERIALS AND METHODS: Six sets of gene comparisons were made at 12, 24, and 48 hours after the creation of PTCDs in immature and mature rats using microarrays. All the genes upregulated in immature cartilage at 12 hours were selected for further analysis if their expression pattern was not irregular such that diminished at 24 hours and re-upregulated at 48 hours. Relationships among genes selected through the above steps were analyzed using Ingenuity Pathway Analysis (IPA) software. After deriving networks, important molecules were further narrowed down by location within a network. Genes were regarded as central if they had relationships with more than 10 molecules in a network. Protein localization in tissues was confirmed by immunohistochemistry. RESULTS: Five networks were identified. Their functional annotations were gene expression, cell cycle, growth and proliferation, and cell signaling. Transforming growth factor-beta (TGF-ß) was centrally located in the network with the highest IPA score and mothers against decapentaplegic homolog-3 (Smad3) were centrally located in the second highest ranking network. Phosphorylated Smad3 was detected in the nuclei of chondrocytes in immature cartilage. CONCLUSIONS: Our data suggest the possible importance of Smad3 in the TGF-ß signaling in the spontaneous healing of PTCDs in immature rats.