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Methods@#Fifty-three patients with 57 fresh pre-lysis-stage lesions who had completed conservative treatment were included in the study (40 men, 13 women; mean age, 14.3 years). We investigated the rate of bone healing and the relationship between bone healing after conservative therapy and factors such as age, sex, vertebral level, unilateral/bilateral lesions, and presence of spina bifida occulta. @*Results@#The overall bone healing rate was 95% (54/57 lesions). Bilateral lesions had a significantly lower bone healing rate than unilateral lesions (86% vs. 100%, p=0.046). There were no statistically significant differences based on age, sex, vertebral level, or presence of spina bifida occulta. @*Conclusions@#The bone healing rate in unilateral lesions was 100%, which was significantly higher than that in bilateral lesions. It is important to detect and initiate treatment while the lesion is still unilateral, if possible.
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Methods@#We evaluated 48 patients (38 boys and 10 girls) with bilateral L5 spondylolysis diagnosed during or before high school. L5 spondylolysis was classified into two groups: fresh group (bilateral fresh spondylolysis cases), and terminal group (cases wherein one side had fresh spondylolysis and the contralateral side had terminal spondylolysis). We investigated the age of examination and bone healing rate in both groups. We investigated progressive-stage lesions and bone healing rate with or without progressive-stage lesions. @*Results@#The bone healing rate in the fresh group was significantly higher than that in the terminal group 72.0% vs. 26.1%, p =0.003). In both the groups, the bone healing rate was significantly higher in patients without progressive-stage lesions than in those with progressive-stage lesions. @*Conclusions@#Bone healing of progressive-stage fresh spondylolysis was not achieved by conservative treatment when contralateral terminal spondylolysis was present in adolescents with bilateral L5 spondylolysis. Our results suggest that bilateral L5 spondylolysis treatment strategies must be determined based on the combination of the stages present.
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Objectives: To examine the efficacy and clinical and radiological outcomes of the use of a streamlined clavicle plate® (MEIRA, Aichi, Japan) for midshaft clavicular fractures.Methods: This was a retrospective cohort study of 155 patients with displaced midshaft clavicular fractures treated using a streamlined clavicle plate between 2015 and 2019 in 18 hospitals across Japan. A questionnaire regarding bone union and postoperative complications was used, and 136 cases were followed up for one year or until bone union. Plate fitting was evaluated retrospectively using surgical records, radiographic findings, and surgeon’s opinion.Results: During surgery, plate bending was needed in 19 cases (12.3%), poor fitting was observed in 8 cases (5.2%), and bone union was achieved in 133 cases (97.8%). Total implantation failure, including plate breakage and screw loosening, occurred in 10 cases (6.5%) from the intraoperative to postoperative period. Subjective complications were observed in 26 cases (16.8%): incongruity around the surgical scar or in the anterior chest in 23, and contracture of the shoulder in three. Plate removal was performed in 66 cases (48.5%) per patient’s request.Conclusion: The use of a streamlined clavicle plate is effective for midshaft fractures of the clavicle, and the success rates of bone union and implantation using this approach are comparable to those of other existing plates.
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Objective: In 2020, coronavirus disease-2019 (COVID-19) became the cause of a pandemic. In response, the Japan Sports Agency issued warnings about secondary damage to health, such as the threat to physical and mental well-being due to the lack of exercise in this situation. In this study, we report on cross-sectional and longitudinal examinations of standing trunk flexion to evaluate how temporary long-term school closures affected musculoskeletal function in elementary school students.Patients and Methods: All children in one public elementary school in T-city during the school years 2019 and 2020 were included in this study. A digital forward flexion meter was used to measure standing trunk flexion.Results: In this study, 284 (284/289: 98.3%) and 266 (266/274: 97.1%) children in school years 2020 and 2019, respectively, were found to have valid data for cross-sectional analysis. The standing trunk flexion did not show significant differences between grades or sexes. In the longitudinal analysis, the results of the comparison of standing trunk flexion in children for two consecutive years revealed significant differences only between grades 3 and 4 (P<0.05) and between girls in grades 3 and 4 (P<0.01), but no significant differences in other grades or among boys or girls were observed.Conclusion: Initially, we expected that there would be a difference in the results of functional assessment using standing trunk flexion depending on the period of absence from school. However, the results of this study showed no significant changes in standing trunk flexion. Moreover, since children’s musculoskeletal functions may be affected by various factors during the COVID-19 pandemic, they should be carefully monitored in the future.
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Objective: In this study, thermoelastic stress analysis was conducted to clarify the surface stress distribution of a femur in which a BiCONTACT E stem was inserted. The contact sites between the stem and femur were examined to investigate the association with the range of stress distribution.Materials and Methods: BiCONTACT E was set up using two synthetic femurs that mimic the morphology and mechanical properties of living bone. Preoperative planning was performed using three-dimensional imaging software. The synthetic bone was placed in a sample holder. After the stem was implanted into the synthetic bone, computed tomography imaging was performed. The contact sites between the stem and the cortical part of the synthetic bone were examined using the imaging software. Subsequently, thermoelastic stress measurements were performed on the sample.Results: The results of thermoelastic stress analysis indicated a minimum change in the sum of principal stresses [Δ (σ1+σ2)] on the medial side and a maximum change in the sum of principal stresses on the lateral side. Thus, no minimum change was observed in the sum of the principal stresses at the maximum proximal part. It is reasonable to assume that the use of a cementless stem can inevitably lead to bone atrophy in the proximal part of the femur. The contact sites between the stem and femur were also investigated, and the results of the study clearly and quantitatively demonstrated the correlation of the contact sites with a range of stress distributions.Conclusion: The surface stress distribution of a femur, in which a BiCONTACT E stem was inserted, was clarified. The contact sites between the stem and femur were also investigated. Furthermore, the correlation between these results and clinical bone response was investigated in this study.
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Objective: To report a case of anterior longitudinal ligament (ALL) injury that was not noticeable during lateral lumbar interbody fusion and was disclosed after posterior corrective fusion surgery.Case presentation: After performing lateral lumbar interbody fusion followed by posterior corrective fusion surgery, we observed an anterior longitudinal ligament rupture that required additional surgery. Postoperative pain in the left lower limb and muscle weakness due to nerve traction appeared, but this was improved by stabilization between the vertebral bodies.Conclusion: Unidentified anterior longitudinal ligament rupture can result in unexpected local lordosis during posterior surgery, possibly related to lower extremity palsy. Therefore, checking for possible rupture during and after anterior surgery is important. If the ALL damage is disclosed before posterior surgery, the proper surgical strategy for the posterior surgery must be considered.
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Methods@#Nineteen volunteers (16 men, three women) lifted a 60-kg doll from a seated position to a standing position. The first transfer was performed without the HAL for Care Support, and the second was performed with the HAL for Care Support assistive robot. We evaluated transfer performance, the visual analog scale (VAS) score for lumbar fatigue, and electromyogram analyses of the trunk and hip. @*Results@#Four participants (two men, two women) succeeded with the HAL for Care Support even though they were unable to perform the task without it. The mean lumbar fatigue VAS score for all participants without the HAL for Care Support was 62 mm, while that with it was 43 mm. With lumbar assistance from the HAL for Care Support, subjective lumbar fatigue during the transfer decreased significantly. A power analysis indicated adequate statistical power to detect a difference in the VAS score for lumbar fatigue (0.99). The activity of the left gluteus maximus alone increased significantly during transfers with the HAL for Care Support. No adverse events occurred during use of the HAL for Care Support for transfers. @*Conclusions@#The HAL for Care Support was able to reduce lumbar load in a simulated patient transfer.
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Objective: Lumbar spondylolysis, caused by stress fracture of the pars interarticularis may lead to a bony defect or spondylolisthesis. In adolescents, its surgical treatment employs the smiley face rod method for direct reduction of pseudoarthrotic spondylolysis and spondylolisthesis. Clinical outcomes of this treatment have been occasionally described; however, implant removal has not been discussed previously. We present a patient with lumbar spondylolysis with grade 1 slip at the 5th lumbar vertebra (L5) per the Meyerding classification.Patient: A 14-year-old boy presented with chronic severe lower back pain. Since conservative therapy did not resolve pain or enable resuming sports activities, the smiley face rod repair was performed 7 months after the initial treatment.Result: Anterior slippage of the L5 was surgically reduced. The patient wore a brace for 3 months postoperatively, and partial bone fusion was noted 6 months postoperatively. He resumed his sports activity 8 months postoperatively, and absolute bone fusion was confirmed 18 months postoperatively. Implant removal was performed 3 years postoperatively. Grade 1 slip was corrected with absolute bone fusion, and long-term follow-up revealed good results in terms of healing and rehabilitation.Conclusion: Smiley face rod method that allows for implant removal after bone fusion is suitable for adolescents.
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Objective: Osteoporotic vertebral fracture (OVF) is conventionally treated with conservative management such as bed rest, but a relatively prolonged bed rest has the potential risk of muscle disuse atrophy. This study aimed to examine whether the 2-week of rigorous bed rest affects muscle disuse atrophy in OVF patients.Patients and Methods: A total of 54 OVF patients (16 males; 38 females; mean age, 80.2 ± 9.2 years) were treated with an initial 2-week rigorous bed rest by hospitalization with persistent rehabilitation. Cognitive function, swallowing function, grip strength, and lower extremity circumference were evaluated at three-time points (admission, end of bed rest, and discharge).Results: Of the 51 patients who were able to walk independently before the injury, one patient (2.0%) had to use a wheelchair after the injury. During hospitalization, cognitive function decline was observed in 33.3% of patients, but not in patients with Revised Hasegawa’s Dementia Scale score ≥25 at admission. Swallowing function decline was observed in one patient, and none of the patients developed aspiration pneumonia during hospitalization. The grip strength significantly improved both at the end of bed rest (P=0.04) and discharge (P=0.02). Although the lower extremity circumference significantly decreased at the end of bed rest (P<0.01), it was recovered afterward. The lower extremity circumference did not significantly differ between the admission and discharge (P=0.17).Conclusion: Our results suggested that conservative treatment of OVF through an initial 2-week rigorous bed rest with persistent hospital rehabilitation poses a low risk of muscle disuse atrophy. If cognitive dysfunction is observed on admission, close monitoring for exacerbation should be performed during the hospital stay.
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Objective: This study aimed to examine differences in platelet-rich plasma (PRP) soak-loaded volumes of β-tricalcium phosphate (β-TCP) with or without a unidirectional porous structure.Materials and Methods: Leukocyte-rich PRP was extracted from 15 healthy volunteers by centrifugation. Two types of artificial bones were soaked for either ten seconds or ten minutes. The volume ratios of PRP soak-loaded onto the artificial bone and soaked area ratios were evaluated. Statistical analyses were performed using the Tukey-Kramer HSD test and the Games-Howell method. A P-value of <0.05 was considered statistically significant.Results: Regardless of the soaking time, the PRP soak-loaded volume ratio and soaked area ratio were significantly higher in the unidirectional porous β-TCP (UDPTCP) group than in the spherical porous β-TCP (SPTCP) group.Conclusion: PRP can be soak-loaded faster and in larger amounts onto UDPTCP compared to SPTCP. Understanding the basic biology of β-TCP soak-loaded with PRP can help develop more novel and effective β-TCP treatments for orthopedic surgery.
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Objective: To compare the outcomes of steroid-associated osteonecrosis of the femoral head in patients with systemic lupus erythematosus who underwent conservative treatment and concentrated autologous bone marrow aspirate transplantationMethods: Osteonecrosis of the femoral head was classified according to the Japanese Investigation Committee system. Concentrated autologous bone marrow aspirate transplantation was performed by aspirating the bone marrow from both iliac crests and then transplanting it to the necrotic area after the core decompression. Patients with >2-year follow-up after the concentrated autologous bone marrow aspirate transplantation in our institution (Group I) and those with >2-year follow-up after the first hospital visit in a cooperative institution (Group II) were included in this study. After a randomized matching based on age, sex, type, stage, and etiology, the collapse rate in pre-collapsed stages and total hip arthroplasty conversion rate in all stages were compared between the two groups.Results: After the matching adjustment, 33 pairs of hips were included. Preoperatively, 1, 2, 16, and 14 hips were classified as types A, B, C1, and C2, respectively, and 15, 13, 2, and 3 hips were classified as stages 1, 2, 3A, and 3B, respectively. The collapse rates in the pre-collapsed stages were 68% and 39% in Groups I and II, respectively. Total hip arthroplasty conversion rates were 33% and 45% in Groups I and II, respectively. However, Group I had significantly higher and lower conversion rates in stages 1 and 3, respectively (both P<0.05).Conclusion: Conservative treatment may be preferable in stage 1 hips. In addition, concentrated autologous bone marrow aspirate transplantation may prevent further collapse in stage 3.
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Objectives: To evaluate the feasibility and efficacy of treatment for the recovery of knee joint function after total knee arthroplasty (TKA) using a robotic suit.Patients and Methods: Knee joint extension exercise sessions were started with a robotic suit (single-joint hybrid assistive limb [HAL-SJ, Cyberdyne, Inc., Tsukuba, Japan]) in one group of patients after TKA. Patients who underwent standard rehabilitation were enrolled in the control group. To evaluate feasibility and safety, we assessed the adverse events, the number of training sessions, and training time. We compared the changes in knee joint pain and extension lag (°) between the groups.Results: The average age was 71.3 ± 6.2 years in the HAL-SJ group and 74.9 ± 8.7 years in the control group. There were no severe adverse events. In the HAL-SJ group, training was performed 2.9 times, on average, and lasted 18.8 min. In the HAL-SJ group, there was a reduction in the visual analog scale (VAS) for pain after training, which was not significant. In the control group, the VAS score worsened after the sessions. The extension lag significantly improved in the HAL-SJ group after the 2nd and 3rd sessions, and this was more due to improvements in their active extension range of motion than their passive extension range of motion.Conclusions: HAL-SJ-based training is safe and effective, and leads to instantaneous improvement of extension lag, without worsening knee joint pain. HAL-SJ-based knee extension training could represent a viable novel post-TKA rehabilitation modality.
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Introduction: Unidirectional porous β-tricalcium phosphate (UDPTCP) consists of a novel porous artificial bone that is structurally different from conventional artificial bone comprised of spherical porous β-tricalcium phosphate (SPTCP).Case presentation: We present our first four clinical cases of opening-wedge high tibial osteotomy (OWHTO) using UDPTCP and SPTCP together. The patients’ mean age was 54.5 ± 5.9 years, and the mean observation period was 20.8 ± 2.8 months. In OWHTO, two wedge shaped pieces of UDPTCP and SPTCP were cut to fit the gap and implanted parallel to each other in the anterior and posterior parts, respectively. We evaluated the correction loss and bone remodeling for UDPTCP and SPTCP over time using radiography and computed tomography, and evaluated the clinical outcomes.Conclusion: There was no correction loss reported in any case, and early bone remodeling was observed with UDPTCP. All patients achieved satisfactory clinical results with no adverse events.
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Objective: Whether or not emergent decompression/fusion surgery for paralysis caused by metastatic spinal tumors of unknown origin improves patient neurological outcome and survival remains unclear. This study aimed to evaluate the clinical outcomes of emergent decompression/fusion surgery for paralysis caused by spinal tumors of unknown or not previously diagnosed origin.Patients and Methods: Data from the medical records of 11 patients with spinal tumors of unknown origin (study group) were compared with those of 15 patients with metastatic spinal tumors of known origin (control group). The outcome measures were postoperative performance status, motor function evaluated with the Frankel grade, and actual survival after surgery as compared with the estimated survival calculated using the Tokuhashi score. χ2 analyses were performed to evaluate differences between the groups.Results: The mean performance status was 3.6 preoperatively, which improved to 2.9 postoperatively (P<0.05), in the unknown origin group and 3.6 preoperatively, which improved to 2.7 postoperatively (P<0.05), in the control group. Seven patients (64%) in the unknown origin group showed improvement in paralysis by ≥1 Frankel grade. By contrast, only 4 patients (27%) in the control group showed improvement in paralysis. The unknown origin group tended to show better improvement (P=0.05). All the patients in the unknown origin group underwent adjuvant therapy after definitive diagnosis following surgery. The unknown origin group showed a slight tendency toward better survival than toward the estimated survival.Conclusion: Emergent decompression/fusion surgery for patients with paralysis caused by metastatic tumors of unknown origin is potentially useful for diagnosing tumor origin and improving neurological outcomes and performance status, and thus for extending survival.
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Objective: In 2016, Japan started conducting musculoskeletal examinations that included “limb status” of students as an essential item. Our institution implemented a unified musculoskeletal examination for all public elementary and junior high schools in T-city. In this study, we aimed to report the progress in the past 4 years.Patients and Methods: The Tsukuba Childhood Locomotive-Organ Screening Sheet (T-CLOSS), which is a questionnaire that includes some nationwide-recommended questions, was prepared and distributed to students. Results of the questionnaires were analyzed, and the orthopedic surgeon conducted examinations for the extracted items. From these questionnaires, the ratio of each item, rate of advisory for screening, and content of the advisory were investigated.Results: During 2016–2019, musculoskeletal examinations were conducted in every public schools, with nearly 20,000 students in T-city. The consultation advisory rate was 6.7% in 2019. Of the 524 students who received the third screening recommendation, the actual consultation rate was 248 (40.8%). After the third screening, the proportion of students requiring treatment and outpatient visits was 46.7% (n=248), which accounted for 1.2% of all elementary and junior high school students in the city.Conclusion: We reported the results of 4-year musculoskeletal examinations in a city. In our screening, we distributed a uniform questionnaire throughout the city, and orthopedic surgeons performed secondary examinations of identified students in all schools. This appears to be an advanced effort to prevent musculoskeletal impairment in students. We hope to conduct more sophisticated musculoskeletal examinations using our results, aiming at early detection, early treatment, and improvement of musculoskeletal function in elementary and junior high school students.
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Introduction: As the average life expectancy is increasing, the number of patients aged >100 years who have fragility fractures will increase in the future. In female patients, the incidence of open fractures increases with age.Case Presentation: We present the case of a 102-year-old woman with open tibial and fibular diaphyseal fractures (Gustilo-Anderson classification type IIIb) treated with temporary external fixation, advancement flap, and negative pressure wound therapy in the first-stage surgery and treatment, and open reduction and internal fixation with skin grafting in the second-stage surgery. Open wound and bone healing were attained.Conclusion: Surgery should not be denied on the basis of age alone. Medical evaluation should focus on identifying risk factors, assessing risk in detail, optimizing status, predicting complications, and making the appropriate surgical plan for the patient status. Moreover, in the present case, meticulous postoperative management was the main reason for the successful surgical treatment.
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Background: In Japan, in 2016, the School Health and Safety Act was revised and examination of extremities in addition to scoliosis became mandatory. Musculoskeletal examinations were subsequently started using a mark sheet-type questionnaire. In the present study, we aimed to analyze the relationship between physical findings and musculoskeletal problems and propose a preventive strategy for musculoskeletal injuries.Methods: In 2017, a total of 4,073 elementary and middle school students underwent direct musculoskeletal examination. In a direct examination, the following elements were included: torticollis; scoliosis; stiffness of the shoulder, elbow, hip, knee, and ankle; flexion and extension in standing position; flat foot; hallux valgus; and alignment of the upper and lower extremities. Of the 4,073 students who underwent direct examination in early 2017, only 3,754 were able to complete the mark sheet-type questionnaires in early 2018. A prospective longitudinal analysis of the data gathered was performed.Results: A total of 396 (11%) students had injuries. The ankle sprain/non-ankle sprain group comprised 119 (3%)/3,635 (97%) students, while the fracture/non-fracture group comprised 105 (2.8%)/3,650 (97.2%) students, respectively. Comparing the sprain group with the non-sprain group, ankle stiffness significantly correlated with ankle sprain in the univariable and multivariable analyses. Injuries occurred more frequently among boys, older students, students with stiff bodies, and students who were involved in sports activities of longer duration.Conclusion: Ankle stiffness was assumed to be a risk factor for ankle sprain. Stretching of the ankle might be effective for preventing ankle sprain. However, further interventional studies are needed to confirm this finding.
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Objective: Atopic dermatitis (AD) is one of the known risk factors for Staphylococcus aureus infection. The authors report the case of a patient with cervical spondylosis and AD who developed delayed surgical site infection after posterior cervical instrumented surgery.Patient: A 39-year-old male presented to our hospital with paralysis of the left upper extremity without any cause or prior injury. He had a history of severe AD. We performed C3–C7 posterior decompression and instrumented fusion based on the diagnosis of cervical spondylotic amyotrophy. One year after surgery, his deltoid and bicep muscle strength were fully recovered. Nevertheless, his neck pain worsened 2 years after surgery following worsening of AD. One month after that, he developed severe myelopathy and was admitted to our hospital. Radiographic findings showed that all the screws had loosened and the retropharyngeal space had expanded. Magnetic resonance imaging and computed tomography showed severe abscess formation and destruction of the C7/T1 vertebrae.Result: We diagnosed him with delayed surgical site infection. Methicillin-resistant Staphylococcus aureus was identified on abscess culture. The patient responded adequately to treatment with antibiotic therapy and two debridements and the infection subsided.Conclusion: We should consider the possibility of delayed surgical site infection when conducting instrumented spinal surgery in patients with severe AD.
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Calcification of the ligamentum flavum (CLF), which is a rare disorder that can potentially cause myelopathy, occurs uncommonly in the thoracic spine. Here, we report a rare case of thoracic myelopathy caused by CLF in a 78-year-old man. Magnetic resonance imaging (MRI) showed posterior spinal cord compression by a hypo-signal intense mass, and computed tomography (CT) revealed CLF and vacuum disc phenomenon at T10/11. After undergoing posterior decompression and instrumented fusion (T9–T12), the patient’s gait difficulties improved. The pathogenesis of CLF is largely unknown; however, it involves accumulation of calcium pyrophosphate dehydrate crystals (CPPD), and CLF from CPPD deposition tends to occur within a thickened and hypertrophic ligament. CLF occurs predominantly in the cervical spine and less frequently in the lumbar spine, with few cases involving the thoraco-lumbar spine. The thoracic spine is characterized by hypomobility; however, the thoraco-lumbar spine has a mobile segment which may potentiate CLF formation. Decompression with fusion surgery can be useful for treating patients with thoraco-lumbar CLF.
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Objective: To treat vertebral fractures with posterior wall injury in the elderly, vertebral bone grafting is generally performed through a posterior transpedicular approach, combined with pedicle screw fixation. An autologous bone is ideal to treat this disorder. However, harvesting autologous bones from the elderly with osteoporosis is limited by the amount and quality of available autologous bone. Thus, we developed a bone-grafting substitute. The newly developed unidirectional porous β-tricalcium phosphate, with a porosity of 57% (UDPTCP; Affinos®, Kuraray Co., Ltd., Tokyo, Japan), is used in the bone-grafting procedure. This is the first report of UDPTCP used as an artificial bone graft in patients with an acute vertebral burst fracture.Materials and Methods: UDPTCP (mean: 4.2 g) was implanted through the pedicle, and posterior instrumentation was achieved with pedicle screws in five elderly patients. Resorption of UDPTCP and substitution with the autologous bone were evaluated on computed tomography (CT) and plain X-ray performed immediately and at 3, 6, and 12 months after the operation.Results: In case 1, the pedicle screws did not loosen, and UDPTCP was completely resorbed and replaced with the autologous bone at 3 postoperative months. In the other four cases, although the pedicle screws or the caudal part loosened because of osteoporosis, resorption of UDPTCP was observed at 3 postoperative months. At 6 postoperative months, progressive substitution with the autologous bone was confirmed, and at 12 postoperative months, formation of the good autologous bone was confirmed.Conclusion: This preliminary case series demonstrated that the newly developed UDPTCP shows good clinical potential as a bone-graft substitute for acute vertebral burst fractures in the elderly, including patients with osteoporosis.