RASopathies and spinal deformities for screening of scoliosis.

BACKGROUND: The RASopathies (Noonan syndrome [NS] and Costello syndrome [CS]) are rare disorders. Although these have been characterized, precise delineation of the differences in the spinal deformities associated with RASopathy has not been described. This study characterized the spinal deformities found in NS and CS and describes a strategy for the screening of scoliosis. METHODS: The clinical records and spinal X-rays of 35 consecutive NS and CS patients were reviewed. Spinal X-rays were assessed to define the presence and progression of scoliosis. Clinical records were examined to identify the risk factors associated with scoliosis. In addition, we investigated the association between clinical records and scoliosis using logistic regression analysis. RESULTS: Twenty-four patients with NS and 11 with CS were included. Nine patients with NS and five with CS showed scoliosis. The mean ± SD age at diagnosis was 12.6 ± 2.4 years in NS and 11.4 ± 2.5 years in CS (p = 0.55), and mean follow-up period was 4.8 ± 2.6 years and 6.3 ± 2.4 years (p = 0.42), respectively. The coronal angular deformity at final follow-up was 27.3 ± 8.5° in NS and 19.4 ± 6.9° in CS (p = 0.030) with a mean annual progression of 2.8 ± 1.1° in NS 1.0 ± 1.0° in CS (p = 0.030). Cardiac disease was present in eight out of nine patients with NS with concomitant scoliosis in NS, and significantly more than in CS (p = 0.007). PTPN11 significantly correlated with scoliosis (odds ratio 12.4 0.035, 95% confidence interval: 1.20-128.00). CONCLUSIONS: Spinal deformity in NS is more severe than in CS. This study identified a relationship between PTPN11 and scoliosis. Therefore, PTPN11 can be used for the screening of scoliosis.

Comparison of the electrophysiological characteristics of tight filum terminale and tethered cord syndrome.

PURPOSE: This study aims to characterize tight filum terminale (TFT) in motor evoked potential (MEP) testing by comparing TFT patients with both tethered cord syndrome (TCS) patients and healthy subjects. METHODS: Fifty TFT patients, 18 TCS patients, and 35 healthy volunteers participated in this study. We recorded MEPs following transcranial magnetic stimulation from the bilateral abductor hallucis muscles as well as compound muscle action potentials and F-waves evoked by electrical stimulation of the tibial nerve from the bilateral abductor pollicis brevis muscles. The peripheral conduction time (PCT) was calculated from the latency of the compound action potential and F-wave. Furthermore, the central motor conduction time (CMCT) was calculated by subtracting PCT from MEP latency. RESULTS: TFT and TCS patients had a significantly longer MEP latency than healthy subjects. PCT in TFT patients was significantly longer than those in TCS patients or healthy subjects. Using the cutoff values for PCT, we were able to diagnose patients with TFT patients with a sensitivity of 72.0% and a specificity of 91.4%. CONCLUSION: Prolonged PCT in the MEP test may be a useful indicator for TFT and suggests that MEP may be used as an adjunct diagnostic tool for TFT.

Prognostic factors for spontaneous spinal epidural hematoma: a multicenter case-control study.

BACKGROUND: To determine the optimal treatment for spontaneous spinal epidural hematoma (SSEH). The aim of this study was to identify factors associated with SSEH. METHODS: In 62 patients with SSEH, several patient-related parameters were analyzed as candidate factors associated with Frankel grade before treatment or at the last follow-up. These parameters were compared between patients with and without surgery. In addition, multivariate ordinal logistic regression analysis was used to identify factors significantly associated with Frankel's grade before treatment or at the last follow-up. RESULTS: There were significant differences in age, location of the hematoma, and Frankel grade before treatment and at the last follow-up between surgical and nonsurgical cases in all patients, but there were no significant differences in any of these parameters when comparing patients with pre-treatment Frankel grade C. The location of the hematoma was significantly associated with the severity of paralysis before treatment. In surgical cases, the time from onset to surgery and the location of the hematoma was significantly associated with the prognosis. When the time from onset to surgery was evaluated using the criteria of 12, 24, and 48 h, 24 and 48 h had a significant impact on the prognosis. In the analysis of nonsurgical cases, only the vertical size of the hematoma was significantly associated with prognosis. CONCLUSION: The time from onset to surgery and the location of the hematoma were prognostic factors in surgical cases, while the vertical size of the hematoma was a prognostic factor in nonsurgical cases.

Fatigue wear test comparing vitamin-E-blended crosslinked polyethylene and conventional polyethylene in a Posterior Dynamic Stabilization System of the spine in the laboratory.

BACKGROUND: Although artificial joints using polyethylene have been developed for various joints, the development of Posterior Dynamic Stabilization system of the spine using polyethylene has proceeded at a much slower pace. There are no studies which compare the abrasion resistance of vitamin-E-blended crosslinked polyethylene (VE) and conventional polyethylene (Virgin) in the spinal region. The purpose of this study was to compare the wear resistance of VE and Virgin in a Posterior Dynamic Stabilization System of the spine. METHODS: Posterior Dynamic Stabilization System of the spine uses a polyethylene ball as a sliding surface. A fatigue wear test was repeated up to 1 million cycles at a speed of ±5°, 1 Hz while the rod was being pulled at a load of 50 N. Balls were compared using VE and Virgin in 6 samples each. Ti-6AL-4 V (Ti 64) and Co-Cr-Mo (CoCr) rods were used. Abrasion loss and shape change of the polyethylene balls were compared. RESULTS: When Ti 64 was used as the rod, the average wear amount was -0.01 mg (0.02 mg, 0.01 mg, -0.06 mg) for VE, and 0.23 mg (0.18 mg, 0.13 mg, 0.38 mg) for Virgin. When CoCr was used as the rod, the average wear amount was 0.42 mg (0.71 mg, -0.06 mg, 0.61 mg) for VE, and 0.73 mg (0.72 mg, 0.70 mg, 0.76 mg) for Virgin. Most polyethylene samples showed indentations of 0.1 m or less at the contact point with the set screw. In the combination of Virgin and CoCr, a white patch was observed on the inner side of the polyethylene samples, with a maximum depression of 0.1 mm. CONCLUSIONS: A fatigue wear test showed VE to be more efficient in abrasion resistance than Virgin in a Posterior Dynamic Stabilization System of the spine in the laboratory.

MRI Findings of Muscle Damage after Total Hip Arthroplasty Using the Complete Muscle Preserving Anterolateral Supine Approach.

Background and Objectives: We performed anterolateral total hip arthroplasty (ALS THA) with the purpose of complete muscle-tendon preservation without muscle-tendon dissection. This study aimed to evaluate muscle damage in the periprosthetic hip joint muscles of patients undergoing ALS THA at 1-year post-operative hip magnetic resonance imaging (MRI). Materials and Methods: We evaluated changes in the muscle cross-sectional area (M-CSA) and fatty atrophy of the periprosthetic muscles. We also assessed the Harris hip score on pre-operative and 12-month post-operative MRI in 66 patients who underwent ALS THA. The grade of M-CSA atrophy was classified into no atrophy, slight atrophy, moderate atrophy, and severe atrophy. Fatty atrophy was classified as improved, no change, and worsened using the Goutallier classification. Results: More than 90% of patients' M-CSA had no atrophy in the obturator internus (Oi), obturator externus (Oe), gluteus medius (Gmed), and gluteus minimus (Gmin), and some improvement was observed in terms of fatty atrophy. In contrast, M-CSA of the tensor fascia latae (TFL) muscle was clearly decreased, and there was no improvement in the TFL fatty atrophy. However, the presence or absence of TFL atrophy did not affect clinical outcome. Conclusions: We performed the complete muscle preserving procedure, ALS THA, with attention to preserving the Oi and Oe by direct visual confirmation and gentle treatment of the Gmed and Gmin with effective retraction. Post-operative M-CSA atrophy evaluation on MRI showed that the Oi, Oe, Gmed, and Gmin were satisfactorily preserved; however, the TFL was clearly atrophic. In the ALS approach, where entry is made between Gmed and TFL, atrophy of the TFL due to superior gluteal nerve injury must be tolerated to some extent.

Long-term outcome of targeted therapy for low back pain in elderly degenerative lumbar scoliosis.

PURPOSE: Treatment of low back pain (LBP) associated with elderly degenerative lumbar scoliosis (DLS) remains controversial. We have developed percutaneous intervertebral-vacuum polymethylmethacrylate injection (PIPI) targeting to the intervertebral vacuum as a minimally invasive surgery. The present study compared the long-term clinical outcomes of PIPI to that of nonoperative treatment. METHODS: Patients with de novo DLS, aged ≥ 65 years, who had LBP with visual analog scale (VAS) of ≥ 50 for ≥ 6 months with intervertebral vacuum on computed tomography and bone marrow edema (BME) on magnetic resonance imaging were included. The clinical outcomes were evaluated using VAS and the Oswestry Disability Index (ODI) at baseline, 1, 6, 12, 24 months, and at the final follow-up. The course of BME was also evaluated. RESULTS: One hundred and one patients underwent PIPI and 61 received nonoperative treatment. The mean follow-up duration after PIPI and nonoperative treatment was 63.7 ± 32.4 and 43.9 ± 20.9 months, respectively. VAS and ODI after PIPI were significantly improved compared to post-nonoperative treatment. BME decreased substantially in the PIPI group and it was significantly correlated with VAS and ODI improvement. Following PIPI, LBP recurred in 28 patients (35%). LBP recurrence was identified at the same level of PIPI in 10 patients, at the adjacent level of PIPI in 11 patients, and at the non-adjacent level of PIPI in seven patients. Eighteen patients underwent additional PIPIs, and both VAS and ODI were significantly improved after additional PIPIs. CONCLUSION: Bone marrow lesions of the endplate are strongly associated with the presence of LBP. PIPI can be considered as an effective, safe and repeatable treatment for LBP in elderly DLS patients.

The medial tangent of the proximal tibia is a suitable extra-articular landmark in determining the tibial anteroposterior axis.

BACKGROUND: Tibial rotational alignment in total knee arthroplasty (TKA) is generally determined based on intra-articular structure, and can be difficult to ascertain in some cases. The aim of this study was to investigate whether the medial tangent angle of the tibia (MTAT) could be useful in determining the anteroposterior axis of the tibia. METHODS: This study was performed on 103 lower limbs in 53 patients who underwent primary total hip arthroplasty. The selection criteria for our study were based on the assumption that knees in patients undergoing THA exhibit fewer degenerative changes than knees in patients undergoing TKA. Using computed tomography images, the MTAT, comprising the medial tangent of the proximal tibia and the anteroposterior (AP) axis of the tibia, was measured on three horizontal planes: at the distal edge of the tibial tubercle (A), at 5 cm distally (B), and at 10 cm further distally (C). The tibial medial surface was grouped into three classes according to shape: valley type, flat type, and hill type. The percentage at which these shapes were observed in each group was also calculated. Measurement reliability was calculated using the intraclass correlation coefficient. RESULTS: The angles were 45.2° (interquartile range: IR 43.0-47.7) at A, 42.7° (IR 38.7-45.9) at B, and 42.4° (IR 38.2-45.9) at C. Intra-rater reliability and inter-rater reliability was 0.982 and 0.974 at A, 0.810 and 0.411 at B, and 0.940 and 0.811 at C, respectively. Regarding the tibial medial surface, the valley type was observed in all cases at A, and the hill type was observed in the highest percentage of cases at B and C. CONCLUSIONS: The MTAT was approximately 45° at level A, and reproducibility was the highest among the three groups. The two points forming the valley on the tibial medial surface were bony ridges. Therefore, the medial tangent of the tibia at level A could be easily determined. Because the distal edge of the tibial tubercle exists at the surgical area and the extra-articular area, it can be a suitable intraoperative, extra-articular landmark in determining the tibial AP axis, even for revision TKA.

The factors related to the poor ADL in the patients with osteoporotic vertebral fracture after instrumentation surgery.

PURPOSE: Osteoporotic vertebral fracture (OVF) with nonunion or neurological deficit may be a candidate for surgical treatment. However, some patients do not show improvement as expected. Therefore, we conducted a nationwide multicenter study to determine the predictors for postoperative poor activity of daily living (ADL) in patients with OVF. METHODS: We retrospectively reviewed the case histories of 309 patients with OVF who underwent surgery. To determine the factors predicting postoperative poor ADL, uni- and multivariate statistical analyses were performed. RESULTS: The frequency of poor ADL at final follow-up period was 9.1%. In univariate analysis, preoperative neurological deficit (OR, 4.1; 95% CI, 1.8-10.3; P < 0.001), perioperative complication (OR, 3.4; P = 0.006), absence of preoperative bone-modifying agent (BMA) administration (OR, 2.7; P = 0.03), and absence of postoperative recombinant human parathyroid hormone (rPTH) administration (OR, 3.9; P = 0.006) were significantly associated. In multivariate analysis, preoperative neurological deficit (OR, 4.6; P < 0.001), perioperative complication (OR, 3.4; P = 0.01), and absence of postoperative rPTH administration (OR, 3.9; P = 0.02) showed statistical significance. CONCLUSIONS: Preoperative neurological deficit, perioperative complication, and absence of postoperative rPTH administration were considered as predictors for postoperative poor ADL in patients with OVF. Neurological deficits and complications are often inevitable factors; therefore, rPTH is an important option for postoperative treatment for OVF. These slides can be retrieved under Electronic Supplementary Material.

The correlation between sagittal spinopelvic alignment and degree of lumbar degenerative spondylolisthesis.

BACKGROUND: Recently, several authors reported that a high pelvic incidence (PI) might be a predisposing factor to the development of anterior slip in the vertebral body in degenerative spondylolisthesis (DS). The purpose of this study was to analyze patients with DS using a multiple linear regression model, in terms of the correlation between the sagittal spinopelvic parameters and the severity of slip in each lumbar spine, including both anterior and posterior directions. METHODS: Standing lateral radiographs were taken of 104 patients (59 women and 45 men) with lower back pain. The spinopelvic parameters, including PI, sacral slope (SS) and pelvic tilt (PT), angle of thoracic kyphosis (TK), angle of lumbar lordosis (LL), and sagittal vertical axis offset (SVA) were measured. Additionally, the %Slip was measured at each level between the L1 and L5. The slip direction was presented as plus to the anterior, and minus to the posterior. RESULTS: The PI, SS, and/or LL correlate with L3, L4, and/or L5%Slips. The TK and SVA did not correlate with %Slip. A multiple linear regression model shows that PI and LL were significant predictors for L4 %Slip. The ROC curve demonstrated a PI cutoff value of 51.3° and an LL cutoff value of 45.0° to be predictors of anterior slip at L4. Also, our regression models revealed that PI for L3 %Slip and SS for L5 %Slip constitute significant risk factors, while determination coefficients were low. CONCLUSIONS: Our results suggest that high PI and LL are significant predictors for L4 anterior slip. At L4, the anterior slip risk-factor cutoff value was 51.3° for PI and 45.0°for LL. Additionally, our results suggest that high PI and SS could comprise risk factors for L3 anterior slip and L5 anterior slip, respectively.

Transforaminal percutaneous endoscopic discectomy for lumbar disc herniation in athletes under the local anesthesia.

BACKGROUND: Percutaneous endoscopic discectomy (PED) has been reported to be less invasive and effective procedure for lumbar disc herniation (LDH). Damage to the back muscle is considered minimal, which is particularly important for athletes. However, the results of PED for LDH in athletes have not been reported well. The purpose of this study was to evaluate the clinical outcomes of PED for LDH in athletes. METHODS: We retrospectively analyzed 21 athlete patients with LDH who had undergone PED. All patients received athletic rehabilitation immediately after surgery. The clinical outcomes were evaluated from the visual analogue scale (VAS) for leg pain and low back pain (LBP), the Oswestry Disability Index (ODI), complications and periods of return to sport. RESULTS: There were 18 men and 3 women, and the mean age at the time of surgery was 22.9 years (range: 15-43 years). The mean VAS scores for leg pain before and after surgery were 64.3 ± 2.7 mm and 12.4 ± 1.4 mm, respectively. The mean VAS scores for LBP before and after surgery were 62.1 ± 2.2 mm and 10.5 ± 1.1 mm, respectively. The mean ODI scores before and after surgery were 31.3 ± 14.0% and 14.6 ± 7.1%, respectively. The VAS for leg pain, as well as the LBP and ODI, significantly improved after surgery. There were no complications related to the surgery. Ninety-five percent (20/21) returned to play sports at the same performance level as before the procedure by an average of 9.2 weeks after PED. CONCLUSIONS: PED is a minimally invasive and effective procedure for patients with LDH, especially in athletes. Not only the patients' leg pain but also their discogenic LBP improved. PED has the benefits of preservation of normal posterior structures and a faster return to sports.

Correlation between spinal and pelvic movements during gait and aggravation of low back pain by gait loading in lumbar spinal stenosis patients.

BACKGROUND: Lumbar alignment of posterior or anterior tilts affects the exacerbation and remission of symptoms of lumbar spinal stenosis patients. This study aimed to clarify the correlation between spinal and pelvic movements during gait and the aggravation of low back pain after gait loading in lumbar spinal stenosis patients. METHODS: A total of 29 patients with lumbar spinal stenosis completed leg and low back pain assessments and gait analysis before and after gait loading tests. Patients were divided into leg and low back pain change (n = 8), leg pain only change (n = 12), and non-change (n = 9) groups based on the differences of leg and low back pain between before and after the tests. Peak kinematic values of the anterior tilts of the trunk, thoracic spine, lumbar spine, and pelvis during the stance phase were obtained via three-dimensional gait analysis. RESULTS: In the leg and low back pain change group, the anterior lumbar and pelvic tilts were larger after than before the tests; however, in the leg pain only change and non-change groups, only the anterior lumbar tilt was larger after than before the tests. Anterior lumbar tilt before and after the tests negatively correlated with the aggravation of low back pain, and an increase in the anterior pelvic tilt positively correlated with the aggravation of low back pain. CONCLUSIONS: In lumbar spinal stenosis patients, smaller anterior lumbar tilt and larger anterior pelvic tilt during gait loading may affect the aggravation of low back pain by gait loading. Increasing in lumbar lordosis during gait might be one of the factors leading to low back pain in lumbar spinal stenosis patients.

Discrimination of a nerve fiber that is the origin of a cauda equina tumor using acetylcholinesterase staining.

Spinal nerve sheath tumors are well known to typically originate from dorsal sensory nerve roots. However, it is difficult to anatomically identify the origin in the case of cauda equina tumors. In this study, we aimed to ascertain whether a cauda equina nerve root removed with a nerve sheath tumor was a motor nerve using acetylcholinesterase (AchE) staining. Nerve rootlet sections removed with tumors were stained for AchE using the AchE Rapid Staining Kit. Additionally, we performed intraoperative motor-evoked potential (MEP) monitoring following either transcranial electrical stimulation (TES) or electrical stimulation of nerve rootlets. The muscular strength of the lower extremities was assessed bilaterally before and after surgery using manual muscle testing. An AchE-positive motor nerve rootlet that was the origin of a cauda equina tumor was observed in one of the 12 patients. In this patient, a MEP in the right quadriceps evoked by electrical stimulation of this rootlet was detected. TES-MEP showed a 30% decrease in the amplitude in the right quadriceps evoked after tumor resection with this nerve rootlet. However, the motor strength in both lower extremities did not change after surgery. AchE staining and intraoperative MEP monitoring could detect the motor nerve rootlet that was the origin of a cauda equina tumor. Nerve sheath tumors originating from the motor nerve might be rare even in cauda equina.

The impact of hypertension on the occurrence of postoperative spinal epidural hematoma following single level microscopic posterior lumbar decompression surgery in a single institute.

PURPOSE: Postoperative spinal epidural hematoma (PSEH) is one of the most hazardous complications after spine surgery. A recent study has reported that a ≥50 mmHg increase in systolic blood pressure after extubation was a significant risk factor for symptomatic PSEH. In this paper, the impact of hypertension on PSEH occurrence was investigated. METHODS: Among a total of 2468 patients who underwent single level microscopic posterior decompression surgery for lumbar spinal stenosis in a single institute, 15 (0.6%) received evacuation surgery for PSEH. Those 15 patients were investigated statistically compared with a randomly selected control group (n = 46) using the Mann-Whitney U test and multiple logistic regression analysis. RESULTS: The univariate analysis showed that there were no significant differences in age, gender, BMI, pre-operative anti-coagulant usage, intraoperative blood loss, operation time, and the rate of patients who received pre-operative hypertension treatment. However, there were significant differences in the rate of patients who showed high blood pressure at admission (66.7 vs 6.5%) and >50 mmHg increases in blood pressure after extubation (53.3 vs 17.4%) in the univariate analysis. Moreover, postoperatively, there was a statistical difference in the amount of post-operative drainage. Multiple logistic regression analysis showed that high blood pressures at admission and poor postoperative drainage were the essential risk factors. CONCLUSIONS: Our results demonstrate that the pre-operative high blood pressure value was the most essential risk factor for PSEH, although there was no difference in the preoperative hypertension treatment. Consequently, management of pre-operative blood pressure and post-operative drainage will be crucial for preventing PSEH.

C2 spondylotic radiculopathy: the nerve root impingement mechanism investigated by para-sagittal CT/MRI, dynamic rotational CT, intraoperative microscopic findings, and treated by microscopic posterior foraminotomy.

PURPOSE: C2 radiculopathy is known to cause occipito-cervical pain, but their pathology is unclear because of its rarity and unique anatomy. In this paper, we investigated the mechanism of C2 radiculopathy that underwent microscopic cervical foraminotomies (MCF). METHODS: Three cases with C2 radiculopathy treated by MCF were investigated retrospectively. The mean follow-up period was 24 months. Pre-operative symptoms, imaging studies including para-sagittal CT and MRI, rotational dynamic CT, and intraoperative findings were investigated. RESULTS: There were 1 male and 2 females. The age of patients were ranged from 50 to 79 years. All cases had intractable occipito-cervical pain elicited by the cervical rotation. C2 nerve root block was temporally effective. There was unilateral spondylosis in symptomatic side without obvious atlatoaxial instability. Para-sagittal MRI and CT showed severe foraminal stenosis at C1-C2 due to the bony spur derived from the lateral atlanto-axial joints. In one case, dynamic rotational CT showed that the symptomatic foramen became narrower on rotational position. MCF was performed in all cases, and the C2 nerve root was impinged between the inferior edge of the C1 posterior arch and bony spur from the C1-C2 joint. After surgery, occipito-cervical pain disappeared. CONCLUSION: This study demonstrated that mechanical impingement of the C2 nerve root is one of the causes of occipito-cervical pain and it was successfully treated by microscopic resection of the inferior edge of the C1 posterior arch. Para-sagittal CT and MRI, rotational dynamic CT, and nerve root block were effective for diagnosis.

Clinical results of microsurgical bilateral decompression via unilateral approach for lumbar canal stenosis with multiple-level involvement.

OBJECT: Microsurgical decompression of the lumbar spine is a beneficial approach for selected patients of lumbar spinal stenosis (LSS). The purpose of this prospective study was to describe the clinical results of surgical treatment for microsurgical bilateral decompression via unilateral approach on patients with LSS with multiple-level involvement. MATERIALS AND METHODS: Seventy-three consecutive patients who had microsurgical bilateral decompression via unilateral approach of more than two spinal levels were included in this study. Seventy-seven patients who had surgery at a single level over the same time periods were compared as a single-level LSS group. RESULTS: The preoperative Japanese Orthopaedic Association scores averaged 11.7 points, and the postoperative scores averaged 21.2 points with an average recovery rate (RR) of 56% in the multiple-level LSS group. There was no significant difference in the RR between the groups. There were no major complications related to the surgery in the both groups. CONCLUSION: Microsurgical bilateral decompression via unilateral approach was a useful and safe operative procedure for LSS patients. Sufficient clinical results that were comparable to single-level LSS patients were obtained even in the patients with multiple-level LSS, if the patient were correctly selected and the microsurgical decompression surgery were carefully performed.

Changes in Health-Related Quality of Life by Patient Education and Rehabilitation Based on a Behavior Change Program in Knee Osteoarthritis.

OBJECTIVE: The purpose of this study was to examine how rehabilitation and patient education for knee osteoarthritis improves health-related quality of life (HRQOL) and to identify factors influencing HRQOL. METHODS: Between May 2020 and March 2022, 30 patients with osteoarthritis of the knee were treated conservatively and rehabilitated with a patient education program. The patient education program was based on the health belief model by Sedlak et al., and patient education using pamphlets was provided during the rehabilitation intervention. The survey items were patient basic information, instrumental activities of daily living (ADL) (FAI), fear of falling (FES), degree of depression (GDS), HRQOL (SF-8), knee function assessment (JOA score), and X-ray classification (K-L classification), and the survey method was a self-administered questionnaire at the start of rehabilitation, 1 month after the intervention, and at the end of the rehabilitation intervention. We examined factors affecting the physical component summary (PCS) and mental component summary (MCS) of HRQOL scores. RESULTS: JOA score, FES, FAI, GDS, and SF-8 improved significantly (p<0.01). MCS was also negatively correlated with FES and age (r=-0.486, -0.368). Sex was extracted as a factor for PCS as a factor affecting HRQOL (p<0.01). MCS was extracted with FES as a factor (p=0.046). CONCLUSION: A rehabilitation intervention incorporating patient education in osteoarthritis of the knee showed improvement in HRQOL and may be useful for improving depression, fear of falling, and instrumental ADL.

Femoral Tunnel Position in Anatomical Double-bundle ACL Reconstruction is not Affected by Blumensaat's Line Morphology.

The aim of this study was to reveal the influence of the morphological variations of the Blumensaat's line on anteromedial (AM) and posterolateral (PL) femoral tunnel position in anatomical double-bundle anterior cruciate ligament (ACL) reconstruction.Fifty-three subjects undergoing anatomical double-bundle ACL reconstruction were included (29 female, 24 male; median age 27.4 years; range: 14-50 years). Using an inside-out transportal technique, the PL tunnel position was made on a line drawn vertically from the bottommost point of the lateral condyle at 90 degrees of knee flexion, spanning a distance of 5 to 8 mm, to the edge of the joint cartilage. AM tunnel position was made 2 mm distal to the PL tunnel position. Following Iriuchishima's classification, the morphology of the Blumensaat's line was classified into straight and hill (large and small) types. Femoral tunnel position was determined using the quadrant method. A Mann-Whitney U test was performed to compare straight and hill type knees according to AM and PL femoral tunnel position.There were 18 straight and 35 hill type knees (13 small and 22 large hill). AM and PL femoral tunnel position in straight type knees were 21.7 ± 7.0 and 33.6 ± 10.5% in the shallow-deep direction, and 42.1 ± 11.1 and 72.1 ± 8.5% in the high-low direction, respectively. In hill type knees, AM and PL femoral tunnel position were 21.3 ± 5.8 and 36.9 ± 7.1% in the shallow-deep direction, and 44.6 ± 10.7 and 72.1 ± 9.7% in the high-low direction, respectively. No significant difference in AM or PL femoral tunnel position was detected between straight and hill type knees.AM and PL femoral tunnel position in anatomical double-bundle ACL reconstruction was not affected by the morphological variations of the Blumensaat's line. Surgeons do not need to consider Blumensaat's line morphology if AM and PL femoral tunnel position is targeted at the bottommost point of the lateral condyle. This was a level of evidence III study.

Therapeutic potential of dedifferentiated fat cells in a rat model of osteoarthritis of the knee.

Introduction: Mature adipocyte-derived dedifferentiated fat cells (DFATs) represent a subtype of multipotent cells that exhibit comparable phenotypic and functional characteristics to adipose-derived stem cells (ASCs). In this study, we assessed the chondroprotective properties of intra-articularly administrated DFATs in a rat model of osteoarthritis (OA). We also investigated in vitro the expression of anti-inflammatory and chondroprotective genes in DFATs prepared from the infrapatellar fat pad (IFP) and subcutaneous adipose-tissue (SC) of human origin. Methods: In the cell transplantation experiment, rats were assigned to the DFAT and Control group (n = 10 in each group) and underwent anterior cruciate ligament transection (ACLT) accompanied by medial meniscus resection (MMx) to induce OA. One week later, they received intra-articular injections of 1 × 106 DFATs (DFAT group) or PBS (control group) four times, with a weekly administration frequency. Macroscopic and microscopic evaluations were conducted five weeks post-surgery. In the in vitro experiments. DFATs derived from the IFP (IFP-DFATs) and SC (SC-DFATs) were prepared from donor-matched tissue samples (n = 3). The gene expression of PTGS2, TNFAIP6, PRG4, BMP2, and BMP6 under TNF-α or IFN-γ stimulation in these cells was evaluated using RT-PCR. Furthermore, the effect of co-culturing synovial fibroblasts with DFATs on the gene expression of ADAMTS4 and IL-6 were evaluated. Results: Intra-articular injections of DFATs significantly inhibited cartilage degeneration in the rat OA model induced by ACLT and MMx. RT-PCR analysis revealed that both IFP-DFATs and SC-DFATs upregulated the expression of genes involved in immune regulation, anti-inflammation, and cartilage protection such as PTGS2, TNFAIP6, and BMP2, under stimulation by inflammatory cytokines. Co-culture with DFATs suppressed the expression of ADAMTS4 and IL6 in synovial fibroblasts. Conclusions: The intra-articular injection of DFATs resulted in chondroprotective effects in the rat OA model. Both SC-DFATs and IFP-DFATs induced the expression of anti-inflammatory and chondroprotective genes in vitro. These results indicate that DFATs appear to possess therapeutic potential in inhibiting cartilage degradation and could serve as a promising cellular resource for OA treatment.

Evaluation of the Angle Between the Long Axis of the Femoral Anterior Cruciate Ligament Footprint and Bony Morphology of the Knee: A Cadaveric Descriptive Study.

Purpose: There have been numerous studies of the anterior cruciate ligament (ACL) anatomy, but few have focused on the long axis angle of the femoral ACL footprint. This study investigated the angle between the long axis of the femoral ACL footprint and the bony morphology of the knee. Methods: This study is a cadaveric descriptive study. Thirty non-paired formalin-fixed knees of Japanese cadavers were used. Anteromedial (AM) and posterolateral (PL) bundles were identified according to the tension pattern differences during the complete range of motion of the knee. In the ACL femoral footprint, there is a fold between the mid-substance insertion site and fan-like extension fibers. After identifying AM and PL bundles of mid-substance fibers, the mid-substance and fan-like extension fibers were divided into those bundles and stained. We defined the line passing through the center of the AM and PL bundles as the long axis of the ACL. The center points of each of the four areas and the angle between the long axis of the ACL and the bony morphology of the knee were calculated using Image J software. Results: The mean angle between the axis of the femoral shaft and the long axis of the ACL mid-substance insertion was 28.8 ± 12.2 degrees. The mean angle between the Blumensaat line and the long axis of the mid-substance was 54.2 ± 13.5 degrees. Conclusion: The mean angle between the axis of the femoral shaft and the long axis of the femoral ACL footprint was approximately 29 degrees. There is a wide variation in the long axis of the femoral ACL footprint. To achieve better clinical results through a more anatomically accurate reconstruction, it can be beneficial to replicate the ACL femoral footprint along its native long axis.