Arthroscopic excision of os acromiale: effects on deltoid function and strength.

Arthroscopic excision of os acromiale is a feasible alternative to open excision or fusion. This article describes the authors' experience with 28 patients (31 shoulders) who underwent arthroscopic excision of os acromiale and its effect on shoulder pain and function, with specific emphasis on deltoid strength measurement. Thirty-one os acromiale (all persistent unfused pre- and meso-acromions) in 28 patients were excised arthroscopically. Sixteen patients underwent concomitant rotator cuff repair (9 arthroscopic and 7 mini-open). At an average follow-up of 41 months, the patients were assessed using the American Shoulder and Elbow Surgeons (ASES) score, and deltoid function and strength were measured. Pain was completely alleviated postoperatively in 20 (65%) shoulders, and 9 (29%) shoulders had less pain postoperatively. Pain worsened postoperatively in 2 patients, both of whom had features of glenohumeral arthritis at arthroscopy. Average postoperative ASES score (80.33) was significantly improved compared with the average preoperative score (33.71). No significant loss of deltoid strength occurred compared with the contralateral side. No objective or subjective loss of normal deltoid appearance occurred. Rotator cuff repair did not compromise deltoid strength or significantly reduce ASES score irrespective of repair technique (arthroscopic vs mini-open). With careful attention to surgical technique maintaining an intact periosteal sleeve to preserve the integrity of the deltoid attachment, arthroscopic excision is an effective management tool for mobile os acromiale in a painful shoulder requiring surgical intervention.

Functional and proteomic analysis of serum and cerebrospinal fluid derived from patients with traumatic brain injury: a pilot study.

BACKGROUND: An enhanced fracture healing response has been reported in patients with traumatic brain injury (TBI). This has been attributed to circulating humoral factors that are thought to be proteins produced and released by the injured brain. However, these factors remain unknown. The aim of this study was to identify osteogenic factors in serum and cerebrospinal fluid (CSF) from TBI patients. This was carried out using in vitro proliferation assays with the human foetal osteoblastic 1.19 cell line (hFOB) combined with a novel proteomic approach. METHODS: Serum was collected from brain-injured (n = 12) and non-brain-injured (n = 9) patients with a comorbid femur shaft fracture. Similarly, CSF was obtained from TBI (n = 7) and non-TBI (n = 9) patients. The osteoinductive potential of these samples was determined by measuring the in vitro proliferation rate of hFOB cells. Highly osteogenic serum and CSF samples of TBI patients were chosen for protein analysis and were compared to those of non-brain-injured patients. A new hFOB cell-based method was used to enrich the proteins in these samples, which had a functional affinity for these osteoprogenitor cells. These enriched protein fractions were mapped using two-dimensional gel electrophoresis and protein imaging methods displaying serum and CSF proteins of brain-injured and control subjects that had an affinity for human osteoprogenitor cells. RESULTS: Serum and CSF derived from brain-injured patients demonstrated a greater osteoinductive potential (P < 0.05) than their non-brain-injured counterparts. Clear-cut differences in the pattern of proteins in two-dimensional gels were detected between TBI and control patients. Fourteen proteins were exclusively present in the serum of TBI patients, while other proteins were either up- or downregulated in samples collected from TBI patients (P < 0.05). CONCLUSION: Osteoinductive factors are present in the serum and CSF of brain-injured patients. These may include one or more of those proteins identified as having an affinity for osteoprogenitor cells that are either exclusively present or up- or downregulated in the serum and CSF of brain-injured patients.

Serum after traumatic brain injury increases proliferation and supports expression of osteoblast markers in muscle cells.

BACKGROUND: Traumatic brain injury is associated with an increased rate of heterotopic ossification within skeletal muscle, possibly as a result of humoral factors. In this study, we investigated whether cells from skeletal muscle adopt an osteoblastic phenotype in response to serum from patients with traumatic brain injury. METHODS: Serum was collected from thirteen patients with severe traumatic brain injury, fourteen patients with a long-bone fracture, and ten control subjects. Primary cultures of skeletal muscle cells isolated from patients undergoing orthopaedic surgery were performed and characterized with use of immunofluorescence microscopy, reverse transcription-polymerase chain reaction, and Western blot analysis. Proliferation and osteoblastic differentiation were assessed with use of commercial cell assays, Western blot analysis (for Osterix protein), and the Villanueva bone stain. RESULTS: All serum-treated cell populations expressed the osteoblast marker Osterix after one week in culture. Cells treated with serum from all study groups in mineralization medium had increased alkaline phosphatase activity and mineralized nodules within the mesenchymal cell subpopulation after three weeks in culture. Serum from patients with traumatic brain injury induced a significant increase (p = 0.02) in the rate of proliferation of primary skeletal muscle cells (1.87 [95% confidence interval, 1.66 to 2.09]) compared with the rate induced by serum from patients with a fracture (1.42 [95% confidence interval, 1.21 to 1.58]) or by serum from controls (1.35 [95% confidence interval, 1.15 to 1.54]). CONCLUSIONS: Human serum supports the osteoblastic differentiation of cells derived from human skeletal muscle, and serum from patients with severe traumatic brain injury accelerates proliferation of these cells. These findings suggest the early presence of humoral factors following traumatic brain injury that stimulate the expansion of mesenchymal cells and osteoprogenitors within skeletal muscle.

Immune response deviation and enhanced expression of chemokine receptor CCR4 in TBI patients due to unknown serum factors.

BACKGROUND: Severe brain trauma leads to an activation of the immune system. To this date, neither the exact perturbation of the specific immune reaction induced by the traumatic brain injury (TBI), nor the interactions leading to the infiltration of peripheral immune cells into the brain are fully understood. PATIENTS AND METHODS: Serum was collected from 17 patients with TBI and a long bone fracture, 24 patients with an isolated long bone fracture and from healthy individuals. The effect of the serum on normal human monocytes and T-lymphocytes was tested in vitro by assessing proliferation and expression of surface markers, chemokine receptors and cytokines. RESULTS: Serum collected from patients with a TBI and a long bone fracture increased the expression of the chemokine receptor CCR4 in monocytes when compared to patients with an isolated long bone fracture. Extending this comparison to T-lymphocytes, the serum from TBI patients induced lower proliferation rates and decreased expression of the pro-inflammatory cytokine TNF-alpha, while simultaneously increasing the secretion of immune-modulatory cytokines (IL-4, IL-10 and TGF-beta) (p<0.05). CONCLUSION: Patients with a TBI release currently unknown soluble factors into the circulating blood that up regulate expression of chemokine receptor CCR4 in peripheral blood monocytes whilst concurrently inducing expression of immunosuppressive cytokines by activated T-lymphocytes.

Serum-mediated osteogenic effect in traumatic brain-injured patients.

BACKGROUND: Patients with a traumatic brain injury (TBI) and bone fractures often show an enhanced fracture healing, as well as an increased incidence of heterotopic ossifications (HO). It has been suggested that unknown osteoinductive factors may be released by the injured brain into the systemic blood circulation and act peripherally on the affected tissues. The aim of this study was to investigate whether serum from TBI patients is osteoinductive. METHODS: Sixty-one consecutive patients were classified into four groups: TBI and long-bone fracture (group I, n = 12), isolated severe TBI (group II, n = 21), isolated long-bone fracture (group III, n = 19) and controls (group IV, n = 9). Blood samples were collected at 6, 24, 72 and 168 h post-injury. The osteogenic potential was determined by measuring the in vitro proliferation rate of the human fetal osteoblastic cell line hFOB1.19, and primary human osteoblasts. Additionally, serum induced osteoblastic differentiation was assessed by measuring the mRNA expression of specific osteoblastic markers, including alkaline phosphatase, runt-related transcription factor 2, cathepsin K and serine protease 7. RESULTS: The sera of group I induced a higher mean proliferation rate of primary human osteoblasts at all time points of sampling than group III (P < 0.05). Group I had a higher mean proliferation rate of hFOB1.19 cells than all other groups at 6, 24 and 72 h post-injury (P < 0.05). The expression of alkaline phosphatase, cathepsin K and runt-related transcription factor 2 mRNA was increased in group I compared with group III and serine protease 7 was exclusively expressed in group I. CONCLUSION: The study results strongly support a humoral mechanism in enhanced fracture healing and the induction of HO after TBI. Increased proliferation of osteoblastic cells and an accelerated differentiation of osteoprogenitor cells may be responsible for increased osteogenesis in TBI.

Humoral factors enhance fracture-healing and callus formation in patients with traumatic brain injury.

BACKGROUND: Scientific evidence is mounting for an association between traumatic brain injury and enhanced osteogenesis. The aim of this study was to correlate the in vitro osteoinductive potential of serum with the features of fracture-healing and the extent of brain damage in patients with severe traumatic brain injury and bone fracture. METHODS: Patients with a long-bone fracture and a traumatic brain injury (seventeen patients) or without a brain injury (twenty-four patients) were recruited. The Glasgow Coma Scale score was determined on admission. Radiographs of the fracture were made before surgery, at six weeks, and at three, six, and twelve months after surgery. The time to union was estimated clinically and radiographically, and the callus ratio to shaft diameter was calculated. Serum samples were collected at six, twenty-four, seventy-two, and 168 hours after injury, and their osteogenic potential was determined by measurement of the in vitro proliferation rate of the human fetal osteoblastic cell line hFOB1.19. RESULTS: Patients with a traumatic brain injury had a twofold shorter time to union (p = 0.01), a 37% to 50% increased callus ratio (p < 0.01), and their sera induced a higher proliferation rate in hFOB cells (p < 0.05). A linear relationship was revealed between hFOB cell proliferation rates and the amount of callus formed (p < 0.05). The Glasgow Coma Scale score was correlated with the callus ratio on both radiographic projections (p < 0.05), time to union (p = 0.04), and the proliferation rate of hFOB cells at six hours after injury (p = 0.03). CONCLUSIONS: Patients with a severe brain injury release unknown humoral factors into the blood circulation that enhance and accelerate fracture-healing.

Arthroscopic suprascapular neurectomy for the management of severe shoulder pain.

HYPOTHESIS: Arthroscopic suprascapular neurectomy is an effective option in the management of patients with severe shoulder pain MATERIALS AND METHODS: We describe and evaluate a technique of suprascapular neurectomy, performed arthroscopically for the treatment of severe shoulder pain in 20 patients (17 with a rotator cuff arthropathy, two with glenohumeral arthritis and one with a rotator cuff deficient shoulder following an unsuccessful arthrodesis). Post-operative pain relief was measured using a new pain scoring system, which combined an assessment of the frequency and severity of pain experienced at night, at rest, with activities and any change in analgesic consumption. RESULTS: At an average follow-up of 29 months, 75% of our patients reported good to excellent pain relief scores, 85% reported less night pain, 90% had less rest pain, 70% reported less pain on movement, whilst 75% reported less consumption of pain medication. There were no surgical complications. DISCUSSION: Suprascapular neurectomy performed arthroscopically provides an additional surgical option in the management of pain in patients with cuff tear arthropathy and in other selected patients with no functioning rotator cuff. The pain scoring system introduced in this article provides a more comprehensive assessment of shoulder pain than existing pain scores. CONCLUSION: We conclude that arthroscopic suprascapular neurectomy introduces an additional effective option in the management of pain in patients with these pathologies. LEVEL OF EVIDENCE: Level 4; Retrospective case series, no control group.

Osteoinductive effect of cerebrospinal fluid from brain-injured patients.

Patients with traumatic brain injury (TBI) are predisposed to heterotopic ossification, which is believed to be due to osteoinductive factors released at the site of the brain injury. To date, little is known about the presence of such factors in human cerebrospinal fluid (CSF). This study investigated whether CSF of TBI patients is osteoinductive. In addition, known osteoinductive factors--such as bone morphogenetic protein (BMP)-2, BMP-4, and BMP-7, and S100B--were measured in CSF. Eighty-four consecutive patients were classified according to brain pathology: TBI (n = 11), non-traumatic brain pathology (NTBP) (n = 26), and no brain pathology (control group) (n = 47). The osteoinductive effect of CSF was measured repeatedly in proliferation assays using a fetal human osteoblast cell line. The mean proliferation rate (normalized to the internal negative control) of the TBI, NTBP, and control groups was 138.2% (SD 13.1), 110.0% (SD 22.1), and 118.8% (SD 16.9), respectively. The potentially confounding effect of age was investigated further by restricting the selection of patients for analysis to that of the oldest patient in the TBI group and use of multiple regression analysis. After implementation of both, it was shown that age is highly unlikely to account for the higher rates of proliferation observed among the TBI patients in this study. Of note, the TBI group had a significantly higher mean proliferation rate than the NTBP (p = 0.001) and the control group (p = 0.006). S100B and BMP-2, -4, or -7 concentrations were measured using enzyme-linked immunosorbent assay (ELISA). There was no correlation between proliferation rates and S100B (r = 0.023). Only three of 36 CSF samples had measurable levels of BMP-2 and -7, and none had detectable concentrations of BMP-4. Consequently, it is unlikely that S100B or BMP-2, -4, or -7 are the putative osteoinductive factors. The results indicate that CSF from TBI patients has an osteoinductive effect in vitro. However, the osteoinductive factor has still to be characterized.

Sideswipe injuries to the elbow in Western Australia.

OBJECTIVE: To examine the conditions leading to sideswipe injury of the upper limb in motor vehicle accidents and to highlight the severity of these injuries. DESIGN AND SETTING: Prospective study of upper-limb sideswipe injuries in patients admitted to Royal Perth Hospital, Western Australia, between August 2003 and January 2005. PARTICIPANTS: Eleven patients sustaining sideswipe injuries to the upper limb. MAIN OUTCOME MEASURES: Accident pattern, type of injury, surgical management, complications, and functional and employment implications. RESULTS: Ten patients required open reduction and internal fixation for open fractures of the humerus, ulna and radius, and nine underwent additional surgical procedures including nerve, artery and tendon repair, and free flaps and split-skin grafting. The injury severity scores ranged from 9 to 25. The severity of injuries led to extensive functional deficits in eight patients, affecting employment prospects in seven. CONCLUSION: Appropriate educational programs, legislation and improvements in traffic conditions, especially in rural areas, as well as changes in current car design, could contribute to preventing these devastating and complex injuries.