Shockwave Treatment Enhanced Extracellular Matrix Production in Articular Chondrocytes Through Activation of the ROS/MAPK/Nrf2 Signaling Pathway.

OBJECTIVE: Shockwave application is a potential treatment for osteoarthritis (OA), but the underlying mechanism remains unknown. Oxidative stress and a counterbalancing antioxidant system might be the key to understanding this mechanism. We hypothesized that reactive oxygen species (ROS) and the transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2),which is an important regulator of cellular redox homeostasis, are plausible elements. DESIGN: Porcine chondrocytes were cultured in a 3-dimensional pellet model and subjected to shockwaves. The effects of shockwaves with various energy-flux densities on optimal extracellular matrix (ECM) synthesis were assessed. ROS, mitogen-activated protein kinase (MAPK) signaling, and the redox activity of Nrf2 were measured. To investigate the signaling mechanism involved in the shockwave treatment in chondrocytes, specific inhibitors of ROS, MAPK signaling, and Nrf2 activity were targeted. RESULTS: Shockwaves increased ECM synthesis without affecting cell viability or proliferation. Furthermore, they induced transient ROS production mainly through xanthine oxidase. The phosphorylation of ERK1/2 and p38 and the nuclear translocation of Nrf2 were activated by shockwaves. By contrast, suppression of ROS signaling mitigated shockwave-induced MAPK phosphorylation, Nrf2 nuclear translocation, and ECM synthesis. Pretreatment of chondrocytes with the specific inhibitors of MEK1/2 and p38, respectively, mitigated the shockwave-induced nuclear translocation of Nrf2 and ECM synthesis. Nrf2 inhibition by both small hairpin RNA knockdown and brusatol reduced the shockwave-enhanced ECM synthesis. CONCLUSIONS: Shockwaves activated Nrf2 activity through the induction of transient ROS signaling and subsequently enhanced ECM synthesis in chondrocytes. This study provided fundamental evidence confirming the potential of shockwaves for OA management.

Early Post-Operative Intervention of Whole-Body Vibration in Patients After Total Knee Arthroplasty: A Pilot Study.

(1) Background: Knee osteoarthritis causes pain, weakness, muscle atrophy, and disability. The application of whole-body vibration in patients with knee osteoarthritis can improve strength, balance, and functional activities. The purpose of the study is to evaluate the effects of early whole-body vibration intervention in patients after total knee arthroplasty. (2) Method: A single-blinded randomized control trial. Fifty-two patients with knee osteoarthritis post total knee replacement from a medical center in southern Taiwan were randomly assigned to either a whole-body vibration group or control group. Main outcome measures included pain severity, leg circumference, knee range of motion, knee extensor strength, a five-times sit to stand test, and a timed up and go test. (3) Results: Immediately post treatment, the patients in the vibration group showed a significant increase in knee extensor strength and improvement in calf swelling compared to the control group. A trend toward decrease in pain severity and improvement in functional performance were observed in both groups without a significant difference between the groups. There was no significant difference in knee range of motion (ROM) and functional performance between the groups. (4) Conclusions: The whole-body vibration intervention in patients early post total knee arthroplasty showed significant immediate effect in increasing knee extensor strength and decreasing calf swelling.

Complications and technical pitfalls of titanium elastic nail fixation for midclavicular fractures.

Intramedullary titanium elastic nails have been reported to fix displaced midclavicular fractures with excellent functional outcomes and minor complications. This study reports and analyzes the complications and technical pitfalls associated with titanium elastic nail fixation of displaced midclavicular fractures and describes how to prevent these problems. The authors operated on 27 patients (17 men, 10 women; mean age, 45.8 years; range, 16.5-66.9 years) with marked displaced midclavicular fractures using intramedullary titanium elastic nail fixation. The mean Constant score and Disability of the Arm, Shoulder, and Hand score were 93.58 (range, 66.5-100) and 6.22 (range, 0-35), respectively. The mean length difference compared with the contralateral clavicle was a shortening of 0.3 cm (range, -1.5 to 1 cm). Eight patients (30%) had different levels of difficulty at the medial entry point. Clavicular length shortening of more than 1 cm occurred in 5 patients (19%), and all of these patients experienced medial nail tip prominence/protrusion. One patient had 1-cm lengthening of the injured clavicle caused by distraction of the fracture site during titanium elastic nail insertion. Iatrogenic perforation of the posterolateral cortex occurred in 3 patients. Initial misplaced nail insertion occurred in 1 woman who underwent revision with the mini-open method. In 2 patients it was impossible to remove the full nail under general anesthesia. In conclusion, high patient satisfaction and functional outcomes were achieved after titanium elastic nail fixation of displaced midclavicular fractures. However, some complications and technical pitfalls must be considered before titanium elastic nails are used to fix displaced midclavicular fractures.

Aggressive continuous passive motion exercise does not improve knee range of motion after total knee arthroplasty.

AIMS AND OBJECTIVES: The aim of this study was to evaluate the effects of continuous passive motion on the range of motion, postoperative pain and life quality of patients undergoing total knee arthroplasty within six months after the operation. BACKGROUND: Total knee arthroplasty reduces pain and improves range of motion of the osteoarthritic knee joint. Continuous passive motion increases postoperative movement, but there is some controversy regarding whether aggressive continuous passive motion can improve range of motion or life quality, and whether it induces more pain. DESIGN: A prospective controlled study was conducted in a medical centre in Taiwan from January to December 2006. METHODS: One hundred and seven patients were recruited. The patients underwent the basic rehabilitation protocols (the control group) or the basic rehabilitation protocols and additional daily use of continuous passive motion for more than six hours per day (the experimental group). The range of motion, modified Short Form-36 (SF-36) and semi-quantitative visual analogue scale were recorded. Results. Range of motion increased from 109° preoperatively to 125° at six months postoperatively in the treatment group and from 111° preoperatively to 125° at six months postoperatively in the control group. Visual analogue scale decreased from 7·78 preoperatively to 0·37 at six months postoperatively in the treatment group and from 7·92 preoperatively to 0·21 at six months postoperatively in the control group. The SF-36 improved from 3·76 preoperatively to 1·77 at six months postoperatively in the treatment group and from 3·68 preoperatively to 1·83 at six months postoperatively in the control group. There was no significant difference in range of motion, visual analogue scale and SF-36 between groups at each visit. CONCLUSION: With the advances in total knee arthroplasty surgical technique, aggressive continuous passive motion does not provide obvious benefits. RELEVANCE TO CLINICAL PRACTICE: Total knee arthroplasty can alleviate pain and improve range of motion, but aggressive continuous passive motion does not provide additional benefits.

Surgical treatment of melorheostosis: report of two cases.

Melorheostosis is a rare disease that usually burdens the patient with painful disability or soft tissue compromise. The treatment is usually symptomatic and conservative. Patients with severe and complicated forms of the disease may require surgery. Involvement of the distal part of a limb usually carries more morbidity, such as tumefaction pain, cosmetic and psychosocial or functional problems that render conservative treatment unsatisfactory to patients. In our series, surgical debulking or decompression of the mass effect provided prompt symptom relief.

In vivo 1H MRS for musculoskeletal lesion characterization: which factors affect diagnostic accuracy?

In vivo (1)H MRS is a noninvasive imaging technique for the identification of malignancy. Musculoskeletal lesions vary in their composition, causing field inhomogeneity and magnetic susceptibility effects which may be technical and diagnostic challenges for MRS. This study investigated the factors that affect diagnostic accuracy in the use of MRS for the characterization of musculoskeletal neoplasms. During a 7-year period, 210 consecutive patients with musculoskeletal lesions larger than 1.5 cm in diameter were examined. MRS of a single-voxel point-resolved spectroscopy sequence with TE = 135 ms was undertaken using a 1.5-T scanner. Lesions with a choline signal-to-noise ratio larger than 3.0 were considered to be malignant tumors. The diagnostic accuracy was calculated for all lesions and for subgroups on the basis of lesion type (bone and soft tissue), lesion composition (mixed and solid nonsclerotic), lesion size (≤4, >4-10 and >10 cm), MR scanner (MR scanner 1 and 2) and selected voxel size (≤3, >3-8 and >8 cm(3)). Multivariate logistic regressions were performed to estimate the associations between each factor and diagnostic accuracy. The diagnostic accuracy was 73.3% for all lesions. The accuracy was 54.4% for mixed lesions and 80.4% for solid nonsclerotic lesions (p < 0.001). The diagnostic accuracy was lower for larger lesions [86.8% for lesions of ≤4 cm, 71.6% for lesions of >4-10 cm (p = 0.04) and 63.6% for lesions of >10 cm (p = 0.007)]. There was no difference in diagnostic accuracy for bone versus soft-tissue lesions or as a function of MR scanner or voxel size. By the use of multivariate logistic regression, a solid nonsclerotic lesion was 3.15 times (95% confidence interval, 1.59-6.27) more likely than a mixed lesion to have a diagnosis (p = 0.001). MRS can be used to characterize musculoskeletal lesions, particularly solid nonsclerotic lesions.

Minimally invasive fixation of displaced midclavicular fractures with titanium elastic nails.

OBJECTIVES: Clavicular fractures account for 2.6% of all fractures, and more than 80% involve the middle third of the clavicle. Plate fixation has been the most common method of fixation reported but has been associated with complications such as infection, wound breakdown, nonunion, implant failures, poor cosmetic outcome, and local skin numbness. We report on a series of cases receiving minimally invasive insertion of titanium elastic nails (TEN) to fix the displaced midclavicular fractures. DESIGN: Prospective, clinical study. SETTING: Regional referral center. PATIENTS/PARTICIPANTS: From November 2006 to October 2007, we operated on 23 patients (16 men) with displaced (no cortical contact between the proximal and distal fragments radiographically and/or greater than 2 cm of shortening) midclavicular fractures fixed with TEN. The mean age of the patients was 41.57 years. INTERVENTION: All patients with displaced midclavicular fractures were treated with TEN. The nails were inserted from the medial entry point on the sternal end and passed through the fracture site under fluoroscopy monitoring. MAIN OUTCOME MEASUREMENTS: Complications, clavicular shortening after TEN fixation, Constant shoulder score, and Disability of the Arm, Shoulder, and Hand score for functional outcome measurement. RESULTS: Closed reduction was successful in 16 patients, and seven patients needed open reduction. There was no nonunion, infection, nail breakage, or refracture after nail removal in our series. The mean operative wound length was 2.2 cm, and mean clavicular length shortening was 0.32 cm. Iatrogenic perforation of the lateral cortex occurred in two patients, and nail misplacement occurred in one patient requiring revision. All patients followed up greater than 12 months. The mean Disability of the Arm, Shoulder, and Hand score was 6 (range, 0-35; standard deviation, 10.47) and mean Constant score was 96 (range, 78-100; standard deviation, 6.34). CONCLUSIONS: Minimally invasive fixation with TEN is a safe method and can be performed with minor complications. This method of fixation of displaced midclaviclular fractures should result in a good cosmetic appearance and satisfactory stabilization of displaced midclavicular fractures without comminution.

Intramuscular low-grade fibromyxoid sarcoma: a case report.

Low-grade fibromyxoid sarcoma (LGFMS) is a rare neoplasm that commonly arises in the deep soft tissues of the lower extremities, particularly in the thigh. LGFMS occurs preferentially in young male adults. The microscopic appearance of LGFMS exhibits bland fibroblastic spindle cells with a whorled or linear arrangement in fibrous and myxoid areas. Although LGFMS has a deceptively benign histologic appearance, local recurrence and late metastases have frequently been reported. Diagnosis of LGFMS is still difficult because of its characteristic bland-looking histologic features that can be confused with other benign or low-grade fibromyxoid lesions. Although immunohistochemical staining can offer an overview of the differential diagnosis of myxoid tumors of soft tissue, it is sometimes limited for diagnosis of LGFMS. However, recent cytogenetic and molecular analyses have provided significant improvements in the diagnosis of LGFMS. Such analyses have demonstrated that most cases of LGFMS have a characteristic t(7,16)(q33;p11) translocation, resulting in the FUS-CREB3L2 fusion gene. We report a 29-year-old female who presented with a LGFMS located in the soleus muscle of her left lower leg. Preoperative imaging suggested the possibility of an intramuscular histiocytoma of the left soleus muscle. In conclusion, diagnosis of LGFMS can be challenging in routine practice in surgical pathology because of its bland-looking features. The immunohistochemical and ultrastructural findings were consistent with the fibroblastic properties of LGFMS. Cytogenetic and/or molecular genetic analyses can be used as ancillary diagnostic tools for LGFMS.

Infection after surgical reconstruction of a clavicle fracture using a reconstruction plate: a report of seven cases.

Mid-shaft clavicle fractures have traditionally been treated conservatively, although this has been associated with non-union and unsatisfactory shoulder function. The preferred approach is plate fixation, with a reconstruction plate for open reduction and internal fixation. Infection is a potential complication after such surgery, with rates of 0.4-7.8% reported in the literature. In our cases, an infection rate of 4.9% (7 of 142 patients) was noted; five of the seven patients suffered from acute postoperative infection within 1 month of surgery. The average time to presentation with an infection was 28 (23-32) days, with signs and symptoms of wound dehiscence in one patient and sinus discharge in four patients. Two patients suffered from subacute infections, with durations of 72 and 103 days, presenting with local heat and radiographic findings of screw loosening. Six of the cases healed with primary bony union after intensive debridement and early removal of the implants.

Transpositional adipofascial flaps for complicated acute finger injries.

Seven patients who presented with complicated acute finger injuries were treated successfully with local transpositional adipofascial flaps. This is a one-stage procedure with advantages of simplicity and rapidity. This flap is thin with good pliability and provides a very versatile and reliable covering for soft-tissue defects of the fingers. Full-thickness skin grafts were applied to the raw surface of the adipofascial flaps in all patients. All cases had excellent wound healing and restored full range of motion. This procedure facilitates early wound healing and early range of motion for finger joints; it also reduces wound pain, minimizes scar formation, and eliminates the need for second-stage surgery.

Immunoprofiles in malignant peripheral nerve sheath tumor: three case reports and literature review.

Because there are no standardized radiologic and histologic criteria, the differential diagnosis of malignant peripheral nerve sheath tumors (MPNSTs) from other spindle cell neoplasms poses great challenges for pathologists. Because early diagnosis of MPNSTs arising from benign peripheral nerve sheath tumors (BPNSTs) means a better prognosis, many immunohistochemical and molecular studies have recently emerged. Nevertheless, no gold standard diagnostic criterion is to be found in the literature. For example, S-100 protein is widely used in the diagnosis of MPNST. Other promising ancillary markers are p53 and Ki-67; however, the staining patterns and possible mechanisms of these markers are seldom mentioned in the literature. These evoke our interest. Only six cases diagnosed as MPNST were retrieved from the archives of the Department of Pathology, Kaohsiung Medical University Chung-Ho Memorial Hospital between 1988 and September 2005. Clinical files were available for three of them, and we found nuances in the immunohistochemistry from these previous reports. Here, we present these rare sarcomas and review the literature.

Use of an external fixation combined with the buttress-maintain pinning method in treating comminuted distal radius fractures in osteoporotic patients.

BACKGROUND: It is difficult to keep the alignment of a distal radius fracture in patients with osteoporosis and prevent malunion. Therefore, we hoped to design better method to maintain alignment. METHODS: Thirty-two patients over 65 years old with a displaced unstable distal radius fracture were treated by the external fixator combined with buttress-maintain pinning method and were compared with a group of 66 patients less than 60 years old treated by the same method. RESULT: The radiologic results demonstrated that postoperative and final radial length and volar tilt were not statistically different between both groups. The functional result (excellent and good) in the elderly group was 87.5% and 89% to that of the control group. There was only one complication of pin tract infection in the elderly group. CONCLUSIONS: External fixation for unstable distal radius fracture combined with buttress-maintain pinning method can be used in the osteoporotic bone of older adults with results similar to those for young adults at 18 months follow-up.

Management of grade III giant cell tumors of bones.

BACKGROUND AND OBJECTIVES: Surgical treatment of high-grade giant cell tumors (GCT) of bones with an intralesional excision or a wide excision still poses a dilemma between eradicating the tumor and saving the extremity's function. Our study evaluates the possibility of managing high grade GCT with an intralesional curettage combined with adjuvant therapies, instead of a wide excision, to better avoid limb salvage procedures with endoprostheses. METHODS: According to the grading system of Campanacci et al., twenty-four patients with grade III giant cell bone tumors were treated between May 1983 and Aug 2001 period. We analyzed the differences in local recurrence rates, functional results, and complications between wide excision and curettage with adjuvant therapy in management of the patients diagnosed with primary lesions after a mean follow-up period of 7.5 years (range: 2.1-20.3 years). RESULTS: Fourteen patients underwent the curettage procedure with adjuvant therapy and reconstruction with bone grafts. In the curettage group, two patients had local recurrences and three patients had fracture complications. None of the nine patients receiving wide excisions had experienced local recurrence at the time of their most recent follow-up examination. Using the Musculoskeletal Tumor Society system to evaluate average function, the results were 25.56 points for the wide excision group and 25.64 points for the curettage group, respectively. CONCLUSIONS: Our results suggest that surgical curettage with various adjuvant modalities might be considered as the first choice for treatment of high-grade GCTs in weight-bearing areas, especially in young patients, to avoid unnecessary endoprosthesis.

Segmental amputation for recurrent malignant bone tumors of the distal femur.

We describe an alternative method for lengthening a short femoral stump after wide amputation of a malignant bone tumor of the distal femur in two patients. The method consists of two procedures during the operation. The first procedure is amputation of the affected cylindrical segment of the involved limb. The second procedure is elongation of the amputation stump using the tumor-free segment of the ipsilateral lower leg as a free composite osseous myocutaneous graft. Both patients had good function and were satisfied with the results with no complications or tumor recurrence 4 years postoperatively. We think the segmental amputation is a good procedure that results in a longer functional stump in patients who have above-knee amputation.

Impact of national health insurance on the survival rate of patients with osteosarcoma in Taiwan: review of 74 patients.

The 2-year survival rate for high-grade osteosarcoma was 46.9% before the introduction of National Health Insurance (NHI) in Taiwan on March 1, 1995, but increased to 73.8% after the implementation of NHI. The 5-year survival rate also increased, from 37.5% to 63.6%. Between May 1990 and May 2001, 74 patients with high-grade osteosarcoma were treated at our hospital. Median age was 17 years (range, 7-63 years). Inadequate surgical margins, poor histologic response to chemotherapy, advanced stage of disease, and incomplete treatment were strongly associated with poor prognosis. Before NHI, 10 patients had incomplete treatment, mainly because of unaffordable medical fees. After NHI, only three patients had incomplete treatment, due to personal reasons. Patient survival improved dramatically with advances in multiagent chemotherapy, but it was the NHI that enabled patients to complete expensive treatment courses, including preoperative neoadjuvant chemotherapy, limb-salvage surgery, and postoperative adjuvant chemotherapy. The NHI also improved the accessibility of medical care, with more patients presenting in the early stages of disease and, as a result, it not only improved survival rate but also increased the number of patients undergoing limb-salvage surgery. We concluded that the NHI significantly improved the survival rate for patients with osteosarcoma in Taiwan.

Hyalinizing spindle cell tumor with giant rosettes: a case report.

Hyalinizing spindle cell tumor with giant rosettes (HSCTGR) is characterized by both giant rosette-like structures with collagen cores sparsely distributed throughout the tumor and fibromyxoid stroma. It is a rare low-grade sarcoma with indolent behavior, and wide excision with long-term follow-up is the best treatment. Although originally considered a distinct entity, it is now regarded as a variant of low-grade fibromyxoid sarcoma. We present a case of HSCTGR arising in the deep soft tissue of the left knee in a 50-year-old woman and provide a brief review of the literature for comparison.

Management strategy for unicameral bone cyst.

The management of a unicameral bone cyst varies from percutaneous needle biopsy, aspiration, and local injection of steroid, autogenous bone marrow, or demineralized bone matrix to the more invasive surgical procedures of conventional curettage and grafting (with autogenous or allogenous bone) or subtotal resection with bone grafting. The best treatment for a unicameral bone cyst is yet to be identified. Better understanding of the pathology will change the concept of management. The aim of treatment is to prevent pathologic fracture, to promote cyst healing, and to avoid cyst recurrence and re-fracture. We retrospectively reviewed 17 cases of unicameral bone cysts (12 in the humerus, 3 in the femur, 2 in the fibula) managed by conservative observation, curettage and bone grafting with open reduction and internal fixation, or continuous decompression and drainage with a cannulated screw. We suggest percutaneous cannulated screw insertion to promote cyst healing and prevent pathologic fracture. We devised a protocol for the management of unicameral bone cysts.

Rotationplasty for limb salvage in the treatment of malignant tumors: a report of two cases.

Limb salvage is now more common than amputation after radical excision to treat malignant tumors. In a skeletally immature patient who has malignant tumors in a lower extremity, rotationplasty offers a more reliable and durable option than other limb salvage procedures. It is an excellent method of resolving the problem of unequal leg lengths, and preserves best limb function with few complications. Here, we present our experience with rotationplasty for limb salvage in the treatment of malignant tumors, with good functional results seen in follow-up examination 11 years after surgery.

Idiopathic frozen shoulder treated by arthroscopic brisement.

Arthroscopic brisement serves as an useful procedure in the treatment of idiopathic frozen shoulder. This series included 186 shoulders with a diagnosis of idiopathic frozen shoulder who had symptoms for an average of 8 months and failed conservative treatment of at least 12 weeks. Using the arthroscopic brisement (distension, debride, release and manipulation) to treat the idiopathic frozen shoulder, it is beneficial not only to detect the inside lesion but also a solution to the problem of stiffness. The average follow-up time was 23 months from 6 months to 5 years. One hundred and seventy (92%) of 186 shoulders had yielded overall satisfactory results in this series. There was no relationship between the end result and the initial pathologic condition. We believe that arthroscopic brisement is an effective way of shortening the course of frozen shoulder and should be considered when conservative treatment has failed.