Use of folded vascularized rib graft in anterior fusion after treatment of thoracic and upper lumbar lesions. Technical note

For lesions involving the anterior and/or middle column of the spine, an anterior approach is adequate for curetting the lesion and restoring spinal stability. Materials such as autogenous bone grafts, cages with bone chips, some artificial materials, or allografts are used as strut materials. Rib material is usually removed when the anterior approach is conducted for thoracic or thoracolumbar lesions. A rib itself is not rigid enough to support the load, and a bone union is not easily obtained. The purpose of this paper is to describe a method of grafting vascularized rib in folded form to fill the defects left after removal of a spinal lesion. The rib, with the artery and vein at two levels cranial to the involved vertebral body, was isolated from surrounding tissues such as the intercostal nerve, muscles, and pleura. After curetting the lesion, the rib was folded into three or four pieces to a length adequate to fill the defect and inserted as a pedicled vascularized graft. A total of 23 cases, including 14 men and nine women, underwent surgery in which this grafting technique was used. The pathological conditions requiring anterior decompression and fusion were spinal trauma in nine cases, spinal infection in six cases, osteoporotic fracture in seven cases, and spinal metastasis in one case. In all cases a solid bone union was obtained and all infections resolved. With vascularized rib graft folded into three to four pieces, solid bone union can be obtained without use of any other grafted materials even in cases of infection and osteoporosis.

Two novel glucose-6-phosphate dehydrogenase variants found in newborn mass-screening for galactosaemia

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked recessive disorder in which haemolytic anaemia is the major symptom. The Beutler spot test employed in mass-screening for galactosaemia in newborns requires several intrinsic erythrocyte enzymes such as G6PD for its reaction and can theoretically detect G6PD deficiency apart from galactose-1-phosphate uridyltransferase deficiency. In this study, we detected two patients with G6PD deficiency using the quantitative Beutler test which was recently developed in our laboratory. Both patients lacked erythrocyte G6PD activity but exhibited no clinical symptoms. Molecular analysis in patients 1 and 2 revealed two novel missense mutations of C853T causing R285C and A1220C causing K407T, respectively. Molecular rather than enzymatic analysis was required in familial studies to detect and diagnose the carrier state. To date these patients have avoided oxidant stress and haemolytic diatheses have not been induced.

CONCLUSION

Our results indicate that the quantitative Beutler test can detect glucose-6-phosphate dehydrogenase deficiency of class 1 and 2 and is therefore useful for early intervention and prevention of haemolytic diathesis in patients with this disorder.

Transclavicular approach for a large dumbbell tumor in the cervicothoracic junction

Neurogenic dumbbell tumors occur more frequently in the cervical than in the thoracic or lumbar spine. Cervical paravertebral masses usually do not become exceptionally large because they are superficial and are palpated easily. Thoracic tumors can become large before they are detected. The authors describe a large intrathoracic dumbbell tumor arising from the C8 nerve root. The intraspinal tumor was resected through a posterior approach. In the second stage, dividing the clavicle, the intrathoracic component was resected by separating it from the lung. Two years after treatment, the preoperative neurologic deficit had improved except for weakness of muscles innervated by the C8 nerve root. Radiographs showed no residual or recurrent mass at the apex of the lung. Sometimes a retroclavicular location may conceal a large paravertebral mass, such as Pancoast tumors. As described here, the transclavicular approach gave adequate access to the cervicothoracic junction.

Distribution of bone mineral density in the proximal tibia in mid-teens

The distribution of bone mineral density (BMD) in the proximal tibia was studied in 94 knees from 47 mid-teens. The subjects were healthy high school freshmen (19 male; 28 female) who engaged in daily physical exercise. We measured BMD at six regions of interest (ROI) at the bilateral proximal tibia (three immediately above and three immediately be-low the physeal line) using dual-energy X-ray absorptiometry (QDR-2000; Hologic, Waltham, MA, USA). Subjects were supine during the measurements, with the knee extended and the foot fixed in a special holding device, ensuring correct rotational alignment of the knee. Measurements were performed using the forearm array scan mode. The precision of this method (coefficient of variation) was 1.1%-4.9% (mean 2.5%) for six ROIs. The BMD of the medial side was higher than that of the lateral side, and the BMD at the center of the metaphysis was higher than that of the epiphysis. The subjects in the present study did not show any misalignment of the knee joints. These findings indicate that the medial side of the proximal tibia already has higher BMD than the lateral side in teenagers with normal alignment of the knee joint, and that the increase in epiphyseal BMD may be slower than that of metaphyseal BMD. It is suggested that this phenomenon should be life-long and may play a role in the progression of osteoarthritis of the knee.

Nitric oxide regulates mitochondrial respiration and functions of articular chondrocytes

OBJECTIVE

Biologic effects of nitric oxide (NO) have been shown to increase under hypoxic conditions. Because the oxygen tension in joint cavities of patients with arthritis is fairly low, biologic effects of NO would be expected to be significantly large in these compartments. This study was undertaken to investigate the effects of NO on the energy metabolism and functions of articular chondrocytes under different oxygen tension conditions.

METHODS

Articular chondrocytes from rabbits were cultured under various oxygen concentrations in the presence or absence of NO and NOC18, an NO donor. Cellular respiration was measured using a Clark-type oxygen electrode. Levels of ATP in the cells were determined according to the luciferin-luciferase method. Cellular synthesis of proteoglycans was determined by measuring the incorporation of radioactivity (derived from 35S-labeled SO4) into glycosaminoglycans. Expression of stress-related proteins was evaluated by Western blotting analysis using specific antibodies.

RESULTS

Respiration and ATP synthesis of cultured chondrocytes were inhibited by NO, particularly under low oxygen concentrations. The presence of either NO or specific inhibitors of mitochondrial electron transport suppressed the synthesis of proteoglycans without affecting cell viability. When exposed to NO, cellular levels of heat-shock protein 70 (hsp70) and heme oxygenase 1 (HO-1) increased markedly. The presence of inhibitors of mitochondrial electron transport also increased cellular levels of hsp70 and HO-1.

CONCLUSION

These results suggest that NO generated in the joint might inhibit energy metabolism and the synthesis of proteoglycans of chondrocytes, thereby modulating pathophysiologic processes occurring in patients with arthritis.

Stereocontrolled Synthesis of Optically Active beta-D-glucopyranosides of 3-Hydroxy-7,8-didehydro-beta-ionol

A stereocontrolled synthesis of optically active beta-D-glucopyranosides 1-4 of 3-hydroxy-7,8-didehydro-beta-ionol utilizing an asymmetric transfer hydrogenation to alpha,beta-acetylenic ketones catalyzed by chiral ruthenium complexes as the key step is described.

Callotasis for post-traumatic shortening and deformity of leg

We have been performed callotasis, including hemicallotasis, in cases of more than 30 mm limb lengthening and more than 15 degrees angular deformity. There were 21 cases in this series. The mean age was 29.8 years old. Ilizarov external fixator (EF) was used in 13 cases and Orthofix EF in 8. The operation site was femur in 12 cases and tibia in 9 cases. Pre-existed complications were noted to occur in 10 cases. Callotasis was indicated in 17 cases, and the average length gain was 28.4 mm. Hemicallotasis was indicated in 5 cases, and the mean degree of correction angle was 18 degrees. Among available types of EF, Orthofix EF was suitable for proximal femoral callotasis, while Ilizarov EF was suitable for corrective deformity using hemicallotasis and tibial callotasis. The bone healing process of callotsis was better in the absence than presence of pre-existed complication. Also, we performed bone transportation using Ilizarov EF in cases of pseudoarthrosis with leg shortening and in all cases where bone grafting was unnecessary.

A preliminary evaluation of intra- and interindividual variations of hOGG1 messenger RNA levels in peripheral blood cells as determined by a real-time polymerase chain reaction technique

The hOGG1 (8-oxoguanine-DNA glycosylase) gene may contribute to further understanding of the relation between oxidative DNA damage and carcinogenesis. A real-time PCR technique was used to determine mRNA levels in peripheral blood cells to assess the possibility of using hOGG1 mRNA as a biomarker in epidemiological studies. To evaluate the intra- and interindividual variation of hOGG1 mRNA levels in peripheral blood cells, we measured them in five healthy nonsmokers three times over a 1-year period. The beta-actin mRNA level in each subject was set equal to 100, and the levels of hOGG1 mRNA were found to range from 1.6-17.6. The intraindividual variation range was 1.8-6.4. Although the difference in the mRNA levels between the sampling dates was not significant (P = 0.73), a significant difference in mRNA levels was found between the subjects (P < 0.01). The subjects seemed to fall into groups according to their individual levels. This preliminary study may provide initial information on the hOGG1 mRNA level of peripheral blood cells as a biomarker in epidemiological studies on oxygen radicals, oxygen radical-related agents, and cancer.

First total synthesis of mytiloxanthin

The first total synthesis of mytiloxanthin 2 was accomplished via the cyclopentyl ketone 7 prepared by stereoselective rearrangement of the epoxide 4a.

Tibiofemoral movement 3: full flexion in the living knee studied by MRI

We studied active flexion from 90 degrees to 133 degrees and passive flexion to 162 degrees using MRI in 20 unloaded knees in Japanese subjects. Flexion over this arc is accompanied by backward movement of the medial femoral condyle of 4.0 mm and by backward movement laterally of 15 mm, i.e., by internal rotation of the tibia. At 162 degrees the lateral femoral condyle lies posterior to the tibia.

Tibiofemoral movement 3: full flexion in the living knee studied by MRI

We studied active flexion from 90° to 133° and passive flexion to 162° using MRI in 20 unloaded knees in Japanese subjects. Flexion over this arc is accompanied by backward movement of the medial femoral condyle of 4.0 mm and by backward movement laterally of 15 mm, i.e., by internal rotation of the tibia. At 162° the lateral femoral condyle lies posterior to the tibia.

Osteoid osteoma of the cervical spine depicted as dumbbell tumor by MRI

We report a case of 14-year-old male patient with osteoid osteoma of the cervical spine. Magnetic resonance imaging (MRI) revealed a large dumbbell-shaped paravertebral tumor in the region of the exiting left C6 nerve. A computed tomographic (CT) scan after myelography showed a much smaller bony defect in the medial aspect of the left C6 pedicle with central calcification and extensive bone sclerosis around the defect, typical of osteoid osteoma. The diagnosis was confirmed postoperatively. The resected specimen exhibited extensive vascularization of the osteoid tissue. The case is presented because MRI did not allow a specific diagnosis of osteoid osteoma, and suggested the tumor was larger than in reality it was, by also depicting the reactive inflammation around the tumor as if it were part of the tumor.

Low-intensity pulsed ultrasound accelerates bone maturation in distraction osteogenesis in rabbits

We investigated the effects of low-intensity pulsed ultrasound on distraction osteogenesis in a rabbit model. Callotasis of the right tibia was performed in 70 male Japanese white rabbits using mini-external fixators. In the first part of the study in 64 animals using normal distraction (waiting period seven days; distraction rate 0.5 mm/12 hours; distraction period ten days), we evaluated the distraction site by radiography, measurement of the bone mineral density (BMD), mechanical testing, and histology. In the second part in six rabbits using fast distraction (waiting period 0 days; distraction rate 1.5 mm/12 hours; distraction period seven days) the site was evaluated radiologically. Half of the animals (35) had received ultrasound to their right leg (30 mW/cm2) for 20 minutes daily after ceasing distraction (ultrasound group), while rigid fixation only was maintained in the other half (control group). With normal distraction, the hard callus area, as shown by radiography, the BMD, and the findings on mechanical testing, were significantly greater in those receiving ultrasound than in the control group. Histological analysis showed no tissue damage attributable to exposure to ultrasound. With fast distraction, immature bone regeneration was observed radiologically in the control group, while bone maturation was achieved in the ultrasound group. We conclude that ultrasound can accelerate bone maturation in distraction osteogenesis in rabbits, even in states of poor callotasis.

Low-intensity pulsed ultrasound accelerates bone maturation in distraction osteogenesis in rabbits

We investigated the effects of low-intensity pulsed ultrasound on distraction osteogenesis in a rabbit model.

Callotasis of the right tibia was performed in 70 male Japanese white rabbits using mini-external fixators. In the first part of the study in 64 animals using normal distraction (waiting period seven days; distraction rate 0.5 mm/12 hours; distraction period ten days), we evaluated the distraction site by radiography, measurement of the bone mineral density (BMD), mechanical testing, and histology. In the second part in six rabbits using fast distraction (waiting period 0 days; distraction rate 1.5 mm/12 hours; distraction period seven days) the site was evaluated radiologically. Half of the animals (35) had received ultrasound to their right leg (30mW/cm2) for 20 minutes daily after ceasing distraction (ultrasound group), while rigid fixation only was maintained in the other half (control group). With normal distraction, the hard callus area, as shown by radiography, the BMD, and the findings on mechanical testing, were significantly greater in those receiving ultrasound than in the control group. Histological analysis showed no tissue damage attributable to exposure to ultrasound. With fast distraction, immature bone regeneration was observed radiologically in the control group, while bone maturation was achieved in the ultrasound group.

We conclude that ultrasound can accelerate bone maturation in distraction osteogenesis in rabbits, even in states of poor callotasis.

Histologic and mechanical evaluation of impacted morcellized cancellous allografts in rabbits: comparison with hydroxyapatite granules

The bioactivity and mechanical properties of morcellized allografts and hydroxyapatite (HA) granules were evaluated in a rabbit model. Allografts were replaced by viable trabecular structures within 8 weeks. The yield strength and stiffness of allografts were within normal cancellous bone levels by 3 weeks and were maintained afterward. The amount of newly formed bone around HA granules was comparable to that around allografts. The yield strength and stiffness of HA granules were significantly higher than those of allografts at 3 and 12 weeks. Allografts offer the advantage of being replaced by host-bone without significant deterioration in mechanical properties over the course of remodeling. HA granules can also be used for a bone substitute given their bioactivity in bone conduction and superiority in mechanical properties to allografts.

Effects of mechanical stress on expression of differentiated phenotypes of chondrocytes

In the patients with dislocated hip arthropathy, cartilage gene expression was confirmed in weight-bearing inner layer tissues of the joint capsule. Because these inner layer tissues of the joint capsule formed joint-like structures with the femoral head for a long period, cartilaginous genes may have been expressed in the weight-bearing inner surface of the joint capsule. There was a difference in expression of the genes between weight-bearing and non-weight-bearing parts. From a quantitative comparison between GAPDH and aggrecan gene expression, aggrecan gene expression was 30-fold higher in the weight-bearing part than in the non-weight-bearing part. Aggrecan gene expression was not detected in outer layer tissues of the joint capsule. Type II collagen and TGF-beta genes were also detected, and both genes showed differences in expression between the weight-bearing and non-weight-bearing parts like the aggrecan gene. This may have been because mechanical stress caused cartilaginous differentiation in undifferentiated mesenchymal tissues in the inner layer of the joint capsule. Cell differentiation and proliferation caused by mechanical stress are indicate key role to osteoarticular tissues, and it is considered important for orthopedic treatment to evaluate the process in detail.

Reconstruction of a double nail deformity: a case report

We report the successful reconstruction of a double nail deformity after fingertip injury. Double nail growth is rather rare. In our case it was not of congenital origin. Double nail deformity results from implantation of the nail matrix associated with damage to the finger tip. We excised the second nail and reconstructed the remaining nail bed using a part of the excised one. The vertical growth of the first nail was also corrected. Four months later, successful regeneration of the nail was observed.

Expression of differentiated phenotype in the pseudo-tendon sheath formed by a silicon rod

We examined the cartilaginous gene expression in the inner layer of the pseudo-tendon sheath formed by an silicon rod. While cartilaginous gene expression was not detected in the outer layer of the tissue, gene expressions of aggrecan and type II collagen were detected in the inner layer of the the newly formed pseudo-tendon sheath around the silicon rod. Relative expression of aggrecan and Type II collagen were 0.15 and 0.28, respectively, compared to that of GAPDH. The expression of type II collagen was 0.57-folds of that of type I collagen. In these tissues, a sliding surface was formed by a silicon rod and the surrounding tissues, and its mechanical stress may induce cartilaginous gene expression. Mechanical stress together with various growth factors and cytokines may be critically important for the formation of more physiological tendon sheath structures. Therefore, we will further examine the changes detected in the tissues and evaluate mechanical stress for formation of the tendon sheath.

Factors influencing the outcome of Chiari pelvic osteotomy: a long-term follow-up

We have reviewed 103 of 126 Chiari osteotomies carried out in our department between 1956 and 1987. The cases were graded radiologically, using the Japanese Orthopaedic Association (JOA) system, into a pre/early osteoarthritis (OA) group and an advanced OA group. In the pre/early group there were 86 hips. The mean follow-up was for 17.1 years (4 to 37). Preoperatively, 51 hips had an average JOA clinical score of 78.6+/-8.4 points and the final mean JOA clinical score was 89.4+/-12.5 points. Advanced degenerative change developed in 33.7% and one hip required a total replacement arthroplasty (TRA). Chiari osteotomy alone, without accompanying intertrochanteric osteotomy, was performed on 62 hips. For these the median survival time was 26.0+/-2.5 years, using as the endpoint progression to advanced OA. Differences in survivorship curves related significantly to the severity of the preoperative OA, the shape of the femoral head and the level of osteotomy. In the advanced OA group, we followed up 17 hips for a mean of 16.2 years (1 to 27). Before operation, the mean JOA clinical score in 13 hips was 63.2+/-7.9 points and the final score 84.0+/-12.0 points. TRA was eventually carried out on four hips. Our findings suggest that the Chiari osteotomy remains radiologically effective for about 25 years. The procedure is best suited to subluxated hips with round or flat femoral heads and early or no degenerative change. Intra-articular osteotomy can lead to osteonecrosis, and should be avoided. In hips with advanced OA, the Chiari procedure creates an acetabulum which facilitates later TRA, and may delay the need for this procedure in younger patients.

Factors influencing the outcome of Chiari pelvic osteotomy: a long-term follow-up

We have reviewed 103 of 126 Chiari osteotomies carried out in our department between 1956 and 1987. The cases were graded radiologically, using the Japanese Orthopaedic Association (JOA) system, into a pre/early osteoarthritis (OA) group and an advanced OA group. In the pre/early group there were 86 hips. The mean follow-up was for 17.1 years (4 to 37). Preoperatively, 51 hips had an average JOA clinical score of 78.6 ± 8.4 points and the final mean JOA clinical score was 89.4 ± 12.5 points. Advanced degenerative change developed in 33.7% and one hip required a total replacement arthroplasty (TRA). Chiari osteotomy alone, without accompanying intertrochanteric osteotomy, was performed on 62 hips. For these the median survival time was 26.0 ± 2.5 years, using as the endpoint progression to advanced OA. Differences in survivorship curves related significantly to the severity of the preoperative OA, the shape of the femoral head and the level of osteotomy. In the advanced OA group, we followed up 17 hips for a mean of 16.2 years (1 to 27). Before operation, the mean JOA clinical score in 13 hips was 63.2 ± 7.9 points and the final score 84.0 ± 12.0 points. TRA was eventually carried out on four hips.

Our findings suggest that the Chiari osteotomy remains radiologically effective for about 25 years. The procedure is best suited to subluxated hips with round or flat femoral heads and early or no degenerative change. Intra-articular osteotomy can lead to osteonecrosis, and should be avoided. In hips with advanced OA, the Chiari procedure creates an acetabulum which facilitates later TRA, and may delay the need for this procedure in younger patients.

Effect of particles and interface conditions on fibrous tissue interposition between bone and implant. A particle challenge model in rabbit

Interposed fibrous tissue at bone-implant interfaces was quantitatively measured in the presence or absence of polyethylene (PE) or alumina particles. Three different conditions of the interface were designed by implanting a pre-polymerized polymethylmethacrylate (PMMA) plug (plug group), a doughy PMMA (injection group) and a hydroxyapatite (HA) plug (HA group) in the hole drilled at the intercondylar notch of rabbit knees. PE (170+/-18 microm) or alumina particles (88+/-26 microm) were repeatedly administered into the knee joints at one month intervals (six times). All animals were sacrificed seven months after the implantation. The bone-implant interface was histomorphometrically examined using undecalcified ground sections. In the plug group, the PE particles significantly increased the extent of the interposed fibrous tissue (p < 0.05), while the alumina particles showed no effect. In contrast, both particles showed no significant effects in the injection and the HA groups. These results indicate that both particle characteristics and conditions of the bone-implant interface affected particle-induced fibrous tissue interposition. The loose PMMA plug with PE particles induced the greatest amount of fibrous tissue interposition.

Estimation of the migration of tibial components in total knee arthroplasty. A roentgen stereophotogrammetric analysis

Accurate quantitative measurements of micromovement immediately after operation would be a reliable indicator of the stability of an individual component. We have therefore developed a system for measuring micromovement of the tibial component using three non-contact displacement transducers attached to the tibial cortex during total knee arthroplasty (TKA). Using this system we measured the initial stability in 31 uncemented TKAs. All the tibial components were fixed by a stem and four screws. The initial stability was defined as the amount of displacement when a load of 20 kg was applied. The mean subsidence was 60.7 microm and the mean lift-off was 103.3 microm. We also studied the migration of the tibial component using roentgen stereophotogrammetric analysis (RSA) for up to two years after operation. Most migration occurred during the first six months, after which all prostheses remained stable. We defined migration as the maximum total point motion (MTPM) at two years after operation. The mean migration was 1.29 mm at two years. Our results show that there was a significant correlation between the initial stability and migration (p < 0.05) and emphasise the importance of the initial stability of the tibial component.

Estimation of the migration of tibial components in total knee arthroplasty

Accurate quantitative measurements of micromovement immediately after operation would be a reliable indicator of the stability of an individual component. We have therefore developed a system for measuring micromovement of the tibial component using three non-contact displacement transducers attached to the tibial cortex during total knee arthroplasty (TKA). Using this system we measured the initial stability in 31 uncemented TKAs. All the tibial components were fixed by a stem and four screws. The initial stability was defined as the amount of displacement when a load of 20 kg was applied. The mean subsidence was 60.7 μm and the mean lift-off was 103.3 μm.

We also studied the migration of the tibial component using roentgen stereophotogrammetric analysis (RSA) for up to two years after operation. Most migration occurred during the first six months, after which all prostheses remained stable. We defined migration as the maximum total point motion (MTPM) at two years after operation. The mean migration was 1.29 mm at two years.

Our results show that there was a significant correlation between the initial stability and migration (p < 0.05) and emphasise the importance of the initial stability of the tibial component.

Aromatic DNA adducts in coke-oven workers, in relation to exposure, lifestyle and genetic polymorphism of metabolic enzymes

OBJECTIVE

This study investigates the effect of multiple factors, including exposure to polycyclic aromatic hydrocarbons (PAHs), lifestyle, genetic polymorphism of cytochrome P450 (CYP)1A1, glutathione transferase (GST)M1, GSTP1, N-acetyltransferase (NAT)2 and gene p53, as well as any family history of cancer, on DNA adduct levels in coke-oven workers.

METHODS

Sixty-five coke-oven workers employed at the largest iron-steel factory in China were recruited for the study. Personal data were collected at the interview. DNA adduct levels in total white blood cells (WBCs) were detected using 32P-postlabeling techniques. Genetic polymorphisms were analyzed by polymerase chain reaction (PCR) methods.

RESULTS

The subjects were divided into low and high exposure groups, according to personal exposure to PAHs. The mean adduct value was 1.57 (range 0.54 to 4.35) per 10(8) nucleotides. A tendency for increased levels of DNA adducts in the high exposure group was observed, compared with the low exposure group (P = 0.07). In the low exposure group, DNA adducts were found to be positively associated with urinary cotinine (r = 0.44, P = 0.01). The rare allele homozygotes of CYP1A1 showed significantly higher DNA adduct levels than those of other CYP1A1 genotypes. Individuals with the NAT2 wild type had significantly increased DNA adduct levels than those with other NAT2 genotypes in the high exposure group. The p53 genetic polymorphism revealed a significantly positive effect on DNA adducts formation. There was a significantly higher adduct level in the subjects with a family history of cancer than those without, in the high exposure category.

CONCLUSIONS

Effects of several variables, such as smoking, genetic polymorphism of 2 CYP1A1, NAT2, and gene p53, and a family history of cancer on DNA adduct levels were found, suggesting that these variables should be considered when evaluating the genotoxic effect of occupational exposure to PAHs using WBCs DNA adducts.