The Efficacy of Systemic Transdermal Diclofenac Patch for Postoperative Pain after Lumbar Spinal Surgery

STUDY DESIGN

A single-center, prospective, comparative study.

OBJECTIVE

This study aimed to investigate the efficacy and safety of the systemic transdermal diclofenac patch (DP) for immediate postoperative analgesia after lumbar spinal surgery.

SUMMARY OF BACKGROUND DATA

Effective wound pain control after spinal surgery has been shown to lead to favorable outcomes. Using multimodal analgesia may decrease opioid use for postoperative pain.

MATERIALS AND METHODS

Patients who underwent posterior lumbar spinal surgery between August 2022 and January 2023 were divided into two groups: patients who underwent surgery on even months and were treated with DP (DP [+] group) and those who underwent surgery on odd months and were not treated with DP (DP [-] group). The demographic data, morphine milligram equivalent (MMEs) within 24 hours, duration of hospitalization, number of rescue analgesics used, visual analog scale (VAS) scores of wound pain, deterioration in renal function, and other complications were compared. Subgroup analysis consisted of subgroups categorized based on surgical procedure (non-fusion or fusion surgery).

RESULTS

In total, 111 and 113 patients were enrolled in the DP (+) and DP (-) groups, respectively. There was no significant difference in the deterioration of renal function in the DP (+) group. Overall comparisons demonstrated a significant difference between the DP (+) and DP (-) groups in the number of rescue analgesics used within 1 hour (P=0.046). In the non-fusion surgery subgroups, the MMEs within 24 hours, the number of rescue analgesics used within 1 and 3 hours, as well as the wound pain VAS at 1 and 3 hours postoperatively were significantly lower in the DP (+) group than in the DP (-) group (P=0.010, 0.015, 0.029, 0.005, and 0.048 respectively).

CONCLUSION

Systemic transdermal DP may potentially offer safe and effective postoperative analgesia, especially in less invasive procedures such as non-fusion lumbar spinal surgery.

LEVEL OF EVIDENCE

Level III.

Fracture healing on non-union fracture model promoted by non-thermal atmospheric-pressure plasma

Non-thermal atmospheric-pressure plasma (NTAPP) is attracting widespread interest for use in medical applications. The tissue repair capacity of NTAPP has been reported in various fields; however, little is known about its effect on fracture healing. Non-union or delayed union after a fracture is a clinical challenge. In this study, we aimed to investigate how NTAPP irradiation promotes fracture healing in a non-union fracture model and its underlying mechanism, in vitro and in vivo. For the in vivo study, we created normal and non-union fracture models in LEW/SsNSlc rats to investigate the effects of NTAPP. To create a fracture, a transverse osteotomy was performed in the middle of the femoral shaft. To induce the non-union fracture model, the periosteum surrounding the fracture site was cauterized after a normal fracture model was created. The normal fracture model showed no significant difference in bone healing between the control and NTAPP-treated groups. The non-union fracture model demonstrated that the NTAPP-treated group showed consistent improvement in fracture healing. Histological and biomechanical assessments confirmed the fracture healing. The in vitro study using pre-osteoblastic MC3T3-E1 cells demonstrated that NTAPP irradiation under specific conditions did not reduce cell proliferation but did enhance osteoblastic differentiation. Overall, these results suggest that NTAPP is a novel approach to the treatment of bone fractures.

Male elite soccer players have a higher incidence of accessory ossicles in the foot and ankle

PURPOSE

Accessory ossicles are caused by the failure of the fusion of secondary ossification centres and are more likely to occur due to heavy loading during the growth period or improper treatment after injury. This study aimed to investigate the incidence of foot and ankle accessory ossicles in male professional soccer players.

METHODS

This study included male professional soccer players who underwent medical checkups at our hospital between 2017 and 2023 as the soccer group. Medical checkups included radiographs of bilateral anteroposterior and oblique foot, as well as bilateral anteroposterior and lateral ankle. Male patients age-matched with the soccer group who visited our hospital undergoing anteroposterior and oblique foot or anteroposterior and lateral ankle radiography were included in the control group. The incidence of accessory ossicles was investigated and compared between the soccer and control groups.

RESULTS

In this study, 276 ankles and 276 feet, as well as 121 ankles and 79 feet, were included in the soccer and control groups, respectively. The incidence of accessory ossicles in the soccer and control groups was as follows: accessory navicular 35.9%, 24% (P = .049), os peroneum 8.0%, 2.5% (P = .09); os supranaviculare 7.6%, 1.3% (P = .039); os infranaviculare 1.4%, 1.3% (P = .090); os calcaneus secundarius 4.3%, 0% (P = .059); os vesalianum 0%, 0%; os subfiblare 12.7%, 2.5% (P < .001); os subtibiale 18.1%, 2.5% (P = .001); and os trigonum 89%, 24% (P < .001).

CONCLUSIONS

Male professional soccer players had a higher incidence of accessory navicular, os supranaviculare, os subfiblare, os subtibiale, and os trigonum.

Quadriceps Tendon With Bone Autograft Has Better Stability and Magnetic Resonance Imaging Maturation Than Hamstring Tendon Autograft After Anterior Cruciate Ligament Reconstruction in Patients With Knee Hyperextension

PURPOSE

To compare the clinical outcomes of anterior cruciate ligament (ACL) reconstruction between methods using quadriceps tendon with bone (QTB) and hamstring tendon (HT) in patients with hyperextension of the knee.

METHODS

The medical records of patients with knee hyperextension greater than 8° who underwent arthroscopic ACL reconstruction between October 2010 and October 2020 with follow-up for at least 2 years (median, 3 years; interquartile range [IQR], 2.0-4.6 years) were retrospectively reviewed. Side-to-side difference in anterior translation, pivot-shift test grade, Lysholm score, and graft intensity using the Howell grade on magnetic resonance imaging at final follow-up were compared between the QTB and HT groups.

RESULTS

The HT and QTB groups consisted of 42 patients and 21 patients, respectively. The overall mean age was 21.5 years (range, 14-48 years), and the median Tegner Activity Scale score was 6 (range, 3-9). Postoperatively, the median side-to-side difference in anterior translation was 1.75 mm (IQR, 1-3 mm) in the HT group and 1.0 mm (IQR, 0-1.75 mm) in the QTB group (P = .01). Pivot-shift testing showed grade 0 in 74.7%, grade 1 in 18.7%, and grade 2 in 6.6% of patients in the HT group and grade 0 in 85.7% and grade 1 in 14.3% of those in the QTB group (P = .03). The median postoperative Lysholm score was 99 in both groups. Graft signal intensity showed a significant between-group difference: grade I in 52%, grade II in 36%, and grade III in 12% of patients in the HT group versus grade I in 85.7%, grade II in 9.5%, and grade III in 4.8% of those in the QTB group (P = .03).

CONCLUSIONS

In patients who underwent ACL reconstruction for hyperextension of the knee, QTB yielded better clinical outcomes than HT with respect to anterior stability, rotational stability, and graft signal intensity on median 2-year follow-up magnetic resonance imaging.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Neurological recovery rate and predictive factors of incomplete AIS grade C spinal cord injury in the older aged population

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To define the prognosis and predictive factors for neurological improvement in older patients with incomplete spinal cord injury (SCI) of American Spinal Injury Association Impairment Scale grade C (AIS-C).

SETTINGS

Multi-institutions in Japan.

METHODS

We included patients aged ≥65 years with traumatic SCI of AIS-C who were treated conservatively or surgically with >3 follow-up months. To identify factors related to neurological improvement, patients were divided into three groups according to their neurological status at the final follow-up, with univariate among-group comparisons of demographics, radiographic, and therapeutic factors. Significant variables were included in the multivariate logistic regression analysis.

RESULTS

Overall, 296 older patients with SCI of AIS-C on admission were identified (average age: 75.2 years, average follow-up: 18.7 months). Among them, 190 (64.2%) patients improved to AIS-D and 21 (7.1%) patients improved to AIS-E at final follow-up. There were significant among-group differences in age (p = 0.026), body mass index (p = 0.007), status of pre-traumatic activities of daily living (ADL) (p = 0.037), and serum albumin concentrations (p = 0.011). Logistic regression analysis showed no significant differences in variables in the stratified group of patients who improved to AIS-D. Meanwhile, serum albumin was a significant variable in patients who improved to AIS-E (p = 0.026; OR: 6.20, pre-traumatic ADL was omitted due to data skewness).

CONCLUSIONS

Most older patients with incomplete AIS-C SCI demonstrated at least 1 grade of neurological improvement. However, <10% of patients achieved complete recovery. Key predictors of complete recovery were high serum albumin levels on admission and independent pre-traumatic ADL.

SPONSORSHIP

No funding was received for this study.

Effect of inside-out meniscal repair on meniscal dimension in meniscal tear patients

Background

It remains controversial whether meniscal repair causes meniscal extrusion. This study aimed to investigate the effect of inside-out meniscal repair on meniscal dimensions in patients with meniscal tear of the mid-body-posterior horn.

Methods

This retrospective study included 75 patients who underwent meniscal repair followed by MRI within 2 weeks after surgery between 2020 and 2022. Patients with a discoid lateral meniscus, pull-out repair, concomitant osteotomy, all-inside repair only, and revision surgery were excluded. Thirty-three meniscal tear treated using an inside-out arthroscopic repair technique were included in the lateral meniscus (LM, n = 19) and medial meniscus (MM, n = 14) tear groups. Thirty-six participants with intact meniscus were included as controls. Meniscal extrusion and posterior shift were measured on coronal and sagittal MRI pre-operatively and within 2 weeks postoperatively.

Results

Preoperative coronal extrusion was significantly greater in the LM tear group than in the control group (P = 0.001). Coronal extrusion and posterior shift were significantly smaller postoperatively than preoperatively in the LM tear group (P < 0.001 and, P = 0.008, respectively). Pre- and postoperative coronal extrusion in the MM tear group were not significantly different (P = 0.291). Postoperative coronal extrusion in both LM and MM tear groups were not significantly correlated with the number of sutures required for repair (LM: P = 0.765, R = -0.076, MM: P = 0.1, R = 0.497).

Conclusions

The torn meniscus of the mid-body - posterior horn before surgery was extruded and shifted posteriorly in both LM and MM tears, and repair using an inside-out arthroscopic technique was effective in reducing meniscal extrusion and posteriors shift in the LM tear immediately after surgery.

Time elapsed from definitive diagnosis to surgery for osteonecrosis of the femoral head: a nationwide observational study in Japan

OBJECTIVES

This study documents the time elapsed from the diagnosis of osteonecrosis of the femoral head (ONFH) to surgery, exploring the factors that influence ONFH severity.

DESIGN

Retrospective observational study of a nationwide database.

SETTING

The Kaplan-Meier method with log-rank tests was applied to examine the period from definitive diagnosis of ONFH to surgery using any surgery as the end point. For bilateral cases, the date of the first surgery was the endpoint.

PARTICIPANTS

This study included 2074 ONFH cases registered in 34 university hospitals and highly specialised hospitals of the multicentre sentinel monitoring system of the Japanese Investigation Committee between 1997 and 2018.

MAIN OUTCOME MEASURE

The primary outcome was the time from diagnosis to surgery. The secondary outcome was the proportion of subjects remaining without surgery at 3, 6 and 9 months, and at 1, 2 and 5 years after diagnosis.

RESULTS

The median time to surgery was 9 months (IQR 4-22 months) after diagnosis of ONFH. The time to surgery was significantly shorter in the alcohol alone group and the combined corticosteroid and alcohol group than in the corticosteroid alone group (p=0.018 and p<0.001, respectively), in early stage ONFH with no or mild joint destruction (stages II and III, p<0.001), and with joint preserving surgery (p<0.001). The proportion without surgery was 75.8% at 3 months, 59.6% at 6 months, 48.2% at 9 months, 40.5% at 1 year, 22.2% at 2 years and 8.3% at 5 years.

CONCLUSION

ONFH has been considered to be an intractable disease that often requires surgical treatment, but the fact that surgery was performed in more than half of the patients within 9 months from diagnosis suggests severe disease with a significant clinical impact.

TRIAL REGISTRATION NUMBER

Chiba University ID1049.

Is bone remodelling around fully hydroxyapatite-coated and tapered-wedge stems related to the stem fixation pattern?

PURPOSE

This study aimed to compare bone mineral density (BMD) changes around the femoral component after total hip arthroplasty (THA) in a fully hydroxyapatite-coated stem (CORAIL) and in a tapered-wedge stem (Taperloc complete) and identify predictors of BMD changes.

METHODS

This retrospective study compared 43 hips in the CORAIL group and 40 hips in the Taperloc group. The relative changes in BMD at 2 years after THA measured using dual-energy X-ray absorptiometry and the three-dimensional quantified contact states of the stem with the femoral cortical bone were assessed. Predictors of the relative change in the BMD around the proximal part of the stem were examined using multiple regression analysis.

RESULTS

The decrease in BMD in Gruen zone 7 was significantly less in the CORAIL group than in the Taperloc group (P = 0.02). In the CORAIL group, the contact area in any zone was not a significant predictor of the relative changes in BMD. The contact area between the Taperloc stem and the femoral cortical bone in zones 2 and 6 was a positive predictor of the relative changes in BMD in zones 1 (P = 0.02 and P = 0.04, respectively) and 2 (P = 0.008 and P = 0.004, respectively).

CONCLUSION

The CORAIL stem suppressed the postoperative BMD loss around the stem, irrespective of the contact state. The Taperloc complete stem required contact with the proximal femoral metaphysis to suppress the postoperative BMD loss around the stem.

Osteoblast differentiation of Gli1⁺ cells via Wnt and BMP signaling pathways during orthodontic tooth movement

OBJECTIVES

Factors that induce bone formation during orthodontic tooth movement (OTM) remain unclear. Gli1 was recently identified as a stem cell marker in the periodontal ligament (PDL). Therefore, we evaluated the mechanism of differentiation of Cre/LoxP-mediated Gli1/Tomato+ cells into osteoblasts during OTM.

METHODS

After the final administration of tamoxifen to 8-week-old Gli1-CreERT2/ROSA26-loxP-stop-loxP-tdTomato mice for 2 days, nickel-titanium closed coil springs were attached between the upper anterior alveolar bone and the first molar. Immunohistochemical localizations of β-catenin, Smad4, and Runx2 were observed in the PDL on 2, 5, and 10 days after OTM initiation.

RESULTS

In the untreated tooth, few Gli1/Tomato+ cells were detected in the PDL. Two days after OTM initiation, the number of Gli1/Tomato+ cells increased in the PDL on the tension side. On this side, 49.3 ± 7.0% of β-catenin+ and 48.7 ± 5.7% of Smad4+ cells were found in the PDL, and Runx2 expression was detected in some Gli1/Tomato+ cells apart from the alveolar bone. The number of positive cells in the PDL reached a maximum on day 5. In contrast, on the compression side, β-catenin and Smad4 exhibited less immunoreactivity. On day 10, Gli1/Tomato+ cells were aligned on the alveolar bone on the tension side, with some expressing Runx2.

CONCLUSIONS

Gli1+ cells in the PDL differentiated into osteoblasts during OTM. Wnt and bone morphogenetic proteins signaling pathways may be involved in this differentiation.

Residual Paresthesia After Surgery for Degenerative Cervical Myelopathy: Incidence and Impact on Clinical Outcomes and Satisfaction

STUDY DESIGN

Multicenter, prospective cohort study.

OBJECTIVE

The current study aimed to identify the incidence of residual paresthesias after surgery for degenerative cervical myelopathy (DCM), and to demonstrate the impact of these symptoms on clinical outcomes and patient satisfaction.

SUMMARY OF BACKGROUND DATA

Surgery for DCM aims to improve and/or prevent further deterioration of physical function and quality-of-life (QOL) in the setting of DCM. However, patients are often not satisfied with their treatment for myelopathy when they have severe residual paresthesias, even when physical function and QOL are improved after surgery.

MATERIALS AND METHODS

The authors included 187 patients who underwent laminoplasty for DCM. All patients were divided into two groups based on their visual analog scale score for paresthesia of the upper extremities at one year postoperatively (>40 vs. ≤40 mm). Preoperative factors, changes in clinical scores and radiographic factors, and satisfaction scales at one year postoperatively were compared between groups. The authors used mixed-effect linear and logistic regression modeling to adjust for confounders.

RESULTS

Overall, 86 of 187 patients had severe residual paresthesia at one year postoperatively. Preoperative patient-oriented pain scale scores were significantly associated with postoperative residual paresthesia ( P =0.032). A mixed-effect model demonstrated that patients with severe postoperative residual paresthesia showed significantly smaller improvements in QOL ( P =0.046) and myelopathy ( P =0.037) than patients with no/mild residual paresthesia. Logistic regression analysis identified that residual paresthesia was significantly associated with lower treatment satisfaction, independent of improvements in myelopathy and QOL (adjusted odds ratio: 2.5, P =0.010).

CONCLUSION

In total, 45% of patients with DCM demonstrated severe residual paresthesia at one year postoperatively. These patients showed significantly worse treatment satisfaction, even after accounting for improvements in myelopathy and QOL. As such, in patients who experience higher preoperative pain, multidisciplinary approaches for residual paresthesia, including medications for neuropathic pain, might lead to greater clinical satisfaction.

LEVEL OF EVIDENCE

3.

Impact of malnutrition on mortality and neurological recovery of older patients with spinal cord injury

This retrospective cohort study established malnutrition's impact on mortality and neurological recovery of older patients with cervical spinal cord injury (SCI). It included patients aged ≥ 65 years with traumatic cervical SCI treated conservatively or surgically. The Geriatric Nutritional Risk Index was calculated to assess nutritional-related risk. Overall, 789 patients (mean follow-up: 20.1 months) were examined and 47 had major nutritional-related risks on admission. One-year mortality rate, median survival time, neurological recovery, and activities of daily living (ADL) at 1 year post-injury were compared between patients with major nutrition-related risk and matched controls selected using 1:2 propensity score matching to adjust for age, pre-traumatic neurological impairment, and activity. In the Kaplan-Meier analysis, the median survival times were 44.9 and 76.5 months for patients with major nutrition-related risk and matched controls, respectively (p = 0.015). Matched controls had more individuals with a neurological improvement of American Spinal Injury Association Impairment Scale ≥ 1 grade (p = 0.039) and independence in ADL at 1 year post-injury than patients with major nutrition-related risk (p < 0.05). In conclusion, 6% of older patients with cervical SCI had major nutrition-related risks; they showed a significantly higher 1 year mortality rate, shorter survival time, poorer neurological improvement, and lower ADL at 1 year post-injury than matched controls.

Comparison of cost, surgical time, and clinical results between arthroscopic transosseous rotator cuff repair with lateral cortical augmentation and arthroscopic transosseous equivalent suture bridge: A propensity score-matched analysis

BACKGROUND

To reduce the healthcare burden, the clinical results of arthroscopic rotator cuff repair and the cost of the implants used have recently been focused upon. This study compared implant cost, surgical time, short-term clinical results, and cuff repair integrity 2 years postoperatively between arthroscopic transosseous rotator cuff repair using lateral cortical augmentation (TOA) and arthroscopic transosseous-equivalent suture bridge (TOE).

METHODS

This study included 220 patients with rotator cuff repairs performed by a single surgeon between December 2013 and December 2018. Overall, 70 TOA and 68 TOE cases met the inclusion criteria. The same surgeon performed the procedures at two different hospitals, and the techniques differed between the facilities. A total of 42 TOA patients were matched with 42 TOE patients. The patients were matched using a propensity score analysis by gender, age, and cuff tear size. The minimum follow-up period was 2 years. Implant cost and surgical time were compared between the two methods. The range of motion, clinical outcomes, and visual analog scale were evaluated. Magnetic resonance imaging was performed to examine cuff repair integrity 2 years postoperatively.

RESULTS

The follow-up rate was 81% (112/138 patients). Implant cost was significantly lower with TOA ($1,396 vs. $2,165; p < 0.001) than with TOE. The average surgical time in the TOA method was significantly shorter than that in the TOE method (82 vs. 109 min; p = 0.001). At a minimum 2-year follow-up, the mean active elevation, abduction, and clinical outcomes improved with both methods, although no improvements in external and internal rotations were observed with either method. There were no significant differences in the postoperative variables and retear rate (TOA, 12%; TOE, 19%; p = 0.548) between the two methods.

CONCLUSIONS

TOA and TOE achieved comparable clinical results; however, TOA was more cost-effective and had a shorter surgical time than TOE.

LEVEL OF EVIDENCE

Level Ⅲ, retrospective matched control study.

Degeneration of Cervical Multifidus Muscles Negatively Affects Physical Activity-related Quality of Life After Laminoplasty for Degenerative Cervical Myelopathy

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The study aimed to investigate the related factors affecting physical activity-related quality of life (QOL) after 2 years of cervical laminoplasty for degenerative cervical myelopathy (DCM), focusing on the degree of preoperative degeneration of the cervical multifidus muscles.

SUMMARY OF BACKGROUND DATA

The association between paraspinal muscle degeneration and clinical outcomes after spinal surgery is being investigated. The effect of preoperative degeneration of the cervical multifidus muscles in patients undergoing cervical laminoplasty is ambiguous.

METHODS

Patients who underwent laminoplasty for DCM and followed up for more than 2 years were reviewed. To evaluate physical QOL, the physical component summary (PCS) of the 36-Item Short-Form Health Survey (SF-36) was recorded at 2 years postoperatively. The degree of preoperative degeneration in the multifidus muscles at the C4 and C7 levels on axial T2-weighted magnetic resonance imaging (MRI) was categorized according to the Goutallier grading system. The correlation between 2-year postoperative PCS and each preoperative clinical outcome, radiographic parameter, and MRI finding, including Goutallier classification, was analyzed. Variables with a P value <0.10 in univariate analysis were included in multiple linear regression analysis.

RESULTS

In total, 106 consecutive patients were included. The 2-year postoperative PCS demonstrated significant correlation with age (R=-0.358, P=0.002), preoperative JOA score (R=0.286, P=0.021), preoperative PCS (R=0.603, P<0.001), C2-C7 lordotic angle (R=-0.284, P=0.017), stenosis severity (R=-0.271, P=0.019), and Goutallier classification at the C7 level (R=-0.268, P=0.021). In multiple linear regression analysis, sex (β=-0.334, P=0.002), age (β=-0.299, P=0.013), preoperative PCS (β=0.356, P=0.009), and Goutallier classification at the C7 level (β=-0.280, P=0.018) were significantly related to 2-year postoperative PCS.

CONCLUSIONS

Increased degeneration of the multifidus muscle at the C7 level negatively affected physical activity-related QOL postoperatively. These results may guide spine surgeons in predicting physical activity-related QOL in patients with DCM after laminoplasty.

LEVEL OF EVIDENCE

Level III.

No Impact of Contact Between the Medial Collar of a Hydroxyapatite-Coated Triple-Tapered Stem and the Femoral Neck on Periprosthetic Bone Mineral Density

BACKGROUND

Hydroxyapatite-coated, triple-tapered, shorter-length stems with a medial collar have been reported with good results for a few years. We investigated whether contact between the medial collar and femoral neck affects clinical outcomes and changes in bone mineral density (BMD) in patients who have this type of stem in their total hip arthroplasty construct.

METHODS

This was a retrospective, single-center study involving 62 patients scheduled for unilateral total hip arthroplasty using a hydroxyapatite-coated, triple-tapered, shorter-length stem who were followed for at least 1 year postoperatively. All patients had a Dorr type B femoral canal shape. Contact between the medial collar and the femoral neck was evaluated by computed tomography at the third postoperative month, and patients were classified into 2 groups. Postoperative clinical outcomes were investigated by the Western Ontario and McMaster Universities Arthritis Index and the Japanese Orthopaedic Association scores; radiological evaluation included stem fixation, spot welds and cortical hypertrophy, postoperative 3-dimensional stem alignment, and periprosthetic BMD changes.

RESULTS

There were 51 patients in the Contact + group (collar and neck contact) and 11 in the Contact-group (no contact). There were no differences between the 2 groups in the improvement of Western Ontario and McMaster Universities Arthritis Index and Japanese Orthopaedic Association scores, stem fixation, occurrence of cortical hypertrophy, or 3-dimensional stem alignment. Radiolucent lines were present in zones 3, 4, and 5 in 6 patients (12%) in the Contact + group only, who had no statistical difference between the 2 groups. Bone mineral density (BMD) decreased most in zone 7 in both groups, with no difference between the 2 groups.

CONCLUSIONS

The presence or absence of contact between the medial collar and femoral neck did not affect postoperative BMD changes or radiological or clinical results.

LEVEL OF EVIDENCE

Therapeutic Level III.

Short-Term Risk Factors for Distal Junctional Kyphosis after Spinal Reconstruction Surgery in Patients with Osteoporotic Vertebrae

STUDY DESIGN

Level 3 retrospective cohort case-control study.

PURPOSE

This study aimed to investigate the risk factors for distal junctional kyphosis (DJK) caused by osteoporotic vertebral fractures following spinal reconstruction surgery, with a focus on the sagittal stable vertebra.

OVERVIEW OF LITERATURE

Despite the rarity of reports on DJK in this setting, DJK was reported to reduce when the lower instrumented vertebra (LIV) was extended to the sagittal stable vertebra in the posterior corrective fixation for Scheuermann's disease.

METHODS

This study included 46 patients who underwent spinal reconstruction surgery for thoracolumbar osteoporotic vertebral fractures and kyphosis and were followed up for 1 year postoperatively. DJK was defined as an advanced kyphosis angle >10° between the LIV and one lower vertebra. The patients were divided into groups with and without DJK. The risk factors of the two groups, such as patient background, surgery-related factors, radiographic parameters, and clinical outcomes, were analyzed.

RESULTS

The DJK and non-DJK groups included 14 and 32 patients, respectively, without significant differences in patient background. Those with instability in the distal adjacent LIV disc had a significantly higher risk of DJK occurrence (28.6% vs. 3.2%, p=0.027). DJK occurrence significantly increased in those with the sagittal stable vertebra not included in the fixation range (57.1% vs. 18.8%, p=0.020). Other preoperative radiographic parameters were not significantly different. Instability in the distal adjacent LIV disc (adjusted odds ratio, 14.50; p=0.029) and the exclusion of the sagittal stable vertebra from the fixation range (adjusted odds ratio, 5.29; p=0.020) were significant risk factors for DJK occurrence.

CONCLUSIONS

Regarding spinal reconstruction surgery in patients with osteoporotic vertebral fractures, instability in the distal adjacent LIV disc and the exclusion of the sagittal stable vertebra from the fixation range were risk factors for DJK occurrence in the short term.

Comparison of short-term clinical outcomes and radiographic changes in Grammont reverse shoulder arthroplasty between the French and Japanese populations: A propensity score-matched analysis

BACKGROUND

Although Grammont-style reverse total shoulder arthroplasty (RSA) showed excellent clinical results in Europe, its utility for Asian populations remains unclear. This study aimed to compare the French and Japanese populations in terms of range of motion (ROM), functional outcomes, and scapular notching rates in patients who underwent standard Grammont-style RSA. We hypothesized that RSA for the Japanese population may not provide as good ROM and functional results at the final follow-up as that for the French population.

METHODS

A total of 25 Japanese patients undergoing RSA were propensity score matched to 25 French patients undergoing RSA. The patients were matched for four different covariates using a propensity score analysis. The minimum follow-up period was 2 years. We investigated differences between the populations with respect to body size and shoulder joint ROM and Constant score (CS) measured preoperatively and at the final follow-up. Scapular notching was examined using radiographs at the final follow-up.

RESULTS

The average height and weight of the French and Japanese patients were 164 cm and 70 kg and 152 cm and 56 kg, respectively. Anterior elevation (AE), external rotation (ER) at the side, internal rotation (IR), and CS total changed from 101° to 145°, 17° to 15°, 4.5 points to 5.5 points, and 36 points to 72 points, respectively, in the French population and from 63° to 119°, 8.5° to 13°, 4.6 points to 4 points, and 28 points to 58 points, respectively, in the Japanese population. AE improved in both the groups; ER and IR remained unchanged before and after surgery. The frequency of scapular notching (>grade 1) was higher in the Japanese population (56%) than in the French population (20%) (p = 0.019).

CONCLUSIONS

Grammont-style RSA improved AE and CS in both the populations, but AE and CS were significantly higher in the French population than in the Japanese population at the final follow-up. Scapular notching frequently occurs in the Japanese population.

Impact of constrained humeral liner on impingement-free range of motion and impingement type in reverse shoulder arthroplasty using a computer simulation

BACKGROUND

Dislocation is a major complication of reverse total shoulder arthroplasty (RSA). The humeral liner may be changed to a constrained type when stability does not improve by increasing glenosphere size or lateralization with implants, and patients, particularly women with obesity, have risks of periprosthetic instability that may be secondary to hinge adduction on the thorax, but there are few reports on its impact on the range of motion (ROM). This study aimed to determine the influence of humeral liner constraint on impingement-free ROM and impingement type using an RSA computer simulation model.

METHODS

A virtual simulation model was created using 3D measurement software for conducting a simulation study. This study included 25 patients with rotator cuff tears and rotator cuff tear arthropathy. Impingement-free ROM and impingement patterns were measured during flexion, extension, abduction, adduction, external rotation, and internal rotation. Twenty-five cases with a total of 4 patterns of 2 multiplied by 2, making a total of 100 simulations: glenosphere (38 mm normal type vs. lateralized type) and humeral liner constraint (normal type vs. constrained type). There were 4 combinations: normal glenosphere and normal humeral liner, normal glenosphere and constrained humeral liner, lateralized glenosphere and normal humeral liner, and lateralized glenosphere and constrained humeral liner.

RESULTS

Significant differences were found in all impingement-free ROM in 1-way analysis of variance (abduction: P = .01, adduction: P < .01, flexion: P = .01, extension: P = .02, external rotation: P < .01, and internal rotation: P < .01). Tukey's post hoc tests showed that the impingement-free ROM was reduced during abduction, external rotation, and internal rotation with the combination of the normal glenosphere and constrained humeral liner compared with the other combinations, and improved by glenoid lateralization compared with the combination of the lateralized glenosphere and constrained humeral liner. In the impingement pattern, the Pearson χ2 test showed significantly greater proportion of impingement of the humeral liner into the superior part of the glenoid neck in abduction occurring in the combination of the normal glenosphere and constrained humeral liner group compared with the other groups (P < .01). Bonferroni post hoc tests revealed that the combination of the normal glenosphere and constrained humeral liner was significantly different from that of the lateralized glenosphere and constrained humeral liner (P < .01). Using constrained liners resulted in early impingement on the superior part of the glenoid neck in the normal glenosphere, whereas glenoid lateralization increased impingement-free ROM.

CONCLUSION

This RSA computer simulation model demonstrated that constrained humeral liners led to decreased impingement-free ROM. However, using the lateralized glenosphere improved abduction ROM.

Bone mineral density around cementless short stems after reverse shoulder arthroplasty: changes over time and its relationship to stem positioning

Background

There are numerous reports of bone adaptation observed on plain radiography studies after the use of cementless short stems in reverse shoulder arthroplasty. However, reports on changes in bone mineral density (BMD) around the stem using dual-energy X-ray absorptiometry (DEXA) are prominently absent. In the present study, we measured BMD around the stem using DEXA and investigated changes over time from postoperative year 1 to year 2. Additionally, the relationship between BMD changes, filling ratio, and stem alignment was examined.

Methods

Forty-seven patients with short cementless stems who could be assessed via DEXA at 1-2 years postoperatively were included. After dividing the zones around the stem into 5, the BMD in each zone was measured, in addition to BMD changes and amount of change from postoperative year 1 to year 2. The relationship between filling ratio and stem alignment on postoperative plain radiography was assessed.

Results

A significant decrease in BMD in zone 3 was observed between postoperative year 1 and year 2 (P = .02). Regarding filling ratio and stem alignment, a negative correlation between valgus stem alignment and BMD change observed in zone 1 (r = -0.470, P < .01). In addition, stem valgus greater than 6° correlated with a significant decrease in BMD in zone 1. (P = .01). No significant differences were found in the other zones. Furthermore, there was no correlation between filling ratio and BMD change.

Conclusion

In reverse shoulder arthroplasty cementless short stems, changes that that occurred between postoperative year 1 to year 2 demonstrated a decrease in BMD in zone 3. In addition, a decrease in BMD in zone 1 was observed with a stem alignment of valgus 6° or higher, suggesting that stem alignment within valgus 6° is required to prevent a decrease in BMD.

Lower preoperative Hounsfield unit values as a risk factor for poor 5-year clinical outcomes after lumbar spine surgery

OBJECTIVE

Hounsfield Unit (HU) value has been associated with future osteoporotic fractures and postoperative complications. However, no studies on the impact of low HU values on mid-term clinical outcomes following lumbar spine surgery have been reported. We aimed to evaluate the usefulness of preoperative HU values for 5-year clinical outcomes following lumbar spine surgery.

METHODS

We enrolled 200 patients who underwent lumbar surgery (≤ 3-disc levels) for lumbar spinal stenosis. HU values were assessed using preoperative lumbar computed tomography as part of routine preoperative planning for lumbar surgery. Patients were divided into two groups based on the cutoff value of the HU values obtained from the receiver operating characteristic curve for the incidence of vertebral fractures within five years postoperatively. Clinical scores preoperatively and 1, 2, and 5 years postoperatively, including Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and Short Form-36 (SF-36), were compared using a mixed-effects model.

RESULTS

Comparative analysis indicated that all domains of JOABPEQ, except for lumbar function, and the physical component summary of the SF-36 were significantly worse in the low HU group than in the high HU group. Using multiple regression analysis, low HU values were significantly correlated with worse 5-year postoperative scores in all domains of JOABPEQ and SF-36.

CONCLUSION

Low preoperative HU values are a risk factor for poor 5-year clinical outcomes after lumbar spine surgery. HU values are not only a valuable tool for analyzing bone mineral density but also may be a valuable poor prognostic factor of postoperative clinical outcomes.

Peripheral nerve regeneration by bioabsorbable nerve conduits filled with platelet-rich fibrin

PURPOSE

To repair peripheral nerve defects and seek alternatives for autografts, nerve conduits with various growth factors and cells have been invented. Few pieces of literature report the effect of nerve conduits plus platelet-rich fibrin (PRF). This study aimed to investigate the effectiveness of nerve conduits filled with PRF.

METHODS

The model of a 10 mm sciatic nerve gap in a rat was used to evaluate peripheral nerve regeneration. The thirty rats were randomly divided into one of the following three groups (n = 10 per group). Autogenous nerve grafts (autograft group), conduits filled with phosphate-buffered saline (PBS) (PBS group), or conduits filled with PRF group (PRF group). We assessed motor and sensory functions for the three groups at 4, 8, and 12 weeks postoperatively. In addition, axon numbers were measured 12 weeks after repair of the peripheral nerve gaps.

RESULTS

Significant differences in motor function were observed between the autograft group and the other two groups at 12 weeks postoperatively. In the test to evaluate the recovery of sensory function, there were significant differences between the PBS group and the other two groups at all time points. The most axon number was found in the autograft group. The axon number of the PRF group was significantly more extensive than that of the PBS group.

CONCLUSIONS

The nerve conduit filled with PRF promoted the axon regeneration of the sciatic nerve and improved sensory function.

Low-Intensity Pulsed Ultrasound for Delayed Union of Distal Radius Fracture After Palmar Locking Plate Fixation: A Case Report

Delayed union and non-union of distal radial fractures (DRFs) are rare, and there are a few reports of delayed union and nonunion of DRFs after palmar locking plate (PLP) fixation. A 68-year-old female patient presented to our hospital with left-sided wrist pain. Radiographs and computed tomography revealed a displaced DRF and ulnar styloid fracture. We performed open reduction and internal fixation with a PLP for the DRF and tension band wiring for the ulnar styloid fracture. However, bone union was not completed three months after the operation. We initiated low-intensity pulsed ultrasound (LIPUS) to achieve fracture healing. Complete bone union was confirmed radiographically five months after LIPUS. There have been few case reports on the delayed union or nonunion of DRFs after PLP fixation treated with LIPUS. LIPUS might be an effective option for the delayed union of DRFs after PLP fixation.

Stem alignment with short tapered-wedge cementless stems affects bone mineral density continuously for at least 5 years after primary total hip arthroplasty

AIM

This study aimed to assess the relationship between the three-dimensional (3D) alignment of short tapered-wedge cementless stems and bone mineral density (BMD) changes in patients followed up for 5 years after total hip arthroplasty (THA).

METHODS

We retrospectively analysed the hips of 52 patients who underwent THA using short tapered-wedge cementless stems at our institution from 2013 to 2016 with complete 5-year follow-up data. We evaluated the relationship between stem alignment, measured using a 3D-templating software, and BMD changes in the 7 Gruen zones.

RESULTS

After 1 year, significant negative correlations between varus insertion and a decrease in BMD in zone 7 and between flexed insertion and decreases in BMD in zones 3 and 4 were noted. After 5 years, significant negative correlations between varus insertion and a decrease in BMD in zone 7 and between flexed insertion and decreases in BMD zones 2, 3, and 4 were observed. With increased amounts of varus/flexion stem alignment, the amount of BMD loss decreased. There was no correlation between anteverted stem insertion and changes in BMD levels.

CONCLUSIONS

Our data showed that stem alignment affects BMD based on 5-year follow-up data after surgery. Careful observation is necessary, especially when using short tapered-wedge cementless stems, as stem alignment may affect changes in BMD levels more than 5 years after surgery.

The Duration of Bone Healing and Nonunion Ratio After Ulnar Shortening Osteotomy Using a 5-Hole Forearm Compression Plate With Transverse Osteotomy

BACKGROUND

Ulnar shortening osteotomy using various osteotomy sites, osteotomy methods, and surgical techniques with a variety of implants has been reported, but nonunion rates and the duration of bone healing are not uniform by the authors. The purpose of this study was to investigate the duration of bone healing and nonunion ratio in patients who underwent ulnar shortening osteotomy by a 5-hole nonlocking plate with a simple transverse osteotomy for ulnar impaction syndrome and to determine the correlation between the gap length of the osteotomy site and the duration of bone healing.

METHODS

We assessed patients who underwent ulnar shortening osteotomy for ulnar impaction syndrome using a 5-hole nonlocking plate fixation followed by a simple transverse osteotomy between July 2012 and October 2021. This study was a case series study, and the level of evidence was IV.

RESULTS

A total of 80 patients were included. The mean age of the patients was 46.7 years, and 46 patients were men. The average bone union period was 41.8 ± 18.7 weeks. The correlation between the gap length of the osteotomy site and the duration of bone union of the osteotomy site was not significant. The nonunion ratio of our method was 2.5%.

CONCLUSION

The nonunion rate of our ulnar shortening osteotomy with a simple transverse osteotomy and a 5-hole nonlocking plate was comparable to that in previous reports, but our method required slightly longer periods for bone union. There was no correlation between the gap length of the osteotomy and the duration of bone union.

LEVEL OF EVIDENCE

Level IV (Case series).

Comparative analysis of discoid lateral meniscus size: a distinction between symptomatic and asymptomatic cases

PURPOSE

This study evaluated the differences in meniscal sizes and occupancy between symptomatic and asymptomatic patients diagnosed with discoid lateral meniscus (DLM) using magnetic resonance imaging (MRI) to understand how these variations relate to the presence of symptoms and the patients' age.

METHODS

A retrospective review of 98 patients with DLM was conducted, excluding those with meniscal displacement. Both the width and extrusion of DLM and the percentage of the meniscus to the tibia were measured using mid-coronal and mid-sagittal MRI and compared between symptomatic and asymptomatic DLM groups. The relationships among each parameter, meniscal size, and patient age were evaluated. Symptomatic cases were divided into those with and without horizontal tears on MRI to compare the differences in meniscal morphology.

RESULTS

A total of 92 knees from 74 patients were included. Sixty-one knees required surgical intervention for symptomatic DLM, while 31 were asymptomatic and included the contralateral side of symptomatic knees. The symptomatic group exhibited larger morphological variations than the asymptomatic group. Moreover, the sagittal meniscal ratio reduced with age in the asymptomatic group (r = - 0.54, p = 0.002) but remained constant in the symptomatic group. The symptomatic cases with horizontal tears demonstrated larger meniscal dimensions and smaller posterior capsule distances than those without tears.

CONCLUSION

Symptomatic patients with DLM had larger knee morphological changes than asymptomatic ones. Age affected the meniscal occupancy in the sagittal plane only in asymptomatic patients.

LEVEL OF EVIDENCE

III.

Nerve Grafting for Isolated Injury to the Intrinsic Motor Branch of the Ulnar Nerve due to a Stab Injury: A Case Report

Isolated injury to the deep motor branch of the ulnar nerve caused by stabbing is sporadic, with only one reported case in the English-language literature. We report one such case treated successfully using nerve grafting. A 33-year-old patient had sustained a stab wound to the right hypothenar eminence and showed a claw hand deformity. Needle electromyography study revealed denervation potentials with no voluntary motor unit action potentials (MUAPs) in the first dorsal interosseous (FDI) muscles. Nerve exploration revealed a neuroma-in-continuity in the intrinsic motor branch of the ulnar nerve. Intraoperative nerve stimulation confirmed the absence of compound muscle action potentials in the FDI. The damaged scarred nerve was resected, and the 15-mm defects were reconstructed with cable autografting. Two years and 5 months after the surgery, voluntary MUAPs were observed in the FDI. The pinch strengths recovered. Laceration of the deep branch of the ulnar nerve caused by stabbing can sometimes remain hidden as the hand sensation remains intact. Pre- and intraoperative electrophysiological examination is essential to assess the severity of the injured nerve and determine an appropriate surgical option. Even nerve grafting can facilitate satisfactory results as target intrinsic muscles are quite close to the repair site.

Saucerization of complete discoid lateral meniscus is associated with change of morphology of the lateral femoral condyle and tibial plateau

PURPOSE

To determine the effect of saucerization surgery on knee joint morphology associated with a complete discoid lateral meniscus (DLM) using magnetic resonance (MR) imaging.

METHODS

This retrospective study included cases had undergone saucerization surgery for symptomatic DLM between 2007 and 2022. All cases were divided into two by age group: < 12 (U13) and > 13 (O13). The cases in the match group were randomly selected from preoperative cases in the O13 group matched with the age at the final follow-up (F/U) of cases in the U13 group. The following morphological parameters were evaluated using MR images preoperatively and at the final postoperative F/U in each group: anterior obliquity of the lateral tibial plateau (AOLTP), posterior obliquity of the lateral tibial plateau (POLTP), and the lowest point of the lateral femoral condyle (LPLFC). Each parameter was compared between the U13 preoperative (pre-OP) group and the O13 pre-OP group, the preoperative and final follow-up in the U13, and the U13 group at the final F/U and the match group preoperatively.

RESULTS

A total of 77 cases were evaluated. 31 cases were in the U13 pre-OP group and 46 were in the O13 pre-OP group. With a minimal F/U of 2 years, 27 cases in the U13 group and 36 in the O13 group were included. The mean F/U period was 4.6 years in the U13 group and 3.2 years in the O13 group. 32 cases were included in the match group. In the match group, the inclination of the POLTP was significantly larger (P = 0.042) and the LPLFC was more lateral (P = 0.0034) than at the final F/U in the U13 group.

CONCLUSIONS

Saucerization surgery for DLM in juvenile patients can prevent progression to the characteristic bone morphology DLM. These results could help the surgeon making the decision when the surgery would be performed for symptomatic DLM patients.

LEVEL OF EVIDENCE

Retrospective comparative study; level of evidence, 3.

Mobile-bearing prosthesis suppresses the postoperative rotational mismatch and improves patient-reported outcome measurements better than fixed-bearing prosthesis: rotational analysis by 3D measurement in total knee arthroplasty

INTRODUCTION

It is preferable to reduce postoperative excessive rotational mismatch between the femur and tibia that causes poor clinical results following total knee arthroplasty (TKA). The aim of this study is to compare postoperative rotational mismatches and clinical outcomes with mobile- and fixed-bearing prostheses.

MATERIALS AND METHODS

This study classified 190 TKAs into two groups equally by propensity score matching: mobile-bearing group (n = 95) and fixed-bearing group (n = 95). Computed tomography images of the whole leg were taken at 2 weeks postoperatively. The component alignments, rotational mismatches between the femur and tibia, and rotations among components were measured three-dimensionally. The knee range of motion, New Knee Society Score (KSS) subjective sores, and Forgotten Joint Score (FJS-12) were assessed at the final follow-up.

RESULTS

Rotational mismatch between the femur and tibia was significantly less in the mobile- (- 0.8° ± 7.3°) than in the fixed-bearing (3.3° ± 8.5°, p < 0.001) group. New KSS functional activity score was significantly poorer in patients with excessive rotational mismatch (61.3 ± 21.4) than in those without it (49.5 ± 20.6, p = 0.02). Comparing mobile-bearing prosthesis, the use of fixed-bearing prosthesis was a risk factor for postoperative excessive rotational mismatch (odds ratio: 2.32, p = 0.03).

CONCLUSION

When compared to a fixed-bearing prosthesis, TKA using a mobile-bearing prosthesis could suppress the postoperative rotational mismatch between the femur and tibia that causes poor subjective functional activity score. However, since this study was conducted for PS-TKA, the results might not be applicable to other models.

Machine-learning-based approach for nonunion prediction following osteoporotic vertebral fractures

PURPOSE

An osteoporotic vertebral fracture (OVF) is a common disease that causes disabilities in elderly patients. In particular, patients with nonunion following an OVF often experience severe back pain and require surgical intervention. However, nonunion diagnosis generally takes more than six months. Although several studies have advocated the use of magnetic resonance imaging (MRI) observations as predictive factors, they exhibit insufficient accuracy. The purpose of this study was to create a predictive model for OVF nonunion using machine learning (ML).

METHODS

We used datasets from two prospective cohort studies for OVF nonunion prediction based on conservative treatment. Among 573 patients with acute OVFs exceeding 65 years in age enrolled in this study, 505 were analyzed. The demographic data, fracture type, and MRI observations of both studies were analyzed using ML. The ML architecture utilized in this study included a logistic regression model, decision tree, extreme gradient boosting (XGBoost), and random forest (RF). The datasets were processed using Python.

RESULTS

The two ML algorithms, XGBoost and RF, exhibited higher area under the receiver operating characteristic curves (AUCs) than the logistic regression and decision tree models (AUC = 0.860 and 0.845 for RF and XGBoost, respectively). The present study found that MRI findings, anterior height ratio, kyphotic angle, BMI, VAS, age, posterior wall injury, fracture level, and smoking habit ranked as important features in the ML algorithms.

CONCLUSION

ML-based algorithms might be more effective than conventional methods for nonunion prediction following OVFs.

Reliability and validity of a new deltoid muscle area measurement method after reverse shoulder arthroplasty

Background

Accurate deltoid muscle assessment after reverse shoulder arthroplasty (RSA) is difficult using magnetic resonance imaging due to metal artifacts. We hypothesized that measuring the deltoid muscle area (DA) in the middle part of the deltoid's total length postoperatively would reduce metal artifacts and allow for an accurate assessment. This study aimed to assess the reliability and reproducibility of magnetic resonance imaging and evaluate its impact on postoperative outcomes.

Methods

The DA in the middle part of the muscle's total length was measured twice by four examiners using pre and postoperative magnetic resonance imaging in 60 patients who underwent RSA (22 men, 38 women; mean age: 77.4 years). The DA at the greater tuberosity was measured preoperatively, and its correlation with the middle part of the deltoid's total length was evaluated. The Constant-Murley Score was measured at 2 years postoperatively, and its correlation with the DA in the middle part of the deltoid's total length pre- and postoperatively was assessed.

Results

Intraclass correlation coefficients for intraobserver measurements of preoperative and postoperative DA in the middle part of the deltoid's total length were almost perfect, with mean values of 0.98 and 0.97, respectively. The intraclass correlation coefficients for interobserver reliability regarding the first and second DA measurements in the middle part of the deltoid's total length were 0.95 and 0.95 (preoperatively) and 0.89 and 0.90 (postoperatively). The Constant-Murley Score was assessed at 2 years postoperatively in 51 patients. Muscle strength was weakly and moderately correlated with preoperative DA (r = 0.33, P = .02) and postoperative DA (r = 0.49, P < .01), respectively.

Conclusion

DA measurement in the middle part of the deltoid's total length after RSA was not affected by metal artifacts and had excellent reproducibility. This measurement method positively correlated with postoperative muscle strength, suggesting its usefulness for predicting postoperative muscle strength.

Optimal Prognostic Factors for Metastatic and Inoperable Sarcomas Treated With Pazopanib, Eribulin, and Trabectedin

BACKGROUND/AIM

The prognosis of metastatic and inoperable sarcomas is extremely poor, and intensive chemotherapy-based treatment is typically administered to prolong survival. Currently, pazopanib, eribulin, and trabectedin are key drugs used in patients with these sarcomas. The aim of the study was to identify prognostic factors for metastatic and inoperable bone and soft tissue sarcomas.

PATIENTS AND METHODS

Clinicopathological data of 46 patients with metastatic and inoperable sarcomas treated with pazopanib, eribulin, and trabectedin between January 2013 and February 2022 at our institution were retrospectively analyzed. Age, sex, primary tumor location, adverse effects, history of doxorubicin and radiation therapy, performance status scores, maximum tumor response, and survival duration were evaluated. The significant prognostic factors were identified using Cox proportional hazards models. Moreover, the 5-year survival rate was evaluated using the Kaplan-Meier method.

RESULTS

The median survival duration after treatment was 13.3 months, where the 5-year overall survival rate was estimated to be 9.85%. Both univariate and multivariate analyses revealed significant relationships among patient prognosis, performance status, and tumor response.

CONCLUSION

Performance status scores and tumor response were significantly associated with patient prognosis. Therefore, regardless of age, sex, primary tumor location, adverse effects, and history of doxorubicin and radiation therapy, use of cutting-edge drugs, such as pazopanib, eribulin, and trabectedin, may be advantageous in patients with advanced sarcomas, if their drug response and performance status scores are good.

The modification of bone cut angle and joint line obliquity did not change the tibiofemoral kinematics and stability of knee joint after total knee arthroplasty

INTRODUCTION

Previous reports using cadaveric knees and musculoskeletal computer simulation have shown that kinematically aligned (KA) total knee arthroplasty (TKA) provides more natural and physiological tibiofemoral kinematic patterns than mechanically aligned (MA) TKA. These reports suggested that the modification of joint line obliquity improve the knee kinematics. This study aimed to determine whether joint line obliquity change the intraoperative tibiofemoral kinematics in TKA candidates with knee osteoarthritis.

METHODS

Thirty consecutive knees with varus osteoarthritis that underwent TKA using a navigation system were evaluated. Two types of trial components were prepared: (1) MA TKA model: component trial in which articulating surface was parallel to the bone cut surface (2) KA TKA model: the femoral component trial, which mimicked the KA TKA method of Dossett et al. was designed 3° valgus and 3° internal rotation to the femoral bone cut surface, and the tibial component trial was designed 3° varus to the tibial bone cut surface. These two trials were set on the same knees during the operation, and the tibiofemoral rotational kinematics and varus-valgus laxity were measured from 0° to 120° of knee flexion using a navigation system.

RESULTS

The joint gap was 20 ± 2 mm and 3° ± 1° varus in extension and 20 ± 2 mm and 3° ± 1°varus in flexion. The differences in femoral component rotation between KA TKA and MA TKA were not statistically significant for any knee flexion angle. The differences in varus-valgus laxity between KA TKA and MA TKA were also not statistically significant for any knee flexion angle.

CONCLUSION

Although the degree of joint line obliquity varies widely in various KA TKA methods, this study, which mimicked the method of Dossett et al. showed that the modification of joint line obliquity did not change the tibiofemoral kinematics and stability of the knee joint in TKA candidates with knee osteoarthritis.

Parathyroid Hormone Inhibits Fatty Infiltration and Muscle Atrophy After Rotator Cuff Tear by Browning of Fibroadipogenic Progenitors in a Rodent Model

BACKGROUND

Progressive fatty infiltration and muscle atrophy after rotator cuff tears lead to tendon repair failure and poor outcomes. Fibro-adipogenic progenitors (FAPs) are involved in fatty infiltration and muscle homeostasis of skeletal muscle. Inducing FAP differentiation into brown adipocyte-like "beige adipocytes" suppresses fatty infiltration and muscle atrophy.

HYPOTHESIS

Parathyroid hormone (PTH) suppresses fatty infiltration and muscle atrophy after rotator cuff tears in a rat model by browning of FAPs.

STUDY DESIGN

Controlled laboratory study.

METHODS

PTH was administered subcutaneously for 4 or 8 weeks to a rotator cuff tear model in rats. After treatment, fatty infiltration of supraspinatus muscles was assessed using Oil Red O staining and muscle atrophy using wet muscle weight and muscle fiber cross-sectional area. Costaining of platelet-derived growth factor receptor α (FAP marker) and uncoupling protein 1 (browning marker) was performed to confirm FAP browning by PTH. Mouse-isolated FAPs were cultured with PTH and evaluated for browning-related gene expression and adipogenic differentiation using BODIPY staining. Myogenic differentiation of C2C12 myoblasts was evaluated using coculture of PTH-treated browning FAPs with C2C12.

RESULTS

PTH inhibited fatty infiltration after rotator cuff tear at 8 weeks. Rotator cuff wet muscle loss of PTH-treated rats was inhibited at 4 and 8 weeks. Furthermore, PTH-treated rats demonstrated larger myofiber cross-sectional area than did untreated rats at 4 and 8 weeks. Costaining indicated colocalization of platelet-derived growth factor receptor α and uncoupling protein 1 and promoted PTH-induced FAP browning. PTH increased the expression of browning-related genes in FAPs and suppressed fat droplet accumulation in vitro. Coculture with PTH-treated FAPs promoted C2C12 cell differentiation into myotubes.

CONCLUSION

PTH induced FAP-derived beige adipocytes by upregulating browning-related gene expression, and the browning effect of PTH on FAPs inhibited fatty infiltration and muscle atrophy in the rat rotator cuff tear model. PTH might have potential as a therapeutic drug for fatty infiltration and muscle atrophy after rotator cuff tears.

CLINICAL RELEVANCE

PTH may expand treatment options for rotator cuff tears by reducing fatty infiltration and muscle atrophy after rotator cuff tears by browning of FAPs.

The Impact of Multidisciplinary Approaches to Social Functioning on Surgical Outcomes After Surgery for Cervical Myelopathy

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To identify the effects of multidisciplinary approaches (MAs) to improve social functioning (SF) on 1-year surgical outcomes in patients with cervical myelopathy.

SUMMARY OF BACKGROUND DATA

Despite significant improvement in cervical myelopathy, a patient's quality of life (QOL) sometimes does not improve postoperatively. A previous study revealed that SF, rather than myelopathy severity, correlated with QOL improvement after decompression surgery for cervical myelopathy.

PATIENTS AND METHODS

This study compared two prospective cohorts in Japan. Patients who underwent cervical laminoplasty for cervical myelopathy from 2018 to 2020 were enrolled in the control cohort. Patients who underwent the same surgery with the same indications between 2020 and 2021 were enrolled in the MA cohort. Patients in the control cohort were treated with a standard care protocol, and those in the MA cohort were treated with a multidisciplinary protocol that focused on SF improvement. The changes in the total Japanese Orthopedic Association (JOA) score and in the domains of the JOA scores (upper limb function, lower limb function, upper limb sensory, and lower limb sensory) from preoperatively to 1 year postoperatively were compared between the control and MA cohorts using a mixed-effect model.

RESULTS

The control and MA cohorts comprised 140 and 31 patients, respectively. The improvement in the JOA score was significantly better in the MA cohort than in the control cohort ( P = 0.040). In analyses of each JOA score domain, the improvement of upper limb function was significantly better in the MA cohort than in the control cohort ( P = 0.033). Similarly, the MA cohort demonstrated significantly higher patient-reported outcomes for upper extremity function than the control cohort ( P < 0.001). In addition, the self-care domain of QOL score at 1 year postoperatively was significantly higher in the MA cohort than in the control cohort ( P = 0.047).

CONCLUSION

MAs to improve/rebuild a patient's SF were effective in improving cervical myelopathy and the self-care domain of QOL. This study is the first to demonstrate the effectiveness of postoperative MAs in patients with cervical myelopathy.

LEVEL OF EVIDENCE

Level 3.

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

Risk of Revision After Vertebral Augmentation for Osteoporotic Vertebral Fracture: A Narrative Review

Osteoporotic vertebral fractures (OVFs) can hinder physical motor function, daily activities, and the quality of life in elderly patients when treated conservatively. Vertebral augmentation, which includes vertebroplasty and balloon kyphoplasty, is a commonly used procedure for OVFs. However, there have been reports of complications. Although serious complications are rare, there have been instances of adjacent vertebral fractures, cement dislocation, and insufficient pain relief due to cement failure, sometimes necessitating revision surgery. This narrative review discusses the common risks associated with vertebral augmentation for OVFs, such as cement leakage and adjacent vertebral fractures, and highlights the risk of revision surgery. The pooled incidence of revision surgery was 0.04 (0.02-0.06). The risks for revision are reported as follows: female sex, advanced age, diabetes mellitus, cerebrovascular disease, dementia, blindness or low vision, hypertension, hyperlipidemia, split type fracture, large angular motion, and large endplate deficit. Various treatment strategies exist for OVFs, but they remain a subject of controversy. Current literature underscores the lack of substantial evidence to guide treatment strategies based on the risks of vertebral augmentation. In cases with a high risk of failure, other surgeries and conservative treatments should also be considered as treatment options.

Long-duration upper extremity surgery under brachial plexus block combined with intravenous dexmedetomidine sedation without an anesthesiologist

BACKGROUND

Dexmedetomidine (DEX) provides a unique conscious sedation without respiratory depression. We examined the usefulness of intravenous (IV) DEX sedation combined with brachial plexus block for long-duration upper extremity surgery without an anesthesiologist.

METHODS

We retrospectively reviewed 90 limbs of 86 patients and measured the actual operative time course in detail. The adverse events and the patient-reported outcomes regarding intraoperative pain and depth of sedation were evaluated.

RESULTS

The mean total time of the operation, tourniquet use, and the IV DEX sedation were 150 min, 132 min, and 117 min, respectively. The mean time between discontinuation of IV DEX sedation and completion of the operation was 51 min. The intraoperative adverse events involved bradycardia (21%), hypotension (18%), and oxygen desaturation (3%). The mean visual analog scale scores of pain during brachial plexus block, surgical site pain, tourniquet pain, and depth of the sedation were 23.4 mm, 0.14 mm, 4.2 mm, and 6.6 mm, respectively. Furthermore, 96% patients expressed a preference for receiving anesthesia as brachial plexus block with IV DEX sedation.

CONCLUSIONS

Long-duration upper extremity surgery, even longer than 2 h, was feasible under brachial plexus block combined with IV DEX sedation without an anesthesiologist. For patients with low blood pressure and/or low heart rate, it is recommended to adjust the continuous infusion of IV DEX to less than 0.4 µg/kg/h. To ensure that the patients are able to promptly leave the operating room fully awake, IV DEX infusion should be stopped at least 30 min before finishing the operation.

Assessment of Prevalence and Risk Factors for Central Sensitization Related to Shoulder Osteoarthritis and Rotator Cuff Tears Using the Central Sensitization Inventory: A Cross-Sectional Study in Shoulder Surgery Patients

Shoulder disorders occasionally cause intractable pain. Central sensitization (CS) may be involved in such pain. Identifying risk factors associated with CS is crucial for effective pain control. This study aimed to determine the effects of shoulder osteoarthritis and rotator cuff tears (RCT) on CS and associated factors. This study included patients evaluated for CS using the Central Sensitization Inventory (CSI) before surgery for shoulder osteoarthritis, RCT, or cuff tear arthropathy. Patients with a CSI score of 40 or higher were defined as having CS. The relationships between glenohumeral osteoarthritis (GHOA), RCT size, and CS were statistically analyzed. Multiple regression analysis was performed to examine the factors affecting CSI scores. Subjects included 167 patients: 131 patients had RCT without GHOA, 23 had GHOA with RCT, and 13 had GHOA without RCT. The GHOA group had a significantly higher CSI score (27.5 [10.8-40.5] vs. 18.0 [10.0-27.5]) and CS prevalence (27.8% vs. 8.4%) than the RCT without GHOA group. There was no significant correlation between RCT size and CSI scores. Multiple regression analysis showed that female sex, severe pain, and long pain duration were associated with higher CSI scores. Considering the risk factors for CS might be helpful in shoulder treatment.

Association between worsening renal function severity during hospitalization and low physical function at discharge: a retrospective cohort study of older patients with heart failure and chronic kidney disease from Japan

BACKGROUND

The number of hospitalized older patients with chronic heart failure, chronic kidney disease, and worsening renal function is rising in Japan. This study aimed to clarify the impact of the severity of worsening renal function during hospitalization on low physical function at discharge of these patients.

METHODS

We included 573 consecutive heart failure patients who underwent phase I cardiac rehabilitation. Worsening renal function severity was defined according to elevation during hospitalization of baseline serum creatinine on admission: non-worsening renal function, serum creatinine < 0.2 mg/dL; worsening renal function II/I, serum creatinine ≥ 0.2 to < 0.5 mg/dL; worsening renal function III, and serum creatinine ≥ 0.5 mL/dL. Physical function was measured with the Short Performance Physical Battery. We compared background factors, clinical parameters, pre-hospitalization walking levels, Functional Independence Measure score, and physical function in the three renal function groups. Multiple regression analysis was performed with the Short Performance Physical Battery at discharge as the dependent variable.

RESULTS

The final analysis included 196 patients (mean age 82.7 years, male 51.5%) categorized into three groups based on worsening renal function: worsening renal function grade III group (n = 55), worsening renal function grade II/I group (n = 36), and non-worsening renal function group (n = 105). There is no significant difference in walking levels before hospitalization between the three groups, but physical function at discharge was significantly lower in the worsening renal function III group. Moreover, worsening renal function III was an independent factor for low physical function at discharge.

CONCLUSION

Worsening of renal function during hospitalization in older patients with heart failure and chronic kidney disease was strongly associated with low physical function at discharge, even after adjusting for other potentially confounding factors, such as pre-hospitalization walking levels, walking start day, and Geriatric Nutrition Risk Index at discharge. Notably, worsening renal function of mild or moderate severity (grade II/I) did not show a significant association with low physical function.

Prediction of the superimposed laser shot number for copper using a deep convolutional neural network

Image-based deep learning (IBDL) is an advanced technique for predicting the surface irradiation conditions of laser surface processing technology. In pulsed-laser surface processing techniques, the number of superimposed laser shots is one of the fundamental and essential parameters that should be optimized for each material. Our primary research aims to build an adequate dataset using laser-irradiated surface images and to successfully predict the number of superimposed shots using the pre-trained deep convolutional neural network (CNN) models. First, the laser shot experiments were performed on copper targets using a nanosecond YAG laser with a wavelength of 532 nm. Then, the training data were obtained with the different superimposed shots of 1 to 1024 in powers of 2. After that, we used several pre-trained deep CNN models to predict the number of superimposed laser shots. Based on the dataset with 1936 images, VGG16 shows a high validation accuracy, higher sensitivity, and more than 99% precision than other deep CNN models. Utilizing the VGG16 model with high sensitivity could positively impact the industries' time, efficiency, and overall production.

A decision tree analysis to predict clinical outcome of minimally invasive lumbar decompression surgery for lumbar spinal stenosis with and without coexisting spondylolisthesis and scoliosis

BACKGROUND CONTEXT

Implementing machine learning techniques, such as decision trees, known as prediction models that use logical construction diagrams, are rarely used to predict clinical outcomes.

PURPOSE

To develop a clinical prediction rule to predict clinical outcomes in patients who undergo minimally invasive lumbar decompression surgery for lumbar spinal stenosis with and without coexisting spondylolisthesis and scoliosis using a decision tree model.

STUDY DESIGN/SETTING

A retrospective analysis of prospectively collected data.

PATIENT SAMPLE

This study included 331 patients who underwent minimally invasive surgery for lumbar spinal stenosis and were followed up for ≥2 years at 1 institution.

OUTCOME MEASURES

Self-report measures: The Japanese Orthopedic Association (JOA) scores and low back pain (LBP)/leg pain/leg numbness visual analog scale (VAS) scores. Physiologic measures: Standing sagittal spinopelvic alignment, computed tomography, and magnetic resonance imaging results.

METHODS

Low achievement in clinical outcomes were defined as the postoperative JOA score at the 2-year follow-up <25 points. Univariate and multiple logistic regression analysis and chi-square automatic interaction detection (CHAID) were used for analysis.

RESULTS

The CHAID model for JOA score <25 points showed spontaneous numbness/pain as the first decision node. For the presence of spontaneous numbness/pain, sagittal vertical axis ≥70 mm was selected as the second decision node. Then lateral wedging, ≥6° and pelvic incidence minus lumbar lordosis (PI-LL) ≥30° followed as the third decision node. For the absence of spontaneous numbness/pain, sex and lateral olisthesis, ≥3mm and American Society of Anesthesiologists physical status classification system score were selected as the second and third decision nodes. The sensitivity, specificity, and the positive predictive value of this CHAID model was 65.1, 69.8, and 64.7% respectively.

CONCLUSIONS

The CHAID model incorporating basic information and functional and radiologic factors is useful for predicting surgical outcomes.

Lateral meniscus autograft transplantation using hamstring tendon with a sandwiched bone marrow - derived fibrin clot: A case report

INTRODUCTION AND IMPORTANCE

Tendon autograft is a durable solution for the sub/total meniscus; however it is still considered a temporary solution.

CASE PRESENTATION

We report the case of a 17-year-old woman with history of subtotal lateral meniscectomy performed 6 years ago. We treated her with lateral meniscus autograft transplantation using a hamstring tendon with a sandwiched bone marrow aspirate (BMA)-derived fibrin clot. T2 relaxation times of the anterior and posterior horns of both menisci and of the cartilage were assessed.

CLINICAL DISCUSSION

Lateral meniscus autograft transplantation using a hamstring tendon with a sandwiched BMA clot improved clinical and radiographic outcomes at the 24-month follow-up. These findings suggest that the lateral meniscus autograft transplantation using a hamstring tendon with a sandwiched BMA clot transformed into a meniscus-like tissue and resulted in preservation of the articular cartilage.

CONCLUSION

Lateral meniscus autograft transplantation using a hamstring tendon with a sandwiched BMA clot can function as a meniscal transplant after total or subtotal meniscectomy in young patients.

Factors Predicting the Final Diagnosis in Image-Guided Percutaneous Needle Biopsy for Suspected Spinal Tumors

In cases of suspected spinal tumors on imaging studies, a biopsy is often necessary for establishing the diagnosis. Predictive factors for tumors or malignancies may help in scheduling biopsies or avoiding unnecessary ones. However, there have been few studies on determining these factors. We aimed to determine the factors associated with the final diagnosis in cases requiring spinal biopsy. This study included 117 patients who underwent image-guided (fluoroscopy- or computed tomography [CT]-guided) needle biopsy of the spine. Data on patient demographic, pathological diagnoses, and final diagnoses were retrospectively collected from the medical records. The imaging features and location of lesions were also evaluated on CT and magnetic resonance imaging. Furthermore, factors related to tumors or malignancies were analyzed. The diagnostic accuracy of biopsy was 94.0%, and there was no difference in the diagnostic accuracy between the fluoroscopic and CT-guided biopsies. Sixty-six and fifty-six patients were diagnosed with spinal tumors and malignant tumors, respectively. Multivariate analysis revealed that a history of malignant tumors and the presence of pedicle lesions and/or extravertebral lesions were related factors for both tumors or malignancy in the final diagnosis. These findings can help determine the necessity for or timing of biopsy in patients with suspected spinal tumors.

Muscle strength rather than appendicular skeletal muscle mass might affect spinal sagittal alignment, low back pain, and health-related quality of life

Sarcopenia is defined as decreasing in muscle strength and mass, and dynapenia is defined as decreasing in muscle strength and maintained muscle mass. This study elucidated the prevalence and characteristics of sarcopenia and dynapenia and evaluate in elderly spinal disorders patients. 1039 spinal disorders patients aged ≥ 65 years were included. We measured age, grip strength, muscle mass, spinal sagittal alignment parameters, low back pain (LBP) scores and health-related quality of life (HR-QoL) scores. Based on the previous reports, patients were categorised into normal group: NG, pre-sarcopenia group: PG, dynapenia group: DG, and sarcopenia group: SG. Pre-sarcopenia, dynapenia, and sarcopenia were found in 101 (9.7%), 249 (19.2%), and 91 (8.8%) patients, respectively. The spinal sagittal alignment parameters, trunk muscle mass, LBP, and HR-QoL scores were significantly worse in DG and SG compared with those in PG and NG. Spinal alignment, trunk muscle mass, and clinical outcomes, including LBP and HR-QoL scores, were maintained in the PG and poor in the DG and SG. Thus, intervention for muscle strength may be a treatment option for changes of spinal sagittal alignment and low back pain.

Deep learning-based screening tool for rotator cuff tears on shoulder radiography

BACKGROUND

Early diagnosis of rotator cuff tears is essential for appropriate and timely treatment. Although radiography is the most used technique in clinical practice, it is difficult to accurately rule out rotator cuff tears as an initial imaging diagnostic modality. Deep learning-based artificial intelligence has recently been applied in medicine, especially diagnostic imaging. This study aimed to develop a deep learning algorithm as a screening tool for rotator cuff tears based on radiography.

METHODS

We used 2803 shoulder radiographs of the true anteroposterior view to develop the deep learning algorithm. Radiographs were labeled 0 and 1 as intact or low-grade partial-thickness rotator cuff tears and high-grade partial or full-thickness rotator cuff tears, respectively. The diagnosis of rotator cuff tears was determined based on arthroscopic findings. The diagnostic performance of the deep learning algorithm was assessed by calculating the area under the curve (AUC), sensitivity, negative predictive value (NPV), and negative likelihood ratio (LR-) of test datasets with a cutoff value of expected high sensitivity determination based on validation datasets. Furthermore, the diagnostic performance for each rotator cuff tear size was evaluated.

RESULTS

The AUC, sensitivity, NPV, and LR- with expected high sensitivity determination were 0.82, 84/92 (91.3%), 102/110 (92.7%), and 0.16, respectively. The sensitivity, NPV, and LR- for full-thickness rotator cuff tears were 69/73 (94.5%), 102/106 (96.2%), and 0.10, respectively, while the diagnostic performance for partial-thickness rotator cuff tears was low at 15/19 (78.9%), NPV of 102/106 (96.2%) and LR- of 0.39.

CONCLUSIONS

Our algorithm had a high diagnostic performance for full-thickness rotator cuff tears. The deep learning algorithm based on shoulder radiography helps screen rotator cuff tears by setting an appropriate cutoff value.

LEVEL OF EVIDENCE

Level III: Diagnostic Study.

Anti-Tumor Effect and Neurotoxicity of Ethanol Adjuvant Therapy after Surgery of a Soft Tissue Sarcoma

Wide resection is the main treatment for sarcomas; however, when they are located near major nerves, their sacrifices might affect limb function. The efficacy of ethanol adjuvant therapy for sarcomas has not been established. In this study, the anti-tumor effect of ethanol, as well as its neurotoxicity, were assessed. In vitro anti-tumor effect of ethanol as evaluated using MTT, wound healing, and invasion assays on a synovial sarcoma cell line (HS-SY-II). In vivo, an assessment was conducted in nude mice (implanted with subcutaneous HS-SY-II) treated with different ethanol concentrations after surgery with a close margin. Sciatic nerve neurotoxicity was assessed with electrophysiological and histological examination. In vitro, ethanol concentrations at 30% and higher showed cytotoxic effects in MTT assay and markedly reduced migration and invasive ability of HS-SY-II. In vivo, both 30% and 99.5% ethanol concentrations, compared to 0% concentration, significantly reduced the local recurrence. However, in the group treated with 99.5% ethanol, nerve conduction tests showed prolonged latency and decreased amplitude, and morphological changes suggestive of nerve degeneration were observed in the sciatic nerve, while the 30% ethanol did not cause neurological damage. In conclusion, 30% is the optimal concentration for ethanol adjuvant therapy after close-margin surgery for sarcoma.

Risk Factors for Poor Outcome after Palliative Surgery for Metastatic Spinal Tumors

Palliative surgery is performed to improve the quality of life of patients with spinal metastases. However, it is sometimes difficult to achieve the expected results because the patient's condition, and risk factors related to poor outcomes have not been well elucidated. This study aimed to evaluate the functional outcomes and investigate the risk factors for poor outcomes after palliative surgery for spinal metastasis. We retrospectively reviewed the records of 117 consecutive patients who underwent palliative surgery for spinal metastases. Neurological and ambulatory statuses were evaluated pre- and post-operatively. Poor outcomes were defined as no improvement or deterioration in functional status or early mortality, and the related risk factors were analyzed using multivariate logistic regression analysis. The results showed neurological improvement in 48% and ambulatory improvement in 70% of the patients with preoperative impairment, whereas 18% of the patients showed poor outcomes. In the multivariate analysis, low hemoglobin levels and low revised Tokuhashi scores were identified as risk factors for poor outcomes. The present results suggest that anemia and low revised Tokuhashi scores are related not only to life expectancy but also to functional recovery after surgery. Treatment options should be carefully selected for the patients with these factors.