Impacts of Segond Fractures on Anterior Cruciate Ligament Reconstruction Outcomes

INTRODUCTION

Segond fractures, characterized by avulsion injuries at the lateral tibial condyle's anterolateral structure (ALS) attachment, often coincide with anterior cruciate ligament (ACL) injuries, potentially leading to knee instability. However, the influence of Segond fractures on knee stability after ACL reconstruction remains uncertain. Despite documented ALS reconstructions, there is a lack of consensus regarding the assessment of ALS failure and the criteria for surgical interventions. This study aimed to determine if Segond fracture presence impacts ACL reconstruction outcomes, utilizing patient-reported subjective assessments and healthcare providers' objective evaluations.

MATERIALS AND METHODS

This retrospective study encompassed 639 patients (328 males, 311 females; mean age 26.9 years) who underwent ACL reconstruction, with a follow-up of at least one year. Subjects were divided into two groups: Segond fractures diagnosed through radiographic findings (Group S+, n = 17) and no Segond fractures (Group S-, n = 622). Clinical evaluation included the 36-item Short Form Survey (SF-36), Lysholm score, visual analog scale (VAS) for knee pain, knee injury and osteoarthritis outcome score (KOOS), and knee instability assessment via Telos SE (Telos Japan, Tokyo, Japan). Statistical comparisons were performed between the two groups.

RESULTS

At the final follow-up, all SF-36 subscales improved in all eight subscales compared to before surgery, reaching national standard scores; no significant inter-group differences were evident. Lysholm scores were 93.0 ± 12.1 (Group S+) and 91.7 ± 10.9 (Group S-) (P = 0.62), VAS for knee pain was 10.0 ± 18.0 (Group S+) and 11.9 ± 16.9 (Group S-) (P = 0.62), total KOOS was 89.0 ± 17.4 (Group S+) and 90.7 ± 9.9 (Group S-) (P = 0.39), and anterior tibial translation differences were 2.8 ± 3.0 mm (Group S+) and 2.7 ± 2.9 mm (Group S-) (P = 0.73). All these values represent postoperative measurements. No significant discrepancies existed between groups across evaluation methods.

CONCLUSIONS

This study's results suggest that Segond fractures have minimal impact on clinical ACL reconstruction outcomes, as assessed through both patient-reported subjective evaluations and objective healthcare provider evaluations. Segond fractures' significance in postoperative outcomes questions the necessity of ALS reconstruction.

Hereditary Anatomical Risk Factors for Anterior Cruciate Ligament Injuries

INTRODUCTION

 Genetic and anatomical factors have been reported as risk factors for anterior cruciate ligament (ACL) injuries. This study aimed to investigate anatomical characteristics in family members sustaining ACL injuries, compared with age- and sex-matched patients with simple meniscus injuries.

MATERIALS AND METHODS

 Medical records of 1548 patients who underwent ACL reconstruction were reviewed. Cases of ACL injury occurring in first-degree relatives were selected. Forty-one patients from 20 families were included in the study (F-ACL group). Fifty patients with meniscus injuries were included as controls. Anatomical factors comprising posterior-inferior tibial slope (PITS), notch width index (NWI), notch angle (NA), and intercondylar notch roof inclination angle (RA) were compared between groups. The correlation of these anatomical factors between parent and child or siblings was also investigated.

RESULTS

 The 41 patients (20 families) consisted of 12 parent-child pairs and 29 siblings (13 pairs and one trio). Injuries occurred during playing the same sport in 11 families (55%). PITS was significantly steeper in the F-ACL group (9.9 vs. 7.8 degrees). NWI and NA were significantly smaller in the F-ACL group (0.262 vs. 0.278 and 50.5 vs. 58.8 degrees). RA was significantly greater in the F-ACL group (130 vs. 126.9 degrees). A positive correlation in NA (r = 0.677) and a weak correlation in NWI and RA were observed between family members.

CONCLUSIONS

 Common anatomical risk factors of ACL injury exist within families, including intercondylar notch stenosis and steep posterior tibial slope. The findings suggest the potential for developing effective ACL injury prevention programs targeting these risk factors.

Pivotal role of IL-8 derived from the interaction between osteosarcoma and tumor-associated macrophages in osteosarcoma growth and metastasis via the FAK pathway

The prognosis of osteosarcoma (OS) has remained stagnant over the past two decades, requiring the exploration of new therapeutic targets. Cytokines, arising from tumor-associated macrophages (TAMs), a major component of the tumor microenvironment (TME), have garnered attention owing to their impact on tumor growth, invasion, metastasis, and resistance to chemotherapy. Nonetheless, the precise functional role of TAMs in OS progression requires further investigation. In this study, we investigated the interaction between OS and TAMs, as well as the contribution of TAM-produced cytokines to OS advancement. TAMs were observed to be more prevalent in lung metastases compared with that in primary tumors, suggesting their potential support for OS progression. To simulate the TME, OS and TAMs were co-cultured, and the cytokines resulting from this co-culture could stimulate OS proliferation, migration, and invasion. A detailed investigation of cytokines in the co-culture conditioned medium (CM) revealed a substantial increase in IL-8, establishing it as a pivotal cytokine in the process of enhancing OS proliferation, migration, and invasion through the focal adhesion kinase (FAK) pathway. In an in vivo model, co-culture CM promoted OS proliferation and lung metastasis, effects that were mitigated by anti-IL-8 antibodies. Collectively, IL-8, generated within the TME formed by OS and TAMs, accelerates OS proliferation and metastasis via the FAK pathway, thereby positioning IL-8 as a potential novel therapeutic target in OS.

Impact of Skeletal Muscle Mass on Physical Function and Locomotive Syndrome of Pre- and Postoperative Adult Spinal Deformity

Background: The purpose of this study is to identify the relationship between locomotive syndrome (LS) status, physical performance and limb and trunk skeletal muscle mass before and after surgery in adult spinal surgery (ASD) patients. Methods: A retrospective observational investigation of 63 consecutive patients with ASD who underwent spinal surgery was conducted. The total skeletal muscle mass of the arms and legs was considered a measure of the total appendicular skeletal muscle mass measured with whole-body dual-energy X-ray absorptiometry. All data pertaining to the physical performance tests and LS were collected preoperatively with follow-up one year postoperatively. Results: Gait speed, the one-leg standing test and the stand-up test were significantly improved one year after surgery compared to preoperative measurements. The lower extremity skeletal muscle mass predominantly influences physical function improvement including gait stride, one-leg standing and the stand-up test after ASD surgery. Conclusions: This study is the first to show that assessing lower extremity muscles prior to ASD surgery is useful in predicting postoperative recovery.

A nationwide multicenter study of the cost effectiveness of five leading drugs for pharmacological management of cervicobrachial symptoms

BACKGROUND

Cervicobrachial pain frequently affects the quality of life (QOL) of the general public and has a significant economic impact on the health care systems of various countries. There are a number of treatment options for this disease, including widely-used drug therapy, but the effectiveness of each option is indeterminate, and there have been no published cost-effectiveness analysis studies so far. This prospective observational study aimed to examine the cost-effectiveness of drug treatment for cervicobrachial symptoms.

METHODS

A 6-month medication regimen for each of five frequently-prescribed drugs for cervicobrachial symptoms was administered to 322 patients at 24 centers in Japan. Outcome measures, including of the EuroQol Group 5D, Short Form-8, and Visual Analog Scale (VAS), were investigated at baseline and every month thereafter. Incremental cost-effectiveness ratios (ICERs) of the drug cost to quality-adjusted life years (QALYs) were calculated. A stratified analysis of patient characteristics was also performed to identify baseline factors potentially affecting cost-effectiveness.

RESULTS

The ICER of entire drug treatment for cervicobrachial symptoms was 7,491,640 yen. Compared with the reference willingness-to-pay, the ICER was assumed to not be cost-effective. A certain number of QALYs were gained during the first 3 months after the treatment intervention, but almost no QALYs were gained during the following 3 months. Stratified analysis showed that cost-effectiveness was extremely low for patients with high baseline VAS and high QOL.

CONCLUSIONS

The available medications for cervicobrachial symptoms did not have excellent cost-effectiveness. Although a certain number of QALYs were gained during the first 3 months after medication, no QALYs were gained in the latter half of the study period, suggesting that it is not advisable to continue the medication needlessly.

LEVEL OF EVIDENCE

II, prospective cohort study.

Case Report: Angiomatoid fibrous histiocytoma in the hand: a rare clinical presentation and diagnostic challenge

Angiomatoid fibrous histiocytoma (AFH) is a rare tumor of mesenchymal origin occurring in young adults. Based on its clinical course, it is said to have an intermediate potential. We present a case of a 59-year-old woman with AFH in the hand that was difficult to diagnose. A benign soft tissue tumor was suspected on magnetic resonance imaging, and its size and open biopsy suggested nodular fasciitis or inflammatory myofibroblastic tumor. A diagnosis of AFH was eventually made based on the analysis of the resected specimens. The characteristic findings of histopathology and immunohistochemistry in this case were relatively poor, so fluorescence in situ hybridization contributed to making the correct diagnosis. Considering its prognosis, careful follow-up was decided upon without additional surgery. Our case is a challenging one because of its atypical presentation and inconclusive imaging and histopathological findings.

The Utility and Appropriateness of Single-Position Circumferential Lumbar Interbody Fusion Using O-Arm-Based Navigation in the Novel Oblique Position

PURPOSE

Single-position surgery with patients in a lateral position, which involves inserting percutaneous pedicular screws (PPS) and lateral interbody fusion (LIF) to avoid changing the position, has been reported. The purpose of the present study was to evaluate the utility and appropriateness of single-position LIF-PPS using O-arm-based navigation in the innovative oblique position.

METHODS

This study involved a retrospective analysis of 92 consecutive patients with lumbar spondylolisthesis who underwent LIF-PPS using O-arm-based navigation. Thirty-five subjects demonstrated surgery with repositioning, as well as 24 in the lateral decubitus position, and 33 in the oblique during PPS, where the position was changed to the lateral decubitus position using bed rotation without resetting. We compared these three groups in terms of the surgery time, blood loss, and the accuracy of the screw placement.

RESULTS

The operative time was significantly shorter in the single-position surgery, both in the lateral and oblique positions, compared to surgery in a dual position. The blood loss was significantly increased in the lateral position compared to the dual and oblique positions. The screw trajectory angle on the downside was significantly smaller in the lateral position, and the accuracy of the screw placement on the downside was significantly lower in the lateral position compared to the dual and oblique positions.

CONCLUSION

Single-position surgery could reduce the average surgery time by about 60 min. The present study indicated the oblique position during PPS insertion might make single-position surgery more useful to improve the accuracy of PPS on the downside, with less blood loss.

Synovial chondromatosis: Rare involvement of metacarpophalangeal joint and diagnostic challenges in MR imaging

Synovial chondromatosis (SC) is a rare benign tumor of the cartilaginous tissue that frequently affects large joints intra-articularly. Characteristic imaging findings were reported for the diagnosis of SC. Herein, we report a case of SC of the metacarpophalangeal joint with atypical MRI findings. Considering the clinical presentation, erosion, absence of calcification on X-ray and CT, and low intensity on short tau inversion recovery (STIR), tenosynovial giant cell tumor was the initially diagnosis. However, histopathological findings revealed SC with fibrosis, which was confirmed using Elastica Van Gieson (EVG) staining. In general, low intensity on STIR in SC indicate calcification; however, it can also represent fibrosis in SC. In this case, the diagnosis of SC using MRI was limited highlighting the importance of histopathological findings for an accurate diagnosis of SC.

Anterior fusion surgery with overcorrection in the treatment of adolescent idiopathic scoliosis with Lenke 1 AR curve type: how to achieve overcorrection and its effect on postoperative spinal alignment

BACKGROUND

The efficacy of anterior fusion with overcorrection in the instrumented vertebra for Lenke 1 AR type curves has been reported, but how to achieve overcorrection and how overcorrection affects spinal alignment are unclear. The purpose of this study was to identify the factors that cause overcorrection, and to investigate how overcorrection affects postoperative spinal alignment in the surgical treatment of Lenke 1 AR type curves.

METHODS

Patients who had anterior surgery for a Lenke type 1 or 2 and lumbar modifier AR (L4 vertebral tilt to the right) type scoliosis and minimum 2-year follow-up were included. The radiographic data were measured at preoperative, postoperative 1 month, and final follow-up. The UIV-LIV Cobb angle was determined as the Cobb angle between the upper instrumented vertebra (UIV) and the lower instrumented vertebra (LIV), and a negative number for this angle was considered overcorrection. The screw angle was determined to be the sum of the angle formed by the screw axis and the lower and upper endplates in the LIV and UIV, respectively. The change (Δ) in the parameters from postoperative to final follow-up was calculated. The relationships between the UIV-LIV Cobb angle and other radiographic parameters were evaluated by linear regression analyses.

RESULTS

Fourteen patients met the inclusion criteria. Their median age was 15.5 years, and the median follow-up period was 53.6 months. The median UIV-LIV Cobb angle was -1.4° at postoperative 1 month. The median screw angle was 4.7°, and overcorrection was achieved in 11 (79%) cases at postoperative 1 month. The screw angle (r2 = 0.42, p = 0.012) and Δ FDUV-CSVL (the deviation of the first distal uninstrumented vertebra from the central sacral vertical line, r2 = 0.53, p = 0.003) were significantly correlated with the UIV-LIV Cobb angle.

CONCLUSIONS

Screw placement in the UIV and LIV not parallel to the endplate, but angled, was an effective method to facilitate overcorrection in the instrumented vertebrae. The results of the present study suggest that overcorrection could bring spontaneous improvement of coronal balance below the instrumented segment during the postoperative period.

Bilateral Patellofemoral Ligament Reconstruction for Patellar Instability in Ehlers-Danlos Syndrome: A Case Report

CASE

We report the case of an 11-year-old boy with Ehlers-Danlos syndrome (EDC) who exhibited simultaneous medial and lateral patellar instability. The patient presented with a medial patellar dislocation, and subsequently, the patella became very unstable both medially and laterally. Despite distal realignment, the patellar instability was so significant that he underwent simultaneous reconstruction of the medial and lateral patellofemoral ligament using the semitendinosus tendon, with a good result.

CONCLUSION

Simultaneous reconstruction of the medial and lateral patellofemoral ligament is an effective method in cases of extreme patellar instability, such as the EDS case.

Assessment of Changes in Hindfoot Alignment of Total Ankle Arthroplasty for Ankle Osteoarthritis on Weightbearing Subtalar X-ray View

Background

Recovering normal hindfoot alignment and correcting deformity of the ankle joint following total ankle arthroplasty (TAA) in osteoarthritis (OA) is essential for improving clinical outcomes and increasing long-term survival. We aim to evaluate hindfoot alignment following standard TAA compared to TAA with a total talar prosthesis ("combined TAA") in varus-type OA patients.

Methods

This retrospective study was conducted between 2010 and 2022. We included 27 patients (30 feet) who underwent standard TAA and 19 patients (22 feet) who underwent combined TAA. Hindfoot alignment at the subtalar joint was measured by weightbearing subtalar radiographic view before and after surgery.

Results

In the standard TAA, the angle between the tibial shaft axis and the articular surface of the talar dome joint (TTS) changed from 75 to 87 degrees (P < .01), the angle between the tibial axis and the surface on the middle facet (TMC) from 89 to 94 degrees (P < .01), and the angle between the tibial axis and the surface on the posterior facet (TPC) from 80 to 84 degrees (P < .01). The angle between the articular surface of the talar dome and the posterior facet of the calcaneus (SIA) decreased from 4.7 to -2.5 degrees (P < .01). In the combined TAA, TTS angle changed from 77 to 88 degrees (P < .01), TMC angle from 93 to 101 degrees (P < .01), TPC angle from 84 to 90 degrees (P < .05), and SIA from 6.6 to 2.1 degrees (P < .01). Varus deviation to the subtalar joint (TMC, TPC) significantly improved postoperatively in both groups. However, TPC was smaller than TTS and SIA was negative in standard TAA, and TPC was larger than TTS and SIA was positive in combined TAA.

Conclusion

The amount of correction of the subtalar joint differed depending on the ligament dissection of the subtalar joint and shape of the talar component.

Level of Evidence

Level III, retrospective cohort study.

Primary Synovial Sarcoma of the Bone: A Case Report and Literature Review

BACKGROUND/AIM

Synovial sarcoma (SS), a spindle cell sarcoma, typically occurs in the soft tissues of the extremities and rarely develops in the bones as a primary tumor. To our knowledge, no case of SS in the metacarpal bone has been reported.

CASE REPORT

We report a case of primary SS of the metacarpal bone. Considering the clinical and imaging findings, SS was difficult to diagnose; therefore, we performed an open biopsy. Next, we performed a wide resection following the management guidelines for SS of the soft tissue. Immunohistochemistry (IHC) showed positive staining for SS18:SSX and SSX, and fluorescence in situ hybridization showed positive staining for the SS18 split. Owing to FNCLCC grade 3 tumor and the R1 margin, adjuvant chemotherapy with ifosfamide and doxorubicin was initiated. Finally, SS of the bone was diagnosed. Furthermore, we reviewed a total of 37 published cases of primary bone SS, including our case. Age and sex were almost the same in all cases of bone SS, and the most frequent site was the long bone in the lower extremity.

CONCLUSION

IHC for SS18::SSX and SSX antibodies are beneficial for diagnosing general SS and SS of the bone. Moreover, SS of the bone should be considered in the differential diagnosis of spindle cell sarcomas of the bone. Wide resection and chemotherapy are recommended as current treatment strategies, although further studies are required regarding treatment validity.

Is histopathological synovitis score a predictor of postoperative requirement for additional or alternative drug treatment in the patients with rheumatoid arthritis?

OBJECTIVES

Histopathological synovitis scoring is useful for assessing activity in patients with rheumatoid arthritis (RA) at sampling, but it is unclear whether it can be a predictor of future drug treatment. The purpose of this study was to examine whether histopathological synovitis score is a predictor of postoperative requirement for additional or alternative drug treatment after total knee arthroplasty (TKA).

METHODS

Thirty patients with RA in whom synovial samples were obtained during TKA were included. Patients were divided into the drug treatment enhanced group (EG), which included patients who needed additional or alternative drug treatment within 1 year after TKA, and the drug treatment maintenance group (MG). The Rooney synovitis score (RSS) was compared between groups. Logistic regression analysis was performed to clarify prognostic factors for postoperative drug treatment change.

RESULTS

The total RSS was significantly higher in the EG than in the MG (29.3 vs 15.1; P < .001). Multivariate analysis showed that total RSS and swollen joint counts were independent variable associated with postoperative requirement for additional or alternative drug treatment (P < .05).

CONCLUSIONS

Histopathological synovitis scoring may predict requirement for additional or alternative drug treatment in patients with RA after TKA.

Clinical differences in preoperative symptoms and surgical outcomes between early and late-teen patients with Lenke type 5C adolescent idiopathic scoliosis

PURPOSE

This study aimed to compare the clinical features and postoperative outcomes in patients with Lenke type 5C AIS in the early and late teens.

METHODS

The study included eligible patients with AIS aged < 20 years with Lenke type 5C curves who underwent selective thoracolumbar/lumbar (TL/L) fusion. The patients were divided into two groups according to the age: younger (11-15 years) and older (16-19 years). Demographic data, radiographic parameters, and 22-item scoliosis research society questionnaire (revised) (SRS-22r) scores were compared.

RESULTS

Seventy-three (female: 69, male: 4, mean age: 15.1 years) patients were included. There were 45 and 28 patients in the younger and older groups, respectively. The older group exhibited a significantly smaller TL/L curve than the younger group, whereas no between-group differences were identified regarding curve flexibility and fusion length. The change in coronal balance and subjacent disc angle from preoperative to 2 years after surgery was significantly greater in the younger group, although each curve was equally corrected. Preoperative SRS-22r scores in the older group were significantly worse; however, they improved to the level of the younger group at 2 years after surgery. Postoperative coronal malalignment was observed in six patients (21.4%) in the older group, whereas no cases in the younger group (p < 0.05).

CONCLUSION

In patients with Lenke type 5C AIS, we showed that late teens had significantly worse SRS-22r scores than did early teens. Postoperative coronal malalignment was frequently observed in the late teens due to the reduced ability of compensation by subjacent disc wedging.

Comparative Study for Characteristics of Locomotive Syndrome in Patients with Lumbar Stenosis and Adult Spinal Deformity

INTRODUCTION

The differential diagnoses of lumbar spinal stenosis (LSS) and adult spinal deformity (ASD) have been demonstrated primarily using sagittal radiographic spinopelvic parameters. However, it is more important to know the differences in the characteristic clinical symptoms to make accurate treatment decisions. Recently, the relationship between spinal disease and Locomotive Syndrome (LS) has been reported. Additionally, the Geriatric Locomotive Function Scale-25 (GLFS-25) was reported to be a useful scale to evaluate disease severity and characteristic clinical symptoms in spinal disease.

METHODS

Sixty-nine consecutive patients with ASD and 196 patients with LSS who underwent spinal surgery were included. Locomotive dysfunction was evaluated using the GLFS-25 questionnaire and physical performance tests including the two-step test and the stand-up test, measured preoperatively. The correlations between sagittal spinopelvic parameters of ASD and LS were examined.

RESULTS

All subjects with lumbar degenerative disease in the present study were diagnosed with LS preoperatively. The severity of LS in patients with LSS and ASD were statistically similar. GLFS-25 scores in the mobility and community domain were similarly poor in both groups. Several scores in the domestic life and self-care domains were significantly worse in the ASD group. Question 20 of the GLFS-25, related to load-bearing tasks and housework, was significantly associated with a large pelvic incidence in ASD patients.

CONCLUSIONS

Lumbar degenerative disease requiring surgery severely affects the LS of older people. ASD patients had more difficulty with load-bearing tasks and housework such as cleaning the yard, carrying heavy bedding, dressing, and bathing compared to LSS patients.

Advancing Tissue Factor-targeted Therapy for Osteosarcoma via Understanding its Role in the Tumor Microenvironment

Coagulation activation is associated with cancer progression and morbidity. Recently, mechanisms through which coagulation proteases drive the tumor microenvironment (TME) have been elucidated. This study aims to develop a new strategy dependent on the coagulation system for treating osteosarcoma (OS). We focused on tissue factor (TF), the main initiator of the extrinsic coagulant pathway, as a target for OS treatment. It was found that cell surface-TF, TF-positive extracellular vesicles, and TF-positive circulating tumor cells could drive progression, metastasis, and TME in carcinomas, including OS. Thus, targeting tumor-associated coagulation by focusing on TF, the principle catalyst of the extrinsic pathway, TF is a promising strategy treatment for OS.

Relationship between floating toes condition and lower limb muscle weight in 8-year-old children: the Yamanashi adjunct study of the Japan Environment and Children's Study (JECS-Y)

[Purpose] Floating toe is a condition in which the toes make insufficient contact with the ground. Weak muscle strength is reportedly one cause of floating toe. However, little evidence exists regarding the relationship between foot muscle strength and floating toe. Here we examined the relationship between foot muscle strength and floating toe by investigating the children' lower extremity muscle mass and floating toe conditions. [Participants and Methods] This cohort study enrolled 118 8-year-old children (62 females, 56 males) with recorded footprints and muscle mass evaluations using dual-energy X-ray absorptiometry. We calculated the floating toe score using the footprint. We measured the muscle weights and the muscle weights divided by the lengths of the lower limbs separately on the left and right sides using dual-energy X-ray absorptiometry. [Results] No significant correlations were observed between the floating toe score and muscle weights or muscle weights divided by lower-limb lengths for either gender or side. [Conclusion] In this study, no significant correlation was found between floating toe degree and lower limb muscle mass, suggesting that lower limb muscle strength is not the primary cause of floating toe, at least in children.

Radiological Assessment of Postoperative Paraspinal Muscle Changes After Lumbar Interbody Fusion With or Without Minimally Invasive Techniques

STUDY DESIGN

Retrospective cohort study.

BACKGROUND

Percutaneous pedicle screws (PPS) have the advantage of being able to better preserve the paraspinal muscles when compared with a traditional open approach. However, the nature of changes in postoperative paraspinal muscle after damage by lumbar fusion surgery has remained largely unknown. It is clinically important to clarify and compare changes in paraspinal muscles after the various surgeries.

OBJECTIVE

(1) To determine postoperative changes of muscle density and cross-sectional area using computed tomography (CT), and (2) to compare paraspinal muscle changes after posterior lumbar interbody fusion (PLIF) with traditional open approaches and minimally invasive lateral lumbar interbody fusions (LLIF) with PPS.

METHODS

We included data from 39 consecutive female patients who underwent open PLIF and 23 consecutive patients who underwent single-staged treatment with LLIF followed by posterior PPS fixation at a single level (L4-5). All patients underwent preoperative, 6 months postoperative, and 1-year postoperative CT imaging. Measurements of the cross-sectional area (CSA) and muscle densities of paraspinal muscles were obtained using regions of interest defined by manual tracing.

RESULTS

We did not find any decrease of CSA in any paraspinal muscles. We did find a decrease of muscle density in the multifidus at 1 year after surgery in patients in the PILF group, but not in those in LLIF/PPS group.

CONCLUSIONS

One year after surgery, a significant postoperative decrease of muscle density of the multifidi was observed only in patients who underwent open PLIF, but not in those who underwent LLIF/PPS.

Factors affecting the quality of life in the chronic phase of thoracolumbar osteoporotic vertebral fracture managed conservatively with a brace

BACKGROUND CONTEXT

Although osteoporotic vertebral fractures (OVFs) are the most common type of osteoporotic fracture, few reports have closely investigated the factors contributing to the quality of life (QOL) in the chronic phase after thoracolumbar OVFs using detailed radiographic evaluation.

PURPOSE

This study aimed to identify factors associated with the QOL in the chronic phase after thoracolumbar OVF.

DESIGN

Post hoc analysis of a prospective randomized study.

PATIENT SAMPLE

Participants included 195 patients with fresh thoracolumbar OVF managed conservatively with a brace who were available for radiographic analysis 48 weeks after injury.

OUTCOME MEASURES

The degree of QOL impairment at 48 weeks after thoracolumbar OVF was assessed using the Japanese three-level version of the EuroQol five-dimensional questionnaire (EQ-5D) score.

METHODS

Univariate and multivariate regression analyses were used to evaluate the relationships between the QOL and radiographic factors.

RESULTS

The univariate analysis showed that age, analgesic use, T10/L5 Cobb angle on magnetic resonance imaging (MRI), subsequent vertebral fracture, and nonunion were significantly associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. The multiple regression analysis showed that nonunion, analgesic use, subsequent vertebral fracture, and sacral slope on MRI were independently associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. Receiver operating characteristic analysis for the deterioration of QOL showed that the cutoff value for sacral slope on MRI was 35 degrees.

CONCLUSIONS

This study demonstrated that nonunion, subsequent vertebral fracture, and lower sacral slope were independently associated with poorer QOL in the chronic phase of thoracolumbar OVF managed conservatively with a brace. Therefore, improving or preventing these factors in patients with thoracolumbar OVF in the chronic phase may improve the QOL of the affected patients.

Risk factors and clinical impact of persistent coronal imbalance after posterior spinal fusion in thoracolumbar/lumbar idiopathic scoliosis

OBJECTIVE

Persistent coronal imbalance (PCI) can develop postoperatively. In this study, the authors aimed to clarify the risk factors and clinical impact of PCI after posterior spinal fusion (PSF) in idiopathic scoliosis (IS) patients with a major thoracolumbar/lumbar (TL/L) curve.

METHODS

Data on 108 patients with Lenke type 5C or 6C IS who underwent PSF with a minimum of 2 years of follow-up were retrospectively analyzed. PCI was defined as coronal imbalance persisting 2 years after surgery. Radiographic parameters and clinical outcomes were compared between the PCI (+) and PCI (-) groups. Multivariate regression analyses of associated factors were performed to determine the risk factors for PCI.

RESULTS

Of the 108 patients, 48 (44%) had immediate postoperative coronal imbalance, and 10 of these patients (9%) had coronal imbalance persisting 2 years after surgery. The PCI (+) group had significantly worse postoperative subtotal and satisfaction scores than the PCI (-) group. Preoperative apical vertebral translation (AVT) of the TL/L curve (AVT-TL/L) and postoperative coronal balance (CB) were identified as independent risk factors for PCI. The cutoff values of preoperative AVT-TL/L at 49.5 mm (area under the curve [AUC] 0.835, p = 0.001, 95% CI 0.728-0.941, sensitivity 70.0%, specificity 72.4%) and those of postoperative CB at -27.5 mm (AUC 0.837, p < 0.001, 95% CI 0.729-0.945, sensitivity 78.6%, specificity 70.0%) were used to predict PCI. In selective fusion cases, older age (OR 2.110, 95% CI 1.159-3.842, p = 0.015), greater preoperative AVT-TL/L (OR 1.199, 95% CI 1.029-1.398, p = 0.020), and less postoperative CB (OR 0.855, 95% CI 0.743-0.983, p = 0.027) were independent risk factors for PCI.

CONCLUSIONS

Preoperative AVT-TL/L and postoperative CB are important parameters for predicting PCI. PCI adversely affects postoperative clinical outcomes. In selective fusion surgery, PCI tends to occur in older patients due to reduced flexibility and compensatory abilities.

Case report: Atypical spindle cell/pleomorphic lipomatous tumor masquerading as a myxoid liposarcoma or intramuscular myxoma

Atypical spindle cell/pleomorphic lipomatous tumors (ASPLTs) were recently categorized as benign lipomatous tumors. However, accurate and complete preoperative diagnosis of ASPLTs may be difficult. Furthermore, diagnosis based on magnetic resonance imaging (MRI) findings is uncertain because of the varying ratios of the fat component within the tumor. Here, we report a case of ASPLT masquerading as a myxoid tumor. Although MRI findings were consistent with a myxoid liposarcoma, needle biopsy findings suggested a myxoma, and we performed marginal resection. Histopathological findings revealed infiltrating spindle cells with atypia. In addition, immunohistochemistry (IHC) showed positive staining for CD34 and heterogeneous retinoblastoma deficiency, and fluorescence in situ hybridization (FISH) showed no amplification of mouse double minute 2 homolog and no rearrangement of FUS or EWSR1. When MRI and histopathological findings suggest a myxoid tumor, IHC and FISH should be considered and performed for a precise and accurate diagnosis.

A cross-sectional study on the correlations between floating toe, plantar arch posture, and body composition in 8-year-old children

BACKGROUND

Floating toe (FT): inadequately in contact with the ground and flexible flat foot (FFF) are frequently seen in children. According to some reports, inadequate foot muscle strength may cause FT or FFF.Therefore, a relationship may exist between arch formation, FT, and pedal muscle strength. This study aimed to evaluate the correlation of FT with plantar arch posture and body composition, including overall muscle mass.

METHODS

We conducted our own cohort study in addition to the Japan Environment and Children's Study conducted by the Ministry of the Environment, Japan. Out of 705 eight-year-old children participating in this adjunct study, 578 with recorded footprints were included. Body composition (body weight, body fat percentage, and predicted muscle mass) was assessed using body composition analyzer. Presence of FT or FFF was evaluated using foot pressure plate. We calculated the FT score (small FT score indicates insufficient ground contact of the toes) and the Chippaux-Smirak Index (CSI) using images of the plantar footprint.

RESULTS

The FT score (an indicator of FT) showed no significant correlation with CSI (an indicator of plantar arch posture). Moreover, no significant correlations between the predicted muscle mass, FT score, and CSI were observed.

CONCLUSIONS

This is the first report that assessed the relationship of FT with plantar arch posture and body composition in children. This study indicated that muscle strength might not be a major factor for FT and FFF development in children.

Should the upper end vertebra be selected as the upper instrumented vertebra in patients with Lenke type 5C adolescent idiopathic scoliosis?

STUDY DESIGN

Retrospective study.

PURPOSE

The upper end vertebra (UEV) is often selected as the upper instrumented vertebra (UIV) in patients with adolescent idiopathic scoliosis (AIS) with Lenke type 5C curves; however, the effect of adjusting UIV selection one level toward the cranial side (UEV + 1) is unknown. Therefore, this study aimed to assess the effect of UIV extension on scoliosis correction and global alignment in patients with the UIV as the UEV and UEV + 1.

METHODS

Data of 52 patients with AIS with Lenke type 5C curves who underwent selective thoracolumbar/lumbar (TL/L) fusion with a minimum follow-up period of 2 years were retrospectively analyzed. The patients were divided according to the UIV in relation to the UEV: the UEV and UEV + 1 groups. Radiographic parameters and clinical outcomes were compared between the two groups.

RESULTS

Among the 52 patients, 24 and 28 were included in the UEV and UEV + 1 group. Baseline data showed no intergroup differences except for the UIV level. While the UEV + 1 group showed a significantly greater TL/L curve correction (72.9% vs. 62.8%, p < 0.05) and a lower UIV tilt, it showed a significantly greater absolute value of radiographic shoulder height (RSH) (- 7.9 vs. - 0.9 mm, p < 0.05) and coronal balance (- 11.0 mm vs - 4.8 mm, p < 0.05) at 2 years postoperatively. The rate of post-operative shoulder imbalance (RSH ≥ 2 cm) was significantly higher in the UEV + 1 than in the UEV group. No intergroup differences were observed in the sagittal alignment and patient outcomes between the two groups.

CONCLUSION

When the UIV was selected as the UEV + 1, correction of the TL/L curve improved; however, it increased the risk of shoulder and coronal imbalance. There is no clinical benefit observed in terms of extending the UIV to the UEV + 1; therefore, the UIV should be selected as the UEV to maintain harmonious global alignment.

LEVEL OF EVIDENCE

Level 3.

The Anatomical Position of Graf’s Standard Plane and Its Relationship With Pelvic Morphology: A Computed Tomography-Based Study

Objective

The Graf method is the most widely used ultrasonographic method for evaluating developmental dysplasia of the hip (DDH), and it relies on a set standard plane. However, no previous reports have discussed the detailed anatomical location of the plane. The aim of this study was to evaluate the exact anatomical position of Graf’s standard plane in the pelvis and to ascertain the correlation between this position and pelvic morphology in children without abnormal pelvic morphology.

Methods

We retrospectively assessed the pelvic CT data of 32 children (64 hips) aged three to five years without abnormal pelvic morphology and measured the pelvic winging and acetabular anteversion and coverage. We defined the coronal plane that passed through the center of the bilateral femoral head as plane A. We determined that Graf’s standard plane could be approximated by rotating plane A until the outer wall of the ilium was parallel to the sagittal plane, and we defined this as plane A′. AA′ was defined as the angle from plane A to plane A′ on the sagittal plane. The anterior rotational angle (clockwise, viewing from the right side) was measured as the positive AA′. Moreover, we measured the pelvic rotation, acetabular anteversion, and acetabular coverage and evaluated the correlation between AA′ and these morphological parameters.

Results

The average AA′ was -8.27° and AA′ had a significant correlation with acetabular anteversion (Spearman’s ρ=0.40**, p<0.01).

Conclusions

We found that Graf's standard plane, as determined by the CT scan, tilts slightly posteriorly. This information may be useful in improving the ease of ultrasonographic examination of DDH.

Analysis of Health-Related Quality of Life and Clinical Evaluations in Patients with the Triad of Combined Knee Injuries

Combined knee injuries of the anterior cruciate ligament (ACL), medial collateral ligament (MCL), and medial meniscus were called "the unhappy triad" in the past. With recent advances in diagnostic technology, combined ACL, MCL, and lateral meniscus injuries are now known to be the predominant triad. We examined and verified the treatment outcomes of the triad of combined knee injuries from both patient-based subjective evaluation and objective assessments. We studied 49 knees (49 patients) with combined injuries of the ACL, MCL, and lateral meniscus. These cases were divided into those who underwent simultaneous ACL and MCL reconstruction (group A, 18 cases) and those who underwent ACL reconstruction only because MCL injury could be treated conservatively (group B, 31 cases). Clinical evaluation was conducted preoperative and 24 months or longer after surgery. The methods included patient-reported outcomes using Short Form-36, and conventional assessments using Lysholm's score, visual analogue scale (VAS), and quantitative measurement of knee instability using Telos SE. Compared with presurgical scores, the postsurgical Short Form-36 scores showed improvements in all eight subscales, all reaching the national standard values. Significant improvements were observed in the five subscales in group A and seven subscales in group B. Furthermore, significant improvements in Lysholm's score, VAS pain score, and quantitative knee instability were achieved in both groups. This study demonstrated successful clinical outcomes in patients with a triad of knee injuries who were treated with lateral meniscus repair or partial meniscectomy and either combined MCL/ACL reconstruction or ACL reconstruction alone.

Clinical Importance, Incidence and Risk Factors for the Development of Postoperative Ileus Following Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective observational study of a cohort of consecutive patients.

OBJECTIVES

Postoperative ileus (POI) is associated with a variety of adverse effects. Although the incidence of and risk factors for POI following spinal surgery have been reported, the frequency and pathology of POI after spinal corrective surgery for adult spinal deformity (ASD) are still largely unknown. The study objectives were to: (1) clarify the prevalence and clinical significance of POI, (2) elucidate the risk factors for POI, (3) determine radiographically which preoperative and/or postoperative spinal parameters predominantly influence the risk of POI after spinal corrective surgery for ASD.

METHODS

We included data from 144 consecutive patients who underwent spinal corrective surgery. Perioperative medical complications and clinical information were extracted from patient electronic medical records. Preoperative radiographic parameters and changes in radiographic parameters after surgery were compared between patients with and without POI. Multivariate logistic regression analyses were performed to clarify potential risk factors for POI.

RESULTS

POI developed in 25/144 (17.4%) patients and was the most common complication in the present study. The frequencies of smoking, gastroesophageal reflux disease, and lateral lumbar interbody fusion (LLIF), as well as the duration of surgery were significantly greater in the group with POI versus the group without POI. Among radiographic parameters, only the change in thoracolumbar kyphosis (TLK) from before to after surgery was significantly larger in the group with POI. Multivariate logistic regression analysis showed that male sex, LLIF and large changes in TLK from before to after surgery were significantly associated with the development of POI.

CONCLUSIONS

These results suggested that LLIF and large corrections in TLK were independent risk factors for POI after ASD surgery. When patients with ASD have large TLK preoperatively, and it is determined that a large correction is needed, physicians must be aware of the potential for occurrence of POI.

The characteristics of the young patients with cervical ossification of the posterior longitudinal ligament of the spine: A multicenter cross-sectional study

BACKGROUND

Ossification of the posterior longitudinal ligament of the spine (OPLL) is characterized by heterotopic bone formation in the posterior longitudinal ligament of the spine. Although the patients with OPLL are more common in the 60s and 70s, we know that there are markedly young patients (e.g., early 40s). However, to the best of our knowledge, there is few reports characterize young patients with cervical OPLL in terms of the imaging features, subjective symptoms, and ADL problems.

METHODS

This is the multicenter cross-sectional study. Two hundred and thirty-seven Japanese symptomatic patients with cervical OPLL confirmed by standard X-rays collected from 16 institutions belonging to the Japanese Multicenter Research Organization for Ossification of the Spinal Ligament formed by the Japanese Ministry of Health, Labor and Welfare were recruited. Whole spine CT data as well as demographic data such as age, gender, patients-based evaluations, and the 36-item Short Form Health Survey (SF-36) were evaluated.

RESULTS

Young group (≦ 45 years old) consisted of 23 patients (8 females and 15 males), accounting for 9.7% of the total. Their characteristics were high body mass index (BMI), significant involvement of trauma in the onset and deterioration of symptoms, and the predominance of thoracic OPLL. The patient-based evaluations did not show a significant difference between the young and non-young groups, or between the genders in the young group except for bodily pain (BP) of SF-36. Female patients in young group had significantly lower BP score of SF-36 than that of male in young group.

CONCLUSIONS

Characteristics of young patients with cervical OPLL were high BMI, significant involvement of trauma in the onset and deterioration of symptoms, lower BP score of SF-36 in female, and the predominance of thoracic OPLL.

Validity of a fall risk assessment score sheet for patients hospitalized in general wards

Falls (including fall on same level and fall to a lower level) are frequent medical accidents among hospitalized patients. We investigated the status of falls in our hospital, aiming to verify the usefulness of a fall risk assessment sheet and identify the risk factors of falls. 5219 patients who were admitted to the general wards of our hospital between April 2016 and March 2019 were studied. Patient background data and the result of risk assessment based on a fall risk assessment score sheet at admission were registered. The frequency and location of falls during hospitalization, and the impact on patients were investigated. Risk factors for falls were analyzed based on the assessment results at admission. 218 falls occurred during hospitalization in 152 of 5219 patients (2.9%). The most common location of falls was bedside (68%). Falls occurred at night in 28%. The impact of falls was level 1 in 18 patients, level 2 in 117, level 3a in 11, and level 3b in 6 (all had head injuries, and one had concurrent fracture). Fall rate was 1.1% (41/3791 patients) at risk level I, 6.8% (91/1335 patients) at level II, and 21.5% (20/93 patients) at level III. Multiple logistic regression analysis identified age, history of fall, tendency to act without pressing nurse call button, unstable gait, unstable when standing, and use of narcotic as risk factors of falls. The incidence of falls at our hospital was lower compared to previous reports, and fall risk assessment was useful overall.

Impact of Early Intervertebral Osseous Union After Posterior Lumbar Interbody Fusion on Health-Related Quality of Life

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Nonunion after posterior lumbar interbody fusion (PLIF) is associated with poor improvements in health-related quality of life (HRQOL). We aimed to investigate the influence of early osseous union after PLIF on HRQOL.

METHODS

We reviewed 138 patients with 1-level PLIF (mean age 67 years, follow-up period ≥1 year). Postoperative lumbar computed tomography was performed to assess screw loosening and intervertebral union. HRQOL was assessed using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire.

RESULTS

Thirty-nine patients (28%) showed complete union at 6 months postoperatively (early union group). Twenty-eight patients (20%) showed complete union at 6 to 12 months postoperatively (delayed union group), while 71 patients demonstrated noncomplete union. Effective improvement of lumbar spine dysfunction and psychological disorders was achieved in 19 (63.3%) and 17 (50.0%) patients in the early union group, in 9 (42.9%) and 14 (53.8%) patients in the delayed union group, and in 22 (34.9%) and 19 (29.2%) patients in the nonunion group, respectively (P = .036 and P = .036, respectively). The nonunion group had a significantly higher proportion of cases with screw loosening at 6 and 12 months postoperatively than the complete union group (P = .033 and P = .022).

CONCLUSIONS

Lumbar spine dysfunction and psychological disorders improved in cases with early complete union compared to those with nonunion. Screw loosening occurred in cases with nonunion predominantly from 6 months postoperatively. Therefore, the achievement of early complete union might be helpful for better HRQOL and lower incidence of postoperative complications.

The Prevalence and Risk Factors for Trigger Digits in a Random Sampling of a Japanese Population Registry between 50 and 89 Years of Age

Background: Trigger digit(s) (TD) is one of the most common disorders of the hand in the elderly population. The aim of this study is to determine the prevalence and identify the risk factors for TD in an elderly Japanese population. Methods: We randomly sampled 1,297 subjects between the ages of 50 and 89 years from the population registry of a town in Japan. About 413 subjects agreed to participate in the study, and all were examined for the presence of TD. Subjects were divided into three groups namely history of treatment for TD in the past (PTD), current evidence of TD (CTD) or both (BTD). The prevalence of TD was weighted by age according to the composition of the Japanese population. Age, female gender, obesity, hard manual work, exposure to vibration tools, sports activity, smoking, alcohol, wrist fracture, hypertension, hypothyroidism, diabetes mellitus, rheumatoid arthritis and carpal tunnel syndrome were assessed as risk factors for TD using univariate and multivariate logistic regression analysis. Results: Forty subjects had TD. This included 18, 19 and 3 subjects with PTD, CTD and BTD, respectively. The weighted prevalence of TD was 9.7% (female, 14.3%; male, 4.4%) in the Japanese population aged 50-89 years. Age 70-79 and female gender were identified as risk factors for TD. Conclusions: The random sampling of a Japanese population registry between the ages of 50 and 89 years revealed the prevalence of TD as 9.7% and identified age between 70 and 79 and female gender as risk factors for developing TD. Level of Evidence: Level II (Therapeutic).

Frequency of Change in Assessment from Bony Union to Nonunion after Lumbar Interbody Fusion: A Multicenter Study

Introduction

Assessments of early postoperative bony union after posterior lumbar interbody fusion via computed tomography (CT) have revealed cases in which interbody fixation by bony union resulted in nonfusion due to bone absorption. The apparent bone union state reverted to a nonunion state several months later, exhibiting a so-called “fake union” phenomenon. Additionally, few reports have evaluated the effect of teriparatide on bony union. The present study aimed to evaluate the frequency of change in assessment from fusion to nonfusion in the postoperative follow-up of lumbar interbody fusion, compare the late postoperative bony union rates in groups with or without early postoperative fusion, and examine the effect of postoperative teriparatide in those groups.

Methods

Sixty-nine subjects enrolled from multiple hospitals were prospectively evaluated following single-level lumbar interbody fusion. The patients were randomly allocated into treatment with or without weekly postoperative teriparatide. The subjects were then classified as having bony union or nonfusion at 2 months postoperatively, and fusion rates at 6 months were compared. For the evaluation of bony union, blinded radiological examinations were performed via CT. Additional comparisons were made according to teriparatide use.

Results

The rate of nonunion at 6 months postoperatively in patients with fusion at 2 months postoperatively was 27.8%. Among subjects with bony union at 2 months postoperatively, the fusion rate at 6 months in those who received teriparatide was 93.3% (p=0.027) versus 57.1% in those who did not.

Conclusions

The rate of nonunion at 6 months postoperatively in patients exhibiting union at 2 months after surgery was 27.8%. Postoperative weekly teriparatide treatment significantly reduced the rate of fake union.

Novel SLC9A6 Variation in Female Carriers With Intellectual Disability and Atypical Parkinsonism

Background and Objectives

Variations in SLC9A6 cause the X-linked neurologic disorder Christianson syndrome in males. Meanwhile, female carriers with SLC9A6 variations may remain asymptomatic or develop intellectual disability, behavioral problems, and psychiatric illnesses. Only a few female carriers have been reported to have associated atypical parkinsonism in late life.

Methods

We present a Japanese family with a novel SLC9A6 variation identified by quad whole-exome sequencing analysis and a reverse phenotyping strategy. The molecular and cellular impacts of the W89R variation in vitro were examined.

Results

The missense variation (c.265T>C, p.Trp89Arg) in SLC9A6 cosegregated with atypical parkinsonism and intellectual disability in female carriers of this family. The female carriers in this family presented with bradykinesia, rigidity, and tremor, predominately on the right side. We found that the W89R variation changed membrane traffic of NHE6-harboring vesicles, indicating potential involvement in the disease pathogenesis.

Discussion

This study might have revealed an example of a monogenic origin of atypical parkinsonism in females with SLC9A6 variations and draw attention to this understudied female-specific phenotype in clinical practice.

Risk Factors for Long Bone Fractures in Patients with Severe Motor and Intellectual Disabilities: A 6-year Follow-up Retrospective Study

Objectives:

Methods:

Results:

Conclusions:

Spindle Cell Lipoma with Ossification Mimicking Atypical Lipomatous Tumor/Well-Differentiated Liposarcoma: A Case Report

Although spindle cell lipoma (SCL) is a subtype of lipoma, the characteristics of SCL are observed in both lipomatous and non-lipomatous tumors. In this article, we present a case of SCL with ossification mimicking atypical lipomatous tumors/well-differentiated liposarcomas (ALTs/WDLs). Considering the findings of magnetic resonance imaging and needle biopsy, which exhibited ALTs/WDLs, marginal resection was performed. Histopathological findings demonstrated mature adipocytes and spindle cells without atypia and no malignant osteoid tissue in the ossified region. In addition, immunohistochemistry (IHC) showed positive staining for CD34, heterogeneous retinoblastoma protein deficiency, and negative staining for mouse double minute 2 homolog (MDM2) and cyclin-dependent kinase. Fluorescence in-situ hybridization showed negative amplification of MDM2. The final diagnosis of the tumor was established using IHC as an extremely rare SCL with ossification.

Associations of LRP5 and MTHFR Gene Variants with Osteoarthritis Prevalence in Elderly Women: A Japanese Cohort Survey Randomly Sampled from a Basic Resident Registry

Objective

Osteoarthritis (OA) is a common and degenerative joint disorder in the elderly. A greater importance of understanding the relationship between genetic factors and OA prevalence has emerged with population aging. We therefore investigated the associations of several bone disease-related genetic variants with the prevalence of OA and osteoporosis in Japanese elderly women from the Obuse study cohort, which was randomly sampled from a basic town resident registry.

Methods and Results

In total, 206 female participants (mean ± standard deviation age: 69.7 ± 11.0 years) who completed OA, bone mineral density, and genotype assessments were included. The number of patients diagnosed as having knee/hip OA and osteoporosis was 59 (28.6%) and 30 (14.6%), respectively. Fisher’s exact testing revealed significant relationships between the minor T allele of LDL receptor related protein 5 (LRP5) rs3736228 and the prevalence of knee/hip OA and osteoporosis. The respective odds ratios (ORs) of the TT genotype for knee/hip OA and osteoporosis were 7.28 (95% confidence interval [CI] 2.22–28.08) and 5.24 (95% CI 0.95–26.98). An additional subgroup analysis for knee OA revealed that the frequency of the common C allele of methylenetetrahydrofolate reductase (MTHFR) rs1801133 had a statistically significant protective association with the prevalence of knee OA (OR 0.58, 95% CI 0.35–0.97).

Conclusion

In sum, the present study demonstrated significant associations of LRP5 rs3736228 and MTHFR rs1801133 with knee/hip OA and osteoporosis prevalences and knee OA prevalence, respectively, in Japanese elderly women. These results will help further the understanding of OA pathogenesis and related genetic risk factors.

Exogenous parathyroid hormone attenuates ovariectomy-induced skeletal muscle weakness in vivo

Osteoporosis commonly affects the elderly and is associated with significant morbidity and mortality. Loss of bone mineral density induces muscle atrophy and increases fracture risk. However, muscle lipid content and droplet size are increased by aging and mobility impairments, inversely correlated with muscle function, and a cause of reduced motor function. Teriparatide, the synthetic form of human parathyroid hormone (PTH) 1-34, has been widely used to treat osteoporosis. Although PTH positively affects muscle differentiation in vitro, the precise function and mechanisms of muscle mass and power preservation are still poorly understood, especially in vivo. In this study, we investigated the effect of PTH on skeletal muscle atrophy and dysfunction using an ovariectomized murine model. Eight-week-old female C57BL/6J mice were ovariectomized or sham-operated. Within each surgical group, the mice were divided into PTH injection or control subgroups. Motor function was evaluated based on grip strength, treadmill running, and lactic acid concentration. PTH receptor was expressed in skeletal muscle cells and myoblasts. PTH inhibited ovariectomy-induced bone loss but not uterine atrophy or increased body weight; PTH not only abolished ovariectomy-induced reduction in grip strength and maximum running speed, but also significantly reduced the ovariectomy-induced increase in lactic acid concentration (compared with that observed in the vehicle control). PTH also abrogated the ovariectomy-induced reduction in the oxidative capacity of muscle fibers, their cross-sectional area, and intramyocellular lipid content, and induced cell proliferation, cell migration, and muscle differentiation, while reducing lipid secretion by C2C12 myoblasts via the Wnt/β-catenin pathway. PTH significantly ameliorated muscle weakness and attenuated exercise-induced lactate levels in ovariectomized mice. Our in vitro study demonstrated that PTH/Wnt signaling regulated the proliferation, migration, and differentiation of myoblasts and also reduced lipid secretion in myoblasts. Thus, PTH could regulate several aspects of muscle function and physiology, and may represent a novel therapeutic strategy for patients with osteoporosis.

Preoperative pelvic obliquity: possible relation to postoperative coronal decompensation in thoracolumbar/lumbar adolescent idiopathic scoliosis

OBJECTIVE

Pelvic obliquity is frequently observed in patients with adolescent idiopathic scoliosis with thoracolumbar/lumbar (TL/L) curve. This study aimed to assess pelvic obliquity changes and their effects on clinical outcomes of posterior fusion surgery.

METHODS

Data in 80 patients (69 with type 5C and 11 with type 6C adolescent idiopathic scoliosis) who underwent posterior fusion surgery were retrospectively analyzed. Pelvic obliquity was defined as an absolute pelvic obliquity angle (POA) value of ≥ 3°. The patients were divided into groups according to preoperative pelvic obliquity. Moreover, patients with preoperative pelvic obliquity were divided based on POA change from preoperative values versus 2 years postoperatively. Patients were divided based on the presence of selective or nonselective TL/L fusion. Radiographic parameters and clinical outcomes were compared between these groups.

RESULTS

Among 80 patients, 41 (51%) showed preoperative pelvic obliquity, and its direction was upward to the right for all cases. Coronal decompensation 2 years postoperatively was significantly elevated in patients with preoperative pelvic obliquity (p < 0.05). Thirty-two patients (40%) displayed pelvic obliquity 2 years postoperatively. Among 41 patients with preoperative pelvic obliquity, 22 patients (54%) were in the group with a decrease in POA, and 19 were in the group with no decrease. The group with no decrease in POA showed significant TL/L curve progression throughout the postoperative follow-up period. The patients with nonselective fusion showed a significantly lower incidence of pelvic obliquity at 2 years postoperatively.

CONCLUSIONS

Postoperative coronal decompensation more frequently occurred in patients with preoperative pelvic obliquity than in those without pelvic obliquity preoperatively. In addition, postoperative pelvic obliquity changes may be related to residual lumbar curve behavior.

Associations between Clinical Findings and Severity of Diffuse Idiopathic Skeletal Hyperostosis in Patients with Ossification of the Posterior Longitudinal Ligament

BACKGROUND

This study investigated how diffuse idiopathic skeletal hyperostosis (DISH) influences clinical characteristics in patients with cervical ossification of the posterior longitudinal ligament (OPLL). Although DISH is considered unlikely to promote neurologic dysfunction, this relationship remains unclear.

METHODS

Patient data were prospectively collected from 16 Japanese institutions. In total, 239 patients with cervical OPLL were enrolled who had whole-spine computed tomography images available. The primary outcomes were visual analog scale pain scores and the results of other self-reported clinical questionnaires. Correlations were sought between clinical symptoms and DISH using the following grading system: 1, DISH at T3-T10; 2, DISH at both T3-10 and C6-T2 and/or T11-L2; and 3, DISH beyond the C5 and/or L3 levels.

RESULTS

DISH was absent in 132 cases, grade 1 in 23, grade 2 in 65, and grade 3 in 19. There were no significant correlations between DISH grade and clinical scores. However, there was a significant difference in the prevalence of neck pain (but not in back pain or low back pain) among the three grades. Interestingly, DISH localized in the thoracic spine (grade 1) may create overload at the cervical spine and lead to neck pain in patients with cervical OPLL.

CONCLUSION

This study is the first prospective multicenter cross-sectional comparison of subjective outcomes in patients with cervical OPLL according to the presence or absence of DISH. The severity of DISH was partially associated with the prevalence of neck pain.

Differences of 2-year longitudinal changes of locomotive syndrome among patients treated with thoracolumbar interbody fusion, total hip arthroplasty, and total knee arthroplasty for degenerative diseases

OBJECTIVES

To clarify the longitudinal changes in patients with preoperative Stage-3 locomotive syndrome (LS) according to different types of surgeries, we investigated the changes in the LS stage in patients who underwent surgery for degenerative musculoskeletal diseases.

METHODS

A prospective cohort study was conducted on 168 patients with degenerative diseases [46 spinal deformities treated with thoracolumbar interbody fusion (T/LIF), 86 hips with osteoarthritis treated with total hip arthroplasty (THA), and 36 knees with osteoarthritis treated with total knee arthroplasty (TKA)]. The results for the LS stage, stand-up test, two-step test, and 25-question Geriatric Locomotive Function Scale (GLFS-25) were evaluated preoperatively and at 6 months, 1 year, and 2 years postoperatively.

RESULTS

Preoperatively, most patients had Stage-3 LS (89.1, 90.8, and 80.6% in the T/LIF, THA, and TKA groups, respectively). At 2 years postoperatively, the Stage-3 LS improved in 41.5, 75.6, and 55.2% of patients in the T/LIF, THA, and TKA groups, respectively. All groups showed similar improvements in the two-step test. The THA group showed the best result in the GLFS-25.

CONCLUSIONS

LS stage improved in different patterns over 2 years postoperatively and the LS risk test revealed differences in postoperative movement ability according to the type of surgery.

Comparison of the Effectiveness of Pharmacological Treatments for Patients with Chronic Low Back Pain: A Nationwide, Multicenter Study in Japan

Introduction

Chronic low back pain (CLBP) is a leading cause of disability, yet there is limited high-quality evidence to identify the most suitable pharmacological therapy. The purpose of this Japanese nationwide, multicenter, prospective study was to compare the effectiveness of four representative drug therapies-acetaminophen, celecoxib, loxoprofen, and a tramadol and acetaminophen (T+A) combination drug-to establish evidence for a drug of choice for CLBP.

Methods

Patients with CLBP (N=471) received one of the four treatments and were evaluated, prospectively and comprehensively, once every month for six months using a visual analog scale (VAS) for LBP, the Japanese Orthopedic Association (JOA) score, the JOA Back Pain Evaluation Questionnaire (JOABPEQ), the Roland-Morris Disability Questionnaire (RDQ), the EuroQol five-dimensions three-levels (EQ-5D-3L), and the Short Form-8 item health survey (SF-8). We conducted multivariable linear regression analyses of the four drugs at 1 and 6 months after drug allocation. Differences with P<0.05 were considered statistically significant.

Results

Patients who received acetaminophen showed a significant improvement from baseline in the mental health subscale of the JOABPEQ at one month (P=0.02) and the JOA score at six months (P<0.01). None of the other outcome measures among the four drugs differed significantly. Across groups, all outcome measures, except the mental component summary (MCS) score of the SF-8, improved equivalently, although most measurements showed no obvious cumulative effect over six months. The MCS score of the SF-8 decreased gradually over six months in all groups.

Conclusions

Most of the outcome measures among the treated groups were not significantly different, indicating similar treatment effects of the four drugs for CLBP. Our study indicated the limit of each outcome measure for evaluating the patient status, suggesting that a single outcome measure is insufficient to reflect treatment effectiveness.

Preoperative Thoracic Curve Magnitude and L4 End Vertebra Were Risk Factors for Subjacent Disc Wedging After Selective Thoracolumbar/Lumbar Fusion with L3 as the Lowest Instrumented Vertebra in Lenke Type 5 Curve Patients

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

This study aimed to investigate the incidence and risk factors of subjacent disc wedging (SDW) in adolescent idiopathic scoliosis (AIS) patients with Lenke type 5 curve.

SUMMARY OF BACKGROUND DATA

SDW is frequently observed after surgery; however, data about its mechanism and relations with outcome are limited.

METHODS

Data of 59 patients with AIS with Lenke type 5 curves who underwent posterior spinal fusion to L3 as the lowest instrumented vertebra (LIV) were retrospectively analyzed. The subjacent disc angle (SDA) was defined as the angle between L3 (LIV) and L4. SDW was defined as the absolute value of SDA of 10° or higher 2 years postoperatively. The incidence of SDW was investigated between nonselective and selective thoracolumbar/lumbar (TL/L) fusion group. In the selective group, patients with and without SDW were compared.

RESULTS

Among 59 patients, 11 had nonselective and 48 had selective fusion. No patients in the nonselective group showed SDW versus 13 patients in the selective group (27%) showed SDW. In the selective group, patients with SDW showed significantly greater main thoracic curve, apical vertebral translation of the main thoracic curve, upper instrumented vertebra tilt, LIV tilt, and SDA 2 years postoperatively, whereas no differences were found in the coronal balance or clinical outcome. Multivariate analysis revealed preoperative T curve and SDA as predictors of SDW occurrence. T curve greater than 30° and SDA greater than 0° were calculated as cutoff values based on the receiver operating characteristic curve.

CONCLUSION

SDW is sometimes seen in Lenke type 5 patients with AIS who underwent selective TL/L fusion. SDW seemed to occur as a compensation mechanism for progressing deformity of unfused segments (thoracic curve and residual lumbar curve) to maintain coronal alignment. Preoperative T curve > 30° and SDA > 0° (lower-end vertebra as L4) were determined as risk factors for SDW occurrence.Level of Evidence: 3.

The impact of ossification spread on cervical spine function in patients with ossification of the posterior longitudinal ligament

Ossification of the posterior longitudinal ligament (OPLL) is a progressive disease. The bridging of ossified lesions to the vertebral body gradually increases, thereby decreasing the mobility of the cervical spine; thus, cervical spine function may decrease over time. However, cervical spine function in patients with cervical OPLL has not been evaluated in large prospective studies. Therefore, we conducted a prospective multicenter study to clarify whether ossification spread can influence cervical spine function and quality of life (QOL) in patients with cervical OPLL. In total, 238 patients (162 men, 76 women; mean age, 63.9 years) were enrolled from 16 institutions. Each patient underwent whole spine computed tomography and was evaluated for cervical spine function and QOL using the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ). In the multivariate regression analysis, a higher neck VAS score and a larger number of bridge formations of OPLL in the whole spine were significant predictors of adverse outcomes related to cervical spine function. This is the first prospective multicenter study to reveal the impact of ossification spread on cervical spine function. These findings are important to understand the natural course of OPLL and can serve as controls when evaluating postoperative cervical spine function.

Should L3 be selected as the lowest instrumented vertebra in patients with Lenke type 5C adolescent idiopathic scoliosis whose lowest end vertebra is L4?

OBJECTIVE

L3 is most often selected as the lowest instrumented vertebra (LIV) to conserve mobile segments in fusion surgery; however, in cases with the lowest end vertebra (LEV) at L4, LIV selection as L3 could have a potential risk of correction loss and coronal decompensation. This study aimed to compare the clinical and radiographic outcomes depending on the LEV in adolescent idiopathic scoliosis (AIS) patients with Lenke type 5C curves.

METHODS

Data from 49 AIS patients with Lenke type 5C curves who underwent selective thoracolumbar/lumbar (TL/L) fusion to L3 as the LIV were retrospectively analyzed. The patients were classified according to their LEVs into L3 and L4 groups. In the L4 group, subanalysis was performed according to the upper instrumented vertebra (UIV) level toward the upper end vertebra (UEV and 1 level above the UEV [UEV+1] subgroups). Radiographic parameters and clinical outcomes were compared between these groups.

RESULTS

Among 49 patients, 32 and 17 were in the L3 and L4 groups, respectively. The L4 group showed a lower TL/L curve correction rate and a higher subjacent disc angle postoperatively than the L3 group. Although no intergroup difference was observed in coronal balance (CB), the L4 group showed a significantly higher main thoracic (MT) and TL/L curve progression during the postoperative follow-up period than the L3 group. In the L4 group, the UEV+1 subgroup showed a higher absolute value of CB at 2 years than the UEV subgroup.

CONCLUSIONS

In Lenke type 5C AIS patients with posterior selective TL/L fusion to L3 as the LIV, patients with their LEVs at L4 showed postoperative MT and TL/L curve progression; however, no significant differences were observed in global alignment and clinical outcome.

Posterior occipitocervical instrumented fusion for atlantoaxial instability in a 27-month-old child with Down syndrome: illustrative case

BACKGROUND

Upper cervical spine instability is one of the most serious orthopedic problems in patients with Down syndrome. Despite the recent advancement of instrumentation techniques, occipitocervical fusion remains technically challenging in the very young pediatric population with small and fragile osseous elements.

OBSERVATIONS

A 27-month-old boy with Down syndrome was urgently transported to the authors’ hospital because of difficulty in standing and sitting, weakness in the upper limbs, and respiratory distress. Radiographs showed os odontoideum, irreducible atlantoaxial dislocation, and substantial spinal cord compression. Emergency posterior occipitoaxial fixation was performed using O-arm navigation. Improvement in the motor paralysis of the upper left limb was observed from the early postoperative period, but revision surgery was needed 14 days after surgery because of surgical site infection. The patient showed modest but substantial neurological improvement 1 year after the surgery.

LESSONS

There are several clinical implications of the present case. It warns that Down syndrome in the very young pediatric population may lead to rapid progression of spinal cord injury and life crisis. This 27-month-old patient represents the youngest case of atlantoaxial instability in a patient with Down syndrome. O-arm navigation is useful for inserting screws into very thin pedicles.

Combined Anticancer Effect of Plasma-Activated Infusion and Salinomycin by Targeting Autophagy and Mitochondrial Morphology

Non-thermal atmospheric pressure plasma (NTAPP)-activated liquids have emerged as new promising anticancer agents because they preferentially injure malignant cells. Here, we report plasma-activated infusion (PAI) as a novel NTAPP-based anti-neoplastic agent. PAI was prepared by irradiating helium NTAP to form a clinically approved infusion fluid. PAI dose-dependently killed malignant melanoma and osteosarcoma cell lines while showing much lower cytotoxic effects on dermal and lung fibroblasts. We found that PAI and salinomycin (Sal), an emerging anticancer stem cell agent, mutually operated as adjuvants. The combined administration of PAI and Sal was much more effective than single-agent application in reducing the growth and lung metastasis of osteosarcoma allografts with minimal adverse effects. Mechanistically, PAI explicitly induced necroptosis and increased the phosphorylation of receptor-interacting protein 1/3 rapidly and transiently. PAI also suppressed the ambient autophagic flux by activating the mammalian target of the rapamycin pathway. PAI increased the phosphorylation of Raptor, Rictor, and p70-S6 kinase, along with decreased LC3-I/II expression. In contrast, Sal promoted autophagy. Moreover, Sal exacerbated the mitochondrial network collapse caused by PAI, resulting in aberrant clustering of fragmented mitochondrial in a tumor-specific manner. Our findings suggest that combined administration of PAI and Sal is a promising approach for treating these apoptosis-resistant cancers.