Anterior debridement may not be necessary in the treatment of tuberculous spondylitis of the thoracic and lumbar spine in adults: a retrospective study.

AIM: Many aspects of the surgical treatment of patients with tuberculosis (TB) of the spine, including the use of instrumentation and the types of graft, remain controversial. Our aim was to report the outcome of a single-stage posterior procedure, with or without posterior decompression, in this group of patients. PATIENTS AND METHODS: Between 2001 and 2010, 51 patients with a mean age of 62.5 years (39 to 86) underwent long posterior instrumentation and short posterior or posterolateral fusion for TB of the thoracic and lumbar spines, followed by anti-TB chemotherapy for 12 months. No anterior debridement of the necrotic tissue was undertaken. Posterior decompression with laminectomy was carried out for the 30 patients with a neurological deficit. RESULTS: The mean kyphotic angle improved from 26.1° (- 1.8° to 62°) to 15.2° (-25° to 51°) immediately after the operation. At a mean follow-up of 68.8 months (30 to 144) the mean kyphotic angle was 16.9° (-22° to 54°), with a mean loss of correction of 1.6° (0° to 10°). There was a mean improvement in neurological status of 1.2 Frankel grades in those with a neurological deficit. Bony union was achieved in all patients, without recurrent infection. CONCLUSIONS: Long posterior instrumentation with short posterior or posterolateral fusion is effective in the treatment of TB spine. It controls infection, corrects the kyphosis, and maintains correction and neurological improvement over time. TAKE HOME MESSAGE: With effective anti-TB chemotherapy, a posterior only procedure without debridement of anterior lesion is effective in the treatment of TB spondylitis, and an anterior procedure can be reserved for those patients who have not improved after posterior surgery. Cite this article: Bone Joint J 2016;98-B:834-9.

Is removal of the implants needed after fixation of burst fractures of the thoracolumbar and lumbar spine without fusion? a retrospective evaluation of radiological and functional outcomes.

METHODS: In this study of patients who underwent internal fixation without fusion for a burst thoracolumbar or lumbar fracture, we compared the serial changes in the injured disc height (DH), and the fractured vertebral body height (VBH) and kyphotic angle between patients in whom the implants were removed and those in whom they were not. Radiological parameters such as injured DH, fractured VBH and kyphotic angle were measured. Functional outcomes were evaluated using the Greenough low back outcome scale and a VAS scale for pain. RESULTS: Between June 1996 and May 2012, 69 patients were analysed retrospectively; 47 were included in the implant removal group and 22 in the implant retention group. After a mean follow-up of 66 months (48 to 107), eight patients (36.3%) in the implant retention group had screw breakage. There was no screw breakage in the implant removal group. All radiological and functional outcomes were similar between these two groups. Although solid union of the fractured vertebrae was achieved, the kyphotic angle and the anterior third of the injured DH changed significantly with time (p < 0.05). DISCUSSION: The radiological and functional outcomes of both implant removal and retention were similar. Although screw breakage may occur, the implants may not need to be removed. TAKE HOME MESSAGE: Implant removal may not be needed for patients with burst fractures of the thoracolumbar and lumbar spine after fixation without fusion. However, information should be provided beforehand regarding the possibility of screw breakage.

Elevated concentrations of matrix metalloproteinase-12 and elastin degradation products in the sera of pregnant women infected with Toxoplasma gondii.

Although the expression of matrix metalloproteinase-12 (MMP-12) appears to be increased in most inflammatory diseases, the role of this enzyme in the pathogenesis of toxoplasmosis in pregnant women, if any, is unknown. In a recent study in Taiwan, the serum concentrations of MMP-12 and its substrate elastin were evaluated in pregnant women with Toxoplasma gondii infection. Compared with the healthy pregnant and non-pregnant women used as controls, the pregnant women with toxoplasmosis had significantly higher serum concentrations of MMP-12 and significantly higher levels of elastin synthesis and degradation. Interaction between MMP-12 and elastin in the serum samples was confirmed by co-immunoprecipitation. It seems possible that MMP-12 may contribute to elastin degradation occurring during the pathogenesis of toxoplasmosis in pregnant women.

Prognostic factors affecting the outcome of early cervical cancer treated with radical hysterectomy and post-operative adjuvant therapy.

The purpose of this study is to investigate the clinical and histological features that may affect the survival of the patients and to evaluate the impact of post-operative adjuvant therapy on the outcomes of patients with stage IB and IIA carcinoma of the cervix. From August 1998 to January 2005, 140 patients with International Federation of Gynecology and Obstetrics stage IB and IIA cervical cancer were treated with radical hysterectomy and post-operative pelvic radiation therapy with or without chemotherapy. The median age was 55 years (range, 29-86 years). Seventy-six patients had stage IB and 64 patients had stage IIA disease. Tumour size was <4 cm in 96 patients and > or = 4 cm in 44 patients. One hundred and eleven patients had histology of squamous cell carcinoma, 12 patients has adenocarcinoma and 17 patients had other histologic types. Depth of stromal invasion was <2/3 in 20 patients and > or = 2/3 in 120 patients. Twenty-three patients had parametrial invasion and 117 patients had no parametrial invasion. Thirteen patients had lymphovascular space invasion and 127 had no lymphovascular space invasion. Nine patients had positive surgical margin and 131 patients had negative margin. Twenty-seven patients had pelvic lymph node metastasis and 113 patients had no pelvic lymph node metastasis. Seventy-five patients received concurrent chemoradiotherapy and 65 patients received radiotherapy alone. The 5-year overall survival (OAS) and disease-free survival were 83% and 72% respectively. In the log rank test, tumour size (P = 0.0235), pararmetrial invasion (P = 0.0121), pelvic lymph node metastasis (P < 0.0001) and adjuvant chemotherapy + radiotherapy (P = 0.0119) were significant prognostic factors for OAS, favouring tumour size <4 cm, absence of parametrial invasion and pelvic lymph node metastasis, and those who received adjuvant chemoradiotherapy. The patients who received radiation with concomitant chemotherapy had a 5-year OAS rate of 90% versus those who received radiotherapy alone, with a rate of 76%. For patients with high-risk early stage cervical cancer who underwent a radical hysterectomy and pelvic lymphadenectomy, adjuvant chemoradiotherapy resulted in better survival than radiotherapy alone. The addition of weekly cisplatin to radiotherapy is recommended. The treatment-related morbidity is tolerable.

The impact of the menopause on coronary artery calcification examined by multislice computed tomography scanning.

BACKGROUND AND AIMS: To examine whether there is a difference in coronary artery calcification (CAC) scores between males and females aged above 50 years. METHODS AND RESULTS: A total of 479 subjects aged between 40 and 70 years with no clinical or family history of cardiovascular disease (CVD) were enrolled for this study. All subjects were assessed by multislice CT scanning (MCTS), and the CAC scores obtained were assigned to one of four quartiles for further assessment and comparison. The main outcome evaluated was the percentage of high CAC scores and mean CAC scores, comparing males and females of different age groups. This study found that the percentage of high CAC scores increased markedly from 5% (40-49 age group) to 21.2% (50-59 age group) among females. The increase was significantly less when comparing males from different age groups (from 25% in the 40-49 age group to 31.2% in the 50-59 age group). Females had higher odds ratios (ORs) postmenopausally (4.3 in the 50-59 age group) than males in the same age group (1.6). CONCLUSIONS: These initial findings seem to indicate that above 50 years of age, CAC is more dependent on age in females than in males, which might be due to the effect of the menopause.

Detection and identification of dyes showing AhR-binding affinity in treated sewage effluents.

A bioassay using the YCM3 recombinant yeast strain was utilised to investigate the presence of dioxin-like compounds that activate the aryl hydrocarbon receptor (AhR) in treated sewage effluents. AhR ligand activity was detected in the concentrated extracts of effluent samples collected in March, June and October 2004 from Kyoto city, Japan. HPLC fractionation was carried out using C18 reversed-phase columns, and possible AhR ligands were further isolated and purified. By using LC/MS/MS, one weak AhR ligand was identified to be rhodamine B base, a fluoran dye. In addition, two other coloured ligands were postulated to be disperse anthraquinone dyes or their metabolites because of their UV spectra and HPLC retention times. The AhR-binding affinities of 12 commercial dyes with different chemical structures were also studied. Among the dyes tested, hydrophobic anthraquinone dyes exhibited higher AhR ligand activity, but azo dyes or hydrophilic acid dyes showed no or very low AhR ligand activity. Rhodamine B base and disperse anthraquinone dyes were suggested to be potential xenobiotic AhR ligands. Future research regarding their contamination in aquatic environments and toxicological information is necessary.

Elbow load with various forearm positions during one-handed pushup exercise.

This is the first study of the one-handed pushup, and tries to show the effects of forearm rotations. Previous studies of elbow loading have focused on passive loading and small loads, because data from large loads during active exercise is not easy to obtain. In order to investigate the biomechanical impact of hand position on the elbow and the potential trauma mechanisms of outstretched elbow, joint loading across the elbow was analyzed for three forearm rotational positions, neutral, 90 degrees internal rotation and 90 degrees external rotation. Both kinematic and kinetic data were collected from eight volunteers by the Motion Analysis System and a Kistler Force Plate. Statistical analysis of the data delineates the relationship between elbow joint load and hand rotational position during one-handed pushup, and also provides useful biomechanical information for this challenging exercise. The axial and valgus stresses and forces are the major concerns. The peak axial forces exerted on the elbow joint averaged 65 % of the body weight when the hand position was neutral, and was significantly reduced with the hand rotated either internally or externally. The peak valgus shear force with the hand externally rotated was 50 % greater than the other two positions. Thus, outward rotation of the hand is a stressful position that should be avoided during one-handed pushup exercise or forward falls with outstretched hands in order to reduce the risk of elbow injuries.

Effect of elbow flexion on upper extremity impact forces during a fall.

OBJECTIVE: The overall objectives are to develop a biomechanical model for a simulated fall with outstretched hand. DESIGN: Cross-sectional study involving young healthy volunteers in a university research laboratory setting. BACKGROUND: Little is known about the factors which influence fracture risk during a fall on outstretched hand. METHODS: A group of 11 male subjects volunteered for this investigation. A set of eight reflective markers was placed bilaterally on selected anatomic landmarks. Subjects were suspended with both elbows extended and wrists dorsiflexed, preparing to impact the ground and force plates from two different fall heights: 3 and 6 cm. Two different postures for the elbows were employed. In the elbow extension experiment, the elbows were extended at all times. In the elbow flexion experiment, the elbows were extended at impact, but then flexed immediately, as though in the initial downward phase of a push-up exercise. RESULT: Increasing the fall height significantly increased the upper extremity axial forces by 10% and 5%. No significantly different differences were found in the axial forces applied to the wrist, elbow or shoulder between the elbow flexion and elbow extension trials, but the elbow mediolateral shear force was 68% larger (P=0.002) in the extension trials. CONCLUSIONS: Performing an elbow flexion movement at impact reduces the first peak impact force value and postpones the maximum peak value. Although changing the fall arrest strategy from elbow extension to elbow flexion did not affect the peak impact force on the hand, it did require substantially greater elbow and shoulder muscle strengths. RELEVANCE: This paper yields insights into how the physical demands of arresting mild falls may relate to upper extremity muscle capacity, joint dislocation and bony fracture.

Primary hyperparathyroidism and acute pancreatitis during the third trimester of pregnancy.

The simultaneous occurrence of maternal primary hyperparathyroidism (PHPT) and acute pancreatitis during pregnancy is very rare. We report a case of concurrent PHPT and pancreatitis during the third trimester of pregnancy. A summary of the relevant literature regarding the clinical course and recommended management in relation to this case is also presented.

Elbow load during pushup at various forearm rotations.

OBJECTIVE: Elbow joint loading was evaluated during pushup exercises at various forearm rotations. DESIGN: Subjects were asked to perform pushup in various forearm rotations: neutral, 90 degrees internal rotation, and 90 degrees external rotation. BACKGROUND: Training with pushup exercise is good for the muscles and joints of the upper extremities. However, excessive shear forces on the elbow might lead to injuries to either normal trainees or to handicapped people, especially for those who rely on elbow prosthesis. METHODS: The kinematics and kinetics of the elbow joint were investigated under various forearm rotations. RESULTS: The loading biomechanics of the elbow joint differed with various forearm rotations. It was noted that greater posterior and varus forces of the elbow are encountered with internal rotation of the hand position and, consequently, full forearm pronation. CONCLUSIONS: Pushup with hands in internally rotated position should be prevented so as to avoid excessive shear forces or moments. RELEVANCE: Knowledge of elbow kinematics and kinetics may be helpful in preventing injuries by reducing the elbow shear force with changes of forearm rotation.

Sit-to-stand at different periods of pregnancy.

OBJECTIVE: This study was performed to determine the biomechanics of chair rising by pregnant women. DESIGN: Relative body joint position and ground reaction forces were measured by a motion analysis system and one force plate. BACKGROUND: Physiological and psychological changes during pregnancy impose postural demands and limit the performance of daily living activities such as rising from sitting to standing position. METHODS: Twenty-four pregnant women, divided into three groups, were studied performing sit-to-stand transition from an armless and adjustable chair. By kinematic and kinetic analysis, the angles and moments of hip, knee and ankle joints were investigated. RESULTS: The chair height has great influence on knee joint and hip joint moments, but less on ankle joints. In the third trimester for all chair heights, because of a marked increase in abdominal depth, the maximum hip moment is significantly less than that in first trimester, while the maximum knee moment is significantly larger. Pregnant women in third trimester produced larger knee moment during sit-to-stand transition from lower chair height. CONCLUSIONS: The mechanism of sit-to-stand is affected by the physical changes of pregnant women at different periods of pregnancy, e.g. increased loading of knee joint and decreased hip joint moment, especially in the last trimester period of pregnancy.

Greater tuberosity osteotomy for treatment of impinge rotator cuff tear.

Forty-two consecutive patients in whom an impingement of rotator cuff tear had been treated with greater tuberosity osteotomy and repair were evaluated by relief of pain, return of range of motion and strength of shoulder. The oriental acromion is thin and easy to break during the traditional acromioplasty procedures. When the decompression is achieved by osteotomy on the greater tuberosity which is the common location of cuff tear, not only is adequate decompression achieved but also the coracoacromial ligament is preserved. Comparison of the results of greater tuberosity osteotomy with those of previous acromioplasty studies shows they are mostly similar. At present, these techniques can be recommended for use by Chinese orthopaedic surgeons who have to deal with the typical oriental bony structures.

Mechanical property analysis of small bone fixators.

The purpose of this study is to establish a database and to compare mechanical properties between various types of small bone fixators. Hollow maple dowels are uniformly produced to simulate small bones in this study. Furthermore, transverse osteotomy, transverse osteotomy with 2 mm gap, and 45 degrees oblique osteotomies are created to simulate stable, unstable, and spiral fractures. Each fracture pattern is then approximated with four types of fixators: (1) Aesculap mini external fixator, (2) mini A-O plate and screw, (3) cross pin, and (4) self-assembled mini external fixator. Finally, tension, torsion, and bending tests are performed with INSTRON. In three different fracture patterns, dorsal plating has the strongest tensile rigidity and lateral bending rigidity. In stable and unstable fractures, Aesculap mini external fixator has the strongest torsional rigidity. However, mini A-O plate has the strongest torsional rigidity in 45 degrees oblique fractures. In stable fractures, dorsal plating, lateral plating, and mini external fixator all have good anterior bending rigidity without significant differences. Nevertheless, only lateral plating and mini external fixator show good anterior bending rigidity in unstable and 45 degrees oblique fractures. Except in torsional rigidity, Aesculap mini external fixator is not significantly stiffer than the self-assembled external fixator. As expected, cross pin is the weakest fixator. Differences in mechanical stiffiness between the four types of small bone fixators are provided in this study. Additionally, one should also consider the indication when choosing a proper fixator. Complication rate can then be lowered to achieve successful surgery in treating small bone fractures.

A fixational method of tendon transfer in foot surgery.

Tendon transfer has been used for correcting foot deformities and improving foot function in paralytic and spastic foot problems. The traditional fixational method by Cole's pull-out button often induces pressure sores which make the button sink and loosens the transferred tendon, leading to poor surgical results. By using a metal eye cover and pull-out wire instead of button and suture material, the transferred tendon can be firmly fixed. Moreover, the concavity of the metal eye cover is suitable for the arch of the foot that provides a large contact surface & even pressure distribution to prevent the most common complications of the pull-out button method, the pressure sore.

The role of central 5-hydroxytryptamine in acupuncture analgesia.

The role played by central 5-hydroxytryptamine (5-HT) in acupuncture analgesia (AA) has been studied in rats with the tail-flick response as the antinociceptive test. The analgesic effect of acupuncture can be enhanced or lowered by the increment or the decrement of the 5-HT level in the CNS. Furthermore, the turnover rate of 5-HT in the CNS has been found to be greatly facilitated during the period of acupuncture. The results imply that 5-HT in the CNS may be one of the most important neurochemical agents mediating AA.