Postoperative Rotation Deformity of Head-Neck Fragments in Unstable Intertrochanteric Fractures Fixed with Intramedullary Nails.

BACKGROUND: Our purpose was to quantify the postoperative rotation deformity (RD) after osteosynthesis of unstable intertrochanteric fractures (ITFx) using 3D-CT / image processing software, and to clarify the clinical meaning of RD. METHODS: Forty-six consecutive patients with unstable intertrochanteric fractures were enrolled in this study. All were fixed with Gamma 3 Trochanteric nail and RC Lag Screw® (Stryker). We performed 3D-CT evaluations for the rotational deformity of head-neck fragments, the medial cortex support (MCS) between main fragments and bone healing at 3 months postoperatively. RESULTS: The RD was significantly larger in the patients without the MCS (5.1 ± 4.0°, N = 9) than those with the MCS (2.4 ± 2.6°, N = 37) (P = 0.006*). Delayed healing (N=3) was observed in patients without the MCS, and the association between RD and delayed healing was significant (P = 0.003*, cut-off value 6.4°, sensitivity 100% and specificity 90.7%, AUC 0.91). CONCLUSIONS: This study proposed a novel method of measuring postoperative RD. Lack of MCS may lead to RD and consequent delayed healing in unstable ITFx fixed with intramedullary nails.

Treatment of Capitellum and Trochlea Fractures Using Headless Compression Screws and a Combination of Dorsolateral Locking Plates.

Introduction This study aimed to evaluate the clinical outcomes of 16 patients with capitellum and trochlea fractures that were treated using isolated headless compression screws or a combination of dorsolateral locking plates and anterior-to-posterior screws. We also investigated the presence of lateral epicondyle fragments because this fragment is especially important when making decisions regarding the surgical approach and implants. Materials and methods We conducted a retrospective analysis of 16 patients with capitellum and trochlea fractures. Clinical, radiographic (based on CT scans), and elbow-specific outcomes, including the Mayo Elbow Performance Index (MEPI), were evaluated at a mean of 23.5 months postoperatively. Results The average MEPI scores in patients with Dubberley type A (non-posterior comminution) and type B (posterior comminution) fractures were 88 and 78, respectively (p=0.08). Headless compression screws were used in 10 cases of type A fracture and one case of type B fracture. A combination of dorsolateral locking plates and anterior-to-posterior screws was used in five cases of type B fracture. Hardware loosening was seen in one case of type B fracture with isolated screw fixation. The presence of a lateral epicondyle fragment was significantly associated with the type B group (6/6 patients; 100%). In contrast, patients in the type A group rarely had posterior comminution of the lateral epicondyle fragment (2/10 patients; 20%). Conclusions Capitellum and trochlea fractures with posterior comminution, which typically presented with lateral epicondylar fragments, were safely and effectively treated with a combination of dorsolateral locking plates and anterior-to-posterior screws through lateral approaches. Cases without posterior comminution were treated with headless compression screws with no complications. The Dubberley classification system provides helpful information to determine the fixation strategy.

Saphenous Nerve Entrapment Neuropathy After Closed Tibial Fracture: A Case Report.

CASE: A 43-year-old man who underwent intramedullary nailing for a closed tibial fracture developed saphenous nerve entrapment neuropathy. He developed severe medial leg pain, which was worse on walking or standing, 2 years postoperatively. Surgical neurolysis resulted in complete pain relief and functional recovery of the limb without recurrence of symptoms. CONCLUSION: Clinicians should consider several etiologies in the diagnostic evaluation of a patient with chronic pain after limb trauma. If a patient complains of lower extremity pain after intramedullary fixation of closed fractures of the tibial shaft, the possibility of saphenous nerve entrapment neuropathy should be considered.

Primary treatment of atlantoaxial rotatory fixation in children: a multicenter, retrospective series of 125 cases.

OBJECTIVE: The primary treatment for atlantoaxial rotatory fixation (AARF) remains controversial. The aim of this study was to investigate the primary treatment for AARF and create an algorithm for primary treatment. METHODS: The authors analyzed the data of 125 pediatric patients at four medical institutions from April 1989 to December 2018. The patients were reported to have neck pain, torticollis, and restricted neck range of motion and were diagnosed according to the Fielding classification as type I or II. As a primary treatment, 88 patients received neck collar fixation, and 28 of these patients did not show symptom relief and required Glisson traction. Thirty-seven patients were primarily treated with Glisson traction. In total, 65 patients, including neck collar treatment failure patients, underwent Glisson traction in hospitals. RESULTS: The success rate of treatment was significantly higher in the Glisson traction group (97.3%) than in the neck collar fixation group (68.2%) (p = 0.0001, Wilcoxon test). In the neck collar effective group, Fielding type I was more predominant (p = 0.0002, Wilcoxon test) and the duration from onset to the first visit was shorter (p = 0.02, Wilcoxon test) than that in the neck collar ineffective group. Using multivariate logistic regression analysis with the above items, the authors generalized from the estimated formula: logit [p(success group by neck collar fixation group)|duration from onset to the first visit (x1), Fielding type (x2)] = 0.4(intercept) - 0.15x1 + 1.06x2, where x1 is the number of days and x2 = 1 (for Fielding type I) or -1 (for Fielding type II). In cases for which the score is a positive value, the neck collar should be chosen. Conversely, in cases for which the score is a negative value, Glisson traction should be the first choice. CONCLUSIONS: According to this formula, in patients with Fielding type I AARF, neck collar fixation should be allowed only if the duration from onset is ≤ 10 days. In patients with Fielding type II, because the score would be a negative value, Glisson traction should be performed as the primary treatment.

Up-regulation in receptor for advanced glycation end-products in inflammatory circumstances in bovine coccygeal intervertebral disc specimens in vitro.

STUDY DESIGN: This study investigated whether or not the receptor for advanced glycation end-products (RAGE) was up-regulated in inflammatory circumstances and consequently associated with aggrecan content in nucleus pulposus in vitro. OBJECTIVE: To investigate the activation of AGEs-RAGE complex by the irritation of IL-1beta in bovine intervertebral disc (IVD). SUMMARY OF BACKGROUND DATA: Although we have demonstrated that the accumulation of AGEs contributed to disc degeneration in human, it may be that acceleration in the AGEs-RAGE complex might be more important, mediated by expression levels of RAGE that increase in inflammatory mediators including IL-1beta in some tissues. Therefore, we investigated, in this study, the correlation if any between IL-1beta and AGEs-RAGE complex in bovine IVD. METHODS: Samples of bovine coccygeal IVDs were harvested (n = 6). The presence of AGEs and RAGE were identified by immunohistochemistry. Real-time polymerase chain reaction (PCR) was used to quantify the messenger RNA levels of aggrecan after 6 days' stimulation of AGEs. Real-time PCR and immunofluorescein cytochemistry were performed to analyze the expression of RAGE after 2 days' stimulation of IL-1beta. The aggrecan expressions were evaluated by real-time PCR after 2 days' stimulation of combination of AGEs and/or IL-1beta. RESULTS: Immunohistochemical analysis revealed that AGEs and RAGE were localized within the bovine IVDs. AGEs significantly decreased the aggrecan expression in bovine IVD as in human IVD. The RAGE expression was significantly increased by 2 days' stimulation of IL-1beta. The aggrecan expression was decreased by stimulated AGEs and IL-1beta together, although not decreased by stimulated AGEs or IL-1beta separately. CONCLUSION: This is the first report to show the correlation between IL-1beta and AGEs-RAGE complex in IVD. Our results suggested that the increased RAGE expression in inflammatory circumstances and interaction with AGEs are risk factors in decreasing of aggrecan content in nucleus pulposus.

Effect of a nonprotein bioactive agent on the reduction of cyclooxygenase-2 and tumor necrosis factor-alpha in human intervertebral disc cells in vitro.

OBJECT: Neurotropin is a nonprotein extract from the inflamed skin of rabbits inoculated with vaccinia virus. In the present study the authors sought to clarify the focal antiinflammatory effects of Neurotropin in intervertebral disc cells, and these effects were compared with those induced by the selective cyclooxygenase (COX)-2 inhibitor 6-methoxy-2-naphthylacetic acid (nabumetone). METHODS: Six human intervertebral disc specimens were harvested during spinal surgery for lumbar disc herniation. Cells were stimulated with 500 pg/ml of interleukin (IL)-1beta in the presence of various concentrations of Neurotropin (0, 10(-5), 10(-4), and 10(-3) Neurotropin Units/ml) or 50 microg/ml of nabumetone for 3 hours. The mRNA was extracted for polymerase chain reaction (PCR), and real-time PCR was used to quantify the mRNA levels of COX- 2, tumor necrosis factor (TNF)-alpha, and phospholipase A2. Cyclooxygenase-2, TNFalpha, and prostaglandin E2 (PGE2) protein concentrations were each determined by enzyme-linked immunosorbent assay. RESULTS: Neurotropin was found to significantly suppress the expression of COX-2 and TNFalpha at mRNA levels as well as the concentration of COX-2 at protein levels in a dose-dependent manner. Nabumetone was found to significantly increase COX-2 at mRNA levels but directly suppress the concentration of PGE2 in culture medium. CONCLUSIONS: Results in this study suggest that Neurotropin has an analgesic effect through the suppression of COX-2 and TNFalpha in a focal area, and nabumetone shows this same effect through the suppression of PGE2 production. Thus, Neurotropin could decrease pain by blocking the central pain pathway or increasing focal antiinflammatory effects.

Immunohistochemical demonstration of advanced glycation end products and the effects of advanced glycation end products in ossified ligament tissues in vitro.

STUDY DESIGN: This study correlates advanced glycation end products with ossified ligament tissues of the cervical spine in vitro. OBJECTIVE: To investigate the effect of advanced glycation end products on ossification of the spinal ligaments in vitro. SUMMARY OF BACKGROUND DATA: We have hypothesized that an accumulation of advanced glycation end products in the spinal ligament might result in some observable change in specific growth factors responsible for ossification in the spinal ligaments. METHODS: Samples of the posterior longitudinal and yellow ligaments were harvested from patients (n = 5) with ossification of the posterior longitudinal ligament, and analyzed for the presence of advanced glycation end products and their receptor advanced glycation end product receptor by immunohistochemistry. Real-time polymerase chain reaction (PCR) was used to quantify the messenger ribonucleic acid (mRNA) levels of bone morphogenetic protein (BMP)-2, BMP-7, alkaline phosphatase, an osteoblast-specific transcription factor 1 (Cbfa1), and osteocalcin from yellow ligament cells treated with advanced glycation end products. RESULTS: Immunohistochemical analysis revealed that advanced glycation end products and advanced glycation end product receptor were localized to within the posterior longitudinal and yellow ligaments. Advanced glycation end products were found to increase significantly the expression of BMP-2, BMP-7, Cbfa1, and osteocalcin at the mRNA levels after treatment with advanced glycation end products (1 microg/mL). CONCLUSIONS: This is the first report to investigate the correlation, if any, between the ossified spinal ligament and advanced glycation end products. These results suggested that accumulation in advanced glycation end products and their interaction with advanced glycation end product receptor were 1 of the important risk factors in the process of ossification in the spinal ligaments.

Advanced glycation end-products downregulating intervertebral disc cell production of proteoglycans in vitro.

OBJECT: The authors sought to clarify the role, if any, of advanced glycation end-products (AGEs) in disc degeneration. METHODS: Intervertebral discs were analyzed for the presence of AGEs and of their receptor (RAGE) by immunohistochemical analysis. Reverse transcriptase polymerase chain reaction (RT-PCR) was performed to detect any RAGE gene expression, and real-time PCR was used to quantify messenger RNA (mRNA) levels of aggrecan and collagen types I and II in nucleus pulposus cells treated with AGEs. Aggrecan protein concentration was determined by enzyme-linked immunosorbent assay. Immunohistochemical analysis revealed that AGEs and RAGE were localized in the nucleus pulposus of the intervertebral disc. Advanced glycation end-products were found to significantly suppress the expression of aggrecan at both mRNA and protein levels in a dose- and time-dependent manner. The levels of collagen types I and II remained unchanged after treatments with AGEs. CONCLUSIONS: These results suggest that the accumulation of AGEs and their interaction with their receptor in the nucleus pulposus might result in the downregulation of aggrecan production responsible for disc degeneration.

Positive feedback loop of interleukin-1beta upregulating production of inflammatory mediators in human intervertebral disc cells in vitro.

OBJECT: Interleukin-1beta (IL-1beta) induces neurological symptoms in intervertebral disc herniation (IDH). Recently, the existence of a positive feedback loop of IL-1beta, which encourages an inflammatory reaction or degeneration in the cells of tendon, has been reported. The authors hypothesized that there is a positive feedback loop of IL-1beta in the cells of IDH. METHODS: Eight human intervertebral disc specimens were harvested during spinal surgery for lumbar disc herniation. The cells were stimulated in serum-free medium with or without exogenous IL-1beta. The messenger RNA (mRNA) was extracted for reverse-transcription polymerase chain reaction (PCR) and real-time PCR to quantify the mRNA of endogenous IL-1beta, IL-6, cyclooxygenase-2 (COX-2), and matrix metalloproteinases (MMPs). The cells were then stimulated in serum-free medium with or without exogenous IL-1beta, and then exogenous IL-1beta was removed. After 2, 4, and 6 days, the medium was collected, and enzyme-linked immunosorbent assay was used to measure the protein concentration of endogenous IL-1beta. The mRNA expressions of endogenous IL-1beta, IL-6, COX-2, and MMPs were increased significantly depending on the concentration of exogenous IL-1beta. The protein concentration of endogenous IL-1beta was increased over time. CONCLUSIONS: There was a positive feedback loop of IL-1beta in the cells of IDH. Furthermore, the productions of IL-6, COX-2, MMP-1, and MMP-3 were upregulated as a result of the increasing concentration of IL-1beta in a positive feedback loop of IL-1beta. The authors concluded that this positive feedback loop of IL-1beta upregulated the production of mediators and thus can cause cessation of symptoms in IDH.