Intraligamentous Hematoma of the Anterior Cruciate Ligament.

Lesions of the anterior cruciate ligament (ACL) are rare entities in clinical practice. Here, we present the case of an intraligamentous hematoma of the ACL. A 20-year-old man (height 173 cm, weight 62.9 kg, body mass index 21) with no significant past medical history developed progressively worsening pain and limitation of range of motion in the left knee due to minor trauma. No abnormality was found on plain radiography; however, magnetic resonance imaging revealed a cystic lesion in the intercondylar fossa that was hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging. We performed knee arthroscopy, made a longitudinal incision in the anterior aspect of the ACL, and identified a hematoma. The patient's postoperative course was uneventful. There is no evidence of recurrence at one year after surgery. Although the ACL is a relatively hypovascular structure, it does contain microscopic blood vessels. In this case, we speculate that the intraligamentous hematoma was the result of rupture of these very small blood vessels in response to a minor injury.

Insertional Torque in Cervical Vertebrae Lateral Mass Screw Fixation: Magerl Technique Versus Roy-Camille Technique.

STUDY DESIGN: This is a prospective multicenter comparison study. OBJECTIVE: To measure the insertional torque (IT) for cervical vertebra lateral mass screw (LMS) fixation using the Magerl and Roy-Camille methods, at the discretion of the surgeon. SUMMARY OF BACKGROUND DATA: Current fixation methods for patients with preoperative cervical spine instability use LMSs; however, few studies have closely examined intraoperative IT. Patients' bone quality was not measured. METHODS: A total of 637 posterior cervical multiaxial screws were inserted for LMS (C3-C6) (Magerl technique, 423; Roy-Camille technique, 214) in 107 cases. Patients' mean age was 66 years. Patients treated with the Magerl method were divided into 2 groups, with the men in the MM group and the women in the MF group. Similarly, patients treated with the Roy-Camille method were divided into 2 groups, with the men in the RM group and the women in the RF group. The contralateral cortex was penetrated, and the IT at cerclage was measured at the last time. RESULTS: IT of the lateral mass screw was 53.8±22.4, 45.4±21, 45.5±16.9, and 34±16.4 cN.m in the MM group (258), MF group (165), RM group (163), and RF group (51), respectively. The MM group had a significantly higher IT than the other 3 groups, and the RM group had a significantly higher IT than the RF group. When the correlation between screw length and IT was evaluated, IT was significantly (P<0.05) higher with a longer screw by the Magerl method. CONCLUSIONS: The IT was higher with the Magerl method with a longer screw. Screw length and IT were not correlated with the Roy-Camille method; furthermore, the Roy-Camille method went through bilateral cortical bone perpendicularly, so that IT was determined by the fixation power in the cortical part of the bone, which was not thought to be affected by screw length. LEVEL OF EVIDENCE: Level III.

Assessment of maximal insertional torque of cervical and thoracic screws during posterior spinal surgery.

STUDY DESIGN: Multicenter intraoperative biomechanical analysis. PURPOSE: This study aimed to assess the maximal insertional torque (MIT) of lateral mass screw (LMS) and pedicle screw (PS) in the cervical or thoracic vertebrae during surgery. METHODS: During posterior spinal fusion, cervical or thoracic multi-axial screws were placed at different cervical or thoracic levels and the MIT was recorded for each screw revolution using an analogue torque wrench. Screw number was as follows: 11 PS at C7, 134 LMS (C3-6) (Magerl technique, 70; Roy-Camille technique, 64), and 33 PS in the thoracic region. RESULTS: Average MIT values (cNm) were as follows: for PS (diameter: 3.5 mm) at C7, 45.3 ± 21.9 in men and 60.0 ± 20.1 in women (p=0.28); for Magerl screws, 69.0 ± 20.5 in men and 58.6 ± 15.7 in women (p=0.13); and for Roy-Camille screws, 51.0 ± 17.9 in men and 42.4 ± 15.9 in women (p=0.52). The average MIT for Magerl screws was significantly higher than that for Roy-Camille screws in men and women (both p<0.01). CONCLUSIONS: Intraoperative insertional torque could be a good indicator to evaluate the purchase and help guide decisions on screw type and insertion technique. Further postoperative assessments with sequential X-rays are needed to reveal the significance of MIT during posterior spinal fusion.

Hybrid technique of cortical bone trajectory and pedicle screwing for minimally invasive spine reconstruction surgery: a technical note.

The pedicle screw (PS) system is widely used for spinal reconstruction. Recently, screw insertion using the cortical bone trajectory (CBT) technique has been reported to provide increased holding strength of the vertebra, even in an osteoporotic spine. CBT is also beneficial due to its low invasiveness. We have been performing hybrid reconstruction with CBT at the cranial level and PS at the caudal level based on the concept of minimal invasiveness. We applied this hybrid technique to 6 cases of degenerative spondylolisthesis. Surgery was completed with a small skin incision of around 5-6 cm, which is shorter than that of the conventional PS procedure. The mean percent slippage before surgery was 19.8%, and this was reduced to 3.9% after surgery and almost maintained 3 months after surgery. Furthermore, no major surgical complications were observed. Here, we introduce the minimally invasive hybrid technique of CBT-PS. Surgeons should be aware of the procedure as an option for minimally invasive lumbar spine reconstructive surgery.

Etiology and revision surgical strategies in failed lumbosacral fixation of adult spinal deformity constructs.

STUDY DESIGN: Retrospective case analysis. OBJECTIVE: The purpose of this study was to evaluate the etiology and salvage strategies of failed lumbosacral fixation in adult spinal deformity patients. SUMMARY OF BACKGROUND DATA: When extending a long spinal deformity fusion to the sacrum, the lumbosacral junction is a common site for implant problems and pseudarthrosis. METHODS: Clinical and radiographic results of 33 patients (26 women/seven men; average age, 53.5 years; range, 21-73) diagnosed and treated for lumbosacral fixation failure between 1995 and 2007 were reviewed. Twenty-one of the 33 patients underwent revision surgery at one institution for these failures and were followed postoperatively for more than 2 years (average, 50.7 months). RESULTS: Twenty-nine of these 33 patients had two sacral screws, two patients one sacral screw, and two patients none. Bicortical sacral screws were placed in 18 patients, only 12 had distal fixation to the sacral screws (bilateral iliac screws, n = 9; others, n = 3). Seventeen of 19 patients without distal fixation to the sacral screws had screw loosening/pullout at L5 or S1. Anteriorly at L5-S1: 4/6 bone grafts collapsed, 5 of 15 intervertebral discs without anterior column support collapsed, and two of 12 titanium cages subsided into the endplates. Rod breakage between L5 and S1 (n = 9) was seen only in patients with distal fixation to the sacral screws. Nineteen of 21 revision patients received two bicortical sacral screws, whereas 20 received distal fixation to the sacral screws consisting of bilateral iliac screws in 16. Nineteen patients received anterior column support at L5-S1. Fifteen of 21 revision patients achieved solid fusion at ultimate follow-up; however, six had additional rod breakage or dislodgement at the lumbosacral junction. CONCLUSION: With long fusions to the sacrum in the treatment of spinal deformity, the use of bilateral S1 screws alone may allow for screw loosening/pullout and/or L5-S1 cage/graft collapse/subsidence. Adding bilateral iliac screws and an anterior structural cage/graft at L5-S1 will protect the S1 screws, but may still allow L5-S1 rod breakage/dislodgement because of lumbosacral pseudarthrosis. Revision surgery in these patients remains a challenge.

Increasing lumbar lordosis of adult spinal deformity patients via intraoperative prone positioning.

STUDY DESIGN: A retrospective evaluation. OBJECTIVE: To evaluate the change in lumbar lordosis in spinal deformity patients who underwent an instrumented posterior spinal fusion on the Orthopedic Systems Inc. (OSI) "Jackson" frame. SUMMARY OF BACKGROUND DATA: Intraoperative prone positioning with hip extension may posturally increase lumbar lordosis during adult spinal deformity reconstructive surgery, as has been shown in adult lumbar degenerative surgery. METHODS: Radiographs of 44 operative spinal deformity patients (43 females/1 male; mean age, 57.4 years) were analyzed. Diagnoses included idiopathic scoliosis (29), degenerative lumbar scoliosis (9), and other (6). Total lumbar lordosis (T12-S1), segmental disc angles, and C7 plumbline were measured on preoperative upright and supine, intraoperative prone, and postoperative upright lateral radiographs. All patients were positioned intraoperatively with hip extension on the OSI frame. RESULTS: Average preoperative upright and supine, intraoperative prone, and postoperative upright lumbar lordosis (T12-SAC) measurements were -38.1 degrees, -46.0 degrees, -46.2 degrees, and -51.8 degrees, respectively (P < 0.05 for preoperative upright to all other comparisons). Two groups were noted: those with increased lumbar lordosis (>5 degrees) during intraoperative prone positioning (n = 25, increased lordosis group) as compared to the preoperative measurement versus those with minimal to no change in lordosis (< or =5 degrees) during intraoperative prone positioning (n = 19, unchanged lordosis group). The corresponding lumbar lordosis measurements for the increased lordosis group were -25.9 degrees, -40.0 degrees, -43.1 degrees, and -48.9 degrees (P < 0.05 for preoperative upright to all other comparisons). The corresponding lumbar lordosis measurements for the unchanged lordosis group were -54.2 degrees, -53.8 degrees, -50.3 degrees, and -55.7 degrees (no significant differences). Preoperative upright lumbar lordosis in the unchanged lordosis group was substantially higher than increased lumbar lordosis group (P < 0.05). CONCLUSION: Adult spinal deformity patients with preoperative hypolordosis who were positioned prone during reconstructive surgery had an enhanced lumbar lordosis via positioning alone compared with theirpreoperative upright radiographs. Conversely, those with substantial preoperative lordosis remained unchanged with intraoperative prone positioning. This knowledge will help in the surgical planning of adult spinal deformity reconstructive surgery to optimize sagittal alignment and balance.

Long adult spinal deformity fusion to the sacrum using rhBMP-2 versus autogenous iliac crest bone graft.

STUDY DESIGN: Comparative study. OBJECTIVE: To compare the radiographic outcome of patients undergoing long spinal deformity surgery to the sacrum/ilium, using either rhBMP-2 without iliac crest bone graft (ICBG) or ICBG without rhBMP-2. SUMMARY OF BACKGROUND DATA: rhBMP-2 has been shown to be more effective in promoting successful bone union in patients undergoing single level lumbar spinal fusion than ICBG. However, to the best of our knowledge, there are no studies that compare the efficacy of rhBMP-2 versus ICBG in long spinal deformity surgery. METHODS: To obtain uniform background, we selected patients with adult spinal deformity who underwent primary spinal fusion from the thoracic spine to the sacrum/ilium and had a minimum 2-year follow-up. Fifty-five consecutive patients, consisting of 32 patients who underwent a fusion using ICBG without rhBMP-2 (ICBG group) and 23 patients who underwent a fusion using rhBMP-2 without ICBG (BMP group) were analyzed. RESULTS: The 2 groups were similar with respect to age, gender, smoking history, comorbidity, and body mass index. The average number of vertebrae fused (11.3 in both groups) and the degree of preoperative deformity (major Cobb angle 58.3 degrees in ICBG group vs. 54.2 degrees in BMP group) were also similar in both groups. All but 2 patients had both anterior and posterior surgery. Both groups were similar in terms of final deformity correction. The average total amount of rhBMP-2 used in the BMP group was 119.2 mg (anterior 11.6 mg/level; posterior 10.0 mg/level). Of the 32 patients in the ICBG group, 9 patients (28.1%) developed a pseudarthrosis, while only 1 of 23 patients (4.3%) in the BMP group developed a pseudarthrosis with the caveat that the follow-up period was shorter in the BMP group (average follow-up of 4.9 vs. 2.7 years). CONCLUSION: The pseudarthrosis rate in the BMP group compares favorably to pseudarthrosis rate in ICBG group, suggesting that the use of rhBMP-2 without iliac harvesting leads to a competitive fusion rate in long adult spinal deformity surgery, while avoiding ICBG harvest site morbidity.

Distinct expression of mast cell tryptase and protease activated receptor-2 in synovia of rheumatoid arthritis and osteoarthritis.

The objective of this study is to examine the differential expression of mast cell tryptase and its receptor, protease-activated receptor-2 (PAR-2), in the synovium and synovial fluid of patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Biochemical and immunohistochemical analyses were performed to determine whether the trypsin-like protease in the synovium is identical to mast cell tryptase. The effects of mast cell tryptase on the proliferation of synovial fibroblast-like cells (SFCs) and the release of IL-8 thereof were evaluated by the [3H]-thymidine incorporation and ELISA, respectively. The trypsin-like protease in the synovium of RA patients was identical to human mast cell tryptase, which was composed of two subunits: 33 and 34 kDa. The 33- and 34-kDa proteins are different glycosylated forms of the 31-kDa protein, which was unglycosylated. Mast cell tryptase activity in RA synovial fluid was significantly higher than that in OA synovial fluid, while their activities and expression in the synovium were similar. Expression of PAR-2 mRNA in the synovium was higher in RA than in OA. Mast cell tryptase containing the unglycosylated 31-kDa subunit was the predominant form in synovial fluid. RA patients had higher amounts of this subunit in their synovial fluid than OA patients. Mast cell tryptase and PAR-2 activating peptide stimulated the proliferation of SFCs and release of IL-8 from these cells. Mast cell tryptase secretion into RA synovial fluid is higher than OA synovial fluid. Mast cell tryptase in synovial fluid stimulates the proliferation of SFCs and the release of pro-inflammatory cytokines via PAR-2, which may contribute to exacerbation of synovitis in RA.

Relationship between cathepsin B and thrombin in rheumatoid arthritis.

OBJECTIVE: To investigate the pathophysiological significance of cathepsin B and thrombin in synovial fluid (SF) from patients with rheumatoid arthritis (RA). METHODS: Thrombin and cathepsin B activities of samples from patients with RA and osteoarthritis (OA) were measured using fluorogenic synthetic substrates. The concentration of interleukin 8 (IL-8) in SF was measured by ELISA. The effect of thrombin on the proliferation of synovial fibroblast-like cells (SFC) was examined by measuring 3H-thymidine incorporation. The effect of thrombin on the release of IL-8 and cathepsin B from SFC was investigated. The expression of IL-8 mRNA in SFC after stimulation with thrombin was evaluated using real-time quantitative RT-PCR. The effect of recombinant IL-8 on the activation of cathepsin B was examined using the knee joints of rabbits. RESULTS: In SF supernatants, cathepsin B and thrombin-like activity was significantly higher in RA than in OA, and there was a significant correlation between them. Cathepsin B activity was also significantly higher in SF cells and synovial tissue extracts from RA patients than in those from OA patients. There was a significant correlation between cathepsin B activity and the concentration of IL-8 in RA SF. Thrombin enhanced the proliferation of SFC in a dose-dependent manner. Thrombin significantly enhanced the release of IL-8 from SFC as well as the expression of IL-8 mRNA in SFC. IL-8 induced activation of cathepsin B in the knee joints of rabbits. However, thrombin did not directly increase cathepsin B activity in SFC. CONCLUSION: In RA, thrombin was found to be related to the enhanced growth of SFC and the release of IL-8 from these cells; thus thrombin is probably related to worsening of inflammation through the recruitment of leukocytes (neutrophils), which release cathepsin B into the SF. Thrombin can induce activation of cathepsin B in SFC via increased expression of IL-8.

Fractures of the distal end of radius in elderly patients: a comparative study of anatomical and functional results.

The functional and anatomical results of distal end of radius fractures with severe displacement in 22 elderly patients are reviewed in this retrospective study. The mean age of the patients was 69.4 years (range, 60-88 years) and the mean follow-up period was 24 months (range, 12-53 months). According to the sum of demerit points (Saito, 1983), the latest follow-up functional end results were excellent in 64% of fractures and good in 36%. As for the anatomical results at follow-up, the average radial tilt was 20.7 degrees, ulnar variance was 4.0 mm, and palmar tilt was -2.7 degrees respectively. Though most of the patients had satisfactory outcome and the functional results did not correlate with the radiographic evidence of minor deformities, the functional results of the patients with radial shortening of 6 mm or over were poor. Furthermore, the grip power was the most significant factor related to subjective evaluation and did not improve significantly in patients with the non-dominant hand injured.

Clinical evaluation of aged patients who underwent surgery for femoral neck fractures -- comparative study of clinical results according to age.

The objective was to assess mortality and ambulatory ability for elderly patients over 90 years of age with femoral neck fractures treated surgically. From January 1998 to March 1999, 60 patients aged over 80 years were chosen for the study. The patients had a mean age of 87.1 years. The mean follow-up period was 12.9 months. The patients were classified into three groups according to age: group A (80-84 years old), group B (85-89 years old) and group C (over 90 years old). The rates of recovered postoperative walking ability were 72.2% (13/18) of group A, 65.2% (15/23) of group B and 84.2% (16/19) of group C. These patients were followed up until death or for at least one year. The overall mortality rates were 11.1% (2/18) of group A, 17.4% (4/23) of group B and 10.5% (2/19) of group C.