Stump classification was correlated with retear in the suture-bridge and double-row repair techniques for arthroscopic rotator cuff repair.

PURPOSE: The Stump classification is significantly correlated with a retear after arthroscopic rotator cuff repair. However, no study has evaluated whether or not the stump classification is correlated with retear in the suture-bridge or double-row repair techniques. The aim of this study was to evaluate the relationship between a retear and the stump classification in the suture-bridge and double-row repair techniques. METHODS: Among 389 patients who underwent arthroscopic repairs of full-thickness rotator cuff tears using suture-bridge or double-row repair techniques, 326 patients (median age 67.0 years; range 25-85) were included. There were 51 small, 172 medium, 83 large, and 20 massive tears. Two hundred forty patients were treated with the suture-bridge technique, and 86 patients were treated with the double-row technique. The following variables were analyzed: age, sex, the Cofield classification, anteroposterior and mediolateral tear size on preoperative MRI, global fatty degeneration index, and the stump classification. Cuff integrity was evaluated on magnetic resonance imaging at 6 months after surgery. The patients were divided into the intact and retear groups and the relationship between the variables and retear was evaluated by multivariate logistic regression analysis. RESULTS: The overall retear rate was 10.1%. In the multivariate logistic regression analysis, the independent predictors of a retear were the stump classification type 3 (Odds ratio: 4.71, p = 0.0246), global fatty degeneration index (Odds ratio: 3.87, p = 0.0030), and anteroposterior tear size (Odds ratio: 1.07, p = 0.0077) in the suture bridge technique. In the double-row technique, the independent predictors of retear were stump classification type 3 (Odds ratio: 7.82, p = 0.0348), and age (Odds ratio: 1.22, p = 0.0163). CONCLUSION: The stump classification was significantly correlated with retear in the suture-bridge and double-row repair technique. Stump classification type 3 was indicated to be an important risk factor for predicting retear. LEVEL OF EVIDENCE: III.

Dynamic scapulohumeral rhythm: Comparison between healthy shoulders and those with large or massive rotator cuff tear.

INTRODUCTION: Assessment of scapular kinematics and the dynamics of the scapulohumeral rhythm (SHR) would be important for understanding pathologies of the shoulder and to inform treatment. Our aim in this study was to evaluate the SHR and scapular kinematics in patients with a rotator cuff tear (RCT), compared to a control group with healthy shoulders using image-matching techniques. MATERIALS AND METHODS: The shoulder kinematics of large or massive RCT patients were evaluated and compared to a control group with healthy shoulders. Radiographic surveillance was performed throughout the full range of external rotation and scapular plane abduction. Computed tomography imaging of the shoulder complex was performed, with three-dimensional image reconstruction and matching to the radiographs to measure three-dimensional positions and orientations. SHR and angular values of the scapula were measured. RESULTS: Scapular external rotation in the late phase of external rotation movement was greater in the RCT group than in the control group (p < 0.05), but with no difference in the SHR. During scapular plane abduction, there were significant differences in SHR, scapular posterior tilt and scapular upward rotation between the RCT and control group (p < 0.05). CONCLUSIONS: Regarding clinical relevance, this study clarified the differences of SHR and angular values of the scapula between the RCT and control group. These results underline the importance of assessment the SHR and scapular kinematics in individuals with a RCT. RCT is associated with specific compensation in the kinematics of the scapula and SHR during external rotation and scapular plane abduction, which could inform treatment.

Biomechanical analysis of four different medial row configurations of suture bridge rotator cuff repair.

BACKGROUND: Rotator cuff tendon rupture after suture bridge repair occasionally occurs at the medial row, with remnant tendon tissue remaining at the footprint. While concentrated medial row stress is suspected to be involved in such tears, the optimal suture bridge technique remains controversial. METHODS: This study aimed to investigate the construct strength provided by suture bridge techniques having four different medial row configurations using artificial materials (n = 10 per group): Group 1, four-hole (two stitches per hole) knotless suture bridge; Group 2, eight-hole (one stitch per hole) parallel knotless suture bridge; Group 3, eight-hole non-parallel knotless suture bridge; and Group 4, eight-hole knot-tying suture bridge. Each construct underwent cyclic loading from 5 to 30 N for 20 cycles, followed by tensile testing to failure. The ultimate failure load and linear stiffness were measured. FINDINGS: Group 2 had the highest ultimate failure load (mean 160.54 N, SD 6.40) [Group 4 (mean 150.21 N, SD 9.76, p = 0.0138), Group 3 (mean 138.80 N, SD 7.18, p < 0.0001), and Group 1 (mean 129.35 N, SD 4.25, p < 0.0001)]. The linear stiffness of Group 2 (mean 9.32 N/mm, SD 0.25) and Group 4 (mean 9.72 N/mm, SD 0.40) was significantly higher (p = 0.0032) than that of Group 1 (mean 8.44 N/mm, SD 0.29) and Group 3 (mean 8.61 N/mm, SD 0.31). INTERPRETATION: In conclusion, increasing the number of suture-passed holes, arranging the holes in parallel, and a knotless technique improved the failure load following suture bridge repair.

Large-defect Resurfacing: A Comparison of Skin Graft Results Following Sarcoma Resection and Traumatic Injury Repair.

INTRODUCTION: Soft tissue sarcomas are rare neoplasms, and most plastic surgeons do not commonly resurface large tissue defects after a wide resection of these tumors. OBJECTIVE: The purpose of this study is to elucidate the clinical results of large skin grafts after wide sarcoma resection by comparison with grafts for traumatic skin defects. MATERIALS AND METHODS: A retrospective review was performed of patients who received skin grafts > 50 cm2 after traumatic injury or wide sarcoma resection from 2014 to 2016. Patient medical records were reviewed; graft take rate, graft loss, and days to complete epithelialization were compared between the 2 groups. RESULTS: In the sarcoma group (n = 8), 5 grafts were partially lost; the sarcoma group mean graft take rate of 67.5% ± 30.0% was significantly lower than that of the trauma group (n = 7) at 99.6% ± 1.1%. The mean time to complete epithelialization from the skin graft placement in the sarcoma group was 113.3 ± 66.0 days, which was significantly longer than that of the trauma group (40.3 ± 38.0 days). Wounds located around the shoulder joint in 2 sarcoma group patients did not heal even after 300 days of conservative treatment; 1 required a secondary flap. CONCLUSIONS: The results of skin grafting for resurfacing large defects after sarcoma resection are inferior to those for traumatic injury repair. Skin grafts may fail because the blood supply for the wound bed is impaired during resection. Furthermore, due to the wound bed movement, epithelialization over muscles of the shoulder joint is difficult to achieve, and skin grafts in this region will likely fail.

Histological evaluation of tendon formation using a scaffold-free three-dimensional-bioprinted construct of human dermal fibroblasts under in vitro static tensile culture.

INTRODUCTION: Tendon tissue engineering requires scaffold-free techniques for safe and long-term clinical applications and to explore alternative cell sources to tenocytes. Therefore, we histologically assessed tendon formation in a scaffold-free Bio-three-dimensional (3D) construct developed from normal human dermal fibroblasts (NHDFs) using our Bio-3D printer system under tensile culture in vitro. METHODS: Scaffold-free ring-like tissues were constructed from 120 multicellular spheroids comprising NHDFs using a bio-3D printer. Ring-like tissues were cultured in vitro under static tensile-loading with or without in-house tensile devices (tension-loaded and tension-free groups), with increases in tensile strength applied weekly to the tensile-loaded group. After a 4 or 8-week culture on the device, we evaluated histological findings according to tendon-maturing score and immunohistological findings of the middle portion of the tissues for both groups (n = 4, respectively). RESULTS: Histology of the tension-loaded group revealed longitudinally aligned collagen fibers with increased collagen deposition and spindle-shaped cells with prolonged culture. By contrast, the tension-free group showed no organized cell arrangement or collagen fiber structure. Additionally, the tension-loaded group showed a significantly improved tendon-maturing score as compared with that for the tension-free group at week 8. Moreover, immunohistochemistry revealed tenascin C distribution with a parallel arrangement in the tensile-loading direction at week 8 in the tension-loaded group, which exhibited stronger scleraxis-staining intensity than that observed in the tension-free group at weeks 4 and 8. CONCLUSIONS: The NHDF-generated scaffold-free Bio-3D construct underwent remodeling and formed tendon-like structures under tensile culture in vitro.

Evaluation of humeral head cartilage using magnetic resonance imaging T1 rho mapping for patients with small-to-medium rotator cuff tears: A pilot study.

BACKGROUND: It is unclear whether smaller rotator cuff tears cause cartilage degeneration. This study was designed to detect early humeral head cartilage degeneration in patients with small-to-medium cuff tears using magnetic-resonance-imaging T1 rho mapping. METHODS: Five male and 5 female volunteers without shoulder symptoms (control group) and 5 male and 5 female patients with small-to-medium (<3 cm) rotator cuff tears underwent 3.0-T magnetic resonance imaging of a single shoulder. T1 rho values of the humeral head cartilage were measured and analyzed. RESULTS: The total mean T1 rho value was 40.4 ± 3.4 ms for the control group and 45.0 ± 5.3 ms for the patient group. In the control group, the T1 rho values in the inferior articular cartilage were significantly higher than those in the superior and middle articular cartilage. In the patient group, there was no significant difference between all regions. A comparison between the patient and control groups showed that the mean T1 rho values in the superior-to-middle articular cartilage were significantly higher for the patient group than for the control group. However, in the inferior articular cartilage, there was no significant difference between both groups. CONCLUSIONS: This study showed the possibility of early cartilage degenerative changes in the superior-to-middle humeral head articular cartilage of patients with small-to-medium rotator cuff tears.

In vivo dynamic acromiohumeral distance in shoulders with rotator cuff tears.

BACKGROUND: There are no previous studies on the acromiohumeral distance in shoulders with large-to-massive full-thickness rotator cuff tears. In this study, the acromiohumeral distance in rotator cuff tear and healthy shoulders was measured using 3D-to-2D model-to-image registration techniques. METHODS: The dynamic glenohumeral kinematics during scapular plane abduction and axial rotation were analyzed in 11 rotator cuff tear patients and 10 healthy control subjects. Periodic radiographic images of scapular plane abduction and axial rotation were taken using a flat-panel radiograph image detector. Movements of the shoulder joint were assessed using radiographic images and computed tomography-derived digitally reconstructed radiographs. The acromiohumeral distance was defined as the shortest 3D distance between the acromion and the proximal humerus. FINDINGS: For scapular plane abduction, the rotator cuff tear group had significantly smaller acromiohumeral distance than the control group at 15°, 30°, 45°, 60°, 75°, 135°, and 150° of humeral abduction (P < 0.05 at each measured angle). For axial rotation in the adducted position, the rotator cuff tear group had significantly smaller acromiohumeral distance than the control group at each point between -20° and 40° of glenohumeral external rotation (P < 0.05 at each measured angle). INTERPRETATION: The minimum measured acromiohumeral distance was 0.9 mm in the rotator cuff tear shoulders and 2.1 mm in the healthy shoulders at 90° of scapular plane abduction. The findings are of clinical relevance because quantitative evaluation of the dynamic acromiohumeral distances in rotator cuff tear and healthy shoulders might provide important insight into subacromial impingement.

Dynamic kinematics of the glenohumeral joint in shoulders with rotator cuff tears.

BACKGROUND: No clear trend has emerged from the literature regarding three-dimensional (3D) translations of the humerus relative to the scapula in shoulders with rotator cuff tears (RCTs). The purpose of this study was to evaluate the kinematics of RCT shoulders using 3D-to-two-dimensional (2D) model-to-image registration techniques. METHODS: Dynamic glenohumeral kinematics during scapular plane abduction and axial rotation were analyzed in 11 RCT patients and 10 healthy control subjects. We measured the 3D kinematic parameters of glenohumeral joints using X-ray images and CT-derived digitally reconstructed radiographs. RESULTS: For scapular plane abduction, the humeral head center was positioned significantly more medially in shoulders with RCTs than in controls at 135° of humeral abduction (p = 0.02; RCTs versus controls: - 0.9 ± 1.6 versus 0.3 ± 1.3 mm). There was no significant difference in the superior/inferior translation of the humeral head center (p = 0.99). For axial rotation in adducted position, the humeral head center was positioned significantly more anteriorly in shoulders with RCTs than in controls at - 30° of glenohumeral external rotation (p < 0.0001; RCTs versus controls: 3.0 ± 1.7 versus 0.3 ± 1.5 mm). CONCLUSIONS: This study revealed the kinematics of shoulders with large to massive full-thickness RCTs: the humeral head center showed a medial shift at the late phase of scapular plane full abduction, and an anterior shift at the internal rotation position during full axial rotation. The kinematic data in this study, which describe the patterns of movement of shoulders with large to massive full-thickness RCTs, provide valuable information for future studies investigating glenohumeral translations in other pathological conditions of the shoulder. For clinical relevance, quantitative assessment of the dynamic kinematics of shoulders with RCTs might be a therapeutic indicator for achieving functional restoration.

A Biomechanical Comparison Between Asymmetric Pennington Technique and Conventional Core Suture Techniques: 6-Strand Flexor Tendon Repair.

PURPOSE: To evaluate the fatigue strength and gap sizes of the asymmetric Pennington technique compared with 2 conventional 6-strand core suture techniques: the triple-looped suture and the Yoshizu #1. METHODS: We recorded the fatigue strength (forces × cycles) and gap sizes of a 6-strand flexor tendon repair with different core suture techniques under cyclic loading in 30 porcine tendons. The asymmetric Pennington technique was performed with a Pennington repair of equal suture purchase in the 2 tendon stumps, with the 2 other Pennington repairs shifted by 3 mm, respectively, along the longitudinal axis of the tendon in relation to the first Pennington repair. The triple-looped suture technique was made with triple Tsuge sutures. The Yoshizu #1 technique was performed with a combined Pennington repair (using a double strand) and Tsuge suture. RESULTS: The asymmetric Pennington technique showed significantly greater fatigue strength and significantly smaller gaps in comparison to the triple-looped suture and Yoshizu #1 techniques. CONCLUSIONS: This study demonstrated that the asymmetric Pennington technique generated increased fatigue strength and reduced gap sizes compared with 2 conventional 6-strand core suture techniques, the triple-looped suture and Yoshizu #1. CLINICAL RELEVANCE: The asymmetric Pennington technique may permit an early active motion rehabilitation protocol similar to the triple-looped suture and Yoshizu #1 techniques.

Effect of the Optimal Asymmetry on the Strength of Six-Strand Tendon Repair: An Ex Vivo Biomechanical Study.

PURPOSE: To evaluate the mechanical properties of a 6-strand core suture repair with asymmetric purchase in the 2 tendon ends, in comparison with a repair with symmetric suture purchases. METHODS: Under cyclic loading of the tendons, we recorded the fatigue strength (Forces × Cycles) of a 6-strand flexor tendon repair with different symmetry in the lengths of suture purchase in 60 porcine tendons. The symmetric repair was made with 3 groups of parallel Kessler repairs of equal suture purchase (10 mm from the cut end) in the 2 tendon stumps. The asymmetric core suture repairs were then made with a Kessler repair of equal suture purchase (10 mm from the cut end) in the 2 tendon stumps, and shifting 2 other Kessler repairs by 1, 2, 3, 4, or 5 mm, respectively, along the longitudinal axis of the tendon in relation to the first (symmetric) Kessler repair. RESULTS: The core repairs with 2 mm or more asymmetry in suture purchases in 2 tendon ends showed significantly greater fatigue strength compared with those with symmetric suture placement. The core repairs with 3 mm or more asymmetry in suture purchases in 2 tendon ends showed significantly smaller gaps compared with those with symmetric suture placement. CONCLUSIONS: The core repairs with 3 mm or more asymmetry in suture purchases in 2 tendon ends generated increased fatigue strength and reduced gap sizes compared with those with symmetric suture placement in an ex vivo porcine model. CLINICAL RELEVANCE: An asymmetric core suture repair with 3 mm or more difference in purchase length may allow for earlier rehabilitation and reduce the risk of postoperative complications.

In vivo kinematic analysis of the glenohumeral joint during dynamic full axial rotation and scapular plane full abduction in healthy shoulders.

PURPOSE: The purpose of this study was to evaluate the kinematics of healthy shoulders during dynamic full axial rotation and scapular plane full abduction using three-dimensional (3D)-to-two-dimensional (2D) model-to-image registration techniques. METHODS: Dynamic glenohumeral kinematics during axial rotation and scapular plane abduction were analysed in 10 healthy participants. Continuous radiographic images of axial rotation and scapular plane abduction were taken using a flat panel radiographic detector. The participants received a computed tomography scan to generate virtual digitally reconstructed radiographs. The density-based digitally reconstructed radiographs were then compared with the serial radiographic images acquired using image correlations. These 3D-to-2D model-to-image registration techniques determined the 3D positions and orientations of the humerus and scapula during dynamic full axial rotation and scapular plane full abduction. RESULTS: The humeral head centre translated an average of 2.5 ± 3.1 mm posteriorly, and 1.4 ± 1.0 mm superiorly in the early phase, then an average of 2.0 ± 0.8 mm inferiorly in the late phase during external rotation motion. The glenohumeral external rotation angle had a significant effect on the anterior/posterior (A/P) and superior/inferior (S/I) translation of the humeral head centre (both p < 0.05). 33.6 ± 15.6° of glenohumeral external rotation occurred during scapular plane abduction. The humeral head centre translated an average of 0.6 ± 0.9 mm superiorly in the early phase, then 1.7 ± 2.6 mm inferiorly in the late phase, and translated an average of 0.4 ± 0.5 mm medially in the early phase, then 1.6 ± 1.0 mm laterally in the late phase during scapular plane abduction. The humeral abduction angle had a significant effect on the S/I and lateral/medial (L/M) translation of the humeral head centre (both p < 0.05). CONCLUSION: This study investigated 3D translations of the humerus relative to the scapula: during scapular plane full abduction, the humerus rotated 33.6° externally relative to the scapula, and during external rotation motion in the adducted position, the humeral head centre translated an average of 2.5 mm posteriorly. Kinematic data will provide important insights into evaluating the kinematics of pathological shoulders. For clinical relevance, quantitative assessment of dynamic healthy shoulder kinematics might be a physiological indicator for the assessment of pathological shoulders.

Recovery of Wrist Function after Volar Locking Plate Fixation for Distal Radius Fractures.

BACKGROUND: The purpose of our present study was to examine the recovery of the postoperative wrist function, and to compare the range of motion among each direction ofthe wrist joint during the same time periods after surgery for distal radius fractures. METHODS: Twenty patients treated with a volar locking plate were evaluated. The active range of motion and grip strength were assessed at four weeks, six weeks, three months, six months and one year after surgery. RESULTS: The ratio of the range of motion in pronation and supination recovered significantly earlier than for any other directions within six months after surgery (p = 0.0205), however, the ratio of the range of motion among the six directions was not significantly different at one year after surgery (p = 0.0823). The recovery of the range of motion in flexion was 96.8% compared with the contralateral wrist at one year after surgery, and it was not significantly lower than that in extension, radial deviation or ulnar deviation (97.8%, 93.5%, 94.4%, respectively). The grip strength of dominant hand recovered from 50% after four weeks to 66% after six weeks, 83% after three months, 91% after six months and 106% at the examination performed after one year compared with the uninjured non-dominant hand. The grip strength of non-dominant hand recovered from 52% after four weeks to 59% after six weeks, 79% after three months, 84% after six months and 94% at the examination performed after one year compared with the uninjured dominant hand. The mean DASH score was 5.3. CONCLUSIONS: The range of motion in flexion can achieve similar improvement to that in the other directions by obtaining the appropriate postoperative parameters. The optimal postoperative radiographic parameters were thus identified to be essential for successfully obtaining a recovery of the wrist function for unstable distal radius fractures.

Less invasive and less technically demanding decompressive procedure for lumbar spinal stenosis--appropriate for general orthopaedic surgeons?

This article presents the clinical and radiological results of the modified spinous process osteotomy decompressive procedure (MSPO), which affords excellent visualisation and provides wide access for Kerrison rongeur use and angulation while minimising destruction of tissues not directly involved in the pathological process. A total of 50 patients with degenerative lumbar spinal stenosis underwent MSPO between 2002 and 2005. The minimum follow-up period was five years. Patient's walking distance ability was 85.4 m (5-180 m) preoperatively and 2,560 m (1500-8000 m) at the last follow-up. Leg pain improved in 100% of the patients and back pain improved in 89% at the last follow-up. The overall results were good to excellent in 90% of the patients, fair in 16% and all patients were satisfied with the outcome at the last follow-up. The osteotomised spinous process eventually united with the retained laminar bridge in all patients within nine months after surgery. Degenerative lumbar spinal stenosis can be adequately decompressed with less violation of the integrity of the posterior elements using MSPO. The described technique of MSPO yielded promising results with few complications. The authors believe MSPO is less technically demanding and appropriate for general orthopaedic surgeons, occasional spine surgeons and chief residents.

Surgical treatment of scoliosis using allograft bone from a regional bone bank.

INTRODUCTION: Routine spinal fusion techniques have involved removal of all soft tissues and articular facets, decortication of all posterior elements, and application of bone graft to the fusion area. Bone grafting has been performed mainly using the patient's own bone (autograft bone), most commonly from the iliac crest. The use of autograft bone is accompanied by complications or problems because of harvesting and donor-site morbidity. Several studies have already reported the use of allograft bone in scoliosis surgery. However, these studies are small series with short-term follow-up. METHOD: Twenty-two patients with scoliosis who underwent posterior spinal fusion and pedicle-screw-alone fixation using banked allograft bone obtained from the regional bone bank in Japan were analyzed. The average age at surgery was 13 years 5 months. The average follow-up was 2 years 7 months, and the average age at the last follow-up was 15 years 6 months. Scoliosis curves were divided into two groups (single curve group and double curve group). RESULTS: For the single curve group, the average preoperative coronal curve measured 78° (48°-85°) and the postoperative curve measured 22° (8°-35°), with no loss of correction at the last follow-up. For the double curve group, the average preoperative thoracic curve measured 64° (48°-85°) and the lumbar curve measured 42° (38°-60°). The average postoperative thoracic curve measured 12° (8°-34°) and lumbar curve measured 15° (8°-32°), with no significant loss of correction at the last follow-up. No patients had clinical complaints in the region of surgery at 9 months after surgery and thereafter. There were no complications including loss of correction, nonunion, infection and instrumentation failure. At the last follow-up, patients/parents were interviewed and asked to complete an outcome satisfaction questionnaire. They were asked to rate the outcome as very satisfactory, satisfactory, neither satisfactory nor unsatisfactory, unsatisfactory, or very unsatisfactory. Seventeen patients (77%) were very satisfied, four patients (17%) were satisfied, and one patient (6%) was neither satisfied nor unsatisfied. Autograft bone and banked allograft bone appear to yield comparable results and clinical outcomes. CONCLUSION: However, in Japan, various expenses accrue to supply a safe and premium quality of banked allograft bone. Financial issue must be resolved as soon as possible.

Surgical correction of spinal deformity in patients with congenital muscular dystrophy.

BACKGROUND: Congenital muscular dystrophy (CMD), among the myopathic disorders is one form of flaccid neuromuscular disorder (NMD). Patients with NMD frequently develop progressive spinal deformity. For NMD patients who have a severe spinal deformity, sitting is often difficult and is accompanied by pain and breakdown of the skin. Spinal deformity surgery in these patients has been highly effective in stabilizing the spine, maintaining upright, comfortable sitting balance, and improving patients' quality of life. However, many studies have reported significant rates of peri/postoperative complications in these patients. To our knowledge, there has been no study on the results of spinal deformity surgery in patients with CMD. The purpose of this study was to review the clinical and radiological results of spinal deformity surgery in this group of patients with CMD. METHODS: Between 2004 and 2007, a total of 10 CMD patients underwent scoliosis surgery. There were three patients with Fukuyama CMD, three with Ullrich CMD, and 4 with nonsyndromic CMD (merosin-negative). They were nonambulatory. All the patients had standard posterior spinal fusion and pedicle-screw-alone fixation from T3 or T4 to L5 for spinal deformity. Our inclusion criteria required that each patient (1) had considerable difficulty with sitting balance and pain or breakdown of the skin due to scoliosis; (2) was able to ventilate his or her lung autonomously; (3) was not ventilator-dependent; and (4) did not have cardiac failure. Sufficient informed consent was important, and the decision to perform surgery was made by the patient/family with sufficient preoperative informed consent. Patients were trained with inspiratory muscle training (IMT) using an inspiratory muscle trainer (Threshold IMT) for 6 weeks prior to surgery Cardiac function was assessed preoperatively. Pulmonary function tests were performed preoperatively and postoperatively. Radiographic assessments were performed on sitting anteroposterior (AP) and lateral radiographs. These assessments were made periodically. The Cobb angles of the curves and spinal pelvic obliquity (SPO) on the coronal plane, thoracic kyphosis, and lumbar lordosis were measured. The preoperative AP radiograph and side-bending films were examined to determine flexibility. Patients' and parents' satisfaction were surveyed by a self-completed questionnaire at the last follow-up. RESULTS: Percent forced vital capacity (%FVC) increased from a mean of 30% before IMT to a mean of 34% the day before surgery. The preoperative scoliosis was 75 degrees (range 61 degrees -95 degrees ). The scoliotic curvature on preoperative side-bending films was 19 degrees (range 11 degrees -28 degrees ). All patients were extubated on the day of surgery. No patients developed cardiac or respiratory complications. The scoliotic curvature was 18 degrees (range 10 degrees -25 degrees ) immediately after surgery, and 19 degrees (range 12 degrees -27 degrees ) at the last follow-up. The pelvic obliquity improved from a mean of 17 degrees (range 14 degrees -20 degrees ) preoperatively to a mean of 6 degrees (range 4 degrees -9 degrees ) postoperatively and to 7 degrees (range 4 degrees -10 degrees ) at the last follow-up. Balanced sitting posture was achieved and maintained. On the sagittal plane, good reconstruction of sagittal plane alignment was recreated and maintained. There were no major complications or deaths. All patients/parents completed the outcome satisfaction questionnaire. Eight patients/parents were very satisfied and two were satisfied. CONCLUSIONS: Pedicle-screw-alone fixation and fusion to L5 was safe and effective in CMD patients with scoliosis of <95 degrees and pelvic obliquity of <20 degrees . Scoliosis curves were flexible (75% correction) on side-bending films preoperatively. Curve correction and maintenance of correction in the coronal and sagittal plane was excellent. The pelvic obliquity significantly improved. Balanced sitting posture was achieved and maintained in all patients. Our patients with CMD spinal deformity and a moderately and severely decreased FVC could be operated on safely and successfully with general anesthesia. All patients were extubated in the operating room. There were no major complications or deaths. We believe a FVC of <30% alone is not a predisposition to pulmonary complications. However, cardiomyopathy might be a determining risk of mortality, and we believe surgery for these patients should be avoided. Patients' and parents' satisfaction was high.

Two-year results for scoliosis secondary to Duchenne muscular dystrophy fused to lumbar 5 with segmental pedicle screw instrumentation.

BACKGROUND: Instrumentation and fusion to the sacrum/pelvis has been a mainstay in the surgical treatment of scoliosis in patients with Duchenne muscular dystrophy since the development of the intrailiac post. It is recommended for correcting pelvic obliquity. However, caudal extent of instrumentation and fusion has remained a matter of considerable debate. This study was performed to determine the efficacy and safety of stopping segmental pedicle screw constructs at L5 during surgical treatment of scoliosis associated with Duchenne muscular dystrophy (DMD). METHODS: From May 2005 to June 2007, a total of 20 consecutive patients underwent posterior spinal fusion and segmental pedicle screw instrumentation only to L5 for scoliosis secondary to DMD. All patients had progressive scoliosis, difficulty sitting, and back pain before surgery. A minimum 2-year follow-up was required for inclusion in this study. Assessment was performed clinically and with radiological measurements. The Cobb angles of the curves and spinal pelvic obliquity were measured on the coronal plane. Thoracic kyphosis and lumbar lordosis were measured on the sagittal plane. These radiographic assessments were performed before surgery, immediately after surgery, and at a 3-month interval thereafter. The operating time, blood loss, and complications were evaluated. Patients were questioned about whether they had difficulty sitting and felt back pain before surgery and at 6 weeks, 1 year, and 2 years after surgery. RESULTS: A total of 20 patients, aged 11-17 years, were enrolled. The average follow-up period was 37 months. Preoperative coronal curves averaged 70 degrees (range 51 degrees -85 degrees ), with a postoperative mean of 15 degrees (range 8 degrees -25 degrees ) and a mean of 17 degrees (range 9 degrees -27 degrees ) at the last follow-up. Pelvic obliquity improved from 13 degrees (range 7 degrees -15 degrees ) preoperatively to 5 degrees degrees (range 3 degrees -8 degrees ) postoperatively and 6 degrees (range 3 degrees -9 degrees ) at the last follow-up. Good sagittal plane alignment was recreated and maintained. Only a small loss of correction of scoliosis and pelvic obliquity was noted. The mean operating time was 271 min (range 232-308 min). The mean intraoperative blood loss was 890 ml (range 660-1260 ml). The mean total blood loss was 2100 ml (range 1250-2880 ml). There was no major complication. All patients reported that difficulty sitting and back pain were alleviated after surgery. CONCLUSION: Segmental pedicle screw instrumentation and fusion only to L5 is safe and effective in patients with DMD scoliosis of <85 degrees and pelvic obliquity of <15 degrees . Good sagittal plane alignment was achieved and maintained. All patients benefited from surgery in terms of improved quality of life. There was no major complication.

Surgical management of severe scoliosis with high risk pulmonary dysfunction in Duchenne muscular dystrophy: patient function, quality of life and satisfaction.

In a previous study, the authors reported the clinical and radiological results of Duchenne muscular dystrophy (DMD) scoliosis surgery in 14 patients with a low FVC of <30%. The purpose of this study was to determine if surgery improved function and QOL in these patients. Furthermore, the authors assessed the patients' and parents' satisfaction. %FVC increased in all patients after preoperative inspiratory muscle training. Scoliosis surgery in this group of patients presented no increased risk of major complications. All-screw constructions and fusion offered the ability to correct spinal deformity in the coronal and pelvic obliquity initially, intermediate and long-term. All patients were encouraged to continue inspiratory muscle training after surgery. The mean rate of %FVC decline after surgery was 3.6% per year. Most patients and parents believed scoliosis surgery improved their function, sitting balance and quality of life even though patients were at high risk for major complications. Their satisfaction was also high.

The expense for one implantation of a banked bone allograft from a cadaveric donor and the issues affecting current advanced medical treatment in the Japanese orthopaedic field.

Demand for banked bone allografts is increasing in Japan; however, there are too few bone banks and the bone bank network is not well-established. One reason for this was lack of funding for banks. Bone banks had to bear all material expenses of banked bone allografts themselves because this was not designated a covered expense. In December 2004, the Japanese government started a new "Advanced Medical Treatment" administration system which allowed an approved institution to charge the expense of authorized advanced medical treatments directly to patients. The treatment named "Cryopreserved allogenic bone and ligamentous tissue retrieved from cadaveric donor" was approved as an advanced medical treatment in March 2007. We present the calculation method and the expense per implantation of a banked bone allograft from a cadaveric donor under this treatment and raise issues which affect this advanced medical treatment and remain to be resolved in the Japanese orthopaedic field.

Suberoylanilide hydroxamic acid (SAHA) induces apoptosis or autophagy-associated cell death in chondrosarcoma cell lines.

BACKGROUND: Since chondrosarcoma has a high resistance to conventional chemotherapy and radiotherapy, surgical resection is currently the only effective treatment. Histone deacetylase (HDAC) inhibitor exert anticancer effects, but have not been tested in chondrosarcoma. MATERIALS AND METHODS: We investigated the phenotypic change in chondrosarcoma cells treated with SAHA by cell viability assay, Western blot, flow cytometric analysis and electron microscopy. RESULTS: SAHA inhibited the growth of chondrosarcoma cell lines and induced apoptosis in SW1353 with a cleaved-PARP expression and sub-G1 fragmentation according to flow cytometric analysis. On the other hand, in RCS and OUMS-27, SAHA induced autophagy-associated cell death as shown by the detection of autophagosome-specific protein and specific ultrastructural morphology in the cytoplasm. In addition, SAHA significantly inhibited tumor growth in an in vivo xenograft model. CONCLUSION: These results suggest that SAHA might be a promising agent for performing clinically useful chemotherapy against chondrosarcomas.