Medial femoral head border is a reliable and reproducible reference for axis determination for femoral component of unicompartmental knee arthroplasty.

PURPOSE: The femoral component should be implanted parallel to the mechanical axis in unicompartmental knee arthroplasty. It was hypothesised that a line between medial femoral condyle centres and medial border of femoral head will be parallel to the mechanical axis; this study set out to examine this hypothesis. METHODS: One hundred X-rays in fifty patients were included for this study. Long-leg standing X-rays including hip and ankle with patellae facing forwards were obtained. On these films, we measured the angle, α, between mechanical axis and the line between the femoral head centre and knee centre (medial mechanical axis), and the angle, ß, between the medial mechanical axis and a line between medial femoral condyle and femoral head centre. RESULTS: The average value of α was 0.1 ± 0.5° and the average value of ß 3.0° ± 0.3°. These data indicate that mechanical axis and medial mechanical axis are virtually parallel to each other. CONCLUSION: As medial femoral head border is easily identified fluoroscopically, it is a reliable landmark for orientating the femoral component of medial UKA.

Calcium pyrophosphate dihydrate deposition in the transverse ligament of the atlas: an unusual cause of cervical myelopathy.

A 75-year-old male presented with progressive myelopathy due to massive retro-odontoid deposits of calcium pyrophosphate dehydrate (CPPD) crystals. Magnetic resonance imaging revealed a non-enhanced isointense extradural mass on a T1-weighted image and a heterogeneous intense mass on a T2-weighted image. Computed tomography (CT) showed linear calcification within the mass. The mass was resected via a posterolateral approach resulting in marked improvement of the symptoms. Histological examination revealed birefringent rhomboid crystals consistent with CPPD. The preoperative differential diagnosis of periodontoid CPPD deposition disease in the elderly population should be considered, particularly if CT studies demonstrate small areas of calcification within the retro-odontoid mass.

Radiculopathy due to microfibrillar collagen hemostat mimicking recurrence of disc herniation.

Microfibrillar collagen hemostat (Avitene) is an absorbable topical hemostatic agent prepared from purified bovine corium collagen. A 65-year-old woman presented with left buttock and lower extremity radicular pain. The patient underwent a disc excision in which Avitene was used to control venous bleeding from the epidural space. Leg pain decreased postoperatively, but she developed radicular pain when she started walking 3 days after the operation. Magnetic resonance imaging (MRI) performed post-operatively showed there was a mass lesion located between the dural sac and L5 nerve root. The lesion exhibited high signal intensity on T1-weighted images and higher signal intensity at the rim of the mass on T2-weighted images. A second operation performed 10 days later revealed that the nerve root was adherent to an extradural granulomatous mass associated with Avitene. Macroscopically, the resected mass was found to be composed mainly of microfibrillar collagen hemostat materials. Hemostat agents may produce a clinically symptomatic, radiologically apparent mass lesion. When considering a mass lesion arising after spine surgery, the differential diagnosis should include foreign body granuloma along with recurrent disc herniation and peridural scar formation.

A prospective comparison of clamping the drain or post-operative salvage of blood in reducing blood loss after total knee arthroplasty.

We undertook a prospective, randomised study in order to evaluate the efficacy of clamping the drains after intra-articular injection of saline with 1:500 000 adrenaline compared with post-operative blood salvage in reducing blood loss in 212 total knee arthroplasties. The mean post-operative drained blood volume after drain clamping was 352.1 ml compared to 662.3 ml after blood salvage (p < 0.0001). Allogenic blood transfusion was needed in one patient in the drain group and for three in the blood salvage group. Drain clamping with intra-articular injection of saline with adrenaline is more effective than post-operative autologous blood transfusion in reducing blood loss during total knee arthroplasty.

Traumatic spondylolisthesis of the lumbosacral spine with multiple fractures of the posterior elements.

We describe a patient with a traumatic spondylolisthesis of L5 and multiple, bilateral pedicle fractures from L2 to L5. Conservative treatment was chosen, with eventual neurological recovery and bony union. We are not aware of previous reports of this pattern of injury.

Contained rupture of the aneurysm of common iliac artery associated with pyogenic vertebral spondylitis.

STUDY DESIGN: A case report. OBJECTIVES: To report and discuss a case of contained rupture of the aneurysm of common iliac artery associated with pyogenic vertebral spondylitis, so that investigators and practitioners may avoid the diagnostic and therapeutic pitfalls associated with pyogenic vertebral spondylitis and aortic disease. SUMMARY OF BACKGROUND DATA: Pyogenic vertebral spondylitis is a rare disorder that may have serious consequences, including death, if it is not diagnosed promptly and treated effectively. The association of pyogenic vertebral spondylitis with infection of the aorta is a rare but potentially fatal condition that requires prompt diagnosis and aggressive surgical and medical therapy. To our knowledge, this is the first report of a contained rupture of the aneurysm of common iliac artery case associated with pyogenic vertebral spondylitis resulting from an infection with Bacteroides fragilis,although Salmonellae infections are commonly associated with vertebral osteomyelitis and lesions of the contiguous aorta. METHODS: A 60-year-old man with chronic lower back pain began to experience a severe pain and had increased difficulty in walking. An MRI scan showed an increased signal in the L4-L5 disc space and an abscess extending into the spinal canal. The presumptive diagnosis was infective spondylitis. While performing a CT-guided needle biopsy, an unexpected contained rupture of the aneurysm of common iliac artery was discovered. RESULTS: A wide resection of all infected tissue, including the right common iliac artery and bony lesions, was performed in combination with antimicrobial therapy. A cryopreserved aortic allograft was used to reconstruct the artery, and an iliac strut graft was used to fill the debrided vertebral cavity. The patient's postoperative recovery was uneventful. CONCLUSION: The coexistence of pyogenic vertebral spondylitis and lesions of the aorta is rare, but may be lethal if not diagnosed promptly and treated effectively. Even if a patient's condition is stable and the hematocrit is normal, it is important to consider the possibility of a contained rupture of a mycotic abdominal aneurysm in all patients with vertebral osteomyelitis who have acute episodes of unusual severe back pain. CT is sometimes more beneficial than MRI in the identification and characterization of contained rupture of aneurysms.

Influence of macrophage infiltration of herniated disc tissue on the production of matrix metalloproteinases leading to disc resorption.

STUDY DESIGN: Herniated lumbar disc specimens were cocultured with peripheral blood mononuclear cells, and cells isolated from extruded disc were cultured to study the production of matrix metalloproteinases. OBJECTIVE: To investigate the role of peripheral blood mononuclear cells infiltrating extruded discs and disc-derived cells in the production of matrix metalloproteinases. SUMMARY OF BACKGROUND DATA: Magnetic resonance imaging analysis of herniated disc patients revealed a progressive decrease in the size of herniated discs. Spontaneous regression of herniated disc is associated with infiltrating macrophages, and matrix metalloproteinases have been implicated in this phenomenon. However, the correlation between infiltrating macrophages and the production of matrix metalloproteinases has received little research attention. METHODS: Each disc specimen was incubated with homologous peripheral blood mononuclear cells. The numbers of peripheral blood mononuclear cells attached to the surfaces of herniated discs were counted and the culture media was assayed for MMP-3. The cells isolated from herniated discs were incubated with cytokines and the production of matrix metalloproteinases was measured. Total RNA was extracted from herniated discs and RT-PCR was carried out. RESULTS: Significantly larger numbers of peripheral blood mononuclear cells were attached to the surfaces of extruded discs, and higher amounts of MMP-3 were detected than those of control discs. The culture medium of extruded discs showed higher MMP-1 and MMP-3 production than those from controls. Significant enhancement of MMP-1 and MMP-3 mRNA expression was observed in the disc-derived cells stimulated with cytokines. CONCLUSION: These results suggest that peripheral blood mononuclear cells infiltrating extruded discs may secrete a variety of biologic materials capable of further recruiting monocytes into herniated discs in an autocrine fashion. Disc cells stimulated with cytokines showed enhanced production of matrix metalloproteinases, which might play an important role in spontaneous regression of disc materials.

Recurrent calcified spinal meningioma detected by plain radiograph.

STUDY DESIGN: A case report of a patient presenting with a rare calcified spinal meningioma that recurred and became symptomatic 33 years after initial surgery was performed. OBJECTIVES: To demonstrate a calcified recurrent spinal meningioma visible on a plain radiograph. The present case is discussed in conjunction with a review of previous cases of calcified spinal meningioma. SUMMARY OF BACKGROUND DATA: Meningioma is a common spinal tumor that has a favorable prognosis if resected completely. Microscopic calcification is frequently found in spinal meningiomas because of psammoma bodies. However, calcified meningiomas in the spinal canal that can be detected on a plain radiograph are uncommon. To the authors' knowledge, there have been no previous reports of recurrent spinal meningioma with calcification visible on a plain radiograph. METHODS: A patient experienced difficulty in walking and was diagnosed as having a spinal meningioma. Laminectomies and a total tumor excision were performed. Histologically, the tumor was diagnosed as a psammomatous meningioma. The tumor recurred and became symptomatic 33 years after the initial operation. The tumor was detected on a plain radiograph, appearing as a calcified tumor at the same thoracic level as the site of the initial operation. The recurrent tumor was completely removed, and a histologic examination showed huge psammoma bodies with calcification, but without ossification. RESULTS: Preoperative paraplegia improved after the surgery, and she was able to walk with a crutch. The patient was discharged from the hospital. CONCLUSIONS: The recurrent psammomatous meningioma contained clusters of calcified psammoma bodies, resulting in a hard tumor that was visible on a plain radiograph.

Spontaneous and cytokine regulated c-fos gene expression in rheumatoid synovial cells: resistance to cytokine stimulation when the c-fos gene is overexpressed.

OBJECTIVE: To study the effect of cytokines on the transactivation of the c-fos gene in relation to the contribution of overexpression of c-fos/AP-1 in rheumatoid joint destruction. METHODS: The promoter region (-447 to +109) of the human c-fos gene was integrated upstream of the chloramphenicol acetyltransferase (CAT) reporter gene, and the effect of cytokines on the expression of the c-fos gene was studied in the rheumatoid synovial cells of early (3-4) or late (14-18) passages, in the presence or absence of cytokines, by the transient transfection assay. RESULTS: Expression of c-fos gene was enhanced by tumour necrosis factor alpha (TNF alpha) and interleukin 6 (IL6) in the synovial cells of early passage, whereas it was not enhanced in the synovial cells of late passage. The c-fos gene expression was also enhanced by 13-O-tetradecanoyl phorbol-13-acetate (TPA) in early passage but was somewhat suppressed in the late passage. It was found that the c-fos gene and c-Fos protein were both increased in the synovial cells of late passage. Similarly, c-fos gene expression was also not increased by TPA or cytokine stimulation in the stable c-fos transformants (fos-pH8) or H-ras transformed NIH3T3 cells (NIH H-ras cells) that constitutively expressed c-fos genes. CONCLUSIONS: Although TNF alpha and IL6 augmented c-fos gene expression of rheumatoid synovial cells, transactivation of c-fos gene became resistant against cytokine stimulation under prolonged expression of c-fos gene, which may impart a tumour-like characteristic to rheumatoid synovial cells.

Surgical management of Sprengel's deformity in adults. A report of two cases.

Sprengel's deformity is a congenital structural abnormality of the shoulder girdle, and most patients with Sprengel's deformity receive surgical treatment as a child or adolescent. Thus, it is uncommon to identify an adult with untreated Sprengel's deformity. Two adult patients who had no previous surgical treatment were treated with resection of an omovertebral bone and resection of the superomedial border of the scapula. This procedure was not overly invasive or technically demanding. In both patients resection of the omovertebral bone provided an improved cosmetic appearance and reduction in neck pain, although shoulder motion was improved in only one patient. Because the patient with a long omovertebral bone adjacent to the levator scapulae muscle showed great improvement in her shoulder motion, the size, shape, and position of the omovertebral bone may predict improvement of shoulder motion after resection. Thus, the surgical treatment of adults patients with Sprengel's deformity can produce good surgical results.

The role of cyclooxygenase-2 and inflammatory cytokines in pain induction of herniated lumbar intervertebral disc.

Lumbar disc herniation (LDH) is the disease which is the major cause of radiculopathy. In terms of the pathogenesis of disease, it is reported that prostaglandinE2 (PGE2) plays an important role to induce radiculopathy. Arachidonate cascade, which is the process of PGE2 synthesis, is mainly regulated by two kinds of enzymes, phospholipaseA2 (PLA2) and cyclooxy genase (COX). Previously, PLA2 was recognized as the rate-limiting enzyme of this cascade, and some authors reported the clinical significance of PLA2 at the site of LDH concerning the radicular pain. Recently, COX was elucidated to consist of 2 types of isoform, a constitutive form of COX-1 and an inducible form of COX-2. COX-2 has been focused as a key enzyme to regulate PGE2 synthesis and plays an important role in inflammation, because COX-2 was induced in many types of cells by the stimulation of inflammatory cytokines such as interleukin-1 beta (IL-1 beta) and tumor necrosis factor alpha (TNF alpha). However, it is not fully discussed whether or not, COX-2 is induced in lumbar disc tissue and if it plays a significant role in the pathogenesis of LDH. To clarify the role of COX-2 in the pathomechanism of radiculopathy of LDH, we have investigated the expression of COX-2, IL-1 beta and TNF alpha in herniated lumbar disc tissue. Immunohistologically, they were detected in the cytosol of chondrocytes constituting the disc tissue. RT-PCR showed that herniated lumbar disc-derived cells expressed mRNA of COX-2, IL-1 beta and TNF alpha in the presence of inflammatory cytokines in vitro. The disc-derived cells also produced much PGE2 by stimulating of inflammatory cytokines at the same time and this PGE2 production was distinctly suppressed by a selective inhibitor of COX-2, 6-methoxy-2-naphtyl acetic acids (6MNA). These results suggest that COX-2 and inflammatory cytokines might play a causative role in the radiculopathy of LDH through upregulating PGE2 synthesis.

Intervertebral disc cell apoptosis by nitric oxide: biological understanding of intervertebral disc degeneration.

While the unphysiological mechanical load is a central etiologic factor of disc degeneration, biologic factors including nitric oxide (NO) seems to play an important role in this condition. It is, therefore, investigated whether NO is related to the degeneration of intervertebral disc by way of inducing the disc cell apoptosis. Twelve herniated lumbar disc and eight control specimens were obtained from the patients underwent surgery. Apoptotic cells were identified by TUNEL procedure and the percent apoptotic cell index (ACI%) of each sample was calculated. Detection of iNOS expression was performed by immunohistochemical analysis. Disc cell monolayer culture was prepared from the surgical specimen of the patients with lumbar disc herniation. NO generation of the disc cells was measured by Griess reaction. Cell proliferation was detected by measuring the incorporation of 3H-Thymidine. The extent of fragmented DNA induced by NO donor, NOC-18, was also measured by an enzyme-linked immunosorbent assay. The incidence of apoptotic cell death (ACI%) was greater in the herniated group (61.3 +/- 24.5%) than that of control group (5.6 +/- 6.8%; P < 0.001). iNOS positive disc cells were detected in all the samples. NO production of disc cells was enhanced by the stimulation of IL-1 alpha. Suppression of 3H-Thymidine incorporation and DNA fragmentation in the disc cells were promoted by treatment of 100 microM NOC-18. These results suggest that disc cells are able to release NO and NO may play an important role in the pathogenesis of disc degeneration through the induction of apoptosis of disc cells in situ.

[The long-term result of implant arthroplasty for hallux valgus deformity in rheumatoid arthritis].

We have reviewed the results of reconstruction of the forefoot in rheumatoid patients with arthroplasty using a Swanson flexible hinge toe implant for the great toe and with resection arthroplasty for the lateral four toes. The follow-up averaged 8 years (range, 5-11 years). All patients were female and an average age was 52 (range, 31-72 years). Preoperative and postoperative hallux valgus angle (HVA), the angles between the axes of the first and second metatarsal shafts (M1-M2) and the first and fifth metatarsal shafts (M1-M5) were measured radiographically. Breakage of the implant and radiolucencies around the implant on X-ray were evaluated. Preoperative average HVA, M1-M2 and M1-M5 were 31, 10, and 30 respectively. Postoperative average HVA, M1-M2, and M1-M5 were 17, 10, and 28 respectively. Breakage of the implant was present in 77% of the feet and the radiolucencies around the implant was present in 63% of the feet. Although only one foot was performed revision surgery for severe pain and breakage of the implant, more than 95% of the feet obtained pain relief. We found that this type of operation was very effective in relieving pain in rheumatoid patients.

[Tendon rupture of the extensor pollicis longus tendon in rheumatoid arthritis].

Seven patients with subcutaneus of the extensor pollicis longus tendon (EPL) in rheumatoid arthritis were studied. There were one man and six women. The mean age of the patients was 56. 9 years, with a range of 47 to 83 years. The duration of the disease was from 0.2 to 6 years, its average 3 years. An interval between rupture of the tendon and operation was 9 days to 18 months. Tendon transfers of the extensor indicis proprius tendons were performed in 3 cases, sutures in 2 cases and free tendon graft of the palmaris longus in one case. All cases showed very active tenosynovitis around the EPLs, which were ruptured near Lister's tubercle. The histopathological findings of the ruptured EPL revealed that synovial proliferative tissue with chronic inflammatory cells infiltration were invading into the tenion tissue directly. The synovial granulatins might weaken the tendon and repetitive mechanical stress on the tendon at Lister's tubercle could result in the rupture of EPLs.

[A case report of systemic calcinosis associated with rheumatoid arthritis].

A 69-year-old female with a fourty-year history of rheumatoid arthritis visited Kobe University hospital with complaints of subcutaneous soft tumor on both hands and arthritic pain of both knees. She has been given 10 mg of predonisolone for several years and had a history of hydronephrosis. Her radiographs revealed periarticular calcification in the hands, shoulder joints and posterior thoracic wall. She had high titer of rheumatoid factor and both erythrocyte sedimentation rate (79 mm/hr) and C-reactive protein (12.79 mg/ml) were elevated. The examination of her serum showed the following values: Ca 7.9 mg/dl, P 5.0 mg/dl, 25 (OH) D3 < 3.6 pg/ml, 1 alpha-. 25 (OH)2 Vit D3 < 6.1 pg/ml, osmolality 974 mOsm/kg, BUN 61 mg/dl, creatinine 1.9 mg/ml, creatinine clearance less than 20 ml/min, indicating chronic renal failure. Intact PTH level was normal, although plasma parathyroid hormone-C (PTH-C) level increased. Together with these findings, it is suggested that metabolic disorders associated with chronic renal failure and tissue damages due to the severe rheumatoid arthritis led to the formation of diffuse soft tissue calcification.

Immunohistologic study of the ruptured intervertebral disc of the lumbar spine.

STUDY DESIGN: This study analyzed immunohistological features of the extruded or sequestrated intervertebral disc of the lumbar spine. To clarify the pathogenesis of neovascularization, cells isolated from herniated disc were cultured and examined biologically. OBJECTIVES: The objectives of this study were to characterize the histologic features of extruded or sequestrated discs and inflammatory cells that infiltrate along the margins of the disc tissue and to clarify the pathogenesis of neovascularization observed at the edge of the disc tissue. SUMMARY OF BACKGROUND DATA: When some of the contents of the disc extrudes into the epidural space and is considered "foreign," an autoimmune response develops, which can lead to a chronic inflammatory response. However, the pathogenesis of inflammatory cell infiltrations and neovascularization are not clearly defined. METHODS: The herniated discs were obtained during surgery and were stained with anti-interleukin-1, intercellular adhesion molecule-1, lymphocyte function-associated antigen, and basic fibroblast growth factor antibodies by using an indirect immunoperoxidase method. Cells isolated from herniated disc were cocultured with human endothelial cells and basic fibroblast growth factor contained by cultured disc cells were measured by radioimmunoassay. RESULTS: The ingrowth of granulation tissue with vascularization, occurring at the edge of fibrocartilage fragment, was present at 11 of 16 of extruded and 3 of 5 of sequestrated discs. Anti-interleukin-1, intracellular adhesion molecule-1, lymphocyte function-associated antigen, and basic fibroblast growth factor were expressed on most of mononuclear cells infiltrating into the extruded or sequestrated disc. Cells from the extruded or sequestrated disc demonstrated significantly greater levels of basic fibroblast growth factor than those from the protruded disc, and they enhanced the proliferation of endothelial cells. CONCLUSIONS: This study showed that mononuclear cells infiltrating along the margins of extruded discs expressed inflammatory mediators and might induce neovascularization and persistence of inflammation.

Effect of soluble aminated beta-1,3-D-polyglucose on human monocytes: stimulation of cytokine and prostaglandin E2 production but not antigen-presenting function.

Glucans are insoluble polymers of beta-1,3-linked glucose derived from yeast cell walls that effectively activate macrophages. Recently, aminated derivatives of beta-1,3-D-polyglucose have been developed that are soluble but also activate murine macrophages. The current studies were undertaken to determine whether soluble aminated beta-1,3-D-polyglucose (AG) would also stimulate human monocytes. The AG employed contained less than 2 ng endotoxin/mg. AG induced the production of intracellular, membrane-associated, and secreted forms of interleukin 1 (IL1) in a dose-dependent manner, with 50 micrograms/ml yielding maximal responses. AG also induced tumor necrosis factor-alpha (TNF alpha) secretion by human monocytes. Prostaglandin E2 (PGE2) production was also stimulated in a concentration-dependent manner. Quantitatively, optimal stimulatory concentrations of AG were comparable to endotoxin in the capacity to induce production of these various mediators. In contrast to its capacity to induce production of IL1, TNF alpha, and PGE2, AG did not stimulate monocytes to become more effective antigen presenting cells. These results indicate that AG is potent inducer of proinflammatory mediators from human monocytes but does not enhance their capacity to initiate immune responses.

Association of HLA-DR antigens with disease severity in Japanese patients with rheumatoid arthritis.

Twenty eight Japanese patients with rheumatoid arthritis (RA) were tested for HLA-DR antigens to investigate genetic influence on disease severity and prognosis. The severity of RA was assessed by clinical, laboratory and radiological indexes. HLA-A, B, C and DR typing was performed using sera described at the 3rd Asia and Oceania Histocompatibility Workshop. HLA-DR4.1 was significantly higher in RA patients (50%) compared with controls (27.6%). HLA-DRw53 was also higher in RA patients, although DRw52 was lower in those than controls. When the relationship between HLA-DR antigens and the clinical severity of RA was investigated, the patients with HLA-DR4 had a severer disease than DR4 negative patients. In contrast, HLA-DR2 positive patients had significantly better functional scores than DR 2 negative patients. We next investigated specific genes likely to be directly involved in the pathogenesis of RA. Although the new restriction fragment length polymorphisms (RFLPs) were found in DR2 positive patients, no association was found between the RFLPs and the clinical severity of RA. Furthermore there were no differences in the frequencies of the RFLPs in HLA-DR4 positive patients compared with DR4 negative patients. It may be concluded that the severity of RA appears to be influenced by several different genes or molecules rather than by a single gene or gene product linked to HLA-DR2 or DR4.

Analysis of lymphocyte subsets of bone marrow in patients with rheumatoid arthritis by two colour immunofluorescence and flow cytometry.

Lymphocyte subsets defined by monoclonal antibodies were investigated in bone marrow and peripheral blood of 17 patients with rheumatoid arthritis (RA); 13 patients with osteoarthritis or aseptic necrosis served as controls. Patients with RA were found to have a raised OKT 4/8 ratio both in bone marrow and peripheral blood in comparison with the controls. Furthermore, bone marrow of RA showed a lower percentage of OKT 8+ T cells than that of controls. The percentage of HLA-DR+ T cells was higher in bone marrow than in peripheral blood of RA, though a slightly lower percentage was detected in bone marrow than in peripheral blood of controls. Thus T cell subsets in bone marrow of RA differ significantly from those of controls. Patients with RA had a higher OKT 4/8 ratio and a higher percentage of HLA-DR+ T cells in bone marrow than controls, suggesting that T cell subsets in bone marrow of RA are in an immunologically activated state and that T cell subsets are affected by rheumatoid inflammation in bone marrow of RA.