Does carpal tunnel release provide long-term relief in patients with hemodialysis-associated carpal tunnel syndrome?

BACKGROUND: Carpal tunnel syndrome (CTS) is a common complication in patients receiving long-term hemodialysis. In the short-term however, these patients are less likely to have pain relief and restoration of function after carpal tunnel release. However, it is unclear whether patients who have release for hemodialysis-associated CTS have differing persisting relief of symptoms compared with patients with idiopathic CTS. QUESTIONS/PURPOSES: We therefore compared (1) the severity of pain and level of function in patients who had release for hemodialysis-associated CTS with scores of patients who had release for idiopathic CTS, and (2) the operation-related complications. METHODS: We retrospectively reviewed 36 patients with CTS who were receiving hemodialysis and 54 patients with idiopathic CTS. Control subjects were matched for age, gender, and symptom severity. We obtained Boston Carpal Tunnel Questionnaire (BCTQ) scores preoperatively and at each followup. The minimum followup was 24 months (mean, 44.3 months; range, 24-90 months), although all comparisons were made at 2 years. RESULTS: Two years after carpal tunnel release, the mean BCTQ-symptom (S) /BCTQ-function (F) scores improved from 3.3/2.1 to 2.1/2.1 in the hemodialysis-associated CTS group and from 3.2/2.3 to 1.4/1.4 in the idiopathic CTS group. All but six patients receiving hemodialysis had lower (better) BCTQ-S scores than their initial scores. Four patients had complications, all with hemodialysis-associated CTS: two had revision carpal tunnel releases and two had delayed wound healing. We observed no arteriovenous fistula-related complication. CONCLUSIONS: Patients with hemodialysis-associated CTS seem to remain impaired, unlike patients with idiopathic CTS, but the majority of them might have much improved CTS-related symptoms at 2 years after carpal tunnel release.

One-bone forearm procedure for acquired pseudoarthrosis of the ulna combined with radial head dislocation in a child: a case with 20 years follow-up.

This report describes a 6 year-old boy who was treated with one-bone forearm procedure for acquired pseudoarthrosis of the ulna combined with radial head dislocation after radical ulna debridement for osteomyelitis. At more than 20 years of follow-up, the patient had a nearly full range of elbow movements with a few additional surgical procedures. Pronation and supination was restricted by 45°, but the patient had near-normal elbow and hand functions without the restriction of any daily living activity. This case shows that one-bone forearm formation is a reasonable option for forearm stability in longstanding pseudoarthrosis of the ulna with radial head dislocation in a child.

Correction of long standing proximal interphalangeal flexion contractures with cross finger flaps and vigorous postoperative exercises.

PURPOSE: We reviewed the results of cross finger flaps after surgical release and vigorous postoperative exercises for long-standing, severe flexion contractures of the Proximal Interphalangeal (PIP) joints of fingers. MATERIALS AND METHODS: In 9 patients, all contracted tissue was sequentially released and the resultant skin defect was covered with a cross-finger flap. The cause of the contracture was contact burn in 4, skin graft in 3, and a previous operation in 2. The mean followup period was 41.2 months. RESULTS: The mean flexion contracture/further flexion in the joints were improved from 73.4/87.8 degrees to 8.4/95.4 degrees at the last follow-up. A mean of 19.5 degrees of extension was achieved with vigorous extension exercise after the operation. The mean gain in range of motion (ROM) was 79.4 degrees. Near full ROM was achieved in 3 cases. There were no major complications. CONCLUSION: In severe flexion contractures with scarring of the PIP joints of fingers, cross finger flaps after sufficient release and vigorous postoperative exercise seems to be a reasonable option to obtain satisfactory ROM of the joints.

Decompression of the ulnar nerve and minimal medial epicondylectomy with a small incision for cubital tunnel syndrome: comparison with anterior subcutaneous transposition of the nerve.

UNLABELLED: The objective of this study is to compare the results of ulnar nerve decompression and minimal medial epicondylectomy with a small incision (group I) and anterior subcutaneous transposition of the ulnar nerve (group II) for cubital tunnel syndrome. METHODS: Out of 56 patients with cubital tunnel syndrome, 29 were in group I and 27 were in group II. The mean age at the time of the operation was 48.9 years, and the mean follow-up period was 36.4 months. Preoperatively, the neuropathy was graded according to Dellon's criteria. RESULTS: There were no significant differences between the results of the two groups according to the modified Bishop's system at the last follow-up. However, four patients showed painful neuroma around the operation scar and one patient in group II had experienced acute deterioration of the symptoms after the procedure. CONCLUSIONS: Decompression and minimal medial epicondylectomy with a small incision seems to be more recommendable than anterior subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome in terms of its simplicity and lesser invasiveness.

Segmental resection and replantation have a role for selected advanced sarcomas in the upper limb.

UNLABELLED: Although limb salvage surgery for primary sarcoma of the upper limb is a standard procedure, it often is technically challenging. We asked whether segmental resection and replantation would provide (1) local control and long-term survival and (2) useful limb function in patients who had advanced primary malignant and aggressive tumors of the upper limbs. We retrospectively reviewed six patients treated with this procedure when a wide resection around the tumor could not be achieved with other limb-salvage procedures. Diagnoses included osteosarcoma (two), Ewing's sarcoma (one), leiomyosarcoma (one), and giant cell tumor (two). Four patients had displaced pathologic fractures. Minimum followup was 40 months (mean, 164 months; range, 40-214 months). All but one patient remained disease-free; the patient with Ewing's sarcoma died from the disease 40 months after surgery. The average functional score at last followup was 20 points. The mean grasping and pinching power of the operative hand were 66% and 72% of the contralateral side, respectively. Two patients had complications: one had wound dehiscence that subsequently healed and one had radial nerve palsy that recovered spontaneously by 3 months. Segmental resection and replantation may have a role in selected cases for treatment of advanced primary sarcoma or aggressive giant cell tumor of the upper limb as partial limb salvage. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Carpal tunnel syndrome caused by space occupying lesions.

PURPOSE: To evaluate the diagnosis and treatment of the carpal tunnel syndrome (CTS) due to space occupying lesions (SOL). MATERIALS AND METHODS: Eleven patients and 12 cases that underwent surgery for CTS due to SOL were studied retrospectively. We excluded SOL caused by bony lesions, such as malunion of distal radius fracture, volar lunate dislocation, etc. The average age was 51 years. There were 3 men and 8 women. Follow-up period was 12 to 40 months with an average of 18 months. The diagnosis of CTS was made clinically and electrophysiologically. In patients with swelling or tenderness on the area of wrist flexion creases, magnetic resonance imaging (MRI) and/or computed tomogram (CT) were additionally taken as well as the carpal tunnel view. We performed conventional open transverse carpal ligament release and removal of SOL. RESULTS: The types of lesion confirmed by pathologic examination were; tuberculosis tenosynovitis in 3 cases, nonspecific tenosynovitis in 2 cases, and gout in one case. Other SOLs were tumorous condition in five cases, and abnormal palmaris longus hypertrophy in 1 case. Tumorous conditions were due to calcifying mass in 4 cases and ganglion in 1 case. Following surgery, all cases showed alleviation of symptom without recurrence or complications. CONCLUSION: In cases with swelling or tenderness on the area of wrist flexion creases, it is important to obtain a carpal tunnel view, and MRI and/or CT should be supplemented in order to rule out SOLs around the carpal tunnel, if necessary.

Corrective dome osteotomy for cubitus varus and valgus in adults.

A corrective dome osteotomy was performed in 19 adult patients for cubitus varus and valgus deformity. The mean age at operation was 31.1 years and the mean follow-up was 41 months. The average postoperative carrying angle in 16 patients with cubitus varus was 6.1 degrees (range, 1-10 degrees), an average correction of 24 degrees (range, 5-36 degrees). The average postoperative carrying angle in 3 patients with cubitus valgus was 6.7 degrees (range, 6-7 degrees), an average correction of 29.3 degrees (range, 29-30 degrees). None of the patients had recurrence of deformity, unsightly scarring, or a prominent lateral or medial condyle at final follow-up. An excellent result was achieved in 13 patients and good in 6. We conclude that corrective dome osteotomy with secure fixation using plates and screws is a reliable option for cubitus varus or valgus deformity in adults.

Clinical significance of margin status in postoperative radiotherapy for extremity and truncal soft-tissue sarcoma.

PURPOSE: To evaluate whether adjuvant radiotherapy (RT) in extremity and truncal soft-tissue sarcoma (STS) patients with microscopically positive or close margins after excision can achieve comparable local control to that of excision with negative margin plus RT. METHODS AND MATERIALS: A total of 150 patients (111 extremity and 39 trunk cases) treated with conserving surgery and adjuvant RT was analyzed. All surgical margins were classified as being a negative margin or a positive or close margin based on pathologic margin width. RT was delivered with a shrinking-field technique in 150 patients (median, 63 Gy). RESULTS: All patients were divided into two groups: (A) excision with negative margins plus RT (n = 56) and (B) excision with positive or close margins plus RT (n = 94). Overall, the 5-year local failure-free survival in all patients was 72.9%, and no significant differences were found between the two groups (Group A, 74.7%; Group B, 71.6%). High tumor grade was found to be a significant predictor of local failure. However, Group A was superior to Group B in distant metastasis-free survival (p = 0.02). No significant differences were shown in overall survival between the two groups. CONCLUSIONS: In our series, margin status did not predict for LF when adjuvant RT was used. We believe that when adjuvant RT is used, re-resection may not be necessary for selected patients with positive or close pathologic margins in the management of extremity and truncal STS patients.

The association of the activation-inducible tumor necrosis factor receptor and ligand with lumbar disc herniation.

PURPOSE: Herniated nucleus pulposus fragments are recognized by the immune system as a foreign-body, which results in an autoimmune reaction. Human activation-inducible tumor necrosis factor receptor (AITR) and its ligand, AITRL, are important costimulatory molecules in the pathogenesis of autoimmune diseases. Despite the importance of these costimulatory molecules in autoimmune disease, their role in the autoimmune reaction to herniated disc fragments has yet to be explored. The purpose of the present study is to investigate whether the overexpression of AITR and AITRL might be associated with lumbar disc herniation. MATERIALS AND METHODS: The study population consisted of 20 symptomatic lumbar disc herniation patients. Ten macroscopically normal control discs were obtained from patients with spinal fractures managed with anterior procedures that involved a discectomy. Peripheral blood samples from both the study patients and controls were collected. The expression levels of AITR and AITRL were investigated by flow cytometric analysis, confocal laser scanning microscopy, immunohistochemistry and by reverse transcriptase-polymerase chain reaction (RT-PCR). The soluble AITR and AITRL serum levels were measured by an enzyme-linked immunosorbent assay. RESULTS: Flow cytometric analysis revealed significantly higher levels of both AITR and AITRL in the lumbar disc herniation patients than in the controls. The AITRL expression levels were also increased in patients with lumbar disc herniation, shown by using confocal laser scanning microscopy, immunohisto-chemistry, and RT-PCR. Finally, soluble AITR and AITRL were elevated in the patients with lumbar disc herniations. CONCLUSION: The AITR and AITRL are increased in both the herniated disc tissue and the peripheral blood of patients with lumbar disc herniation.

Paraspinal abscess communicated with epidural abscess after extra-articular facet joint injection.

Facet joint injection is considered to be a safe procedure. There have been some reported cases of facet joint pyogenic infection and also 3 cases of facet joint infection spreading to paraspinal muscle and epidural space due to intra-articular injections. To the author's knowledge, paraspinal and epidural abscesses after facet joint injection without facet joint pyogenic infection have not been reported. Here we report a case in which extra-articular facet joint injection resulted in paraspinal and epidural abscesses without facet joint infection. A 50-year-old man presenting with acute back pain and fever was admitted to the hospital. He had the history of diabetes mellitus and had undergone the extra-articular facet joint injection due to a facet joint syndrome diagnosis at a private clinic 5 days earlier. Physical examination showed tenderness over the paraspinal region. Magnetic resonance image (MRI) demonstrated the paraspinal abscess around the fourth and fifth spinous processes with an additional epidural abscess compressing the thecal sac. The facet joints were preserved. The laboratory results showed a white blood cell count of 14.9 x 10(9) per liter, an erythrocyte sedimentation rate of 52 mm/hour, and 10.88 mg/dL of C-reactive protein. Laminectomy and drainage were performed. The pus was found in the paraspinal muscles, which was communicated with the epidural space through a hole in the ligamentum flavum. Cultures grew Staphylococcus aureus. Paraspinal abscess communicated with epidural abscess is a rare complication of extra-articular facet joint injection demonstrating an abscess formation after an invasive procedure near the spine is highly possible.

Treatment of osteofibrous dysplasia and associated lesions.

PURPOSE: To report long term treatment outcomes of osteofibrous dysplasia and association with adamantinoma. PATIENTS AND METHODS: From January 1984 to July 2001, 14 patients with osteofibrous dysplasia were followed for an average of 108 months (78 to 260 months). Our patient group consisted of 6 men and 8 women, with a mean age of 13.9 years (2 to 65 years). We reviewed the clinical and pathological features of all 14 patients. RESULTS: Thirteen patients had a lesion in the tibia, while one patient had lesions in both the tibia and the fibula. Initial treatments were observation after biopsy (6 patients), curettage with or without a bone graft (3 patients), resection followed by a free vascularized fibular bone graft (4 patients), or resection and regeneration with the Ilizarov external fixation (1 patient). Curettage was performed on 6 patients due to recurrence or progression after the initial treatment. Among these patients, one was diagnosed with AD from the biopsy of the recurrent lesion. This patient was further treated by segmental resection and pasteurization. After the initial pathology slides of the 13 patients were reviewed with immunohistochemical cytokeratin staining, one patient diagnosis was changed from osteofibrous dysplasia to osteofibrous dysplasia-like adamantinoma. CONCLUSION: Some patients with osteofibrous dysplasia require close observation because of the high association risk between osteofibrous dysplasia and adamantinoma, Immunohistochemical staining may be helpful in differentiating these two diagnoses.

A comparison of autologous and homologous transfusions in spinal fusion.

Autologous transfusion has been used to overcome adverse effects of homologous transfusion. Clinical studies evaluating general orthopaedic postoperative results have been designed to compare these transfusion methods. However, few studies have evaluated postoperative results in spinal fusion surgeries, which have larger blood loss volumes. The purpose of this study is to determine if there are differences in postoperative infection and clinical results of spinal fusion with autologous, as compared to homologous, blood transfusion. A total of 62 patients who underwent instrumented spinal fusion and received autologous (n = 30) or homologous (n = 32) transfusions were reviewed. Information on gender, age, preoperative and 3-day postoperative hematologic features, total transfused units, segmental estimated blood loss, transfused units, and surgery time were collected. In addition, postoperative infection data on wound infection, pneumonia, urinary tract infection, cellulitis, and viral disease, incidence and duration of fever, as well as clinical results, fusion rates, and patient feedback were collected. No differences in postoperative infection and clinical results were found between the two types of transfusions; however, homologous transfusion was associated with an increased number of total units transfused, longer duration of fever, and decreased patient satisfaction regarding the transfusion.

Cervical myelopathy from atlantal hypoplasia and torticollis.

Cervical myelopathy caused by atlantal hypoplasia has been reported in only 11 patients. Atlantal hypoplasia combined with torticollis has not been reported. Rotation of the atlantoaxial joint causes spinal canal narrowing at the atlantoaxial level and stretches the vertebral artery, which may aggravate the symptoms and signs of compressive cervical myelopathy from atlantal hypoplasia. We present a patient with cervical myelopathy from atlantal hypoplasia, retrodental pseudotumor, and torticollis.

Operative treatment for proximal phalangeal neck fractures of the finger in children.

Displacement and inappropriate treatment of a proximal phalangeal neck fracture may result in malunion of the fracture with consequent loss of motion and gross deformity, especially in children. We performed a retrospective study of twenty-four patients who had undergone operative treatment for a proximal phalangeal neck fracture, with a mean follow-up evaluation of 14 months (range: 12-30 months). We analyzed the types of fractures, their causes, operative treatments, complications, and functional outcomes. The age of the patients ranged from 2 to 14 years (average: 4.8 years). Twenty of the 24 patients had open reduction and internal fixation, and fourteen of these 20 patients had criss-cross pin fixation. Four of the 24 patients had closed reduction and percutaneous pinning. The average length of immobilization was 3.5 weeks. Excellent or good results were seen in 18 patients (75%). Two patients had complications, which included volar angular deformity and mild button-hole deformity. We recommend that careful initial radiography, particularly, true lateral view radiographs, be required for proper diagnosis. The best results can only be obtained with accurate anatomical reduction of the fracture and early active motion exercise.

Tumor volume change after chemotheraphy as a predictive factor of disease free survival for osteosarcoma.

Change in tumor volume after chemotherapy appears to have a prognostic significance for the outcome of osteosarcoma. A newly developed volume measurement method based on three-dimensional summation with a proved reproducibility was utilized to measure osteosarcoma tumor volume. This retrospective analysis included 38 patients with biopsy- proven, nonsurface, skeletal high-grade osteosarcoma. The treatment was started by using three cycles of preoperative chemotherapy with cisplastin (100 mg/m2) and adriamycin (30 mg/m2). The tumor volume was measured before and after preoperative chemotherapy using three-dimensional magnetic resonance image measurement. The percentage of tumor necrosis was assessed by pathologic exam. After three cycle of postoperative chemotherapy, the patients were followed up at regular interval. For the 23 good responder patients, the mean survival time was 73.2 months (95% confidence interval 61.9-84.5 months), and for the 15 poor responder patients, the mean survival time was 50.8 months (95% confidence interval 38.6-63.1 months) (p<0.05). For the 14 patients with increased tumor volume after chemotherapy, the mean survival time was 47.5 months (range: 36.3-58.6 months) and for the 24 patients with stable or decreased tumor volume, the mean survival time was 74.3 months (range: 63.79-84.88 months) (p<0.05). Among the various factors, histopathologic response and tumor volume change after chemotherapy predicted disease free survival (p<0.05). Change in the tumor volume that was measured with a reproducible method and the histopathologic response after chemotherapy were the important predictors of disease free survival for osteosarcoma patients.

Chondrogenic differentiation of mesenchymal stem cells and its clinical applications.

Tissue engineering has the potential to provide cartilaginous constructs capable of restoring the normal function of native articular cartilage following joint injury or degradation. One approach to functional tissue engineering of cartilage involves the in vitro cultivation of tissue constructs by using: (i) chondrogenic cells that can be selected, expanded, and transfected to overexpress the genes of interest, (ii) scaffolds that provide a defined three-dimensional structure for tissue development and biodegrade at a controlled rate. Understanding the functional potential of the cells and the signaling mechanisms underlying their differentiation should lead to innovative protocols for clinical orthopaedic interventions. A large number of growth factors and hormones have been implicated in the regulation of chondrocyte biology, relatively little is known about the intracellular signaling pathways involved. We have tried to define the roles of specific TGF- dependent signaling pathways involved in the regulation of chondrogenesis from human mesenchymal stem cells. Chondrogenesis induced by TGF-beta3 in alginate bead system was confirmed by examining cartilage specific type II collagen expression and aggrecan, whereas type I collagen expression was not affected by TGF-beta3. Type II collagen mRNA expression was expressed strongly during chondrogenesis and MEK inhibition (U0126) resulted in complete down-regulation of type II collagen. In contrast, aggrecan expression was detected in same level by treatment of U0126. These results strongly suggest that the ERK signaling cascade is involved in TGF-beta3 induced-chondrogenesis signaling pathways and a role of its pathway is necessary over a longer period to promote type II collagen expression. However, their end product properties in vivo have not been well known. In this study, an articular cartilage from chondrogenic MSCs with PLGA scaffolds (75:25 and 65:35) were made and analyzed its biochemical, histological and mechanical properties in vitro and in vivo. And also, we evaluated the cartilage formation in vivo through the injection of cell-thermosensitive gel complex, a newly developed injectable material. At 12 weeks after PLGA scaffolds containing chondrogenic MSCs transplantation, the separated rabbit distal femur showed a good gross articular cartilage appearance in the transplanted site. In indentation test, compare to the native articular cartilage, the engineered cartilage from two types of (75:25 and 65:35) achieved up to 30-60% in mechanical stiffness. And also, a new model for cartilage formation in bladder, at 14 weeks after injection, we could find out mass formation in the submucosal area grossly. H&E staining, alcian blue staining and other special staining confirmed the chondrogenic differentiation in the mass. These cell therapy technologies can provide the possibility of clinical applications for vesicoureteral reflux and reflux esophagitis, and urinary incontinence as well as articular cartilage regeneration.

Importance of integrin beta1-mediated cell adhesion on biodegradable polymers under serum depletion in mesenchymal stem cells and chondrocytes.

To evaluate the predominant mechanism of chondrogenic cell [mesenchymal stem cells (MSCs) and chondrocytes] adhesion under serum free conditions, we measured the surface roughness and wettability of poly(lactic acid:polyglycolic acid=75:25) (PLGA), poly(lactic acid) (PLA), and poly(-epsilon-caprolactone) (PCL)-coated glass plates. Also to evaluate the biological reactions involved in cell-polymer interactions, integrin beta1, one of the cell adhesion molecules, was blocked with monoclonal antibody. In cell attachment test, MSCs and chondrocytes adhesion to synthetic polymers in 1h were very low and ranged from 2.8% to 8.0%. In present study, the correlation between attachment rate and surface roughness, contact angle, or integrin beta1 blocking on PLGA, PLA and PCL-coated plates could not be proved. However, we found that L-arginine-coated PLA highly increased the attachment rates of MSCs (30.2%) and of chondrocytes (26%), whereas integrin beta1 blocking significantly decreased these attachment rates to 5.6% and 7.4%, respectively, suggesting that increased cell adhesion to L-arginine-coated plates is mediated by integrin beta1. In this study, we showed that polymer characteristics such as roughness and wettability did not play an important role in cell adhesion under serum free conditions, because there was no significant difference according to polymer characteristics, whereas biological interactions mediated by integrin beta1 were critical during the early period of cell adhesion. The results suggest that L-arginine could be useful for facilitating early cell adhesion to synthetic polymers in cartilage tissue engineering.

Bone morphogenetic protein-2 facilitates expression of chondrogenic, not osteogenic, phenotype of human intervertebral disc cells.

STUDY DESIGN: In vitro experiment using bone morphogenetic protein-2 (BMP-2) and human intervertebral disc (IVD) cells. OBJECTIVES: To demonstrate the effect of BMP-2 on mRNAs expression (collagen type I, collagen type II, aggrecan, and osteocalcin), proteoglycan synthesis, expression of alkaline phosphatase, bone nodule formation in human IVD cells. SUMMARY OF BACKGROUND DATA: BMP-2 was widely known as a powerful agent for osteoinduction and a crucial growth factor for early chondrogenesis and maintenance of cartilaginous phenotype. BMP-2 proved to be effective in stimulating proteoglycan synthesis in articular chondrocytes and IVD cells. Nevertheless, the effect of BMP-2 on IVD cells, whether chondrogenic or osteogenic, was not thoroughly elucidated in transcriptional level and histochemical stains. MATERIALS AND METHODS: Human IVDs were harvested and enzymatically digested. Then IVD cells were cultured three-dimensionally in alginate beads. Osteoblasts were cultured from cancellous bone of ilium for histochemical stains. Recombinant human BMP-2 (rhBMP-2) was produced by Chinese hamster ovary cells after transduction of BMP-2 cDNA, then concentrated and purified. Then IVD cell cultures were exposed to various concentrations of rhBMP-2. Reverse transcription-polymerase chain reaction for mRNA expression of aggrecan, collagen type I, collagen type II, and osteocalcin was performed. Newly synthesized proteoglycan was measured by 35S-sulfate incorporation on Sephadex G-25 M in PD 10 columns. As a histochemical examination, alkaline phosphatase and Alizarin red-S stains were used to detect osteogenic marker and bone nodule formation, respectively. RESULTS: In the rhBMP-2 treated cultures, there was increased newly synthesized proteoglycan (67% in 300 ng/mL and 200% in 1,500 ng/mL of rhBMP-2) and up-regulated expression of aggrecan, collagen type I, and collagen type II mRNA over untreated control. However, rhBMP-2 did not up-regulate expression of osteocalcin mRNA in the given dose and culture period. IVD cell cultures with rhBMP-2 showed no evidence of bone formation in histochemical stains, i.e., alkaline phosphatase and Alizarin red-S, while osteoblast culture exhibited strong positive stains. CONCLUSIONS: The rhBMP-2 clearly up-regulated mRNA expression of chondrogenic components and also stimulated proteoglycan synthesis without expression of osteogenic phenotype. Taken together, this study raise the possibility of rhBMP-2 can be anabolic agent for regenerating matrix of intervertebral disc.

Correction of lumbosacral hyperlordosis in achondroplasia.

Anterior bulging of the abdomen and posterior protrusion of the buttocks are externally visible deformities reflecting lumbosacral hyperlordosis. Imbalance in pelvic femoral muscles may account for this posture. Despite the clinical significance of hyperlordosis, its surgical treatment has not been well-described. In the current preliminary study, the authors compare two techniques used at the authors' institution for lower limb lengthening, one of which affects the correction of lumbosacral hyperlordosis. Ten patients had bilateral lower extremity lengthening procedures. Seven patients had bilateral tibial lengthening and three patients had combined femoral and tibial lengthening. Ring external fixators were used. Correction of hyperlordosis was assessed by comparing four radiographs with measurements in the sagittal plane obtained preoperatively with those at the latest followup. In the femoral lengthening group, the average preoperative lumbar lordosis angle was 18 degrees, the lumbosacral joint angle was 12 degrees, the sacral inclination angle was 58.3 degrees, and the sacrohorizontal angle was 31 degrees. The mean changes at the latest followup were: lumbar lordosis angle (+1 degree), lumbosacral joint angle (+0.3 degrees), sacral inclination angle (-19 degrees), and sacrohorizontal angle (-15 degrees). In the tibia lengthening group, all parameters were relatively unaltered at the last followup compared with their preoperative levels. Tibial lengthening had no effect on lumbosacral hyperlordosis. However, femoral lengthening resulted in an improved apparent lumbosacral hyperlordosis, although the lumbar lordosis angle was not changed significantly. The change in sacrum tilting provides a likely explanation for the improvement in cosmetic hyperlordosis observed in patients who have had femoral lengthening.

Surgical treatment of malignant and aggressive bone tumors around the knee by segmental resection and rotationplasty.

In patients having malignant or aggressive bone tumors around the knee joint and requiring amputation, segmental resection and rotationplasty was performed and the clinical results were analyzed. Twenty-six patients underwent segmental resection and rotationplasty between February 1988 and June 1994. The mean follow-up period was 57 (6 - 120) months and the average age of patients was 21.4 (5 - 37) years. Out of 26 patients, there were 18 osteosarcomas (>/= stage IIB), 2 synovial sarcomas, and 6 giant cell tumors. Clinical results were evaluated by the Shriner's rating system. Four patients were excluded due to death or amputation and the remaining twenty-two patients were included for assessment. Eighteen patients had excellent results, 3 good, and 1 fair. Range of motion of the ankle joint was -11 (dorsiflexion) - 80 (plantarflexion) degrees and daily walking activity was possible. Local recurrence developed in 2 patients and distant metastasis in 10. Early complications include 3 thromboses and 1 sepsis, and late complications were 6 nonunion, 2 malrotation and 1 stiffness of the ankle joint. Rotationplasty, which is functionally excellent, may serve as an effective partial limb salvage procedure, especially in patients younger than 10 years old who are expected to have leg length discrepancy or loosening of the tumor prosthesis due to the growth of the medullary cavity or when amputation is inevitable for a wide resection margin.