Patient trends in orthopedic traumas and related disorders after tsunami caused by the Great East Japan Earthquake: An experience in the primary referral medical center.

BACKGROUND: In the Great East Japan Earthquake, the Japanese Red Cross Ishinomaki Hospital played an important role as a principal referral center within the Ishinomaki region, one of the most severely affected areas in eastern Japan. The present study describes the patient population, clinical characteristics, and time courses of the medical problems observed at this hospital. METHODS: A retrospective survey of medical logs and records was conducted on the first 2 weeks after the earthquake to characterize orthopedic traumas and related disorders treated during this catastrophe. Patient number, severity of injuries, number of patients secondarily transported to the referral medical centers in the inland area, and the number of surgeries performed during the study period were investigated. RESULTS: Totally, 7686 patients visited the hospital. Of which, 1807 patients suffered from exogenous diseases, such as trauma, burns, crush syndrome, deep venous thrombosis, and infectious diseases. Patients who suffered from hypothermia were the most frequently seen within the first 2 weeks after the earthquake. Interestingly, most patients' conditions were not severe and required only simple treatments. Four patients (0.2% of patients with exogenous diseases) were secondarily transported to the referral medical centers in the inland area and only four patients were surgically treated because of a lack of available implants, surgical devices, and electric power supply. DISCUSSION AND CONCLUSIONS: The Great East Japan Earthquake and subsequent tsunami, which occurred during an early spring afternoon, resulted in a unique orthopedic patient population, which included few severely injured patients compared with numerous deaths. We believe that each coastal region hospital should develop its own emergency medical care system to address future tsunami events while considering their surrounding environment. The information described in the present study should be important for preparation toward future events involving massive earthquakes followed by tsunami disasters.

Passive mechanical properties and related proteins change with botulinum neurotoxin A injection of normal skeletal muscle.

The effects of botulinum neurotoxin A on the passive mechanical properties of skeletal muscle have not been investigated, but may have significant impact in the treatment of neuromuscular disorders including spasticity. Single fiber and fiber bundle passive mechanical testing was performed on rat muscles treated with botulinum neurotoxin A. Myosin heavy chain and titin composition of single fibers was determined by gel electrophoresis. Muscle collagen content was determined using a hydroxyproline assay. Neurotoxin-treated single fiber passive elastic modulus was reduced compared to control fibers (53.00 kPa vs. 63.43 kPa). Fiber stiffness and slack sarcomere length were also reduced compared to control fibers and myosin heavy chain composition shifted from faster to slower isoforms. Average titin molecular weight increased 1.77% after treatment. Fiber bundle passive elastic modulus increased following treatment (168.83 kPa vs. 75.14 kPa). Bundle stiffness also increased while collagen content per mass of muscle tissue increased 38%. Injection of botulinum neurotoxin A produces an effect on the passive mechanical properties of normal muscle that is opposite to the changes observed in spastic muscles.

Psoas muscle architectural design, in vivo sarcomere length range, and passive tensile properties support its role as a lumbar spine stabilizer.

STUDY DESIGN: Controlled laboratory and cross-sectional study designs. OBJECTIVE: To determine psoas major (PM) muscle architectural properties, in vivo sarcomere-length operating range, and passive mechanical properties. SUMMARY OF BACKGROUND DATA: PM is an important hip flexor but its role in lumbar spine function is not fully understood. Several investigators have detailed the gross anatomy of PM, but comprehensive architectural data and in vivo length-tension and passive mechanical behaviors have not been documented. METHODS: PM was isolated in 13 cadaver specimens, permitting architectural measurements of physiological cross-sectional area (PCSA), normalized fiber length (Lf), and Lf:muscle length (Lm) ratio. Sarcomere lengths were measured in vivo from intraoperative biopsies taken with the hip joint in flexed and extended positions. Single-fiber and fiber bundle tensile properties and titin molecular weight were then measured from separate biopsies. RESULTS: Architecturally, average PCSA was 18.45 ± 1.32 cm2, average Lf was 12.70 ± 2 cm, and average Lf: Lm was 0.48 ± 0.06. Intraoperative sarcomere length measurements revealed that the muscle operates from 3.18 ± 0.20 µm with hip flexed at 10.7° ± 13.9° to 3.03 ± 0.22 µm with hip flexed at 55.9° ± 21.4°. Passive mechanical data demonstrated that the elastic modulus of the PM muscle fibers was 37.44 ± 9.11 kPa and of fiber bundles was 55.3 ± 11.8 kPa. CONCLUSION: Analysis of PM architecture demonstrates that its average Lf and passive biomechanical properties resemble those of the lumbar erector spinae muscles. In addition, PM sarcomere lengths were confined to the descending portion of the length-tension curve allowing the muscle to become stronger as the hip is flexed and the spine assumes a forward leaning posture. These findings suggest that the human PM has architectural and physiologic features that support its role as both a flexor of the hip and a dynamic stabilizer of the lumbar spine.

Regional Myosin heavy chain distribution in selected paraspinal muscles.

STUDY DESIGN: Cross-sectional study with repeated measures design. OBJECTIVE: To compare the myosin heavy-chain isoform distribution within and between paraspinal muscles and to test the theory that fiber-type gradients exist as a function of paraspinal muscle depth. SUMMARY OF BACKGROUND DATA: There is still uncertainty regarding the fiber-type distributions within different paraspinal muscles. It has been previously proposed that deep fibers of the multifidus muscle may contain a higher ratio of type I to type II fibers, because, unlike superficial fibers, they primarily stabilize the spine, and may therefore have relatively higher endurance. Using a minimally invasive surgical approach, using tubular retractors that are placed within anatomic intermuscular planes, it was feasible to obtain biopsies from the multifidus, longissimus, iliocostalis, and psoas muscles at specific predefined depths. METHODS: Under an institutional review board-approved protocol, muscle biopsies were obtained from 15 patients who underwent minimally invasive spinal surgery, using the posterior paramedian (Wiltse) approach or the minimally invasive lateral approach. Myosin heavy chain (MyHC) isoform distribution was analyzed using SDS-PAGE (sodium dodecyl sulfate polyacrylamide gel electrophoresis) electrophoresis. Because multiple biopsies were obtained from each patient, MyHC distribution was compared using both within- and between-muscle repeated measures analyses. RESULTS: The fiber-type distribution was similar among the posterior paraspinal muscles and was composed of relatively high percentage of type I (63%), compared to type IIA (19%) and type IIX (18%) fibers. In contrast, the psoas muscle was found to contain a lower percentage of type I fibers (42%) and a higher percentage of type IIA (33%) and IIX fibers (26%; P<0.05). No significant difference was found for fiber-type distribution among 3 different depths of themultifidus and psoas muscles. CONCLUSION: Fiber-type distribution between the posterior paraspinal muscles is consistent and is composed of relatively high percentage of type I fibers, consistent with a postural function. The psoas muscle, on the other hand, is composed of a higher percentage of type II fibers such as in the appendicular muscles. Our data do not support the idea of a fiber-type gradient as a function of depth for any muscle studied.

Passive mechanical properties of the lumbar multifidus muscle support its role as a stabilizer.

The purpose of this study was to compare the passive mechanical properties and titin isoform sizes of the multifidus, longissimus, and iliocostalis muscles. Given our knowledge of each muscle's architecture and the multifidus' operating range, we hypothesized that multifidus would have higher elastic modulus with corresponding smaller titin isoforms compared to longissimus or iliocostalis muscles. Single-fiber and fiber-bundle material properties were derived from passive stress-strain tests of excised biopsies (n=47). Titin isoform sizes were quantified via sodium dodecyl sulfate-vertical agarose gel electrophoresis (SDS-VAGE) analysis. We found that, at the single-fiber level, all muscles had similar material properties and titin isoform sizes. At the fiber-bundle level, however, we observed significantly increased stiffness (approximately 45%) in multifidus compared to longissimus and iliocostalis muscles. These data demonstrate that each muscle may have a different scaling relationship between single-fiber and fiber-bundle levels, suggesting that the structures responsible for higher order passive mechanical properties may be muscle specific. Our results suggest that divergent passive material properties are observed at size scales larger than the single cell level, highlighting the importance of the extracellular matrix in these muscles. In addition to architectural data previously reported, these data further support the unique stabilizing function of the multifidus muscle. These data will provide key input variables for biomechanical modeling of normal and pathologic lumbar spine function and direct future work in biomechanical testing in these important muscles.

Architectural analysis and intraoperative measurements demonstrate the unique design of the multifidus muscle for lumbar spine stability.

BACKGROUND: Muscular instability is an important risk factor for lumbar spine injury and chronic low-back pain. Although the lumbar multifidus muscle is considered an important paraspinal muscle, its design features are not completely understood. The purpose of the present study was to determine the architectural properties, in vivo sarcomere length operating range, and passive mechanical properties of the human multifidus muscle. We hypothesized that its architecture would be characterized by short fibers and a large physiological cross-sectional area and that it would operate over a relatively wide range of sarcomere lengths but would have very stiff passive material properties. METHODS: The lumbar spines of eight cadaver specimens were excised en bloc from T12 to the sacrum. Multifidus muscles were isolated from each vertebral level, permitting the architectural measurements of mass, sarcomere length, normalized fiber length, physiological cross-sectional area, and fiber length-to-muscle length ratio. To determine the sarcomere length operating range of the muscle, sarcomere lengths were measured from intraoperative biopsy specimens that were obtained with the spine in the flexed and extended positions. The material properties of single muscle fibers were obtained from passive stress-strain tests of excised biopsy specimens. RESULTS: The average muscle mass (and standard error) was 146 +/- 8.7 g, and the average sarcomere length was 2.27 +/- 0.06 microm, yielding an average normalized fiber length of 5.66 +/- 0.65 cm, an average physiological cross-sectional area of 23.9 +/- 3.0 cm(2), and an average fiber length-to-muscle length ratio of 0.21 +/- 0.03. Intraoperative sarcomere length measurements revealed that the muscle operates from 1.98 +/- 0.15 microm in extension to 2.70 +/- 0.11 microm in flexion. Passive mechanical data suggested that the material properties of the muscle are comparable with those of muscles of the arm or leg. CONCLUSIONS: The architectural design (a high cross-sectional area and a low fiber length-to-muscle length ratio) demonstrates that the multifidus muscle is uniquely designed as a stabilizer to produce large forces. Furthermore, multifidus sarcomeres are positioned on the ascending portion of the length-tension curve, allowing the muscle to become stronger as the spine assumes a forward-leaning posture.

Effect of resting interval for muscle regeneration in mice.

BACKGROUND: Muscle tissue has an exceptional ability to regenerate, however, unresting damage to the muscles by intense and frequent exercises occasionally causes prolonged muscle fatigue, soreness, and underperformance in sports. Taking rest is generally considered to be crucial for regular training to avoid the accumulation of muscle damage. We hypothesized that differences in the resting intervals between two periods of exercise may result in histological differences in muscle regeneration. METHOD: An eccentric contraction model of mouse gastrocnemius muscle was made using percutaneus electrical stimulation. The mice received eccentric exercises twice with resting intervals of 0, 12, 24 hours, 2, and 3 days. The authors investigated the ratio of myofibers with central nuclei to whole myofibers histologically (the centronuclear cell ratio; CNCR) at 14 days after the second exercise as an index of the muscle regeneration. RESULTS: The CNCR of the group that exercised one-time was 29.5%. In the groups exercised twice, it increased from 31.8% with an interval of 0 hours to a peak of 43.9% with 24 hours, then decreased to 32.8% with an interval of 3 days. The ratios of the groups with intervals of 12 and 24 hours were higher than those with one-time exercise and those with the intervals of 0 hours, 2 days, and 3 days. CONCLUSIONS: The resting interval between two periods of eccentric exercises affected the histology of muscle regeneration. The amount of muscle damage and/or the recovery process of damaged muscles should vary depending on the length of resting interval between strenuous exercises. An appropriate interval for rest must be necessary in order to avoid further muscle damage.

Myofibers express IL-6 after eccentric exercise.

BACKGROUND: Interleukin (IL)-6 is locally produced in skeletal muscles and shows a remarkable increase in plasma after eccentric exercises. OBJECTIVE: To elucidate the cell types in the muscles responsible for IL-6 production after eccentric exercises. STUDY DESIGN: Controlled laboratory study. METHODS: An eccentric contraction model was made using electrical stimulation. The authors investigated the muscle damage and regeneration processes after eccentric exercises histologically, and the cell types expressing IL-6 and its subcellular compartimentalization with time immunohistochemically after eccentric exercises. RESULTS: Swollen myofibers were detected from 8 hours to 3 days after exercises. Disrupted myofibers were detected from 24 hours to 7 days, with a peak of 3 days. IL-6 was detected only in the cytoplasm of myofibers until 12 hours; thereafter, it was found in the inflammatory cells and proliferating satellite cells as well. The swollen myofibers were negatively stained for IL-6. The positive ratios of IL-6 in myofibers immediately increased after exercises, peaked in 12 hours, and then decreased. CONCLUSIONS: After eccentric exercises, IL-6 expression increased in myofibers preceding the disruption of myofibers. IL-6 might be closely related to muscle damage caused by strenuous exercises.