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Background Deep surgical site infection (DSSI) is one of the most challenging complications in lumbar fusion surgery. Few investigations examined the effect of vancomycin powder mixed with autogenic bone graft (ABG) and bone substitutes on preventing DSSI in degenerative lumbar fusion surgeries as well as any interference with bony fusion. The aim of the study was to investigate the effects of ABG along with bone substitutes as a local vancomycin delivery system on preventing DSSI in lumbar instrumented fusion and compared with those who did not use vancomycin powder. Methods From January, 2015 through December, 2015, a one-year prospective study using vancomycin powder mixed with ABG and bone substitute for degenerative lumbar fusion surgeries as vancomycin (V) group, 1 gm vancomycin for 2 and 3-level, and 2 gm for more than 3-level instrumentation. From December, 2013 through December 2014, patients received degenerative lumbar fusion surgeries without using vancomycin before the vancomycin protocol were retrospectively enrolled as non-vancomycin (NV) group. Vancomycin concentration was checked at post-operative days 1 and 3 for both the serum and drainage. Patients’ demographic data, microbiology reports, fusion status and functional outcomes were evaluated. Results One hundred and ten patients were enrolled prospectively in the V group, and 86 for the NV group. After an average 41 months follow-up (range, 36–54), 3 patients (3.48%) developed postoperative DSSIs in the NV group, thereby requiring revision surgeries and parenteral antibiotics treatment versus no DSSIs (0%, 0/100) in the V group. (p = 0.048). The postoperative serum vancomycin levels were undetectable and no vancomycin related side effects was encountered. The mean vancomycin concentration of drainage at postoperative days 1 and 3 were 517.96 ± 174.4 and 220.14 ± 102.3 μg/mL, respectively. At final follow-up, there was no statistical difference observed in terms of clinical and radiologic outcomes. Conclusions Our vancomycin protocol may reduce the incidence of DSSI in degenerative lumbar fusion surgery without affecting bony fusion. Level of Evidence Level III ambispective comparative study.

Background Involvement in cervical ligamentum flavum is a rare manifestation of the calcium pyrophosphate dihydrate deposition disease. Only few cases of this condition have been reported. We revealed eighteen cases of CPPD in cervical ligamentum flavum that diagnosed at a single medical center. In our case series, clinical characteristics and magnetic resonance imaging findings of patients are described. Methods We retrospectively reviewed the medical charts and imaging studies of the eighteen patients with pseudogout attack of the cervical ligamentum flavum. In addition, we discussed the differences between this disease and ossification of ligamentum flavum in image manifestations. Results There were fourteen men and four women aged between 59 and 87 years. Diabetes mellitus and hypertension were the most common comorbidities. Myelopathy and neck pain were presented in most patients. C4–5 and C5–6 were attacked most frequently, and multiple- rather than single-level involvement could be observed in our series. “Acute on chronic phenomenon” was a specific magnetic resonance image finding in patients whose symptom durations were between 2 to 5 months. Compared to ossification of ligamentum flavum, calcium pyrophosphate dihydrate crystal deposition had different image signs, including morphology, side of the involved ligament, no continuity with the lamina, acute on chronic phenomenon, and presence of retro-odontoid mass. Conclusions Nodular calcifications in cervical ligamentum flavum raise highly suspicion for calcium pyrophosphate dihydrate deposition and must be diagnosed by histological examination and polarized light microscopy. This disease is different from ossification of ligamentum flavum, and it could be recognized by specific image features.

Study design Retrospective cohort study. Objectives To compare the surgical results between targeted therapy and post-operative chemotherapy for patients with spinal metastasis of inoperable non-small-cell lung cancer (NSCLC). Setting Single-center study at an academic orthopedic department in Taiwan. Methods Sixty-five patients were treated surgically for spinal metastasis of inoperable NSCLC with long posterior instrumentation with or without posterior decompression according to the patient's neurologic status. Post-operative radiotherapy of the spinal lesion and targeted therapy or chemotherapy were done following surgery after the surgical wound healed. Post-operative clinical outcomes and survival were evaluated and compared between these two groups. The overall survival represented survival from the date of diagnosis to death. Results Thirty-five patients were grouped as the targeted therapy group and 30 patients as the chemotherapy group. The overall median survival times were 12.0 and 10.0 months in the targeted therapy and chemotherapy groups, respectively. Sixty-two patients were able to walk with or without an aid postoperatively. There was no significant difference observed between these two groups in terms of pain relief, neurologic improvement, ambulatory improvement, and survival. Conclusions Surgical stabilization with or without laminectomy improved functional outcomes in patients with inoperable non-small-cell lung cancer, and post-operative functional outcomes were similar between chemotherapy and targeted therapy groups. A longer survival was observed with targeted therapy for the patients whose NSCLC was diagnosed before spinal metastasis, however, the longer survival was not statistically significant.

To evaluate the impact of the preoperative severity of facet joint arthropathy on long-term functional outcomes and spinopelvic parameters in patients undergoing lumbar-stability-preserving decompression and Dynesys fixation. In this retrospective study, 88 patients undergoing combined surgery at our hospital from 2008 to 2015 were included. The patients were divided into two groups, the less and more than mean degeneration groups, based on preoperative facet joint arthropathy of the index level(s). The clinical outcomes were the Visual Analogue Scale (VAS) score, the Oswestry Disability Index (ODI) score and spinopelvic parameters. The mean follow-up durations for the less and more than mean degeneration groups were 84.83 ± 27.58 and 92.83 ± 20.45 months, respectively. The combined surgery significantly improved VAS and ODI scores, and increased sacral slope (SS) regardless of preoperative arthropathy severity. In addition, facet joint arthropathy at adjacent levels continued to worsen after surgery in both arthropathy severity groups. Preoperative facet joint arthropathy did not influence most long-term clinical outcomes in patients undergoing lumbar-stability-preserving decompression and Dynesys fixation. This combined surgery may be suitable for patients with facet joint arthropathy regardless of disease severity.

This study aimed to compare the accuracy of navigation-assisted percutaneous pedicle screw insertions between traditional posterior superior iliac spine (PSIS) fixed and cutaneously fixed dynamic reference frame (DRF) in minimally invasive surgery of transforaminal lumbar interbody fusion (MIS TLIF). This is a prospective randomized clinical study. Between May 2016 and Nov 2017, 100 patients who underwent MIS TLIF were randomly divided into bone fixed group (with PSIS fixed DRF) and skin fixed group (with cutaneously fixed DRF). The pedicel screws were inserted under navigational guidance using computed tomography (CT) data acquired intraoperatively with a Ziehm 3-dimensional fluoroscopy-based navigation system. Screw positions were immediately checked by a final intraoperative scan. The accuracy of screw placement was evaluated by a sophisticated computed tomography protocol. Both groups had similar patient demographics. Totally Five-hundred Twelve pedicle screws were placed in the lumbar spine. There were 2 moderate (2-4 mm) pedicle perforations in each group. The accuracy showed no significant difference between bone fixed and skin fixed DRF. There were no significant procedure-related complications. The skin fixed DRF provides similar accuracy in pedicle screw insertions with bone fixed DRF using intraoperative 3D image guided navigation in MIS TLIF. Skin fixed DRF not only serves as an alternative method but also saves a separate incision wound for bony attachment.

Retrospective cohort study.To compare the surgical results between targeted therapy and post-operative chemotherapy for patients with spinal metastasis of inoperable non-small-cell lung cancer (NSCLC).Single-center study at an academic orthopedic department in Taiwan.Sixty-five patients were treated surgically for spinal metastasis of inoperable NSCLC with long posterior instrumentation with or without posterior decompression according to the patient's neurologic status. Post-operative radiotherapy of the spinal lesion and targeted therapy or chemotherapy were done following surgery after the surgical wound healed. Post-operative clinical outcomes and survival were evaluated and compared between these two groups. The overall survival represented survival from the date of diagnosis to death.Thirty-five patients were grouped as the targeted therapy group and 30 patients as the chemotherapy group. The overall median survival times were 12.0 and 10.0 months in the targeted therapy and chemotherapy groups, respectively. Sixty-two patients were able to walk with or without an aid postoperatively. There was no significant difference observed between these two groups in terms of pain relief, neurologic improvement, ambulatory improvement, and survival.Surgical stabilization with or without laminectomy improved functional outcomes in patients with inoperable non-small-cell lung cancer, and post-operative functional outcomes were similar between chemotherapy and targeted therapy groups. A longer survival was observed with targeted therapy for the patients whose NSCLC was diagnosed before spinal metastasis, however, the longer survival was not statistically significant.

Background Ulnar shortening is a common and useful method for treating ulnar wrist pain from many causes. Many devices used to perform osteotomy have been introduced in the literature; however, the devices are not universally available. The standard freehand technique is still commonly used in clinical practice; however, it is associated with several complications and is time-consuming. We present a freehand technique for ulnar-shortening osteotomy using a predrilled hole method. Methods From 2011 to 2013, we performed the predrilled hole method for ulnar shortening in 18 cases using the six-hole limited-contact dynamic compression plate (LC-DCP) and in two cases using the Acumed six-hole Locking Midshaft Ulna Plate. Results All patients had uneventful union, and the average operative time was 39.7 minutes (range, 32–50 minutes). The average follow-up period was 21 months (range, 12–30 months). There were no complications except in three patients in the LC-DCP group who complained of implant irritation. Good functional outcomes were achieved with this method. Conclusion Our technique is easy and quick to use and can minimize soft-tissue manipulation. The union rate is high and complications are few.

Intervertebral discs (IVDs) are important biomechanical components of the spine. Once degenerated, mesenchymal stem cell (MSC)-based therapies may aid in the repair of these discs. Although hypoxic preconditioning enhances the chondrogenic potential of MSCs, it is unknown whether bone marrow MSCs expanded under hypoxic conditions (1% O2 , here referred to as hypoxic MSCs) are better than bone marrow MSCs expanded under normoxic conditions (air, here referred to as normoxic MSCs) with regards to disc regeneration capacity. The purpose of this study was to compare the therapeutic effects of hypoxic and normoxic MSCs in a rabbit needle puncture degenerated disc model after intra-disc injection. Six weeks after needle puncture, MSCs were injected into the IVD. A vehicle-treated group and an un-punctured sham-control group were included as controls. The tissues were analyzed by histological and immunohistochemical methods 6 and 12 weeks post-injection. At 6 and 12 weeks, less disc space narrowing was evident in the hypoxic MSC-treated group compared to the normoxic MSC-treated group. Significantly better histological scores were observed in the hypoxic MSC group. Discs treated with hypoxic MSCs also demonstrated significantly better extracellular matrix deposition in type II and XI collagen. Increased CD105 and BMP-7 expression were also observed upon injection of hypoxic MSCs. In conclusion, hypoxic MSC injection was more effective than normoxic MSC injection for reducing IVD degeneration progression in vivo. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1440-1450, 2019.

Background Osteonecrosis of the femoral head (ONFH) is an important indication for total hip arthroplasty in Taiwan. We demonstrated the etiologies of ONFH and outcomes based on stratification of patients according to different etiologies. Methods We reviewed medical records and images from January 2000 to May 2010 in our database with the diagnosis of “osteonecrosis of the femoral head.” We categorized all patients into different etiologies, including corticosteroid, alcohol, and idiopathic. All patients received subsequent follow up for ipsilateral precollapse ONFH and contralateral disease-free femoral head status after initial diagnosis. Results Of the 1153 patients who had undergone 1674 hip surgeries including core decompression and total hip replacement, alcohol use was the most prevalent etiology in our population (45.2%). Patients with corticosteroid- and alcohol-associated ONFH were younger and more likely to have bilateral disease. Patients with alcohol- or steroid-associated ONFH were found to have a higher rate of contralateral disease and faster progression of precollapse ONFH than patients who had or had not undergone core decompression. Conclusion Alcohol use had the greatest impact on ONFH in our population. Nonidiopathic ONFH patients had the worst outcome. Understanding the nature of progression of ONFH and incidence of contralateral disease may provide great prognostic value to detect and perform early intervention.

Pigmented villonodular synovitis (PVNS) is a benign tissue proliferation characterized by its hyper-vascularity within the lesion. The true etiology and cell source of this disease entity still remain unclear. Mesenchymal stem cells (MSCs) exist in various tissues of human body. However, it has not been clarified whether MSCs could be isolated from tissue of PVNS. Here, we isolated MSCs from PVNS (PVNS-SCs), and by comparing to the MSCs from normal synovium (Syn-SCs) of the same individual, we investigated whether PVNS-SCs differed in the capacity for multi-differentiation and inducing angiogenesis. We first demonstrated that PVNS-SCs existed in the lesion of PVNS of three individuals. Moreover, we showed PVNS-SCs had better osteogenic differentiation potential than Syn-SCs, whereas Syn-SCs had better capacity for adipogenic and chondrogenic differentiation. By genome-wide analysis of gene expression profile using a complementary DNA microarray and comparing to Syn-SCs, we identified in PVNS-SCs a distinct gene expression profile characterized by up-regulation of genes involved in angiogenesis. In vitro and in vivo studies further confirmed that PVNS-SCs had better capacities for promoting angiogenesis. In summary, the identification of PVNS-SCs in PVNS tissue and their distinct angiogenic potential may help elucidate the underlying etiology of this disease.

Background The local recurrence rate after surgical excision of intramuscular hemangioma reported is between 18% and 61%. The aim of this study was to review the clinical outcome and local recurrence rate after surgical excision of nonpalpable intramuscular hemangioma using preoperative ultrasound-guided hookwire localization. Methods We performed ultrasound-guided hookwire localization before excision surgery for nonpalpable intramuscular hemangioma in 37 cases between January 1997 and 2011. There were 20 females and 17 males, with a mean age of 30.2 years (range, 17–49 years). The mean localization procedure time was 10.6 minutes (range, 3–20 minutes). Results The average operation time was 48.6 minutes (range, 30–80 minutes). The average length of the excision wound was 5 cm (range, 4–11 cm), and the average hospital stay was 2.5 days (range, 2–4 days). The postoperative therapeutic report confirmed the diagnosis of intramuscular hemangioma. The average tumor size was 2.11 cm and all excision margins were free in all specimens. After the mean follow-up of 92.9 months (range, 14–179 months), one of the 37 patients had local recurrence (recurrence rate 2.7%). Conclusion The use of ultrasound-guided hookwire localization before excision surgery is safe and effective in treating nonpalpable intramuscular hemangioma and could provide a better cosmetic result and functional recovery.

Cu-poor electrodeposited CuIn1−xAlxSe2 (CIAS) precursor films were prepared to investigate the alteration in surface morphology of post-annealed CIAS films through post-annealing temperature adjustment. Scanning electron microscopy (SEM) and atomic force microscope (AFM) analyses demonstrated that surface morphology and root–mean–square (RMS) roughness of post-annealed CIAS films exhibited uneven and rough triangular structures. The crystal size of post-annealed CIAS films can be increased by increasing post-annealing temperature. The precursor film structure was modified by substituting Cu–Se/CIAS binary structure with CIAS single structure to proceed with the investigation. The apparent variation in surface morphology of post-annealed CIAS films changed from rough triangular structures to smooth round structures, and the RMS roughness of post-annealed CIAS films was reduced to

Background Pulmonary embolism is a relatively uncommon, but serious, postoperative complication of hip and knee arthroplasty; however, little information is available about the prevalence of pulmonary embolism in Taiwan. Methods We report here a series of five patients who sustained a symptomatic pulmonary embolism after undergoing total knee arthroplasty (TKA). These patients were identified during a retrospective study of 1768 patients carried out between January 2007 and January 2010. Results Five (0.28%) patients who sustained a symptomatic pulmonary embolism after TKA were identified in a series of 1768 patients. The diagnosis was confirmed by computed tomography angiography findings in four patients and an increased d-dimer level in one patient. All the patients were women, with a mean age of 68.0 years (range 64–76 years). The average body mass index of these patients was 32.6 kg/m 2 (24–38 kg/m 2 ). Four patients underwent simultaneous bilateral TKA, and one patient who was undergoing unilateral TKA also underwent revision TKA for a previously treated contralateral knee. None of the patients had a history of pulmonary embolism, and none was given prophylaxis for venous thromboembolism. The time at which pulmonary embolism occurred ranged from 2 to 8 days in five patients. After treatment, no patient had died by the end of the follow-up period. These case reports highlight the equal incidence of pulmonary embolism after TKA in Taiwanese and Western populations. Conclusion Steps to prevent pulmonary embolism should be undertaken in selected patients, such as these patients with a high body mass index and simultaneous bilateral TKA.

Background Concomitant tibial shaft and posterior malleolar fractures (PMFs) are often encountered in clinical settings. Plain films were reviewed for concomitant PMF, and fracture patterns were analyzed by focusing on the integrity of the fibula and the location of the fibular fracture. Methods A retrospective review of patients who presented with tibial shaft fractures between January 2005 and January 2010 was performed. Patients were included if they were at least 18 years of age and had a tibial diaphyseal fracture. Exclusion criteria were age less than 18 years, previous surgery on the same leg, and pathological fractures. Medical records were reviewed for information on injury mechanisms. Pre- and post-operative radiographs were analyzed for PMFs, tibial fracture pattern, fibular integrity, fibular fracture pattern, treatment type, and time to fracture union. Descriptive statistical tests were used. Results Among 240 patients, there were 20 cases (15 male and 5 female) of concomitant PMF, all detected in lateral radiograph views. The incidence of PMF was 8.3%. Most patients had a motorcycle injury ( n = 15, 75%). Distal tibia spiral fracture was the most common fracture pattern (85%) and there was no proximal tibia fracture (0%). Combined fibular fractures were found in 17 patients (85%). There were nine proximal fibular fractures (45%). Intact fibulas were found in three patients (15%). Only one PMF was treated with screw fixation. All PMFs showed radiographic evidence of healing within 5 months post-operatively. Conclusion We recommend careful radiographic examination to evaluate PMF, especially in patients with distal tibial spiral fractures combined with proximal fibular fractures or intact fibulas.

Background Adhesive capsulitis is commonly associated with medical diseases such as diabetes mellitus, hyperthyroidism, and obesity. Intra-articular injection has been used to speed recovery and relieve pain associated with frozen shoulder. In this study, we evaluated and compared the effects of an intra-articular injection of corticosteroid and lidocaine in the treatment of primary adhesive capsulitis in overweight and normal-weight patients. Methods This is a prospective clinical study of patients with adhesive capsulitis, in which the main treatment strategy was an intra-articular injection of corticosteroid (3 mL) and lidocaine (3 mL). Active range of motion exercise was initiated immediately after the injection and performed four times daily. The evaluation included the recording of a detailed medical and orthopedic history, and the assessment of pain and function by determining the Constant score at baseline (before injection) and every 2 weeks thereafter. Patients were classified as normal weight (body mass index [BMI] 2 ) or overweight (BMI ≥ 25 kg/m 2 ). The Constant scores of all patients were compared at 8 weeks after injection. Results After clinical examinations and radiographic and ultrasonographic studies, 79 patients were treated for adhesive capsulitis between 2010 and 2012. In the normal-weight group, the mean Constant score increased from 35.4 to 74.6 after 8 weeks, whereas in the overweight group, the mean Constant score increased from 32.0 to 47.2. There was a significant difference in the mean Constant score between the normal-weight and overweight groups at 8 weeks. Conclusion Active range of motion exercise after an intra-articular injection of corticosteroid and lidocaine improved pain and functional outcome at 8 weeks in normal-weight (BMI 2 ) patients with primary adhesive capsulitis. Manipulation under anesthesia may be considered a priority in overweight patients.

Osteoblastoma occurring in the region of the hip is very rare, and vague symptoms with uncharacteristic radiographic features often lead to misdiagnosis. Because of radiographic and histological similarities, it must be carefully distinguished from osteoid osteoma, aneurysmal bone cyst, giant cell tumor, and osteosarcoma. Computed tomography is the preferred imaging modality as it is able to detect the nidus and images will not exhibit the flare phenomenon caused by surrounding inflammation seen with magnetic resonance imaging. For hip joint lesions in weight-bearing areas, intralesional curettage may achieve satisfactory outcomes as compared with wide resection. We herein report two cases of osteoblastoma in the hip region in which diagnosis was delayed that were successfully treated with curettage and followed by high-speed burring.

Background Different biologic approaches to treat disc regeneration, including growth factors (GFs) application, are currently under investigation. Human annulus fibrosus (hAF) repair or regeneration is one of the key elements for maintenance and restoration of nucleus pulposus function. However, so far there is no effective treatment for this purpose. The aim of the present study was to investigate the response of hAF cells to different combinations of GFs, and develop a protocol for efficient culture expansion. Methods hAF cells were harvested from degenerated disc tissues during surgical intervertebral disc removal, and hAF cells were expanded in a monolayer. The experiments were categorized based on different protocols with transforming growth factor (TGF-β1) and fibroblast growth factor (FGF-2) culture for 14 days: group 1 had no GFs (control group); group 2 received TGF-β1; group 3 received FGF-2; group 4 received both GFs; and group 5 (two-step) received both GFs for the first 10 days and TGF-β1 only for the next 4 days. Cell proliferation, collagen, and noncollagen extracellular matrix (ECM) production and genes expression were compared among these groups. Results At days 3, 7 and 10 of cultivation, groups 4 and 5 had significantly more cell numbers and faster cell proliferation rates than groups 1, 2, and 3. At 14 days of cultivation, significantly more cell numbers were observed in groups 3 and 4 than in group 5. The group 4 had the most cell numbers and the fastest proliferation rate at 14 days of cultivation. After normalization for cell numbers, group 5 (two-step) produced the most collagen and noncollagen ECM at 10 and 14 days of cultivation among the five groups. In group 5, ECM gene expression was significantly upregulated. High expression of matrix metalloproteinase-1 was upregulated with FGF-2 on the different days as compared to the other groups. Annulus fibrosus cell phenotypes were only marginally retained under the different protocols based on quantitative polymerase chain reaction results. Conclusion Taken together, the two-step protocol was the most efficient among these different protocols with the most abundant ECM production after normalization for cell numbers for culture expansion of hAF cells. The protocol may be useful in further cell therapy and tissue engineering approaches for disc regeneration.

Mesenchymal stem cell (MSC)-based therapies may aid in the repair of articular cartilage defects. The purpose of this study was to investigate the effects of intraarticular injection of allogeneic MSCs in an in vivo anterior cruciate ligament transection (ACLT) model of osteoarthritis in rabbits. Allogeneic bone marrow-derived MSCs were isolated and cultured under hypoxia (1% O2). After 8 weeks following ACLT, MSCs suspended in hyaluronic acid (HA) were injected into the knees, and the contralateral knees were injected with HA alone. Additional controls consisted of a sham operation group as well as an untreated osteoarthritis group. The tissues were analyzed by macroscopic examination as well as histologic and immunohistochemical methods at 6 and 12 weeks post-transplantation. At 6 and 12 weeks, the joint surface showed less cartilage loss and surface abrasion after MSC injection as compared to the tissues receiving HA injection alone. Significantly better histological scores and cartilage content were observed with the MSC transplantation. Furthermore, engraftment of allogenic MSCs were evident in surface cartilage. Thus, injection of the allogeneic MSCs reduced the progression of osteoarthritis in vivo.

Summary Tumor with bone metastases to the periacetabulum is rare, and its surgical management is challenging. Instead of wide excision with reconstruction of the hip joint, we used a relatively noninvasive method to manage periacetabular metastasis. Such a procedure for this condition has the benefits of short surgical time, less bleeding, and fewer complications during surgery. Our surgical management of the case reported here included curettage, phenol cauterization and filling of cisplatin-loaded cement in order to reduce local recurrence. After following-up for 2 years, there was no local recurrence and disease progression.

Background Treatment options for nonunion of the femoral shaft fracture after intramedullary nail fixation are controversial. The methods of exchanging an existing nail with a larger-sized nail, dynamization, removal of the nail followed by plating, and bone grafting have all been reported. From those options, exchange nailing seems to be the most popular choice. In our study, we used plate augmentation and bone grafting with retention of the nail. The purpose of our study was to evaluate the effectiveness of this method in treating femoral shaft nonunion after open reduction and internal fixation with intramedullary nail fixation. Methods Between January 2003 and December 2009, 22 patients who had nonunion after open reduction and internal fixation with intramedullary nail for femoral shaft fracture were included in our study. There were 13 men and nine women participants, with a mean age of 34.3 years (range, 17–77 years). The mean period of nonunion after surgery was 20.0 months (range, 7–63 months). The patients were classified into three groups, atrophic, oligotrophic, and hypertrophic. We retained the nail and performed plate augmentation for all patients, with simultaneous autologous bone grafting as indicated. We followed up on all patients with plain film examination, and to assess functional recovery status to determine osseous union condition. Results All 22 of the patients achieved postoperative bony union uneventfully at a mean time of 22.1 weeks (range, 12–40 weeks). The mean operative time was 105 minutes (range, 60–150 minutes), and the mean blood loss was 340 ml (range, 150–700 ml). All of the patients could walk bearing full weight without pain within 3 months. There were no significant complications such as broken hardware, implant back-out, axial or rotational malalignment, or deep infections. Conclusion Plate augmentation with retention of the nail with autologous bone grafting may be an effective and reliable alternative in treating nonunion of the femoral shaft fracture after open reduction and internal fixation with intramedullary nail.

Study design A finite element analysis to simulate the behavior of lumbar spines implanted with a posterior dynamic neutralization system, Dynesys, under displacement-controlled loading. Objective To investigate whether Dynesys spacers with different diameters would alter the distribution of range of motion, disk stress, and facet contact force at the Dynesys bridging level and the cranial adjacent level. Summary of background data The Dynesys system is designed to preserve intersegmental motion and reduce loading at adjacent levels, but clinical reports do not support these claims. This system has been shown to be almost as stiff as rigid fixation, which acts to hinder intersegmental motion. Few studies have investigated methods of reducing this stiffness. Methods In the finite element study, a previously validated lumbar spine model was used. Five Dynesys constructs with different spacer diameters (0.8, 0.9, 1.0, 1.1, and 1.2 times the original standard size) were implanted into the spine model and bore 4 displacement-controlled loading cases: flexion, extension, torsion, and lateral bending. Resultant range of motions (ROMs), disk stress, and facet contact forces at the bridged level and the cranial adjacent level were compared with the results of a spine model without Dynesys implantation. Results The results of ROMs, disk stress, and facet contact forces at the bridged levels were all less than those in the intact spine, except for contact forces at the left facet under lateral bending, facet contact forces at the right facet under torsion, and disk stress under torsion. The results of ROMs, disk stress, and facet contact forces at the cranial adjacent levels were all higher than those in the intact spine. Conclusions The results of the present study show that changing the diameter of the spacers will alter the stiffness of the Dynesys construct. Dynesys constructs with larger diameters behave stiffer under flexion but behave softer under extension, torsion, and lateral bending. Changing the diameter of the Dynesys spacers does not significantly influence the load distribution at adjacent levels.

The current treatment methods for diffuse intraarticular or extraarticular type pigmented villonodular synovitis (PVNS) include arthroscopic synovectomy or staged anterior and posterior open synovectomies. However, it is unclear whether simultaneous anterior and posterior synovectomies achieve local control and recovery of function.We therefore determined the recurrence rate and function in patients with diffuse PVNS treated with anterior and posterior synovectomies and adjuvant radiotherapy.We retrospectively reviewed all 19 patients with diffuse PVNS involving the knee treated with anterior and posterior synovectomies and adjuvant radiotherapy between January 2001 and November 2007. From the records, we determined local recurrence and Tegner-Lysholm scores. The minimum followup was 42 months (median, 98 months; range, 42-143 months).Postoperative MRI revealed residual tumor in five of the 19 patients, although three had no disease progression during followup and had knee scores of 86 to 90. Two patients had recurrences at 6 and 9 months with knee scores of 88 at 42 months and 90 at 68 months. The mean Tegner-Lysholm knee score improved from 59 to 93 points. Mean maximum extension and flexion angles improved from 11° to 2° and from 76° to 127°, respectively.Compared with the literature, simultaneous anterior and posterior synovectomies associated with postoperative radiotherapy provided rates of residual or recurrent tumor and knee function recovery comparable to that with staged synovectomies reported in the literature.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background Ewing sarcoma is extremely rare in people from East and Southeast Asia. Methods The records of 12 patients diagnosed with primary Ewing sarcoma and treated at our institution from 1997 to 2009 were retrospectively reviewed. Results There were seven male and five female patients and their mean age at diagnosis was 22 years (range, 12–48 years). Two patients (16.7%) had distant metastasis at diagnosis. The primary tumor sites were the trunk in seven patients (58.3%) and the extremities in five patients (41.7%). Eleven patients received neoadjuvant chemotherapy followed by wide excision surgery, and then adjuvant chemotherapy. One patient received only chemotherapy without surgical intervention due to poor cardiac and pulmonary function. At a mean follow-up of 33 months, the 2-year overall survival rate (OS) was 45.5%. Distant metastasis was the only statistically significant prognostic factor of OS in our study. The 2-year OS rates of patients with lung metastasis and without lung metastasis were 0% and 42.9%, respectively ( p = 0.021). The t(11;22)(q24:q12) translocation was present in all patients in our series. Conclusion We confirmed that distant metastases is highly predictive of a poor outcome, and that the t(11;22)(q24:q12) translocation was present in all patients in our series.

Background: Open reduction and internal fixation with tension band wire is the standard treatment for displaced transverse patellar fractures. Recently, some minimally invasive techniques have been proposed as possible alternative methods. This retrospective study compared a newly reported percutaneous osteosynthesis with conventional open method for the treatment of displaced transverse patellar fractures. Methods: The minimally invasive technique was performed by percutaneous osteosynthesis with modified Carpenter’s (POMC) technique, using figure-eight wiring through two-paired cannulated screws under the control of arthroscopy and fluoroscopy. The conventional open surgery was performed with open modified anterior tension band (OMATB) technique. Totally 60 displaced transverse fractures were included in our study. Twenty were treated with percutaneous technique and 40 with open method. Outcome assessment included analysis of radiographic images, range of motion, Lysholm scores, complications, and reoperations. Results: Mean follow-up was 37.3 months. Comparison of POMC and OMATB groups showed statistically significant results as follows: shorter surgical time, 70.4 � 12.5 minutes for POMC group; greater degrees of flexion, 140.4 � 6.1 for POMC group; better total range of motion, 139.6 � 8.2 for POMC group; higher Lysholm scores, 93.6 � 3.1 for POMC group. Frequencies of total complications and reoperations were significantly lower in POMC group. Conclusion: POMC method was a reproducibly reliable method, offering better functional outcome, lower incidence of complications, and reoperations, as compared with standard OMATB group for transverse patellar fractures. Nevertheless, it is not recommended for severely comminuted fractures. Copyright 2011 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.

Manipulation under anaesthesia (MUA) has been used to speed up recovery. However, the outcome of frozen shoulder after MUA in patients with diabetes has not been well documented in the past. A higher prevalence of frozen shoulder has been reported in diabetes mellitus (DM) patients. In this study, we revealed the short- and long-term outcomes for treatment of frozen shoulders by MUA and compared these results in patients with and without non-insulin dependent DM by adjusted Constant score. The scores showed no significant differences between the two groups at both early and late follow-ups. Our results revealed that MUA for frozen shoulders is a simple and noninvasive procedure to improve symptoms and shoulder function within a short period of time. Even though DM is a predisposing factor to frozen shoulder, non-insulin dependent DM alone does not influence both the short- and long-term outcomes of frozen shoulder.

Polo-like kinase 1 (PLK1), a serine/threonine kinase and an oncogene, is crucial in regulating cell cycle progression. PLK1 also has been demonstrated as a potential target of osteosarcoma (OS) by using short hairpin RNA libraries in lentiviral vectors for screening of protein kinase. In preclinical studies, GSK461364, a potent and selective ATP-competitive PLK1 inhibitor, showed antiproliferative activity against multiple tumor cell lines. In the present study, we evaluated the expression level of PLK1 in OS and explored the cytotoxic mechanism of GSK461364 against OS. PLK1 was significantly overexpressed in OS compared with normal osteoblasts and other types of sarcoma. GSK461364 inhibited PLK1 and caused mitotic arrest by inducing G2/M arrest in OS cells. Moreover, GSK461364 exerted a cytotoxic effect by inducing apoptosis in OS, and induced cellular senescence in OS cell lines, as indicated by an increased senescence-associated β-galactosidase activity and enhanced DcR2 and interleukin-1α expression. In addition, we demonstrated a synergistic cytotoxic effect of GSK461364 and paclitaxel, possibly resulting from combined mitotic arrest. In conclusion, the present study revealed that PLK1 was overexpressed in OS and that GSK461364 exerted its cytotoxic effect on OS by inducing mitotic arrest and subsequent apoptosis and induced cellular senescence; therefore, senescence-associated markers can be used as treatment biomarkers, and a combination of GSK461364 and paclitaxel can potentially treat OS.

Background Mechanical loading plays an important role in the regulation of extracellular matrix (ECM) homeostasis as well as pathogenesis of intervertebral disc (IVD) degeneration. The human annulus fibrosus (hAF) in the IVD is subjected to contact shear stress during body motion. However, the effects of shear stress on hAF cells remain unclear. This aim of the study was to investigate the expression of the ECM (COLI, COLIII and aggrecan) and matrix metalloproteinase (MMP-1, MMP-3 and ADAMTS-4) genes in hAF cells following fluid-induced shear stress in a custom-fabricated bio-microfluidic device. Methods hAF cells were harvested from degenerated disc tissues in routine spine surgery, staged by magnetic resonance imaging, expanded in monolayers and then seeded onto the bio-microfluidic device. The experimental groups were subjected to 1 and 10 dyne/cm2 shear stress for 4 h, and no shear stress was applied to the control group. We used real time polymerase chain reaction for gene expression. Results Shear stress of 1 dyne/cm2 exerted an anabolic effect on COLI and COLIII genes and catabolic effects on the aggrecan gene, while 10 dyne/cm2 had an anabolic effect on the COLI gene and a catabolic effect on COLIII and aggrecan genes. The COLI gene was upregulated in a stress-dependent manner. Expression of MMP-1 was significantly higher in the 10 dyne/cm2 group compared to the control group (P 2 groups. Expression of MMP-3 and ADAMTS-4 were similar in all three groups. Conclusion Taken together, hAF cells responded to shear stress. The findings help us understand and clarify the effects of shear stress on IVD degeneration as well as the development of a new therapeutic strategy for IVD degeneration.

Most epidemiological studies of soft tissue sarcoma (STS) were performed in the Western countries, and only limited data highlighting that in the Asian population. The aim of this study is to conduct a comprehensive analysis for the incidence rates of STS in Taiwan. This was a population-based study analyzing the incidence rates and trends of the primary STS over extremities and trunk wall during 2003 to 2011 by using the nationwide Taiwan Cancer Registry. More specific analyses were conducted for subtypes. Incidence rates of overall STS by cities and counties were also investigated. A total of 3843 cases were diagnosed with STS during the study period, giving an age-standardized rate (ASR) of 1.63 per 100,000 person-years. Liposarcoma was the most frequent subtype, followed by undifferentiated pleomorphic sarcoma and leiomyosarcoma. STS was more frequently diagnosed in males and angiosarcoma was the most prominent sex-specific type. ASR increased with age in most of the STS subtypes and varied by histologic subtype. The incidence of peripheral primitive neuroectodermal tumor was highest in children, whereas rhabdomyosarcoma revealed a bimodal age distribution. Annual percent change (APC) of STS was 2.2%, and significant change in trend was only in males (APC, 3.5%, P

Although the Brantigan cage and Bagby and Kuslich (BAK) cage have different geometrical characteristics, clinical observations suggest that they are equally effective in restoring disc height and stability across the involved spinal segments. This study was designed to compare their performance as posterior lumbar interbody fusion devices at two levels in fresh ligamentous cadaver lumbar spines (L2–S1). After mounting in a testing frame, the three-dimensional load-displacement behaviour of each vertebra was quantified using the Selspot II Motion Measurement System for; the intact state, posterior decompression, and stabilisation, using a pair of Brantigan or BAK cages across L4–S1, additional stabilisation using Isola spinal instrumentation across L4–S1, and cyclic loading in flexion/extension. In the “cage-only” state, the Brantigan cage did not restore the stability in right axial rotation, whereas the BAK cage not only restored stability in all six directions but also improved lateral bending. After implanting the posterior instrumentation, both groups exhibited similar stability, and cyclic loading did not alter this. Although the Brantigan cage appears less effective than the BAK cage, implantation of posterior instrumentation significantly improves stability and reduces the differences between them. This underscores the need to use posterior instrumentation to achieve a higher initial stability.

A retrospective group study was done to evaluate the effect of the small AO external fixator in the management of acute intra-articular fractures of the distal radius.Between January 1995 and December 1996, 70 consecutive patients with articular fractures of the distal radius were treated by closed reduction and external fixation with small AO external fixators. The mean age at the time of surgery was 58.9 years (range, 14-87 years). There were 58 Colles' Barton's fractures and 12 Smith's Barton's fractures. The follow-up period was 104 months (range, 92-118 months).All fractures united in a mean of 5.8 weeks (range, 4-10 weeks). At the final follow-up, the average range of motion was 56.3 +/- 11.6 degrees in flexion, 58.6 +/- 10.7 degrees in extension, 21.5 +/- 4.2 degrees in ulnar deviation, 9.1 +/- 2.9 degrees in radial deviation, 71.5 +/- 8.5 degrees in pronation, and 67.3 +/- 9.2 degrees in supination. Compared with the normal side, the average grip force was 87 +/- 6%. The overall clinical and functional outcomes, according to the scoring system of Gartland and Werley, showed that 22 patients (31.4%) had excellent results, 36 (51.4%) had good results, 9 (12.9%) had fair results, and 3 (4.3%) had poor results.Closed reduction and external fixation with the small AO external fixator is useful and effective in the management of displaced comminuted articular fractures of the distal radius.

Background: A retrospective cohort study was conducted to evaluate the outcomes of massive allograft arthrodesis in the management of high-grade osteosarcoma around the knee. Methods: The results of 19 patients with high-grade osteosarcoma around the knee, which was treated by wide resection and reconstruction using allograft arthrodesis, were evaluated for a mean length of 7.3 years (range, 3-13 years). The mean age at the time of surgery was 13.3 years (range, 6-27 years). According to the Musculoskeletal Tumor Society staging system, 17 patients were stage IIB and 2 were stage IIIB at presentation. Evaluations were based on the oncologic results, non-oncologic results and complications. Functional evaluation was performed with the Enneking functional evaluation form. Results: Four patients (21.1%) died of their disease; 3 (15.8%) are alive with disease; and 12 (63.2%) are free of disease. Four patients (21.1%) had local recurrence of their tumor at a mean of 23 months postoperatively (range, 9-44 months). The mean time to union of the metaphyseal junction was 24.7 weeks (range, 16-30 weeks) and the diaphyseal junction was 47 weeks (range, 24-78 weeks). The overall complication rate was 31.6%, including 2 (10.5%) infections, 3 (15.8%) allograft fractures, and 1 (5.3%) nonunion. Our mean final functional result was 65%. Conclusion: Due to the high rate of complications in this study, we conclude that allograft arthrodesis should be left as a salvage or "back-up" reconstructive procedure after resection of osteosarcoma around the knee, unless there are special indications for this procedure. We found allograft fracture to be the most common complication. (J Chin Med Assoc 2005;68(9):425-430)

The biotechnology to immobilize biomolecules on material surfaces has been developed vigorously due to its high potentials in medical applications. In this study, a simple and effective method was designed to immobilize biomolecules via amine-N-hydroxysuccinimide (NHS) ester conjugation reaction using functionalized poly-p-xylylene coating on material surfaces. The NHS ester functionalized coating is synthesized via chemical vapor deposition, a facile and solvent-less method, creating a surface which is ready to perform a one-step conjugation reaction. Bone morphogenetic protein 2 (BMP-2) is immobilized onto material surfaces by this coating method, forming an osteogenic environment. The immobilization process is controlled at a low temperature which does not damage proteins. This modified surface induces differentiation of preosteoblast into osteoblast, manifested by alkaline phosphatase (ALP) activity assay, Alizarin Red S (ARS) staining and the expression of osteogenic gene markers, Alpl and Bglap3. With this coating technology, immobilization of growth factors onto material surface can be achieved more simply and more effectively.

In this study, 22 women patients with adult idiopathic scoliosis treated surgically with Cotrel-Dubousset instrumentation (CDI) or Texas Scottish Rite Hospital instrumentation (TSRHI) were followed up for 56.2+/-4.0 months. The overall immediate and final corrections were respectively 21.5+/-40 (58%) and 26.6+/-2.90 (48%), giving a loss of correction of 5.1+/-1.00 (10%). No significant differences were found in these two parameters between the two groups. The functional outcomes were good in 21 patients. There was no difference between CDI and TSRHI in deformity correction.

Background Determining the actual painful vertebral level is difficult when evaluating osteoporotic vertebral fracture, especially when there are acute and chronic fractures simultaneously. In this study, we retrospectively evaluated and compared the findings between plain film, bone scan, and magnetic resonance imaging (MRI) in the diagnosis of new fracture in osteoporotic vertebral fractures. Methods This is a retrospective clinical study of patients who were diagnosed with osteoporotic vertebral fractures using plain film, bone scan, and MRI within a 1-month interval between February 2008 and December 2012. The findings in plain film, the extent of increased uptake in bone scan, and signal change in MRI were compared to evaluate the actual level of pain. All patients received percutaneous vertebroplasty according to MR finding. Pain scores (visual analog scale) of the study patients were compared prior to and after the procedure. Results A total of 52 patients with a mean age of 79.1 years (range 59–92 years) were enrolled in this study, and were treated by vertebroplasty confirmed by MRI. It was observed that patient pain score (visual analog scale) improved from 7.6 to 2.8. Plain film examination revealed 79 vertebrae that were suspected to be compression fractures. Among the suspected vertebrae, 62 showed increased uptake in bone scan, and MRI showed bony edema change in 58 vertebrae. The consistency between bone scan and MRI was 96.9% in patients with single-level suspected fracture on plain film. There was moderate agreement (kappa was 0.56) in patients where multiple levels were noted. Fifteen vertebrae with vacuum cleft sign on plain film showed total concordance in both bone scan and MRI. Conclusion For patients with single-level compression fracture, the painful level in osteoporotic vertebral fractures can be determined by plain film and bone scan testing. Vacuum cleft sign noted on plain film may be enough to localize the level of pain. However, MRI testing is further needed in multiple osteoporotic vertebral fracture patients.

Assessing student performance becomes challenging when course enrollment becomes very large (~10^4 students). As part of a Massive Open Online Course (MOOC) in introductory physics offered by Georgia Tech in 2013, students submitted video reports on mechanics labs. Peer evaluation of these reports provided the primary method for evaluating student laboratory work. This paper describes the methods developed and used to guide students in evaluating each other's video lab reports. We also discuss how students' peer evaluation behavior changed with different interventions provided in the course., 4 pages, 2 figures, submitted to 2014 Physics Education Research Conference Proceeding