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Various syndesmotic fixation methods in ankle injury are recommended; however, a lack of biomechanical information persists regarding the stiffness of the fixation methods. The current study thus aimed to assess biomechanical cadaveric validation and perform a finite element analysis of syndesmotic fixation comparing endobutton vs. screw after syndesmotic injury with an ankle fracture.Five pairs of ankles of fresh cadavers were used for the validity test for Anterior Inferior Tibiofibular Ligament (AITFL), Posterior Inferior Tibiofibular Ligament (PITFL), and Interosseous ligament biomechanics properties. Four finite element models (FEM) were created: an intact model, a fracture model with/without syndesmotic injury, an endobutton fixation model, and a syndesmotic screw fixation model. Each FEM was tested vis-à-vis external rotation force, anteroposterior translation force, and compression force until model failure. The primary outcomes were stiffness and force until failure.The respective anteroposterior translation force for the stiffness of the intact model, the screw fixation model, and the endobutton fixation was 8.14, 9.15, and 8.17 N/mm. The respective external rotation force for the stiffness of intact, screw fixation, and endobutton model was 0.927,0.949, and 0.940 Nm/degree. The respective stress under compression force in the intact, screw fixation, and endobutton model was 39.94,25.59, and 37.30 MPa.Both screw and endobutton fixation models provided more translation, compression, and rotation stability than normal syndesmosis, but the screw model provided greater translation and compression force stability than the endobutton model. There was no difference in rotational stability between the two models. We thus recommend the same rehabilitation protocol for both fixation methods; however, vigorous translation and compression should be avoided when using endobutton fixation.

BACKGROUND: The L2 nerve root is considered part of the lumbar plexus that innervates the iliopsoas (IP) and quadricep muscles (Qd). Total en bloc spondylectomy (TES) at the L2 vertebra requires bilateral nerve root transection to facilitate surgical dissection and vertebral body removal. Information regarding neurological function recovery of the IP and Qd in patients with muscle weakness before TES is lacking. We aimed to report the neurological recovery of IP and Qd after TES involving the L2 vertebra in preoperative lower extremity weakness in spinal tumor patients. METHODS: We prospectively recorded all L2-involved spinal tumor patients undergoing TES between January 2018 and November 2020. As a primary outcome, we recorded the Manual Muscle Testing (MMT) grade of the IP and Qd preoperatively, immediately postoperatively, and at follow-up. Secondary outcomes included the Frankel neurological status, sensation impairment, and the Eastern Cooperative Oncology Group score. RESULTS: From 8 TES-involving L2 patients, 6 (4 males) met the inclusion criteria. One patient had first-grade deterioration of the Qd MMT immediately postoperatively. All patients could ambulate independently 6 months after surgery. Five patients required follow-up for more than 1 year and could walk without any gait aids. All patients had persistent anterior groin and bilateral thigh numbness until the final follow-up. CONCLUSION: Neurological recovery of the IP and Qd muscles as measured by MMT can occur within 6 months of bilateral L2 nerve root transection. Bilateral L2 nerve root sacrifice can have acceptable neurological outcomes and recovery, even in patients with preoperative IP and Qd weakness. LEVEL OF EVIDENCE: 4.

Aim The biological reconstruction of the knee with osteoarticular allografts and resection arthrodesis have been reported but there has not yet been a direct comparison between both these procedures. This study aimed to identify the prognostic factors that influence failure of biological reconstruction and compared the results between both procedures. Methods Between 1994 and 2017, we performed 92 limb-sparing procedures using resection arthrodesis (n = 53) and osteoarticular allograft reconstruction (n = 39) for the management of primary bone tumors around the knee. The minimum follow-up time was 2 years in both groups. Results The failure rate of reconstruction in the osteoarticular allograft and resection arthrodesis group was 48.7% and 39.6%, respectively (p = 0.75). The mean MSTS score in the osteoarticular allograft and resection arthrodesis group was 23.7 and 21.8, respectively (p = 0.01). The significant risk factor for failure after biological reconstruction was the administration of chemotherapy (p = 0.001; HR = 3.39; 95% CI, 1.60-7.17). Conclusion Patients who underwent osteoarticular allograft had a better functional outcome than those who underwent resection arthrodesis reconstruction, but clinical outcomes between the groups were comparable. Chemotherapy is a significant adverse prognostic factor for failure of biological reconstruction.

PurposeThere is little information available regarding the cage diameter that can provide the most rigid construct reconstruction after total en bloc spondylectomy (TES). The aim of this study was thus to determine the most appropriate titanium mesh cage diameter for reconstruction after spondylectomy.MethodsA finite element model of the single level lumbar TES was created. Six models of titanium mesh cage with diameters of 1/3, 1/2, 2/3, 3/4, 4/5 of the caudad adjacent vertebra, and 1/1 of the cephalad vertebra were tested for construct stiffness. The peak von Mises stress (MPa) at the failure point and the site of failure were measured as outcomes. A cadaveric validation study also conducted to validate the finite element model.ResultsFor axial loading, the maximum stress points were at the titanium mesh cage, with maximum stress of 44,598 MPa, 23,505 MPa, 23,778 MPa, and 16,598 MPa, 10,172 MPa, 10,805 MPa in the 1/3, 1/2, 2/3, 3/4, 4/5, and 1/1 diameter model, respectively. For torsional load, the maximum stress point in each of the cages was identified at the rod area of the spondylectomy site, with maximum stress of 390.9 MPa (failed at 4459 cycles), 141.35 MPa, 70.098 MPa, and 88.972 MPa, 42.249 MPa, 15.827 MPa, respectively. A cadaveric validation study results were coincided with the finite element model results.ConclusionThe most appropriate mesh cage diameter for reconstruction is 1/1 the diameter of the lower endplate of the adjacent cephalad vertebra, due to its ability to withstand both axial and torsional stress. According to the difficulty of large size cage insertion, a cage diameter of more than half of the upper endplate of the caudad vertebrae is acceptable in term of withstand stress. A cage diameter of 1/3 is unacceptable for reconstruction after total en bloc spondylectomy.

Study design An in vitro biomechanical study. Objective The purpose of this study is to discuss whether pedicle screw systems can control spinal rotational instability in a functional spinal unit of lumbar spine on human cadaver. Summary of background data Rotational experiments using deer lumbar cadaveric models showed that rotational range of motion (ROM) of the model fixed by a pedicle screw system with crosslinking after total facetectomy for both the sides was larger than that in the intact model, and stated that spinal rotational instability could not be controlled using a pedicle screw system. Methods A rotation experiment using 10 functional spinal units (L3-4) of lumbar spine on human cadavers was performed by preparing the four models (intact model, damaged model, pedicle screw model, and crosslink (CL) model) in stages, then calculating and comparing rotational ROM among the four models. Results Rotational ROM in the CL model was still larger than that of the intact model in all the samples. And, rotational ROM decreased in the order of damaged model >> pedicle screw model > CL model > intact model. Statistical analysis revealed significant differences between all models (P Conclusions Pedicle screw systems may not control severe spinal rotational instability in human lumbar cadaveric models with total facetectomy on both the sides. This may represent a major biomechanical drawback to the pedicle screw system. Level of evidence N/A.

There have been no studies comparing the outcomes of nonvascularized autograft (NA) and allograft after resection of primary bone tumors. This study compares the clinical, functional outcomes of NA and allograft reconstruction and analyzes the risk factors for failure after these procedures. A retrospective study of patients with primary bone tumors of the extremities who underwent NA (n = 50) and allograft reconstruction (n = 47). The minimum follow up time was 24 months. The mean time to union for the NA and allograft group was 9.8 ± 2.9 months and 11.5 ± 2.8 months, respectively (p = 0.002). Reconstruction failure in the NA and allograft group was 19 (38%) and 26 (55.3%), respectively. Nonunion (30%) was the most common complication found in the NA group, while structural failure (29.8%) was the most common in the allograft group. There was no significant difference in functional outcome in terms of the mean Musculoskeletal Tumor Society score between the NA and allograft groups (23.5 ± 2.8 and 23.9 ± 2.1, respectively, p = 0.42). Age, sex, tumor location, graft length, method of reconstruction did not significantly influence failure of reconstruction. Chemotherapy was the only significant risk factor affecting outcomes (HR = 3.49, 95% CI = 1.59–7.63, p = 0.002). In the subgroup analysis, the use of chemotherapy affected graft-host nonunion (p p = 0.02). Both NA and allograft reconstruction methods provide acceptable clinical and functional outcomes. Chemotherapy is a risk factor for failure of both reconstructions, particularly graft-host nonunion and structural failure.

Biological reconstruction is widely used to reconstruct bone defects after resection of bone tumors in the extremities. This study aimed to identify risk factors for failure and to compare outcomes of the allograft, nonvascularized autograft, and recycled frozen autograft reconstruction after resection of primary malignant bone tumors in the extremities. A retrospective study was performed at a single center between January 1994 and December 2017. Ninety patients with primary malignant bone tumors of the extremities were treated with tumor resection and reconstruction using one of three bone graft methods: nonvascularized autograft (n = 27), allograft (n = 34), and recycled frozen autograft (n = 29). The median time for follow-up was 59.2 months (range 24–240.6 months). Overall failure of biological reconstruction occurred in 53 of 90 patients (58.9%). The allograft group had the highest complication rates (n = 21, 61.8%), followed by the recycled frozen autograft (n = 17, 58.6%) and nonvascularized autograft (n = 15, 55. 6%) groups. There was no statistically significant difference among these three groups (p = 0.89). The mean MSTS score was 22.6 ± 3.4 in the nonvascularized autograft group, 23.4 ± 2.6 in the allograft group, and 24.1 ± 3.3 in the recycled frozen autograft group. There was no significant difference among the groups (p = 0.24). After bivariate and multivariable analyses, patient age, sex, tumor location, graft length, methods, and type of reconstruction had no effects on the failure of biological reconstruction. Biological reconstruction using allograft, nonvascularized autograft, and recycled frozen autograft provide favorable functional outcomes despite high complication rates. This comparative study found no significant difference in functional outcomes or complication rates among the different types of reconstruction.

Background In recent years, pedicle screw (PS) fixation has often been used to stabilize the spine and correct deformities, yielding good clinical results. On the other hand, PS fixation is known to show problems such as instrumentation failure. However, few biomechanical studies have described causes of instrumentation failure. In this study, causes of instrumentation failure in lumbar PS fixation were investigated from the perspective of load sharing by measuring both strains generated in the rod and intradiscal pressure.Methods Four human cadaveric multi-segmental lumbar vertebrae (L2-L5) were used to prepare a control model and a PS fixation model. Next, axial compression tests were performed on each model using a universal material testing machine, and the strains generated in the rods and the intradiscal pressures were measured from strain gauges attached to the rods and a pressure sensor installed between L3-L4.Results Combined compressive and bending stresses were found to be generated in the rod, with bending stress around 10 times higher than compressive stress, and with vast differences in the levels of stress generated between right and left rods. Moreover, the stress shielding by PS fixation was small, and intervertebral discs were still subjected to a large load. Conclusion Preventing instrumentation failure in lumbar spine PS fixation, it seems necessary to strengthen the durability of the rod against bending stress and to ensure the stability of the anterior stabilizing element of the spine.

BACKGROUND: Modified tension band wiring is a common surgical technique forfixation of patella fractures; however, various complications have been associated withmetal implants in this configuration. Modification of techniques and non-metallicimplants have been proposed in order to reduce hardware associated complications whileoptimizing fixation strength. Our study investigated the biomechanical strengthprovided by various modifications of figure-of-eight tension band constructs. MATERIALS AND METHODS: A finite element (FE) model of normal patella wasreconstructed based on CT images of a 46-year old man. Mathematical variations fromconversion of actual DICOM images into 3D geometric mesh were recorded. Simpletransverse fracture at the midpole was established with a 0.5 mm fracture gap. Twointerfragmentary fixations were made by using: 1) 2.0 mm K-Wires or 2) 4.0 mm. cannulatedcancellous screws. Figure-of-eight loop with 1.25 mm stainless-steel wire or FiberWireno.5 were allocated to each group. Figure of-eight loops in the K-wire group were invertical orientation while figure-of-eight loops in the cannulated screw group were inhorizontal orientation. These combinations constituted four different FE models. Analysiswas done on each model under the same environment, which was a 400N load on eachfragment at 45o flexion. Implant stress/strain and material deformation were determined. RESULTS: The models with cannulated screws have von Mises stress on implant thatis three times less than those with K-wires. The least von Mises stress occurred on thecombined cannulated screws and horizontal FiberWire loop model (471.2 MPa). Thiscombination also provided least deformation to loading condition (0.1267 mm).Traditional construct with K-wires and metal wire loop was found to have maximalstress (1422.9 MPa) and maximal deformation (0.3856 mm). CONCLUSION: Cannulated screws combined with FiberWire figure-of-eight loopoffers favorably low implant stress. Our findings demonstrate superior stability andresistance to implant failure of the construct. This low-profile tension band fixation couldbe a good alternative for transverse patella fracture.

HOOS was developed as an extension of the Western Ontario and McMaster Universities' Osteoarthritis Index questionnaire for measuring symptoms and functional limitations related to the hip(s) of patients with osteoarthritis. To determine the validity and reliability of the Thai version of the Hip disability and Osteoarthritis Outcome Score (HOOS) vis-à-vis hip osteoarthritis, the original HOOS was translated into a Thai version of HOOS, according to international recommendations. Patients with hip osteoarthritis (n = 57; 25 males) were asked to complete the Thai version of HOOS twice: once then again after a 3-week interval. The test-retest reliability was analyzed using the intraclass correlation coefficient (ICC). Internal consistencies were analyzed using Cronbach's alpha, while the construct validity was tested by comparing the Thai HOOS with the Thai modified SF-36 and calculating the Spearman's rank correlation coefficients. The Thai HOOS produced good reliability (i.e., the ICC was greater than 0.9 in all five subscales). All of the Cronbach's alpha showed that the Thai HOOS had high internal consistency (Cronbach's alpha greater than 0.8), especially for the pain and ADL subscales (0.89 and 0.90, respectively). The Spearman's rank correlation for all five subscales of the Thai HOOS had moderate correlation with the Bodily Pain subscale of the Thai SF-36. The pain subscale of the Thai HOOS had a high correlation with the Vitality and Social Function subscales of the Thai SF-36 (r = 0.55 and 0.54)-with which the symptom subscale had a moderate correlation. The Thai version of HOOS had excellent internal consistency, excellent test-retest reliability, and good construct validity. It can be used as a reliable tool for assessing quality of life for patients with hip osteoarthritis in Thailand.

Background The Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) was developed to resolve problems associated with the original evaluation of cervical myelopathic patients. The aim of this study was to translate the JOACMEQ into Thai as per international recommendations, and to test its reliability and validity in the Thai context Methods The JOACMEQ was translated into Thai, using international guidelines. Cervical myelopathy patients (n = 70; 31 males) were asked to complete the Thai version JOACMEQ twice (4 weeks apart). Test-retest reliability was analyzed using the intra-class correlation coefficient (ICC). Internal consistencies were analyzed using Cronbach's alpha, while the construct validity was compared with the Thai version modified SF-36; using the Spearman's rank correlation coefficient. Results The Thai JOACMEQ produced good reliability (i.e., the ICC was >0.9 in 2 parameters and >0.8 in one). Overall the Cronbach's α for the 24 questions showed very high internal consistency (Cronbach's α > 0.8) and almost all Cronbach's α showed satisfactory internal consistency except for bladder function. The Spearman's rank correlation for all the JOACMEQ parameters had a positive correlation with all Thai SF 36 subscales, especially the quality of life parameter, which showed a strong correlation with all SF-36 subscales. Conclusion The Thai version of the JOACMEQ had satisfactory internal consistency and test-retest reliability: it also had good construct validity. It can therefore be used as a reliable tool for assessing quality of life for cervical myelopathy patients in Thailand.

Background Allografts and recycled bone autograft are commonly used for biological reconstruction. The dual locking plates fixation method has been advocated for increasing allograft stability and preventing fixation failure; however, the biomechanical properties of the various configurations of dual locking plates have not been extensively studied. Methods In a finite element (FE) analysis, we developed 6 patterns of different dual locking plate configurations for fixation of the mid shaft of the femur. The maximum strains were recorded for each of the 6 models then axial, bending and torsion stiffness were calculated. The FE analysis was validated the results with mechanical testing (axial compression, bending, and torsional stiffness) on a cadaveric femur. Findings The highest axial compression (715.41 N/mm) and lateral bending (2981.24 N/mm) was found in Model 4 (with two 10-hole locking plates placed at the medial and lateral side), while the highest torsional stiffness (193.59 N·mm /mm) was found in Model 3 (with 8- and 10-hole locking plates placed at the posterior and lateral side). Excellent agreement was found between the finite element analysis and biomechanical testing (r2 = 0.98). Interpretation The dual locking plate configuration with medial and lateral, 10-hole locking plates provided the most rigid and strongest fixation of the femur; both in terms of axial compression and lateral bending stiffness.

Background: The aim of this study was to evaluate survival of metastatic bone disease of an upper extremity, and to identify the prognostic factors that influence survival. Methods: Patients with metastatic bone disease of an upper extremity between 2008 and 2015 were reviewed from the database of a tertiary university hospital. Results: Of 102 patients, 48 males and 54 females with a median age of 61 (range, 28–82 years), the humerus (64.7%), clavicle (13.7%), and scapula (12.7%) were the common sites for bone metastasis of an upper extremity. Fifty-nine (57.8%) presented with pathologic fracture. No history of cancer was found in 76.5% of patients. The mean onset of metastatic bone disease after the first diagnosis of primary cancer was 4.74 ± 14.07 months (range, 0–84 months). Lung (31.4%) was the most common primary cancer followed by liver (14.7%), breast (12.7%), thyroid (7.8%), and renal (3.9%). Eighty-two cases (80.39%) died from the disease such that the median survival was 4.08 months (95% CI 2.57–6.17). The significant risk factors were the type of primary tumor (P

This is the protocol for a review and there is no abstract. The objectives are as follows: To compare the efficacy and safety of different chemotherapy regimens in children and young adults with high‐grade osteosarcoma when compared to other chemotherapeutic regimens.

Aim To evaluate the clinical results of primary malignant musculoskeletal tumors treated with wide resection and recycling autograft reconstruction using liquid nitrogen. Methods We reviewed 12 patients who had a primary malignant bone and soft tissue tumor treated by wide resection and recycling autograft reconstruction using liquid nitrogen between March 2006 and March 2013. The results were judged by recurrence, functional status and complications. Functional status was assessed according to the Musculoskeletal Tumor Society Score (MSTSS). Clinical failure was defined as need for reoperation in order to change the type of reconstruction or to amputate, and the presence of local recurrence. Results The most common tumor was osteosarcoma (eight cases) followed by Ewing's sarcoma (two cases). The tibia was the most frequently involved skeletal site (six cases) followed by the femur (three cases). The median follow-up period was 32 months. In 12 patients, 7 were still alive without recurrence. There were 3 clinical failures: 1 local recurrence and 2 graft complications at 28, 51 and 20 months after reconstruction, respectively. The main complication was infection (three cases). All osteotomy sites were radiographic unions, and the union time was 8.2 ± 2.7 months. The mean ± SD MSTSS score was 79% ± 11%; excellent functional results were achieved in seven patients. Conclusions Recycling autograft reconstruction using liquid nitrogen had favorable clinical outcomes in terms of functional status and local recurrence. This reconstruction method, therefore, represents a reasonable alternative for limb salvage surgery.

Malpositioning of cervical screws risks neurovascular injury. A cervical screw fixation system can provide proper rigidity, alignment correction, and high rates of fusion afforded by high pullout biomechanical strength. The objective is to assess the dimensions and axis of the C3-C7 cervical pedicles. A 1-mm slice thickness computed tomography (CT) scan of the cervical spine of 30 patients (15 males, 15 females) were analyzed and reconstructed in three-dimensions using Mimics(®) 10.01 software. We measured pedicle axis length (PAL), pedicle and lateral mass length (PL-LM), pedicle length (PL), outer pedicle width (OPW), and pedicle transverse angle (PTA) from the axial image and outer pedicle height (OPH) and pedicle sagittal angle (PSA) from the sagittal image. The OPH and OPW at all subaxial cervical spines were suitable for insertion of 3.5 mm cervical pedicle screws. PSA was directed cranially at C3 to C5 (13.84, 7.09, and 2.71) and directed caudally at C6 and C7 (-4.55, -6.94). PTA was greatest at C5 and smallest at C7. The respective difference between the left and right side for nearly all parameters was not statistically significant (except for C6 PL and C7 OPH). Females had a significantly smaller OPH and OPW than males at nearly all levels. The PTA was not significantly different between the sexes. Cervical pedicle screw fixation in the Thai population can be safely performed and guidelines for insertion at each vertebra documented. Appropriate preoperative planning is necessary to achieve safe and accurate placement of the screws.

The aim of this study was to perform a survival analysis of Cholangiocarcinoma (CCA) with spinal metastases. 55 cases of CCA with spinal metastases were retrospectively reviewed. We recorded age, sex, Kanofsky performance score, Frankel scale, number and region of affected vertebrae, presence of appendicular bone metastases, treatment received, and survival time; then performed a survival analysis. Overall median survival was 4months (95%CI, 2.89-5.11). Frankel A had the poorest survival (2months-95%CI, 1.15-2.85) compared to Frankel C and D (P=0.004 and

Background The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was developed by the Japanese Orthopedic Association (JOA) for assessment of lower back pain and lumbar spinal disease. We aimed to translate the JOABPEQ into Thai and test its reliability and validity in the Thai context. Methods The original JOABPEQ was translated into Thai in accordance with international recommendations. Then 180 lumbar spinal disease patients (mean age 58.58 ± 11.97, 68.3% female) were asked to complete the Thai version of the JOABPEQ twice at 2-week intervals. Test-retest reliability was analyzed using the intra-class correlation coefficient (ICC). Internal consistencies were analyzed using Cronbach's alpha, while the construct validity was compared with the Thai version of the modified SF-36, and tested using the Spearman's rank correlation coefficient. Results The Thai JOABPEQ showed satisfactory test-retest reliability in all parameters (Intra-class Correlation Coefficient 0.761–0.862). The variables low back pain, walking ability, social life function, and mental health had satisfactory internal consistency (the respective Cronbach's α was 0.798, 0.721, 0.707, and 0.795). Only the lumbar function parameter showed moderate reliability (Cronbach's α = 0.654). All of the variables in the Thai JOABPEQ had a statistically positive correlation with the correspondent Thai SF-36 subscales (Spearman's rank correlation p value Conclusion The Thai version of JOABPEQ had satisfactory internal consistency, test-retest reliability, and construct validity; it can be used as a reliable tool for assessing quality of life for lumbar spinal disease patients in Thailand.

Aims To evaluate the clinical outcomes and identify which prognostic factors influence the clinical outcomes of synovial sarcoma patients at a tertiary university hospital in Thailand. Methods Patients with synovial sarcoma of the extremities between 1997 and 2007 were reviewed from the database of the Musculoskeletal Oncology Unit, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand. Results Of 41 patients, 23 males (56%) and 18 females (44%) with a median age of 39 (range, 1–78 years), 18 (44%) had metastasis at the first diagnosis and 23 (56%) had only a localized tumor. The 5-year overall survival of all the patients was 36%; 64% in patients with localized disease and 0% in patients with metastasis at first diagnosis. In all 23 patients (56%) died of the disease at a median duration of 11 months (range 3–47 months). All patients with metastases died at a median 9 months (range 1–41 months). Metastasis at first diagnosis influenced overall survival for patients with synovial sarcoma (P

We determined the prevalence of carpal tunnel syndrome (CTS) at a fishnet factory in order to discern the possible associated risk factors at this type of workplace. The 662 workers were interviewed then physically examined. The prevalence of CTS was 14.5%, which is significantly higher than in the general population. Workers directly involved in the production of fishnets had a significantly higher risk of CTS than the factory's office workers or housemaids (odds ratio = 1.84; range, 1.03–3.29; 95% CI, p = 0.049). There was no association between the length of employment in the factory with CTS (odds ratio = 1.13; range, 0.77–1.66; 95% CI, p = 0.591). Our results confirm that factory jobs with repetitive hyperflexing and twisting of the wrists are at risk of CTS.

Background: Melioidotic septic arthritis is an infection caused by the gram-negative bacillus Burkholderia pseudomallei . It is commonly found in Northeast Thailand. The goal of our study was to identify specific characteristics of patients with melioidotic septic arthritis by comparing them with patients with non-melioidotic septic arthritis and to describe the results of treatment of melioidotic septic arthritis. Methods: We conducted a retrospective study of seventy-seven patients with septic arthritis who were treated in our hospital over a period of four years. Twenty-five of the patients had melioidotic septic arthritis, and fifty-two had non-melioidotic septic arthritis. Univariate and multivariate analyses were conducted to identify the risk factors for melioidotic septic arthritis, and the clinical course of the twenty-five patients with melioidotic septic arthritis was followed until the infection resolved. Results: Patients with melioidotic septic arthritis differed significantly (p = 0.002 ) from those with non-melioidotic septic arthritis with regard to the frequency of diabetes mellitus and of involvement of an upper-extremity joint. The odds ratio that melioidosis was the cause of the infection was 15.7 (95% confidence interval, 4.5 to 55.6) in a patient with diabetes mellitus and 4.51 (95% confidence interval, 1.04 to 19.65) in a patient with involvement of an upper-extremity joint. Twenty-two of the twenty-five patients with melioidotic septic arthritis responded to treatment, which consisted of six months of antibiotic therapy combined with needle aspiration, as well as surgical drainage of the affected joint when necessary (sixteen patients). Conclusions: A diagnosis of melioidotic septic arthritis should be considered when septic arthritis is seen in an individual who is indigenous to or has recently visited Southeast Asia. The infection is more likely to be melioidotic septic arthritis if it involves an upper-extremity joint and if the patient has diabetes mellitus. Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Background: Pain has been regarded as important in the improvement of quality of life (QOL). In the advanced countries of Europe and the North America, a number of large-scale epidemiological surveys on pain, particularly chronic pain, have thus been performed in general populations. However, few epidemiological surveys of chronic pain have been reported from developing countries, and no surveys appear to have examined chronic pain in the least developed countries. Objectives: To compare the incidence of chronic pain in Asian countries, using Japan as an advanced country, Thailand as a developing country, and Myanmar as one of the least developed countries. Study Design: Cross-sectional study in 4 hospitals. Setting: A university hospital and a general hospital in Japan, a university hospital in Thailand, and a general hospital in Myanmar. Methods: Patients were 1,000 nursing staff working in Japan, 448 nursing staff working in Thailand, and 405 nursing staff working in Myanmar. The survey was performed by requesting all nursing staff to anonymously answer the questionnaire. Data were used to calculate chronic pain prevalence, pain site, presence or absence of consultation with doctors, methods of handling pain other than consultation with doctors, and whether pain was controlled for each country. The results were then compared between countries. Results: The prevalence of chronic pain in Myanmar was 5.9%, which was significantly lower (P < 0.01) than in Japan (17.5%) or Thailand (19.9%). The most frequent pain sites were the lower back, head, and shoulders in Japan, and the shoulders, ankle, upper back, and head in Thailand, whereas in Myanmar, no clear certain tendencies were observed. The most frequent method for handling pain other than consultation with doctors was over-the-counter drugs in Japan, massage in Thailand, and relaxation therapy (meditation) in Myanmar. Limitations: Limitations of this study were the cross-sectional design study, the small number of hospitals included, the limitation of patients to nursing staff, and the omission from the questionnaire of questions regarding body height and weight, working situation, family background, trauma history, sports activity history, smoking history, psychological/character tests, QOL, and pain levels of patients. Conclusion: The prevalence of chronic pain was significantly lower in Myanmar than in Japan or Thailand. With regard to the site and treatment of chronic pain, no clear tendencies were observed between countries, suggesting that frequency and the character of chronic pain differ from county to country around the world. Key words: Chronic pain, epidemiology, prevalence, low back pain, shoulder pain, ankle pain, headache, developing countries, least developed countries

Manual thigh girth measurement is a simple tool to roughly estimate capacity change of the thigh. Yet, there is no good evidence supporting the most relevant anatomical landmarks to detect girth difference from the normal limb.The present study consecutively enrolled 30 patients sustaining unilateral anterior cruciate ligament deficiency and measured both thigh girths in series at 2-cm intervals from anteromedial joint line until 30 cm cephalad. The measurements were also performed in intervals at 1/16 ratio of the thigh length marked between the tibial tuberosity (TT) and the anterior superior iliac spine (ASIS). The results from both normal and the injured side were compared by analyzing means and standard deviations for the statistical difference.Levels of significant mean girth difference between the two thighs were located at 18 cm and 20 cm above the anteromedial joint line or at 6/16 (3/8 or approximately 1/3) the thigh length measured from the TT towards the ASIS.In patients with knee problems using deficient ACL as the prototype, the most relevant level to detect thigh girth difference from the normal side is located at 18 cm and 20 cm above the anteromedial knee joint line or at 6/16 (3/8 or approximately 1/3) the thigh length measured from the TT towards the ASIS.

Background Non-operative treatments for mild to moderate knee osteoarthritic (OA) is recommended. Plai (Zingibercassumunar Roxb.) belongs to the ginger family. It is a Thai herb used in Thai traditional medicine for relieving muscle and joint pain (1–2). Plai has anti-inflammatory activities due to compounds found in its extracts (1–4). These findings suggest that topical plai cream is a potentially useful drug for the treatment of painful OA of the joints. Since there have not been any studies on the efficacy of plai cream alone for relieving symptoms of OA knee joint, we aimed to test its value. Objectives To assess the efficacy of topical plai cream for the treatment of primary osteoarthritis (OA) knee. Methods This was a 9-week (4 weeks treatment + 1 week wash-out + 4 weeks placebo) phase III randomized, double-blind, controlled, cross-over, community trial of Plai vs. placebo, in adults with OA of the knee. This study aimed to determine whether Plai cream was more effective at reducing pain than a placebo cream, as measured using a visual analog scale (VAS) plus the Western Ontario McMaster (WOMAC) score. Results A total of 120 pairs of subjects were enrolled. The mean different VAS favoring Plai varied between 0.46 and 1.4 (p Conclusions This cross-over, randomized, controlled, communit, trial demonstrated that Plai cream is an effective topical agent for relieving the symptoms of mild to moderate OA knee. References Panthong A, Kanjanaponthi D, Niwatananun V, Tuntiwachwuttikul P, Reutrakul V. Anti-inflammatory activity of compounds isolated from Zingiber cassumunar. Planta Med. 1990;56:655. Han AR, Kim MS, Jeong YH, Lee SK, Seo EK. Cyclooxygenase-2 inhibitory phenylbutenoids from the rhizomes of Zingiber cassumunar. Chem Pharm Bull (Tokyo). 2005;53(11):1466–8. Chaiwongsa R OS, Tangyuenyong S, Kongtawelert P, Panthong A, Reutrakul V. Chondroprotective potential of bioactive compounds of Zingiber cassumunar Roxb. Against cytokine-induced cartilage degeneration in explant culture. J Med Plants Res. 2012;6 (39):5204–13. Leelarungravub D SM. Potential antioxidant and anti-inflammatory activity of Thai plai (Zingiber cassumunar Roxb.) essential oil. International Journal of Essential Oil Therapeutics. 2009;3(1):25–30. Disclosure of Interest None declared

The posterior tibial inlay technique is currently accepted as a standard operation for the posterior cruciate ligament–deficient knee. The classical technique requires a graft construct consisting of a bony part to be fitted into the posterior tibial socket. When an autogenous source is chosen, morbidity at the donor site generated by obtaining the graft with a bony part (e.g., bone–patellar tendon–bone or quadriceps tendon–bone) can be more serious than when obtaining the soft-tissue graft (e.g., hamstring). This study describes an alternative use of soft-tissue graft anchored in a bone socket at the posterior tibial margin by a transfixing cancellous screw. The graft is secured on top by a “bone washer” harvested from this bone socket to provide biological bone-tendon-bone healing. The posterior cruciate ligament remnant with integral fibers at the femur can have its tibial part revised, tensioned, and reattached concomitantly. This additional procedure is deemed to enhance joint stability and promote graft healing.

Study Design: A retrospective study. Objectives: Three objectives have been designated for this study: (1) to determine the prevalence of identifiable and non-identifiable primary tumor sites in patients with spinal metastasis, (2) to identify the most common site of the known primary tumor sites, and (3) to identify the factors associated with survival time. Summary of Background Data: The spine is the third most common metastatic site for several primary visceral carcinomas. The primary tumor site could not be identified in 15% to 20% of patients who had been diagnosed of with a skeletal metastasis. Most of the previous studies on skeletal metastasis have not been limited to spinal metastasis alone. Methods: Between January 2007 and July 2011 reviews were done for 82 patients with spinal metastasis who had not received a previous diagnosis of carcinoma. The assessment parameters included the following: general demographic data, Karnofsky score, Frankel score, number of spinal vertebra affected, region of the spine affected by metastasis, other skeletal metastasis site, visceral metastasis, known or unknown primary sites of metastasis, histological cell type of metastasis, and the survival period. The log-rank test and Cox proportional hazard model were used to study the survival analysis. Results: Of the 82 patients included in the study, 56 were male. The mean age was 57 years. 86.6% had a known primary carcinoma site while the remaining 13.4% had none. The two most common known carcinoma sites were the lung and biliary systems. Among the 11 unknown primary sites, the most common histological finding was adenocarcinoma. The mean survival period was 8.7 ± 11.7 months. The survival analysis revealed two statistically significant factors: the primary tumor site’s aggressiveness (Pthe presence of visceral metastasis (P Conclusion: The prevalence of identifiable primary site was 86.6% and the most common site was the lungs followed by the biliary system. The primary carcinoma site’s aggressiveness and the presence of visceral metastasis were the factors associated with patient survival.

To compare bioabsorbable screw (BS) against metal screw (MS) primarily on adverse effects and secondarily on clinical outcomes after single-bundle primary anterior cruciate ligament reconstruction. Electronic searches were performed using search strategies meeting the mentioned purposes. Retrieved articles were selected for randomised controlled trials (RCTs) reporting at least 1-year follow-up. Potential studies were selected under inclusion and exclusion criteria. Risk of biases and data extraction was completed by two review authors. Discrepancies were resolved through discussion. Mean difference and risk ratio with 95 % confidence interval (CI) were used for continuous and binary outcomes, respectively. Heterogeneity was assessed using I 2. Pooled treatment effects with 95 % CI were estimated using the fixed- or random-effect model where appropriate. Eleven RCTs with 878 randomly allocated patients were included, and 711 patients (81 %) with eligible follow-up time up to 8 years were analysed. Comparing with the MS group, BS group using medial hamstring graft showed evidence of larger tunnel widening on the femoral side measured from radiographs or magnetic resonance imaging, though data could not be pooled because diverse measurement methods had been used. Significantly higher rates of effusion and screw breakage, and fewer cases of complete tunnel healing were reported in the BS group. Nevertheless, functional and clinical results were not deteriorated by the presence of these adverse effects for both short- and longer-term follow-ups. This is the first systematic review focusing on adverse effects of the BS, such as larger tunnel widening and higher rates of other complications. With these effects, routine use of the BS should be balanced with the advantages claimed. Cost-effectiveness is another issue, and well-designed RCTs are needed to better validate the implication. Systematic review of randomised controlled therapeutic studies, Level II.

To evaluate the clinical outcomes and identify which prognostic factors influence the clinical outcomes of synovial sarcoma patients at a tertiary university hospital in Thailand.Patients with synovial sarcoma of the extremities between 1997 and 2007 were reviewed from the database of the Musculoskeletal Oncology Unit, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand.Of 41 patients, 23 males (56%) and 18 females (44%) with a median age of 39 (range, 1-78 years), 18 (44%) had metastasis at the first diagnosis and 23 (56%) had only a localized tumor. The 5-year overall survival of all the patients was 36%; 64% in patients with localized disease and 0% in patients with metastasis at first diagnosis. In all 23 patients (56%) died of the disease at a median duration of 11 months (range 3-47 months). All patients with metastases died at a median 9 months (range 1-41 months). Metastasis at first diagnosis influenced overall survival for patients with synovial sarcoma (P 0.001). According to a univariate analysis, the significant adverse factors were biphasic histological subtype and an inadequate surgical margin of the definitive surgery (P 0.05).Synovial sarcoma is still a disease with a poor prognosis. Distant metastasis at initial diagnosis is a significant adverse prognostic factor for overall survival. A biphasic histological subtype and an inadequate surgical margin are significant adverse prognostic factors in localized synovial sarcoma.

Background: Osteoarthritis (OA) of the knee is prevalent and associated with both pain and functional disability. Visco-supplementation is an intra-articular therapeutic modality for the treatment of knee OA, based on the physiologic importance of hyaluronan in synovial joints. The therapeutic goal is to restore the viscoelasticity of synovial hyaluronan, decrease pain, improve mobility and restore the natural protective functions of hyaluronan in the joint radiography is currently the most widely used modality for assessing damage in OA: this technique allows the measurement of joint space width (JSW) the appropriate primary endpoint for demonstration of efficacy. There are, however, questions regarding its validity and reliability. Magnetic resonance imaging (MRI) with its superior soft tissue contrast is the best technique available for assessment of normal articular cartilage and cartilage volume. Therefore, this study aimed to evaluate the short-term benefit of intra-articular injection of hyaluronic acid (GoOn®) for protecting the articular by using MRI in patient with OA knee. Patients and Methods: This was a phase III double-blinded (i.e., both the patients and MRI examiners), randomized, controlled trial of 60 patients with mild to moderate knee OA, diagnosed according to both clinical signs and X-ray. All of the patients received MRIs (1.5 T) of the affected knee(s) at visit 0 and 6 months after the first injection. The patients received either an intra-articular injection into the affected knee weekly for 5 weeks of HA (GoOn®) or a placebo. Blinded examiners used the visual analog scale (VAS) and the WOMAC score to do weekly and monthly assessments for 6 months. The engineer used Mimics 10.01 to transform the MRI scanner data into 3D images of the articular cartilage for measuring CV, which was also blinded to the treatments. Results: Subjects averaged 59.5 years of age (range, 46 to 84). During the enrollment phase, only female farmers attended came. Four patients in the placebo group and one in the GoOn® group refused to undergo the second MRI. The mean body weight and height was 64.20 ± 10.25 kg and 1.53 ± 0.057 m, respectively. The respective baseline VAS and WOMAC score was 6.40 ± 1.64 and 51.65 ± 13.3. Forty-four patients were KL grade 2 and 16 were grade 3. The mean total CV at baseline in the GoOn® and placebo groups was 14.7 ± 3.5 ml and 15.5 ± 3.9 ml, respectively. There was no significant difference in the mean total CV after 6 months in either group (p>0.05) except at the femorotibial junction of the GoOn® group was increase CV more than the placebo group (p

To assess the reliability and validity of the Thai version of the Disability of the Arm, Shoulder and Hand (KKU-DASH) questionnaire in patients with brachial plexus injuries.The Thai KKU-DASH version was performed based on translation/back translation methodology. Thirty-four Thai-speaking patients with brachial plexus injuries completed the KKU-DASH and the 36-item short-form health survey (SF-36) questionnaires preoperatively and then were reassessed for test-retest reliability two months later Reliability was investigated for reproducibility and internal consistency The validity was evaluated by using component analysis and the correlations coefficients between the KKU-DASH and the SF-36.The internal consistency of the degree of difficulty, severity of pain, and social activity domains of the KKU-DASH was good to excellent (Cronbach's alpha 1.00, 0.75, and 1.00). The intraclass correlation coefficient (ICCs) for the test-retest reliability was 0.52. For the degree ofdifficulty, severity of pain, social activity, and psychological effect on self-image, the ICC were 0.5, 0.45, 0.57, and 0.53 respectively The convergent validity between the KKU-DASH and SF-36 was -0.76. The convergent validity of each domain between both instruments ranged from 0.46 to 0.69 and the strongest correlation was observed in the social activity domain.According to the reliability and validity testing, the KKU-DASH questionnaire is suitable for Thai-speaking patients with brachial plexus injuries.

Knee osteoarthritis (OA) is prevalent and associated with both pain and functional disability. Current treatments aim to alleviate mild to moderate symptoms by various methods. Topical capsaicin (0.075% and 0.05%) has been evaluated for the treatment of the painful joints. A burning sensation was the most common side effect at these strengths. Therefore, the authors aimed to evaluate the efficacy of 0.0125% capsaicin gel (Capsika gel) compared to a placebo (the vehicle gel) in patients with symptomatic OA knee.This was a cross-over; double blinded, randomized, controlled trial of 100 patients with mild to moderate knee OA. All of the patients received either capsaicin gel or placebo gel applied to the affected knee, three times daily for 4 weeks with one week washout period after which the treatment switched to either capsaicin gel or placebo gel for the next 4 weeks. A blinded examiner used the visual analog scale (VAS) and WOMAC score to do weekly assessments.Subjects averaged 61 years of age (range, 44 to 82). During the enrollment phase, only female farmers presented. Mean body weight and height was 62.97 +/- 10.25 kg and 1.54 +/- 0.053 m, respectively The respective baseline VAS and WOMAC score was 6.40 +/- 1.64 and 51.65 +/- 13.3. The severity of OA, according to the KL criteria was: 83 patients with grade 2 and 16 with grade 3. The respective mean difference of VAS and total WOMAC score in the capsaicin group vs. the placebo group was statistically significant (p0.05). The mean difference of the WOMAC pain, stiffness and functional subscales in the capsaicin vs. the placebo group was also significant (p0.05). The only adverse event reported was a burning sensation. During the 4-week treatment with capsaicin, approximately 67% of patients had a burning sensation but none withdrew for this reason.0.0125% capsaicin gel was an effective treatment in mildly to moderately painful OA knees. The burning sensation reported by patients in the capsaicin group was less disturbing than in previous studies and none of the present patients withdrew for this reason.

We use the measurement iterative loop as a conceptual framework to examine the economics of common therapies for acute non-specific low back pain. The measurement iterative loop systematically assesses the interlocking facets of an illness from the community health perspective, including quantifying burden of illness, etiology, assessment of therapeutic effectiveness, and economic evaluation of therapies. The iterative loop reveals that: (1) burden of illness, although known to be substantial, is so far inaccurately measured, (2) little is known about such factors as provider and patient compliance; and (3) the economics of therapy can guide us in this time of clinical uncertainty when no therapy appears clearly superior. For therapies with at least some support from randomized controlled trials, bedrest appears to be economically superior. Besides burden of illness, compliance, and current therapies, future research should address such “therapeutic” options as early return to work and patient self-management.

To compare the biomechanical properties of the single strand monofilament Nylon 2-0 Khon Kaen tendon repair device for flexor tendon repair and standard 4-stranded cruciate repair sutures.80 flexor digitorum longus tendons from fresh cadavers, were cut and sutured by Khon Kaen tendon repair device (core nylon) or 4-stranded, cruciate repair (3-0 monofilament nylon) and both groups were divided into two groups; the first group combined with 5-0 monofilament nylon circumferential epitendinous suture and the second group without epitendinous suture. The sutured tendons were tested by using biomechanical testing machine (LLOYD instruments, LR30K), in rate 5 mm/s. Force, stiffness and energy absorbed at peak force (calculated from the force-displacement curves) and mode of failure were comparedThe Khon Kaen tendon repair device (core nylon) without epitendinous sutured group has 2 mm gap force, peak force and stiffness significantly lower than standard 4-stranded, cruciate repair; but with no statistical difference in the epitendinous sutured group; 90% of Khon Kaen tendon repair device failed by suture breakage and 10% failed by ankle pullout.Although the strength of Khon Kaen tendon repair device (core nylon) alone is lower than the strength of 4-stranded, cruciate repair, and 90% mode of failure was core suture breakage, the authors recommended to change core suture from nylon to a stiffer material and re-inforced with epitendinous suture.

To evaluate the usefulness of an intra-operative tissue imprint as a role to provide a provisional diagnosis in patients with musculoskeletal tumors.118 patients underwent surgical treatment for musculoskeletal tumors. Tissue imprints from suspected tissues were conducted in all of the patients and the results were compared with the final permanent section.The usefulness of the imprint slides (i.e., the diagnostic yield) was 88.14%. The respective, overall sensitivity, specificity, accuracy, positive and negative predictive value was 93.75%, 100%, 96.15%, 100% and 90.90%.Tissue imprinting is a useful method for intra-operative evaluation of adequacy and provides a provisional diagnosis of the musculoskeletal tumors lesions.

The most common technique used for non-surgical treatment of trigger fingers is the direct injection of steroids into the flexor tendon sheath over the metacarpal head. However, this method causes more pian to the patient and can result in tendon rupture due to insertion of needle into the tendon. Carlson and Curtis described the mid-axial injection technique which is simple and relatively painless. We aim to compare the pain result from the injection between these two methods. The prospective randomised control trial study was designed. There were 103 trigger fingers included in the study which were divided into two groups: the conventional technique of injection (CI technique) and the mid-axial injection technique (MAI technique). The visual analogue scale for pain score had been recorded at the time of injection: one, three and six weeks. The complication after injection and the recurrent symptoms within one year were also recorded. The Student's t-test, Chi-squared and Fisher-exact analysis were used for statistical testing. The results showed that the mean VAS pain scores immediately after needle insertion were 40.19 ± 23.3 and 48.39 ± 26.5 in the MAI and CI technique groups, respectively. The MAI technique was less painful than the CI technique (p < 0.05). There were no complications from the injections in both methods. However, the recurrent rate seems to be higher in the conventional technique (p = 0.23). We concluded that the MAI injection technique provided less pain result than the CI technique and there were no complications from this injection technique.

Autogenous tricortical iliac crest bone graft is the most widely used for the anterior cervical interbody fusion procedure. The authors performed systematic measurements to delineate the thickest areas of the iliac crest, so that surgeons would know where to select the appropriate grafts for cervical interbody fusion. The Department of Anatomy, Faculty of Medicine, Khon Kaen University, supplied 232 iliac crests (116 left; 116 right) dried hip bones donated by 67 Thai males and 49 Thai females. The deceased averaged 59 years of age (range, 26-86). The thickest part of the iliac crest extended from 3 to 5 cm posterior to the ASIS and ranged between 15.59 and 17.02 mm. These regions have an appropriate thickness for harvesting graft material.

Clavicle fracture is the most common childhood fracture and one of the most common fractures in adults. Only some types of distal clavicular fractures, and dislocation of the acromioclavicular joint, require internal fixation. Many surgeons prefer closed pinning; however, the difficulty inserting many of the various kinds of pins from acromion into the medullary canal, of the distal clavicle, means the likelihood of iatrogenic complications from repeated drilling is heightened. The purpose of the present study was to establish what would be the optimum insertion point and direction for safe intramedullary pinning of the distal clavicle. Embalmed cadaveric shoulders (32) were studied. A bone window was created at the distal one-thirds of the clavicle, approximately 1.5 cm medial from the conoid tuberosity - as wide as could be freely, retrogradely drilled into the medullary canal of the distal clavicle. A 2.0-mm Kirschner wire was inserted until it penetrated the acromion. The point of emergence was recorded as ratio compared with the acromial width and length in coronal and sagittal planes, respectively. K-wire directions were measured as the angle between the K-wire and the reference line from the anterosuperior tubercle of the clavicle to the anterior angle of the acromion. The process was repeated until the acromion fractured 304 drillings were performed on 32 specimens. The length of the sagittal vs.coronal pin insertion point from the anterior vs. lateral borders of the acromion divided by its length vs. width averaged 0.325 +/- 0.04 and 0.397 +/- 0.09, respectively. The angle of the K-wire and the reference was 7.69 +/- 3.04 and 14.59 +/- 4.34 degrees in the coronal and horizontal planes, respectively. At 8 and 10 drillings survival was 0.72 (95%CI: 0.53-0.84) and 0.41 (95%CI: 0.24-0.57), respectively. The optimum pin inserting point for fixation of distal clavicle fracture and acromioclavicular joint dislocation is 32.5% and 39.7% of acromial length and width, respectively. If a 2.0-mm K-wire is used for fixation, drilling should not be repeated drilled more than 8 times to avoid sudden, high risk iatrogenic acromial fracture.