We report the case of a 60-year-old woman with left knee pain for 6 years, and left knee osteoarthritis was diagnosed by physical examination and radiography. She had a prior history of the right knee osteoarthritis and underwent total knee arthroplasty (TKA). After we performed TKA on her left knee, drop foot and sensory impairment were observed in the ward postsurgery, complicated with common peroneal nerve injury.

Osteoarthritis (OA) is a common degenerative joint disease characterized by progressive deterioration of articular cartilage. There have been reports that small molecule inhibitors have anti-osteoarthritis effects; however, the effects of 3-(4-chloro-2-fluorophenyl)-6-(2,4-difluorophenyl)-2H-benzo[e] [1,3]oxazine-2,4(3H)-dione (Cm-02) and 6-(2,4-difluorophenyl)-3-(3,4-difluorophenyl)-2H-benzo[e] [1,3]oxazine-2,4(3H)-dione (Ck-02), small molecule inhibitors which share many structural similarities with quercetin (a potent anti-inflammatory flavonoid), remain unclear. In this study, TNF-α-stimulated porcine and human chondrocyte models were used to investigate the inhibitory effects of Cm-02 and Ck-02 on the molecular mechanisms underlying the anti-OA effects. TNF-α was used to stimulate porcine and human chondrocytes to mimic immunomodulatory potency in-vitro. Anti-osteoarthritic effects were characterized in terms of protein and mRNA levels associated with the pathogenesis of OA. We also examined (1) the inducible nitric oxide synthase (iNOS)-nitric oxide (NO) system in cultured chondrocytes, (2) matrix metalloproteinases (MMPs) in cultured chondrocytes, and (3) aggrecan degradation in cartilage explants. Finally, we tested the activation of nuclear factor-kappaB (NF-κB), interferon regulatory factor-1 (IRF-1), and activate the protein-1 (AP-1), and we tested the signal transduction and activation of transcription-3 (STAT-3). Our results indicate that, in chondrocytes, Cm-02 and Ck-02 inhibit TNF-α induced NO production, iNOS, MMP, the expression of disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS), and the enzyme activity of MMP-13. Furthermore, both Cm-02 and Ck-02 were found to stimulate TNF-α, which has been shown to suppress the activation of several transcription factors, including NF-κB, STAT-3, and IRF-1 in porcine and human chondrocytes. Cm-02 and Ck-02 were also found to help prevent the release of proteoglycans from cartilage explants. Our findings demonstrate that both Cm-02 and Ck-02 have potent anti-inflammatory activities and the ability to protect cartilage in an OA cell model. These findings indicate that Cm-02 and Ck-02 have the potential to be further developed for the therapeutic treatment of OA.

Osteoarthritis (OA) is the most common joint disorder and primarily affects older people. The ideal anti-OA drug should have a modest anti-inflammatory effect and only limited or no toxicity for long-term use. Because the antitussive medication dextromethorphan (DXM) is protective in atherosclerosis and neurological diseases, two common disorders in aged people, we examined whether DXM can be protective in pro-inflammatory cytokine-stimulated chondrocytes and in a collagen-induced arthritis (CIA) animal model in this study. Chondrocytes were prepared from cartilage specimens taken from pigs or OA patients. Western blotting, quantitative PCR, and immunohistochemistry were adopted to measure the expression of collagen II (Col II) and matrix metalloproteinases (MMP). DXM significantly restored tumor necrosis factor-alpha (TNF-alpha)-mediated reduction of collagen II and decreased TNF-alpha-induced MMP-13 production. To inhibit the synthesis of MMP-13, DXM blocked TNF-alpha, downstream signaling, including I kappa B kinase (IKK)alpha/beta-I kappa B alpha-nuclear factor-kappaB (NF-kappa B) and c-Jun N-terminal kinase (JNK)-activator protein-1 (AP-1) activation. Besides this, DXM protected the CIA mice from severe inflammation and cartilage destruction. DXM seemed to protect cartilage from inflammation-mediated matrix degradation, which is an irreversible status in the disease progression of osteoarthritis. The results suggested that testing DXM as an osteoarthritis therapeutic should be a focus in further research.

In this study, we synthesized hundreds of analogues based on the structure of small-molecule inhibitors (SMIs) that were previously identified in our laboratory with the aim of identifying potent yet safe compounds for arthritis therapeutics. One of the analogues was shown to share structural similarity with quercetin, a potent anti-inflammatory flavonoid present in many different fruits and vegetables. We investigated the immunomodulatory effects of this compound, namely 6-(2,4-difluorophenyl)-3-(3-(trifluoromethyl)phenyl)-2H-benzo[e][1,3]oxazine-2,4(3H)-dione (Cf-02), in a side-by-side comparison with quercetin. Chondrocytes were isolated from pig joints or the joints of patients with osteoarthritis that had undergone total knee replacement surgery. Several measures were used to assess the immunomodulatory potency of these compounds in tumor necrosis factor (TNF-α)-stimulated chondrocytes. Characterization included the protein and mRNA levels of molecules associated with arthritis pathogenesis as well as the inducible nitric oxide synthase (iNOS)–nitric oxide (NO) system and matrix metalloproteinases (MMPs) in cultured chondrocytes and proteoglycan, and aggrecan degradation in cartilage explants. We also examined the activation of several important transcription factors, including nuclear factor-kappaB (NF-κB), interferon regulatory factor-1 (IRF-1), signal transducer and activator of transcription-3 (STAT-3), and activator protein-1 (AP-1). Our overall results indicate that the immunomodulatory potency of Cf-02 is fifty-fold more efficient than that of quercetin without any indication of cytotoxicity. When tested in vivo using the induced edema method, Cf-02 was shown to suppress inflammation and cartilage damage. The proposed method shows considerable promise for the identification of candidate disease-modifying immunomodulatory drugs and leads compounds for arthritis therapeutics.

Subtle injuries of the Lisfranc joint complex are uncommon and difficult to diagnose clinically and thus are easily missed even by experienced orthopedic doctors. Misdiagnosed injuries can lead to chronic disability until eventual fusion surgery. We describe 10 cases diagnosed with subtle injury of the Lisfranc joint that were treated with combined innovative portal arthroscopy and fluoroscopy-assisted reduction and percutaneous screw fixation in an interfragmentary fashion. The distance between the first and second metatarsals (the Lisfranc distance) and that between the medial cuneiform and fifth metatarsal base (foot arch height) was measured before and after surgery. The American Orthopaedic Foot and Ankle Society function score was evaluated perioperatively. The average preoperative and postoperative Lisfranc distance was 4.38 ± 0.39 mm and 2.68 ± 0.9 mm, the foot arch height was 12.63 ± 2.75 mm and 21.80 ± 3.50 mm, and the American Orthopaedic Foot and Ankle Society score was 59.1 ± 5.69 and 86.8 ± 10.1, respectively. Of the 10 patients, 3 had excellent outcomes, 6 had good outcomes, and 1 had a fair outcome. In conclusion, we report a useful and minimally invasive surgery for acute, subacute, and even chronic subtle injury of the Lisfranc joint. The Lisfranc distance, foot arch height, and function of the foot were restored clinically, and all measurements showed statistically significant differences.

High uric acid levels are a risk factor for cardiovascular disorders and gout; however, the role of physiological concentrations of soluble uric acid (sUA) is poorly understood. This study aimed to clarify the effects of sUA in joint inflammation. Both cell cultures of primary porcine chondrocytes and mice with collagen-induced arthritis (CIA) were examined. We showed that sUA inhibited TNF-α- and interleukin (IL)-1β–induced inducible nitric oxide synthase, cyclooxygenase-2 and matrix metalloproteinase (MMP)-13 expression. Examination of the mRNA expression of several MMPs and aggrecanases confirmed that sUA exerts chondroprotective effects by inhibiting the activity of many chondro-destructive enzymes. These effects attenuated collagen II loss in chondrocytes and reduced proteoglycan degradation in cartilage explants. These results were reproduced in chondrocytes cultured in three-dimensional (3-D) alginate beads. Molecular studies revealed that sUA inhibited the ERK/AP-1 signalling pathway, but not the IκBα-NF-κB signalling pathway. Increases in plasma uric acid levels facilitated by the provision of oxonic acid, a uricase inhibitor, to CIA mice exerted both anti-inflammatory and arthroprotective effects in these animals, as demonstrated by their arthritis severity scores and immunohistochemical analysis results. Our study demonstrated that physiological concentrations of sUA displayed anti-inflammatory and chondroprotective effects both in vitro and in vivo .

Mesenchymal stromal/stem cells (MSCs) are widely distributed in different tissues such as bone marrow, adipose tissues, peripheral blood, umbilical cord and amnionic fluid. Recently, MSC-like cells were also found to exist in rat olfactory bulb and are capable of inducing differentiation into mesenchymal lineages - osteocytes, chondrocytes and adipocytes. However, whether these cells can differentiate into myocardial cells is not known. In this study, we examined whether olfactory bulb-derived MSCs could differentiate into myocardial cells in vitro. Fibroblast-like cells isolated from the olfactory bulb of neonatal rats were grown under four conditions: no treatment; in the presence of growth factors (neuregulin-1, bFGF and forskolin); co-cultured with cardiomyocytes; and co-cultured with cardiomyocytes plus neuregulin-1, bFGF and forskolin. Cell differentiation into myocardial cells was monitored by RT-PCR, light microscopy immunofluorescence, western blot analysis and contractile response to pharmacological treatments. The isolated olfactory bulb-derived fibroblast-like cells expressed CD29, CD44, CD90, CD105, CD166 but not CD34 and CD45, consistent with the characteristics of MSCs. Long cylindical cells that spontaneously contracted were only observed following 7 days of co-culture of MSCs with rat cardiomyocytes plus neuregulin-1, bFGF and forskolin. RT-PCR and western blot analysis indicated that the cylindrical cells expressed myocardial markers, such as Nkx2.5, GATA4, sarcomeric alpha-actinin, cardiac troponin I, cardiac myosin heavy chain, atrial natriuretic peptide and connexin 43. They also contained sarcomeres and gap junction and were sensitive to pharmacological treatments (adrenal and cholinergic agonists and antagonists). These findings indicate that rat olfactory bulb-derived fibroblast-like cells with MSC characteristics can differentiate into myocardial-like cells. Copyright (C) 2013 John Wiley & Sons, Ltd.

Subtle injuries to the Lisfranc joint complex are difficult to diagnose clinically and radiographically and can ultimately result in obvious disability if misdiagnosed. However, no previous study has shown the true mean average distance between the base of the first and second metatarsals (the Lisfranc distance). Therefore, in the present study, the anatomic and radiographic parameters of the Lisfranc joint were studied in detail to assist in the evaluation of Lisfranc injuries. The parameters of the Lisfranc joint complex in 100 normal volunteers and 10 cadavers were measured, including the medial, lateral depth of the mortise joint, width and height of the second metatarsal base, and distance between the base of the first and second metatarsals. The mean average Lisfranc distance was 0.24 ± 0.06 mm in the left foot and 0.25 ± 0.06 mm in the right foot for the radiographic group (p = .089) and 0.39 ± 0.04 mm in the left foot and 0.37 ± 0.04 mm in the right foot for the cadaver group (p = .129). The medial depth and Lisfranc distance in the radiographic group were smaller than the same measurements in the cadaver group, and these differences were statistically significant (medial depth, p < .001; Lisfranc distance, p < .001). The lateral depth and second metatarsal height in the radiographic group were larger than the same measurements in the cadaver group, and these differences were statistically significant (lateral depth, p < .001; second metatarsal height, p < .001). The second metatarsal width was the same in the 2 groups (p = .651). In conclusion, if the Lisfranc distance is >3.0 mm radiographically, a subtle injury to the Lisfranc joint should be highly suspected. No test of stability was performed between shallow and narrow versus deeper and broader Lisfranc mortise configurations. We merely speculated that a deeper and wider mortise is likely to be more stable than one that is shallow and narrow, probably owing to the presence of broader ligaments.

Gauzoma is also called as gauze-induced granuloma, and it always grows rapidly. It is a familiar surgical complication although it is a rare orthopaedic condition. We described a 26-year-old male and he had ever received the operation of open reduction and internal fixation with interlocking nail under the diagnosis of fracture of left femoral shaft about 3 years ago. Removal of implant was performed about two years ago. Unfortunately, a huge mass over medial side of left thigh was found after operation. He received magnetic resonance imaging study and it showed a heterogenous tumor with clear margin. A well-capsuled tumor was resected and multiple-piece gauze retention was noted. It was proved by pathologic report later. Early detection and avoid surgical complication were necessary.

Purpose: The aim of this study was to compare the initial fixation strength of tendon grafts between different sizes of bioabsorbable interference screws (BioScrew; Linvatec, Largo, FL) with bioabsorbable bead (EndoPearl; Linvatec) augmentation through biomechanical analysis of a porcine femoral bone model. Methods: Forty pairs of porcine femurs and porcine flexor digitorum profundus tendons were divided into control and study groups. In the control group 8 X 30-mm BioScrews alone (n = 10) were inserted, whereas different sizes of BioScrews, measuring 7 X 30 mm (n = 10), 8 X 30 mm (n = 10), and 9 X 30 mm (n = 10), with 8-mm EndoPearl augmentation were inserted individually for fixation of tendon grafts in the study groups: All specimens were cyclically loaded with axial forces between 50 and 250 N at 1 Hz for 3,000 cycles and then incrementally loaded to failure at a rate of 150 mm/mm. Results: BioScrews with EndoPearl augmentation had a significantly higher failure load than BioScrews alone (8-mm BioScrew alone v 8-mm BioScrew and EndoPearl, P < .05). There were no significant differences in the ultimate failure load (8 mm v 7 mm and 9 mm, P = .201 and P = .871, respectively), stiffness (8 mm v 7 mm and 9 mm, P = .789 and P = .823, respectively), displacement (8 mm v 7 mm and 9 mm, P = .695 and P = .781, respectively), and bone mineral density (P = .728 for all comparisons) except insertion torque (8 mm v 7 mm and 9 mm, P = .045 and P = .518, respectively) between study groups. Less tendon laceration by the screw thread was noted in the group in which smaller-sized BioScrews were used. Conclusions: When EndoPearl augmentation was used, smaller-sized BioScrews (BioScrew size I mm smaller than bone tunnel) offered equivalent graft fixation strength to BioScrews of similar or larger sizes. Clinical Relevance: Smaller-sized BioScrews can be chosen if EndoPearl augmentation has been used, and EndoPearl augmentation may reduce the risk of tendon rupture while BioScrews are inserted.

Purpose: To determine if the arthroscopic removal of gouty crystal deposits from the first metatarsophalangeal (MTP) joint will reduce the recurrence rate and improve foot function compared to medical treatment alone. Methods: Twenty-eight male patients with hyperuricemia (>7.0 mg/dL) and repeated attacks of gouty arthritis of the first MTP joint were included in this study. Arthroscopic intervention of the first MTP joint was performed on 15 patients (group 1), while the other 13 patients were treated with medication alone (group 2). The follow-up period (mean +/- standard deviation) was 3.9 +/- 1.1 years in group 1 and 2.4 +/- 0.3 years in group 2. Results: After treatment, both groups showed a significant improvement in the number of acute attacks of gouty arthritis and in their functional scores on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale. On both measures, the results for group 1 were significantly better than those for group 2. Conclusions: Arthroscopic removal Of gouty crystals from the first MTP joint can reduce the rate of acute repeated attacks Of gouty arthritis and increase foot and ankle function. Level of Evidence: Level IV, therapeutic case series.

BACKGROUNDNeglected or chronic rupture of the Achilles tendon usually needs a reconstruction procedure. Many graft sources have been reported for this procedure, such as a proximal V-Y gastrocnemius tendon flap, flexor hallucis longus tendon, fascia lata, plantaris tendon, synthetic materials, and peroneus brevis. However, how to fix the graft at the calcaneal site remains controversial.METHODSAn alternative technique to anatomically reconstruct the Achilles tendon using an autogenous peroneal longus tendon with EndoButton-CL fixation at the calcaneal site for treatment of a patient who had a chronic neglected rupture of the Achilles tendon is described.RESULTSThe patient was allowed to begin gentle exercise, such as swimming and cycling 12 weeks after surgery, and encouraged to augment rehabilitation of hindfoot eversion and ankle plantar flexion. The ankle plantar flexion and hindfoot eversion strength was not reduced after active rehabilitation in 2.5 years of follow-up.CONCLUSIONSOur technique reuses two small central incisions, thus, preserving skin integrity as much as possible to reduce wound breakdown or infection. The management of chronic or neglected Achilles tendon rupture by autogenous peroneal longus tendon with EndoButton-CL fixation at the calcaneal site is an anatomic and safe, but technically demanding technique.

We present the case of a 9-year-old girl who had complained of mid-back pain for two months. The plain X ray of the thoracic spine revealed vertebra plana (collapse of the vertebral body), and magnetic resonance imaging of the thoracic spine showed that the T-7 vertebral body had collapsed, and there was slight compression of the spinal cord. The patient underwent a fluoroscopy-guided percutaneous transpedicular biopsy and the histology led to a diagnosis of Langerhans' cell histiocytosis. After low-dose radiotherapy and six months immobilized in a spinal brace, the mid-back pain subsided but the plain X ray of the thoracic spine revealed collapse of the vertebral body. Therefore, we report it as a rare case and discuss the clinical significance of this disorder.

Background: The surgical treatment methods for recurrent dislocation of peroneal tendons are controversial. A simpler and more effective treatment method is valuable for these patients.Hypothesis: A new rerouting operation designed by the authors will have satisfactory results and avoid disadvantages of the old rerouting methods.Study Design: Case series; Level of evidence, 4.Methods: Seventeen consecutive male patients with unilateral recurrent peroneal tendon dislocations were treated by transposition of the calcaneofibular ligament from the tubercle of calcaneofibular ligament with a 1 x 1 x 1 cm(3) bone block and elevation of this tubercle with another 1 x 1 x 1 cm(3) calcaneal bone block, which were fixed by a 3.5-mm cancellous screw with a washer. All patients received clinical and radiographic follow-up for at least 2 years. The preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scales were used for functional results assessment.Results: All bone transposition sites healed radiographically at 6 weeks after surgery. Four patients had transient numbness over the lateral aspect of the injured foot, and 3 patients had swelling and pain involving the operative sites. All complications resolved by 3 to 5 months after the operation. No recurrent dislocation of the peroneal tendons was noted. The mean AOFAS ankle-hindfoot scale improved significantly, from 73.4 +/- 5.5 preoperatively to 100 at 2- to 5-year follow-up (P < .001). Normal ankle stability and no tightening of the lateral side of the injured ankles in the inversion position were noted.Conclusion: This method is a simple, reliable, and reproducible operation to treat recurrent dislocation of the peroneal tendons. It allows early return to daily, working, and sports activities with satisfactory results.

We determined the relationship between atrophy of the supraspinatus muscle and functional outcomes in 27 patients with full-thickness rotator cuff tears who underwent orthroscopic ocromioplosty and mini-open cuff repair. Before surgery, all underwent a physical examination and magnetic resonance imaging of the involved shoulder. Using image-processing software, we measured the cross-sectionol area of the total supraspinatus muscle (including regions of fatty degeneration and atrophy) and of the atrophic supraspinatus muscle on sagittal oblique images obtained about 20 mm proximal to the glenoid surface. The atrophic-to-total ratio (A/T ratio) of these areas was then calculated. We assessed functional outcomes by the Constant and Murley functional score at long-term follow-up. The correlation between the A/T ratios and the functional ratings was statistically analyzed. The results demonstrated a significant positive correlation between A/T ratios of the suprospinatus muscle and functional outcomes.

Background. The purpose of this study was to evaluate an alternate method using endoscopic bursectomy with mini-open partial scapulectomy for treating snapping scapula in patients who did not respond to conservative therapy.Materials and methods. Between November 2000 and November 2004, endoscopic bursectomy with mini-open partial scapulectomy was performed in 12 cases with snapping scapula. Four cases had bilateral involvement; eight had unilateral involvement. Nine cases had a history of trauma. The mean duration of conservative therapy was 4.1 (range, 1-8) y. The procedure was performed at the superomedial angle of the scapula in 10 cases, at the medial border in two cases, and at the inferomedial angle in one case. The mean postoperative follow-up was 3.1 (range, 2-5) years.Results. The American Shoulder and Elbow Surgeon score increased (preoperatively, 36.3 to postoperatively, 88.3), the Simple Shoulder Test score increased (3.8 to 10.1), and the Visual Analogue Score decreased (8.3 to 2.3) significantly (all P < 0.01). The snapping sound and pain improved in 10 of 12 cases. All patients returned to work.Conclusion. Endoscopic bursectomy with mini-open partial scapulectomy is a reliable, alternate treatment for snapping scapula. (C) 2008 Elsevier Inc. All rights reserved.

Posterior instrumentation through the pedicle is a common surgery. Understanding the morphometry of the pedicle and the anatomy of adjacent neural structures should help decrease the risk of postoperative complications. T1-L5 segments from 15 sets of human vertebrae were separated into individual vertebrae and the morphometric characteristics of the thoracic and lumbar spine and the safe zone of the pedicle were analyzed. T11-L5 segments from six human cadavers were dissected. Measurements were taken from the pedicle to the dura and nerve roots superiorly, inferiorly, medially, and laterally, and the transverse angles of the nerve roots were measured. Pedicles were widest in L5 and narrowest in T4 in the transverse plane, and widest in T11 or T12 and narrowest in T1 in the sagittal plane. In individual pedicle, the ranges of the safe zone width and height were 3.4-7.7 and 8.6-13.7 mm, respectively, in T1-T10; and 7.2-17.8 and 13.9-16.7 mm, respectively, in T11-L5. The transverse angle of the pedicle decreases progressively from T1 to T12, then increase from L1 to L5. In sagittal angle, the largest angle localized at T2 and the smallest at L5. The mean distances from pedicles to adjacent neural structures were greater superiorly and laterally than inferiorly and medially. The lateral distance between nerve root and the pedicle ranged from 2.4 to 9.6 mm in lumbar spine. This study provides potential safe zones for the application of through-pedicle procedures to help decrease the risk of postoperative complications.

Pigmented villonodular synovitis (PVNS) is a rare proliferative process affecting synovial joints, tendon sheath and bursal membranes. Monoarticular involvement is typical with the knee most common affected. It occurred in the third or fourth decade of life without sex predilection. Recurrence is common, but malignant transformation is rare. We reported a 24-year-old male who sustained swelling and locking of left knee following anterior cruciate ligament reconstruction(ACLR)with bone patella tendon bone(BPTB) autograft. After second look of knee arthroscopy, it was proven as localized pigmented villonodular synovitis(PVNS)in pathologic report. We performed arthroscopic synovecto my using vaporization system simultaneously. Postoperative range of motion and weightbearing were suggested. We didn't find any limitation of motion and swelling after surgery 2 weeks later, and in following year. Localized PVNS following ACLR is really uncommon and no previous articles had been reported. Arthroscopic synovectomy is a reliable, less invasive method to treat localized PVNS.

A solid fusion of a knee is still considered the most successful treatment for intractable pyogenic, tuberculous arthritis or varying arthritis. The indications for knee joint arthroplasty following solid fusion were certainly few and the procedure of total knee arthroplasty (TKA) in fused knee was technical demanding and high-risk of postoperative complications. We reported a 40-year-old male who had undergone right knee fusion 30 years previously because of knee trauma. We performed TKA via a medial parapatellar incision to follow the previous incision scar without performing V-Y quadricepsplasty. After 12 months' follow-up, no instability, skin necrosis or prosthesis loosening was found except persistent limitation of range of motion (ROM). The postoperative ROM was 0o to 30o and arthrofibrosis was diagnosed at the latest follow-up. The preoperative Hospital for Special Surgery Knee rating system was 57 and 69 postoperatively. Because such a complication was high, takedown of a formal knee fusion with TKA should be performed only in carefully selected cases with high motivation. Perioperative quadricepsplasty and aggressively postoperative rehabilitation were important to prevent such complication.