Kenjiro Nakama

Collagen Production at the Edge of Ruptured Rotator Cuff Tendon is Correlated With Postoperative Cuff Integrity

PURPOSE The purpose was to evaluate the correlation between messenger RNA (mRNA) expression of collagen at the edge of the ruptured rotator cuff tendon and postoperative cuff integrity. METHODS The edge of the ruptured tendon was sampled during open rotator cuff surgery in 12 patients with full-thickness rotator cuff tears (mean age, 58.2 years). The mean period from symptom onset was 9.3 months (range, 1 to 36 months), and the mean tear size was 4.1 cm. As controls, rotator cuff tendons with no gross rupture were taken from 5 fresh cadavers. Production of type I and type III collagen was examined by real-time reverse transcription polymerase chain reaction. By use of magnetic resonance imaging, postoperative cuff integrity was evaluated based on the classification of Sugaya et al. and then scored, ranging from 5 points for type I to 1 point for type V. RESULTS Looking at the mRNA of type I and type III collagen in tendons, we found that the expression of mRNA for both collagen types in ruptured tendons was significantly greater than in control tendons (P = .0462 for type I collagen and P = .0306 for type III collagen). Correlating the mRNA of type I and type III collagen with repaired cuff integrity on postoperative magnetic resonance imaging, we found a close relation between expression of mRNA for both collagen types and postoperative rotator cuff integrity (r = 0.63 [P = .038] for type I collagen and r = 0.626 [P = .03] for type III collagen). Furthermore, expression of type I collagen mRNA showed a significant inverse correlation with the period from symptom onset (r = -0.845, P < .0005). CONCLUSIONS This study showed that expression of mRNA for type I and type III collagen at the edge of the ruptured rotator cuff tendon was significantly correlated with postoperative cuff integrity and that mRNA expression for type I collagen was significantly associated with the period from symptom onset. These results may suggest that conservative treatment should not be prolonged if patients do not respond within a certain period. LEVEL OF EVIDENCE Level III, prognostic case-control study.

Effects of Hyaluronan on Cell Proliferation and mRNA Expression of Procollagens α1 (I) and α1 (III) in Tendon-Derived Fibroblasts from Patients with Rotator Cuff Disease: An in Vitro Study

Background Hyaluronan (HA) improves postoperative recovery after flexor tendon surgery, preventing postoperative adhesion. However, its influence on the rotator cuff tendon after cuff repair has not yet been clarified in detail. Hypothesis Hyaluronan is likely to modulate cell proliferation and mRNA expression of procollagens α1 (I) and α1 (III) in tendon-derived fibroblasts in patients with rotator cuff disease. Study Design Controlled laboratory study. Methods The study subjects were 10 patients with rotator cuff disease, with an average age of 62 years (range, 44-72). Various concentrations of HA (1.0-5.0 mg/mL) were added to monolayer-cultured tendon-derived fibroblasts from these patients. Hyaluronan binding and CD44 expression on the tendon-derived fibroblasts were evaluated by confocal microscopy using fluorescein-conjugated HA and antihuman CD44 antibody (OS/37). Cell proliferation was evaluated by recording changes in cell number. The levels of expression of procollagen α1 (I) and α1 (III) mRNA were measured by real-time reverse transcriptase polymerase chain reaction. Results Immunofluorescence cytochemistry detected constitutive binding of HA and CD44 expression on the tendon-derived cells. Treatment with various concentrations of HA significantly inhibited cell proliferation and decreased the expression level of procollagen α1 (III) mRNA, but not that of procollagen α1 (I) mRNA, in the tendon-derived fibroblasts. Conclusion Hyaluronan modulates cell proliferation and the expression level of procollagen α1 (III) mRNA, but not that of procollagen α1 (I), in fibroblasts from patients with rotator cuff disease. Clinical Relevance Postoperative use of exogenous HA may allow the healing of a repaired rotator cuff tendon with minimal adhesion.

Use of autologous fibrin sealants to treat ganglion cysts: a report of two cases

Two patients underwent arthroscopy-guided injections of autologous fibrin sealants to treat ganglion cysts causing suprascapular nerve palsies. After at least 2 years of follow-up, both patients had no suprascapular nerve symptoms and their external rotation strength had returned to normal. Magnetic resonance imaging revealed no evidence of ganglion cyst recurrence.

The modified massive cuff stitch: functional and structural outcome in massive cuff tears

BackgroundThe massive cuff stitch (MCS) is known to be a strong suture, suitable for rotator cuff repair. We modified this technique for massive cuff tears by employing a horizontal medial mattress suture from an anchor as well as a vertically crossing transosseous suture.MethodsWe included 42 patients with massive cuff tears suitable for repair: 22 were treated with the modified MCS (MCS group), and 20 with a simple transosseous suture (STS group). The range of motion (ROM), muscle strength, visual analog scale, and the Japanese Orthopaedic Association (JOA) scores were evaluated pre-operatively and 12 and 24 months post-operatively. The incidence of post-operative re-tears was examined at least 1 year post-operatively using Sugayas classification.ResultsThe ROM, muscle strength, degree of pain, and the JOA scores were much improved after surgery in both groups, and there was no significant intergroup difference throughout the pre- and post-operative periods. In contrast, post-operative MRI revealed a significantly lower re-tear rate in the MCS group than in the STS group (9.1% vs. 40%, P = 0.0296).ConclusionsThe techniques tested were comparable in terms of functional outcome after surgical repair of massive cuff tears; however, the modified MCS repair technique produced superior structural outcomes with a significantly lower re-tear rate.

Epiphyseal Fracture of the Coracoid Process Occurring at the Conjoined Tendon Origin

Fracture of the coracoid process is uncommon, and most previous studies have reported this fracture occurring in association with direct trauma to the shoulder or transmission of force from the upper arm or elbow (Ada and Miller 1991, Benton and Nelson 1971, Eyres et al. 1995). We present a case in which epiphyseal fracture occurred at the origin of the conjoined tendon following excessive muscle contraction. We believe this represents the first description of such a method of injury.

Calcific Tendonitis of the Rotator Cuff: An Unusual Case

Few case reports have described the surgical treatment of calcifying tendonitis of the subscapularis tendon. We present a case of symptomatic diffuse calcifying tendonitis involving the subscapularis and infraspinatus insertions that was difficult to detect arthroscopically. The patient was treated with arthroscopic incision of the tendinous insertions thorough removal of the calcific deposits and subsequent repair using a suture-anchor technique. Two years after the surgical procedure, the patient was completely pain-free and attained full range of motion. Radiographic evaluation performed 2 years after the procedure revealed no calcific deposits. We conclude that the combination of incision of the subscapularis and infraspinatus insertions, complete removal of the calcific deposits, and subsequent suture-anchor repair in an all-arthroscopic manner can lead to an excellent clinical outcome without compromising the functional integrity of the rotator cuff tendons.

Frequency of Scapholunate Ligament Injuries Associated with Distal Radius Shearing Fracture: Correlation of Fracture Patterns and Ligament Tear

BACKGROUND This retrospective study assessed the prevalence and outcome of intercarpal ligament injuries in non-osteoporotic patients with AO/ASIF classification type B distal radius shearing fractures treated with or without scapholunate temporary fixation. METHODS Fifteen patients (mean age, 33 years) were analyzed according to their scapholunate ligament status at the time of injury and graded with a modified Geissler classification system. Each patients postoperative pain and occupational status were assessed in the context of the Modified Mayo wrist score. Second-look arthroscopy was performed for all cases. RESULTS Scapholunate ligament injuries were present in 14 of 15 type B fractures. Surgical outcomes yielded an improvement in the Mayo wrist score with pinning in cases involving grade 3 or 4 scapholunate injuries. Two cases without pinning had a worse score, as well as a persistent scapholunate tear that was not healed at second-look arthroscopy after eight postoperative months. However, in grade 1 or 2 scapholunate injuries, the Mayo wrist score did not differ between those treated with and without pinning. CONCLUSIONS Scapholunate ligament injury is an important risk factor associated with high-energy distal radius shearing fractures. To prevent these problems, temporary scapholunate joint fixation is a recommended treatment for grade 3 or 4 scapholunate injuries.

Disseminated Mycobacterium intracellulare infection with multiple abscesses on extremities in a woman with chronic corticosteroid therapy

A 78‐year‐old Japanese woman with rheumatoid arthritis was admitted to our hospital due to fever. She had been prescribed prednisolone and bucillamine. Computed tomography revealed abscesses on extremities. M. intracellulare was cultured from her calcaneus osteomyelitis, and this result pointed to a disseminated mycobacterial infection. We drained the abscesses and found M. intracellulare. We started antimycobacterial agents, but the patient died finally. Disseminated mycobacterial infection is rare but critical, and the possibility of such an infection in an immunocompromised patient should be a prime consideration when choosing appropriate drugs and surgical approaches.

Emergency Operation for Spinal Diseases

There are few reports on the prognosis of emergency operations for spinal diseases. We investigated the prognosis of emergency operations. Twenty-nine out of 632 patients with spinal diseases, who were operated during the fifteen years between 1998 and 2003, were treated by emergency operations. These patients were followed up for an average of one and a half years. Operations were performed for the following diseases; nine lumbar disc herniations, four spinal epidural hematomas, three spinal tumors, three spinal fractures, two osteoporotic vertebral fractures, one cervical disc herniation, one lumbar canal stenosis, and five pyogenic spondylitis with sepsis. When operations were performed 24 hours from paralysis, the dysuria or sepsis occured. Nineteen patients showed paralysis, 13 of which improved. Lumbar disc degenerative diseases and spinal epidural hematomas tended to improved better than the spinal fractures. Fifteen patients showed dysuria, 9 of which improve. Four out of five pyogenic spondylitis improved, and the remaining one with secondary pyogenic spondylitis after posterior spinal fusion with instrumentation needed further closed suction irrigation. Emergency operation was effective for paralysis, dysuria, and severe inflammation. The indication should be considered depending on disease.

Surgical Treatment for Cervical Myelopathy in Young Adult Patients under 40 Years Old.

We investigated the clinical results in 28 young adult patients with cervical myelopathy under 40, from January 1990 to December 2001. Four patients were female and 24 were male. The diagnosis was disc herniation in 19 patients, ossification of the posterior longitudinal ligament (OPLL) in 3, athetoid cerebral palsy in 3, Klippel-Feil syndrome in 1, and developmental canal stenosis without other cervical disease in 2. Their mean age was 34 (22 to 40) years. Nineteen patients were treated by expansive laminoplasty, and the other 9 by anterior interbody fusion. The operative results were evaluated according to the Japanese Orthopaedic Association (JOA) score, after a mean follow-up period of 44 (2-139) months. The mean JOA score was 11.0 points before surgery and 15.1 points after surgery. The overall mean recovery rate by JOA score was 63.2%. The preoperative and postoperative JOA scores were significant lower in patients with a preoperative long duration of symptoms compared with patients with a short duration of symptoms before surgery. These results suggest that early surgical treatment provides satisfactory results in young adult patients with cervical myelopathy.