Reliability of gadolinium-enhanced magnetic resonance imaging findings and their correlation with clinical outcome in patients with sciatica

Background contextGadolinium-enhanced magnetic resonance imaging (Gd-MRI) is often performed in the evaluation of patients with persistent sciatica after lumbar disc surgery. However, correlation between enhancement and clinical findings is debated, and limited data are available regarding the reliability of enhancement findings.PurposeTo evaluate the reliability of Gd-MRI findings and their correlation with clinical findings in patients with sciatica.Study designProspective observational evaluation of patients who were enrolled in a randomized trial with 1-year follow-up.Patients samplePatients with 6- to 12-week sciatica, who participated in a multicentre randomized clinical trial comparing an early surgery strategy with prolonged conservative care with surgery if needed. In total 204 patients underwent Gd-MRI at baseline and after 1 year.Outcome measuresPatients were assessed by means of the Roland Disability Questionnaire (RDQ) for sciatica, visual analog scale (VAS) for leg pain, and patient-reported perceived recovery at 1 year. Kappa coefficients were used to assess interobserver reliability.MethodsIn total, 204 patients underwent Gd-MRI at baseline and after 1 year. Magnetic resonance imaging findings were correlated to the outcome measures using the Mann-Whitney U test for continuous data and Fisher exact tests for categorical data.ResultsPoor-to-moderate agreement was observed regarding Gd enhancement of the herniated disc and compressed nerve root (kappa<0.41), which was in contrast with excellent interobserver agreement of the disc level of the herniated disc and compressed nerve root (kappa>0.95). Of the 59 patients with an enhancing herniated disc at 1 year, 86% reported recovery compared with 100% of the 12 patients with nonenhancing herniated discs (p=.34). Of the 12 patients with enhancement of the most affected nerve root at 1 year, 83% reported recovery compared with 85% of the 192 patients with no enhancement (p=.69). Patients with and without enhancing herniated discs or nerve roots at 1 year reported comparable outcomes on RDQ and VAS-leg pain.ConclusionsReliability of Gd-MRI findings was poor-to-moderate and no correlation was observed between enhancement and clinical findings at 1-year follow-up.     

Reconstruction of epidural fat with engineered adipose tissue from adipose derived stem cells and PLGA in the rabbit dorsal laminectomy model

Epidural fibrosis resulted from epidural fat destruction following laminectomy operation is regarded as a main cause of failed back surgery syndrome, which represents one of the most common complications in spine surgery. Up to now, the effectiveness of currently available treatments to prevent such a syndrome is quite limited. In the present study, we aimed to restore epidural fat using adipose tissue engineered from adipose derived stem cells (ASCs) in a rabbit dorsal laminectomy model. ASCs isolated from subcutaneous fat were first expanded to passage 3, seeded on porous poly(lactic-co-glycolic acid, PLGA) scaffold and then adipogenically induced for 7 days in?vitro to form cell-scaffold complex. Laminectomy sites were created at T13-L1 level in each animal. The laminectomy defect was implanted either with cell-scaffold complex or PLGA scaffold alone. Non-treated defect was also included as a control. The animals were subjected to MRI evaluation at 1, 12 and 24 weeks post-surgery, and sacrificed at 24 weeks for gross and histological observation. It was demonstrated by MRI evaluation that scar tissue of coarse and high density was formed within laminectomy site in PLGA alone and non-treated groups as early as 12 weeks. However, the defect implanted with engineered adipose had formed a continuous linear adipose tissue regenerated along the spinal cord at 24 weeks. Histologically, a distinct area of adipose tissue just overlaying the dura mater could be identified in cell-scaffold complex treated group at 24 weeks post-operation. Regeneration of epidural fat was further confirmed by positive Oil Red O staining. As to the defect treated with PLGA alone or left untreated, either fine or dense scar tissue adhering to the dura mater was observed. Moreover, we could track the implanted ASCs labeled by magnetic nanoparticles within epidural area for as long as four weeks by MRI detection. Thus, adipose tissue engineered from ASCs exhibited great potential in restoration of epidural fat to prevent formation of epidural fibrosis.     

自体富血小板血浆局部注射治疗糖尿病足溃疡的临床研究

目的探讨局部注射自体富血小板血浆（platelet-rich plasma，PRP）治疗糖尿病足溃疡的疗效。方法将 2017 年 10 月—2018 年 10 月收治且符合选择标准的 90 例糖尿病足溃疡患者随机分为 3 组：PRP 注射组（A 组，创面及创周局部注射 PRP+水凝胶敷料覆盖创面）、PRP 覆盖组（B 组，PRP 凝胶+水凝胶敷料覆盖创面）和对照组（C 组，单纯水凝胶敷料覆盖创面），每组 30 例。3 组患者性别、年龄、侧别、病程及术前糖化血红蛋白、创面面积、Wagner 分级等一般资料比较，差异均无统计学意义（P>0.05），具有可比性。比较 3 组患者治疗次数、住院时间及 A、B 组 PRP 使用总量。治疗期间观察创面愈合情况，首次清创术后 3 个月测算创面愈合率。 结果A、B、C 组治疗次数分别为（10.2±0.8）、（11.4±0.6）、（12.5±0.5）次，A、B 组 PRP 使用总量分别为（306±24）、（342±18）mL，组间比较差异均无统计学意义（P>0.05）。A、B、C 组住院时间分别为（40.5±1.8）、（62.1±2.3）、（88.6±1.4）d，差异有统计学意义（P<0.05）。治疗过程中，3 组创面坏死渗出均逐渐减少，创面面积逐渐缩小；A 组均明显优于 B、C 组，B 组优于 C 组。首次清创术后 3 个月，A、B、C 组创面愈合率分别为 93.2%±0.8%、52.1%±1.1%、21.3%±1.3%，组间比较差异均有统计学意义（P<0.05）。 结论PRP 能有效促进糖尿病足溃疡创面修复，而且 PRP 局部注射疗效优于 PRP 凝胶覆盖。     

基于中日友好医院分型的股骨头坏死保髋手术疗效的影响因素分析

目的探讨基于中日友好医院(China-Japan Friendship Hospital,CJFH)分型的保髋手术疗效的影响因素。方法2012年6月至2016年9月接受保髋手术治疗的非创伤性股骨头坏死患者325例432髋。依据CJFH分型行髓芯减压自体骨髓单个核细胞移植141髋(髓芯减压组)和头颈部开窗减压病灶清除植骨术291髋(开窗减压组)。采用Harris髋关节功能评分评估临床疗效,摄X线片观察坏死修复、股骨头塌陷及关节退变。临床失败定义为末次随访时Harris评分较术前评级降低和(或)影像学上股骨头塌陷进展(ARCO分期增加)。终点事件为疼痛明显加重、Harris评分为差(<70分)和(或)股骨头进行性塌陷。采用Cox比例回归模型分析临床失败的危险因素。结果髓芯减压组67髋临床失败(47.5%,67/141),其中CJFH分型C+M型3髋(13.0%,3/23)、L1型24髋(38.1%,24/63)、L2型14髋(82.4%,14/17)、L3型26髋(68.4%,26/38)。开窗减压组106髋临床失败(36.4%,106/291),C+M型1髋(33.3%,1/3)、L1型41髋(31.3%,41/131)、L2型22髋(84.6%,22/26)、L3型42髋(32.1%,42/131)。髓芯减压组中不同年龄(χ2=3.887,P=0.049)、不同术前CJFH分型(χ2=40.943,P=0.000)的临床失败率的差异有统计学意义;Cox回归模型分析显示年龄≥40岁[HR=2.325,95%CI(1.398,3.866),P=0.000]、术前Harris评分70~80分[HR=2.163,95%CI(1.140,4.105),P=0.018]和<70分[HR=2.597,95%CI(1.173,5.749),P=0.019]、术前CJFH分型L2型[HR=35.052,95%CI(7.721,159.133),P=0.000)和L3型[HR=13.242,95%CI(3.104,56.491),P=0.000]是临床失败的危险因素。开窗减压组中不同年龄(χ2=8.437,P=0.004)、不同术前Harris评分(χ2=19.737,P=0.000)、不同术前CJFH分型(χ2=29.265,P=0.000)的临床失败率的差异有统计学意义;Cox回归模型分析显示术前Harris评分<70分[HR=5.102,95%CI(2.339,11.129),P=0.000]、术前CJFH分型L2型[HR=32.761,95%CI(6.165,43.507),P=0.000]是临床失败的危险因素。结论股骨头坏死保髋手术治疗效果受年龄、术前Harris评分和CJFH分型的影响;术前临床症状越明显,受累股骨头负重关节面及外侧柱支撑结构未得到有效重建,保髋手术的预后越差。     

The EndoPearl device increases fixation strength and eliminates construct slippage of hamstring tendon grafts with interference screw fixation

Purpose: The EndoPearl (Linvatec, Largo, FL), a biodegradable device to augment the femoral interference screw fixation of hamstring tendon grafts has been developed. The first objective of this study was to compare the initial fixation strength of quadrupled hamstring tendons and biodegradable interference screw fixation with and without the application of the EndoPearl device. The second objective was to determine the influence of the EndoPearl device on the fatigue behavior under incremental cyclic loading conditions in a simulation of critical fixation conditions. Type of Study: Biomechanical study. Methods: Fresh human hamstring tendons were harvested and grafts were fixed with biodegradable poly-L-lactide interference screws. Twenty proximal calf tibias were used to compare the initial fixation strength of the study and the control group. In the study group, the EndoPearl device was secured to the graft using two No. 5 Ethibond sutures (Ethicon, Somerville, NJ). Specimens were loaded until failure in a materials testing machine. For cyclic testing, human hamstring tendons and 20 distal porcine femurs were used. Critical graft fixation conditions were simulated by increasing tunnel diameter 2 mm over the graft diameter. Grafts were loaded progressively in increments of 100 N until failure; 100 cycles were applied per load increment. Results: Graft fixation with the additional EndoPearl device had a significantly higher maximum load to failure (658.9 ± 118.1 N v 385.9 ± 185.6 N, P =.003) and stiffness (41.7 ± 11 N/mm v 25.7 ± 8.5 N/mm). Graft fixation with the EndoPearl device sustained a significant higher total number of cycles (388.5 ± 125.6) compared with the control group (152.8 ± 144.9, P =.002). Conclusions: We demonstrated that the augmentation of a hamstring tendon graft with the EndoPearl device increases interference screw fixation strength significantly. Under dynamic loading conditions, specimens of the study group sustained substantially higher loads and a larger number of cycles, which indicates a greater resistance to graft slippage. The application of the EndoPearl device may also allow for a secure soft-tissue graft fixation with interference screws in cases of critical fixation conditions.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 4 (April), 2001: pp 353–359     

外旋型踝关节骨折中后踝的治疗

目的：总结踝关节骨折中后踝的诊断、手术方法,阐述后踝骨折复位固定的重要性。方法：2004年1月至2008年1月手术治疗的踝关节外旋型骨折合并后踝骨折患者25例,男17例,女8例;年龄21-67岁,平均34岁。按Lauge—Hansen分型,旋前外旋型Ⅳ型13例,旋后外旋型Ⅲ型7例、Ⅳ型5例。后踝骨折中20例采用螺钉内固定,5例采用石膏外固定。术后用X线即时评估标准观察手术复位效果。结果：随访时间为7～36个月,平均15个月,按Leeds临床评定标准进行评定,优21例,良2例,差2例。对踝关节作活动范围的评估并与健侧比较,两者在背伸、跖屈方面无明显差异。结论：良好的复位、固定,以及后踝正确处理是恢复踝关节正常功能的保证。