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Purpose: Low skeletal muscle mass has been associated with poor prognosis in patients with advanced lung cancer. However, little is known about the relationship between skeletal muscle mass and overall survival in patients with bone metastases from lung cancer. The objective of the present study was to evaluate the prognostic value of low trunk muscle mass in predicting overall survival in these patients., Methods: The data from 198 patients who were diagnosed with bone metastases from lung cancer from April 2009 to May 2017 were retrospectively reviewed. The areas of the psoas and paravertebral muscles were measured at the level of the third lumbar vertebra on computed tomography scans taken at the time nearest to the diagnosis of bone metastasis. Muscle area was evaluated for male and female cohorts separately using different cutoff points. Cox proportional hazards analysis was performed to evaluate the factors independently associated with overall survival., Results: The overall survival of patients in the lowest quartile for psoas muscle area or paravertebral muscle area was significantly shorter than that of patients above the 25th percentile for muscle area (p < 0.001). Multivariate analyses showed that paravertebral muscle mass (hazard ratio, 1.73; 95% confidence interval, 1.17-2.56; p = 0.006), epidermal growth factor receptor-targeted therapy, and performance status were independent prognostic factors., Conclusions: Low paravertebral muscle mass was associated with shorter survival, independently of known prognostic factors.

Balloon kyphoplasty (BKP) sometimes fails to improve patients' outcomes, with revision surgery, using anterior or posterior reconstruction, being required. The purpose of this study was to investigate the radiological risk factors of failure after BKP in the treatment of osteoporotic vertebral fractures (OVFs). This case-control study included 105 patients treated with single BKP and 14 patients  who required revision BKP. We evaluated radiological findings differentiating both groups, using plain radiography and computed tomography, before BKP. Angular flexion-extension motion was significantly greater in the revision than BKP group. While the frequency of pedicle fracture and posterior wall injury was not different between the groups, a split type fracture was more frequent in the revision group. Split type fracture had the highest adjusted odds ratio (OR) for revision (16.5, p = 0.018). Angular motion ≥14° increased the risk for revision surgery by 6-fold (p = 0.013), with endplate deficit having an OR of revision of 5.0 (p = 0.032). The revision rate after BKP was 3.8%, with split type fracture, greater angular motion and large endplate deficit being risk factors for revision. Treatment strategies for patients with these risk factors should be carefully evaluated, considering the inherent difficulties in performing revision surgery after BKP.

The purpose of this study was to clarify the clinical impact of sarcopenia on the outcome of minimally invasive lumbar decompression surgery. The records of 130 patients who were >65 years and underwent minimally invasive lumbar decompression surgery were retrospectively reviewed. We collected the Japanese Orthopaedic Association (JOA) score before surgery and at the final follow-up and measured appendicular muscle mass using bioimpedance analysis, hand-grip strength and gait speed. We diagnosed the patients with sarcopenia, dynapenia and normal stages using the European Working Group on Sarcopenia in Older People definition and used cutoff thresholds according to the algorithm set by the Asian Working Group for Sarcopenia. The average age of patients undergoing surgery was 76.9 years old. The JOA score improved from 12.6 points preoperatively to 24.3 points at final follow up. The prevalence of the sarcopenia, dynapenia and normal stages was 20.0, 31.6 and 43.8%. Clinical outcomes, such as JOA score, JOA score improvement ratio, visual analog scale for low back pain, leg pain and numbness, were not significantly different among each group. Multiple regression analysis showed that preoperative JOA score and low physical performance (low gait speed) were independently associated with poor clinical outcomes. The JOA score improved after minimally invasive lumbar decompression surgery even when the patients were diagnosed as being at different stages of sarcopenia. Low physical performance had the greater clinical impact on the clinical outcome of lumbar surgery than low skeletal muscle index.

Study Design: Case-control study of an animal model., Objective: To investigate the factors that are upregulated and potentially related to degenerative changes in the ligamentum flavum (LF) upon mechanical stress concentration., Summary of Background Data: LF hypertrophy is reported to be associated with mechanical stress. However, few studies, using exhaustive analysis with control subjects, on the molecular mechanisms of LF hypertrophy have been published., Methods: Fourteen rabbits were used for this study. The first group underwent L2-3 and L4-5 posterolateral fusion with instrumentation and resection of the L3-4 supraspinal muscle to concentrate the mechanical stress on L3-4, whereas the other group underwent a sham operation. The deep layer of the LF from L2-3 to L4-5 in both groups was harvested after 16 weeks. Gene expression was evaluated exhaustively using DNA microarray and real-time polymerase chain reaction (RT-PCR). Fibroblast growth factor 9 (FGF9) protein expression was subsequently examined by immunohistological staining., Results: A total of 680 genes were found to be upregulated upon mechanical stress concentration and downregulated upon mechanical shielding compared with those in the sham group. Functional annotation analysis revealed that these genes not only included those related to the extracellular matrix but also those related to certain FGF families. On RT-PCR validation and immunohistological analysis, we identified that the FGF9 protein increases in the LF upon mechanical stress, especially in the area wherein degenerative changes were frequently identified in the previous literature., Conclusion: FGF9 and its pathway are suggested to contribute to the degenerative changes in the LF following mechanical stress. This finding will be helpful in further understanding the molecular mechanism of human LF degeneration., Level of Evidence: N/A.

Background Context: Ligamentum flavum (LF) hypertrophy plays a dominant role in lumbar spinal stenosis (LSS). Although LSS prevalence is known to be higher in patients with diabetes mellitus (DM), the underlying pathomechanisms are not well understood. Abnormal advanced glycation end products (AGEs) formation occurs in DM and promotes tissue damage in various organs through degeneration and inflammation., Purpose: To analyze and compare LF histology focused on AGE status between control patients, LSS patients with DM, and LSS patients without DM., Study Design/setting: Basic research study design utilizing human LF tissue for histologic analyses., Patient Sample: LF tissue samples were collected from patients who underwent lumber decompression surgery for LSS in the author's institution., Outcome Measures: Quantitative visualization of Masson's Trichrome (MT) stains, and AGE immunohistochemistry (IHC) for the three groups., Methods: Ten LF specimens from LSS patients with DM (DM group, mean age 71.4 years), 10 from LSS patients without DM (non-DM group, mean age 71.2 years), and 9 from patients with lumbar disc herniation or cauda equina tumor (control group, mean age 49.0 years) were harvested during surgery and histologically analyzed. Percentage of elastic fiber areas (%EF) was measured with MT staining, and the percentage of AGE immuno-positive areas (%AGEs) was measured with IHC., Results: The average %EFs were 12.8 in the DM group, 17.1 in the non-DM group, and 24.9 in the control group. The decrease in the elastic fibers was significantly more in the DM group than in the non-DM (p<.01) and control groups (p<.001). Accumulation of AGEs was found mainly in the extracellular matrix in areas of elastic fiber disruption. The %AGEs were 18.3 in the DM group, 12.1 in the non-DM group, and 4.6 in the control group. These were significantly larger in the DM group than in the non-DM (p<.01) and control (p<.01) groups. The %AGEs also positively correlated with patient age (p<.01, R=0.47)., Conclusions: Accumulation of AGEs is significantly greater in the LF of DM patients and correlates with patient age. AGEs may accelerate degeneration and hypertrophy of LF with age and may lead to higher prevalence of LSS in patients with DM., Clinical Significance: The present results partly reveal the molecular mechanism of LF hypertrophy, suggesting that AGEs may be involved in the process of LF degeneration in the elderly and patients with DM., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To clarify the relationship between sarcopenia and spinopelvic parameters., Methods: Among outpatients of spine surgery department, 126 patients (mean age 77.2 years. M/F = 71/55) were included. We diagnosed patients with sarcopenia using the diagnostic algorithm of the Asian Working Group for Sarcopenia. Spinopelvic parameters and the prevalence of spinopelvic mismatch (pelvic incidence minus lumbar lordosis ≥ 10°) were investigated and compared between patients with and without sarcopenia. Furthermore, we compared the spinopelvic parameters between the Sarcopenia and No Sarcopenia groups under each condition of spinopelvic match and mismatch., Results: The prevalence of sarcopenia in this study was 21.4%. Overall, the spinopelvic parameters except thoracic kyphosis (TK) (Sarcopenia: 34.7°, No Sarcopenia: 24.3°, p < 0.01) were not significantly different between the Sarcopenia and No Sarcopenia groups. Prevalence of patients with spinopelvic mismatch was also not significantly different between the Sarcopenia and No Sarcopenia groups (37.0% vs. 42.4%, p = 0.66). Among patients without spinopelvic mismatch, there was no spinopelvic parameter with a significant difference between the 2 groups. However, among patients with spinopelvic mismatch, sagittal vertebral axis (SVA) (115.7 mm vs. 58.7 mm, p < 0.01) and TK (36.6° vs. 21.3°, p < 0.01) of the Sarcopenia group were significantly larger than those of the No Sarcopenia group. Moreover, sarcopenia was independently related to a significant increase in SVA (β = 50.7, p < 0.01) and TK (β = 14.0, p < 0.01) in patients with spinopelvic mismatch, after adjustment for age., Conclusions: Sarcopenia is related to spinal sagittal imbalance because of insufficient compensation by flattening thoracic kyphosis in patients with spinopelvic mismatch. These slides can be retrieved under Electronic Supplementary Material.

Morphometric analyses have shown that the psoas muscle mass is associated with mortality in cancer patients. Because of the low incidence of cervical spine metastasis, few studies have been reported in this population. The present study aimed to identify the prognostic value of a psoas muscle mass in predicting overall survival. We also evaluated factors associated with surgical intervention for cervical spine metastases. We retrospectively evaluated 97 patients (mean age 65.2 years) diagnosed with cervical spine metastases between February 2009 and July 2016. The psoas muscle area was measured at the L3 level on computed tomography at the time nearest the diagnosis of cervical spine metastasis. Cox proportional hazards analyses were performed to evaluate the relation between overall survival and the psoas muscle's composition. The mean overall survival for patients who underwent surgery was not significantly different from that for those without surgery. Multivariate analyses showed that the lowest percentage quartile (0%-25%) of the psoas muscle mass was associated with poor overall survival after adjusting for age and the prognostic predictive value (hazard ratio 1.93, 95% confidence interval 1.12-3.32; p = 0.017). Spinal cord compression, spinal instability, palsy, and the poor prognostic predictive value were factors associated with surgical intervention. In conclusion, a psoas muscle mass in the lowest quartile was independently associated with shorter survival among patients with cervical spine metastases. Although the poor prognostic predictive value was associated with surgical treatment, the overall survival was not different between patients who did or did not undergo surgery., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Study Design: A multicenter cross-sectional study., Objectives: To clarify the relationship of trunk muscle mass with low back pain, spinal sagittal balance, and quality of life. Few reports have investigated the relationship of trunk muscle mass with lumbar spine function and spinal balance, and the clinical significance of trunk muscle mass remains unclear., Methods: Patients attending spinal outpatient clinics at 10 different medical institutions were enrolled in this study. Patient demographics, trunk muscle mass and appendicular skeletal muscle mass (ASM) measured by bioelectrical impedance analysis (BIA), body mass index (BMI), Charlson Comorbidity Index (CCI), the Oswestry Disability Index (ODI), visual analog scale (VAS) for low back pain, sagittal vertical axis (SVA), and EuroQol 5 Dimension (EQ5D) score were investigated. Multivariate nonlinear regression analysis was used to investigate the association of trunk muscle mass with the ODI, VAS score, SVA, and EQ5D score., Results: Of 2551 eligible patients, 1738 (mean age 70.2 ± 11.0 years; 781 men and 957 women) were enrolled. Trunk muscle mass was significantly correlated with the ODI, VAS score, SVA, and EQ5D score (P < 0.001) when adjusted for age, sex, BMI, ASM, CCI, and history of lumbar surgery. Patient deterioration was associated with a decrease in trunk muscle mass, and the deterioration accelerated from approximately 23 kg., Conclusions: Trunk muscle mass was significantly associated with the ODI, VAS score, SVA, and EQ5D score. Trunk muscle mass may assume an important role to elucidate and treat lumbar spinal dysfunction and spinal imbalance. These slides can be retrieved under Electronic Supplementary Material.

Purpose: Morphometric analyses have shown that trunk muscle mass and density are associated with mortality in cancer patients. Because of the low incidence of spinal metastasis from gastrointestinal cancer and the limited life expectancy of these patients, few studies have been reported in this population. We evaluated the prognostic value of trunk muscle area and density in predicting overall survival., Methods: The data from 78 patients with spinal metastases from gastrointestinal cancer, collected from February 2009 to July 2016, were evaluated. Psoas muscle and paravertebral muscle area and density were measured at the L3 level on CT scans taken at the time nearest to the diagnosis of spinal metastasis. Cox proportional hazards analysis was performed to evaluate the factors independently associated with overall survival., Results: The mean patient age was 68.3 years (range, 42-88 years). The overall median survival time was 4.8 months: 2.2 months in the extremely rapid growth group (stomach, biliary tract, and pancreas) and 7.6 months in the rapid growth group (esophagus, liver, and colorectum). Multivariate analyses showed that lower paravertebral muscle density (HR 2.23 [95% CI 1.24-3.99], p = 0.007), extremely rapid growth group, presence of abnormal laboratory data, poor performance status, and chemotherapy after spinal metastasis were independent prognostic factors., Conclusions: Median overall survival was poor among patients with spinal metastases from gastrointestinal carcinoma, especially among those with gastric, biliary tract, or pancreatic cancer. Lower paravertebral muscle density was an independent poor prognostic factor in patients with spinal metastases from gastrointestinal cancer.

Study Design: A propensity score matching study., Objective: The aim of this study was to assess the cost-effectiveness of balloon kyphoplasty (BKP) in Japan., Summary of Background Data: Osteoporotic vertebral fracture (OVF) is a common disease in elderly people. In Japan, the incidence of painful OVF in 2008 was estimated as 880,000, and approximately 40% of patients with painful OVF are hospitalized due to the severity of pain. Japan is the front runner among super-aged societies and rising health care costs are an economic problem., Methods: BKP and nonsurgical management (NSM) for acute/subacute OVF were performed in 116 and 420 cases, respectively. Quality-adjusted life years (QALY) and incremental costs were calculated on the basis of a propensity score matching study. QALY was evaluated using the SF-6D questionnaire. Finally, using a Markov model, incremental cost-effectiveness ratios (ICERs) were calculated for 71 matched cases., Results: In the comparison between BKP and NSM, mean patients age was 78.3 and 77.7 years, respectively (P = 0.456). The BKP procedure cost 402,988 JPY more than NSM and the gains in QALY at the 6-month follow-up were 0.153 and 0.120, respectively (difference = 0.033). ICERs for 3 and 20 years were 4,404,158 JPY and 2,416,406 JPY, respectively. According to sensitivity analysis, ICERs ranged from 652,181 JPY to 4,896,645 JPY (4418-33,168 GBP)., Conclusion: This study demonstrated that BKP is a cost-effective treatment option for OVF in Japan. However, the effect might be blunted in patients aged > 80 years. Further research is necessary to elucidate the cost-effectiveness of BKP in this population., Level of Evidence: 4.

Purpose: To evaluate the correlations between back muscle strength, trunk muscle mass, and sarcopenia-related parameters in patients with spinal disorders., Methods: This cross-sectional observational study included 230 consecutive patients with spinal disorders who visited our outpatient clinic (age range 65-92 years). We measured back muscle strength, handgrip strength, gait speed, and appendicular and trunk skeletal muscle mass using bioimpedance analysis. We classified the subjects into the sarcopenia, dynapenia, or normal stages in accordance with the guidelines set by the European Working Group on Sarcopenia in Older People, and used the cutoff values reported in the guidelines set by the Asian Working Group for Sarcopenia., Results: Back muscle strength was significantly correlated with trunk muscle mass (males: r = 0.47, P < 0.001; females: r = 0.39, P < 0.001), handgrip strength (males: r = 0.67, P < 0.001; females: r = 0.59, P < 0.001), and gait speed (males: r = 0.49, P < 0.001; females: r = 0.51, P < 0.001). The respective incidences of the sarcopenia, dynapenia, and normal stages were 16.4%, 26.7%, and 56.9% for males, and 23.7%, 50.9%, and 25.4% for females. Dynapenia was significantly more prevalent in females than in males. Back muscle strength in the normal group was significantly greater than that in the sarcopenic and dynapenic groups., Conclusion: Back muscle strength is significantly correlated with trunk muscle mass and sarcopenia-related parameters in patients with spinal disorders. Back muscle strength in the sarcopenic stage is significantly lesser than that in the normal stage. Although sarcopenia is a multifaceted geriatric syndrome, spinal disorders might be one of the risk factors for disease-related sarcopenia. These slides can be retrieved from Electronic Supplementary Material.

Posterior lumbar interbody fusion with cortical bone trajectory (CBT-PLIF) is a form of minimally invasive decompression and fusion, whereas microendoscopic laminotomy (MEL) is a form of minimally invasive decompression surgery. No study has compared the clinical outcomes of the two methods for patients who have degenerative spondylolisthesis (DS) with instability. In this study, CBT-PLIF and MEL were both offered to 64 patients who met the inclusion criteria. Each patient then selected his or her preferred treatment. Twenty patients received CBT-PLIF. They were matched to 30 of the 44 patients receiving MEL based on age, sex, disease duration, and surgical levels. The 20 patients with CBT-PLIF formed the CBT group and the 30 matched patients with MEL formed the MEL group. At 2 years of follow-up, Japanese Orthopaedic Association scores improved to 72.6% and 70.5% in the CBT and MEL groups, respectively. The difference in scores was not statistically significant. Further, improvements in visual analogue scale scores for back and leg symptom did not differ significantly between the two groups. Regarding complications, 1 CBT-group patient (5%) had adjacent-segment degeneration and 7 MEL-group patients (23%) had same-segment degeneration. Three CBT-group patients (15%) and 5 MEL-group patients (16%) required reoperation within the follow-up period. In summary, among patients who had DS with instability, MEL and CBT-PLIF offered comparable clinical outcomes at 2 years of follow-up. Although the rate of segmental degeneration was relatively high in the MEL group, both groups had similar reoperation rates., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Despite ongoing improvements in both dialysis and surgical techniques, spinal surgery in patients undergoing hemodialysis (HD) is a challenge to surgeons because of the high mortality rate. However, no previous studies have examined clinical outcomes after lumbar surgery in HD patients. The purpose of this study is to compare clinical outcomes and complication rates after lumbar spinal surgery in patients with or without hemodialysis., Methods: This retrospective, matched cohort study was conducted to compare surgical outcomes between HD vs non-HD patients who underwent lumbar surgery at our hospital. Controls were individually matched to cases at a ratio of 1:2. Clinical outcomes, complications, and mortality rates were compared between the two groups., Results: Twenty-nine patients in the HD group and 57 in the non-HD group were included in the current study. Five patients in the HD group died during the follow-up period, whereas no patients died in the non-HD group (mortality rate, 17.2% vs. 0%, P = 0.003). Japanese Orthopaedic Association (JOA) scores were significantly less improved in the HD group than in the non-HD group (11.9 vs. 14.2 preoperatively, P = 0.001; 19.9 vs. 25.1 at final follow-up, P < 0.001). Five patients underwent repeat surgery in the HD group, which was significantly higher than the non-HD group (17.2% vs. 3.5%, P = 0.041)., Conclusions: The current study indicates that patients undergoing HD had poor outcomes after lumbar spinal surgery. Moreover, 5 of 29 patients died within a mean 2.4-years follow-up. The indications for lumbar spine surgery in HD patients must be carefully considered because of poor surgical outcomes and high mortality rate., Competing Interests: Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.

Study Design: A cross-sectional study., Objective: To identify the best indicator for reproducible representation of craniocervical sagittal balance (CCSB)., Summary of Background Data: Spinal sagittal balance is considered one of the most critical factors affecting the health-related quality of life. Although standard indicators of spinopelvic balance have been established, these do not include the craniocervical balance and there is no standard parameter for evaluating the CCSB., Materials and Methods: Six kinds of sagittal vertical axis (SVA) were drawn by a total of 9 spine or orthopedic surgeons, from the anterior margin of the external auditory canal: cranial center of gravity (CCG), C1 (center of the anterior arch), C2 (C2vb: center of the vertebral body, C2e: center of the lower endplate), and C7 (C7vb: center of the vertebral body, C7p: posterosuperior corner). Eight SVA distances were measured by using 30 radiographs; CCG-C7vb, C1-C7vb, C2e-C7vb, C2vb-C7vb, CCG-C7p, C1-C7p, C2e-C7p, and C2bv-C7p.The interobserver and intraobserver reliabilities, and the correlations between CCG and C1, C2e, or C2bv were calculated among the main groups or subgroups., Results: In the overall analysis, although the intraclass correlation coefficients (ICC) (1, 1) of all parameters were >0.900, the ICC (2, 1) of CCG-C7p and CCG-C7vb were <0.900. The same trends were noted in the subgroups based on observer's experience. Comparing C7p-related and C7vb-related parameters, ICC (2, 1) showed 0.901 in C7p-related and 0.849 in C7bv-related parameters. In the analysis of the correlation between cranial SVAs, C1-C7p and C2vb-C7p SVAs correlated highly with CCG-C7p SVA (0.905, 0.805, respectively)., Conclusions: Although the CCG SVA represents the center of the head, the current results revealed its low reproducibility. The low values were notable in those unfamiliar with craniocervical anatomy. The correlation analysis indicated that C1-C7p and C2vb-C7p SVA parameters are suitable for CCG-C7p SVA. Therefore, these 2 are considered as possible standard parameters in evaluating CCSB., Level of Evidence: Level III.

In this prospective multicenter study of osteoporotic vertebral fractures (OVFs), delayed union of OVF at 6-month follow-up caused prolonged pain, QOL impairment, ADL impairment, cognitive status deterioration, and vertebral collapse progression., Purpose: Delayed union following osteoporotic vertebral fracture displayed as an intravertebral cleft on plain X-rays was reported to be a factor for prolonged severe pain. However, the difference of clinical course between bone union and delayed union cases still remains unclear. The purpose of this study was to identify how OVF delayed union following conventional conservative treatment influences the clinical course with a prospective multicenter study., Methods: A total of 324 OVF patients from 25 institutes in Osaka, Japan, were included in the study. At the 6-month follow-up after initial visit to each institute, the patients were classified into bone union and delayed union groups based on plain X-ray findings. The outcome assessments included a VAS for back pain, SF-36 for quality of life (QOL), severity of bed-ridden state for activities of daily living (ADL), MMSE for cognitive functions, and degree of vertebral collapse on plain X-rays., Results: Overall, 280 patients were included into the union group and 44 into the delayed union group. The VAS score at 6 months was significantly worse in the delayed union group (p = 0.01). The scores for the SF-36 scales of physical functioning and bodily pain at 6 months were significantly lower in the delayed union group (p = 0.019, p = 0.01, respectively). The percentage of nearly or completely bed-ridden patients was significantly higher in the delayed union group. The percentage of newly developed cognitive impairment was significantly higher in the delayed union group (p = 0.02). Progression of vertebral collapse during the 6-month follow-up was more pronounced in the delayed union group (p < 0.01)., Conclusion: The present results revealed that delayed union following OVF causes prolonged pain, QOL impairment, ADL impairment, cognitive status deterioration, and vertebral collapse progression.

MINI: Fourteen hundred consecutive patients were investigated for evaluating the utility of waterless hand rub before orthopaedic surgery. The risk in the surgical site infection incidence was the same, but costs of liquids used for hand hygiene were cheaper and the hand hygiene time was shorter for waterless protocol, compared with traditional hand scrub., Study Design: A retrospective cohort study with prospectively collected data., Objective: The aim of this study was to compare SSI incidences, the cost of hand hygiene agents, and hand hygiene time between the traditional hand scrub and the waterless hand rub protocols before orthopedic surgery., Summary of Background Data: Surgical site infections (SSI) prolong hospitalization and are a leading nosocomial cause of morbidity and a source of excess cost. Recently, a waterless hand rub protocol comprising alcohol based chlorhexidine gluconate for use before surgery was developed, but no studies have yet examined its utility in orthopedic surgery., Methods: Fourteen hundred consecutive patients who underwent orthopedic surgery (spine, joint replacement, hand, and trauma surgeries) in our hospital since April 1, 2012 were included. A total of 712 cases underwent following traditional hand scrub between April 1, 2012 and April 30, 2013 and 688 cases underwent following waterless hand rub between June 1, 2013 and April 30, 2014. We compared SSI incidences within all and each subcategory between two hand hygiene protocols. All patients were screened for SSI within 1 year after surgery. We compared the cost of hand hygiene agents and hand hygiene time between two groups., Results: The SSI incidences were 1.3% (9 of 712) following the traditional protocol (2 deep and 7 superficial infections) and 1.1% (8 of 688) following the waterless protocol (all superficial infections). There were no significant differences between the two groups. The costs of liquids used for one hand hygiene were about $2 for traditional hand scrub and less than $1 for waterless hand rub. The mean hand hygiene time was 264 seconds with the traditional protocol and 160 seconds with the waterless protocol., Conclusion: Waterless hand rub with an alcohol based chlorhexidine gluconate solution can be a safe, quick, and cost-effective alternative to traditional hand scrub., Level of Evidence: 3.

Long intercalated defects in canine ribs can be repaired successfully using porous beta-tricalcium phosphate (beta-TCP) cylinders, infused with a biodegradable polymer (poly D,L-lactic acid-polyethylene block copolymer) containing recombinant human bone morphogenetic protein-2 (rhBMP-2). We previously reported the successful regeneration of bony rib and periosteum defects using beta-TCP cylinders containing 400 microg of rhBMP-2. To reduce the amount of rhBMP-2 and decrease the time required for defect repair, we utilized a biodegradable polymer carrier, in combination with rhBMP-2 and the porous beta-TCP cylinders. An 8 cm long section of rib bone was removed and replaced with an implant comprised of the porous beta-TCP cylinders and the polymer containing 80 microg of rhBMP-2. Six weeks after surgical placement of the beta-TCP cylinder/polymer/BMP-2 implants, new rib bone with an anatomical configuration and mechanical strength similar to the original bone was regenerated at the defect site. The stiffness of the regenerated ribs at 3, 6, and 12 weeks after implantation of the composite implant was significantly higher than that of ribs regenerated by implantation of rhBMP-2/beta-TCP implants. Thus, addition of the synthetic polymer to the drug delivery system for BMP potentiated the bone-regenerating ability of the implant and enabled the formation of mechanically competent rib bone. This new method appears to be applicable to the repair of intercalated long bone defects often encountered in clinical practice.

Background: In maxillofacial, spinal, and orthopedic surgery, bony ribs have been used as a source of donor bone. The resultant defects are not usually repaired, despite the pain or cosmetic morbidity experienced by the patient. The authors evaluated the efficacy of an osteoconductive beta-tricalcium phosphate and the contribution of the periosteum in rib bone regeneration., Methods: Two 8-cm-long intercalated rib defects were generated in each of 30 beagle dogs. In the first group (n = 15), one defect was implanted with 16 small, short, porous beta-tricalcium phosphate cylinders that were connected with a titanium wire, and the other defect was left untreated. In the remaining 15 dogs, the periosteum was devitalized by ethanol, and then the same surgical procedures were performed. Each group was subdivided into three groups (n = 5), and the animals were euthanized at 3, 6, and 12 weeks. Bone regeneration was assessed radiologically, histologically, and mechanically., Results: In the defect implanted with beta-tricalcium phosphate on intact periosteum, newly formed bone was present on and in the beta-tricalcium phosphate cylinders and bridged both ends of the resected ribs at 12 weeks, with replacement of beta-tricalcium phosphate by new bone. Mechanical testing of these ribs revealed that they had 70 percent of the strength of normal ribs when compared in a bending stress test at 12 weeks after surgery. No regenerative bone bridging the rib defects was seen in the ethanol-devitalized or untreated groups., Conclusions: Porous beta-tricalcium phosphate cylinders placed in tandem on the intact periosteum might be useful for the repair of rib bone donated at surgery, presenting a new and unique method for regenerating rib defects.