Background:The combination of a glenoid defect and a Hill-Sachs lesion in a shoulder with anterior instability has recently been termed “bipolar bone loss,” but the prevalence and influence of this condition on postoperative recurrence after arthroscopic Bankart repair are still unclear.Purpose:To investigate bipolar bone loss in male athletes using a new scoring system and to evaluate its efficacy by comparing it with the glenoid track concept.Study Design:Case-control study; Level of evidence, 3.Methods:The sizes of both lesions were evaluated retrospectively in 80 male athletes (85 shoulders) using computed tomography. The glenoid defects and the length, width, and depth of the Hill-Sachs lesions were classified into 5 size categories and were allocated scores from “0” for no defect to “4” for the largest defect. Patients were then classified into 5 classes according to the total score for both lesions: class 1, 0-1 point; class 2, 2 points; class 3, 3 points; class 4, 4 points; and class 5, ≥5 points. The prevalence of bipolar bone loss and postoperative recurrence rates for patients with at least 2 years of follow-up were compared among the classes. The recurrence rate for each class was also compared between shoulders with an off-track lesion and shoulders with an on-track lesion as well as among 3 sporting categories: rugby, American football, and other sports.Results:Based on the combination of glenoid defect size and Hill-Sachs lesion length, the postoperative recurrence rate was 0% for shoulders in class 1, 12.5% for class 2, 33.3% for class 3, 28.6% for class 4, and 31.3% for class 5, while the recurrence rates were 0%, 16.7%, 28.6%, 27.3%, and 31.6%, respectively, for the combination of glenoid defect size and Hill-Sachs lesion width and 0%, 8.3%, 26.7%, 28.6%, and 35.3%, respectively, for the combination of glenoid defect size and Hill-Sachs lesion depth. Postoperative recurrence was frequently recognized regardless of the presence of off-track Hill-Sachs lesions. No recurrence was recognized in class 1 shoulders among rugby players, in classes 1 and 2 among American football players, and in classes 1 through 3 among other athletes based on the combination of glenoid defect size and Hill-Sachs lesion size.Conclusion:Our scoring system for bipolar bone loss was useful to evaluate the influence on postoperative recurrence in male athletes. The postoperative recurrence rate was influenced by the extent of bipolar bone loss and the sporting category regardless of the presence of off-track lesions.

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Background: Recurrence of glenohumeral joint instability after primary traumatic anterior instability is not rare, and bipolar bone loss is one of the most critical factors for recurrent instability, but the development process of bipolar bone defects is still unclear. Purpose: To investigate the development process of bipolar bone defects from primary to recurrent instability among shoulders with traumatic anterior instability evaluated at least twice by computed tomography (CT). Study Design: Case series; Level of evidence, 4. Methods: There were 44 patients (47 shoulders) with recurrence after primary instability in which bone morphology was evaluated by 3-dimensional reconstructed CT at primary instability (initial CT) and after recurrence. As CT was performed 3 times for 3 shoulders including primary injury and the second episode of instability (first recurrence), there were 50 CT evaluations. Morphological changes between the initial CT evaluation at primary instability and the second CT evaluation at first recurrence were investigated for 25 shoulders, with the mean interval since initial CT being 9.8 months (range, 2-23 months). Changes between initial CT evaluation and final CT evaluation after ≥2 recurrences were also investigated for 25 shoulders, while the mean number of instability episodes including primary instability was 8.0 (range, 3-40) and the mean interval since initial CT was 18.5 months (range, 5-56 months). Results: At primary instability, the prevalence of Hill-Sachs lesions (66.0%) was almost double that of glenoid defects (34.0%), but their prevalence was different between shoulders with primary subluxation (42.3% and 23.8%, respectively) and those with primary dislocation (84.7% and 42.3%, respectively). After recurrence, glenoid defects became significantly more frequent (at first recurrence, 72%; after ≥2 recurrences, 76%), while Hill-Sachs lesions showed a smaller increase (88% and 80%, respectively), so there was no difference between the prevalence of the 2 lesions. The sizes of glenoid defects and Hill-Sachs lesions also enlarged after recurrence, and large bone defects were frequently recognized after recurrence. While bipolar bone loss was not so frequent at primary instability (29.8%), bipolar bone loss increased significantly after recurrence (at first recurrence, 72%; after ≥2 recurrences, 72%). All Hill-Sachs lesions were on track at primary instability, but off-track lesions were recognized in 3 of 47 shoulders (6.4%) after recurrence. Conclusion: In most shoulders with recurrent instability, a Hill-Sachs lesion developed first, followed by a glenoid defect, leading to bipolar bone loss. Off-track Hill-Sachs lesions were detected only after recurrence.

BackgroundIt is well studied that preparations of decellularized extracellular matrix (ECM) obtained from mesenchymal tissues can function as biological scaffolds to regenerate injured musculoskeletal tissues. Previously, we reported that soluble decellularized ECMs derived from meniscal tissue demonstrated excellent biocompatibility and produced meniscal regenerate with native meniscal anatomy and biochemical characteristics. We therefore hypothesized that decellularized mesenchymal tissue ECMs from various mesenchymal tissues should exhibit tissue-specific bioactivity. The purpose of this study was to test this hypothesis using porcine tissues, for potential applications in musculoskeletal tissue engineering.MethodsNine types of porcine tissue, including cartilage, meniscus, ligament, tendon, muscle, synovium, fat pad, fat, and bone, were decellularized using established methods and solubilized. Although the current trend is to develop tissue specific decellularization protocols, we selected a simple standard protocol across all tissues using Triton X-100 and DNase/RNase after mincing to compare the outcome. The content of sulfated glycosaminoglycan (sGAG) and hydroxyproline were quantified to determine the biochemical composition of each tissue. Along with the concentration of several growth factors, known to be involved in tissue repair and/or maturation, including bFGF, IGF-1, VEGF, and TGF-β1. The effect of soluble ECMs on cell differentiation was explored by combining them with 3D collagen scaffold culturing human synovium derived mesenchymal stem cells (hSMSCs).ResultsThe decellularization of each tissue was performed and confirmed both histologically [hematoxylin and eosin (H&E) and 4’,6-diamidino-2-phenylindole (DAPI) staining] and on the basis of dsDNA quantification. The content of hydroxyproline of each tissue was relatively unchanged during the decellularization process when comparing the native and decellularized tissue. Cartilage and meniscus exhibited a significant decrease in sGAG content. The content of hydroxyproline in meniscus-derived ECM was the highest when compared with other tissues, while sGAG content in cartilage was the highest. Interestingly, a tissue-specific composition of most of the growth factors was measured in each soluble decellularized ECM and specific differentiation potential was particularly evident in cartilage, ligament and bone derived ECMs.ConclusionIn this study, soluble decellularized ECMs exhibited differences based on their tissue of origin and the present results are important going forward in the field of musculoskeletal regeneration therapy.

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Background: There are currently no disease-modifying treatments available for knee osteoarthritis (OA), although cultured adipose-derived stromal cells (ASCs) have shown promise in experimental models. However, given the regulatory limits on the use of cultured cells in humans, previous trials have focused primarily on the stromal vascular fraction (SVF) intra-articular injection. Therefore, the therapeutic value of ASCs for knee OA remains unknown. Purpose: To study ASC versus SVF intra-articular injection in patients with Kellgren-Lawrence (KL) knee OA grades 2 to 4 in parallel single-arm trials. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 80 patients were enrolled, with 42 (72 knees) receiving ASC intra-articular injection and 38 (69 knees) receiving SVF. Patient-reported outcome measures were assessed at 1, 3, 6, 12, and 24 months using the Knee injury and Osteoarthritis Outcome Score 5 (KOOS5) and pain visual analog scale (VAS). The percentages of patients achieving the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) were also calculated. Per protocol, a subset of the ASC group received an ASC booster injection after 6 months. A repeated-measures analysis of variance compared results between treatment arms and by KL grade over time. Results: Patient-reported outcome measures improved substantially after both treatments ( P < .05 at all time points), with the ASC group more likely to achieve the MCID (50% vs 24%; P = .01) and PASS (45% vs 24%; P = .04) for the pain VAS and the MCID (43% vs 16%; P = .02) for the KOOS5 at 12 months, although not at 24 months. Knees treated with ASC for KL grade 2/3 OA had significantly superior outcomes compared with those with KL grade 4 OA for the KOOS5 ( P = .01) and pain VAS ( P = .03), but no such difference was observed in knees treated with SVF. Three patients receiving ASCs (7%; all KL grade 3) sought additional nonoperative treatment by 24 months versus 9 patients receiving SVF (24%; all KL grade 3) ( P = .06). ASC booster injections conferred no additional benefit. Notably, patients in the ASC cohort reported more injection-site pain and swelling after the booster injection than after the initial injection ( P < .01). Conclusion: This represents the first head-to-head comparison of ASCs and SVF for the treatment of knee OA in humans. ASC and SVF injections both substantially improved knee pain and function at all follow-up time points, although ASC injections demonstrated significantly better improvements with regard to the MCID and PASS for the pain VAS and the MCID for the KOOS5 at 12 months. There appears to be no benefit to a booster ASC injection after initial treatment. Given less donor-site morbidity and equivalent superior outcomes at 2 years, the use of ASCs over SVF in the treatment of knee OA may be warranted.

Successful treatment of two patients with obstructive jaundice due to choledocholithiasis after Billroth II gastrectomy was performed by elimination of stones by percutaneous transhepatic balloon dilatation of the sphincter of Oddi. Patient 1 was an 82-year-old man and Patient 2 was a 73-year-old man. Both patients presented with obstructive jaundice. The papilla was not observed in either patient because of previous Billroth II gastrectomy. Because an endoscopic approach was impossible, percutaneous transhepatic cholangiodrainage (PTCD) was performed to alleviate jaundice. Choledocholithiasis was treated as follows: The sphincter of Oddi was dilated by percutaneous transhepatic balloon, and stone particles were removed from the papilla with a stone-eliminating balloon catheter via the same route of PTCD. This method is less invasive than the percutaneous transhepatic cholangioscopic method, and the use of existing appliances such as a balloon for papillary dilation is possible. Hence, this method appears to be an effective and simple method for the treatment of choledocholithiasis after gastrectomy that is difficult to treat endoscopically.

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