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BACKGROUND AND OBJECTIVES As individuals with blood types A, B and AB have approximately 25% higher levels of vWF than those with type O, the risk of developing venous thrombotic events has been investigated in a number of clinical studies, but whether individuals with type O blood experience increased bleeding remains to be clarified. The purpose of this study was to evaluate an association of ABO blood group with intraoperative bleeding and postoperative total bleeding in patients undergoing total hip arthroplasty. MATERIALS AND METHODS We prospectively recruited 84 women who were undergoing total hip arthroplasty. The differences between blood groups in mean age, body weight, preoperative and postoperative Hct levels, and postoperative/preoperative Hct ratio, intraoperative bleeding volume (IBV), and total bleeding volume (TBV) were evaluated. RESULTS Twenty-six patients had type A blood, 17 had type B, 9 had type AB, and 30 had type O. There were no significant differences in mean age, body weight or operating time between the different ABO blood groups. While there was no significant difference in these Hct levels or IBV among the different blood groups, there was a significant difference in TBV between type O and type AB, and between type O and non-type O. CONCLUSION Our study in patients undergoing total hip arthroplasty suggests that patients in blood group O tend to have large amounts of bleeding.

When children around 2-year-old show leg bowing without lower-limb radiographic abnormalities for rickets, the leg bowing is classified as “physiologic” genu varum without conducting a blood test. However, it has recently been suggested that toddlers who are diagnosed with physiologic genu varum may in fact have some form of bone metabolic disorder. In this 1:2 case–control study, blood samples were obtained from 33 toddlers with genu varum without radiographic abnormalities for rickets and 66 age- and gender-matched healthy children. Serum alkaline phosphatase (sALP), intact parathyroid hormone (siPTH), 25-hydroxy vitamin D [s25(OH)D], calcium (sCa), and inorganic phosphate (sP) were measured. s25(OH)D of the subjects with genu varum (24.8 ng/ml) were significantly lower than those of the control (33.6 ng/ml) (p

Purpose: Some studies reported that measuring serum creatine kinase (CK) level is an objective method with which to determine the relative invasiveness of surgery. The purpose of this study was to evaluate the change in postoperative serum CK levels as a measure of whether the direct anterior approach (DAA) is less invasive than the posterior approach (PA) regarding postoperative rehabilitation. Materials and methods: We prospectively recruited 71 women who were undergoing total hip arthroplasty, 47 were treated by the PA and 24 by the DAA. Serum CK and C-reactive protein (CRP) levels were measured preoperatively and 3 hours and 1, 4, 7, 10, and 14 days after the operation. Results: The serum CK levels were significantly higher in the DAA group than in the PA group on postoperative days 1, 4, 7, 10, and 14. On postoperative day 4 and 7, the percentage of patients whose serum CK levels were above the normal range was 46.8% and 8.5% in the PA group and 95.2% and 45.5% in the DAA group. Conclusions: CK levels were significantly higher in the 2 weeks after THA by a DAA than after the same procedure by a PA indicating that DAA causes prolonged muscle damage. Although the DAA is considered to be a muscle-sparing approach this may not be the case and DAA may not actually be a minimally-invasive approach.

When children around 2 years of age show leg bowing and diseases are ruled out based on radiographic findings without conducting blood tests, they are classified as "physiologic" genu varum. Since whether or not physiologic genu varum is associated with bone metabolism is unclear, this study was conducted to clarify the association between genu varum and bone metabolism in children. Thirty-five pediatric patients with genu varm who visited our out-patient clinic were enrolled. While two of the 35 children had nutritional rickets, showing abnormalities on both blood test (ALP, ≥1000 IU/L; iPTH, >65 pg/mL and 25(OH)D, ≤20 ng/mL) and radiographs (such as cupping, fraying or splaying), five of 35 children showed abnormalities on blood tests but not radiographs. While metaphyseal-diaphyseal angle (MDA) correlated with serum 25-hydroxy vitamin D (r = -0.35, p = 0.04) and magnesium (r = -0.36, p = 0.04), MDA and femorotibial angle (FTA) correlated with alkaline phosphatase (r = 0.43, p = 0.01 and r = 0.51, p = 0.006, respectively). A ridge regression analysis adjusted for age and body mass index indicated that ALP was associated with MDA and FTA. A logistic regression analysis adjusted for age and BMI indicated that higher ALP influenced an MDA >11°, which indicates the risk for the progression of genu varum (odds ratio 1.002, 95% confidence interval 1.0003-1.003, p = 0.021). The higher ALP (+100 IU), the higher risk of an MDA >11° (odds ratio 1.22). In conclusion, genu varum is associated with the alkaline phosphatase level regardless of the presence of radiographic abnormalities in the growth plate in children.

The surgical treatment of osteonecrosis with collapse of the femoral head is still controversial. The purpose of this study was to investigate the clinical outcome of rotational acetabular osteotomy by Ninomiya and Tagawa for osteonecrosis of the femoral head in young patients. Rotational acetabular osteotomy was performed in 202 consecutive patients between 1995 and 2003. Among them, rotational acetabular osteotomy with osteonecrosis of the femoral head was performed in 31 patients (42 hips). The mean age at the time of surgery was 31.2 years (range 16–45). The mean duration of follow-up was 16.1 years (range 13.1–21 years). The mean preoperative Japanese Orthopedic Association hip score of 56.8 points improved to a mean of 72.4 points at the final follow-up. The 10-year survival rate with conversion to total hip arthroplasty as an end-point was 91.9%, and the 15-year survival rate was 75.5%, the 20-year survival rate was 67.9%. The conversion to total hip arthroplasty was performed in nine hips. The average time to the conversion to total hip arthroplasty was 12.1 years. Even though the necrotized range is wide, if normal cartilage remains on the lateral side of the femoral head, it can be utilized for the weight-bearing region by laterally rotating the acetabulum. Since the outcome was favorable, we believe that this is a valuable treatment option for this disease.

Collagen is an extracellular matrix protein present in the skin, tendon, cartilage and bone. Collagen peptides (CP) are produced by the hydrolysis of gelatin (heat-denatured collagen) by proteases and are utilized as a component of nutraceuticals. The current study investigated the effect of CP on the articular cartilage of OA by evaluating the serum levels of biomarkers (CTX-II for type II collagen degradation and CPII for type II collagen synthesis), histopathological changes (Mankin score, based on the toluidine blue staining of proteoglycans), and immunohistochemical staining of matrix metalloproteinase (MMP)-13 and type II collagen, using a rat experimental osteoarthritis (OA) model. Anterior cruciate ligament transection (ACLT) was performed on the right knee joint to surgically induce OA. Animals were divided into four groups: Control group (Control), sham-operated group (Sham), ACLT group without collagen peptide (ACLT group) and ACLT group with oral administration of CP (CP group). ACLT induced histological damages and significantly increased the Mankin score (P

Rotational acetabular osteotomy (RAO), a joint-conserving surgery in which the femoral head coverage by autologous cartilage is improved to achieve joint stability, is one of the most common joint-conserving surgeries for acetabular dysplasia of the hip in adult patients. Favorable outcome of RAO for pre- and initial coxarthrosis has been reported with middle- to long-term observation; however, surgery should be selected for advanced coxarthrosis. The objective of this study was to investigate the long-term clinical outcomes and radiological arthritis changes in patients who were treated with RAO and could be followed for 15 years or longer, and to investigate the joint conservation rate by preoperative arthritis stage. The subjects were 156 patients (178 joints) treated with rotational acetabular osteotomy alone between January 1989 and June 2000. Of those, 106 patients (115 joints) were retrospectively investigated. The mean age at the time of surgery was 41.4 years (14–60 years), and the mean duration of follow-up was 20 years and 4 months (15–26 years and 7 months). There were no significant differences in the Harris hip score among the three groups before surgery; however, the score was significantly lower in the advanced than pre/initial coxarthrosis cases at final follow-up. The joint conservation rate with the end point defined as time of total hip arthroplasty was 70.4% at 20 years after surgery. By stage, joint conservation rates were 88.9, 78.9, and 59.3% in pre-, initial, and advanced coxarthrosis cases, respectively, demonstrating a significantly lower rate in the advanced coxarthrosis cases (p = 0.034). The mean time to conversion was 23, 14.5, and 13.7 years in the pre-, initial, and advanced coxarthrosis cases, respectively. The outcome of rotational acetabular osteotomy in most hips with pre- or initial coxarthrosis was satisfactory. Rotational acetabular osteotomy is an effective surgery for treating symptomatic developmental dysplasia of the hip in selected patients.

Most surgical treatment options for metastatic acetabular lesions involve variants of total hip arthroplasty (THA). However, these are technically complex reconstructions performed in very frail patients, and previous reports indicate complications such as dislocation, deep infection, aseptic loosening, and intraoperative death. A 73-year-old man presented to the emergency department at our hospital with right hip pain following a fall. He had undergone nephrectomy for the treatment of right kidney cancer at the age of 68 years. Four years after the nephrectomy, multiple lung metastases, pelvic bone metastases, and right femoral head and neck bone metastases were found. A radiograph of the hip joint showed a pathological proximal femoral fracture with a radiolucent lesion of the acetabulum. THA with acetabular reconstruction using a Kerboull-type (KT) plate through the direct anterior approach (DAA) was performed. After removal of the femoral head, curettage of the metastatic acetabular dome lesion was carefully performed under fluoroscopic guidance. After the KT plate was placed, cementation of the metastatic acetabular dome lesion was performed, and an optimally sized polyethylene liner was fixed with cement. A cemented stem was inserted after confirming the hip joint stability. At the 14-month follow-up, he could walk steadily without any complications and his modified Harris hip score was 100. The DAA conserves soft tissue because it is an intermuscular approach. Accordingly, postoperative recovery is fast and thus associated with a low dislocation rate and effective pain reduction. The acetabulum with metastatic disease was reconstructed using a KT plate for hip joint stability. Bone with metastatic disease that appears adequate at the time of THA may become incompetent after a few years. THA with acetabular reconstruction using a KT plate through the DAA was an effective treatment for metastatic bone disease of the acetabulum combined with pathological proximal femoral neck fracture.

Motor disorders are caused by orthopedic problems that are mainly related to aging. These disorders can lead to a decline of physical activity and impairment of ADL. When evaluating a patient's motor function after treatment, it is necessary to determine whether or not the level of function is age-appropriate. To investigate the influence of hip joint dysfunction on motor disorders, we determined the JHEQ and GLFS-25 scores and performed muscle strength testing in female patients with hip osteoarthritis.The subjects were 108 women who had received THA, 56 women scheduled for THA, and 64 women on conservative treatment. The JHEQ score (evaluation scale for hip joint function) and GLFS-25 score (evaluation scale for ADL) were determined and muscle strength testing was conducted at a routine outpatient visit.A strong correlation was found between the total JHEQ score and the GLFS-25 score (r = - 0.837). Patients after THA and patients with successful conservative treatment aged 60-79 years showed similar motor function to healthy persons of the same age. There was a significant difference of straight leg raising and abduction strength (both p 0.01) between patients in GLFS-25 levels 1-3 and patients in GLFS-25 levels 4-7.While hip joint dysfunction has a strong influence on overall motor function, the patients after THA and patients with successful conservative treatment showed similar motor function to healthy persons of the same age. And patients with hip osteoarthritis must preserve or increase SLR strength to maintain adequate motor function.

Background The presence/absence of postoperative anemia are presumed to have an impact on early recovery after surgery. This study was performed to compare hip muscle strength and hemoglobin during the perioperative period in 82 patients undergoing THA. Methods Evaluation of presence/absence of anemia was performed by calculating the 10-day postoperative/preoperative Hb ratio. Muscle strength was investigated before and 2 months after surgery. Results Postoperative SLR strength showed a significant difference between the patients whose 10-day postoperative/preoperative Hb ratio was Conclusion We need to consider perioperative strategies to minimize anemia in order to improve patient outcomes.

Background As improvement of gait is an important reason for patients to undergo total hip arthroplasty (THA) and they generally tend to evaluate its success based on postoperative walking ability, objective functional evaluation of postoperative gait is important. However, the patient’s normal gait before osteoarthritis is unknown and the changes that will occur postoperatively are unclear. We investigated the change in gait and hip joint muscle strength after THA by using a portable gait rhythmograph (PGR) and muscle strength measuring device. Patient and methods The subjects were 46 women (mean age: 65.9 years) with osteoarthritis of the hip. Gait analysis and muscle strength testing were performed before THA, as well as 3 weeks and 3 months after surgery. We measured the walking speed, step length, and gait trajectory using PGR prospectively. PGR is attached to the patient’s waist and records signals at a sampling rate of 100 Hz. Isometric torque of hip flexion and abduction were measured by using a hand-held dynamometer. Results There was no improvement at 3 weeks postoperatively, but the walking speed, stride length and muscle strength were clearly showed improvement at 3 months postoperatively. The walking trajectory was not normal preoperatively, since the trajectory was not symmetrical and did not intersect in the midline or form a butterfly pattern, and abnormality of the trajectory tended to persist postoperative 3 months despite resolution of hip joint pain after surgery. Conclusion Since postoperative improvement of gait is an important consideration for patients undergoing THA, it seems relevant to evaluate changes in the gait after surgery and three-dimensional analysis with a PGR may be useful for this purpose.

We reported the longitudinal changes in serum chromium levels over a minimum of 7 years postoperatively in five men and 25 women with a mean age of 60.3 years after primary unilateral total hip arthroplasty with a Metasul metal-on-metal articulation. The serum chromium ion level showed little variation (0.6–1.2 μg/L) from 2 to 12 years postoperatively in 16/30 patients after unilateral primary Metasul metal-on-metal total hip arthroplasty. On the other hand, the serum chromium level stayed high or showed gradual elevation in 8/30 patients, even though they had well-fixed and well-functioning prostheses.

Despite objectively good results, up to 70 % of individuals may not return to their pre-injury level of sports activity after anterior cruciate ligament (ACL) reconstruction surgery. Although psychological responses have been shown to affect outcomes after ACL injury, an appropriate means of measuring their effects, in addition to functional status, has not been determined. The purpose of this study was to develop a patient-reported questionnaire for measuring psychological factors associated with outcomes after ACL injury and to evaluate its reliability, validity, and responsiveness. After item analysis based on the results of two pilot studies and a short relevance assessment, 25 questionnaire items were selected for the Japanese Anterior Cruciate Ligament Injury Questionnaire 25 (JACL-25) and assessed for validity, reliability, and responsiveness in subjects with ACL injury. The JACL-25 had no floor or ceiling effects and no confounding factors. A Cronbach’s alpha coefficient of 0.981 and a Guttman split-half coefficient of 0.983 indicated excellent reliability. Large standardized response means (1.30–1.62) and effect sizes (0.96–1.51) from the preoperative to postoperative period indicated good responsiveness. Construct structures were created, and these items were separated into three domains. Strong correlations between the JACL-25 and the International Knee Documentation Committee Subjective Knee Form (r s = −0.86), Lysholm Score (r s = −0.73), and Tegner Activity Scale (r s = −0.65) indicated good concurrent validity of the JACL-25. The present study demonstrated that the JACL-25 was valid, reliable, and responsive enough to evaluate psychological factors associated with outcomes in individuals with ACL injuries. Diagnostic study, Level III.

Purpose Atypical femoral fractures (AFFs) are stress-related fractures that are speculated to associate with long-term treatment with bisphosphonates for osteoporosis. A history of AFF is a high risk factor for the development of a subsequent AFF in the same location of the contralateral femur, suggesting that a patient's individual anatomical factor(s) are related to the fracture site of AFFs. In this study, we investigated the radiographs of fourteen AFFs (four bilateral fractures among ten patients) treated at six hospitals associated with our university between 2005 and 2010. The fracture site and standing femorotibial angle (FTA), which reflects the mechanical axis of the lower limb, were measured on weight-bearing lower limb radiographs. The fracture site and FTA of patients with typical femoral fractures (TFF) were compared to those of patients with AFFs. The correlations were examined using Spearman's rank correlation coefficients. The fracture locations in the femora were almost the same in the patients with bilateral AFFs. There was a positive correlation between the fracture site and the standing FTA in the patients with AFFs (r = 0.82, 95% confidence interval; 0.49 to 0.94), indicating that the larger the standing FTA (varus alignment), the more distal the site of the fracture in the femur. The FTA of the patients with atypical diaphyseal femoral fracture were significantly larger compared to that of those with not only atypical subtrochanteric fractures but also TFFs. In conclusion, the fracture sites of AFFs are associated with the standing lower limb alignment, while those of TFFs are not.

The long-term treatment with anti-resorptive drugs for osteoporotic patients is suggested to be associated with an increase in atypical femoral fractures (AFFs). However, their incidence, patient characteristics, and risk factors have not been fully elucidated especially in Asian countries. This retrospective observational cohort study found fourteen AFFs in ten patients (four bilateral fractures) among 2,238 hip and femoral shaft fractures treated in our associated hospitals between 2005 and 2010; this incidence (0.63%) was similar to Caucasians. Of the ten patients with AFFs, nine (90%) and six (60%) were using bisphosphonates (BPs) and glucocorticoids (GCs), respectively, compared to 14.3 and 8.6% for patients with typical femoral fractures who were using these agents. As comorbid conditions, five patients had collagen disease (CD) and two had diabetes. A fracture location-, age- and gender-matched (1:3) case-control study revealed that administration of BPs, GCs, and suffering from collagen disease (CD) were significant risk factors for developing AFFs [odds ratios 36.0 (95% confidence intervals 3.8-342.2), 13.0 (2.3-74.1) and 9.0 (1.6-50.3), respectively]. Interestingly, all of the patients with atypical subtrochanteric femoral fractures, defined as those within 5 cm of the lesser trochanter, were taking GCs due to CD, and the age of these patients (average of 54.8 years) was significantly younger than those with atypical diaphyseal femoral fractures (average of 77.2 years, p < 0.05). In conclusion, the incidence of AFFs in the Japanese population was similar to that of Caucasians, and taking BPs and GCs and suffering from CD were risk factors for developing AFFs.

Purpose.To compare the midterm outcome in 12 women who underwent total hip arthroplasty (THA) for rapidly destructive coxarthrosis (RDC) and in 12 controls who underwent THA for osteoarthritis.Methods.Records of 12 women aged 50 to 80 (mean, 72.3) years who underwent THA for RDC after a mean of 9 (range, 4–11) months since symptom onset were reviewed. They were compared with 12 age-and sex-matched controls who underwent THA for primary or secondary osteoarthritis. Acetabular bone deficiency of the 12 RDC patients was classified as type I (n=7), type II (n=4), or type III (n=1). Type I was treated with cementless THA, and types II and III were treated with THA with a cemented acetabular component. The femoral component was cementless. Pre- and post-operative Harris Hip Score was assessed. Radiographs of the hip were evaluated for implant migration, osteolysis, and periprosthetic radiolucency in the acetabulum and proximal femur.Results.The 12 women who underwent THA for RDC and the 12 controls who underwent THA for osteoarthritis were comparable in terms of pre-, intra-, and post-operative parameters. After a mean follow-up of 9.3 years, the mean Harris Hip Score improved from 38.3 to 81.1 in RDC patients and from 43.6 to 84.2 in controls (p=0.13). One RDC patient had dislocation but did not require revision surgery. One RDC patient developed a radiolucent line Conclusion.Despite the rapid destruction of the acetabulum and femoral head in RDC patients, cemented or cementless THA achieved a good midterm outcome comparable to that for patients with primary or secondary osteoarthritis.

We evaluate the clinical and radiological results of cementless total hip arthroplasties (THAs) in patients aged ≥80 years.We compared the clinical and radiological results of 30 cementless THAs done in patients aged ≥80 years (older group) and aged 60-69 years (control group).The Harris Hip score significantly decreased in the older group 1 year after the operation and at the final follow-up observation (p = 0.001), but no joints required revision surgery due to poor initial fixation or early loosening.Cementless THA in the elderly is safe and durable at the time of the follow-up.

Although many authors have reported the serum concentrations of metal ions in patients who had metal-on-metal coupling prostheses, most of the studies were not longitudinal, and the follow-up periods were short. We evaluated the longitudinal changes of serum chromium levels in 44 patients who had undergone unilateral metal-on-metal total hip arthroplasty for a minimum of 7 years postoperatively. Although there was a consistent increase in the mean serum chromium level until 3 years after implantation, there was little difference in the levels from years 3 to 7 postoperatively. Although the serum chromium concentration was low throughout postoperative follow-up for 7 years in about 25% of patients, the serum chromium level stayed high or showed gradual elevation in 16.3% of our patients.

The purpose of this study was to examine the postoperative results following THA for ankylosing spondylitis, which is very rare in Japanese. We performed uncemented THA in 31 hips between 1982 and 2007. Patients were followed up for a mean of 12 years. The 10-year survival rate was 100%, and the 15-year survival rate was 63.5%. Revision surgery was performed in 4 hips. Complications developed in 5 cases. Two patients sustained an intraoperative non-displaced fracture at the level of the calcar femorale. Three patients experienced postoperative dislocation. Although the study scale was small because of the very low prevalence (0.0065%) of the disease in Japan, the survival rate was similar to those reported overseas. All revision cases were due to mechanical loosening of the acetabular component of Lord THA, suggesting that the low survival rate was due to the performance of the prosthesis and not the pathology of ankylosing spondylitis.

We report a rare case of late recurrence of a giant cell tumour (GCT) of bone 16 years after curettage and cryosurgery treatment. A 46-year-old man presented with swelling and progressively worsening pain in the lateral aspect of his right distal femur. He had undergone 4 procedures elsewhere to manage a GCT of bone and its recurrence 16 to 23 years previously. He underwent en bloc resection with an adequate wide margin and reconstruction with prosthesis. At the one-year follow-up, there was no evidence of recurrence or metastasis.

In 19 patients with RA and 20 with OA who underwent autotransfusion with unwashed salvaged blood (USB) after total knee arthroplasty, we performed serial measurement of D-dimer, FgDP, t-PA, and PIC in the plasma and salvaged blood. The PIC level at the completion of salvaged blood transfusion was closely correlated with the volume of USB reinfused in the RA group (p < 0.001). The t-PA level of salvaged blood showed a significant positive correlation with the total volume of postoperative drainage in both the RA and OA groups (p < 0.05). The increase of total postoperative drainage associated with reinfusion of USB is largely caused by an increase of t-PA in the salvaged blood.

Two cases of closed dislocation of the interphalangeal joint of the thumb are presented. It was impossible to achieve manual reduction in either patient. This rare injury required open reduction with anatomical repositioning of the volar plate in both patients. We fixed the IP joint with a steel wire after reduction in both cases because of slight joint instability. At the latest follow-up, both patients do not have any problems with in daily life.

The natural history of osteonecrosis of the femoral head is generally thought to be one of progressive deterioration if no intervention is undertaken. However, it is unknown whether surgical intervention is beneficial for patients with a small region of osteonecrosis. We observed rapid improvement of MRI findings after rotational acetabular osteotomy (RAO) was performed in a young patient with osteonecrosis of the femoral head. The band-like low signal area on T2-weighted images almost resolved by six months after surgery. He returned to work as an electrician by six months after surgery. Early surgical intervention such as RAO that alters the mechanical force acting on the necrotic region of the femoral head may accelerate the recovery of osteonecrosis and the improvement of symptoms.

Autotransfusion with unwashed salvaged blood (USB) is effective for avoiding allogeneic blood transfusion (ABT) in patients undergoing total knee arthroplasty (TKA). We performed a retrospective study to determine the percentage of patients receiving ABT and the volume of postoperative blood drainage after introduction of autotransfusion with USB for patients with rheumatoid arthritis (RA) undergoing TKA. In 100 patients without autotransfusion (group 1) and 100 patients receiving autotransfusion of USB (group 2), we compared the number of patients who required ABT, as well as the postoperative drainage volume, ABT volume, and autotransfusion volume. In group 1, 83% of the patients received ABT, while only 47% received ABT in group 2, and there was a significant decrease (p

Between August 1986 and July 1997, we performed rotational acetabular osteotomy (RAO) according to the methods of Ninomiya and Tagawa in 161 patients (179 hips). Among them, 63 patients (68 hips) had advanced osteoarthritis. We assessed the outcome at a mean of 12 years after rotational acetabular osteotomy was performed for the treatment of advanced osteoarthritis in a series of patients with acetabular dysplasia. Eleven patients did not return for final follow-up and were excluded from the study, leaving 52 patients (57 hips) for analysis. The mean Merle d’Aubigné clinical score improved from 12.6 points (range 9–16) preoperatively to 14.3 points (range 7–18) postoperatively (p

Fracture of both the femoral head and neck associated with posterior hip dislocation is a rare injury. This report describes a rare case of fracture-dislocation of the hip joint with a separated femoral head with a residual fragment in the acetabulum, and a subcapital fracture. We performed open reduction with internal fixation immediately after the injury. Osteonecrosis of the femoral head was detected one year after the surgery, however this patient had no symptoms related to the hip joint.

Background:The fifth metatarsal bone is a common site of stress fractures in soccer athletes. Although several endocrine risk factors for stress fractures have been proposed, the endocrine risks for fifth metatarsal (5-MT) stress fractures have not been evaluated.Methods:To evaluate the endocrine risks of fifth metatarsal stress fractures, we conducted a cumulative case-control study. The present study included 37 athletes, of which 18 had a history of a zone 2 or zone 3 fifth metatarsal stress fracture and 19 controls. We analyzed serum 25-hydroxyvitamin D (25-OHD), serum parathyroid hormone (PTH), as well as biochemical markers of bone turnover by univariate or multivariate analyses.Results:Logistic regression analyses adjusted for multiple confounders revealed that insufficient serum 25-OHD levels less than 30 ng/mL (odds ratio [OR], 23.3), higher serum PTH levels (OR, 1.01), or higher serum bone-specific isoform of alkaline phosphatase levels (OR, 1.10) rather than serum tartrate-resistant acid phosphatase 5b were associated with statistically significantly increased odds of 5-MT stress fractures. A postestimation calculation demonstrated that 25-OHD levels of 10 and 20 ng/mL were associated with 5.1 and 2.9 times greater odds for 5-MT stress fractures, respectively.Conclusion:25-OHD insufficiency was associated with an increased incidence of 5-MT stress fractures. This insight may be useful for intervening to prevent 5-MT stress fractures.Level of Evidence:Level III, case-control study.

Rotational acetabular osteotomy (RAO) is a joint-conserving surgery in which femoral head coverage is improved using autologous cartilage to stabilize the joint. For advanced coxarthrosis, it has been reported that radical surgery should be selected, compared to the pre- and early stages. The objective of this study was to determine the clinical outcomes of patients in whom coxarthrosis progressed after RAO and came to undergo total hip arthroplasty (THA). We compared 24 total hip arthroplasties done in dysplastic hips after previous rotational acetabular osteotomy (RAO group) with a well-matched control group of 24 primary arthroplasties (control group) done during the same period at an average follow-up of 85 months (range 15–195). RAO group required significantly longer operative times and had more intraoperative blood loss. There was no significant difference between the two groups in terms of Harris Hip Score and radiographic outcome. Revision was performed in four and one joints in the RAO and control groups, respectively, showing no significant difference between the two groups (p = 0.165). THA after previous RAO leads to midterm results similar to those of other dysplastic hips. RAO does not seem to compromise the midterm clinical and radiographic outcome.

In 54 patients (1 man and 53 women), 55 hips underwent primary metal-on-metal total hip arthroplasty (Metasul) with a Wagner standard cup (44-48 mm in outer diameter) and were followed for a minimum of 3 years. All patients received the same type of cementless femoral component (Natural Hip Stem) and femoral head (28 mm in diameter). Twelve (21.8%) of the 55 Wagner standard cups showed aseptic loosening over a mean period of 31 months postoperatively, and there were no bone anchors on the outer surface of the 9 retrieved cups. From our experience, the small Wagner standard cup does not achieve sufficient osteointegration and we do not recommend use of this cup, especially for dysplastic hips.

The operative procedures chosen to treat arthrosis in patients with severe acetabular dysplasia vary among orthopaedic surgeons, particularly in younger patients. We operated on 450 hips with acetabular dysplasia by using the rotational acetabular osteotomy (RAO) method of Ninomiya and Tagawa by Ninomiya (Clin Orthop 247:127-137, 1989). In this report, we describe our technique of performing RAO with hydroxyapatite tricalcium phosphate-composite (HAP-TCP) blocks to achieve good acetabular coverage and the results of this procedure in 16 hips with severe dysplasia, including nine with advanced arthrosis. Adequate coverage of the osteotomized acetabulum was maintained and symptoms, especially pain, showed marked improvement at the latest follow up.

At present in Japan, there are neither reports on antibiotic prophylaxis regardless of underlying diseases nor precise guidelines on prophylactic antibiotics in orthopedic surgery. Therefore, the preventive effect of antimicrobial agents on surgical site infection (SSI) after clean orthopedic surgery was studied to control the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in our ward and to reduce SSI caused by MRSA.Regardless of the type of operation or underlying disease, a regimen of prophylaxis that is of shorter duration than before was conducted in 419 patients admitted to our orthopedic ward (one ward) and who underwent clean orthopedic surgery between 2001 and 2002.The annual usage of beta-lactam antibiotics in the ward decreased by 960.9 g, the isolation rate of MRSA in the ward decreased to 50% (the lowest isolation rate in the past 4 years), and SSIs caused by MRSA were found in 3 of 419 (0.71%) patients in one year compared with 6 of 470 (1.28%) during the previous year. Comparison of two antibiotics revealed that SSI caused by MRSA did not occur in any of the 187 patients receiving sulbactam/ampicillin as prophylaxis but did occur in 1.29% (3/232) patients receiving cefazolin. Concerning all SSIs caused by any organisms, they occurred in 0.53% of patients receiving sulbactam/ampicillin and in 2.16% of patients receiving cefazolin. The difference in the SSI rates between the two groups was not statistically significant.Although there is statistically no significant difference in the incidence of SSI caused by MRSA, we were able to decrease the isolation rates of MRSA and prevent MRSA from spreading owing to the reduced antibiotic usage in this study. Sulbactam/ampicillin can be recommended, as well as cefazolin, for antibiotic prophylaxis in clean orthopedic surgery.

Background: While rotational acetabular osteotomy has been reported to be successful for the treatment of osteoarthritis of the dysplastic hip, little is known about its efficacy in the treatment of osteonecrosis of the femoral head. Methods: We retrospectively reviewed the results for a consecutive series of twenty-one patients (twenty-five hips) who had undergone rotational acetabular osteotomy between 1995 and 2001 for the treatment of extensive osteonecrosis of the femoral head associated with collapse. All but two of the patients had a history of steroid therapy as part of a treatment regimen for various diseases. At the time of surgery, the mean age of the five men and sixteen women was 29.0 years. The mean duration of follow-up was forty-nine months. No patient was lost to follow-up. The lesions were classified according to the staging system described by Steinberg et al., and the extent of necrosis was measured with use of the criteria described by Kerboul et al. Clinical evaluation was performed with use of the scoring system of Merle d'Aubigne and Postel. Radiographic evaluation was performed with use of yearly serial anteroposterior and lateral plain radiographs. Results: The mean Merle d'Aubigne and Postel score improved from 11.3 points preoperatively to 14.9 points at the time of the final follow-up (p < 0.001). The mean pain score improved from 3.0 to 5.6 points (p < 0.001). However, the mean mobility score was 5.3 points preoperatively but only 4.9 points postoperatively (p = 0.1). All of the osteotomy sites showed radiographic evidence of osseous union at the time of the latest follow-up. Collapse of the femoral head progressed in seven hips, but in six of these hips the change in the extent of collapse was

In this study, we examined the influence of gender difference on postoperative stability in cases of anterior cruciate ligament (ACL) reconstruction. We studied 101 patients who had been followed for 24 months or longer after they underwent ACL reconstruction using multiple-looped semitendinosus. They comprised 51 men and 50 women aged 15–45 (mean, 24) years. Parameters examined were size of the graft tendon and joint stability. Results were compared between men and women. Graft tendon size ranged from 8.0 to 11 mm (mean ± standard deviation, 9.8±0.8 mm) in men and from 8.0 to 10.5 (9.0±0.7) mm in women, and the difference between men and women was statistically significant (P

Eight knees of seven patients with osteochondritis dissecans of the knee underwent internal fixation of the fragments. The affected location was the medial femoral condyle in four knees, the lateral femoral condyle in one knee and the patellar groove in three knees. At the time of surgery, patient age ranged from 13 to 20 years (mean 16.9 years). Open reduction and internal fixation of the unstable fragments was performed with autologous bone pegs in one knee. In the other seven knees, the procedures were carried out with biodegradable poly-L-lactide pins. At a mean follow-up of 5 years (range 4-6.8 years), seven fragments were united, whereas one knee required arthroscopic removal of the loose fragment. Neither effusion nor synovitis was noticed in any of the patients treated with biodegradable pins. The technique is simple and provides satisfactory results, suggesting a valid option for the treatment of osteochondral defects where possible.

We determined changes in serum chromium concentration every 6 months up to 3 years after implantation in 44 patients (mean age 63 (49-79) years, 35 women) who underwent modern metal-on-metal total hip arthroplasty (Metasul). The serum chromium levels increased between the first and second year after implantation (1 year: 1.05 (SD 0.76) microg/L, 2 years: 1.46 (SD 0.91) microg/L). A small increase was observed during the third year (1.61 (SD 1.31) microg/L). The clinical relevance of this finding is uncertain and should be determined in long-term studies on a large scale.

We investigated the clinical and radiographic outcome of 35 Lord-type noncemented total hip arthroplasties (THAs) in 30 patients who were aged 70 years or older at surgery and were followed for a minimum of 5 (mean 7.0) years. The mean Harris hip score was 38.6±9.3 before surgery and 85.6±9.1 after 5 years of follow-up. Eighty-nine percent of the patients were satisfied with the functional outcome. Reoperation was done on two hips (6%) because of aseptic loosening—revision of both stem and cup in one, and revision of the stem in one. At the 5-year examination, stem subsidence occurred more frequently with the smooth-surfaced stem (Polarisee and LFR prostheses) than the bead-coated stem (Madreporic and Mark-II prostheses) (p

Patients undergoing upper extremity surgery generally have a low risk of pulmonary embolism. We encountered a rare case of fatal pulmonary embolism after surgical treatment of a clavicle fracture. A 46-year-old man fell off the roof of his car and suffered fractures of the left clavicle, temporal bone and ribs, as well as cerebral and lung contusions. He was admitted to a local hospital, and was later transferred to our hospital for surgical treatment of the clavicle fracture at 6 days after injury. He had no dyspnea and was ambulant. On day 7 after the injury, open reduction and internal fixation of the clavicle fracture using a plate and screws were performed under general anesthesia. Although surgery was uneventful, the patient had bradycardia postoperatively that progressed to cardiopulmonary arrest, which required resuscitation and intubation. Spontaneous cardiac output was restored 10 minutes after cardiac arrest, but the GCS score was E1V1M2. Enhanced CT of the chest revealed a 15 mm defect in the right pulmonary artery, leading to a diagnosis of pulmonary embolism. Thrombolytic therapy was started immediately. However, the patient’s condition worsened and he died 20 days postoperatively. We suggest that use of mechanical and chemical thromboprophylaxis should be considered for clavicle surgery.

We measured the cobalt and chromium concentrations in the serum and urine of 32 patients with current designed metal-on-metal total hip arthroplasty and 43 patients with conventional metal on ultrahigh molecular weight polyethylene (UHMWPE) cementless total hip arthroplasty. The results of our study showed that the serum and urine chromium concentrations increased in 37.5% and 90.6%, respectively, of 32 patients with well-fixed metal articulation (the mean values were 0.09 microg/dl and 2.2 microg/l, respectively) and also increased in 28.6% and 85.7%, respectively, of 7 patients who received metal-on-UHMWPE articulation with loosened acetabular component or stem made of Co/Cr alloy (the mean values were 0.06 microg/dl and 1.6 microg/l, respectively). On the other hand, the serum and urine cobalt concentrations were below the detection limit in all patients.

We investigated the radiographic changes in 22 hip joints of 17 patients with secondary advanced osteoarthritis of the hip who received conservative treatment for more than 10 years. Arthritic changes progressed in 16 out of 22 joints (73%) and the remaining six joints (26%) did not change. Remodeling occurred in 15 of the hips (68%). During this process, joint congruity improved markedly in eight hips, so the number with good joint congruity increased from 13 (59%) to 21 (95%). In the remaining one hip, remodeling did not occur and joint incongruity was persistent. In this series, there were four radiographic patterns. One pattern was that the hip maintained good joint congruity without progression of osteoarthritis for more than 10 years (five joints, 23%). The second pattern was that hips with good joint congruity initially improved further after remodeling (eight joints, 36%). The third pattern was that hips with joint incongruity initially underwent remodeling to achieve good joint congruity with the passage of time (eght joints, 36%). The fourth pattern was that one hip showed persistent joint incongruity without remodeling (one joint, 5%). Clinically, hip pain did not worsen significantly, but moderate (approximately 70% decrease) limitation of flexion and abduction occurred eventually. These findings suggest that some patients with advanced osteoarthritis of the hip with good joint congruity or hips showing remodeling may be suitable for conservative treatment, especially in younger patients.

The outcome of cementless total hip arthroplasty depends on many factors. We must not forget fundamental things those are design of outer surface of the component, that leads bone ingrowth into the prosthesis, better initial stability, and better insertional techniques. The purpose of this study was to review our experience with metal-on-metal total hip arthroplasty with a Wagner standard cup for patients who had acetabular dysplasia.Fifty-four patients with 55 hips underwent primary metal-on-metal total hip arthroplasty (Metasul prosthesis) with a Wagner standard cup (44-48 mm in outer diameter) and were followed for a minimum of 10 years. All patients received the same type of cementless femoral component (Natural hip stem) and femoral head (28 mm in diameter).Seventeen of the 55 Wagner standard cups (30.9%) showed aseptic loosening over a mean period of 3.6 years after surgery, and there were no bone anchors on the outer surface of the 16 retrieved cups.From our experience, the small Wagner standard cup does not achieve sufficient osteointegration and we do not recommend the use of this cup, especially for patients with acetabular dysplasia and/or those with a small stature.

Two groups of 53 cementless total hip replacement were compared retrospectively after 3–7 years average follow-up. The design of femoral components in cementless total hip arthroplasty has progressed with emphasis placed on prevention of stress shielding in recent years. However, whether the stress shielding is actually prevented with the progress in stem design is open to debate. The purpose of this manuscript is to study radiologically whether the progress of the stem design in cementless total hip arthroplasty really reduced stress-shielding. We used 24 Omnifit stems and 29 Lord Mark ll stems. They were investigated in accordance with Gruen's classification with respect to osteolysis, atrophy, cortical hypertrophy and pedestal bone formation at the tip of the stem. With the Omnifit stem less bone atrophy was produced at the proximal femur but hypertrophic changes at the distal femur were more pronounced compared with Lord Mark II. It is concluded that the press-fit design does not prevent stress shielding completely.

A false aneurysm of the profunda femoris artery occurred after metal-on-metal total hip arthroplasty in 70-year-old woman. At 39 days after the operation, the wound suddenly opened, and a large hematoma was discharged. Eleven tornade coils were inserted into the base of the false aneurysm, and the bleeding was arrested. The prevention and management of this complication are discussed.

The operative procedures chosen for arthrosis with severe acetabular dysplasia vary among orthopaedic surgeons. We operated on 250 hips using the rotational acetabular osteotomy (RAO) method of Ninomiya and Tagawa [8]. In this report, we describe the technique of RAO and the results of this procedure in patients with severely dysplastic hips. Among the 250 hips, there were 6 which were classified as Severin group V. In those hips, the CE angle was less than 0 degrees, and the femoral head showed superolateral subluxation. After acetabular osteotomy with straight and curved osteotomes, smooth inferolateral rotation could be done in all cases. At the latest follow-up symptoms were improved remarkably, especially pain. Radiographically, adequate coverage of the femoral head was achieved and joint congruence improved in all 6 hips.

We report a case of bizarre accessory metatarsal located between the left fourth and fifth metatarsals without a supernumerary digit in a 6-year-old girl. The accessory metatarsal was resected to alleviate foot pain on walking. This metatarsal dysplasia might have arisen from sequential failures of digital formation at an early stage of development.

Although various operative procedures have been applied for advanced or terminal osteoarthritis of the hip joints in relatively young patients, the long-term results are controversial. Since 1974, we have performed the triple-cup arthroplasty developed by Aoki in 110 patients who were comparatively young. The triple-cup assembly is composed of stainless-steel outer and inner cups between which a high density polyethylene cup is incorporated, so that there are basically four mobile surfaces, but the major movement is actually taking place between the outer cup and the plastic cup [8]. We have sometimes encountered migration of the cups, which caused hip joint pain and decreased the range of motion. Revision surgery was required for 25 hip joints in 21 patients (23%). The acetabulum was very thin in almost all cases, so that reaming of the cavity had to be restricted to the minimum possible. The femoral head in the cup was often covered with a layer of fibrous tissue. We could utilize the femoral head as a bone graft, even though the residual volume of bone varied in each case. The result of revision surgeries after the triple-cup arthroplasty was good clinically and radiographically at last follow-up.

Purpose. To evaluate the chromium level of the salvaged blood in patients undergoing revision total hip arthroplasty (THA). Methods. Records of 7 women and one man aged 54 to 83 (mean, 64.3) years who underwent revision THA for aseptic loosening of the acetabular component (n=6), osteolysis of the acetabulum (n=1), or migration of the outer head (n=1) were reviewed, as were 2 controls who underwent primary THA. The initial THA entailed a metal-on-metal prosthesis (n=4), a metal-on-polyethylene prosthesis (n=3), and a bipolar head prosthesis (n=1). Chromium levels in the preoperative peripheral blood and intraoperative salvaged blood were measured using atomic absorption analysis. Results. For controls and the patient with a bipolar head prosthesis, the mean chromium level in salvaged blood was 0.4 (range, 0.2–0.6) μg/l, which was significantly lower than that in the remaining 7 patients undergoing revision THA (mean, 5.6 μg/l; range, 1.2–9.8 μg/l). Conclusion. Salvaged blood of patients with a metal-on-metal prosthesis undergoing revision THA contained higher levels of chromium.

Background:Internal fixation is advocated as the primary treatment for fifth metatarsal Jones fractures in athletes; however, screw insertion site discomfort and refracture can occur especially in competitive athletes. The ideal implant has not been determined.Hypothesis:Headless compression screw fixation of proximal fifth metatarsal Jones fractures is an effective treatment approach especially in competitive athletes.Study Design:Case series; Evidence level, 4.Methods:We studied 60 athletes treated surgically with a headless compression screw for fifth metatarsal Jones fractures (mean age, 19 years). The mean follow-up time was 178 weeks. We evaluated the clinical and radiographic outcomes of headless compression screw fixation of Jones fractures.Results:All athletes returned to full activity. The mean time to start running after surgery was 6.3 weeks (range, 3-12.7 weeks), and the mean time to full activity after surgery was 11.2 weeks (range, 6-25 weeks). One athlete suffered a delayed union, which healed uneventfully. One athlete suffered a nonunion and underwent reoperation for a screw exchange to an autogenous bone graft harvested from the iliac crest. No screw breakage was reported. No athlete suffered a refracture or discomfort in the screw insertion site.Conclusion:Headless compression screw fixation of fifth metatarsal Jones fractures provided excellent results, allowing athletes to return to full activity without both screw insertion site irritation and clinical refracture.