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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.

This study was undertaken to evaluate a dosing time-dependent effect of temocapril, an angiotensin-converting enzyme (ACE) inhibitor, on the mortality of stroke-prone spontaneously hypertensive rats (SHRSP). Temocapril (1 mg/kg/day) prolonged the survival rate of these animals, with a maximum effect after dosing at the early resting period and a minimum effect after dosing at the early active period. The pharmacokinetics of temocaprilat, an active metabolite of temocapril, did not differ significantly between the two dosing times. However, the inhibition of ACE activity in serum and organs (brain and aorta) and the reduction of blood pressure were significantly greater after dosing at the early resting period than at the early active period. These data suggest that the effect of temocapril on the mortality of SHRSP depends on the time of dosing, with a maximum effect seen after dosing at the early resting period. Dosing time-dependent differences in the pharmacodynamics of temocapril might be involved in explaining this phenomenon.

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

Twelve men and eighteen women with a mean age of 22 (15–32) years who underwent anterior cruciate ligament (ACL) reconstruction using semitendinosus muscle tendon were studied. The quadriceps strength was isokinetically measured during concentric and eccentric contractions. When the muscle strength was examined before ACL reconstruction, the injured/uninjured ratio was 72.9% for eccentric contraction, which was significantly lower than the 81.4% for concentric contraction. For postoperative muscle, the injured/uninjured ratio was 98.6% for eccentric contraction and 80.6% for concentric contraction, showing better recovery of muscle strength for eccentric contraction. The observation of lower muscle strength for eccentric contraction than for concentric contraction in knees before ACL reconstruction may be explained by the fact that movements such as stop and turn become difficult due to ACL dysfunction. The result is that the patient avoids exerting eccentric knee extension and contraction forces even in daily living activities. On the other hand, once the joint instability is improved by ACL reconstruction, patients do not need to avoid movements such as stop and climbing down stairs that require eccentric contraction strength. This may account for good recovery of the muscle strength for eccentric contraction.

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.

Telmisartan and valsartan have angiotensin II receptor blocking activity. Because telmisartan has also an agonistic action for peroxisome proliferators-activator receptor (PPAR)-γ, it is speculated that an effect of telmisartan on insulin sensitivity is different from that of valsartan, which lacks of PPAR-γ agonistic activity. To address the issue, effects of telmisartan and valsartan on insulin sensitivity, adipocytokines and PPAR-γ target genes were evaluated in obese diabetic mice. KK-A(y) mice were treated with telmisartan (5mg/kg) and valsartan (15 mg/kg), once daily for 3 weeks. Insulin tolerance test was performed on day 14, and plasma adiponectin concentration and mRNA expression levels of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in adipose tissues were measured on day 21. Time-course of plasma glucose level after the injection of insulin in mice with telmisartan was not significantly different from that of animals with valsartan. In addition, PPAR-γ antagonist did not diminished the improvement of insulin sensitivity by telmisartan. Telmisartan and valsartan elevated plasma adiponectin concentration and suppressed the mRNA expressions of TNF-α and IL-6 in adipose tissues. These variables of the telmisartan- and valsartan-treated groups did not significantly differ. Influence of telmisartan on the PPAR-γ target genes (ap2 and fatty acid synthase) mRNA expressions was not detected in adipose tissues under the present condition. These data suggest that the effect of telmisartan on insulin sensitivity is similar to that of valsartan, and a role of PPAR-γ-mediated stimuli is small in the telmisartan-induced improvement of insulin sensitivity.

We performed revision total hip arthroplasty on 12 patients via the transfemoral approach because difficulty with surgery was anticipated preoperatively. The total hip score improved in all of the patients. Radiographically, there were no radiolucent lines around the acetabular and femoral components, but one hip still showed sinking of the stem by 2 cm. Although the transfemoral approach might seem very aggressive, this is actually a relatively simple method that allows rapid removal of the prosthesis and cleaning of the medullary canal.

Delayed onset of sciatic neuropathy after total hip arthroplasty is uncommon, and late hardware-induced sciatic nerve complications are rarely reported. Here, we report a patient in whom the posterior flange of the reinforcement ring caused severe late sciatic nerve injury. Sciatic nerve radiography was useful for diagnosing flange-related sciatic nerve injury.

The neuroelectric activity that ascends the sciatic nerve and moves to the spinal cord was visualized by measuring the magnetic compound action fields (CAFs) with a superconducting quantum interference device gradiometer. The sciatic nerve of a dog was stimulated electrically, and propagating evoked CAFs were measured non-invasively. Isomagnetic field maps were made on the basis of this data, and the signal propagation was visualized. The evoked magnetic fields presented a quadrupole consisting of two elements: depolarization and repolarization. Measuring the magnetic CAFs of the sciatic nerve on the body surface enabled us to visualize the non-invasively the signal movement continuously from the sciatic nerve to the spinal cord.

Purpose. To review records of 161 consecutive hip surgery patients for whom preoperative autologous blood donation (PABD) was used in combination with intra-operative cell salvage (ICS). Methods. 114 women and 14 men aged 41 to 86 (mean, 64) years underwent 135 primary total hip arthroplasties (THAs), whereas 19 women and 7 men aged 16 to 52 (mean, 35) years underwent 26 rotational acetabular osteotomies (RAOs). Two or 3 weeks before the operation, patients deposited one unit (400 ml) of blood weekly, so long as their haemoglobin levels exceeded 110 g/1 (if they had osteoarthritis) or 100 g/1 (if they had rheumatoid arthritis). Patients were given oral ferrous sulphate, lactated Ringer's solution, and recombinant human erythropoietin. 800 and 1200 ml of blood were deposited for patients undergoing THA and RAO, respectively. Intra-operatively, ICS was carried out using a continuous autotransfusion system. The blood from ICS was transfused first, and then the blood from PABD was transfused during the latter half of the operation. Results. By combining PABD and ICS, homologous blood transfusion was avoided in all patients, even in those with unexpected massive bleeding during surgery. In 3 patients, one unit of deposited autologous blood was discarded, because they showed no sign of anaemia. The mean total blood loss was almost 1.5 times higher in RAO than in THA patients (1095 vs 1550 ml). In the THA and RAO patients respectively, the mean amount of ICS was 181 and 210 ml, whereas the mean total blood transfusion volume was 975 and 1394 ml. No complications (including infection) related to autologous blood transfusion were observed during PABD, the surgery or the postoperative period. Conclusion. Homologous blood transfusion was avoided with the use of PABD and ICS. Preoperative donation of 800 and 1200 ml of blood (combined with ICS) seemed optimal, as only 3 units of blood were discarded.

Subcapital femoral neck fractures are a rare complication after fixation of an intertrochanteric fracture with a proximal femoral nail. We report 2 such cases where the patients had severe osteoporosis, based on Singh's index and pathological findings. In one case there was a technical error leading to a tip-apex distance of more than 20 mm, but osteoporosis appeared to be a more significant cause than any technical problems.

Insufficiency fracture of the superior part of the acetabulum after hemiarthroplasty has not been reported before. Here we report a case of dislocation after hemiarthroplaty due to insufficiency fracture of the acetabulum. In our patient, insufficiency fracture of the ilium immediately above the acetabulum produced obvious evidence of compression and collapse that led to dislocation of the outer head of the femoral component. This patient hadsubsequentlybeen treated with a cementless socket inserted into the fractured acetabulum. We should remember the possibility of insufficiency fracture of the superior acetabulum after hemiarthroplasty, particularly in elderly patients suffering from chronic postoperative pain and disability.

The treatment of residual deformity following surgery for developmental dysplasia of the hip remains controversial. The rationale for the use of the rotational acetabular osteotomy (RAO) is that it increases the weight-bearing area by shifting the osteotomized acetabulum to cover the femoral head. This can improve joint function as well as achieve relief of pain. However, it is unclear if this osteotomy can improve a compromised hip when performed for the treatment of residual deformity and acetabular dysplasia after surgery for developmental dysplasia of the hip. We aimed to report the clinical outcome as assessed by need for total hip arthroplasty (THA) and by the Merle d'Aubigné and Postel scores. In addition, we tried to assess the radiographic outcomes as assessed by Tönnis's classification. Only two hips required THA, which was performed in two patients at 11 and 12 years after RAO, respectively. The mean Merle d'Aubigné clinical score improved from 14.1 ± 2.3 points (range, 10 to 17) preoperatively to 15.8 ± 2.9 points (8 to 18) at final follow-up ( p < 0.02). Radiological assessment at final follow-up showed the obvious progression of osteoarthritis in five hips. One patient in grade 1 preoperatively progressed into grade 3 at final follow-up; four patients in grade 2 preoperatively progressed into grade 3. In our study, this osteotomy prolonged the functional life of the hip, and only two hips needed THA after a mean follow-up of 11 years. We found that advanced arthritis pre-osteotomy is associated with progression of radiologic changes

Acetabular dysplasia (AD) contributes to the development of osteoarthritis of the hip. A rotational acetabular osteotomy (RAO) is one of the methods of pelvic osteotomy to prevent or treat secondary osteoarthritis of the hip. Although most of the patients that undergo RAO show satisfactory results, some have poor results. This study investigated whether gene polymorphisms of both the vitamin D receptor (VDR) and oestrogen receptor (ER) are involved in both AD and the postoperative results following RAOs. Sixty-four Japanese patients with AD who were treated by an RAO were enrolled in this study (59 women and 5 men, aged 13–59, with an average age of 40.3). Gene polymorphisms of the VDR [ApaI and TaqI restriction fragment length polymorphisms (RFLPs)] and ER (PvuII and XbaI RFLPs) were determined in these patients. The relationship between both the AD and radiographic postoperative changes of the hip joint after an RAO with these gene polymorphisms were examined. The frequencies of ER gene polymorphism coded as pp (RFLP/PvuII) in patients with AD were statistically significantly different (p = .011) from those coded as both PP and Pp. The joint space width narrowed even after RAO in 90% of the patients with the pp gene polymorphism, while it narrowed in only 35% of the patients with either PP or Pp seven years or longer after an RAO. The PvuII polymorphism in the ER gene was associated with the postoperative result of an RAO, while no association was observed between the AD with VDR and ER gene polymorphisms.

We encountered a rare case of severe subluxation of the femoral head after the performance of rotational acetabular osteotomy to treat osteoarthritis of the hip, secondary to acetabular dysplasia. The subluxation was corrected by performing varus and flexion osteotomy.

We investigated the changes of serum chromium levels before and after revision surgery in 10 patients (1 male and 9 females) who underwent exchange of a metal-on-metal articulation for a metal-on-polyethylene component because of aseptic loosening of a metal-on-metal total hip prosthesis. Of the 10 patients, 2 had bilateral metal-on-metal total hip arthroplasty. In the 8 patients who had no residual metal articulation, the mean serum chromium levels before and after revision surgery were 2.53 microg/L and 0.46 microg/L, respectively. In the 2 patients who still had a metal articulation on the contralateral side, the mean serum chromium levels before and after revision surgery were 2.85 microg/L and 1.90 microg/L, respectively. Moderate serum chromium levels in patients with metal-on-metal total hip arthroplasty show a decrease after removal of the metal-on-metal articulation.

Marked activation of thrombosis is common in patients undergoing total hip arthroplasty, especially during reaming of the femur and after insertion of the femoral prosthesis. This suggests that management designed to minimize deep vein thrombosis and fatal pulmonary embolism after total hip arthroplasty should be focused on the period during insertion of the femoral component. In some previous studies, a low dose of heparin administered intraoperatively was shown to suppress the formation of fibrin.The present study was performed to evaluate the influence of intraoperative heparin administration on the D-dimer level and on the prevention of pulmonary embolism after total hip arthroplasty.A total of 22 and 26 consecutive patients respectively underwent total hip arthroplasty with and without intraoperative administration of unfractionated heparin. Postoperatively, all patients wore knee-high elastic stockings and were fitted with calf-to-thigh intermittent pneumatic compression devices. Active ankle flexion and extension exercises were commenced as soon as motor function recovered. None of the 48 patients received prophylactic anticoagulants postoperatively.There was a significant difference of the mean D-dimer level on the 1st day between the patients with and without intraoperative administration of heparin (8.9 +/- 6.6 vs. 15.7 +/- 12.7, P0.05). Although there were no patients with symptomatic deep venous thrombosis and pulmonary embolism, asymptomatic pulmonary embolism was detected by pulmonary perfusion scintigraphy in three patients who did not receive intraoperative heparin. The operative blood loss and postoperative drainage were similar in both groups and no bleeding complications were observed. In conclusion, we recommend a safe and inexpensive regimen comprising 1,000 U of intravenous unfractionated heparin intraoperatively, postoperative pneumatic compression, and early active mobilization for prevention of thoromboembolic complications after total hip arthroplasty.

C hondroblastoma is a rare primary bone tumor that usually affects the epiphysis or apophysis of long bones, especially the proximal part of the tibia, the proximal part of the humerus, and the proximal and distal parts of the femur. Its clinical course is unpredictable, and it can behave aggressively without treatment. Even with curettage, the local recurrence rate can be ≥20% within three years after the operation1-7. A few cases of metastasis have been reported despite the histologically benign appearance of the tumor5,6. There have been reports of the development of osteoarthritis of the hip joint secondary to femoral head collapse after curettage of lesions in the femoral head2,6. In this paper, we report the case of a patient with chondroblastoma of the femoral head and acetabular dysplasia who was treated with rotational acetabular osteotomy to prevent femoral head collapse after curettage of the lesion. The patient was informed that data concerning this case would be submitted for publication. Figs. 1-A and 1-B The initial anteroposterior plain radiographs of the hip. Fig. 1-A The extent of the lesion is delineated with dotted lines. One millimeter of collapse superiorly is shown by the superimposed Mose circle on the femoral head (arrowheads). A twenty-eight-year-old man was seen at another hospital because of right hip pain with walking, which had lasted for six months. A diagnosis of solitary bone cyst was made at that institution, and he was treated with core decompression. The pain did not decrease postoperatively, and he subsequently consulted our hospital. Fig. 1-B The intact lateral cortex is outlined. Note that there is moderate developmental dysplasia of the hip (center-edge angle, 18°; acetabular head index, 63%). The hip joint is congruent, and there is no loss of joint space. On examination, the patient …

Low‐intensity pulsed ultrasound (LIPUS) has recently been shown to accelerate long bone fracture healing, but its effect on osteoporosis is not clear. The aim of this study is to investigate whether bone mineral density (BMD) of distal one‐third radius of older woman is influenced with LIPUS. Six Japanese women who were outpatients at our hospital were recruited in this study and ranged from seventy to seventy‐four years of age. In this study LIPUS exposed unilateral distal one‐third of the radius for 20 min/once, 3 times and over every week for six months. The contralateral side was not exposed. The intensity of ultrasound was 30 mW/cm2 spatial‐average temporal‐average. Bone status was assessed by dual energy X‐ray absorptiometry at baseline and 3 and 6 months later. Medication for osteoporosis were not changed. A significant increases in BMD at the treatment site were found in 3 women without alendronate and menatetrenone medication (averaged 4.5%). No significant differences were found in women on these medications. No remarkable changes were found away from the treatment site. These results suggest the possibility of effectiveness of LIPUS applied to a local area of osteoporosis and that pharmacological intervention is capable of influencing the effect of LIPUS for osteoporosis.

Stress fracture of the femoral neck has been considered a typical injury of two age groups: active youths and elderly people with osteoporosis. Its occurrence in children with an open capital femoral epiphysis is rare, and only 11 cases have been reported. Here we report two cases, in a 12-year-old boy and a 5-year-old girl (among the youngest patients on record). This fracture can be classified as a compression fracture or a tension fracture. Although tension fractures are not uncommon in military recruits and young athletes, all 13 cases (including our two cases) of femoral neck stress fracture associated with an open capital epiphysis were compression fractures that were treated conservatively.

We encountered a rare case of osteochondritis dissecans of the femoral head after rotational acetabular osteotomy that recovered with conservative treatment 4 years after the detection of characteristic radiological findings.

Biodegradable polylevolactic acid implants have become more commonly used for the treatment of fractures and osteotomies over the past few years. In the present study, the biocompatibility and degradation of polylevolactide screws used for rotational acetabular osteotomy were assessed on the basis of radiographic and MRI findings. Forty-nine hips of 47 patients were analyzed for this study. The average age of the patients at the time of surgery was 38.0 years (range 18–62 years). The original diagnosis was osteoarthritis in 43 hips and osteonecrosis in 6 hips. The mean duration of follow-up was 2.8 years (range 1.5–5.5 years). Anteroposterior radiographs obtained at 1 week, 6 months, 1 year after the operation, as well as the most recent radiographs, were used to assess bony union, the radiolucent tract of each screw, and the sclerotic rim around each screw. Fifteen patients were chosen randomly to undergo MRI. Union of the osteotomized surfaces occurred in all patients within 6 months of surgery. Radiographs showed no osteolysis, no formation of bone cysts, and no displacement of the osteotomized acetabulum in any of the 49 hips. None of the patients was found to have any complications caused by problems with the biocompatibility of the implants. At the final postoperative examination, a central radiolucent tract and a sclerotic rim around the screws were seen in 34/49 hips (69%) and 23/49 hips (47%), respectively. On MRI findings, we were able to detect significant resorption of the screws in two patients after 1.2 and 1.7 years of follow-up. Though localized low-intensity areas on T1-weighted images and high-intensity areas on T2-weighted images were observed at the top of the screws in 5 patients, there was no development of pain, tenderness, or a sinus during the follow-up period. Although absorption of polylevolactic acid screws did not occur in a large majority of cases, rotational acetabular osteotomy appears to be a good indication for the use of polylevolactic acid screws.

Background Athletes suffering from any injuries want to know when they will be able to return sports activity. The period of return-to-sport after the arthroscopic meniscectomy is still unknown. The aim of this study is to investigate the period of the return-to-sport from surgery and the clinical symptoms after the meniscectomy on stable knees. Methods Fifty-six athletes who underwent the arthroscopic meniscectomy were evaluated. The patients with an average age of 26.7 years (range, 13–67) comprised 45 men and 11 women, 16 medial meniscus and 40 lateral meniscus injuries. The average of the follow-up period was 9.2 months. The parameter examined were age, the injured side of meniscus (medial or lateral), articular cartilage status, amount of resection, and sports activity level. Results The mean period was 54 days in young group, and was 89 days in old group (p = 0.0013). The period was 79 days in medial meniscus (MM) injured group, and was 61 days in lateral meniscus (LM) group (p = 0.017). There was a significant difference among the groups in activity levels and in amount of resection. Pain and/or effusion in the knee after the return-to-sport were found 22% of the MM group and 53% in the LM group. Conclusions The period of the return-to-sport was shorter in young age, high activity and large amount of resection group. Although athletes in LM group can return to sports earlier than those in MM group, more than half of athletes have pain or effusion at the time of return-to sport.