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Background: Acetabular dysplasia (AD) is the main cause of hip osteoarthritis in Japan. A simple method to evaluate acetabular dysplasia would be helpful for early treatment or prevention of hip osteoarthritis. Acetabular dysplasia is reported to be associated with pathological transverse growth of the pelvis, indicating that the distance between the 2 anterior superior iliac spines might be useful for screening and detection of acetabular dysplasia. The purpose of this study was to determine if the acetabular dysplasia radiographic parameters are related to the distance between the 2 anterior superior iliac spines in patients with hip osteoarthritis. Material/Methods: In this study, data obtained in a previous multi-institutional examination of patients with hip osteoarthritis in Japan were evaluated. The anterior superior iliac spine distances of 176 female patients (mean age, 54 years; range, 18-85 years) were measured by physical examination. The relationship between the anterior superior iliac spine distance and acetabular dysplasia was analyzed, and the anterior superior iliac spine distances of the patients with acetabular dysplasia who were at relatively high risk for hip osteoarthritis were compared with that of the patients at lower risk. Results: A statistically significant relationship between the anterior superior iliac spine distance and all of the acetabular dysplasia parameters was observed. The anterior superior iliac spine distances of the acetabular dysplasia patients with a relatively high risk for radiographic acetabular dysplasia parameters were significantly smaller than those of patients at lower risk. Even after adjustment for age, height, and weight, significantly increased relative risk for having high risk AD was found in patients with an ASIS distance of less than 24.5 cm. Conclusions: There was a significant relationship between the anterior superior iliac spine distance and the degree of acetabular dysplasia., Medical Science Monitor, 20, pp.116-122; 2014

The purpose of this multicenter study was to evaluate the clinical performance of an ultrahigh molecular weight polyethylene (UHMWPE) fiber cable for re-attachment of the osteotomized greater trochanter in hip surgery. Included in the study were 85 hips that had undergone surgery with greater trochanter osteotomy, including 50 hip arthroplasty procedures and 35 hip osteotomies. The osteotomized greater trochanter was reattached using one or more UHMWPE fiber cables. The bone union and displacement of the greater trochanter were assessed in radiographs for up to 12 months after surgery. Non-union of the osteotomy site occurred in 4.7% of the cases. In approximately 90% of the cases, displacement was less than 2 mm at up to 12 months after surgery. The UHMWPE fiber cable was a good biomaterial for reattaching the osteotomized greater trochanter and may also be an option for osteosynthesis procedures.

The purpose of this study was to assess the removability and biological reactivity of an ultrahigh molecular weight polyethylene (UHMWPE) fiber cable as a new biomaterial for osteosynthesis. We used a pull-out test and an implantation test to analyze the performance of the UHMWPE fiber cable using a dog model, and compared its characteristics with those of a wire cable and a soft wire. In the pull-out test, the UHMWPE fiber cable was as easy to remove as the soft wire, and both the UHMWPE fiber cable and the soft wire were significantly easier to remove than the wire cable. The fixation capability and the biological reactivity of the UHMWPE fiber cable were examined in an osteosynthesis model of the dog greater trochanter, and were compared with those of the soft wire. The bone union rate, assessed radiographically, was very similar when using the UHMWPE fiber cable and the soft wire. However, in the soft wire group, both the surface of the greater trochanter under the fixation material and the penetration area around the fixation material showed an increased tendency toward a biological reaction, including inflammation and granulation tissue formation, as compared to the UHMWPE fiber cable group. The UHMWPE fiber cable was as easily removed from the bone tissue as the soft wire, and was easier to remove than the wire cable. Additionally, the UHMWPE fiber cable caused reduced biological reactivity with the surrounding tissue, as compared with the soft wire. In conclusion, the UHMWPE fiber cable appeared to be a suitable fixation material for osteosynthesis.

Aim As society ages, there is a vast number of elderly people with locomotive syndrome. In this study, the factors associated with functional limitations in daily living activities evaluated by female hip osteoarthritis (OA) patients were investigated. Methods This study was a cross‐sectional study. The subjects were 353 female patients who were newly diagnosed with hip OA at an orthopedic clinic with no history of hip joint surgery. Outcome indices were functional limitations in two daily living activities obtained from a questionnaire completed by the patients: (i) standing up (standing from a crouched position) and (ii) stair‐climbing (climbing and/or descending stairs). The odds ratios (ORs) and 95% confidence intervals (CIs) were computed for explanatory variables using the proportional odds model in logistic regression to evaluate their associations with functional limitations. Results Functional limitations in standing up were associated with heavy weight (third tertile vs. first tertile: 1.91, 1.11–3.27), participation in sports at school (0.62, 0.40–0.98), parity (vs. nullipara: 1.96, 1.08–3.56), old age and OA stage. Associations with functional limitations in stair‐climbing were seen with short height (< 151.0 cm vs. ≥ 156.0 cm: 2.05, 1.02–4.12), bilateral involvement (vs. unilateral: 1.71, 1.01–2.88), old age and OA stage. Conclusion Old age, OA stage, heavy weight, parity, shorter height and bilateral OA were associated with functional limitations in standing up and/or stair‐climbing, whereas participation in sports such as club activities in school maintained standing up.

Background In Japan, the majority of hip osteoarthritis (OA) was caused by acetabular dysplasia, and about 90 % of patients were female. The present study focused on Japanese female patients with hip OA due to acetabular dysplasia, and examined the associated factors with OA staging at diagnosis, in special reference to body weight. Methods Study subjects were 336 Japanese women who were newly diagnosed with hip OA caused by acetabular dysplasia at 15 hospitals in 2008. The self-administered questionnaire elicited patients’ body weight at age 20 and at OA diagnosis. Four ranked OA staging according to radiographic findings of the hip joint (pre-OA, initial stage, advanced stage or terminal stage) was regarded as the outcome index. Proportional odds models in logistic regression were used to calculate odds ratios (ORs) and 95 % confidence intervals (CIs) for severer stage of OA. Results At diagnosis, 45 % of patients suffered from terminal stage of OA, whereas 13 % and 14 % were categorized into pre-OA and initial stage, respectively. After adjustment for potential confounders, weight gain since age 20 revealed the increased ORs for severer OA stage at diagnosis (OR 2.02; 95 % CI, 1.07–3.80). Other significant characteristics were age (67+ vs. 20–49 years, OR 12.4), lower education (junior high school vs. junior college or higher, OR 4.00), parity (OR 2.19), lower acetabular head index (

We conducted a nationwide epidemiologic study regarding hip osteoarthritis (OA) in Japan, and a previous report found these patients to be unique in comparison to Caucasians. This report focused on the data regarding each hip joint, and the involvement of acetabular dysplasia with hip OA was analyzed.Seven hundred twenty OA hips were examined. Sixty-five joints with osteonecrosis of the femoral head and 215 non-OA contralateral joints of the unilateral patients were examined as controls. The revised system of stage classification for hip OA of the Japanese Orthopedic Association (JOA) was used according to the reproducibility in order to ensure reliable data from the multiple institutions. The acetabular dysplasia indexes were also chosen according to the reproducibility and measured in the radiograph of bilateral hip joints. The clinical score was assessed using the JOA scoring system. The relative risk of the grade of acetabular dysplasia indexes for hip OA was calculated as the odds ratio and the 95% confidence interval.The stage of the OA joints deteriorated with increasing age. The clinical scores also decreased. The grade of the acetabular dysplasia indexes of the OA joints was significantly higher than that of the control joints. Each index of acetabular dysplasia demonstrated significantly increased odds ratios for hip OA. Among the OA joints, the deterioration of the OA stage was found to be significantly associated with an increasing grade of acetabular dysplasia. The odds ratio for OA deterioration in the acetabular dysplasia index was also obtained. The joints of females tended to have a higher grade and prevalence of acetabular dysplasia than those of males.These findings confirmed a high prevalence of acetabular dysplasia in hip OA joints in Japan. Acetabular dysplasia was one of the most important factors associated with hip OA.

脳性麻痺（以下；CP）患者の股関節は股関節周囲筋力の不均衡や骨形態異常により，亜脱臼や脱臼をしばしば生じ，若年発症の変形性股関節症の原因となる．従来，CP患者の病期の進んだ変股症に対しては大腿骨頭切除術や股関節固定術が施行されてきたが，確実な除痛とADL維持という点で十分に満足できる成績をえられていない．そこで，より早期の除痛，機能回復を目的としてTHAが選択される．今回，中高年のCP患者の末期OA2例3股に対し，THAを施行した．それぞれ術後1年，5ヶ月と短期成績であるが，いずれの症例も股関節痛は消失し，疼痛出現前のADLを再獲得できており，患者満足度も高い．術後合併症に関しては今後更なる長期の経過観察が必要であるが，今回の症例のように股関節痛の出現前はある程度ADLが自立しており，低下した機能が回復する見込みのある場合にはTHAの手術適応があると考える．

Fibroblast growth factor 2 (FGF-2) is a potent mitogen for mesenchymal cells, and a local application of recombinant human FGF-2 (rhFGF-2) in a gelatin hydrogel has been reported to accelerate bone union in our animal studies and preparatory dose-escalation trial on patients with surgical osteotomy. We have performed a randomized, double-blind, placebo-controlled trial in which patients with fresh tibial shaft fractures of transverse or short oblique type were randomly assigned to three groups receiving a single injection of the gelatin hydrogel containing either placebo or 0.8 mg (low-dosage group) or 2.4 mg (high-dosage group) of rhFGF-2 into the fracture gap at the end of an intramedullary nailing surgery. Of 194 consecutive patients over 2 years, 85 met the eligibility criteria, and 70 (24 in the placebo group and 23 each in low- and high-dosage groups) completed the 24-week study. The cumulative percentages of patients with radiographic bone union were higher in the rhFGF-2-treated groups (p = .031 and .009 in low- and high-dosage group, respectively) compared with the placebo group, although there was no significant difference between low- and high-dosage groups (p = .776). At 24 weeks, 4, 1, and 0 patients in the placebo, low-dosage, and high-dosage groups, respectively, continued to show delayed union. No patient underwent a secondary intervention, and the time to full weight bearing without pain was not significantly different among the three groups (p = .567). There also was no significant difference in the profiles of adverse events among the groups. In conclusion, a local application of the rhFGF-2 hydrogel accelerated healing of tibial shaft fractures with a safety profile. © 2010 American Society for Bone and Mineral Research.

Subchondral insufficiency fracture of the femoral head occurs mainly in elderly patients with osteoporosis. Spontaneous resolution is observed after nonoperative treatment in some patients whereas other show progressive joint destruction requiring THA. Several studies report the occurrence of subchondral insufficiency fracture of the femoral head in dysplastic hips.We asked whether the extent of hip dysplasia or osteoporosis was greater in patients with subchondral insufficiency fracture of the femoral head than in normal control subjects.We compared the clinical and imaging findings of 13 patients with subchondral insufficiency fractures of the femoral head and 12 patients scheduled for TKA with asymptomatic hips. Age, gender, and body mass index were comparable in the two groups.Higher mean Sharp angles, lower acetabular head indices, lower center-edge angles, and higher acetabular roof angles in patients with subchondral insufficiency fracture of the femoral head than in those with asymptomatic hips suggested a greater degree of hip dysplasia. Bone mineral density and serum levels of Type I collagen cross-linked N-telopeptide and bone alkaline phosphatase were similar in the two groups.We speculate an excessive amount of stress on the acetabular edge from dysplasia may be associated with the occurrence of subchondral insufficiency fracture of the femoral head.

We are planning a multicenter survey on coxarthrosis and acetabular dysplasia in Japan. To collect reliable data, we performed a preliminary study to elucidate the observer agreement on assessment items.We collected radiographs of hip joints in eight patients with various findings of coxarthrosis. Twelve registered orthopedic specialists evaluated them regarding the roentgenographic stage of coxarthrosis and five indexes of acetabular dysplasia (acetabular angle, center-edge angle, acetabular roof obliquity, acetabular head quotient, approximate acetabular quotient). To assess observer agreement, we calculated the value of the kappa statistic for stages and the coefficient of variation for the indexes. The same 12 specialists then assessed the coxarthritis stage on the same radiographs 1 month after the first evaluation based on our own descriptions of the roentgenographic stages.For the first evaluation of the roentgenographic stage, the value of the kappa statistic was 0.448; and for the second evaluation it was 0.600. The results of the coefficient of variation for the indexes of acetabular dysplasia, ranked in ascending order, were as follows: acetabular angle, acetabular head quotient, acetabular roof obliquity, center-edge angle, approximate acetabular quotient.For the upcoming multicenter survey, clear descriptions of the stages of coxarthrosis and selection of appropriate indexes can be helpful for collecting dependable results.

The purpose of this study was to quantify the effects of femoral offset and head size on range of motion (ROM) after total hip arthroplasty. Modular prostheses were implanted into 11 cadaveric hips using a posterolateral approach and tested for ROM with 3 different offsets and 5 different femoral head sizes. Increasing the femoral offset to 4 and 8 mm resulted in 21.1 degrees and 26.7 degrees of improved flexion, and 13.7 degrees and 21.2 degrees of improved internal rotation, respectively. The ROM improved in a head size-dependent manner primarily because of increasing the jumping distance of the femoral head rather than delaying any impingement. In contrast, the effectiveness of femoral offset was driven by delayed osseous impingement.

【目的】特に誘因無く両側骨頭下骨折を生じた両側大腿骨頭壊死症例を経験したので報告する．【症例】59歳 男性．主訴は両大腿部痛．ステロイド使用歴なし．飲酒歴は，30歳から15年間，毎日日本酒3合程度．年間60日の潜水歴があった．1年前より特に誘因なく両股部痛が出現．半年後歩行不能となり近医受診し，両側大腿骨頭骨折と診断され，当科紹介となった．単純X線写真にて両側骨頭下骨折を認めた．右側には頚部に比較的大きな嚢胞像を認めた．CTでは右側は嚢胞との近位境界で骨頭骨折を生じていた．両側ともTHAが行われ，摘出骨頭の病理組骨診断でempty lacunaeがみられ，骨壊死の診断であった．【考察】広範な大腿骨頭壊死であった為に，荷重部の骨頭圧潰ではなく，骨頭下骨折を起こしたと考えられた．右側は頚部に形成された嚢胞も骨頭骨折に関わっている可能性があると思われた．

We describe a 79-year-old woman with rheumatoid arthritis who suffered from subchondral insufficiency fracture of the femoral head (SIF) and contralateral femoral neck fracture. Radiographs obtained two months after the onset of thigh pain showed collapse of the right femoral head and contralateral femoral neck fracture. MRI revealed a subchondral serpiginous low-intensity band in the right femoral head on the T2-weighted image. This case report suggests that SIF should be considered in the differential diagnoses of rheumatic patients who suffer from thigh pain without antecedent trauma.

Several animal and human studies suggest pharmacological approaches may prevent steroid-induced osteonecrosis (ON). We asked whether the newly developed 3-hydroxymethyl-3-glutaryl-CoA (HMG-CoA) reductase inhibitor, pitavastatin, could prevent steroid-induced ON in rabbits. We injected 65 adult male Japanese white rabbits once with 20 mg/kg of methylprednisolone acetate into the right gluteus medius muscle. The rabbits were divided into two groups; one group of 35 rabbits received pitavastatins (PS), and the other group of 30 rabbits received no prophylaxis (CTR). Hematological examinations were performed just before the steroid injection (0 weeks) and at 1 and 2 weeks after steroid injection; both the femora and the humeri were histologically examined 2 weeks postinjection. The incidence of histologic changes consistent with early ON in the PS group (13 of 35; 37%) was lower in comparison to the CTR group (21 of 30; 70%). The size of the bone marrow fat cells in the PS group (56.6 +/- 10 microm) was smaller than those in the CTR group (60 +/- 4 microm). The data suggest pitavastatin has the potential to lower the incidence of steroid-induced ON in rabbits.

A 49-year-old woman had suffered from a left hip pain. Radiographs showed a focal loss of radiodensity in the left femoral head and neck, and magnetic resonance imaging revealed a bone marrow edema in the femoral head. She was diagnosed as transient osteoporosis of the hip and was treated conservatively. Three years later, right hip pain occurred. Based on the imaging appearances, she was diagnosed as transient osteoporosis of the hip in the right and was treated conservatively. Five years after the onset of right hip pain, she suffered from a recurrent right hip pain. Imaging findings were similar to those obtained 5 years before. Five months after the onset of pain, both hip pain and imaging abnormalities disappeared by the same treatments as the previous episodes. This case was considered to have recurrent transient osteoporosis of the hip.

For osteoarthritis hips due to severe acetabular dysplasia such as Crowe type 3 or 4, placement of the socket is a difficult procedure in total hip arthroplasty. Because the acetabular bone stock is poor, suitable location for the socket is very limited with respect to achieving good coverage with the host bone. A 51-year-old woman who had an osteoarthritis hip with a large leg length discrepancy due to severe acetabular dysplasia required total hip arthroplasty. The purpose of the total hip arthroplasty was to improve the hip disorder as well as to reduce the leg length discrepancy to achieve good gait function. We present technical solutions to aid the surgeons in placing the acetabular socket at the proper location by using computed tomography–based navigation system.

Postoperative delayed union and nonunion is the most common complication in fracture treatment. Recent studies have shown an accelerating effect of low-intensity pulsed ultrasound (LIPUS) on fracture repair. However, the indications for delayed union and nonunion are not clear. To clarify the factors which influence the effects of LIPUS, the data from a previous prospective multicenter study on LIPUS treatment for postoperative delayed union and nonunion of long bone fractures were reanalyzed.Seventy-two cases of long bone fracture, including those of the femur, tibia, humerus, radius, and ulna, were analyzed. The mean time from the most recent operation to the beginning of LIPUS treatment was 11.5 (3-68) months. The relationship between the background factors and the union rate was analyzed using a logistic regression method. In addition, long bone fractures in an upper extremity or in a lower extremity were analyzed separately.The union rate was 75% in all the cases of long bone fracture. There was a significant relationship between the union rate and the period from the most recent operation to the beginning of LIPUS treatment in all cases and in those that had long bone fracture of an upper extremity. There was also a significant relationship between the union rate and the time when a radiological improvement was first observed after the beginning of the treatment in all cases and in those with fractures in a lower extremity. When LIPUS treatment was started within 6 months of the most recent operation, 89.7% of all fractures healed. When an improvement in the radiological changes at the fracture site was observed after 4 months in those cases, then the sensitivity and specificity for union were more than 90%.LIPUS treatment should be started within 6 months of the most recent operation. Because LIPUS has been shown to be effective without causing either serious invasiveness or any undue risk to the patient, it may be considered the treatment of first choice for cases of postoperative delayed union or nonunion.

We investigated the outcome of the contralateral hip in patients with rapidly destructive arthrosis of the hip after total hip arthroplasty. Twenty-four patients were included, and the mean duration of radiographic follow-up was 7.0 years (range, 3.8-17.8 years). To assess the capable parameters for predicting the development of osteoarthritis, we evaluated the receiver operating characteristic curves. Three (12.5%) of 24 patients developed osteoarthritis and underwent total hip arthroplasty within 3.8 to 6.5 years. In these 3 patients, both the acetabular-head index and the center-edge angle were significantly lower than those in patients without osteoarthritis (P < .005). Based on the receiver operating characteristic curves, both an acetabular-head index of less than 72% and a center-edge angle of less than 16 degrees were considered to be associated with the development of osteoarthritis.

The gold standard of bone graft substitutes is vascularized autologous bone. Our strategy to acquire this bone substitute is using recombinant human bone morphogenetic protein (rhBMP)-2 with beta-tricalcium phosphate (TCP) as carrier to induce bone tissue in muscle and grafting as a muscle-pedicled bone flap. In our previous studies, morphologically controlled living bone was successfully induced in a rat muscular pedicle. Moreover, concurrent administration of bisphosphonate controlled the subsequent resorption of the induced bone. This study was conducted (1) to confirm that when the size of carrier is increased, the induced bone can form the same in the center as well as on the periphery of the carrier, and (2) to simulate in vivo banking for vascularized autograft bone.In experiment 1200 microg rhBMP-2 and 10(-5) M bisphosphonate (Minodronate) were applied to a 1-cm-diameter sphere of beta-TCP. This sphere was then inoculated into rabbit quadriceps and harvested 5 weeks later (n = 3). In experiment 2, beta-TCP was generated as a one-third hollow cylinder with 4-mm outer radius, 2-mm inner radius, and 10-mm length. After 50 microg rhBMP-2 and 10(-5) M Minodronate were applied, this structure was then inoculated into rat quadriceps. Four weeks later, the induced bone was transplanted as a muscle-pedicled flap onto the adjacent femur and harvested after 4 and 8 weeks more (n = 3).In experiment 1, good bone formation was observed at the central as well as the peripheral region of the sphere. In experiment 2, good bone formation and bony union to the femur at both 4 and 8 weeks were detected on the X-ray film. The presence of new bone formation around the screw was observed.Transplantation of the beta-TCP carrier treated with rhBMP-2 and bisphosphonate into the muscular tissue may have clinical potential for in vivo banking for muscle-pedicled bone flaps.

Osteonecrosis (ON) of the femoral head is a serious complication in patients who have undergone organ transplantation. Introduction of cyclosporin A has resulted in lower-dosage steroid treatment and a decrease in the occurrence of ON. We examined the effect of cyclosporin A on the development of ON in rabbits.In experiment A, rabbits were given cyclosporin A and 20 mg/kg methylprednisolone acetate. The control group was given 20 mg/kg methylprednisolone acetate only. Experiment B was then performed to mimic the clinical situation in which the use of cyclosporin A and lower steroid doses resulted in a decrease in occurrence of ON. In Experiment C, the effects of treatment with cyclosporin A only on development of ON were examined. 4 weeks after injection, bilateral femora and humeri were examined histopathologically for ON.Cyclosporin A increased the incidence of ON in rabbits when given in combination with steroid (p = 0.04). No ON lesions were observed in rabbits treated with cyclosporin A alone.Our findings suggest that the clinically reported reduction in occurrence of ON following the use of cyclosporin A is probably attributable to the lower steroid doses used.

We documented a case of rapidly destructive arthrosis of the hip joint (RDA), in whom abnormal findings were observed not only in the femoral head but also in the acetabulum on magnetic resonance images (MRI) in the early stage. Radiographs made 1 month after the onset of pain showed a slight narrowing of the joint space. MRI obtained 2 months after the onset detected small foci of low signal intensity in the subchondral area of the femoral head on the T1-weighted images, and a linear pattern of high signal intensity in the lateral side of the acetabulum on the T2-weighted images. During the 17-month follow-up period, this case eventually underwent massive destruction of the femoral head as well as the acetabulum.

An ideal substitute for bone graft is autobone tissue, of which there is an ample supply of the required form and with vascularity. Our strategy is to generate intramuscular autogenous bone by administering recombinant human bone morphogenetic protein 2 (rhBMP-2) with beta-tricalcium phosphate (beta-TCP) as a carrier, and to transplant this bone as a muscle-pedicled autograft. However, in a previous study (Jingushi et al., J. Orthop. Sci. 7, 490, 2002), bone resorption occurred early after bone induction. This study was conducted to determine whether rhBMP-2-induced bone tissue could be maintained by simultaneous administration of bisphosphonate, and to investigate whether the induced bone could be used for bone grafting. In this study, we first applied rhBMP-2 alone to a beta-TCP disk and inoculated it into rat quadriceps muscle. Bone area and the number of tartrate-resistant acid phosphatase (TRAP)-positive cells in the induced bone disk peaked at 2 weeks, and induced bone resorption occurred later. Bisphosphonate and rhBMP-2 were then simultaneously applied to a beta-TCP disk and inoculated as in the first experiment. The addition of bisphosphonate decreased the number of TRAP-positive cells and increased the bone area and compression strength at 4 weeks. In the last experiment, a rhBMP-2 applied beta-TCP disk treated with or without bisphosphonate was free-grafted to parietal bone 4 weeks after inoculation. Both bone disks united similarly. We concluded that the concurrent use of bisphosphonate prevented bone absorption attributed to osteoclast activity after bone induction by rhBMP-2. The bisphosphonate application did not disturb the union of induced bone to host bone.

Objective To investigate the effects of combination treatment with an anticoagulant (warfarin) plus a lipid-lowering agent (probucol) on the prevention of steroid-induced osteonecrosis (ON) in rabbits. Methods Adult male Japanese white rabbits were injected once intramuscularly with 20 mg/kg of methylprednisolone acetate into the right gluteus medius muscle. The rabbits were then divided into 4 groups and treated as follows: one group received warfarin plus probucol (WP; n = 25), one received probucol alone (PA; n = 30), one received warfarin alone (WA; n = 26), and one received no treatment (nonprophylactic [NP]; n = 20). Two weeks after the steroid injection, the femora and humeri were examined histopathologically for the presence of ON. The sizes of the bone marrow fat cells were examined morphologically. Hematologic examinations were performed before and after the steroid injection. Results The incidence of ON in the WP group (5%) was significantly lower than that observed in the NP group (70%). While the incidence rates of ON in the PA (38%) and WA (33%) groups were also significantly lower than that in the NP group, they were significantly higher than that observed in the WP group. The sizes of the bone marrow fat cells in both the WP (53.5 ± 4.1 μm) and the PA (52.0 ± 5.0 μm) groups were significantly smaller than those in the NP group (60.0 ± 4.0 μm). We also observed a prolongation of the prothrombin time and a reduction in the plasma lipid levels in the WP group during the study. Conclusion This study experimentally confirmed that the combined use of an anticoagulant and a lipid-lowering agent helps prevent steroid-induced ON in rabbits.

We hypothesized that venous obstruction by deep vein thrombosis (DVT) only slightly augments venous outflow from lower limbs by active ankle movements. If our hypothesis is true, we thought that we could develop a new screening method for DVT using duplex ultrasonography. Subjects were 22 lower limbs of 11 patients who gave informed consent for venography after total hip or knee arthroplasty. Around postoperative 19.0 days (range 15-32 days), we measured the ratios, called flow ratios, of the peak flow signal with active maximum ankle dorsiflexion and that at rest using duplex ultrasonography in the bilateral femoral veins. On the same day, we then performed bilateral venography. Thrombosis was detected in 5 of the 22 lower limbs. The mean flow ratios with and without DVT were 1.18 (range 1.0-1.3) and 3.31 (range 1.8-4.8), respectively. The flow ratios with DVT were significantly lower than those without DVT. Pain or difficulty performing active maximum ankle dorsiflexion was not observed in any of the operated or unoperated lower limbs during the ultrasound examination. In conclusion, ultrasonographic measurement of flow ratios may become a simple screening method for DVT in lower limbs without the pain or difficulty of performing active maximum ankle dorsiflexion.

Progression of slip is apt to cause complications including osteonecrosis and osteoarthritis. Such complications result in a poor prognosis for the joint. Therefore, to diagnose slipped capital femoral epiphysis (SCFE) while it is still mild is important to avoid complications as well as to prevent further slippage. In Japan, as the number of obese patients increases, obesity seems to be involved in the onset of slip both biomechanically and endocrinologically. We need to take care of obese children as they comprise a reservoir for SCFE patients. For severe slip cases, treatment is difficult owing to significant deformity of the femoral head with or without such complications as osteonecrosis and osteoarthritis. Transtrochanteric anterior rotational osteotomy is a promising option for preventing further slippage as well as to improve the congruity of the joint.

Parathyroid hormone-related peptide (PTHrP) and insulin-like growth factor I (IGF-I) are both involved in the regulation of bone and cartilage metabolisms and their interaction has been reported in osteoblasts. To investigate the interaction of PTHrP and IGF-I during fracture healing, the expression of mRNA for PTHrP and IGF-I, and receptors for PTH/PTHrP and IGF were examined during rat femoral fracture healing using an in situ hybridization method and an immunohistochemistry method, respectively. During intramembranous ossification, PTHrP mRNA, IGF-I mRNA and IGF receptors were detected in preosteoblasts, differentiated osteoblasts and osteocytes in the newly formed trabecular bone. PTH/PTHrP receptors were markedly detected in osteoblasts and osteocytes, but only barely so in preosteoblasts. During cartilaginous callus formation, PTHrP mRNA was expressed by mesenchymal cells and proliferating chondrocytes. PTH/PTHrP receptors were detected in proliferating chondrocytes and early hypertrophic chondrocytes. IGF-I mRNA and IGF receptor were co-expressed by mesenchymal cells, proliferating chondrocytes, and early hypertrophic chondrocytes. At the endochondral ossification front, osteoblasts were positive for PTHrP and IGF-I mRNA as well as their receptors. These results suggest that IGF-I is involved in cell proliferation or differentiation in mesenchymal cells, periosteal cells, osteoblasts and chondrocytes in an autocrine and/or paracrine fashion. Furthermore, PTHrP may be involved in primary callus formation presumably co-operating with IGF-I in osteoblasts and osteocytes, and by regulating chondrocyte differentiation in endochondral ossification.

We observed ultrasonographic blood flow findings of the nutritional artery of the recollapsed femoral head in patients with osteonecrosis treated by transtrochanteric rotational osteotomy of the femoral head. Between July 1998 and September 2000, the nutritional artery of 26 hips (23 patients) were observed intraoperatively by ultrasonography. After rotating the femoral head, the nutritional artery was checked by ultrasonography in fibrofatty tissue beneath divided quadratus femoris muscle seven times while changing the angle of hip flexion. The patients consisted of 16 males and seven females with a mean age of 41 years (age range: 23 to 60 years). Recollapsed femoral head was identified in five (19%) of the 26 patients after one year or more followup. The hips of the recollapsed femoral head confirmed ultrasonographic flow at an average of one (range: 0 to 3 times), and the hips without recollapsed femoral heads demonstrated a mean four times (range: 2 to 7 times). There was significant difference between with and without recollapse. We conclude that ultrasonographic findings of the nutritional artery is helpful for assessing the short-term results of hips treated by transtrochanteric rotational osteotomy of the femoral head.

An ideal replacement for bone defects is auto-bone tissue, of which there is an ample supply with the required form and with vascularity. Our strategy for generating such bone tissue is as follows. First, bone tissue is induced in muscle by bone morphogenetic protein-2 (BMP-2) with beta-tricalcium phosphate as a carrier to maintain its form in the muscle. Second, the induced bone in the muscle pedicle is grafted to the bone defect to maintain vascularity. In the first experiment, 50 microg of recombinant human BMP-2 (rhBMP-2) was inoculated into the hip abductor muscle of rabbits with beta-tricalcium phosphate under anesthesia. Five weeks after the operation, intramuscular bone formation was observed in all of the samples, and the form and size of the induced bone tissue were identical to those of the carrier. Ten weeks after the operation, the induced bone was partly absorbed. In the second experiment, 50 microg of rhBMP-2 was inoculated in the same manner as previously. Five weeks after the operation, the muscle tissue around the induced bone was incised, leaving just the proximal part as a pedicle. Two or four weeks after the second operation, the induced bone tissue had rich vascularity and no empty lacunae. This indicates the possibility of in vivo bone banking to enable morphologically controlled and vascularized auto-bone grafts.

To determine the relationship between pain at flexion-rotation and the status of a labral tear in patients with dysplastic hips, physical examination maneuvers and hip arthroscopy were carried out in 59 patients with dysplastic osteoarthritis (5 men and 54 women; mean age, 41 years; range, 16 to 64 years). Between January 1998 and June 2000, these patients underwent 60 hip arthroscopies at Kyushu University Hospital. All hip joints arthroscoped demonstrated incomplete or complete detaching tears of the acetabular labrum in one portion of the weight-bearing area. Twenty-three patients (39%) experienced pain during the maximum flexion-internal rotation test; 16 patients (27%) showed a positive result for the maximum flexion-external rotation test. There was no statistically significant relationship between the results of the maximum flexion-external rotation test and the arthroscopic findings of labral tears. A positive maximum flexion-internal rotation test result, however, correlated well with incomplete detaching tears in the posterosuperior portion of the acetabular labrum. In contrast, a complete detaching tear of the posterosuperior labrum was associated with a negative maximum flexion-internal rotation test result. The maximum flexion-internal rotation test is useful for assessing the magnitude of a labral tear in the posterosuperior portion of the acetabular labrum in dysplastic hips.

Between February and September of 2000, we carried out radial magneic resonance imaging (MRI) on 8 hips consisting of 5 pre-osteoarthritis and 3 early stage osteoarthritis. There were 7 female patients with a mean age of 28 years (age range: 16-50 years). The radial MRI results were compared with intraoperative arthroscopic findings. In the weight-bearing portion, from 45° ante rosuperior to 45° posterosuperior, all patients had various tears of the acetabular labrum. In the anterosuperior portion, 4 hips (50%) showed imcomplete tears, 3 hips (38%) showed complete tears, and only 1 hips (18%) showed intact labrum. In the superior portion, each of the 3 hips (38%) showed imcomplate and complete tears. In the posterosuperior portion, each of the 3 hips (38%) showed imcomplete tears and intact labrum. The arthroscopic normal labrum was clearly depicted as a homogenous triangular area of low signal intensity. The incomplete tears were depicted as a moderate signal intensity or central high signal intensity. The complete tears were depicted as a diffuse and obscure high signal intensity. We conclude that radial MRI may be a useful non-invasive diagnostic method for tears of the acetabular labrum in oseoarthritis.

Objective. To review the subchondral changes on MR imaging in transient osteoporosis of the hip (TOH) and to consider the pathophysiology. Design and patients. MR images of 12 hips of 11 consecutive patients with TOH were retrospectively studied. The diagnoses of TOH were confirmed on the basis of previously published criteria, including decreased bone density of the femoral head and/or neck on radiographs, bone marrow edema (BME) pattern on MR images, spontaneous resolution of the symptoms and a return to normal radiodensity. Results. All 12 hips showed a BME pattern in the femoral head and/or neck. Linear patterns of very low signal intensity were identified on T1-weighted images in the subchondral area within the diffuse low signal intensity area in all 12 hips. On T2-weighted images, a low signal intensity line was observed in the corresponding area in eight hips only. These linear patterns were thought to represent subchondral fracture lines. Conclusions. The presence of a subchondral fracture may be important when considering the pathophysiology of TOH.

Chondrocytes produce several local regulatory factors such as basic fibroblast growth factor (bFGF), transforming growth factor-beta (TGF-beta) and insulin-like growth factor-I (IGF-I). In this study, we examined the effect of bFGF on the expressions of both mRNA and protein of the growth factors synthesized by chondrocytes. Treatment of chondrocytes with bFGF (1-100 ng/ml) stimulated the mRNA expression of bFGF and TGF-beta up to 121-604% and 130-220% at 12 h compared with the controls, respectively. On the other hand, the treatment of chondrocytes with bFGF (1-100 ng/ml) suppressed IGF-I mRNA expression to 79-47% at 12 h compared with the controls. An enzyme-linked immunosorbent assay (ELISA) revealed that the treatment of chondrocytes with bFGF (1-100 ng/ml) also enhanced the production of TGF-beta proteins in the chondrocytes up to 299-508% at 24 h compared with controls. We conclude that bFGF influenced the local expression of growth factors by chondrocytes, suggesting autoregulation of growth factor expression during chondrogenesis.

We observed lower extremity blood flow in deep venous thrombosis (DVT) patients using ultrasonography after orthopaedic hip joint operation. Between July 1999 and June 2000, four patients underwent total hip arthoplasty and hemi-surface arthroplasty was performed on one. We measured the flow volume of the femoral vein and the great saphenous vein using ultrasonography on all patients after venography. The patients consisted of one male and four females with a mean age of 67 years (age range: 47 to 74 years). Deep venous thrombosis was identified in two (40 percent) of the five patients. There was no significant difference in the flow volume of the femoral vein between the DVT (+) group and DVT (-) groups (129±33ml/m, 165±89ml/m). The flow volume of the great saphenous vein in the DVT (+) group increased significantly (189±108ml/m, 51±22ml/m p

We observed the blood flow in the femoral vein and greater saphenous vein using color Doppler ultrasonography after orthopaedic lower extremity operation. Between March 1999 and February 2000, 108 patients underwent 18 total knee arthroplasties, 46 total hip arthroplasties, and 44 hip osteotomies. We performed venous duplex ultrasonography twice on both lower extremities of all patients at a mean of seven days (range; five to eight days) and fourteen days (range; twelve to fifteen days) postoperatively. There were 25 male and 83 female patients with a mean age of 55 years (age range; 20 to 84 years). Greater saphenous blood flow increased in 49 (23 percent) of the 216 extremities. Thirty-two were ipsilateral, and 17 were contralateral. We suggest that these findings indicate asymptomatic deep venous thrombosis. With the numbers available, we were able to detect an association between an increase in the greater saphenous venous flow and procedures (P

It is well known that in femoral head osteonecrosis patients, necrosis and collapse are usually located in the anterosuperior portion of the femoral head. We evaluated the usefulness of a “look-up” plane X-ray view of osteonecrosis for early detection of femoral head collapse. We examined 20 joints in 17 patients. Osteonecrosis was classified into four stages according to radiographic signs (demarcation line, crescent line, collapse and joint space narrowing). Eight joints were classified as stage 2 and 12 joints as stage 3. Collapse, crescent line and demarcation line were evaluated on three types of radiographs; ordinary anteroposterior (AP) and lateral views and the “look-up” view. Seventeen of the 20 hips clearly showed more than 2mm collapse on the “look-up” view. The incidence of clear collapse was higher than that on the AP view. The incidence of crescent line was also higher. There were no significant differences in the demarcation line between the look-up view and AP view. Magnetic resonance imaging and tomography are useful and routinely used to define necrotic lesions. However, the “look-up” view is a simple and inexpensive method for the early detection of femoral head collapse in osteonecrotic patients.

Osteonecrosis of the femoral head often results in secondary osteoarthritis of the hip joint; however, the pathologic processes underlying the destruction of articular cartilage are not fully understood. Molecular markers in the hip joint fluids were measured to examine the changes in turnover of cartilage and other joint tissues. Marker data were related to clinical, radiological, and histopathological changes in the articular cartilage of the hip. Forty-five patients (median age: 43 years) were studied. The median time between the onset of symptoms and sampling of hip synovial fluid was 6 months. Aggrecan fragments, C-propeptide of type-II collagen, matrix metalloproteinase-3, and tissue inhibitor of metalloproteinases-1 levels in joint fluid were determined by immunoassay. Osteonecrosis of the femoral head was graded by radiology as minimal collapse of the femoral head (stage 2: 26 patients), severe collapse (stage 3: 15 patients), or severe collapse with osteoarthritis (stage 4: four patients). Histological changes of the articular cartilage, consistent with early-stage osteoarthritis, were evident at stage 3 and were more advanced at stage 4. The average concentrations of proteoglycan fragments and C-propeptide of type-II collagen were 207 (SD 182) μg/ml and 19.6 (SD 19.3) ng/ml, respectively. The average concentrations of matrix metalloproteinase-3 and tissue inhibitor of metalloproteinases-1 were 177 (SD 291) nM and 23.0 (SD 9.9) nM, respectively. Measurable levels for all markers assayed were noted in the earliest stage of the disease, only a few months after the onset of symptoms and well before the appearance of radiological changes. Levels of matrix metalloproteinase-3 and molar ratios of matrix metalloproteinase-3/tissue inhibitor of metalloproteinases-1 were higher in early stage disease than in later stage disease. (Less)

Hip joints in radiographs were magnified in order to examine the appropriate magnification of templates for preoperative planning in total hip arthroplasty (THA). The magnification of each hip joint, in postoperative radiographs after THA, was calcurated using inserted implants (socket or femoral stem) as scales. The relationship between the magnifications and grade of obesity or hip flexion contracture was also examined. In most hips, the percentage of magnification was between 110 and 120. Obesity or hip flexion contracture did not influence the magnification. These date suggest that degrees above 110% are more appropriate than 110% for the magnification of templates.

We treated a patient who had been suffering from a wide range of deep venous thrombosis (DVT) in the lower right extremity after the right transfer of the acetabulum. The patient noticed swelling and pain in the lower right extremity two weeks after the operation. The defects of the contrast medium were seen between the right common iliac vein and calf venula when venography was performed. A slight wedgeshaped defect was also seen in the lower left lung when lung blood flow scintigram was performed. The patient was diagnosed as DVT with slight pulmonary embolism (PE). Immediately we routinely treated this patient with anticoagulant therapy that consists of intravenous heparin medication. In order to prevent lethal PE during the therapy, we implanted a percutaneous infra vena cava filter (IVC filter) capable of trapping large thrombus and inducing spontaneous fibrinolysis at this site. Furthermore, fibrinolytic therapy consisting of intravenous urokinase medication was added. During the therapy, swelling and pain of the lower right extremity improved with the decreasing in the serum D-dimer. The IVC filter seems to be useful for preventing acute lethal PE following a wide range of DVT after hip surgery. However, long term follow-up of this patient seems to be required.

We combined Tanabe's extensive anterolateral-approach open reduction involving 360-degree circumferential capsulotomy with Pemberton pericapsular osteotomy and/or femoral osteotomy for the reduction of 7 dislocated hip joints in 5 toddlers. patients were placed in the lateral decubitus position. After Tanabe's original procedure of open reduction, femoal osteotomy (shortening/derotation/varus) and/or Pemberton's pericapsular osteotomy were performed easily via this approach. After surgery, X-ray showed the femoral head to be perfectly reduced and excellent acetabular coverage. The latest follow-up X-ray demonstrated no sign of avascular necrosis of the femoral head or acetabulum, and that excellent reduction and acetabular coverage had been maintained. The combination of Tanabe's open reduction with femoral and/or Pemberton pericapsular osteotomies thus appears to present a feasible, safe, practical option in treating hip dislocation in children who have already begun walking.

29 hips (follw-up rate: 44%) underwent hemiarthropathy for the treatment of osteonecrosis of the femoral head (ONFH). Bipolar hemiarthroplasty (Kyocera Physiohip type) was carried out for all the patients. The average age at operation was 47 years old (24-65), and the mean follow-up interval was 6.4 years (2.8-10.9). 1 was at stage 2, 14 at stage 4 at operation. 4 hips receired a second operation due to the failure of rotational osteotomy, and 1 was unknown. The JOA score was evaluated. The pain, ROM, walk and ADL scores were 35 (20-40), 17 (13-20), 13 (5-20), and 16 (820) respectively. The mean total score was 81 (65-100). Femoral head migration was observed in 7 hips (29%). The distance of migration of most hips was within 5mm. 1 hip which had acetabular reaming at operation showed central migration. There was a tendency for migration in most hips at stage 4 at operation. This study showed that bipolar heimarthroplastyis a promising treatment for ONFH hip although further evaluation is required.

We reviewed 18 cases of arthrodesis for hip osteoarthritis at advanced or terminal stage. The average age at operation was 43 years old (22-52), and the mean postoperative period was 10 years (2-20). The mean walking and daily activity life (ADL) JOA scores were 14.8 and 17.0 points, respectively. Although most cases showed good walking and ADL scores, the results of 3 cases with contralateral hip osteoarthritis at operation were poor. Most of the patients could go up and down the stairs without any support, sit on chairs, and put socks on the operated limb by themselves. On the contrary, many could cut the toe nails of the operated limb nor sit on the floor (SEIZA). There was a tendency for gradual increage in low back pain or contralateral-sided knee joint pain after arthrodesis in patients with there symptoms. The degree of pain was low, and no cases underwent operation of the lumbar spine or knee joints after hip arthrodesis. There results suggest that arthrodesis is a promising operation for hemilateral hip osteoarthritis of young patients, especially those who need to stand or walk for long periods in their work.