Hiroaki Minehara

Growth factor expression in the osteophytes of the human femoral head in osteoarthritis.

Osteoarthritis is characterized by marked osteophyte formation consisting of new cartilage and bone. Because several growth factors are known to be involved in chondrogenesis and osteogenesis, the expression of transforming growth factor-β1 and basic fibroblast growth factor in the osteophytes of the human femoral heads in osteoarthritis were examined. Transforming growth factor-β1 messenger ribonucleic acid was detected in the osteophytes by reverse transcription-polymerase chain reaction. All of the nine examined osteophytes expressed transforming growth factor-β1 messenger ribonucleic acid, whereas one of four osteoarthritic femoral heads and none of four osteonecrotic femoral heads expressed transforming growth factor-β1 messenger ribonucleic acid. The extent of transforming growth factor-β1 messenger ribonucleic acid expression varied among the osteophytes. Transforming growth factor-β1 or basic fibroblast growth factor was analyzed in osteophytes immunohistochemically. Transforming growth factor-β1 was localized in the superficial cells in the osteophyte cartilage, but it was scarcely detected in the superficial cells in the degenerative articular cartilage. Basic fibroblast growth factor was detected in the cells in the whole layer of osteophyte cartilage and in the articular cartilage. There was a difference in the localization, which suggests the different roles of transforming growth factor-β1 and basic fibroblast growth factor in bone and cartilage metabolism in osteophyte formation.

Involvement of Cyclins in Cell Proliferation and Their Clinical Implications in Soft Tissue Smooth Muscle Tumors

Expression of cyclins A and E and cyclin-dependent kinase 2 (cdk2) was examined immunohistochemically in 55 cases of soft tissue smooth muscle tumors, including vascular leiomyoma, and compared to expression of Ki-67 and proliferating cell nuclear antigen. Cyclin A was expressed in 70% of the leiomyoma cases, but with much lower labeling indexes than in leiomyosarcoma. Cyclin E was expressed exclusively in leiomyosarcoma. Although the differences of cyclin A- and cyclin E-labeling indexes between leiomyoma and leiomyosarcoma were statistically significant, no significant differences were found in the other markers. Furthermore, cyclin A- and/or E-positivity predicted a poor prognosis in recurrence- or metastasis-free survivals and overall survival. Immunoblotting revealed that cyclins A and E were expressed, in complex with cdk2, exclusively in tumors. In addition, not only leiomyosarcoma, but also leiomyoma specimens that exhibited negligible levels of complex expression, manifested detectable cdk2 activity. These results suggest 1) up-regulation of active cyclin A/cdk2 expression and associated kinase activity is critical for unrestrained cell proliferation; 2) cyclin E/cdk2 complexes may play a crucial role in leiomyosarcoma; 3) immunohistochemical detection of cyclins can be a more reliable tool for differential diagnosis between leiomyoma versus leiomyosarcoma than that of Ki-67 or proliferating cell nuclear antigen, and be a possible prognostic indicator.

Osteoarthritic Changes of the Patellofemoral Joint in STR/OrtCrlj Mice Are the Earliest Detectable Changes and may be Caused by Internal Tibial Torsion

STR/ort mice develop a naturally occurring osteoarthritis (OA) of the knee joints. However, the evaluation of early OA changes has been difficult due to variability caused by gender, individual differences, and differences between the right and left lower limbs. The objective of this study was to analyze the variability of the early OA changes with age in STR/ort mice and to identify the cause of onset. A total of 115 STR/OrtCrlj mice aged 10–45 weeks were examined. In addition to conventional radiological and histological evaluation of the knee joints, histological sections were used to examine the patellofemoral, femorotibial, and growth plate cartilage under similar conditions. A morphological evaluation of tibiae, including micro-3-dimensional computed tomography, was performed. Radiological evaluation showed OA changes in the joints of mice over 35 weeks old and histological evaluation showed early OA changes in the femorotibial joints of mice over 26 weeks old. However, these changes were not common in all individuals. In contrast, most common and reproducible OA changes were observed in the bilateral patellofemoral joints of all individuals, and even in subjects ranging from 10 to 20 weeks of age. Morphological evaluations also demonstrated an abnormal tibial internal torsion that increased with age and was associated with medial patellar dislocation. In conclusion, the earliest histological OA change was observed in the patellofemoral joint prior to similar observations in the femorotibial joint. Internal tibial torsion may be a cause of OA in the patellofemoral joints, which leads to the development of medial femorotibial OA.

Status of Bone Allografting in Japan - Nation-Wide Survey of Bone Grafting Performed from 1995 through 1999.

We report the status of bone allografting in Japan on the basis of the information obtained through questionnaires performed by the Japanese Orthopaedic Association (JOA). JOA performed a nation-wide survey in 2000, in order to clarify the current status of musculoskeletal tissue grafting in the orthopaedic practices in Japan. Conducted period was for 5 years from 1995 to 1999. As the results of this survey, it had been clarified that 92,984 bone graftings, which included autografts, allografts and synthetic bone substitutes, were performed during conducted 5 years. While the allografts were used only in 3,212 cases (3%), autograftings were performed in 64,193 cases (69%), synthetic bone substitutes were used in 25,576 cases (28%) in this series. The proportion of the number of operations for use bone substitutes increased every year, whereas that autografting decreased. The proportion of the number of allografting remained almost unaltered. Of the 706 institutions which answered to have experiences of tissue grafting, only 193 (27%) performed allograft.Since Kitasato University Hospital Bone Bank was developed in 1971, we have applied to clinical while doing basic research for preserved bone allograft. When extensive bone graft is required, allograft is very useful. In Japan, however, allograft is not performed widely. The foundation of regional bone banks is expected to resolve this problem. Since excision of bone preparations from cadaver donors is not common, bone allografts are not supplied sufficiently at present. It is needed to develop a network connecting bone banks in Japan. The enlightenment activities to the ordinary people and medical institutions will also be required.

Hybrid treatment combining emergency surgery and intraoperative interventional radiology for severe trauma

OBJECT To evaluate the efficacy of hybrid treatment combining emergency surgery and intraoperative interventional radiology (IVR) for severe trauma. PATIENTS AND METHODS The records of 63 severely injured patients who underwent concurrent emergency surgery and IVR at our emergency centre from 1999 through 2013 were retrospectively reviewed. Mobile digital subtraction angiography device was used in the operating room when performing IVR. Patients undergoing hybrid treatment combining intraoperative IVR and emergency surgery (intraoperative IVR group) were compared with those undergoing IVR in the angiography suite before or after emergency surgery (control group). RESULTS Thirteen patients underwent hybrid treatment (intraoperative IVR group). Of these 13 patients, 7 underwent treatment for abdominal organ injuries, and 6 for multiregional injuries. Emergency operations were laparotomy (n=12), thoracotomy (n=1), craniotomy (n=1), and haemostasis of the lower extremities (n=1). Five patients underwent damage control surgery. IVR included transarterial embolisation (n=12), endovascular stent or stent-graft placement (n=2), and embolisation of a portal vein by laparotomy (n=2). The mean ISS was 40. The actual overall survival rate was 85%, and the probability of survival (Ps) was 62%. The control group included 45 patients. Five patients who met exclusion criteria were not included in the control group. Age, ISS, RTS, Ps, pH and base excess on arrival, and blood transfusion volume during operation and IVR did not differ significantly between the groups. Total time during operation and IVR was significantly shorter in the intraoperative IVR group than in the control group (229 [SD 72]min vs. 355 [SD 169]min; p=0.007). The mortality were 15 (95% CI 2-45) % in the intraoperative IVR group vs. 36 (95% CI 22-51) % in the control group. CONCLUSION Hybrid treatment combining emergency surgery and intraoperative IVR can be a novel treatment strategy for severe trauma, and it will improve patient outcomes due to reduction of the time for resuscitation.

Anatomic study for pubic medullary screw insertion.

Purpose. To study the anatomy of the pubic ramus and adjacent structures in 160 Japanese to establish a safer pubic screw fixation technique. Methods. 80 male and 80 female Japanese aged 16 to 89 (mean, 50) years (10 persons in each decade of age) underwent 3-dimensional computed tomographic scanning of their pelvises. The angle at which the screw should be targeted, the appropriate length of the screw, the size of the canal for screw insertion, and the proximity to the bladder, iliac artery, and iliac vein were determined. Correlations between the canal diameters (of the acetabular, base, and parasymphyseal areas) and body features (age, height, and weight) were analysed. Results. In men and women respectively, the appropriate mean screw length was 124.6 and 123.8 mm; the guide wire should be targeted at a mean of 66° and 67° cephalad and 54.1° and 55.9° laterally for insertion of a retrograde pubic screw; the minimum distances from the pubis to the bladder/iliac artery/iliac vein were 0 and 0 mm/4.9 and 4.6 mm/0.8 and 0.2 mm. In both men and women, the canal diameters at the base were positively correlated to weight. In women, the canal diameters at the parasymphyseal area were correlated to height and weight. Canal diameters at the acetabulum were not correlated to height and weight. Conclusion. Pubic screw fixation may be potentially disastrous (owing to joint penetration and iliac vein injury) and should be performed with caution. When the canal diameter at the acetabulum is extremely narrow, plate fixation, computer-assisted surgery, or changing to a smaller-diameter screw is recommended.

Influence of hooks and a lag screw on internal fixation plates for lateral malleolar fracture: a biomechanical and ergonomic study

BackgroundFor internal fixation of AO classification Type B lateral malleolar fracture, insertion of lag screws into the fracture plane and fixation with a one-third tubular plate as a neutralization plate are the standard treatment procedures. The one-third tubular plate is processed to a hook shape and hung on the distal end of the fibula. In this study, to compare the function of the hook and lag screws of a one-third tubular plate and LCP for osteosynthesis of lateral malleolar fracture, mechanical indices of internal fixation were compared among the one-third tubular plates with lag screws with and without the hook and a locking compression plate.MethodsAs mechanical tests, a compression test was performed in which compression in the bone axis direction produced by supporting the body weight was simulated, and a torsion test was performed in which external rotation of the bone axis caused by plantar flexion of the ankle joint was simulated. Muscle strength during walking and the force and torque acting on the ankle and knee joints were determined using inverse dynamic analysis. Finite element analysis was performed to analyze the function of hooks and lag screws. The joint reaction force determined by inverse dynamic analysis was adopted as the loading condition of finite element analysis.ResultsA stiffness equivalent to that of healthy bone could be achieved by all three internal fixations. It was clarified that the presence of the hook does not make a difference in stiffness. Displacement of the one-third tubular plate was small regardless of the presence or absence of the hook compared with those of locking compression plates.ConclusionsThe presence of the hook did not make any difference in stiffness, suggesting that active preparation of the hook is unnecessary. We also clarified that lag screws inhibit displacement.

Spinal Epidural Hematoma after Thoracolumbar Posterior Fusion Surgery without Decompression for Thoracic Vertebral Fracture.

We present a rare case of spinal epidural hematoma (SEH) after thoracolumbar posterior fusion without decompression surgery for a thoracic vertebral fracture. A 42-year-old man was hospitalized for a thoracic vertebral fracture caused by being sandwiched against his back on broken concrete block. Computed tomography revealed a T12 dislocation fracture of AO type B2, multiple bilateral rib fractures, and a right hemopneumothorax. Four days after the injury, in order to promote early orthostasis and to improve respiratory status, we performed thoracolumbar posterior fusion surgery without decompression; the patient had back pain but no neurological deficits. Three hours after surgery, he complained of acute pain and severe weakness of his bilateral lower extremities; with allodynia below the level of his umbilicus, postoperative SEH was diagnosed. We performed immediate revision surgery. After removal of the hematoma, his symptoms improved gradually, and he was discharged ambulatory one month after revision surgery. Through experience of this case, we should strongly consider the possibility of preexisting SEH before surgery, even in patients with no neurological deficits. We should also consider perioperative coagulopathy in patients with multiple trauma, as in this case.

Surgical treatment for suicidal jumper's fracture (unstable sacral fracture) with thoracolumbar burst fracture: a report of three cases

Introduction Suicidal jumpers fracture (unstable sacral fracture) is characterized not only by multiple fractures including thoracolumbar fractures, but also major chest and abdominal injuries. Early stabilization of these fractures and early ambulation are required for the treatment and management of chest and abdominal injuries. We present 3 cases of suicidal jumpers fracture with thoracolumbar burst fracture, treated with minimally invasive posterior fixation surgery, which is a combination of percutaneous pedicle screws (PPS) and the mini-open Galveston technique. Case reports Case 1. A 50-year-old woman was injured by a fall from the 5th floor of a building as the result of a suicide attempt. Computed tomography revealed an H-shaped unstable sacral fracture and thoracolumbar fractures with major chest and abdominal injuries. For early stabilization of spinopelvic instability and early ambulation, we treated the patient with PPS and the mini-open Galveston technique. Her early postoperative emergence from bedrest contributed to the improvement of her general condition. One year after surgery at the final follow-up, she was able to walk with a T-cane without any motor, bladder, or bowel dysfunction (BBD) and achieved almost complete healing of the fractures. Cases 2 and 3. A 25-year-old woman (Case 2) and a 43-year-old woman were injured in falls. They had multiple injuries including unstable sacral fractures, and thoracolumbar fractures with major chest and abdominal injuries. We treated these patients with PPS and the mini-open Galveston technique. One year after surgery, they were able to walk with a T-cane and achieved almost complete healing of thoracolumbar fractures, but delayed healing of an unstable sacral fracture in Case 2, and remaining BBD in Case 3. Conclusion PPS and the mini-open Galveston technique is a good approach to fixation because they are minimally invasive and provide moderately rigid fixation, especially in patients with multiple trauma whose general condition is poor.