Jih-Yang Ko

Treatment of osteonecrosis of the hip: comparison of extracorporeal shockwave with shockwave and alendronate

Background and purposeExtracorporeal shockwave therapy (ESWT) and alendronate are reported effective in early osteonecrosis of the femoral head (ONFH). We hypothesized that joint effects of ESWT and alendronate may produce superior results. This prospective study compared the results of ESWT and alendronate with that of ESWT without alendronate in early ONFH.Patients and methodsForty-eight patients with 60 hips were randomly divided into tow groups. There were 25 patients with 30 hips in group A and 23 patients with 30 hips in group B. Both groups showed similar demographic characteristics. All patients were treated with 6,000 impulses of ESWT at 28xa0KV (equivalent to 0.62xa0mJ/mm²) to the affected hip as a single session. Patients in group B also received alendronate 70xa0mg per week for 1xa0year, whereas patients in group A did not. The evaluations included clinical assessment, radiograph and MR image of the affected hip. Both groups were compared statistically using paired t, Mann–Whitney and Chi square tests with statistical significance at Pxa0<xa00.05. The primary end point is the need for total hip arthroplasty (THA). The secondary end point is the improvement in pain and function of the hip. The third end point is the progression or regression of the lesion on image study.ResultsThe overall clinical outcomes were improved in 83%, unchanged in 7% and worsened in 10% for group A; and improved in 77%, unchanged in 13% and worsened in 10% for group B. THA was performed in 10% of group A and 10% of group B (Pxa0=xa01.000). Significant improvements in pain and function of the hip were noted in both groups (Pxa0<xa00.001), however, the differences between the two groups were not significant (Pxa0=xa00.400, 0.313). On MR images, the lesions showed progression in 10%, regression in 47% and unchanged in 43% in group A, and progression in 7%, regression in 53% and unchanged in 40% in group B (Pxa0=xa00.830).ConclusionESWT and alendronate produced comparable result as compared with ESWT without alendronate in early ONFH. It appears that ESWT is effective with or without the concurrent use of alendronate. The joint effects of alendronate over ESWT in early ONFH are not realized in short-term.

Extracorporeal shockwave therapy shows regeneration in hip necrosis

OBJECTIVESnThe effect of shockwave in osteonecrosis of the femoral head (ONFH) is poorly understood. The purpose of this study was to investigate the regeneration effects of shockwave in ONFH.nnnMETHODSnThis study consisted of 14 femoral heads from 14 patients undergoing total hip arthroplasty for ONFH. Seven patients with seven hips who received shockwave prior to surgery were designated as the study group, whereas, seven patients with seven hips who did not receive shockwave were assigned to the control group. Both groups showed similar demographic characteristics. The femoral heads were investigated with histopathological examination and immunohistochemical analysis with von Willebrand factor (vWF), VEGF, platelet endothelial cell adhesion molecule-1 (PECAM-1) also referred to as (CD 31) and vascular cell adhesion molecule (VCAM) for angiogenesis, and with proliferation cell nuclear antigen (PCNA), Dickkopf-1 (DKK1) and Winless 3a (Wnt 3) for bone remodelling and regeneration.nnnRESULTSnIn histopathological examination, the study group showed significantly more viable bone and less necrotic bone, higher cell concentration and more cell activities including phagocytosis than the control group. In immunohistochemical analysis, the study group showed significant increases in vWF (P < 0.01), VEGF (P = 0.0012) and CD 31 (P = 0.0023), Wnt3 (P = 0.008) and PCNA (P = 0.0011), and decreases in VCAM (P = 0.0013) and DKK1 (P = 0.0007) than the control group.nnnCONCLUSIONSnShockwave treatment significantly promotes angiogenesis and bone remodelling than the control. It appears that application of shockwave results in regeneration effects in hips with ONFH.

The effects of shockwave on bone healing and systemic concentrations of nitric oxide (NO), TGF-β1, VEGF and BMP-2 in long bone non-unions

This study investigated the effects of extracorporeal shockwave treatment (ESWT) on bone healing and the systemic concentrations of nitric oxide (NO), TGF-beta1, VEGF and BMP-2 in long bone non-unions. Forty-two patients with 42 established non-unions of the femur and tibia were enrolled in this study. Each long bone non-union was treated with 6000 impulses of shockwave at 28 kV in a single session. Ten milliliters of peripheral blood were obtained for measurements of serum NO level and osteogenic growth factors including TGF-beta1, VEGF and BMP-2; serum levels of calcium, alkaline phosphatase, calcitonin and parathyroid hormone before treatment and at 1 day, 1, 3 and 6 months after treatment. The evaluations for bone healing included clinical assessments and serial radiographic examinations. At 6 months, bony union was radiographically confirmed in 78.6%, and persistent non-union in 21.4%. Patients with bony union showed significantly higher serum NO level, TGF-beta1, VEGF and BMP-2 at 1 month after treatment as compared to patients with persistent non-union. Shockwave-promoted bone healing was associated with significant increases in serum NO level and osteogenic growth factors. The elevations of systemic concentration of NO level and the osteogenic factors may reflect a local stimulation of shockwave in bone healing in long bone non-unions.

Effect of sodium hyaluronate treatment on rotator cuff lesions without complete tears: a randomized, double-blind, placebo-controlled study.

HYPOTHESISnA randomized, double-blind, placebo-controlled study of sodium hyaluronate (ARTZ Dispo) treatment was performed in 51 patients with rotator cuff lesions without complete tears. We hypothesized that ARTZ Dispo would render better results than the placebo.nnnMATERIALS AND METHODSnTwenty-five patients (ARTZ Dispo group) had injections of 25 mg/wk of sodium hyaluronate into the subacromial bursa for 5 consecutive weeks. Twenty-six patients (placebo group) were given 2.5 mL of normal saline solution with the same injection protocol as the ARTZ Dispo group. No significant difference in age, height, weight, gender, vocation, involved shoulder, duration of symptoms, baseline Constant score, or visual analog scale (VAS) score existed between the 2 groups.nnnRESULTSnThe 2 groups did not significantly differ with regard to Constant scores, VAS scores, or global improvement assessments 1 week after injections. The ARTZ Dispo group had a better Constant score (P = .0095) and VAS score (P = .0018) than the placebo group 6 weeks after treatment. Patients in the placebo group were given 5 sodium hyaluronate injections, rather than placebo, after disclosure of the blind list, if they wished. Forty-one patients who underwent hyaluronate injection exhibited a significantly improved Constant score, from 64.0 +/- 11.7 at baseline to 88.9 +/- 10.4 (P < .0001), and a significantly improved VAS score, from 6.4 +/- 1.3 to 1.5 +/- 1.6 (P < .0001), at a mean follow-up of 33.1 months. No significant adverse effect was noted.nnnCONCLUSIONSnSubacromial injections of sodium hyaluronate are effective in treating rotator cuff lesions without complete tears.

Increased IL‐1β expression and myofibroblast recruitment in subacromial bursa is associated with rotator cuff lesions with shoulder stiffness

We evaluated whether proinflammatory cytokine expression and myofibroblast recruitment in subacromial bursa was linked to rotator cuff lesions with shoulder stiffness. We analyzed expressions of IL‐1β, IL‐6, and TNF‐α in subacromial bursa and joint fluid collected from 14 patients with cuff tears with stiffness as a study group (Group I) and 14 patients with rotator cuff tears without shoulder stiffness as a control group (Group II) using real‐time RT‐PCR, immunohistochemistry, and ELISA. Myofibroblast apoptosis in subacromial bursa was analyzed using terminal deoxynucleotidyl transferase ‐mediated deoxyuridine triphosphate‐biotin nick end‐labeling (TUNEL) and α‐smooth muscle actin immunofluorescence staining. Shoulder function was evaluated using the Constant score. Group I had higher mRNA expression (pu2009<u20090.001) and immunoreactivities (pu2009<u20090.001) of IL‐1β. They also had higher levels of IL‐1β, IL‐6, and TNF‐α in joint fluid. Increased IL‐1β mRNA expression in the subacromial bursa and IL‐1β levels in joint fluid were correlated with a preoperative deficit in shoulder motion (pu2009<u20090.001) and preoperative Constant scores (pu2009<u20090.001). Immunofluorescence observations showed that Group I subjects had more myofibroblasts (pu2009<u20090.001) than Group II. In Group II, a significant correlation was found between apoptotic myofibroblasts and total myofibroblasts (pu2009=u20090.002), but not in Group I (pu2009=u20090.510). Increased expression of IL‐1β and myofibroblast recruitment in the subacromial bursa in rotator cuff lesions are linked to shoulder stiffness.

Increased Dickkopf-1 expression accelerates bone cell apoptosis in femoral head osteonecrosis.

Intensive bone cell apoptosis contributes to osteonecrosis of femoral head (ONFH). Dickkopf-1 (DKK1) reportedly mediates various types of skeletal disorders. This study investigated whether DKK1 was linked to the occurrence of ONFH. Thirty-nine patients with various stages of ONFH were recruited. Bone specimens were harvested from 34 ONFH patients underwent hip arthroplasty, and from 10 femoral neck fracture patients. Bad, Bcl2 TNFalpha, DKK1, Wnt3a, LRP5, and Axin1 expressions were analyzed by quantitative RT-PCR and ELISA. Apoptotic cells were assayed using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end-labelling (TUNEL). Primary bone-marrow mesenchymal cells were treated with DKK1 RNA interference and recombinant DKK1 protein. ONFH patients with the histories of being administrated corticosteroids and excessive alcohol consumption had significantly higher Bad and DKK1 mRNA expressions in bone tissue and DKK1 abundances in serum than femoral neck fracture patients. Bone cells adjacent to osteonecrotic bone displayed strong DKK1 immunoreactivity and TUNEL staining. Increased DKK1 expression in bone tissue and serum correlated with Bad expression and TUNEL staining. Serum DKK1 abundance correlated with the severity of ONFH. The DKK1 RNA interference and recombinant DKK1 protein regulated Bad expression and apoptosis of primary bone-marrow mesenchymal cells. Knock down of DKK1 reduced dexamethasone-induced apoptosis of mesenchymal cells. Taken together, promoted DKK1 expression was associated with bone cell apoptosis in the occurrence of ONFH patients with the histories of corticosteroid and alcohol intake and progression of ONFH. DKK1 expression in injured tissue provides new insight into ONFH pathogenesis.

Surgical Results in Rotator Cuff Tears with Shoulder Stiffness

BACKGROUND/PURPOSEnLittle has been mentioned about the treatment of rotator cuff tears and associated shoulder stiffness. We prospectively treated a series of patients with rotator cuff tears associated with shoulder stiffness concomitantly and reported the outcomes.nnnMETHODSnA combined procedure of manipulation, lysis of adhesions, anterior acromioplasty and repair of rotator cuff was performed on 43 patients (47 shoulders) who were available for follow-up for a minimum of 2 years. Ten patients (11 shoulders) had diabetes mellitus and 33 patients (36 shoulders) were non-diabetic. Partial tear of the rotator cuff was noted in 27 shoulders, complete tears in 15 shoulders and massive tears in five shoulders. A functional score of Constant and Murley was used to evaluate the overall outcomes, the results between patients with and without diabetes mellitus and the results among different types of rotator cuff tears.nnnRESULTSnAt a mean (+/- SD) of 48.61 +/- 18.0 months (range, 24-85 months) after the operation, each patient showed a significant improvement in subjective score, objective score and strength score as well as in the total score of Constant and Murley. There was no statistical difference in postoperative total Constant scores between patients with and without diabetes mellitus (p = 0.123). Comparison of the scores among the three types of rotator cuff tears revealed that all had a significant improvement in the total scores of Constant and Murley (44.6 +/- 7.7 vs. 91.7 +/- 4.9, p < 0.001 for a partial cuff tear; 42.9 +/- 11.3 vs. 86.0 +/- 9.6, p = 0.001 for a complete tear; and 44.2 +/- 4.8 vs. 82.0 +/- 12.1, p = 0.043 for a large tear), but patients with partial tears of the rotator cuff had significantly better total scores than did those with complete tears (92.6 +/- 4.8 vs. 82.0 +/- 12.1, p = 0.018) or large tears (92.6 +/- 4.8 vs. 86.1 +/- 9.7, p = 0.041).nnnCONCLUSIONnA combined procedure of manipulation, lysis of adhesions, acromioplasty and repair of rotator cuff is a satisfactory procedure for patients with rotator cuff tears and associated shoulder stiffness.

Navigation-assisted total knee arthroplasty for a knee with malunion of the distal femur.

Conventional total knee arthroplasty (TKA) has been developed for several decades. However, very few previous reports describe TKA with less invasive modality for extra-articular angular deformity. Herein, we report a case of navigation-assisted TKA for severe osteoarthritis associated with malunited distal femoral fracture. Fourteen months after navigation TKA surgery, satisfactory alignment, diminished length discrepancy, and improved range of motion were noted. Our report reveals that navigation system without intramedullary reaming is a feasible and less invasive alternative for TKA surgery for complex arthritic knee disorders.

Complement component C3: Serologic signature for osteogenesis imperfecta. Analysis of a comparative proteomic study

BACKGROUND/PURPOSEnOsteogenesis imperfecta (OI) is a disease characterized by low bone mass and bony fragility. This study investigated the serum proteomic profiles and their correlation with bone density for OI cases.nnnMETHODSnTwenty OI patients and 20 control participants were included. Comparative serum proteomic profiles were analyzed by two-dimensional electrophoresis and tandem mass spectrometry. Serum protein levels were measured by enzyme-linked immunosorbent assay. Cutoff values and areas under the curve were estimated by the receiver operating characteristic curve. Bone mineral density data was obtained from all OI patients.nnnRESULTSnCandidate proteins identified by electrophoresis were complement component C3 (C3), vitamin D-binding protein (DBP), and haptoglobin (HP). Enzyme-linked immunosorbent assay validation showed that OI patients had decreased C3 and DBP and increased HP. The results were not affected by age or bisphosphonate use. Serum C3 levels significantly correlated with bone mineral density of the lumbar spine and hip. C3 had the greatest areas under the curve to distinguish OI from healthy controls.nnnCONCLUSIONnSerum C3, DBP, and HP are emerging serologic signatures for OI. Concentrations of serum C3 correlated with the T score of OI patients. C3 had the greatest areas under the curve of the three proteins to distinguish OI from healthy controls.

Overgrowth of the femoral neck after hip fractures in children

BackgroundOvergrowth after pediatric femoral shaft fractures is well documented; however, overgrowth of the femoral neck after hip fractures has not been especially reported previously. The purpose of this study was to evaluate the incidence and characteristics of femoral neck overgrowth after hip fractures in children.MethodsFrom January 1990 to December 2012, there were 30 consecutive patients with pediatric hip fractures. We retrospectively reviewed the medical record of all the patients, including age at injury, gender, injury mechanism, fracture type, methods of treatment, time to bony union, and complications. The functional outcome was evaluated by Ratliff’s criteria. The radiography of the pelvis was performed in controlled positions of abduction and external rotation. The length of the femoral neck was measured by two observers. The overgrowth of the femoral neck was defined as lengthening more than 3xa0mm in comparison with the uninjured hip.ResultsAt a mean follow-up of 4.9xa0years (range 2–8xa0years), 12 patients (40xa0%) had an overgrowth of the femoral neck. The average overgrowth of the femoral neck was 6.2xa0mm (range 3.2–8.5xa0mm). The patients with femoral neck overgrowth were younger (pu2009=u20090.0002), have lower rate of avascular necrosis of the femoral head (pu2009=u20090.0006), and have better functional outcome (pu2009=u20090.0026).ConclusionsOur results provide evidence that overgrowth of the femoral neck following hip fractures may occur in children and the overgrowth phenomenon in the femoral neck was a predictor of good outcomes after treatment.