Koji Nozaka

Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial.

BACKGROUND An initial anterior dislocation of the shoulder becomes recurrent in 66% to 94% of young patients after immobilization of the shoulder in internal rotation. Magnetic resonance imaging and studies of cadavera have shown that coaptation of the Bankart lesion is better with the arm in external rotation than it is with the arm in internal rotation. Our aim was to determine the benefit of immobilization in external rotation in a randomized controlled trial. METHODS One hundred and ninety-eight patients with an initial anterior dislocation of the shoulder were randomly assigned to be treated with immobilization in either internal rotation (ninety-four shoulders) or external rotation (104 shoulders) for three weeks. The primary outcome measure was a recurrent dislocation or subluxation. The minimum follow-up period was two years. RESULTS The follow-up rate was seventy-four (79%) of ninety-four in the internal rotation group and eighty-five (82%) of 104 in the external rotation group. The compliance rate was thirty-nine (53%) of seventy-four in the internal rotation group and sixty-one (72%) of eighty-five in the external rotation group (p = 0.013). The intention-to-treat analysis revealed that the recurrence rate in the external rotation group (twenty-two of eighty-five; 26%) was significantly lower than that in the internal rotation group (thirty-one of seventy-four; 42%) (p = 0.033) with a relative risk reduction of 38.2%. In the subgroup of patients who were thirty years of age or younger, the relative risk reduction was 46.1%. CONCLUSIONS Immobilization in external rotation after an initial shoulder dislocation reduces the risk of recurrence compared with that associated with the conventional method of immobilization in internal rotation. This treatment method appears to be particularly beneficial for patients who are thirty years of age or younger.

Arthroscopic Quadriceps Tendon Repair: Two Case Reports

Recently, although some studies of open repair of the tendon of the quadriceps femoris have been published, there have been no reports in the literature on primary arthroscopic repair. In our present study, we present two cases of quadriceps tendon injury arthroscopically repaired with excellent results. Case 1 involved a 68-year-old man who was injured while shifting his weight to prevent a fall. MRI showed complete rupture at the insertion of the patella of the quadriceps tendon. The rupture was arthroscopically repaired using both suture anchor and pull-out suture fixation methods via bone tunnels (hereafter, pull-out fixation). Two years after surgery, retearing was not observed on MRI and both Japan Orthopedic Association (JOA) Knee and Lysholm scores had recovered to 100. Case 2 involved a 50-year-old man who was also injured when shifting his weight to prevent a fall. MRI showed incomplete superficial rupture at the insertion of the patella of the quadriceps tendon. The rupture was arthroscopically repaired using pull-out fixation of six strand sutures. One year after surgery, MRI revealed a healed tendon and his JOA and Lysholm scores were 95 and 100, respectively. Thus, arthroscopic repair may be a useful surgical method for repairing quadriceps tendon injury.

Relationship between Pain and Medial Meniscal Extrusion in Knee Osteoarthritis

Purpose. In knee osteoarthritis, the degree of pain varies despite similar imaging findings. If there were quantitative findings related to the pain of knee osteoarthritis, it could be used for diagnosis or screening. The medial meniscal extrusion was investigated as a candidate quantitative finding related to the pain of knee osteoarthritis. Methods. Seventy-six knees of 38 patients (mean age, 73 years) who received intra-articular injections of hyaluronic acid into unilateral knees at the time of diagnosis of knee arthritis were investigated. Cartilage thickness of the femoral medial condyle and medial meniscal extrusion of bilateral knees were measured by ultrasonography. Thirty-eight knees that had hyaluronic acid injections were compared with 38 other side knees from the same patients as the control group. Results. The average cartilage thicknesses of the knees with pain that received intra-articular injections and the knees without pain that received no injections were 1.02 and 1.05 mm, respectively (P = 0.6394). On the other hand, the average medial meniscal extrusions of the knees with and without pain were 7.58 and 5.88 mm, respectively (P = 0.0005); pain was associated with greater medial meniscal extrusions. Conclusion. Medial meniscal extrusion is a quantitative finding related to the pain of knee osteoarthritis.

Comminuted distal humeral fracture treated using the Ilizarov technique in a patient with rheumatoid arthritis and osteoporosis

The goal of treatment for distal humeral fractures in patients with rheumatoid arthritis (RA) is to obtain sufficient bone union and good elbow function. However, treating comminuted distal humeral fractures in patients with RA and osteoporosis is challenging. We present the case of a 58-year-old woman with RA and osteoporosis who suffered a comminuted distal humeral fracture and was successfully treated with the Ilizarov technique. The Ilizarov technique is minimally invasive compared with conventional open surgery, can obtain good stabilization, and allows earlier rehabilitation, even if the fractured bone is severely osteoporotic. The patient exhibited good elbow function and alignment at the final follow-up examination (18 postoperative months). To the best of our knowledge, the present case is the first in which a comminuted distal humeral fracture in a patient with RA and severe osteoporosis was successfully treated with an Ilizarov external fixator.

Applications of Teriparatide for Fracture Repair and Osteosynthetic Surgery in Osteoporosis

Teriparatide (TPTD), consisting of amino acids 1–34 of human parathyroid hormone (PTH), is a powerful systemic bone anabolic agent that increases osteoblastic activity, decreases osteoblast apoptosis, and improves bone quality. TPTD enhances cancellous bone healing at the site of osteotomy with, at least in part, a local regulating action that increases osteoblastogenesis and decreases adipocytogenesis. In addition, TPTD administered before osteosynthesis stimulates cancellous bone union in rat. TPTD treatment may also have positive effects on bone-hydroxyapatite (HA) block bonding in patients with osteoporosis by increasing cancellous bone formation and enhancing cancellous bone healing around the HA block. Use of TPTD accelerated the fusion rate and shortened the duration of fusion after instrumented lumbar posterolateral fusion in women with postmenopausal osteoporosis. Furthermore, TPTD led to early clinical and radiological improvement of chronic nonunion fractures of the upper and lower extremities, with subsequent complete healing. In bisphosphonate-associated atypical femoral fractures (AFFs), TPTD treatment appears to significantly shorten the postoperative time to fracture healing and reduces rates of delayed healing or nonunion after bisphosphonate-associated AFFs.

AB1091 Power Doppler Ultrasonographic Assessment of Foot and Ankle Synovitis in Rheumatoid Arthritis

Background Rheumatoid arthritis (RA) can cause various types of foot and ankle deformities. However, the foot and ankle are not always taken into account in indices of RA severity such as the Disease Activity Score in 28 Joints (DAS28). Although joint ultrasonography is frequently used for the evaluation of disease activity in RA, few studies have used it for the joints of the foot and ankle. Objectives We aimed to assess the prevalence of foot and ankle synovitis in RA patients using joint ultrasonography. Methods Sixty patients (18 men and 42 women) with 82 arthritic feet and a mean age of 65 years (range 27 to 88) took part in the study. Thirty-seven were Steinbrocker class I, 14 were class II, and 9 were class III. Fifteen were in disease stage I, 18 in stage II, 7 in stage III, and 20 in stage IV. Power Doppler ultrasonography was performed by a single examiner. The scanned area included the distal part of the lateral malleolus (peroneal tendon), the subtalar joint (sinus tarsi, tibiocalcaneal part of the medial ligament of the ankle joint), the anterior ankle, the calcaneocuboid joint, the talonavicular and cuneonavicular joints, the posterior tibial tendon, and the first through fifth metatarsophalangeal joints. Synovitis was defined as the presence of a blood flow signal on ultrasonography. Results Synovitis of the foot or ankle was detected in 49 of 82 feet (59.8%). It was observed in 78.3% of the patients with moderate to high disease activity scores on the DAS28 as assessed based on erythrocyte sedimentation rate, as well as 44.7% of those with low disease activity. Even among patients without foot complaints, synovitis was present in 22 of 49 feet (44.9%). Conclusions According to some recent reports, the number of foot surgeries performed for RA has been increasing in spite of advances in pharmacotherapy. This study found a high prevalence of synovitis of the foot or ankle in RA patients irrespective of the presence or absence of symptoms or the degree of disease activity, although some cases may have been related to other diseases, as the scanned area included the peroneal and posterior tibial tendons. We propose that RA patients with persistent synovitis may be candidates for further treatment, and clinicians should consider additional pharmacotherapy to prevent joint destruction. For selected patients with foot and ankle synovitis, excision of the synovial membranes of small joints may be beneficial. Regarding the technical aspects of ultrasonography, it was difficult to differentiate joint synovitis from tendon sheath synovitis in the subtalar joint; the reason for this requires further investigation. Acknowledgements The authors thank Miss Sasaki, for her assistance with this project. Disclosure of Interest None declared

Massive Deposition and Accumulation of Hydroxyapatite Crystal after Total Hip Arthroplasty: A Case Report

We presented a case in which massive hydroxyapatite accumulation was observed around the artificial hip joint. A 66-year-old female showed a massive accumulation of fluid in and around the hip joint, and milk-like aspirate was obtained. Her aspirate culture was negative, and sediment analysis by X-ray diffraction showed that its component was hydroxyapatite. Since pain was mild, the patient was treated conservatively. To our knowledge, this is the first case in which liquid hydroxyapatite (milk of calcium) was accumulated around the artificial hip joint.