Ryohei Takeuchi

Medial Opening Wedge High Tibial Osteotomy With Early Full Weight Bearing

PURPOSE We performed clinical and radiographic evaluation of patients with medial compartment osteoarthritis of the knee who had undergone treatment with opening wedge high tibial osteotomy (OWHTO) followed by early full weight bearing. OWHTO procedures were performed by use of TomoFix (Synthes, Bettlach, Switzerland) and bone substitute materials. METHODS OWHTO was performed in 57 knees in 52 patients with a mean age of 69 years (range, 54 to 82 years) at the time of operation. The diagnosis was primary osteoarthritis in 34 knees in 29 patients and osteonecrosis in a further 23 knees in 23 patients. We established an early weight-bearing exercise program during which these patients were permitted partial weight-bearing exercise 1 week after their osteotomy procedure. All patients performed full weight-bearing exercises at 2 weeks after surgery. The mean follow-up period was 40 months (range, 24 to 62 months). RESULTS The American Knee Society Score and Function Score showed significant improvement from 50.9 +/- 12.3 to 91.7 +/- 6.9 points and 59.3 +/- 13.1 to 94.1 +/- 8.8 points, respectively. Before surgery, the mean femorotibial angle during standing was 181.3 degrees +/- 2.4 degrees (1.3 degrees anatomic varus), but it measured 169.6 degrees +/- 2.3 degrees (10.4 degrees valgus) at the time of follow-up. There were no instances of nonunion or implant failure in any of our patients. CONCLUSIONS We have shown that an early weight-bearing exercise program enables full weight bearing at 2 weeks after OWHTO with TomoFix and artificial bone wedges. Overall, this combination was a highly successful course of treatment for correcting knee malalignment in patients with medial compartment osteoarthritis. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Low-intensity pulsed ultrasound activates the phosphatidylinositol 3 kinase/Akt pathway and stimulates the growth of chondrocytes in three-dimensional cultures: a basic science study

IntroductionThe effect of low-intensity pulsed ultrasound (LIPUS) on cell growth was examined in three-dimensional-cultured chondrocytes with a collagen sponge. To elucidate the mechanisms underlying the mechanical activation of chondrocytes, intracellular signaling pathways through the Ras/mitogen-activated protein kinase (MAPK) and the integrin/phosphatidylinositol 3 kinase (PI3K)/Akt pathways as well as proteins involved in proliferation of chondrocytes were examined in LIPUS-treated chondrocytes.MethodsArticular cartilage tissue was obtained from the metatarso-phalangeal joints of freshly sacrificed pigs. Isolated chondrocytes mixed with collagen gel and culture medium composites were added to type-I collagen honeycomb sponges. Experimental cells were cultured with daily 20-minute exposures to LIPUS. The chondrocytes proliferated and a collagenous matrix was formed on the surface of the sponge. Cell counting, histological examinations, immunohistochemical analyses and western blotting analysis were performed.ResultsThe rate of chondrocyte proliferation was slightly but significantly higher in the LIPUS group in comparison with the control group during the 2-week culture period. Western blot analysis showed intense staining of type-IX collagen, cyclin B1 and cyclin D1, phosphorylated focal adhesion kinase, and phosphorylated Akt in the LIPUS group in comparison with the control group. No differences were detected, however, in the MAPK, phosphorylated MAPK and type-II collagen levels.ConclusionLIPUS promoted the proliferation of cultured chondrocytes and the production of type-IX collagen in a three-dimensional culture using a collagen sponge. In addition, the anabolic LIPUS signal transduction to the nucleus via the integrin/phosphatidylinositol 3-OH kinase/Akt pathway rather than the integrin/MAPK pathway was generally associated with cell proliferation.

Fractures Around the Lateral Cortical Hinge After a Medial Opening-Wedge High Tibial Osteotomy: A New Classification of Lateral Hinge Fracture

PURPOSE The purpose of this study was to determine the frequency of lateral hinge fractures after opening-wedge high tibial osteotomy and investigate the patterns of fracture and their clinical outcome. METHODS We analyzed 104 knees in 93 patients with a mean age of 68 ± 7 years. Of the knees, 74 were diagnosed as having primary osteoarthritis and 30 with osteonecrosis. The mean follow-up period was 41 months. Lateral hinge fractures were classified as follows: type I, the fracture reaches just proximal to or within the tibiofibular joint; type II, the fracture reaches the distal portion of the proximal tibiofibular joint; and type III, a lateral plateau fracture. A standard postoperative rehabilitation protocol was used for type I fractures, 3 of 5 patients with type II fractures were treated with non-weight bearing, and type III fractures were treated with non-weight bearing until visible callus formation. RESULTS The Knee Society scores for the knee and for function showed improvement from 49 ± 11 to 91 ± 7.7 points and from 62 ± 13 to 95 ± 8.2 points, respectively. Lateral cortex fractures were observed in 26 knees (25%): 19 type I, 5 type II, and 2 type III. In the type II fracture group, 2 of 5 patients were judged to have a delayed bone union. There were 2 cases of infection (2%) and 1 case of traumatic neuroma (1%) but no instances of implant failure, nonunion, or deep vein thrombosis among our patient cohort. CONCLUSIONS High tibial osteotomy patients treated with a combination of TomoFix (Synthes, Bettlach, Switzerland) and bone substitute were able to walk with full weight bearing 2 weeks after surgery. No complications were seen in 19 patients with type I fractures. Of 5 patients with type II fractures, 2 had delayed unions with a correction loss of 3° and 7°, respectively. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Effects of collagen gel mixed with hydroxyapatite powder on interface between newly formed bone and grafted Achilles tendon in rabbit femoral bone tunnel

The Achilles tendon was implanted into a bone tunnel made in the femoral condyle of 20 rabbits. In the left femur, collagen gel mixed with hydroxyapatite powder (C-HAp) was injected between the graft and the bone tunnel. On the other hand, as a control, simple saline was injected in the right femur. Five rabbits were sacrificed at 4, 8, 12, and 16 weeks after surgery. Histological findings showed that in the C-HAp group, the grafted tendon came in direct contact with new bone, and Sharpey-like collagen fibers arising from the grafted tendon were observed to penetrate new bone by 4 weeks after surgery. In the control group, however, fibrous tissue was observed between new bone and the grafted tendon, but no penetrating fibers from the grafted tendon into the new bone were observed until 16 weeks. The area of new bone in the C-HAp group was significantly greater than that in the control group 4, 8, and 12 weeks after surgery (p < 0.0001, p < 0.0007, p < 0.0013, respectively).

Cross-cultural adaptation and validation of the Japanese Knee Injury and Osteoarthritis Outcome Score (KOOS)

BackgroundIn Japan, only few cross-culturally adapted, internationally used orthopaedic patient self-assessed outcome scores are available. In addition, the high incidence of knee osteoarthritis (OA) suggests the need for validated outcome measures such as the widely used Knee Injury and Osteoarthritis Outcome Score (KOOS) for Japanese populations. The purpose of this study was to provide a cross-culturally adapted and validated KOOS questionnaire for further use in national and international clinical projects involving Japanese patients.MethodsThe Japanese KOOS was developed according to the standard cross-cultural adaptation guidelines. For validation, the KOOS was tested on 58 patients diagnosed with OA. Reliability was tested using the intraclass correlation coefficient (ICC). Internal consistency or homogeneity was assessed using Cronbach’s alpha. Construct validity was evaluated by quantifying the correlation between the KOOS and the Japanese OKS and SF-36 questionnaires with Spearmann’s correlation coefficients.ResultsNo major difficulties were encountered during the translation and pre-testing stages. All five KOOS subscales showed adequate reproducibility with ICC values greater than 0.85, high internal consistency with Cronbach’s alpha values around 0.90, and high Spearmann’s coefficients over 0.50 signifying good correlation between the KOOS subscales and the OKS as well as the majority of the established subscales of the SF-36. No floor and ceiling effects were observed for the five subscales.ConclusionsOur validated Japanese KOOS is a reliable and stable outcomes measure that provides a valuable basis for national and international clinical projects focusing on patient-based assessments in knee OA.

A mid term comparison of open wedge high tibial osteotomy vs unicompartmental knee arthroplasty for medial compartment osteoarthritis of the knee.

BackgroundThe choice of surgical treatments for unicompartmental osteoarthritis (OA) of the knee is still somewhat controversial. Midterm results from cases treated using unicompartmental knee arthroplasty (UKA) or open wedge high tibial osteotomy (OWHTO) were evaluated retrospectively.MethodsTwenty-seven knees of 24 patients with varus deformities underwent OWHTO and 30 knees of 18 patients underwent UKA surgeries for the treatment of medial compartmental osteoarthritis (OA). The KSS score, FTA, range of motion and complications were evaluated before and after surgery.ResultsThe preoperative mean KSS scores were 49 points in the OWHTO group and 62 in the UKA group which improved postoperatively to 89 (excellent; 19 knees, good; 8 knees), and 88 (excellent; 25, good; 4, fair; 1), respectively. There was no significant difference between the OWHTO and UKA scores. Seventeen patients in the OWHTO group could sit comfortably in the formal Japanese style after surgery. The preoperative mean FTA values for the OWHTO and UKA groups were 182 degrees and 184, and at follow-up measured 169 and 170, respectively. In the UKA group, the femoral component and the polyethylene insertion in one patient was exchanged at 5 years post-surgery and revision TKAs were performed in 2 cases. In the OWHTO group, one tibial plateau fracture and one subcutaneous tissue infection were noted.ConclusionsTreatment options should be carefully considered for each OA patient in accordance with their activity levels, grade of advanced OA, age, and range of motion of the knee. OWHTO shows an improved indication for active patients with a good range of motion of the knee.

Clinical results of a valgus high tibial osteotomy for the treatment of osteoarthritis of the knee and the ipsilateral ankle

The treatment of patients with osteoarthritic knees accompanied by ipsilateral osteoarthritic ankles is not well documented. We here report both clinical results and radiographic evaluations of such patients treated using a high tibial osteotomy (HTO). HTO was performed on 16 knees of 10 patients (all women with a mean age; 68 years; range 58 to 73 years) who had a varus deformity of both their legs as a result of medial compartmental osteoarthritis of their knees. The Hospital for Special Surgerys (HSS score) knee scoring system and the clinical rating system for the ankle-hindfoot by Kitaoka (AOFAS) were used to evaluate the patients clinically before and after HTO. Radiographic findings were measured using antero-posterior one-leg weight bearing radiographs of the whole lower extremity taken before surgery. The mean time of follow-up was 8 years (range, 4-10 years). The HSS score improved from 54 to 91 points after HTO and the mean ankle score improved significantly from 54 to 86 points. After HTO also, the alignment of the knees changed from 6 degrees varus to 12 degrees valgus. The decrease of the inclination angle of the tibial axis changed from 10 degrees laterally to - 2 degrees medially and the talar tilt angle improved from 18 degrees to 6 degrees resulting in an improvement of the ankle congruity. HTO, which can correct the total alignment of the lower extremity, is thus recommended as one of more effective surgical procedures for patients with an ipsilateral osteoarthritis of the knee and ankle.

Minimally invasive fixation for Unstable two-part proximal humeral fractures: Surgical techniques and clinical results using J-nails

Objectives To evaluate the outcome of a minimally invasive treatment of unstable two-part proximal humeral fractures using a J-nail. Design Retrospective case series. Patients Forty-one unstable two-part proximal humeral fractures (thirty women and eleven men) with a mean age of sixty-five years (range 18 to 95 years) were studied. Intervention Closed reduction and internal fixation with J-nails. Main Outcome Measures All fractures were classified using Neers classification and were displaced and unstable. Forty of the two-part fractures were at the surgical neck and one at the anatomic neck. All patients had a closed reduction and intramedullary fixation using three J-nails. The mean follow-up period was twenty-nine months (range 2 to 4 years). Clinical assessment was performed by doctors who did not participate in the primary surgery and was graded according to Neers scoring system. Results All patients experienced immediate pain relief. At the two-year follow-up, the mean angles of active forward elevation, abduction, and extension were 138 degrees (range 80 to 180 degrees), 132 degrees (range 80 to 170 degrees), and 65 degrees (range 40 to 85 degrees), respectively. According to Neers criteria, the outcome was excellent in twenty-five patients, satisfactory in twelve, unsatisfactory in three, and a failure in one. The final Neers score showed a significant negative correlation with age (p < 0.01). Conclusion J-nail fixation has the advantage of being an almost closed method without the disadvantage of muscle transfixation associated with other methods. The procedure is simple and involves minimal invasion of the soft tissue. Shoulder and elbow function is not impeded because the nails are inserted just below the distal part of the deltoid muscle insertion. This surgical technique may be one of the more reliable and effective treatments for proximal humeral fractures.

Low‐intensity pulsed ultrasound accelerates fracture healing by stimulation of recruitment of both local and circulating osteogenic progenitors

We investigated the effect of low‐intensity pulsed ultrasound (LIPUS) on the homing of circulating osteogenic progenitors to the fracture site. Parabiotic animals were formed by surgically conjoining a green fluorescent protein (GFP) mouse and a syngeneic wild‐type mouse. A transverse femoral fracture was made in the contralateral hind limb of the wild‐type partner. The fracture site was exposed to daily LIPUS in the treatment group. Animals without LIPUS treatment served as the control group. Radiological assessment showed that the hard callus area was significantly greater in the LIPUS group than in the control group at 2 and 4 weeks post‐fracture. Histomorphometric analysis at the fracture site showed a significant increase of GFP cells in the LIPUS group after 2 weeks (7.5%), compared to the control group (2.4%) (p < 0.05). The LIPUS group exhibited a significantly higher percentage of GFP cells expressing alkaline phosphatase (GFP/AP) than the control group at 2 weeks post‐fracture (5.9%, 0.3%, respectively, p < 0.05). There was no significant difference in the percentage of GFP/AP cells between the LIPUS group (2.0%) and the control group (1.4%) at 4 weeks post‐fracture. Stromal cell derived factor‐1 and CXCR4 were immunohistochemically identified at the fracture site in the LIPUS group. These data indicate that LIPUS induced the homing of circulating osteogenic progenitors to the fracture site for possible contribution to new bone formation.

Simultaneous anterior cruciate ligament reconstruction and opening wedge high tibial osteotomy: Report of four cases.

Four patients, aged 37-50 years, with chronic anterior cruciate ligament (ACL) deficiency, medial compartment osteoarthritis and varus deformity, underwent simultaneous arthroscopic ACL reconstruction and opening wedge high tibial osteotomy using the TomoFix fixation device and hydroxyapatite wedges. The simultaneous procedure allowed our patients to perform a full weight-bearing exercise at 4 weeks after surgery. At device removal and concomitant second-look arthroscopy, all patients had either a cyclops-like lesion or partial tears at the point of contact between the reconstructed ACL and intercondylar notch. Therefore, subsequent notchplasty or re-notchplasty was required. Because of the small number of patients, the results should be considered preliminary. Given our findings of graft morbidity caused by the corrected postoperative alignment, adequate intercondylar notchplasty should be performed at the initial operation.