Seiya Jingushi

Low-Intensity Pulsed Ultrasound Accelerates Rat Femoral Fracture Healing by Acting on the Various Cellular Reactions in the Fracture Callus

Low‐intensity pulsed ultrasound (LIPUS) has been shown to accelerate fracture healing in both animal models and clinical trials, but the mechanism of action remains unclear. In fracture healing, various consecutive cellular reactions occurred until repair. We investigated whether the advanced effects of LIPUS depended on the duration and timing of LIPUS treatment in a rat closed femoral fracture model to determine the target of LIPUS in the healing process. Sixty‐nine Long‐Evans male rats that have bilateral closed femoral fractures were used. The right femur was exposed to LIPUS (30 mW/cm2 spatial and temporal average [SATA], for 20 minutes/day), and the left femur was used as a control. Rats were divided into four groups according to timing and duration of treatment (Ph‐1, days 1–8; Ph‐2, days 9–16; Ph‐3, days 17–24; throughout [T], days 1–24 after the fracture). Animals were killed on day 25. After radiographs and microfocus X‐ray computed tomography (μCT) tomograms were taken, the hard callus area (HCA), bone mineral content (BMC) at the fracture site, and mechanical torsion properties were measured, and histological analysis was conducted. Interestingly, the maximum torque of the LIPUS‐treated femur was significantly greater than that of the controls in all groups without any changes in HCA and BMC. The multiviewing of three‐dimensional (3D) μCT reconstructions and histology supported our findings that the partial LIPUS treatment time was able to accelerate healing, but longer treatment was more effective. These results suggest that LIPUS acts on some cellular reactions involved in each phase of the healing process such as inflammatory reaction, angiogenesis, chondrogenesis, intramembranous ossification, endochondral ossification, and bone remodeling.

Bone marrow fat cell enlargement and a rise in intraosseous pressure in steroid-treated rabbits with osteonecrosis

The etiology of steroid-induced osteonecrosis (ON) is unclear. This study was designed to determine whether bone marrow fat cell size, intraosseous pressure, and blood flow rate differed between steroid-treated rabbits with ON and those without. Twenty-nine rabbits were intramuscularly injected once with 20 mg/kg of methylprednisolone acetate (MPSL), and five rabbits were injected once with physiologic saline (PS) as a control. Intraosseous pressure and blood flow rate in the proximal femur were determined before and at 2 weeks after the injection. After these measurements, both femora and humeri were histopathologically examined for the presence of ON, and size of bone marrow fat cells were morphologically examined. At 2 weeks after steroid injection, the intraosseous pressure was significantly higher in rabbits with ON than in those without (p = 0.0251), and the blood flow rate had decreased significantly more in rabbits with ON than in those without (p = 0.0051). The size of the bone marrow fat cells was significantly (p = 0.0004) larger in rabbits with ON (diameter, 63.5 +/- 5.8 microm) than in those without (diameter, 53.3 +/- 6.9 microm). Injection of PS (5 rabbits), 1 (10 rabbits), 5 (10 rabbits), and 20 (10 rabbits) mg/kg of body weight of MPSL showed that a larger dose of steroid increased both fat cell size and prevalence of ON. These results suggest that bone marrow fat cell enlargement and a rise in intraosseous pressure may be important when considering the pathophysiology of steroid-induced ON in rabbits.

A local application of recombinant human fibroblast growth factor 2 for tibial shaft fractures: A randomized, placebo‐controlled trial

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.

Localization and quantification of proliferating cells during rat fracture repair: detection of proliferating cell nuclear antigen by immunohistochemistry.

Bilateral femurs of 12‐week‐old female Sprague‐Dawley rats were fractured, and the fractured femurs were harvested 36 h, 3, 7, 10, and 14 days after the fracture. Localization of cell proliferation in the fracture calluses was investigated using immunohistochemistry with antiproliferating cell nuclear antigen (PCNA) monoclonal antibodies. Thirty‐six hours after the fracture, many PCNA‐positive cells were observed in the whole callus. The change was not limited to mesenchymal cells at the fracture site where the inflammatory reaction had occurred, but extended in the periosteum along almost the entire femoral diaphysis where intramembranous ossification was initiated. On day 3, periosteal cells or premature osteoblasts in the newly formed trabecular bone during intramembranous ossification still displayed intense staining. On day 7, many premature chondrocytes and proliferating chondrocytes were PCNA positive. Endochondral ossification appeared on days 10 and 14, and the premature osteoblasts and endothelial cells in the endochondral ossification front were stained with anti‐PCNA antibodies. Quantification of PCNA‐positive cells was carried out using an image analysis computer system, obtaining a PCNA score for each cellular event. The highest score was observed in the periosteum early after the fracture near the fracture site. Immunohistochemistry using anti‐PCNA antibodies showed that the distribution of proliferating cells and the degree of cell proliferation varied according to the time lag after the fracture, suggesting the existence of local regulatory factors such as growth factors, and that significant cell proliferation was observed at the beginning of each cellular event.

Inhibitory effects of activin-A on osteoblast differentiation during cultures of fetal rat calvarial cells.

Activin‐A is a member of the transforming growth factor‐β (TGF‐β) superfamily and is expressed by osteoblasts. However, the role of activin‐A on osteoblasts is not clearly understood. We examined the effects of activin‐A on osteoblast proliferation or differentiation, and mineralization by the osteoblasts in the first subcultures of fetal rat osteoblasts obtained from calvarial bones. Exogenous activin‐A led to impaired formation of bone nodules in a dose‐dependent manner, although it did not influence cell proliferation using an MTT assay. This inhibitory effect depended upon the time at which activin‐A was added to the culture media, and the effect was most significant when addition took place at the early phase of the culture. In addition, exogenous activin‐A inhibited gene expression of type I procollagen, alkaline phosphatase, osteonectin, and osteopontin in the cultured cells using Northern blot analysis. The peak of osteocalcin mRNA was delayed. Gene expression for TGF‐β was not influenced by exogenous activin‐A. The βA subunit (activin‐A) mRNA was detected during the early phase of this culture. These results indicate that activin‐A inhibited early differentiation of the fetal rat calvarial cells, or osteoblasts. J. Cell. Biochem. 75:206–214, 1999.

Acetabular retroversion in developmental dysplasia of the hip

BACKGROUND Patients with developmental dysplasia of the hip are prone to the development of degenerative changes in the affected hip. The aim of this study was to evaluate the prevalence, morphological features, and clinical relevance of acetabular retroversion in these patients. METHODS We investigated the version and morphological features of the acetabulum using pelvic radiographs and computed tomography images of ninety-six hips in fifty-nine patients with developmental dysplasia of the hip. A diagnosis of acetabular retroversion was based on the presence of a positive cross-over sign on the pelvic radiograph. Using computed tomography images, we determined the acetabular anteversion angle at various levels in the axial plane. The acetabular sector angle served as an indicator of acetabular coverage of the femoral head. We evaluated the association between acetabular version and the patients age at the onset of pain. Fifty normal hips were examined as controls. RESULTS We observed acetabular retroversion in 18% (seventeen) of the ninety-six hips in the patients with developmental dysplasia of the hip. The mean acetabular anteversion angle in the hips with acetabular retroversion was significantly smaller, at all levels, than that in the hips with acetabular anteversion; this tendency was more evident at proximal levels. There was significantly less posterior and posterosuperior coverage in the hips with acetabular retroversion than in those with acetabular anteversion, but superior acetabular coverage did not differ between the groups. Multivariate analysis showed that the onset of pain occurred at a significantly earlier age in patients with acetabular retroversion (27.9 years) than in those with acetabular anteversion (40.5 years), regardless of the severity of the dysplasia (p = 0.003). CONCLUSIONS In patients with developmental dysplasia of the hip, acetabular retroversion results from relatively deficient coverage by the posterior portion of the acetabulum. Developmental dysplasia with acetabular retroversion is associated with an earlier onset of pain than is developmental dysplasia with anteversion, suggesting a correlation between deficiency of the posterior acetabular wall and the earlier onset of pain.

Effects of the Femoral Offset and the Head Size on the Safe Range of Motion in Total Hip Arthroplasty

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.

Intraarticular findings in symptomatic developmental dysplasia of the hip

Background: The purpose of this study was to examine intraarticular pathology in patients younger than 20 years with symptomatic developmental dysplasia of the hip. Methods: We performed hip arthroscopy during corrective osteotomy in 23 hips in 22 patients. All patients were female, and the average age at operation was 16.4 years. Eighteen hips were in a prearthritic stage, and 5 hips were in an early stage. The presence and location of cartilage degeneration and labral tears were evaluated. Second-look arthroscopy was performed in 13 hips in 12 patients. Results: Fourteen hips (77.8%) in the prearthritic stage had cartilage degeneration. Cartilage lesions were more frequent in the acetabulum than in the femoral head (72.2% vs 16.7%). Sixty-one percent of acetabular lesions were located at the anterosuperior area. Labral tears were observed in 77.8% of hips in prearthritic stages located at the anterosuperior (72.2%) and superior (44.4%) areas. The degree of cartilage and labral lesions in the early stage was more severe than in the prearthritic stage. On second-look arthroscopy, there were no changes in the state of the cartilage and labrum in the majority (84.6%) of hips. Conclusions: The incidence of intraarticular lesions in developmental dysplasia of the hip was high, even in the prearthritic stage. These lesions tended to originate in the anterosuperior area of the acetabulum and were generally progressive. Level of evidence: Therapeutic study, level IV.

Subchondral changes in transient osteoporosis of the hip.

Abstract 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.

Effects of FGF-2 on metaphyseal fracture repair in rabbit tibiae

Fibroblast growth factor-2 (FGF-2) has been found to have stimulatory effects on fracture repair at diaphysis, while its effect on metaphyseal fracture repair, where spongiosal bone is dominant, has not been studied. This study was conducted to investigate the effect of FGF-2 on metaphyseal fracture healing in a rabbit proximal tibial metaphyseal model. The proximal tibial metaphysis of 6-month-old Japanese white rabbits was osteotomized bilaterally. Then 400 µg of FGF-2, mixed with gelatin hydrogel, and gelatin hydrogel alone (the control) were injected to each osteotomy site of the rabbit proximal tibiae, and the osteotomies were fixed with staples. One and 2 weeks after surgery, the osteoid area in the repairing spongiosal bone at the fracture site was significantly larger in the FGF-2 group than in the control group (P < 0.05). On immunohistochemistry, proliferating-cell nuclear antigen-positive cells had a tendency to show greater numbers in the FGF-2 group. After 4 and 8 weeks, values for bone mineral density and the cancellous bone area in the healing region of the fracture site were significantly larger in the FGF-2 group (P < 0.05). These data suggest that local application of FGF-2 may have an accelerating effect on the repair of metaphyseal fractures. Exogenous recombinant human rhFGF-2 may have potential clinical applications in metaphyseal fracture treatment.