Takeo Matsuno

Mid-term prognosis of non-traumatic osteonecrosis of the femoral head

We followed, prospectively, 77 patients (90 hips) with early-stage, non-traumatic osteonecrosis of the femoral head for a mean period of nine years. At the time of final review, 56 (62%) were symptomatic. Using the Cox model, the initial radiological stage, the progression of staging, the reduction in size of the lesions and the percentage of necrotic volume on MRI were identified as risk factors. Using the Harris score of < 70 or surgery as the endpoint, the cumulative rates of survival were 60.0% at one year, 43.3% at two years, 38.9% at five years and 37.2% at ten years. Survival curves demonstrated that clinical deterioration could occur 90 months after the initial diagnosis, suggesting that asymptomatic patients should be followed carefully for several years. Radiological time-dependent reduction in size without progressive collapse may represent repair even when the collapse is minimal.

Intermediate to Long-Term Results of Periacetabular Osteotomy in Patients Younger and Older Than Forty Years of Age

BACKGROUNDnThe treatment of middle-aged patients with periacetabular osteotomy remains controversial. The goal of the present retrospective study was to analyze the intermediate to long-term functional and radiographic results of periacetabular osteotomy in patients below and above the age of forty years.nnnMETHODSnBetween February 1990 and December 2004, 166 periacetabular osteotomies were performed in 146 patients. We evaluated 158 hips in 139 patients who had a mean age of thirty-two years at the time of surgery. The mean duration of follow-up was eleven years (range, five to twenty years). We compared thirty-six patients (forty-one hips) who were forty years of age or older with 103 patients (117 hips) who were younger than forty years of age at the time of surgery.nnnRESULTSnThe average Harris hip score increased from 70 points preoperatively to 90 points postoperatively. The mean Harris hip scores at the time of the five-year follow-up were similar in the older and younger groups (p = 0.57), although the latest follow-up scores were significantly higher in the younger group than in the older group (91 compared with 88 points; p = 0.02). The average modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score (with 0 representing the worst score and 100 representing the best score) was higher for the younger group than for the older group (92 compared with 90 points; p = 0.03). Kaplan-Meier analysis with progression of the Tönnis grade of osteoarthritis as the end point showed a ten-year survival rate of 90.8% (95% confidence interval, 88.3% to 93.3%) and a fifteen-year survival rate of 83.0% (95% confidence interval, 78.5% to 87.5%); the ten-year survival rates in the younger and older groups were 94.4% and 81.3%, respectively, and the fifteen-year survival rates were 86.9% and 71.2%, respectively (p = 0.025).nnnCONCLUSIONSnPeriacetabular osteotomy yielded similar results for the two groups at the time of the five-year follow-up, although the results for the older group deteriorated thereafter. Decrease in physical function due to aging and increased susceptibility to the progression of osteoarthritis may be responsible for the poorer results over time in the older group.

Effects of dry needling at tender points for neck pain (Japanese: katakori): near-infrared spectroscopy for monitoring muscular oxygenation of the trapezius

BackgroundNeck pain (katakori) is a common symptom in adult Japanese people. However, the pathophysiological aspect of this condition has not been well documented to date. The purpose of this study was to investigate the effects of tender point dry needling to the trapezius muscles and the resultant changes in muscular hemodynamics.Methods“Neck pain” patients were defined as those complaining of dull pain or discomfort mainly along the trapezius muscles without serious spinal or shoulder disorders. We used near-infrared spectroscopy to monitor the changes of oxyhemoglobin (oxyHb) and deoxyhemoglobin (deoxyHb) of the trapezius muscles and a Visual Analogue Scale (VAS) to assess subjective neck pain intensity. Experiment I: Nine subjects with “neck pain” and four control subjects were recruited. Total hemoglobin (Hb) and SdO2 [= oxyHb/(oxyHb + deoxyHb)] were measured before and immediately after needling for 15 min. We compared these parameters and VAS before and immediately after needling. Experiment II: Thirteen subjects with “neck pain” were instructed to perform isometric contraction of their trapezius muscles for 1 min; the half-recovery time of SdO2 (defined as TR) was measured. After that, all subjects underwent needling. On the next day, we repeated the measurements of TR after the same voluntary contraction of the trapezius muscle in the same patients. We compared TR and VAS before and on the day after needling.ResultsExperiment I: All subjects with “neck pain” reported significant pain relief (P = 0.0147) measured by VAS immediately after needling, but total Hb and SdO2 exhibited no significant change after needling. Experiment II: TR was shortened on the day after needling in 10 of 13 patients (P = 0.0043), and neck pain was decreased in 12 patients (P = 0.0158).ConclusionsAfter dry needling, total Hb and SdO2 did not change in real time, but TR was shortened on the next day. These results showed that the shortening of TR would provide a measure by which to assess the effectiveness of treatment for neck pain.

Long-term results of conventional varus half-wedge proximal femoral osteotomy for the treatment of osteonecrosis of the femoral head

We have previously described the mid- to long-term results of conventional simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head, showing that 19 of the 26 hips had good or excellent results. We extended the follow-up to a mean of 18.1 years (10.5 to 26) including a total of 34 hips in 28 patients, with a mean age at surgery of 33 years (19 to 53). There were 18 men and ten women and 25 hips (74%) had a satisfactory result with a Harris hip score ≥ 80. In all, six hips needed total hip replacement (THR) or hemiarthroplasty. The collapse of the femoral head or narrowing of the joint space was found to have progressed in nine hips (26%). Leg shortening after osteotomy was a mean of 19xa0mm (8 to 36). With conversion to THR or hemiarthroplasty as the endpoint, the ten-year survival rate was 88.2% (95% confidence interval (CI) 82.7 to 93.7) and the 20-year survival rate was 79.7% (95% CI 72.1 to 87.3); four hips were converted at ten years and other two hips were converted at 20 years. Shortening of the leg after osteotomy remains a concern; however, the conventional varus half-wedge osteotomy provides favourable long-term results in hips with less than two-thirds of the medial part of the femoral head affected by necrotic bone and with normal bone superolaterally.

The Chiari pelvic osteotomy for patients with dysplastic hips and poor joint congruency : LONG-TERM FOLLOW-UP

We report the mid- to long-term (mean 20.3 years, 10 to 32.5) results of the Chiari pelvic osteotomy in patients with pre- to advanced stage osteoarthritis in dysplastic hips. We followed 163 Japanese patients (173 hips) with a mean age at surgery of 20 years (9 to 54). Overall, 124 hips (72%) had satisfactory results, with Harris hip scores ≥ 80. Satisfactory results were seen in 105 of 134 hips with pre- or early osteoarthritis (78%) and 19 of 39 hips with advanced osteoarthritis (49%). A total of 15 hips (9%) underwent a total hip replacement (THR) with a mean interval between osteotomy and THR of 16.4 years. With conversion to THR as the endpoint, the 30-year survival rate was 85.9% (95% confidence interval 82.3 to 89.5). It was 91.8% for patients with pre- or early osteoarthritis and 43.6% for those with advanced osteoarthritis (p < 0.001). We now perform the Chiari osteotomy for patients with dysplastic hips showing poor joint congruency and who prefer a joint-conserving procedure to THR.

Blockade of JNK and NFAT pathways attenuates orthopedic particle-stimulated osteoclastogenesis of human osteoclast precursors and murine calvarial osteolysis.

Particles released from orthopedic implants attract immune host defense cells to the bone‐implant interface and contribute to development of inflammation. The inflammatory microenvironment supports recruitment and differentiation of osteoclasts, the primary culprit of osteolysis. Therefore, understanding the complex signals that contribute to osteoclastogenesis and osteolysis is a sensible approach to design strategies to inhibit bone loss. The signaling cascades that coordinate osteoclastogenesis have been widely investigated. These include MAP kinases, Akt/PI3K pathway, NF‐κB signal transduction pathway, and NFAT pathway. We have recently reported that polymethylmethacrylate (PMMA) particles activate the NFAT pathway in murine osteoclast precursors and that NFAT inhibitors dose‐dependently block PMMA‐induced osteoclastogenesis. In the current study, we examined the role of JNK and NFATc1 in mice in response to PMMA particles using murine calvaria model. We show that locally administered MAPK/JNK inhibitor SP600125 and calcineurin/NFAT inhibitor cyclosporine‐A effectively blocked PMMA‐induced osteolysis in murine calvaria. To buttress the clinical relevance of JNK/NFATc1‐based regulation of PMMA‐induced osteoclastogenesis, we evaluated the effect of PMMA using human macrophages. We demonstrate that SP600125 and cyclosporine‐A abolished particle‐induced osteoclastogenesis in human osteoclast progenitors retrieved from patients undergoing total hip replacement. Thus JNK and NFATc1 appear to act as significant mediators of orthopedic particle‐induced osteolysis in humans.

Hybrid total hip arthroplasty using specifically-designed stems for patients with developmental dysplasia of the hip. A minimum five-year follow-up study

A 4-U hybrid total hip arthroplasty (THA) system was specifically designed for patients with developmental dysplasia of the hip (DDH). Straight stem with an appropriate offset and various size variations are advantages. We followed 128 hips in 124 patients, 13 men and 111 women, for a mean of 6.5xa0years (range, 5.0–7.5xa0years). Two acetabular and femoral components in two patients had been revised for infection, one acetabular component had been revised for recurrent dislocation, and one femoral component had been revised for periprosthetic femoral fracture. None of the acetabular or femoral components were revised for loosening or were found to be loose at follow-up. The Harris hip score increased from a preoperative average of 42 points to 88 points at the most recent follow-up. Primary THA using the 4-U system had a good mid-term result in patients with DDH. This system could be applied for all patients including those with the narrowest and deformed femurs.

Early weight-bearing after periacetabular osteotomy leads to a high incidence of postoperative pelvic fractures

BackgroundIt has not been shown whether accelerated rehabilitation following periacetabular osteotomy (PAO) is effective for early recovery. The purpose of this retrospective study was to compare complication rates in patients with standard and accelerated rehabilitation protocols who underwent PAO.MethodsBetween January 2002 and August 2011, patients with a lateral center-edge (CE) angle ofu2009<u200920°, showing good joint congruency with the hip in abduction, pre- or early stage of osteoarthritis, and age younger than 60xa0years were included in this study. We evaluated 156 hips in 138 patients, with a mean age at the time of surgery of 30xa0years. Full weight-bearing with two crutches started 2xa0months postoperatively in 73 patients (80 hips) with the standard rehabilitation protocol. In 65 patients (76 hips) with the accelerated rehabilitation protocol, postoperative strengthening of the hip, thigh and core musculature was begun on the day of surgery as tolerated. The exercise program included active hip range of motion, and gentle isometric hamstring and quadriceps muscle sets; these exercises were performed for 30xa0minutes in the morning and 30xa0minutes in the afternoon with a physical therapist every weekday for 6xa0weeks. Full weight-bearing with two axillary crutches started on the day of surgery as tolerated. Complications were evaluated for 2xa0years.ResultsThe clinical results at the time of follow-up were similar in the two groups. The average periods between the osteotomy and full-weight-bearing walking without support were 4.2xa0months and 6.9xa0months in patients with the accelerated and standard rehabilitation protocols (Pu2009<u20090.001), indicating that the accelerated rehabilitation protocol could achieve earlier recovery of patients. However, postoperative fractures of the ischial ramus and posterior column of the pelvis were more frequently found in patients with the accelerated rehabilitation protocol (8/76) than in those with the standard rehabilitation protocol (1/80) (Pu2009=u20090.013).ConclusionThe accelerated rehabilitation protocol seems to have advantages for early muscle recovery in patients undergoing PAO; however, postoperative pelvic fracture rates were unacceptably high in patients with this protocol.

Three-dimensional shape optimization of a cemented hip stem and experimental validations

This study proposes novel optimized stem geometry with low stress values in the cement using a finite element (FE) analysis combined with an optimization procedure and experimental measurements of cement stress in vitro. We first optimized an existing stem geometry using a three-dimensional FE analysis combined with a shape optimization technique. One of the most important factors in the cemented stem design is to reduce stress in the cement. Hence, in the optimization study, we minimized the largest tensile principal stress in the cement mantle under a physiological loading condition by changing the stem geometry. As the next step, the optimized stem and the existing stem were manufactured to validate the usefulness of the numerical models and the results of the optimization in vitro. In the experimental study, strain gauges were embedded in the cement mantle to measure the strain in the cement mantle adjacent to the stems. The overall trend of the experimental study was in good agreement with the results of the numerical study, and we were able to reduce the largest stress by more than 50xa0% in both shape optimization and strain gauge measurements. Thus, we could validate the usefulness of the numerical models and the results of the optimization using the experimental models. The optimization employed in this study is a useful approach for developing new stem designs.

Intermediate- to Long-Term Results After Hybrid Total Hip Arthroplasty in Patients With Rheumatoid Arthritis

There have been few reports describing intermediate- to long-term results after hybrid total hip arthroplasty in patients with rheumatoid arthritis. We followed up 52 hips in 44 patients aged 5 men and 39 women, with a mean of 11.5 years (range, 5-23.5 years). Revisions had been performed in 6 hips in 6 patients: 1 both acetabular and femoral components for infection, 1 acetabular component for aseptic loosening, 3 acetabular components for recurrent dislocation, and 1 acetabular component for dislodgement of the polyethylene liner from the metal shell. None of other acetabular or femoral components were revised or found to be loose at the final follow-up. Although postoperative dislocation remains a concern, hybrid total hip arthroplasty had an acceptable result in patients with rheumatoid arthritis.