Takuya Tajima

Effect of genu recurvatum on the anterior cruciate ligament-deficient knee during gait

PurposeThis study aimed to investigate the effects of genu recurvatum, which is considered to carry a high risk for anterior cruciate ligament (ACL) injury, on healthy and post-ACL injury gait and lower extremity muscle strength.MethodsSubjects were 36 patients with ACL-deficient knee and 40 healthy controls without pain or restricted range of motion of the lower extremity during gait. The knee joints of all subjects were examined; those with over 10° hyperextension of both knees were defined as exhibiting genu recurvatum. On this basis, the subjects were further subdivided into two groups: with or without genu recurvatum. A three-dimensional motion analysis system and force plates were used for gait analysis. Isokinetic dynamometers were used to measure knee muscle strength.ResultsThere were no differences in joint angles, joint moments, or components of ground reaction force during gait or in knee strength for the healthy control subjects with and without genu recurvatum. ACL-deficient subjects without genu recurvatum showed a decrease in knee angles during the stance phase and a decrease in extension moments during the early stance phase compared with ACL-deficient subjects with genu recurvatum and controls. In contrast, neither knee angles nor extension moments during the stance phase differed significantly between ACL-deficient subjects with genu recurvatum and controls.ConclusionsThis study provides clinically relevant information regarding the effects of genu recurvatum on gait parameters. The results suggest that in ACL injuries, the presence of genu recurvatum alters gait pattern. Consideration of the presence of genu recurvatum would be useful during rehabilitation following ACL injuries or ACL reconstruction.Level of evidenceII. Prospective comparative study.

Arthroscopic anatomical double-bundle anterior cruciate ligament reconstruction for asian patient using a bone-patellar tendon-bone and gracilis tendon composite autograft: a technical note

BackgroundRecent years have seen anterior cruciate ligament (ACL) reconstruction being performed in a broad range of patients, regardless of age, sex and occupation, thanks to great advances in surgical techniques, surgical instruments and basic research. In cases of ACL reconstruction, bone-patellar tendon-bone (BTB) graft or hamstring graft are frequency used. However, potential complications associated with tunnel enlargement due to soft tissue graft such as hamstring were reported. On the other hand, an altered rotational axis resulting in significantly greater translation of the lateral compartment in the single bundle compared with double bundle ACL reconstruction was reported.Method and procedureA reconstruction procedure was modified for the ACL using a double bundle that is the combination of BTB and gracilis tendon composite autograft. Two tibial and two femoral bone tunnels are used to reconstruct two bundles of ACL; an anteromedial bundle (AMB) and a posterolateral bundle (PLB). The femoral bone tunnels are created just posterior to the residents ridge. The tibial bone tunnels are created at the center of AM and PL tibial attachment, respectively. BTB is fixed in the AM tunnels produced on the anatomical points of tibia and femur. The gracilis graft is fixed in an anatomical PL tunnel produced. The mean width of BTB is 7 mm, since10 mm graft is sometimes not suitable for patients, especially small Asian people and females. For these patients, 10 mm graft is bigger than one third of patella tendon width.ConclusionThe devised surgical procedure based on a combination of BTB and gracilis autograft is suitable reconstruction method for patients who have small or medium width of patellar tendon such as Asian people and females. This technique is also applicable to revision surgery.

Copy number loss in the region of the ASPN gene in patients with acetabular dysplasia

Objectives We have previously investigated an association between the genome copy number variation (CNV) and acetabular dysplasia (AD). Hip osteoarthritis is associated with a genetic polymorphism in the aspartic acid repeat in the N-terminal region of the asporin (ASPN) gene; therefore, the present study aimed to investigate whether the CNV of ASPN is involved in the pathogenesis of AD. Methods Acetabular coverage of all subjects was evaluated using radiological findings (Sharp angle, centre-edge (CE) angle, acetabular roof obliquity (ARO) angle, and minimum joint space width). Genomic DNA was extracted from peripheral blood leukocytes. Agilent’s region-targeted high-density oligonucleotide tiling microarray was used to analyse 64 female AD patients and 32 female control subjects. All statistical analyses were performed using EZR software (Fisher’s exact probability test, Pearson’s correlation test, and Student’s t-test). Results CNV analysis of the ASPN gene revealed a copy number loss in significantly more AD patients (9/64) than control subjects (0/32; p = 0.0212). This loss occurred within a 60 kb region on 9q22.31, which harbours the gene for ASPN. The mean radiological parameters of these AD patients were significantly worse than those of the other subjects (Sharp angle, p = 0.0056; CE angle, p = 0.0076; ARO angle, p = 0.0065), and all nine patients required operative therapy such as total hip arthroplasty or pelvic osteotomy. Moreover, six of these nine patients had a history of operative or conservative therapy for developmental dysplasia of the hip. Conclusions Copy number loss within the region harbouring the ASPN gene on 9q22.31 is associated with severe AD. A copy number loss in the ASPN gene region may play a role in the aetiology of severe AD. Cite this article: T. Sekimoto, M. Ishii, M. Emi, S. Kurogi, T. Funamoto, Y. Yonezawa, T. Tajima, T. Sakamoto, H. Hamada, E. Chosa. Copy number loss in the region of the ASPN gene in patients with acetabular dysplasia: ASPN CNV in acetabular dysplasia. Bone Joint Res 2017;6:439–445. DOI: 10.1302/2046-3758.67.BJR-2016-0094.R1.

Anterior cruciate ligament reconstruction in a patient with Athetoid cerebral palsy: a case report

Recent years have seen ACL reconstruction performed in a broad range of patients, regardless of age, sex or occupation, thanks to great advances in surgical techniques, instrumentation and the basic research. Favorable results have been reported; however, we have not been able to locate any reports describing ACL reconstruction in patients with athetoid cerebral palsy.We present herein a previously unreported anterior cruciate ligament (ACL) reconstruction performed in a patient with athetoid cerebral palsy. The patient was a 25-year-old woman with level II athetoid cerebral palsy according to the Gross Motor Function Classification System. She initially injured her right knee after falling off a bicycle. Two years later, she again experienced right-knee pain and a feeling of instability. A right-knee ACL tear and avulsion fracture was diagnosed upon physical examination and confirmed with magnetic resonance imaging (MRI) and X-ray examination at that time. An ACL reconstruction using an autologous hamstring double-bundle graft was performed for recurrent instability nine years after the initial injury. Cast immobilization was provided for 3 weeks following surgery and knee extension was restricted for 3 months with the functional ACL brace to prevent hyperextension due to involuntary movement. Partial weight-bearing was started 1 week postoperatively, with full weight-bearing after 4 weeks. The anterior drawer stress radiography showed a 63% anterior displacement of the involved tibia on the femur six months following the surgery, while the contralateral knee demonstrated a 60% anterior displacement of the tibia. The functional ACL functional brace was then removed. A second-look arthroscopy was performed 13 months after the ACL reconstruction, and both the anteromedial and posterolateral bundles were in excellent position as per Kondo’s criteria. The Lachman and pivot shift test performed under anesthesia were also negative. An anterior drawer stress radiography of the involved knee at 36 months following surgery showed a 61% anterior translation of the tibia. The preoperative symptoms of instability resolved and the patient expressed a high degree of satisfaction with the result of her surgery.

Screening for musculoskeletal problems in Japanese schoolchildren: a cross-sectional study nested in a cohort

OBJECTIVES To clarify the frequency of musculoskeletal problems in public elementary and junior high school children and to determine the advantages and problems of musculoskeletal examinations. STUDY DESIGN School-based cross-sectional study nested in a cohort. METHODS We examined 41,376 public elementary and junior high school children (aged 6-15 years) in Miyazaki, Japan, from 2008 to 2014. Participation was voluntary. Participants received an in-school primary musculoskeletal examination (clinical examination with check items and a questionnaire) and a secondary examination at an orthopaedic outpatient clinic as indicated. Estimated prevalence rates for musculoskeletal problems were calculated from the results of both examinations. RESULTS The total estimated prevalence of musculoskeletal problems was 8.6%. Prevalence by school grade ranged from 3.2% to 13.7%. Estimated prevalence rates increased as grade increased and were higher in junior high school students than in elementary school students. The secondary examination identified musculoskeletal problems on the back (65.4%), knee (8.1%), ankle or feet (7.3%) and elbow (5.4%). Of those referred for a secondary examination, 44.4% had not reported musculoskeletal complaints on the initial questionnaire. Overall, 69.8% of problems diagnosed in the secondary examination were previously undiagnosed. CONCLUSIONS School-based musculoskeletal examination enables early detection of abnormal growth and disorders of the locomotive organs and is expected to support childrens musculoskeletal growth and development. We recommend musculoskeletal examinations as part of school check-ups in Japan. Our findings suggest musculoskeletal examinations should be conducted for students in higher elementary school grades and for all junior high school students. Evaluation should include both direct clinical examination and questionnaires.

Remnant-preserving, selective single-bundle augmentation of the anterior cruciate ligament using a bone-patellar tendon-bone autograft: A technical note.

BACKGROUND To the best of our knowledge, there has been no detailed study on bone-patellar tendon-bone (BTB) grafts for remnant-preserving, selective-bundle anterior cruciate ligament (ACL) augmentation. Therefore, we aimed to develop such a technique using a BTB graft. METHOD A total of five patients underwent surgery using the presented procedure. These patients were young, male, and with high body mass index, and hence required very high durability of reconstructed ACL. A femoral bone tunnel was created using the inside-out technique via an accessory far-medial portal, protecting the remnant using a probe, regardless of the presence of an anteromedial (AM) or posterolateral (PL) tunnel. A single tibial tunnel was drilled at the center of the AM or PL attachment and two transverse skin incisions were made in the ipsilateral knee. The central third of the patellar tendon attached to a patellar and tibial bone plug autograft with a width of seven millimeters was harvested by subcutaneous tunneling. The femoral side was fixed using a cortical fixation device for BTB and the tibial bone plug was fixed using an interference screw with the knee at an angle of 20° of flexion by applying maximal manual traction. RESULTS Bone tunnel enlargement, which was measured by computed digital radiography, was not observed in all cases. A BTB autograft for remnant-preserving, selective-bundle ACL augmentation offers reduced risk of tunnel enlargement. CONCLUSION The presented procedure might be considered one of the potentially available options for patients with ACL partial tear who require very high durability of reconstructed ACL. LEVEL OF EVIDENCE 5.

Comprehensive Safety Management and Assessment at Rugby Football Competitions

The present study aims to improve medical systems by designing objective safety assessment criteria for rugby competitions. We evaluated 195 competitions between 2002 and 2011 using an original safety scale comprising the following sections: 1) competence of staff such as referees, medical attendants and match day doctor; 2) environment such as weather, wet bulb globe temperature and field conditions; and 3) emergency medical care systems at the competitions. Each section was subdivided into groups A, B and C according to good, normal or fair degrees of safety determined by combinations of the results.Overall safety was assessed as A, B and C for 110, 78 and 7 competitions, respectively. The assessments of individual major factors were mostly favorable for staff, but the environment and medical care systems were assessed as C in 25 and 70, respectively, of the 195 competitions. Medical management involves not having a match day doctor, but also comprehensive management including preventive factors and responses from the staff, environment and medical-care systems. 6 cases of severe injuries and accidents occurred between 2002 and 2011, which were observed in Grade A competition. These cases revealed better prognosis without obvious impairment, thus confirming the value of the present assessment scale.

Hemoglobin Stimulates the Expression of Adamts-5 and -9 by Synovial Cells; A Possible Cause of Cartilage Damage after Intra-articular Bleeding

Objectives: A disintegrin and metalloprotease with thrombospondin motifs (ADAMTS)-5 and -9 play an important pathologic role in matrix degeneration. Aggrecanase-mediated aggrecan degradation is a significant and critical event in early-stage osteoarthritis. To determine the effect of hemoglobin (Hb) on the ability of synovial tissues to produce ADAMTS family that play important roles in the degradation of articular cartilage, examining the influence of Hb by synovial cells in vitro experimental system. Methods: Synovial tissues were obtained from five young patients with meniscus injury. The mean age of patients was 14 years (range: 10-16). The experimental design was reviewed and approved (Accession No. 405) by the Committee for Ethics at the Faculty of Medicine, Miyazaki University. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. We obtained written, informed consent from all patients before entering the study. Primary cultures of human knee synovial cells were treated with different doses of human Hb (0, 25, 50, 100 μg/ml) for the preliminary examination. The culture media were collected 24 h after Hb-treatment. In the time-course studies, cells were treated with 100 μg/ml Hb and culture media were taken at 6, 12, and 24 h. To identify the proteins those are responsible for aggrecanase activity, Western blot analysis using antibodies against human ADAMTS-5, -8, -9, and -10, Enzyme-Linked ImmunoSorbent Assay (ELISA) and gene expression for ADAMTS-5, and -9 were examined. Results: Western blot analysis revealed that Hb-treatment resulted in the detection of ADAMTS-5 and -9 proteins in a dose-, and time-dependent manner. Neither control nor Hb-treated medium showed immunoreactivity against anti-ADAMTS-8, and -10 IgG. In a dose-dependency study which were measured by ELISA, the peak immunoreactivity was confirmed at Hb concentration of 100μg/ml. Even if 25μg/ml treated with Hb at 24h, there are significantly increasing expression compared with the control group both in the results of ADAMTS-5, and -9 (p<0.05). In a time-course study analyzed, the levels of ADAMTS-5 and -9 antigen level in the conditioned medium which were measured by ELISA reveals significantly increasing expression at 6, 12, and 24h in the Hb-treated group compared with the results of control group (p<0.05). Hb evoked significantly expression of ADAMTS-9 mRNA at 12 and 24 hours (p<0.05). Hb induced highly expression of ADAMTS-9 at 6 hours without significant difference. The mRNA level of ADAMTS-5 was not enhanced by Hb, significantly. Conclusion: Our results suggest a possible role of Hb for joint damage after intra-articular bleeding. Hb induces the expression of ADAMTS family proteinase such as ADAMTS-5 and -9 by synovial cells at low doses even at an acute phase. These findings suggest that single instance of intra-articular bleeding during trauma or sports injury could affect on articular cartilage metabolism deleteriously during an acute phase. Immediate treatment for intra-articular bleeding, such as washing out and removing the blood from the joint cavity, may be required regardless of whether it occurs once or repeatedly.

Clinical Results of Arthroscopic Surgery for Osteoarthritis of the Elbow

我々は疼痛や可動域制限を有する変形性肘関節症に対して関節鏡視下関節形成術を行なっている．今回，その短期成績を報告する．症例は変形性肘関節症に対し肘関節鏡を施行し術後4ヶ月以上経過観察可能であった5例5肘で男性5肘を対象とした．手術時平均年齢は54.0歳，平均経過観察期間は14.2ヶ月であった．評価方法として，術前後の日本整形外科学会肘機能評価法（JOAスコア）および可動域，合併症の有無で評価した．JOA肘スコアは平均69.0点から91.2点に，可動域は屈曲が平均106.4度から115.6度に，伸展が平均－12.4度から－3.6度と改善が見られたが，術前可動域制限が強い症例での改善度が低い傾向にあった．術後合併症は全例なかった．変形性肘関節症に対する鏡視下手術は組織への侵襲が少なく，有効な手術法であるが，術前可動域制限が強い症例では手術手技の更なる検討が必要である．