Tetsuo Hagino

Prediction of ambulation prognosis in the elderly after hip fracture

We investigated the factors influencing ambulation prognosis after hip fracture in the elderly patient and examined whether it is possible to predict the ambulation status upon hospital discharge at the time of admission. Two hundred and five patients aged 60 or older with a hip fracture who were ambulant before injury were studied. The patients were divided into two groups according to their ability to walk at the time of discharge from hospital: the ambulatory group and the non-ambulatory group. We assessed the value of various predictive factors. At discharge, 136 patients (66.3%) were ambulatory while 69 patients (33.7%) were non-ambulatory. Factors significantly affecting walking ability at discharge were: (1) age, (2) dementia, (3) residence before injury, (4) anaemia, (5) electrolyte abnormality, (6) abnormal chest X-ray, and (7) chronic systemic disease. Each patient was scored on the basis of the above factors (1=yes, 0=no), and the total was used as the predictive score. The mean score was significantly higher (p<0.0005) in the non-ambulatory group. It is possible to predict ambulation prognosis after hip fracture using our scoring system at the time of admission.RésuméNous avons analysé les facteurs influençant le pronostic de la marche après fracture de la hanche chez les patients âgés en nous posant la question de la possibilité de prévoir, lors de l’admission, le statut du patient après sa sortie de l’hôpital. Ont été étudiés 205 patients âgés de 60 ans ou plus, avec une fracture de la hanche, patients « marchant » avant le traumatisme. Ces patients ont été divisés en deux groupes selon leur statut ambulatoire à la sortie de l’hôpital. Un premier groupe de patient autonome sur le plan de la marche et un deuxième groupe non-autonome. Sont sortis de l’hôpital 136 patients: 66,3% étaient autonomes sur le plan de la marche pendant que 69 patients (33,7%) n’étaient pas autonomes. Les facteurs significatifs affectant l’autonomie de la marche après la sortie de l’hôpital étaient l’âge, la démence, le statut résidentiel avant le traumatisme, l’existence ou non d’une anémie, les anomalies électrolytiques, la radio anormale du poumon et une pathologie systémique chronique. Chaque patient a été sérié selon ces facteurs (1=présence du facteur, 0=pas de présence du facteur), le total des différents facteurs donnant le score prédictif. Le score moyen était hautement significatif dans le groupe des patients non-ambulatoires. Il est donc possible de prévoir le pronostic de marche après une fracture de la hanche en utilisant ce score au moment de l’admission du patient avant le traitement de sa fracture.

Prognosis of proximal femoral fracture in patients aged 90 years and older.

Purpose. To examine the walking ability and survival outcome of patients aged 90 years and older who sustained proximal femoral fractures, and to compare the findings with those of younger patients reported in previous studies. Methods. Between January 1997 and June 2004 inclusive, 56 patients (11 men and 45 women) aged 90 years and older (range, 90–103 years; mean, 93 years) with hip fracture were reviewed. Their walking ability and survival outcome at discharge was investigated. Comparison was made between patients aged 60 to 89 years and those aged 90 years and older with respect to sex, fracture type, and other characteristics. Results. Of 56 patients, 26 injured the right side and 30 the left side. Before injury, 33 (59%) were living at home and 23 (41%) were institutionalised in long-term care facilities or other hospitals. Fracture occurred at the femoral neck in 14 patients and at the trochanter in 42. Ten patients were treated conservatively because of severe dementia, comorbidity, or refusal of surgery by the patients or their families, whereas 46 underwent surgery. Of the 45 who were previously ambulatory, 22 regained walking ability on discharge from hospital. None of the 10 patients treated conservatively were ambulatory on discharge. During hospitalisation, 4 became bedridden and 5 died (mainly due to pneumonia); among these 9 patients, 5 were deemed physically unfit for surgery. Conclusion. Surgery is the treatment of choice for patients aged 90 years and older with proximal femoral fracture. However, they have a lower rate of regaining pre-injury walking ability and a higher in-hospital death rate than younger patients.

High molecular weight hyaluronic acid increases the differentiation potential of the murine chondrocytic ATDC5 cell line.

Osteoarthritis (OA) is a group of common, chronic, and painful inflammatory joint diseases. One important finding in OA patients is a remarkable decrease in the molecular weight of hyaluronic acid (HA) in the synovial fluid of affected joints. Therapeutic HA is available to patients in most parts of the world as a viscosupplementation product for the treatment of OA. Previous clinical reports show that high molecular weight HA (HMWHA) more effectively relieves pain than low molecular weight HA (LMWHA). However, the mechanism behind this finding remains unclear. In this study, we investigated whether a LMWHA (Low‐0.9 MDa) and two types of HMWHA (High‐1.9 MDa and 6 MDa) differentially affected chondroregulatory action. We tested this using ATDC5 cell, a murine chondrocytic cell line widely used in culture systems to study chondrogenic differentiation. We found that HMWHA, especially hylan G‐F 20 (High‐6 MDa), significantly induced aggrecan and proteoglycan accumulation, nodule formation, and mRNA expression of chondrogenic differentiation markers in a time‐ and dose‐dependent manner. In addition, we showed that HMWHA prevented TNF‐α induced inhibition of chondrogenic differentiation, with no effect on cell proliferation or viability. These results reveal that HMWHA significantly promotes chondrogenic differentiation of ATDC5 cells in vitro, and suggest that HMWHA plays a significant chondroregulatory role in vivo.

Intraarticular nodular fasciitis causing limitation of knee extension: A case report

We report a patient with intraarticular nodular fasciitis who developed mechanical symptoms in the knee, limiting knee extension. A 24 year-old man presented with mechanical restriction of extension and pain at maximum extension. MRI revealed an intraarticular mass within the knee joint. The mass was excised arthroscopically. Histological examination of the excised tissue led to a diagnosis of nodular fasciitis. Pain and limitation of motion of the knee disappeared from one day after surgery. No recurrence was found after 1 year. Intraarticular nodular fasciitis is rare, and although this lesion within the knee has been reported previously, it has not been associated with mechanical symptoms. This case indicates that intra-articular fasciitis should be considered in the differential diagnosis of a patient presenting with mechanical limitation of knee extension and a mass lesion inside the knee joint.

Efficacy of early surgery and causes of surgical delay in patients with hip fracture.

BACKGROUND Whether early surgery for hip fractures is effective remains controversial. The current Japanese medical system poses some constraints on conducting early surgery. We examined the usefulness of early surgery and factors that delay surgery in patients with hip fractures treated at our hospital. METHODS Among 314 patients aged ≥60 years treated for hip fractures since January 2006, 270 patients (55 men, 215 women; mean age 84.1 years; femoral neck fracture in 111, trochanteric fracture in 159) who underwent surgery were studied. They were divided into an early surgery group (surgery up to 1 day after admission) and a delayed surgery group (later than 1 day). Clinical parameters analyzed included age, gender, pre-injury residence, pre-injury ambulatory ability, admission during public holiday, fracture site, fracture type, blood tests and urinalysis at admission, chest radiography, electrocardiography, number of systemic chronic diseases, dementia, surgical modality, blood transfusion, length of hospital stay, ambulatory ability at discharge, and hospital death. After performing univariate analysis between two groups, the parameters that were identified as significant were further tested by multivariate analysis. RESULTS Among 270 patients treated for hip fracture, 112 patients (41.5%) received early surgery. Multivariate analysis identified admission during public holiday, electrocardiographic abnormalities, femoral head replacement, and length of hospital stay as significant independent factors. CONCLUSION The causes of surgical delay were admission during public holiday, electrocardiographic abnormalities, and femoral head replacement. Although length of hospital stay was shorter in patients with early surgery, there was no difference in outcome.

One strategy for arthroscopic suture fixation of tibial intercondylar eminence fractures using the Meniscal Viper Repair System

BackgroundPrinciples for the treatment of tibial intercondylar eminence fracture are early reduction and stable fixation. Numerous ways to treatment of this fracture have been invented. We designed a simple, low-invasive, and arthroscopic surgical strategy for tibial intercondylar eminence fracture utilizing the Meniscal Viper Repair System used for arthroscopic meniscal suture.MethodsWe studied 5 patients, who underwent arthroscopic suture fixation that we modified. The present technique utilized the Meniscal Viper Repair System for arthroscopic suture of the meniscus. With one handling, a high-strength ultra-high molecular weight polyethylene(UHMWPE) suture can be passed through the anterior cruciate ligament (ACL) and the loops for suture retrieval placed at both sides of ACL. Surgical results were evaluated by the presence or absence of bone union on plain radiographs, postoperative range of motion of the knee joint, the side-to-side differences measured by Telos SE, and Lysholm scores.ResultsThe reduced position achieved after surgery was maintained and good function was obtained in all cases. The mean distance of tibia anterior displacement and assessment by Lysholm score showed good surgical results.ConclusionThis method simplified the conventional arthroscopic suture fixation and increased its precision, and was applicable to Type II fractures that could be reduced, as well as surgically indicated Types III and IV. The present series suggested that our surgical approach was a useful surgical intervention for tibial intercondylar eminence fracture.

Thrombin induced by the extrinsic pathway and PAR-1 regulated inflammation at the site of fracture repair

Thrombin (coagulation factor IIa) is a serine protease encoded by the F2 gene. Pro-thrombin (coagulation factor II) is cut to generate thrombin in the coagulation cascade that results in a reduction of blood loss. Procoagulant states that lead to activation of thrombin are common in bone fracture sites. However, its physiological roles and relationship with osteoblasts in bone fractures are largely unknown. We herein report various effects of thrombin on mouse osteoblastic MC3T3-E1 cells. MC3T3-E1 cells expressed proteinase-activated receptor 1 (PAR1), also known as the coagulation factor II receptor. They also produced monocyte chemoattractant protein (MCP-1), tissue factor (TF), MCSF and IL-6 upon thrombin stimulation through the PI3K-Akt and MEK-Erk1/2 pathways. Furthermore, MCP-1 obtained from thrombin-stimulated MC3T3-E1 cells induced migration by macrophage RAW264 cells. All these effects of thrombin on MC3T3-E1 cells were abolished by the selective non-peptide thrombin receptor inhibitor SCH79797. We also found that thrombin, PAR-1, MCP-1, TF as well as phosphorylated AKT and p42/44 were significantly expressed at the fracture site of mouse femoral bone. Collectively, thrombin/PAR-1 interaction regulated MCP-1, TF, MCSF and IL-6 production by MC3T3-E1 cells. Furthermore, MCP-1 induced RAW264 cell migration. Thrombin may thus be a novel cytokine that regulates several aspects of osteoblast function and fracture healing.

Acute onset of intracranial subdural hemorrhage five days after spinal anesthesia for knee arthroscopic surgery: a case report

IntroductionSpinal anesthesia is a widely used general purpose anesthesia. However, serious complications, such as intracranial subdural hemorrhage, can rarely occur.Case presentationWe report the case of a 73-year-old Japanese woman who had acute onset of intracranial subdural hemorrhage five days after spinal anesthesia for knee arthroscopic surgery.ConclusionThis case highlights the need to pay attention to acute intracranial subdural hemorrhage as a complication after spinal anesthesia. If the headache persists even in a supine position or nausea occurs abruptly, computed tomography or magnetic resonance imaging of the brain should be conducted. An intracranial subdural hematoma may have a serious outcome and is an important differential diagnosis for headache after spinal anesthesia.

Comparison of the prognosis among different age groups in elderly patients with hip fracture.

Background: The outcome of treatment of hip fractures in different age groups in the elderly population is largely unknown. Hence, we stratified elderly patients with hip fracture into age groups and compared the prognosis in various age groups. Materials and Methods: Among 459 patients with hip fracture treated at our hospital from 1997, 430 patients aged 65 years or above at the time of injury were studied. The patients comprised 98 males and 332 females and the ages at injury ranged from 65 to 103 years (mean 83.4 years). There were 167 cases of femoral neck fracture and 263 cases of trochanteric fractures. Surgery was performed in 383 cases, while 47 cases were treated conservatively. The subjects were classified by age into young-old for those aged 65-74 years (group A, n = 55), middle-old for those aged 75-84 years (group B, n = 172), old-old for those aged 85-94 (group C, n = 180), and oldest-old for those aged 95 years or above (group D, n = 23). The functional and survival prognosis at discharge in each group was investigated. Results: Numbers of patients who were ambulatory at discharge among those ambulatory before injury were 43 of 49 (87.8%) in group A, 113 of 152 (74.3%) in group B, 86 of 138 (62.3%) in group C, and 5 of 14 (35.7%) in group D, showing worse recovery of walking ability as age advanced. Among those ambulatory before injury, 42 patients in group A, 139 patients in group B, 130 patients in group C, and 12 patients in group D underwent surgery and of these patients, 38 patients (90.5%) in group A, 109 patients (78.4%) in group B, 83 patients (63.8%) in group C, and 5 patients (41.7%) in group D were ambulatory at discharge. On the other hand, the numbers of patients who were ambulatory at discharge among those receiving conservative treatment were 5 of 7 (71.4%) in group A, 4 of 13 (30.8%) in group B, 3 of 8 (37.5%) in group C, and 0 of 2 (0%) in group D, showing better walking ability in surgical patients than in conservatively treated patients even in the elderly. There were two in-hospital deaths in group B, 11 in group C, and two in group D. Five of the 15 deaths were inoperable cases due to poor performance status at admission. Conclusion: Walking ability at discharge and survival prognosis worsened as age advanced. On the other hand, since surgical cases achieved better walking ability than conservatively treated cases, efforts should be made to achieve better functional prognosis even in the old-olds, including surgery together with early ambulation and rehabilitation.

Twin hook fixation for proximal femoral fractures

Purpose. To report results of twin hook fixation for proximal femoral fractures in comparison to those fixed with the conventional lag screw. Methods. Between August 2005 and July 2006, 2 men and 15 women aged 74 to 94 (mean, 85) years with proximal femoral fractures underwent open reduction and internal fixation using the twin hook system. The tip-apex distance was compared with that in 20 patients treated with the sliding hip screw between August 2004 and July 2005. Results. In the 17 patients, the hook was inserted into the centre of the femoral head. Bone union was achieved and no intra- or post-operative cut-out or device failure was encountered. In patients using the twin hook and sliding hip screw respectively, the mean tip-apex distance was 22.3 mm and 14.6 mm (p<0.001). Conclusion. Using the twin hook system requires more surgical skill than using the sliding hip screw, because failure to insert the pin into the centre of the femoral head risks intra-articular perforation by the hooks.