Toshio Kitano

Closed reduction of slipped capital femoral epiphysis: high-risk factor for avascular necrosis.

How should we treat acute/unstable slipped capital femoral epiphysis (SCFE) without the development of avascular necrosis (AVN)? To answer this question, we investigated the risk factors of AVN development after SCFE. Seventy-six hips of 64 patients were classified using two kinds of classification systems, Loder’s classification based on instability and the conventional classification based on the duration of symptom, because both classifications are related to AVN development. Of 21 unstable SCFEs, seven hips developed AVN. Of 35 hips defined as acute or acute on chronic, nine hips developed AVN. Two stable SCFEs of Loder’s classification developed AVN, one was acute and the other was acute on chronic. No hips of chronic SCFE developed AVN. The factor that had influenced AVN development was only closed reduction, whether purposefully or inadvertently, in an acute or unstable SCFE. On the basis of the findings of this study, one should not embark on any modality of closed reduction for an unstable or acute form of SCFE, as there is a high risk for occurrence of AVN. For the same reason, a traction table should not be used for SCFE fixation, so as to avoid an inadvertent reduction or force that can lead to AVN.

New treatment method for developmental dysplasia of the hips after walking age: arthroscopic reduction with limboplasty based on the findings of preoperative imaging

BackgroundWhat makes treatment choice for developmental dysplasia of the hips diagnosed after walking age difficult is the poor understanding of prereduction conditions that obstruct the reduction in spatial terms. To evaluate these problems, we employed subtraction three-dimensional imaging to search for the factors involved in intraarticular obstruction. On the basis of the findings of preoperative subtraction threedimensional imaging from computed tomography, we developed a new method, a minimum invasive arthroscopic reduction with limboplasty, for reduction of developmental dysplasia of the hips after walking age. The purposes of this report were to: (1) describe the technique of the arthroscopic procedure, and (2) evaluate our new method using radiographic parameters.MethodsTen patients with ten hips with developmental dysplasia after walking age treated by arthroscopic reduction with limboplasty were included in this study. The mean age of the patients at reduction was 22.6 months (range, 18.6–29.7 months); mean age at follow up was 7.2 years (range, 3.9–10.9 years); and mean follow up was 5.4 years (range, 1.7–9.0 years). These ten hips were evaluated using radiographic measurements.ResultsModerate or severe avascular necrosis of the femoral head was not observed. Two hips that had a spherical-shaped head with minimal residual height loss or coxa magna were classified as Kalamchi and MacEwen grade 1. Additional surgery had been performed for two hips classified as Severin group 4 during the course of follow up. These two hips were classified as Severin group 1 at final examination. One more hip was classified as Severin group 4 at final examination, and additional surgery was recommended. The remaining seven hips (70%) therefore obtained good evaluations by arthroscopic reduction with limboplasty alone.ConclusionsWe developed a new reduction method by using an arthroscopic procedure for the reduction of developmental dysplasia of the hips after walking age when this dysplasia failed to be reduced with nonoperative methods. The result of our new method is acceptable because good evaluations were obtained in 70% of hips 5.4 years after reduction by our new method alone.

The epidemiology of developmental dysplasia of the hip in Japan: Findings from a nationwide multi-center survey

BACKGROUND It has been reported that the national incidence of developmental dysplasia of the hip (DDH) has decreased in Japan. This is because of prevention activities after birth since around 1970. However, cases of late-diagnosed DDH have still been noted in some childrens hospitals. There has been no recent survey of DDH in Japan. The purpose of this study was to investigate the current epidemiology of DDH using a comprehensive nationwide survey. METHODS A questionnaire was sent to orthopedic surgeons in 1987 facilities nationwide, who were asked to complete and return a survey card on each DDH patient treated between April 2011 and March 2013. RESULTS A total of 783 (39%) facilities completed and returned the card. Of these, 79% reported no cases of DDH-related dislocation over the 2-year period, while the remaining facilities reported 1295 cases. The characteristics of children diagnosed with DDH-related dislocation were as follows: girls (89%), left side involvement (69%), bilateral involvement (4%), positive family history (27%), first-born (56%), and pelvic position at birth (15%). Seasonal variation showed an increase in DDH incidence among those born in the winter. Overall, 199 cases (15%) were diagnosed at >1 year of age, and these included 36 cases diagnosed very late, at >3 years of age. The majority of the 199 cases of late diagnosis had received earlier routine screening at <1 year of age. CONCLUSION The characteristics of the children diagnosed with DDH nationwide were similar to past data from local regions. However, many children were diagnosed late (>1 year of age), particularly in the more populous regions. The findings identify a need for improved early routine screening for DDH in Japan.

Treatment for unstable slipped capital femoral epiphysis: Current status and future challenge in Japan

BACKGROUND Treatment for unstable slipped capital femoral epiphysis (SCFE) is challenging and controversial. For many years, the debate centered around closed treatments and especially the pros and cons of manual reduction and its concrete procedure. However, recent studies reported on open treatments such as open reduction through an anterior approach and modified Dunn procedure. Being in a period of such transition, we investigated the current status and future challenge of treatment for unstable SCFE. METHODS A questionnaire survey of medical institutions specializing in pediatric hip disorders across Japan was conducted. Survey items were the accurate diagnosis of physeal stability, the pre- and intra-operative evaluation of epiphyseal hemodynamics, and current treatment strategy. RESULTS Survey responses returned from 29 out of 40 participant institutions (response rate: 73%) revealed that 55% of the institutions evaluated physeal stability based on clinical findings of ambulation capability in accordance with the Loder classification. Another 38% diagnosed physeal stability comprehensively by combining the Loder classification and imaging findings. Epiphyseal hemodynamics was assessed preoperatively in 18% of the institutions, effectively using angiography, contrast-enhanced magnetic resonance imaging (MRI), and bone scintigraphy. Intraoperative assessment was performed in 13% based on the bleeding through a drilling hole on the articular surface and observation of the cancellous bone color during open surgeries. As a treatment strategy, 52% of the institutions used in-situ fixation, while another 38% used manual reduction and internal fixation. On the other hand, open reduction was used at 3 institutions (the remaining 10%): the modified Dunn procedure at 2 institutions and arthrotomy at 1 institution. CONCLUSION Treatment for unstable SCFE remains controversial, but closed treatments without hemodynamic monitoring is no longer the center of the controversy. Today, the topic of the discussion is shifting toward how to correlate hemodynamic findings with treatment procedures and the indications for open treatments.

A novel LMX1B nonsense mutation in a family with nail-patella syndrome.

The nail-patella syndrome (NPS, OMIM #161200), also known as hereditary osteo-onychodysplasia, is a rare autosomal dominant disorder that is characterized by nail and bone abnormalities and, frequently, renal disease. Nail hypoplasia or dysplasia and absent or hypoplastic patellae are features essential for the diagnosis. Other diagnostic signs include deformation or luxation of the head of the radius, resulting in impaired mobility of the elbow, and iliac horns, which are pathognomonic and reported to be present in about 70% of cases [1]. NPS is caused by a loss of function mutation in the transcription factor LMX1B at 9q34. Expansion of the clinical phenotype is supported by the role of LMX1B during development [2,3]. LMX1B is a LIM-homeodomain transcription factor required for the normal development of dorsal limb structure, the glomerular basement membrane, the anterior segment of the eye, and dopaminergic and serotonergic

Clinical experiences of focal periphyseal edema zones in adolescent knees: case reports.

Focal periphyseal edema (FOPE) zones were first described in 2011. The aim of this report was to investigate the clinical course of patients with FOPE zones. Three adolescent patients with a FOPE zone in the knee were treated and observed for a maximum of 2 years. No symptoms or leg-length discrepancy developed at the final follow-up after conservative therapies. This is the first report on the follow-up of FOPE zones with a maximum of 2 years. The results suggest that observation of FOPE zones may be sufficient without invasive examinations and treatment.

Identifying key indicators for the clinical diagnosis of bacille Calmette-Guérin Tokyo-172 strain osteomyelitis: two case reports

Vaccination against tuberculosis (TB) by intracutaneous inoculation with bacille Calmette-Guerin (BCG) is widely used and generally well tolerated [1]. In Japan, the BCG Tokyo-172 substrain is administrated percutaneously by the multipuncture method at approximately 3 months of age in accordance with the national vaccination program guidelines. This vaccine has shown favorable characteristics of good efficacy and rare side reactions [2]. However, we report two cases of BCG Tokyo-172-related osteomyelitis without any underlying immunodeficiency disorders and discuss the key indicators for diagnosing BCG osteomyelitis (BCGO).