Tsuyoshi Nakai

Cyclic therapy with etidronate has a therapeutic effect against local osteoporosis after cementless total hip arthroplasty

Proximal bone resorption around the femoral stem is one of the major complications of cementless total hip arthroplasty (THA). The potential complications resulting from proximal bone resorption include femoral fracture and late stem loosening. The purpose of this study was to evaluate the effects of cyclic therapy with etidronate on periprosthetic bone mineral density (BMD) after cementless THA. Fifty-two patients who had undergone cementless THA were randomized for this study. Group A consisted of 30 hips in 29 patients without osteoactive drugs. Group B consisted of 23 hips in 23 patients with cyclic therapy with etidronate (i.e., 400 mg/day of oral etidronate for 2 weeks followed by 12 weeks of 500 mg/day of calcium lactate and repeated every 14 weeks), one of whom was excluded from the study because of side effects attributed to the drug. Periprosthetic BMD in seven regions of interest based on the zones of Gruen et al. (Clin. Orthop. 141 (1979), 17-27) was measured with dual energy X-ray absorptiometry (DXA) at 3 weeks, 6 months, and 12 months postoperatively. The postoperative decreases of BMD in group B were significantly lower than those in group A in zones 1 and 7 (P < 0.05 and P < 0.05, respectively) at 6 months and in zones 1, 2, 6, and 7 (P < 0.05, P < 0.05, P < 0.05, and P < 0.001, respectively) at 12 months. The BMD change appeared to be stabilized at 6 months in all zones in group B, while in group A there was a progressive decrease of average BMD (6.1%) in zone 7 between 6 months and 12 months. These findings suggested that cyclic therapy with etidronate may help to reduce the resorptive changes in the proximal part of the femur after cementless THA. Further follow-up study with larger populations will be required to define the potential efficacy of intermittent cyclic etidronate therapy on postoperative bone loss.

Therapeutic effect of transtrochanteric rotational osteotomy and hip arthroplasty on quality of life of patients with osteonecrosis

Abstract We reviewed 37 patients with avascular necrosis of the femoral head (ANF). There were 23 men and 14 women with a mean age of 36 years at the time of the operation. The duration of follow-up was 9 years. Twenty patients had undergone transtrochanteric rotational osteotomy (TRO) and 17, hip arthroplasties. Assessment of their quality of life (QoL) was performed using the Rosser Index Matrix for disability and distress. Concerning TRO, the mean preoperative and postoperative QoL scores were 0.944 and 0.957, respectively. Twelve patients exhibited increases and 7 patients decreases in their scores. Regarding the arthroplasty, the mean preoperative and postoperative QoL scores were 0.949 and 0.998, respectively. All patients showed increases in QoL scores after arthroplastic surgery. Concerning heavy manual work, all five of those patients returned to their preoperative occupations. These findings suggest that hip arthroplasty has more reliable therapeutic effects than TRO on QoL improvement for patients with ANF.

Predictive Value of a Preoperative Biochemical Bone Marker in Relation to Bone Remodeling After Cementless Total Hip Arthroplasty

To identify the factors predicting proximal bone resorption of the femur after cementless total hip arthroplasty (THA), we studied 24 postmenopausal women with osteoarthritis. Periprosthetic bone mineral density (BMD) measurements of the seven Gruen zones were determined with dual-energy X-ray absorptiometry at 3 wk, 6, 12, and 18 mo after operation. The greatest decrease in BMD (13.2%) was found in zone 7 at 18 mo. At 18 mo, preoperative serum bone alkaline phosphatase was associated univariately with BMD loss in zones 1 (r = 0.407, p = 0.048) and 7 (r = 0.543, p = 0.006) and urinary N-telopeptide cross-linked collagen type I (NTX) was associated univariately with that in zone 7 (r = 0.520, p = 0.009). Patient age correlated with BMD loss in zone 7 (r = 0.425, p = 0.039). Multiple regression analysis identified a significant relationship between the BMD loss and patient age and NTX in zone 7 at 18 mo (r2 = 0.422, p = 0.001). We conclude that preoperative bone markers are significant predictors of bone remodeling after THA with the particular implants used in our study.

Painful nonunion of fracture of the entire posterior process of the talus: a case report

We report a 14-year-old boy in whom isolated nonunion fracture of the posterior process of the talus. He underwent surgical repair with Herbert Whipple screw fixation and plaster immobilization. Osseous union was achieved 3xa0months after surgery, resulting in the resolution of symptoms and complete functional recovery. To our knowledge, the present report is the first to describe a successful outcome for surgical treatment of painful nonunion of fracture of the entire posterior process of the talus.

Pathology of femoral head collapse following transtrochanteric rotational osteotomy for osteonecrosis.

Abstract We investigated the pathology of femoral head collapse following transtrochanteric anterior rotational osteotomy. Six femoral heads were obtained during total hip arthroplasty some 2–12 years after osteotomy. In all cases, the preoperatively necrotic lesions exhibited mostly osteonecrosis with accumulation of bone marrow cell debris and trabecular bone with empty lacunae, although repair tissue such as granulation tissue and appositional bone formation were observed in limited areas in some cases. In the transposed intact articular surface of the femoral head, osteoarthritic changes such as fissure penetration to the subchondral bone and osteophyte formation were commonly observed. In newly created subchondral areas at weight-bearing sites, trabecular thickness and the number of trabecular bones had decreased, with few osteoblasts, osteoclasts, and osteocytes being present, resulting in a coarse lamellar structure of the trabecular bone. These findings suggest that transposed areas in cases of failure consist mostly of low-turnover osteoporotic lesions which could cause collapse of the femoral head.

Scintigraphic assessment of the rotated femoral head after transtrochanteric rotational osteotomy for osteonecrosis.

Background: The purpose of this study was to assess the usefulness of bone scintigraphy in predicting progressive collapse of the femoral head after transtrochanteric rotational osteotomy for the treatment of osteonecrosis of the femoral head. Methods: We studied thirty-three hips in thirty patients with osteonecrosis of the femoral head who had undergone transtrochanteric rotational osteotomy. There were twenty male and ten female patients, with a mean age of 34.4 years at the time of the operation. The mean duration of follow-up was 10.0 years. According to the staging system of Ficat and Arlet, there were nineteen stage-2 hips and fourteen stage-3 hips at the time of the operation. Conventional anteroposterior and lateral radiographs were assessed. In addition, bone scans were performed at three weeks after the operation to predict the outcome with regard to the rotated femoral head. On the basis of the location of low scan activity within the femoral head, the scintigraphic findings were classified into one of two categories: type A if there was no low scan activity in the weight-bearing area of the femoral head or type B if low scan activity occupied the entire weight-bearing area. Six hips with collapse were studied histologically. Results: Postoperative scintiscans revealed sixteen type-A hips and seventeen type-B hips. Of the type-A hips, only three exhibited progressive collapse of the femoral head after the osteotomy, whereas fourteen of the type-B hips exhibited progressive collapse. A significant association was found between the postoperative scintigraphic findings and the final radiographic result (p < 0.01). Conclusions: Bone scintiscans made three weeks after transtrochanteric rotational osteotomy were useful for predicting the final clinical result.

Early complications of primary total hip arthroplasty in the supine position with a modified Watson-Jones anterolateral approach

BACKGROUNDnFor total hip arthroplasty (THA), minimally invasive surgery (MIS) has been developed to reduce incision length, muscle damage, and a shorter hospital stay. However, reduced exposure of anatomical landmarks may result in technical errors and inferior implant survivorships. The aim of this study was to report the short-term results and clinical complications of primary MIS THA in the supine position.nnnMETHODSnA consecutive series of 103 patients who underwent MIS cementless THA with a modified Watson-Jones anterolateral approach (AL) were enrolled. Outcomes data were reviewed at a minimum of 12 months following the procedure. Clinical evaluations were made using the Merle dAubigne and Postel hip score. The results of these procedures were retrospectively compared with those of a historical series of 98 total hip arthroplasties that had been performed by the same surgeon with use of a posterolateral approach (PL).nnnRESULTSnIn the MIS AL THA group, intraoperative fracture was observed in 6 hips; 3 in greater trochanter and 3 in calcar femoral. One hip was subjected to irrigation because of postoperative infection was suspected. In the PL group, intraoperative fracture was demonstrated in 4 hips in calcar femoral. No postoperative dislocation and no pulmonary embolism or nerve paralysis was observed in both groups.nnnCONCLUSIONSnThe MIS AL THA did not show a clinically relevant superior outcome compared with the PL THA. When performing MIS AL THA, special attention should pay for prevention of greater trochanter fracture.

Hip arthropathy associated with hemodialysis

Abstract There were 56 consecutive patients enrolled in our study from the outpatient clinic of our institution, mean age of 59 years, who had been on hemodialysis for 2–26 years. The duration of hemodialysis was less than 10 years for 36 patients (short-term group) and 10 years or more for 20 patients (long-term group) with a mean duration of 11 years at time of the investigation. In the short-term group, plain radiography revealed bone cysts in 9 hips (17%) and joint space narrowing in 10 hips (19%), while in the long-term group, there were bone cysts in 19 hips (48%) and joint space narrowing in 6 hips (15%). Bone mineral density as determined by dual-energy X-ray absorptiometry was 0.621 g/cm2 for patients in the short-term group and 0.503 g/cm2 for patients in the long-term group. Hip arthroplasties were performed in 3 patients suffering from femoral neck fracture due to bone cysts. All of them showed marked bone loss (mean 0.380 g/ cm2). In conclusion, plain radiography and dual-energy X-ray absorptiometry are useful for evaluating the hip arthropathy of hemodialysis patients, especially those who have undergone long-term hemodialysis.

Total hip arthroplasty via an anterolateral supine approach for obese patients increases the risk of greater trochanteric fracture

PurposenThe aim of this study was to evaluate the outcomes and early complications of obese patients who underwent total hip arthroplasty for osteoarthritis via an anterolateral approach in the supine position (ALS-THA) and compare these outcome with of a matched control group of non-obese patients.nnnPatients and methodsnThirty-one hips in 28 patients with obesity (BMIu202f≧u202f30u202fkg/m2) were included in this study. As a control group, 31 hips of 31 patients with a normal weight (BMI between 20 and 25u202fkg/m2) were matched based on age, sex, and laterality. Clinical evaluations using the Merle dAubigne and Postel hip score, radiological evaluations and perioperative complications were compared in two groups.nnnResultsnThere were no significant differences between the groups in the operative time, period of hospitalization, clinical hip score, or cup positioning, although the position of the cup tended to deviate from the optimal safe zone in the obese compared with non-obese group (32.3 and 16.1%, respectively). There was no infection, dislocation, nerve palsy, or life-threatening event in either group. The rate of avulsion fractures of the greater trochanter in the obese group was 3 times higher compared to that in the non-obese group.nnnConclusionsnAs the clinical outcome of ALS-THA for the obese group is not inferior to that for the non-obese group, obesity is not considered to be a contraindication for ALS-THA. However, obesity increases the risk of intraoperative greater trochanteric fracture. Thus, surgeons should be particularly careful when manipulating the femur in this class of patients, who should be informed of this risk.