Yasuhiro Homma

Cancer Risk Is Not Increased in Patients Treated for Orthopaedic Diseases with Autologous Bone Marrow Cell Concentrate

BACKGROUND There is concern that regenerative cell-based therapies could result in increased risk of tumor formation. We investigated the long-term risks for systemic and site-specific cancers in patients who had received autologous bone marrow-derived stromal progenitor cells to treat orthopaedic lesions. METHODS A total of 1873 patients were treated from 1990 to 2006 with bone marrow-derived concentrated cells. Patients were monitored for cancer incidence from the date of the first operation (1990) until death, or until December 31, 2011. The mean follow-up time was 12.5 years (range, five to twenty-two years). The average number of colony-forming unit fibroblasts returned to the patients was 483,000 fibroblasts (range, 62,000 to 2,095,000 fibroblasts). The primary outcome was to evaluate with radiographs and/or magnetic resonance imaging the risk of tumorigenesis at the cell therapy treatment sites. The secondary outcome was to evaluate the risk of cancer diagnosed in areas other than the treatment site during the follow-up period. The relative risk of cancer was expressed as the ratio of observed and expected number of cases, that is, the standardized incidence ratio, according to the cancer incidence in the French population. RESULTS No tumor formation was found at the treatment sites on the 7306 magnetic resonance images and 52,430 radiographs among the 1873 patients. Fifty-three cancers were diagnosed in areas other than the treatment site. On the basis of cancer incidence in the general population during the same period, the expected number of cancers was between ninety-seven and 108 for the same age and sex distribution. The range of the standardized incidence ratio for the follow-up period was between 0.49 and 0.54 (95% confidence interval, 0.30 to 0.80). CONCLUSIONS This study found no increased cancer risk in patients after application of autologous cell-based therapy using bone marrow-derived stromal progenitor cells either at the treatment site or elsewhere in the patients after an average follow-up period of 12.5 years.

Cellular therapies for the treatment of non-union: The past, present and future

Non-union fracture is a pathological condition having some impairment of the cellular part of the repair: a reduction of MSC and of the osteoblastic activation. Non union is therefore a good indication for cell-based therapies using stem cells. We described the rational of this treatment and described the technique of autologous bone marrow concentrate implantation that was until now used. With the development of stem cell research and regenerative medicine, we believed that therapy based on cytotherapy has great potential. In this review, clinical applications of cytotherapy are summarized and analyzed. Current problems and future challenges are discussed.

Does primary or secondary chondrocalcinosis influence long-term survivorship of unicompartmental arthroplasty?

BackgroundCoexistence of degenerative arthritis and calcium pyrophosphate dihydrate (CPPD) crystals (or radiological chondrocalcinosis) with osteoarthritis (OA) of the knees is frequent at the time of arthroplasty. Several studies suggest more rapid clinical and radiographic progression with CPPD than with OA alone. However, it is unclear whether chondrocalcinosis predisposes to higher risks of progression of arthritis in other compartments.Question/purposesWe questioned whether chondrocalcinosis influences clinical scores, degeneration of other compartments, rupture of the ACL, survivorship, reason for revision, or timing of failures in case of UKA.MethodsWe retrospectively reviewed 206 patients (234 knees) who had UKAs between 1990 and 2000. Of these 234 knees, 85 had chondrocalcinosis at the time of surgery and 63 of the knees subsequently had radiographic evidence of chondrocalcinosis observed during followup. We evaluated patients with The Knee Society rating system and compared function and radiographic progression in the other compartments of patients without and with chondrocalcinosis.ResultsThe use of conventional NSAIDs, radiographic progression of OA in the opposite femorotibial compartment of the knee, failure of the ACL, and aseptic loosening did not occur more frequently among patients with chondrocalcinosis. The 15-year cumulative survival rates were 90% and 87% for the knees without and with chondrocalcinosis, respectively, using revision to TKA as the end point.ConclusionOur findings show chondrocalcinosis does not influence progression and therefore is not a contraindication to UKA.Level of EvidenceLevel II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Autologous bone marrow stromal cells are promising candidates for cell therapy approaches to treat bone degeneration in sickle cell disease

Osteonecrosis of the femoral head is a frequent complication in adult patients with sickle cell disease (SCD). To delay hip arthroplasty, core decompression combined with concentrated total bone marrow (BM) treatment is currently performed in the early stages of the osteonecrosis. Cell therapy efficacy depends on the quantity of implanted BM stromal cells. For this reason, expanded bone marrow stromal cells (BMSCs, also known as bone marrow derived mesenchymal stem cells) can be used to improve osteonecrosis treatment in SCD patients. In this study, we quantitatively and qualitatively evaluated the function of BMSCs isolated from a large number of SCD patients with osteonecrosis (SCD-ON) compared with control groups (patients with osteonecrosis not related to SCD (ON) and normal donors (N)). BM total nuclear cells and colony-forming efficiency values (CFE) were significantly higher in SCD-ON patients than in age and sex-matched controls. The BMSCs from SCD-ON patients were similar to BMSCs from the control groups in terms of their phenotypic and functional properties. SCD-ON patients have a higher frequency of BMSCs that retain their bone regeneration potential. Our findings suggest that BMSCs isolated from SCD-ON patients can be used clinically in cell therapy approaches. This work provides important preclinical data that is necessary for the clinical application of expanded BMSCs in advanced therapies and medical products.

Spontaneous healing of lateral femoral cutaneous nerve injury and improved quality of life after total hip arthroplasty via a direct anterior approach: Survey at average 12.8 and 26.2 months of follow-up

Purpose: How the symptomatology of lateral femoral cutaneous nerve (LFCN) injury changes after total hip arthroplasty (THA) via direct anterior approach (DAA) is not known. Our hypothesis was that the symptoms of LFCN injury after THA via DAA in longer follow-up periods would resolve spontaneously, leading to an improved quality of life (QOL). The aims of this study were to investigate how the symptom LFCN injury changed after DAA–THA, and how those changes affected QOL. Methods: We investigated the incidence of LFCN injury after DAA–THA using self-reported questionnaires at two time points (initial survey: August 2014, present survey: August 2015). QOL was assessed by the Western Ontario and McMaster Universities Osteoarthritis Index, the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, and the Forgotten Joint Score-12 (FJS-12). Types (dysesthesia or hypesthesia) and changes of the symptom were surveyed. Results: About 122 hips at average12.8 months postoperatively (initial survey), and of those, 89 hips at average 26.2 months postoperatively (present survey) were analyzed. The incidence of LFCN injury decreased significantly, from 31.9% to 11.2% (p < 0.001). Spontaneous improvement of symptoms was seen in 96%. The difference of FJS-12 between patients with and without LFCN injury at the initial survey disappeared at the present survey. The dysesthesia group showed significant correlations between rate of improvement in LFCN injury and increase of QOL. Conclusion: Most symptoms of LFCN injury resolved spontaneously with longer follow-up periods. In particular, improvement of dysesthesia as a symptom of LFCN injury was associated with better QOL.

New classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line for intertrochanteric fractures

PURPOSE There are various types of intertrochanteric fractures that are unstable pertrochanteric fractures of the hip. The aim of this study was to develop a systematic and comprehensive classification of intertrochanteric fractures. MATERIALS AND METHODS This study enrolled 74 patients with intertrochanteric fractures treated by us between 2012 and 2015. The fractures were classified using 3D-CT images taken immediately after the fractures occurred based on the course of the lateral fracture line (LFL) that extends through the lateral femoral cortex distal to the vastus ridge of the greater trochanter in the intertrochanteric area. Furthermore, the presence or absence of additional typical fractures was also studied. Then, 4 orthopedic specialists examined the 3D-CT images of 20 patients randomly selected from the 74 patients to evaluate both the inter-rater and intra-rater agreement levels. RESULTS Intertrochanteric fractures were classified into three types according to the LFL patterns. Type I (41.9%), the Lateral Wall Pattern, has a LFL that extends towards the lateral fiber bundle attachment area of the iliofemoral ligament. Type II (24.3%), the Transverse Pattern, has a LFL that extends towards the medial bundle attachment area. Type III (33.8%), the Reverse Oblique Pattern, has a LFL that extends between the lateral and medial fiber bundle area of the iliofemoral ligament. Each type showed characteristic displacement and was associated with various combinations of typical fractures (fracture across the intertrochanteric line, posteromedial fragment, including the lesser trochanter, posterolateral fragment posterior to the femoral greater trochanter, and banana-shaped big fragment, including both the greater trochanter and the lesser trochanter). The mean κ values for the interobserver and intraobserver agreement levels were 0.77 (0.70-0.85) and 0.76 (0.70-0.85), respectively, which were considered substantial agreement levels. CONCLUSION We believe our new classification is a useful communication tool for medical professionals in the diagnosis of fractures.

Enlarged transacromial superior approach with reverse shoulder arthroplasty for fractures

The authors describe a step-by-step technique for reverse total shoulder arthroplasty using arthrotomy via the enlarged transacromial superior approach. This technique seems ideal for reinsertion of the tuberosities and to ensure adequate postoperative tensional balance of the infraspinatus and the subscapularis, which is critical for the rotator cuffs to function properly and to achieve optimal arthroplasty stability. Reviewing these different steps helps understanding each rotator cuff individual components contribution to achieve optimal arthroplasty stability and external rotation with a reverse shoulder arthroplasty.

Kerboull-type plate in a direct anterior approach for severe bone defects at primary total hip arthroplasty: technical note

Introduction: For cases with extensive acetabular bone defects, we perform surgery combining the Kerboull-type (KT) plate and bone graft through direct anterior approach (DAA) in primary total hip arthroplasty (THA) requiring acetabular reconstruction as minimally invasive surgery. This paper provides the details of the surgical procedure. Methods: The basic structure of the Kerboull-type plate is a cruciform plate. Since the hook of the Kerboull-type plate has to be applied to the tear drop, a space for it was exposed. The tear drop is located in the anterior lower region in surgery through DAA in supine position. It was also confirmed by fluoroscopy as needed. The bone grafting was performed using an auto- or allogeneic femoral head for bone defects in the weight-bearing region of the hip joint. Results: Of 563 patients who underwent primary THA between 2012 and 2014, THA using the KT plate through DAA was performed in 21 patients (3.7%). The mean duration of postoperative follow-up was 31.8 months. The mean operative time was 188.4 min, and the mean blood loss was 770 g. The patients became able to walk independently after 2.4 days on average (1–4 days). On clinical evaluation, the modified Harris Hip Score was 45.6 ± 12.4 before surgery, and it was significantly improved to 85.3 ± 8.97 on the final follow-up. Discussion: DAA is a true intermuscular approach capable of conserving soft tissue. Since it is applied in a supine position, fluoroscopy can be readily used, and it was very useful to accurately place the plate.

Rapid hip osteoarthritis development in a patient with anterior acetabular cyst with sagittal alignment change.

Rapidly destructive coxarthrosis (RDC) is rare and develops unusual clinical course. Recent studies suggest multiple possible mechanisms of the development of RDC. However the exact mechanism of RDC is still not clear. The difficulty of the study on RDC is attributed to its rareness and the fact that the data before the onset of RDC is normally unavailable. In this report, we presented the patient having the radiographic data before the onset who had rapid osteoarthritis (OA) development after contralateral THA, which meets the current criteria of RDC. We thought that the increased posterior tilt of the pelvis after THA reinforced the stress concentration at pre-existed anterior acetabular cyst, thereby the destruction of the cyst was occurred. As a result the rapid OA was developed. We think that there is the case of rapid osteoarthritis developing due to alternating load concentration by posterior pelvic tilt on preexisting anterior acetabular cyst such as our patient among the cases diagnosed as RDC without any identifiable etiology. The recognition of sagittal alignment changes and anterior acetabular cyst may play important role in prediction and prevention of the rapid hip osteoarthritis development similar to RDC.

Septic arthritis of the hip in adults with sickle cell anemia

Although the presence of osteonecrotic bone is known to make joints more prone to infection, acute septic joint in hip osteonecrosis has not frequently been reported in adults with sickle cell disease. The clinical features at the time of admission, imaging findings suggesting the diagnosis, modes of treatment and sequelae of septic arthritis of twenty-four hip joints with osteonecrosis in patients with sickle cell disease were studied retrospectively over a 25-years period. This study evaluated also the complications, the efficiency and the risk of total hip arthroplasty in these patients. Most patients were in the third decade of life. Staphylococcus and Gram negative infection predominated. Treatment was first conservative but most of the patients needed surgery to treat infection and sequelae related to infection. A total hip arthroplasty was performed later in twenty joints. No deaths were observed, but complications occurred. Twenty of the patients in our study underwent delayed total hip arthroplasties following repeated aspirations of the joint and intravenous antibiotics. With an experienced surgical and medical team and multidisciplinary management of these patients undergoing total hip arthroplasty after hip infection, our rate of complications was acceptable.