[Show abstract][Hide abstract] ABSTRACT: Despite recent advancements in rheumatoid arthritis (RA) pharmacotherapy, surgeons still encounter severely damaged knees. The purpose of the present study was to analyze the mid-term clinical results of total knee arthroplasty (TKA) with metal block augmentation and stem extension.
A total of 26 knees in 21 patients who underwent primary TKA with metal block augmentation and stem extension were retrospectively reviewed. All patients with a mean age of 63 years had RA for a mean duration of 15 years. Functional and radiographic results as well as complications were evaluated at the mean follow-up period of 6 years after TKA. Eight knees were lost follow-up after the two-year evaluation.
Tibial bone defects with average depth of 19 mm were preoperatively recognized in all 26 knees. The postoperative joint line was reconstructed on average 11 mm above the fibular head using average thickness of 11 mm tibial inserts and 9 mm metal blocks with stem extension. Significant improvements (p < 0.05 for all comparisons) were observed postoperatively in maximum extension angle from -10° to -1°, range of motion from 101 ° to 115 °, and Knee Society Score (knee score/function score) from 35/18 to 90/64. Non-progressive radiolucent lines beneath the metal block and osteosclerotic changes around the medullary stem were found in 16 knees (62 %) and 14 knees (54 %), respectively. There was two failures (8 %): fragile supracondylar femur fractures and knee instability. No knees showed any radiographic implant loosening, dislocation, polyethylene insert breakage, peroneal palsy, or infection.
Primary TKA with metal block augmentation and stem extension could effectively restore function in RA patients with advanced forms of knee joint destruction, and be reliable and durable for a mean postoperative period of 6 years. Further study is needed to determine the long-term results of TKA using metal block augmentation and stem extension.
[Show abstract][Hide abstract] ABSTRACT: CCAAT/enhancer-binding protein β (C/EBPβ) is a transcription factor that is activated in the synovium in rheumatoid arthritis (RA) and promotes expression of various matrix metalloproteinases. In this study, we examined whether C/EBPβ mediates the expression of receptor activator of nuclear factor-kappa-B ligand (RANKL) and drives osteoclast formation in primary fibroblast-like synoviocytes (FLS) from RA patients. The cooperation of C/EBPβ and activation transcription factor-4 (ATF4) in the regulation of the RANKL promoter was also investigated.
Immunofluorescence staining was performed for C/EBPβ, RANKL, and ATF4 in synovium from RA patients. Adenovirus expression vectors for two major isoforms, C/EBPβ-liver-enriched activator protein (LAP) and - liver-enriched inhibitory protein (LIP), or small interfering RNA for C/EBPβ, were used to manipulate C/EBPβ expression in RA-FLS. RA-FLS over-expressing C/EBPβ were co-cultured with peripheral blood mononuclear cells (PBMCs) to test osteoclast formation by tartrate-resistant acid phosphatase (TRAP) staining. A promoter assay for RANKL, a chromatin immunoprecipitation (ChIP) assay and an immunoprecipitation (IP) assay were also performed.
Immunofluorescence staining showed colocalization of C/EBPβ, ATF4 and RANKL in RA synovium. Western blotting revealed the expression of C/EBPβ-LAP and -LIP in RA-FLS. Over-expression of either C/EBPβ-LAP or -LIP significantly increased the expression of RANKL mRNA, while C/EBPβ-LIP down-regulated osteoprotegerin (OPG) mRNA. The RANKL/OPG mRNA ratio was significantly increased by C/EBPβ-LIP over-expression. Knockdown of C/EBPβ with siRNA decreased the expression of RANKL mRNA. The number of TRAP-positive multinucleated cells was increased in co-cultures of PBMCs and FLS over-expressing either C/EBPβ-LAP or -LIP, but was more significant with LIP. C/EBPβ-LIP does not have a transactivation domain. However, promoter assays showed that C/EBPβ-LIP and ATF4 synergistically transactivate the RANKL promoter. ChIP and IP assays revealed the cooperative binding of C/EBPβ and ATF4 on the RANKL promoter.
We demonstrated that C/EBPβ, especially C/EBPβ-LIP in cooperation with ATF4, is involved in osteoclast formation by regulating RANKL expression in RA-FLS. These findings suggest that C/EBPβ plays a crucial role in bone destruction in RA joints.
[Show abstract][Hide abstract] ABSTRACT: In patients with degenerative meniscal tears, subclinical cartilage degeneration may be present even if gross morphological changes are not evident. The aim of this study was to detect occult cartilage degeneration using T1ρ MRI mapping in patients with meniscal tears without obvious radiographic osteoarthritis (OA).
A total of 22 subjects with degenerative meniscal tears in the early stages of osteoarthritis [Kellgren-Lawrence (KL) grade of 0-2] and 19 healthy subjects as the control group were examined. The femoral condyle was divided into four 30° wedges (-30°-0° anteriorly, 0°-30°, 30°-60° and 60°-90° posteriorly), and each area of cartilage was further divided into superficial and deep layers of equal thickness. The tibial side was divided into anterior and posterior areas with superficial and deep layers in each. The mean T1ρ values (ms) in each area were calculated.
On the femoral side, T1ρ values of the superficial and deep regions (-30°-0°, 0°-30° and 30°-60°) in the meniscal tear group were significantly higher than those in the control group [superficial (-30°-0°): 49.0 ± 4.0 (meniscal tear group) vs 45.1 ± 2.1 (control group), deep (-30°-0°): 45.2 ± 3.3 vs 39.5 ± 5.0, superficial (0°-30°): 54.5 ± 5.3 vs 47.4 ± 5.7, deep (0°-30°): 46.8 ± 4.0 vs 40.7 ± 6.3, superficial (30°-60°): 50.5 ± 3.1 vs 47.1 ± 5.7]. On the tibial side, the meniscal tear group had significantly higher T1ρ values superficially in both anterior and posterior regions compared with the control group [superficial (anterior): 52.0 ± 4.3 vs 46.7 ± 5.4, superficial (posterior): 53.1 ± 5.1 vs 46.0 ± 4.9]. Moreover, these significant differences were observed when comparing patients in the meniscal tear group with KL grades of 0 or 1 and the control group.
Our study suggested that early biochemical changes in cartilage associated with degenerative meniscal tears occur first in the superficial zones in areas of contact during slight flexion. Characterising the early relationship between cartilage degeneration and degenerative meniscal tears using T1ρ MRI mapping may be of clinical benefit and provide further evidence linking meniscal injury to OA.
[Show abstract][Hide abstract] ABSTRACT: Osteonecrosis of the femoral head is considered to occur early during the course of corticosteroid treatment. However, it remains unclear exactly how early it can develop after initiation of corticosteroid treatment. We report a case of osteonecrosis of the femoral head in which abnormal findings were observed on short-tau inversion recovery (STIR) sequence image performed 2 weeks and 4 days after initiation of high-dose corticosteroid therapy. A 45-year-old man with hemophagocytic syndrome was started on prednisolone, with a maximum dose of 40 mg/day. On day 13 after initiation of this corticosteroid therapy, he transiently experienced left hip pain with no apparent cause. STIR sequence image 5 days after the onset of pain revealed high-intensity bone marrow lesions at the femoral neck of both hips. At 3 months after initiation of corticosteroid therapy, T1-weighted magnetic resonance imaging revealed concave-shaped low-intensity bands, which corresponded to the preceding high-intensity lesions on both hips. Because of the subsequent progression to collapse of the left femoral head, he underwent prosthetic replacement surgery. The high-intensity lesions on STIR sequence image indicate the possibility that osteonecrosis can occur within 3 weeks after initiation of high-dose corticosteroid therapy.
Rheumatology International 08/2015; DOI:10.1007/s00296-015-3346-6 · 1.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Few studies have examined dyslipidemia in patients with rheumatoid arthritis (RA), especially in Japanese cohorts. The aims of this study were to investigate the lipid profiles of RA patients, to assess the relationships between lipid profiles and RA activity and treatment, and to elucidate the effects of HMG-CoA reductase inhibitors (statins) in Japanese patients with RA. A multicenter observational study was conducted in 488 patients with RA. Serum total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) levels, and RA activity as assessed by disease activity score 28 (DAS28), and treatment for RA were analyzed retrospectively. In statin-treated patients, drug efficacy was also analyzed. The prevalence of hyper LDL-C, hyper TG, and hypo HDL-C were 29.3, 24.2, and 10.2 %, respectively, and the overall prevalence of dyslipidemia was 56.5 %. The level of HDL-C was inversely correlated with DAS28. Patients treated with low-dose glucocorticoids showed significantly higher levels of HDL-C and lower TC/HDL-C ratios compared with patients not receiving glucocorticoid treatment. Conversely, patients treated with biologic agents showed significantly higher levels of LDL-C, lower levels of HDL-C, and higher TC/HDL-C ratios. Atorvastatin significantly improved lipid profiles after a few months of treatment. The prevalence of dyslipidemia in Japanese patients with RA is higher than that in the non-RA population. Our result suggests that controlling RA disease activity might improve lipid profiles and eventually lower cardiovascular risk. Low-dose atorvastatin was effective for treatment of dyslipidemia in RA patients but had no apparent effect on RA disease activity.
[Show abstract][Hide abstract] ABSTRACT: Fracture of the femoral stem in total hip arthroplasty (THA) is a rare complication. We have encountered 2 cases of neck fractures of the femoral stem occurring 9 and 12 years after THA. Morphological and biomechanical analysis were performed to investigate the mechanism of these fractures.
A titanium alloy femoral stem having a slot with sharp corners (R = 0.2 mm) at the neck had been implanted in both cases. Fracture surfaces were examined by use of scanning electron microscopy (SEM). Stress concentration was simulated by using a finite element method (FEM) to compare slots with sharp (R = 0.2 mm) and smooth (R = 2 mm) corners.
Study of the retrieved stems revealed that neck fractures had occurred at the distal end of the slot in both cases. SEM revealed numerous fine fissures extending from the anterolateral edge, striations on the middle of the fracture surface, and dimples on the posteromedial surface, suggesting that the fractures had occurred from the anterolateral aspect toward the posteromedial aspect because of metallic fatigue. FEM analysis showed that mechanical stress was concentrated at the distal and anterolateral corners of the slot. Under 3500-N loading force, the stress at the sharp corner was 556 MPa, which was approximately twofold that at the smooth corner and exceeded the fatigue strength of titanium alloy.
These findings showed that the sharp corner of slot increased stress concentrations at the anterolateral aspect and led to the neck fractures.
Journal of Orthopaedic Science 07/2015; DOI:10.1007/s00776-015-0745-1 · 1.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study examined the outcomes of applying transtrochanteric rotational osteotomy (TRO) for posttraumatic osteonecrosis of the femoral head (ON).
We retrospectively reviewed 28 hips in 28 patients (male, n = 17; female n = 11) with a mean age of 34.8 years (12-61 years) at the time of TRO. Transtrochanteric anterior rotational osteotomy (ARO) was used when the lesion was localized on the anterior aspect of the femoral head, and transtrochanteric posterior rotational osteotomy (PRO) was indicated in patients with lesions limited to the posterior aspect of the femoral head. The mean follow-up period was 12.3 years (5.0-21.3 years). We investigated the patients' clinical and radiological factors, including age, sex, body mass index, preoperative Harris Hip Score (HHS), type of antecedent trauma, preoperative stage, and postoperative intact ratio (the ratio of the intact articular surface of the femoral head to the weight-bearing surface of the acetabulum). We divided the patients into a hip-survival group and a conversion-to-total hip arthroplasty (THA) group and then compared these factors between the two groups.
At the final follow-up, 22 hips had survived with a mean HHS of 85.8. The remaining six hips underwent THA at a mean of 10.2 years after TRO. The preoperative stage was correlated with hip survival. Furthermore, the postoperative intact ratio was significantly lower in the conversion-to-THA group. Based on the receiver operating characteristic curve, a ratio of less than 33.6 % was found to be associated with the need to convert to THA.
TRO to correct posttraumatic ON resulted in favorable midterm results. The possible risk factors for conversion to THA were an advanced preoperative stage and a postoperative intact ratio of less than 33.6 %.
Archives of Orthopaedic and Trauma Surgery 07/2015; DOI:10.1007/s00402-015-2282-y · 1.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Subchondral insufficiency fracture of the femoral head may be confused with osteonecrosis, mainly because of radiological overlap. SPECT/CT with Tc-99 m hydroxymethylene diphosphonate images in 7 patients with subchondral insufficiency fracture were retrospectively reviewed and compared with those from 11 patients with symptomatic early osteonecrosis. In all of the hips with subchondral insufficiency fracture, SPECT/CT showed increased uptake at the subchondral lesions of the femoral head. On the other hand, in all of the hips with osteonecrosis, absence of uptake was confirmed at the subchondral lesions. SPECT/CT may assist in differentiating subchondral insufficiency fracture from osteonecrosis.
Clinical nuclear medicine 07/2015; DOI:10.1097/RLU.0000000000000886 · 2.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Ewing sarcoma (ES) is a small round-cell tumor of the bones and soft tissues. ES frequently causes distant metastases, particularly in the lung and bone, which worsens patient prognosis. Cadherin-11 (Cad-11) is an adhesion molecule that is highly expressed in osteoblasts. Its expression is associated with bone metastases in prostate and breast cancer patients, and is known to occur in ES. Here we investigated the effects of Cad-11 on bone metastases of ES. Human ES cell lines RD-ES, SK-ES-1, SK-N-MC, and TC-71 cells were transduced with lentivirus containing Cad-11 shRNA or control shRNA (ES/Cad-11 and ES/Ctr). RD-ES and TC-71 were infected with a lentivirus luciferase vector. Adhesion assays were performed using these cells and recombinant Cad-11-Fc chimera or mouse osteoblast cell line MC3T3-E1. Cell motility was investigated via wound-healing assay. Intracardiac injection of RD-ES/Cad-11 and RD-ES/Ctr was used to create a mouse model of experimental bone metastasis. The association between Cad-11 expression and bone metastases and clinical prognosis in ES patients was analyzed by immunohistochemistry. We found knockdown of Cad-11 in ES cells resulted in reduced attachment ability and cell motility. In a mouse model of metastasis, RD-ES/Cad-11 cells caused fewer metastases than RD-ES/Ctr cells. The expression of Cad-11 in ES patients was significantly related to bone metastases (P < 0.05, logistic regression) and poorer overall survival (P < 0.05, log-rank test). These findings may explain that Cad-11 in ES cells may be essential for cell adhesion and motility, and is a promising molecular target for patients with ES.
Clinical and Experimental Metastasis 06/2015; DOI:10.1007/s10585-015-9729-y · 3.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A 37-year-old female had been treated with corticosteroids for systemic lupus erythematosus clinically diagnosed at age 10. She suddenly had right hip pain without any antecedent trauma. Four months after the onset of pain, she visited her primary care physician. On magnetic resonance imaging, joint space narrowing at the weight-bearing area was already seen with bone marrow edematous lesions in both the femoral head and acetabulum. She was treated non-operatively; however, her pain continued to worsen in severity. Thirteen months after the onset of pain, she was referred to our hospital. A plain radiograph showed subluxation of the collapsed femoral head accompanied by destruction of the acetabular rim. Because of her severe intractable pain, she underwent total hip arthroplasty 1 month after her first visit. Histological examination of the resected femoral head revealed pseudogranulomatous lesions along with prominent callus formation, suggesting rapid destruction of the femoral head.
Rheumatology International 06/2015; DOI:10.1007/s00296-015-3304-3 · 1.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We aimed to clarify the distance between the anteromedial (AM) bundle and posterolateral (PL) bundle tunnel-aperture centers by simulating the anatomical femoral tunnel placement during double-bundle anterior cruciate ligament reconstruction using 3-D computer-aided design models of the knee, in order to discuss the risk of tunnel overlap. Relationships between the AM to PL center distance, body height, and sex difference were also analyzed.
The positions of the AM and PL tunnel centers were defined based on previous studies using the quadrant method, and were superimposed anatomically onto the 3-D computer-aided design knee models from 68 intact femurs. The distance between the tunnel centers was measured using the 3-D DICOM software package. The correlation between the AM-PL distance and the subject's body height was assessed, and a cutoff height value for a higher risk of overlap of the AM and PL tunnel apertures was identified.
The distance between the AM and PL centers was 10.2±0.6 mm in males and 9.4±0.5 mm in females (P<0.01). The AM-PL center distance demonstrated good correlation with body height in both males (r=0.66, P<0.01) and females (r=0.63, P<0.01). When 9 mm was defined as the critical distance between the tunnel centers to preserve a 2 mm bony bridge between the two tunnels, the cutoff value was calculated to be a height of 160 cm in males and 155 cm in females.
When AM and PL tunnels were placed anatomically in simulated double-bundle anterior cruciate ligament reconstruction, the distance between the two tunnel centers showed a strong positive correlation with body height. In cases with relatively short stature, the AM and PL tunnel apertures are considered to be at a higher risk of overlap when surgeons choose the double-bundle technique.
Open Access Journal of Sports Medicine 06/2015; 6:219-24. DOI:10.2147/OAJSM.S80809
[Show abstract][Hide abstract] ABSTRACT: Background Combined anteversion is the sum of femoral and acetabular anteversion and represents their morphological relationship in the axial plane. Few studies have investigated the native combined anteversion in patients with symptomatic dysplastic hips. Questions/purposes We hypothesized the following: (1) dysplastic hips have two distinct populations, which differ from each other and from normal hips in their combined anteversion; and (2) these populations differ clinically in terms of correlation between age of onset of symptoms and amount of anteversion. Methods We measured radiographic parameters by CT of 100 dysplastic hips in 76 patients who were symptomatic enough to undergo periacetabular osteotomy and of 50 normal hips in 44 patients who had CT scans as part of preparation for computer-navigated TKAs; these patients had no visible hip arthritis or dysplasia and no hip symptoms. Dysplastic hips were divided into the anteversion (83 hips) and retroversion groups (17 hips) based on acetabular version. Age at pain onset was determined from their medical charts. Results Combined anteversion in the anteversion group was greater than that in the retroversion and control groups: 47° ± 12°, 30° ± 16°, and 36° ± 9°, respectively. In the anteversion group, combined anteversion (r = −0.49; 95% confidence interval [CI], −0.66 to −0.27; p Conclusions These results suggest that not only lateral coverage of the femoral head, but also axial joint morphology is important for the development of pain in the anteversion group. Optimal combined anteversion should be considered during periacetabular osteotomy. Level of Evidence Level IV, prognostic study.
Clinical Orthopaedics and Related Research 05/2015; DOI:10.1007/s11999-015-4373-z · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Patients with anterior cruciate ligament (ACL)-injured knees are at an increased risk of posttraumatic osteoarthritis (OA). OA changes secondary to ACL injuries have many variations, and when and where early cartilage degenerative change begins has not yet been established.