Comparative Study for Postoperative Initial Fixation Patterns of Two Different Types of Cementless Short Stem Using Three-Dimensional Templating Software

Background

While cementless short stems have become popular in total hip arthroplasty (THA), Metha is a relatively recent development that differs from other short stems in its initial fixation concept of partial collum-sparing metaphyseal anchorage. The purpose of this study was to quantify the contact state between Metha and the femur. Additionally, we investigated the difference in contact points between Meta and Fitmore, which is one of the more popular curved short stems.

Methods

We conducted a retrospective review of 42 hips that underwent THA using Metha and 41 hips using Fitmore. Stem-to-femur contact was evaluated by density mapping using a three-dimensional digital template system to quantify the contact condition according to the modified Gruen zone. The criterion for the stem-to-bone contact boundary was defined as a computed tomography value of 543 Hounsfield.

Results

Quantitative evaluation of Metha according to the modified Gruen zones showed the ratio of surface area with high cortical contact in each zone. The results were 4.6% ± 5.7% in zone 1, 0.9% ± 2.3% in zone 2, 19.1% ± 12.9% in zone 3, 1.4% ± 3.2% in zone 5, 29.6% ± 16.4% in zone 6, and 25.1% ± 17.7% in zones 7. Evaluation of Fitmore for the same zones was as follows: 1.6% ± 2.4%, 18.5% ± 16.9%, 20.8% ± 17.4%, 12.7% ± 12.8%, 3.7% ± 5.8%, and 13.3% ± 10.3%. Comparing the two groups, the contact area was significantly greater for Metha in zones 1, 6 and 7 and Fitmore in zones 2 and 5 (p < 0.05).

Conclusions

It is possible for Metha to achieve metaphyseal anchoring by contacting the cortical bone at the proximal femur, thus avoiding proximal offloading. To the best of our knowledge, no previous studies have quantitatively reported stem-to-cortical bone contact conditions in curved short stems.

Efficacy of Anterior Quadratus Lumborum Block and Pain After Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Anterior quadratus lumborum block (AQLB) is one of the compartment blocks and has recently attracted attention as a new method of analgesia for postoperative hip surgery analgesia. This study aimed to compare the analgesic efficacy of AQLB in patients undergoing primary total hip arthroplasty (THA).

METHODS

There were 120 patients undergoing primary THA under general anesthesia randomly allocated to receive a femoral nerve block (FNB) or an AQLB. The primary outcome was total morphine consumption over the initial 24-hour postoperative period. Secondary outcomes included the pain score evaluation while at rest and during active and passive motion over the 2 days following surgery and the manual muscle testing of the quadriceps femoris. The numerical rating scale (NRS) score was used for evaluating the postoperative pain score.

RESULTS

There were no significant differences between the 2 groups concerning morphine consumption within 24 hours after surgery (P = .72). The NRS score at rest and passive motion were similar at all-time points (P > .05). However, there was a statistically significant difference in pain reported during the active motion for the FNB group compared to the AQLB (P = .04). No significant differences were found between the 2 groups concerning muscle weakness incidence.

CONCLUSION

Both AQLB and FNB demonstrated adequate efficacy for postoperative analgesia at rest in THA. However, based on our study, whether AQLB is inferior or noninferior to FNB as an analgesic method for THA was inconclusive.

Difficult Preoperative Diagnosis of Suspected Metal Hypersensitivity in a Case with Early Failure of Bipolar Hemiarthroplasty

Background

Metal hypersensitivity is a rare complication after total hip arthroplasty (THA), and no reliable diagnostic method for metal hypersensitivity to orthopedic metal implants has yet been established. Case report. A 57-year-old woman underwent hemiarthroplasty using a metal implant despite a skin allergy to metal jewelry. Two years after surgery, the patient developed early hemiarthroplasty failure and refractory erythema. Although the patient was clinically suspected to have a hypersensitivity to metal, the preoperative screening test was negative, and patient underwent revision surgery with cemented THA. Postoperatively, the erythema as well as her hip pain disappeared completely.

Conclusion

Patients with clinically suspected metal hypersensitivity should undergo primary and revision total hip arthroplasty using hypoallergenic implants regardless of preoperative screening results.

Long term results of the Bicontact D stem in dysplastic osteoarthritis: a 10-15 year follow-up study

PURPOSE

The purpose of the present study was to investigate the results of total hip arthroplasty (THA) using the Bicontact D stem with a minimum 10 year follow-up that focused on patients with developmental dysplasia of the hip (DDH).

METHODS

One hundred five patients with osteoarthritis due to DDH who underwent primary THA were included in this study. The mean final follow-up period was 12.7 ± 1.2 years (range 10-15 years). All cases were evaluated both clinically and radiographically, and Kaplan-Meier survivorship was determined as stem revision for any reason as the end point.

RESULTS

Modified Harris hip score averaged 89.0 ± 1.1 (range 60-98) at the final follow-up. The survivorship was 99.0% (95% confidence interval 93.4-99.9%) at 15.0 years, and only one hip with a well-fixed stem required stem revision due to recurrent dislocations. Cortical hypertrophy (CH) was observed in 40 of 105 hips (38.1%), and stress shielding (SS) progressed to grade 3 or 4 in six hips (6 of 105 hips: 5.7%) during the study period. Among the six hips with progressed SS, Dorr type C proximal femoral geometry was seen in five hips.

CONCLUSION

This study of 105 THAs using the Bicontact D stem that focused on DDH patients with a minimum 10 year follow-up period achieved satisfactory clinical and radiological outcomes. Dorr type C proximal femoral geometry could be considered a risk factor for progressed SS.

Atezolizumab plus bevacizumab versus lenvatinib or sorafenib in non-viral unresectable hepatocellular carcinoma: an international propensity score matching analysis

BACKGROUND

A growing body of evidence suggests that non-viral hepatocellular carcinoma (HCC) might benefit less from immunotherapy.

MATERIALS AND METHODS

We carried out a retrospective analysis of prospectively collected data from consecutive patients with non-viral advanced HCC, treated with atezolizumab plus bevacizumab, lenvatinib, or sorafenib, in 36 centers in 4 countries (Italy, Japan, Republic of Korea, and UK). The primary endpoint was overall survival (OS) with atezolizumab plus bevacizumab versus lenvatinib. Secondary endpoints were progression-free survival (PFS) with atezolizumab plus bevacizumab versus lenvatinib, and OS and PFS with atezolizumab plus bevacizumab versus sorafenib. For the primary and secondary endpoints, we carried out the analysis on the whole population first, and then we divided the cohort into two groups: non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) population and non-NAFLD/NASH population.

RESULTS

One hundred and ninety patients received atezolizumab plus bevacizumab, 569 patients received lenvatinib, and 210 patients received sorafenib. In the whole population, multivariate analysis showed that treatment with lenvatinib was associated with a longer OS [hazard ratio (HR) 0.65; 95% confidence interval (CI) 0.44-0.95; P = 0.0268] and PFS (HR 0.67; 95% CI 0.51-0.86; P = 0.002) compared to atezolizumab plus bevacizumab. In the NAFLD/NASH population, multivariate analysis confirmed that lenvatinib treatment was associated with a longer OS (HR 0.46; 95% CI 0.26-0.84; P = 0.0110) and PFS (HR 0.55; 95% CI 0.38-0.82; P = 0.031) compared to atezolizumab plus bevacizumab. In the subgroup of non-NAFLD/NASH patients, no difference in OS or PFS was observed between patients treated with lenvatinib and those treated with atezolizumab plus bevacizumab. All these results were confirmed following propensity score matching analysis. By comparing patients receiving atezolizumab plus bevacizumab versus sorafenib, no statistically significant difference in survival was observed.

CONCLUSIONS

The present analysis conducted on a large number of advanced non-viral HCC patients showed for the first time that treatment with lenvatinib is associated with a significant survival benefit compared to atezolizumab plus bevacizumab, in particular in patients with NAFLD/NASH-related HCC.

Nonalcoholic steatohepatitis in hepatocarcinoma: new insights about its prognostic role in patients treated with lenvatinib

BACKGROUND

Hepatocellular carcinoma (HCC) treatment remains a big challenge in the field of oncology. The liver disease (viral or not viral) underlying HCC turned out to be crucial in determining the biologic behavior of the tumor, including its response to treatment. The aim of this analysis was to investigate the role of the etiology of the underlying liver disease in survival outcomes.

PATIENTS AND METHODS

We conducted a multicenter retrospective study on a large cohort of patients treated with lenvatinib as first-line therapy for advanced HCC from both Eastern and Western institutions. Univariate and multivariate analyses were performed.

RESULTS

Among the 1232 lenvatinib-treated HCC patients, 453 (36.8%) were hepatitis C virus positive, 268 hepatitis B virus positive (21.8%), 236 nonalcoholic steatohepatitis (NASH) correlate (19.2%) and 275 had other etiologies (22.3%). The median progression-free survival (mPFS) was 6.2 months [95% confidence interval (CI) 5.9-6.7 months] and the median overall survival (mOS) was 15.8 months (95% CI 14.9-17.2 months). In the univariate analysis for OS NASH-HCC was associated with longer mOS [22.2 versus 15.1 months; hazard ratio (HR) 0.69; 95% CI 0.56-0.85; P = 0.0006]. In the univariate analysis for PFS NASH-HCC was associated with longer mPFS (7.5 versus 6.5 months; HR 0.84; 95% CI 0.71-0.99; P = 0.0436). The multivariate analysis confirmed NASH-HCC (HR 0.64; 95% CI 0.48-0.86; P = 0.0028) as an independent prognostic factor for OS, along with albumin-bilirubin (ALBI) grade, extrahepatic spread, neutrophil-to-lymphocyte ratio, portal vein thrombosis, Eastern Cooperative Oncology Group (ECOG) performance status and alpha-fetoprotein. An interaction test was performed between sorafenib and lenvatinib cohorts and the results highlighted the positive predictive role of NASH in favor of the lenvatinib arm (P = 0.0047).

CONCLUSION

NASH has been identified as an independent prognostic factor in a large cohort of patients with advanced HCC treated with lenvatinib, thereby suggesting the role of the etiology in the selection of patients for tyrosine kinase treatment. If validated, this result could provide new insights useful to improve the management of these patients.

Revision Total Hip Arthroplasty due to Catastrophic Osteolysis Caused by Massive Chronic Expanding Hematoma

An 84-year-old woman who underwent bilateral cementless total hip arthroplasty (THA) for dysplastic osteoarthritis 22 years ago was subjected to analysis. A huge soft-tissue mass was revealed in her left medial thigh. Plain radiographs of the left hip joint revealed severe osteolysis around the stem, cup, and ischium. Magnetic resonance imaging showed a 25 × 14-cm multilobulated mass with a thick-walled pseudocapsule. Two-stage surgery was performed with resection of the mass followed by a subsequent revision THA. The mass was diagnosed as a chronic expanding hematoma through gross and histologic findings. Two years after the revision THA, there was no recurrence of a hematoma. Two-stage revision THA was useful for definitive diagnosis, and good functional recovery was obtained after surgery.

Programmed cell death 1 positive lymphocytes at palate tonsils in the elder patients with chronic tonsillitis

Circulating lymphocytes infiltrate into local foci at the inflammatory phase of acute wound healing for activation of the immune system and express an immune checkpoint protein programmed cell death 1 (PD-1) at the resolution phase for inactivation of the immune system. Conversely, the PD-1 expression was still found even on circulating lymphocytes of the elder patients with chronic tonsillitis at the palliative stage. Recently, an adhesion G protein coupled receptor 56 (GPR56) was reported to at least work as a proliferation factor for infiltrated lymphocytes into local foci at the resolution phase of acute wound healing. To preliminary examine a similar role of PD-1 and GPR56 at local foci at chronic inflammation, palate tonsils were prepared from small amounts of patients with chronic tonsillitis and tonsillar hypertrophy. A positive relationship of RNA expression might be observed between PD-1 and GPR56 in the elder patients with chronic tonsillitis. In regard to immunohistopathological findings, there were huge and small amounts of PD-1 and GPR56 expression at the marginal zone of lymphoid follicles of palate tonsils with chronic tonsillitis. Moreover, the positive relationship of RNA expression between PD-1 and GPR56 confirmed in large numbers of the elder patients with chronic tonsillitis. Probably, GPR56 participates in a supplement of PD-1⁺ lymphocytes to circulating bloods of the elder patients with chronic tonsillitis through a lymphocyte cell maintenance system at the marginal zone of the lymphoid follicles of palate tonsils.

Radiological Evaluation of the Relationship Between Cortical Hypertrophy and Stress Shielding After Total Hip Arthroplasty Using a Cementless Stem

Background

Unloading of the proximal medial femoral cortex is usually associated with an increased bone strain at the distal part of the prosthesis, which may cause distal femoral cortical hypertrophy (CH). The objective of this study was to determine the factors that may be considered a predisposition to distal femoral CH and its effect on the stress shielding (SS) or durability of the fixation of the stem.

Methods

A total of 240 total hip arthroplasties were performed between January 2006 and December 2016, with all hips implanted with a Bicontact stem. The minimum follow-up period was more than 2 years, and the mean follow-up period was 7.2 years. The radiographic outcome was assessed on an anteroposterior hip radiograph. CH and SS were assessed on postoperative radiographs in the Gruen zone. We defined CH that appeared in zone 3 or 5 as ‘the focal type’ and defined CH that appeared in zones 2, 3, 4, 5, and 6 as ‘the diffuse type.’ SS followed the procedures from the Engh classification.

Results

CH was found in 72 hips (30% of the 240 hips), the focal type was found in 23 hips (9.6% of the 240 hips), and the diffuse type was found in 49 hips (20.4% of the 240 hips). SS was found in 41 hips (17.1% of 240 hips), including 32 hips with SS, which was found after the development of CH. One hip was from the focal-type CH and 31 hips were from the diffuse-type CH. SS, which is typically found in Engh classification types 1 and 2 developed in 13 hips, and SS, which is widely seen in Engh classification types 3 and 4 developed in 19 hips. All 19 hips with progressed SS were found after the diffuse-type CH had developed. In addition, among the 19 hips with progressed SS, Dorr type A was found in 0 hips, Dorr type B in 8 hips, and Dorr type C in 11 hips.

Conclusions

According to the results of our radiological evaluation, development of the diffuse-type CH after total hip arthroplasty using Bicontact stems is one of the critical causes of the later development of SS and could be predicted to progress to SS. To prevent the development of the diffuse-type CH, the indication to choose a Bicontact stem for a Dorr type C with osteoporotic bone should be considered.

New combined anteversion technique in hybrid THA: cup-first procedure with CT-based navigation

PURPOSE

Combined anteversion (CA) technique (stem-first procedure) is generally accepted as the optimal technique to attain an appropriate CA value in total hip arthroplasty (THA). However, cup anteversion is strongly influenced by the native femoral anteversion. Accordingly, anterior protrusion of the cup in the acetabulum might occur. The purpose of the present study is to investigate the achievement of the optimal CA while avoiding anterior cup protrusion and examine the significance of our new CA technique with cup-first procedure in hybrid THA.

METHODS

Seventy-nine hybrid THAs with the cup-first procedure used a CT-based navigation system for cup positioning. In the preoperative planning, cup anteversion was aimed at approximately 20°. However, in actuality, sufficient cup coverage in the original acetabulum based on individual anatomy is given priority over cup placement based on CT-based planning to ensure adequate cup coverage. The target stem anteversion was determined following Widmer's mathematical formula (37.3 = femoral stem anteversion × 0.7 + cup anteversion). Cemented stem was inserted according to the target stem anteversion angle.

RESULTS

Regarding the assessment of overall alignment, the calculated Widmer's CA values during surgery and postoperative CT evaluation were 34.1° ± 6.0° (range 20.7°-51.2°) and 35.1° ± 6.7° (range 21.6°-50.7°). There were 72 hips (91.1%) within 25°-50° of CA. Cup protrusion length averaged 2.0 mm ± 2.6 mm (0-8.8 mm) in the axial view and 0.4 mm ± 1.0 mm (0-3.6 mm) in the sagittal view. Cup protrusion length of more than 5 mm was indicated in 10 hips, and no hips observed more than 10 mm.

CONCLUSION

Our new CA technique (cup-first procedure) with hybrid THA was able to achieve optimal CA value while avoiding anterior cup protrusion.

Acetabular reconstruction for primary and revision total hip arthroplasty using Kerboull-type acetabular reinforcement devices-case-control study with factors related to poor outcomes of surgery

Kerboull-type acetabular support rings (KT) and allogenic bone graft were used for severe periacetabular bone loss with primary and revision total hip arthroplasty (THA). The purpose of this case-control study is to evaluate the risk factors related to poor outcomes of surgery.Sixty patients underwent primary THA and revision THA using allogenic bone graft with KT for large acetabular deficiency. These patients were retrospectively evaluated postoperatively and followed-up by radiograph. The minimum follow-up period was 4 years and averaged 7 years. A radiological failure was defined by the following criteria:Expected risk factors were defined as female, age >75 years, body mass index (BMI) >25%, medical history of hypertension, renal failure, liver steatosis, diabetes, hyperlipidemia, cardiac infarction, smoking, American Academy of Orthopedic Surgery (AAOS) classification III or IV, bleeding>500 mL, time of surgery >3hours, high hip center-type KT, inclination of KT >45 degrees, screw angle >25 degrees, morselized bone graft, Kawanabe's classification stage 3 or 4 and revision surgery. Nineteen hips (31.6%) revealed radiological failure according to our criteria, and revision THA was performed in 2 hips (3.3%). In the statistical analysis, morselized bone graft and high hip center-type KT were identified as factors of poor outcomes of surgery.

Evaluating the Effect of Intravenous Acetaminophen in Multimodal Analgesia After Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Postoperative pain is a significant concern of patients before surgery. Multimodal pain management is an effective method of pain control after major orthopedic surgery. Acetaminophen is the most commonly used analgesic for the management of pain. It was hypothesized that 1000 mg of intravenous acetaminophen (IA) dosed every 6 hours would significantly reduce the postoperative pain score at rest and the opioid consumption volume in patients who would undergo total hip arthroplasty (THA) when compared to a control group.

METHODS

A single-center, prospective, open-label randomized control study was conducted. A total of 97 patients undergoing unilateral primary THA were divided into 2 groups: the study group (IA) (n = 45) and the control group (n = 52). The study group received administered IA after surgery, while the control group received only a standard pain control. Both groups received a preoperative femoral nerve block and postoperative intravenous fentanyl citrate. The primary outcome was the evaluation of the pain score at rest 24 hours after surgery. The pain score was measured using the Numerical Rating Scale. The primary outcome of this study was analyzed using generalized estimating equation.

RESULTS

The IA group had a significant improvement in Numerical Rating Scale score at rest 24 hours after THA compared to the control group (-0.91, 95% confidence interval -1.56 to -0.26, P = .006), suggesting a positive effect of IA usage for pain relief. The total fentanyl citrate consumption after surgery for 24 hours was significantly lower in the IA group than those of the control group (52.07 ± 7.64 vs 57.83 ± 12.44 mg, P < .001).

CONCLUSION

Postoperative administration of IA significantly reduced the postoperative pain score and opioid consumption volume after primary THA. IA was useful as one role of multimodal pain management after THA.

LEVEL OF EVIDENCE

Level 2.

Influence of Spinopelvic Alignment on Pelvic Tilt after Total Hip Arthroplasty

Objective

To evaluate the impact of spinopelvic parameters and hip contracture on change in the pelvic tilt (PT) after Total hip arthroplasty (THA).

Methods

One hundred patients (15 male and 85 female) who underwent THA were included in this prospective study. Radiographic data were obtained preoperatively and 1 year after THA. Radiographic parameters included sagittal anterior pelvic plane (APP), sagittal vertical axis (SVA), sacral slope (SS), pelvic inclination (PI), and lumbar lordosis angle (LL). The APP was defined as the angle between the anterior pelvic plane and the vertical plane. A positive value indicates pelvic retroversion. Postoperative changes in PT were divided into three groups: the PA group (pelvic anteversion, ΔAPP < −5°), the PR group (pelvic retroversion, ΔAPP > 5°), and the PT group (minimal change, ΔAPP ≤ ± 5°). The Kruskal–Wallis test and the Steel–Dwass test were used to compare the preoperative and postoperative spinopelvic parameters among the three groups. The Spearman's rank correlation coefficient was used to evaluate the correlation between ΔAPP and spinopelvic parameters.

Results

Minimal change in pelvic tilt was observed in 59% of patients, while pelvic anteversion was observed in 16% of patients and pelvic retroversion was observed in 25% of patients. There were no significant changes in the spinopelvic parameters, including TK, LL, SVA, LL, SS, and APP after THA. The Femoral angle (FA) was significantly decreased after THA (P < 0.001). Preoperative APP was significantly more retroverted in the PA group than the PR group, and the PT group (6.8 ± 12.2, 0.2 ± 9.9, −8.3 ± 8.3, P < 0.001). Preoperative SS, PI‐LL, and PI were significantly smaller in the PA group than the PT group and the PR group. A significant negative correlation was identified between preoperative APP and ΔAPP (r = −0.418, P < 0.001).

Conclusion

Approximately 60% of the patients did not have any marked change in PT after THA. Preoperative APP was the only predictive factor associated with marked anterior or posterior change in PT.

Comparison of G-guide and Image-free Navigation System in Accuracy of Stem Anteversion Assessment During Total Hip Arthroplasty

Introduction:

We have developed and utilized the Gravity-guide (G-guide) as a simple manual instrument for intraoperative assessment and adjustment of stem anteversion (AV). Since 2013, we simultaneously measured stem AV using the G-guide and image-free navigation during THA procedure. The purpose of this study was to compare the measurement accuracy of the G-guide and navigation system using the postoperative CT results as a reference.

Methods:

In total, 59 hips in 56 patients who underwent primary THA using both the G-guide and image-free navigation system were included in the study. All patients underwent postoperative CT examination, and the femoral stem AV was assessed using a 3D image analysis system (Zed hip, LEXI, Japan). The AV angle derived from the postoperative CT image analysis was used as the reference value to assess the accuracy of the two intraoperative measurement systems.

Results:

The discrepancy between the G-guide and the postoperative CT-measured values averaged 5.0° ± 3.9°, while the corresponding value for the navigation system was 5.2° ± 4.1°. Acceptable accuracy with a measurement error of less than 10° was achieved in 86% and 90% of the cases for the G-guide and navigation measurements respectively.

Conclusion:

Consequently, it was shown that both navigation and G-guide measurements can achieve comparative accuracy and are clinically useful.

Curved periacetabular osteotomy using intraoperative real-time 3-dimensional computed tomography with a robotic C-arm system: A case report

RATIONALE

Curved periacetabular osteotomy (CPO) is a procedure with excellent surgical outcome that has been proposed for patients with development dysplasia of the hip (DDH). However, the surgical outcomes depend on the surgeon's experience and proficiency.

PATIENT CONCERNS

A 38-year-old female indicated she was experiencing left hip pain while walking.

DIAGNOSES

The patient was diagnosed with early-stage hip osteoarthritis due to DDH.

INTERVENTIONS

The patient underwent CPO while a 3-dimensional flat-panel C-arm (Artis zeego; Sciemens Healthcare, Forchheim, Germany) was used to confirm the real-time 3-dimensional computed tomography (CT) images during surgery. It was possible to confirm the accurate osteotomy curve using CT images twice during surgery: at the time of the ischial osteotomy and the quadrilateral surface osteotomy.

OUTCOMES

An ideal C-shaped osteotomy line was created as shown on the postoperative CT images. In addition, neither posterior column fracture nor intra-articular osteotomy was confirmed.

LESSONS

The CPO using Artis zeego resulted is a satisfactory outcome, and this is the 1st report in the world to discuss the benefits of Artis zeego in pelvic osteotomy.

Subtrochanteric femoral shortening osteotomy concomitantly performed with revision total hip arthroplasty: A case report

RATIONALE

Total hip arthroplasty (THA) concomitant with subtrochanteric femoral shortening osteotomy for Crowe type IV dysplastic hip has been reported. However, the combination of subtrochanteric femoral osteotomy and revision THA has only been mentioned in one case report.

PATIENT CONCERNS

A 67-year-old female had a history of congenital dislocation of both hips.

DIAGNOSES

Right hip was diagnosed the aseptic loosening of THA with extremely high replacement of the acetabular component.

INTERVENTIONS

Revision THA concomitant with subtrochanteric femoral shortening osteotomy using a cement stem was performed. Before the revision surgery, primary THA with subtrochanteric shortening osteotomy was performed on the opposite side. Regarding leg length, the actual leg length of the affected side was 9 mm longer, and the subjective leg length discrepancy was 45 mm shorter in the affected limb due to pelvic obliquity. Subtrochanteric osteotomy was performed with an amount of osteotomy equal to the amount of distal translation of the hip center to the original acetabulum.

OUTCOMES

As a result, pelvic obliquity improved, and the subjective leg length discrepancy disappeared after revision surgery.

LESSONS

The combination of subtrochanteric femoral shortening osteotomy with revision THA resulted in a satisfactory outcome.

Inhibition of Asparagine-linked Glycosylation Participates in Hypoxia-induced Down-regulation of Cell-surface MICA Expression

BACKGROUND/AIM

Hypoxia down-regulates the expression of cell surface major histocompatibility class I-related chain molecule A (MICA) without increasing its shedding. Recently, the inhibition of N-linked glycosylation was also shown to reduce the cell-surface expression of MICA. We investigated the participation of asparagine (Asn)-linked glycosylation in hypoxia-induced down-regulation of cell-surface MICA using osteosarcoma cells.

MATERIALS AND METHODS

The cell-surface expression and Asn-N-glycosylation of MICA were estimated by flow cytometry, and western blot analyses, respectively.

RESULTS

Hypoxia reduced the expression of N-linked glycosylated MICA, as well as the ratio of N-linked glycosylated to non-glycosylated MICA. 2-Deoxy-D-glucose, which inhibits N-linked glycosylation, reduced the cell-surface expression of MICA under normoxia, while D-Mannose increased N-glycosylated MICA, increasing cell-surface MICA under hypoxia. Cells transfected with wild-type MICA expression vector expressed cell surface MICA more than those transfected with mutant MICA expression vectors designed for abrogation of N-linked glycosylation.

CONCLUSION

The inhibition of Asn-N-linked glycosylation participates in hypoxia-induced down-regulation of cell-surface expression of MICA.

Accuracy of Component Orientation and Leg Length Adjustment in Total Hip Arthroplasty Using Image-free Navigation

Purpose:

The purpose of this study was to examine the accuracy of implant orientation and leg length in total hip arthroplasty (THA) with an image-free navigation system based on a comparison of the intraoperative navigation and postoperative CT evaluations.

Material and Methods:

A consecutive series of 111 patients (118 hips) who underwent THA using the current version of the image-free navigation system constituted the basic study population. Subsequently, a total of 101 patients (108 hips) meeting the inclusion and exclusion criteria were selected as study subjects for the analysis. THA was performed using an image-free navigation system that was capable of adjusting both the prosthetic position and leg length. Postoperative CT examination was performed for all study subjects, and the prosthetic position and leg length were measured on CT images using the image analysis software. Subsequently, the intraoperative navigation results and the corresponding values obtained from the postoperative CT measurements were compared to test the accuracy of the navigation system.

Results:

The average discrepancies between the intra- and postoperative assessments were 6.8°, 3.7°, and 5.7° for cup anteversion, cup inclination, and stem anteversion, respectively. The corresponding value in leg length averaged 4.1 mm.

Conclusion:

Average discrepancies between the intra- and postoperative measurements were less than 10° in all prosthetic alignment parameters and less than 5 mm in leg length. Intraoperative assessments with the use of the image-free navigation in THA could afford satisfactory result.

Treatment strategy for amyloid hip arthropathy in long-term hemodialysis patients

BACKGROUND

The number of hemodialysis patients has been progressively increasing in our country. On the other hand, chronic hip arthropathy associated with long-term hemodialysis is a devastating problems affecting patients' quality of life. In our previous study, we proposed a classification system for radiological abnormalities seen in hemodialysis-related hip lesions. The purpose of the study was to propose the surgical strategy for hip disorders caused by long-term hemodialysis.

METHODS

Patients with a history of hemodialysis for more than 10 years, 191 hip lesions in 165 consecutive patients who visited our institute due to hip symptoms. Various abnormalities were identified in 116 out of 191 hips. A retrospective assessment of the patient record and radiographs was performed for the included subjects examining the natural course of the disease process as well as the results of surgical treatment.

RESULTS

Seventy-six hip lesions (69.0%) were conservatively managed at the time of the initial visit. Surgeries were performed for 75 hips (64.7%) during the study period. Among those, surgical treatment was indicated for 40 hips at the time of the initial visit. On the other hand, surgeries were performed for 35 hips during the subsequent follow-up period due to progression of the disease process.

CONCLUSIONS

Based on the analysis of our surgical experiences by the retrospective chart review, we have established a flowchart of the treatment strategy for chronic hip arthropathy in long-term hemodialysis patients.

STUDY DESIGN

This study is retrospective clinical study.

Comparison of Continuous Femoral Nerve Block with and Without Combined Sciatic Nerve Block after Total Hip Arthroplasty: A Prospective Randomized Study

In association with the growing interests in pain management, several modalities to control postoperative pain have been proposed and examined for the efficacy in the recent studies. Various modes of peripheral nerve block have been proposed and the effectiveness and safety have been examined for each of those techniques. We have described our clinical experiences, showing that continuous femoral nerve block could provide a satisfactory analgesic effect after total hip arthroplasty (THA) procedure. In this study, we compared the effectiveness and safety of continuous femoral nerve block with and without sciatic nerve blockade on pain control after THA. Forty patients scheduled for THA were included in the study and randomly divided into 2 groups. Postoperative analgesic measure was continuous femoral nerve block alone, while the identical regimen of continuous femoral nerve block was combined with sciatic nerve block. The amount of postoperative pain was evaluated in the immediate postoperative period, 6 hours, and 12 hours after surgery. Moreover, postoperative complications as well as requirement of supplemental analgesics during the initial 12 hours after surgery were reviewed in the patient record. The obtained study results showed that the supplemental sciatic nerve blockade provided no significant effect on arrival at the postoperative recovery room, while the NRS pain score was significantly reduced by the combined application of sciatic nerve blockade at 6 and 12 hours after surgery. In the investigation of postoperative analgesiarelated complications, no major complication was encountered without significant difference in complication rate between the groups.

Comparison of Complications Following Revision of Metal-on-Metal Versus Metal-on-Polyethylene Total Hip Arthroplasty

The aim of this study was to examine the clinical characteristics of patients who required revision and the rate of early complications after revision for metal-on-metal total hip arthroplasty (MOM THA) and metal-on-polyethylene total hip arthroplasty (MOP THA). Matched cohorts were selected by retrospective review from a single-center database of revision THAs for failed MOM and MOP THAs from 2010 to 2014. A total of 140 hips in 140 patients comprised the study population; 39 revisions were performed for failed MOM THAs (MOM group), and 101 revisions were performed for failed MOP THAs (MOP group). Data included patient demographics, reason for revision, type of revision procedure, any complication within 90 days after surgery, admission type, and discharge disposition. Primary diagnosis, time from primary THA to revision, operative time, blood loss, and length of stay were reviewed. The analysis showed the time from the index primary procedure to first revision was earlier (P=.01) in the MOM group despite no significant intergroup differences in age, gender, primary diagnosis, or body mass index. Surgical morbidity, as indicated by operative time, blood loss, and length of stay, was lower in the MOM group. The stem was retained more often in the MOM group. There was no significant difference between the groups in overall complication rate. These findings indicate that when performed at an earlier time period before extensive soft tissue reaction to metal ions, revision following MOM THA is not associated with an increased complication rate compared with revision following MOP THA. [Orthopedics. 2017; 40(1):e164-e169.].

Use of the G-guide for Measuring Stem Antetorsion During Total Hip Arthroplasty

Implant positioning is one of the critical factors influencing postoperative outcomes in total hip arthroplasty (THA). Several studies have reported that the postoperative antetorsion (AT) measurement for the femoral stem inserted without navigation showed wide variability. The current authors developed a simple instrument, the Gravity-guide (G-guide), for intraoperative assessment of stem AT and adjustment. They evaluated the effectiveness of the G-guide with postoperative computed tomography (CT) examination. Ninety patients (96 hips) who underwent primary THA using the G-guide for stem adjustment were evaluated. The G-guide consists of 2 parts: one attached to the lower leg and the other attached to the handle of the rasp. The G-guide was used to evaluate the AT at the time of inserting the final rasp. In addition, the AT value in the G-guide evaluation system required correction by the angle obtained in the preoperative epicondylar view. Intraoperative stem AT was defined as the sum of the intraoperative G-guide value and the correction angle. Postoperative AT was evaluated by CT examination. The discrepancy between the intra- and postoperative measurements was 4.6°±4.1°. Acceptable accuracy with discrepancy of less than 5° and 10° was achieved in 66 (69%) hips and 85 (89%) hips, respectively. The use of the G-guide could effectively reduce the variability of stem anteversion compared with manual adjustment. This study proved the effectiveness of the newly developed G-guide system in intraoperative stem AT adjustment.

Assessment of Accuracy and Reliability in Acetabular Cup Placement Using an iPhone/iPad System

Implant positioning is one of the critical factors that influences postoperative outcome of total hip arthroplasty (THA). Malpositioning of the implant may lead to an increased risk of postoperative complications such as prosthetic impingement, dislocation, restricted range of motion, polyethylene wear, and loosening. In 2012, the intraoperative use of smartphone technology in THA for improved accuracy of acetabular cup placement was reported. The purpose of this study was to examine the accuracy of an iPhone/iPad-guided technique in positioning the acetabular cup in THA compared with the reference values obtained from the image-free navigation system in a cadaveric experiment. Five hips of 5 embalmed whole-body cadavers were used in the study. Seven orthopedic surgeons (4 residents and 3 senior hip surgeons) participated in the study. All of the surgeons examined each of the 5 hips 3 times. The target angle was 38°/19° for operative inclination/anteversion angles, which corresponded to radiographic inclination/anteversion angles of 40°/15°. The simultaneous assessment using the navigation system showed mean±SD radiographic alignment angles of 39.4°±2.6° and 16.4°±2.6° for inclination and anteversion, respectively. Assessment of cup positioning based on Lewinnek's safe zone criteria showed all of the procedures (n=105) achieved acceptable alignment within the safe zone. A comparison of the performances by resident and senior hip surgeons showed no significant difference between the groups (P=.74 for inclination and P=.81 for anteversion). The iPhone/iPad technique examined in this study could achieve acceptable performance in determining cup alignment in THA regardless of the surgeon's expertise. [Orthopedics. 2016; 39(4):e621-e626.].

Histologic evaluation of the bone-ceramic interface of an alumina ceramic cup arthroplasty retrieved after 25 years in vivo

A 47-year-old man underwent ceramic cup arthroplasty when he was 22 years old. Revision total hip arthroplasty was performed 25 years later because of limited range of motion without implant loosening. Histologic examination revealed that the femoral head and ceramic implant were well fixed through a thin fibrous membrane. The energy-dispersive X-ray analysis indicated that calcium and phosphorus were detected in the same peak pattern as cancellous bone in the bone-ceramic interface.

Surgical Treatment of Synovial Osteochondromatosis of the Hip Using a Modified-Hardinge Approach with a Z-Shaped Capsular Incision

Synovial osteochondromatosis of the hip is a rare condition, and the surgical treatment approach for this condition requires complete removal of loose bodies combined with synovectomy. While these, procedures are generally accepted as the optimal treatment method, this is still controversial topic. Recent studies have reported that open surgical procedures remain acceptable for synovial osteochondromatosis of the hip. These procedures include the dislocation of the femoral head, and complications such as femoral head necrosis and bursitis or great trochanter non-union due to trochanteric osteotomy have been reported. The present study reports a modified technique for surgical dislocation through a Z-shaped capsular incision without trochanteric flip osteotomy for the treatment of synovial osteochondromatosis of the hip.

Significance of preoperative 3D-CT angiography for localization of the femoral artery in complicated THA

BACKGROUND

Major vascular injury is one of the most devastating complications in total hip arthroplasty (THA). Risk for intraoperative vascular injury is increased when the normal vascular anatomy is distorted by previous surgery or dislocation with displacement. Therefore, an appreciation of the vascular anatomy in relation to the anticipated surgical field is critical to avoid this complication during preoperative assessment for a complicated THA.

METHODS

Preoperative three-dimensional (3D) CT angiography was performed for 24 complicated THAs when altered vascular anatomy around the acetabulum was suspected. When assessing the CT images, the presence of apparent proliferation of vessels close to the original acetabulum as well as a distance of <10 mm from the artery to the acetabulum was deemed a potential risk factor for intraoperative vascular injury. Additionally, the relationships of clinical characteristics and the presence of these risk factors were analyzed to identify the patient population at risk.

RESULTS

The incidence of proliferation of collateral vessels was higher in patient groups with proximal femoral migration of 5 cm or more and multiple previous surgeries prior to the index THA. Moreover, in three ankylosed hips, lateral deviation of the main vascular trunk with an artery-acetabulum distance of <10 mm was identified in all cases.

CONCLUSION

Preoperative 3D-CT angiography in cases of complicated THA revealed altered vascular anatomy which may increase the risk for intraoperative vascular injuries. Patient characteristics related to the risk for this complication were marked proximal femoral migration, multiple previous surgeries, and hip ankylosis. Preoperative image examination of the vascular anatomy is thought to help reduce the risk of inadvertent vascular injury in these complicated THA cases.

Comparison of Continuous Femoral Nerve Block, Caudal Epidural Block, and Intravenous Patient-controlled Analgesia in Pain Control After Total Hip Arthroplasty: A Prospective Randomized Study

Thirty-six patients who underwent primary unilateral total hip arthroplasty (THA) were randomly allocated to 4 groups with different pain control protocols; continuous femoral nerve block (FNB group), single-shot caudal epidural block with morphine (EB group), intravenous patient-controlled analgesia with fentanyl (IV-PCA group), and systemic administration of nonsteroidal anti-inflammatory drugs (NSAIDs group). Postoperative pain was assessed using the numerical rating scale (NRS) scores and the analgesic effect was compared among the groups. The NRS upon arrival at the recovery room and 6 hours after surgery in the FNB, EB, and IV-PCA groups were significantly lower than that in the NSAIDs group. The amount of additional analgesics requested by the patient was smaller in the FNB, EB, and IV-PCA groups as compared to the NSAIDs group. Regarding the complications related to the analgesia, 5 of the 9 patients in the IV-PCA group complained nausea and vomiting and received antiemetic drugs. Delay in the rehabilitation process due to drowsiness was encountered in 3 patients in this group, while no patient in the FNB and EB groups suffered from delayed rehabilitation. Considering both the analgesic effect and the potential risk of complications, continuous femoral nerve blocks and caudal epidural blocks for are recommended for postoperative pain control after THA procedure.

Arthroscopic labral repair concomitantly performed with curved periacetabular osteotomy

A 23-year-old female presented with pain in the left hip. Radiological examination showed developmental dysplasia of the hip (DDH) combined with acetabular retroversion and posterior wall deficiency. Findings in the physical examination were coincident with femoroacetabular impingement. At surgery, we performed curved periacetabular osteotomy concomitant with arthroscopic labral repair and osteochondroplasty, simultaneously addressing dysplastic acetabulum and femoroacetabular impingement. The final follow-up examination at 18 months showed satisfactory outcome with the D'Aubigne and Postel hip score of 17/18. In addition to accurate diagnosis, the arthroscopic procedure for associated intra- and peri-articular problems seems to help improve the surgical outcome of periacetabular osteotomy performed for patients with DDH.

Fascia iliaca compartment block: its efficacy in pain control for patients with proximal femoral fracture

BACKGROUND

Proximal femoral fractures are common in elderly patients. Recently, use of regional blockade has gained popularity as a means of relieving pain among this patient population. Among the procedures, fascia iliaca compartment block (FICB) is believed to be advantageous because of its safety and efficacy.

METHODS

In this study fifty-six consecutive patients who sustained a proximal femoral fracture were assigned to two groups. For 31 patients in group 1, FICB was used to control pre and postoperative pain. FICB was performed by an orthopaedic resident on arrival of the patient at the hospital and in the immediate postoperative period. Systemic administration of non-steroidal anti-inflammatory drugs (NSAIDs) alone was adopted for pain control for 25 patients in group 2. The severity of pain was assessed by use of a visual analog scale (VAS).

RESULTS

Neither blockade-associated complications nor analgesic failure were encountered among patients who underwent FICB (group 1). In this group of patients, the mean preoperative VAS scores before FICB and at 10 min and 12 h after the blockade were 91, 31, and 36 respectively, indicating significant pain reduction. The corresponding values for group 2 patients were 92, 92, and 81. In addition, postoperative pain was also successfully managed by FICB with mean VAS scores at immediate, 6-h and 12-h time points of 15, 22, and 31 respectively, whereas the corresponding values for the group 2 patients were 62, 49, and 59. Consequently, significant differences in VAS scores were demonstrated between the groups in both the pre and postoperative periods.

CONCLUSION

FICB is clinically safe and efficient, providing consistent analgesic effects irrespective of the performing doctor's experience of elderly patients with proximal femoral fracture.

Assessment of acetabulum anteversion aligned with the transverse acetabulum ligament: cadaveric study using image-free navigation system

The transverse acetabulum ligament (TAL) has been used as an intraoperative anatomical landmark to position the acetabulum cup in total hip arthroplasty (THA). However, the validity of the use of TAL has not been clarified. The purpose of this study was to examine the orientation of the cup component aligned with the TAL in cadaveric study. The 31 hips in 25 whole-body embalmed cadavers were examined. The donors were 12 men and 13 women. Simulated THA procedure using image-free navigation system was performed and a trial cup with a diameter of approximately 2 mm less than the size of the acetabulum were inserted and snugly fitted on the TAL through the posterior wall of acetabulum. The orientation of the cup component was measured using an image-free THA navigation system. The measured radiographic anteversion and inclination angles averaged 18.2±7.2° (range: 2.0-33.2°) and 43.5±4.2° (range: 33.1-51.0°) respectively. Based on the Lewinnek's safe zone criteria, 26 hips (80.6%) were judged to be within the. Moreover, in the analysis of the gender difference of TAL angles, the average anteversion angle was shown to be significant larger in female than male population. The TAL can be effectively used an intraoperative landmark to align the acetabulum component helping reduce the risk of dislocation after surgery. In the intraoperative judgment, a gender difference in the alignment of the TAL should be taken into consideration.

Combined anteversion of the total hip arthroplasty implanted with image-free cup navigation and without stem navigation

In total hip arthroplasty (THA), combined anteversion (CA), the sum of cup anteversion (AV) and stem antetorsion (AT) are used as parameters to assess the appropriateness of overall prosthetic alignment. In this study, we evaluated the CA value based on the post-operative computed tomography (CT) measurements in our patient population who underwent THA using the OrthoPilot™ image-free navigation system (B/BRAUN-Aesculap, Tuttlingen, Germany). During surgery, cup alignment was adjusted with the use of the navigation system while the positioning of the femoral stem was arbitrarily adjusted by the surgeon. Seventy-nine THAs were included in the study. Post-operative CT assessment for the prosthetic alignment showed the average cup inclination and AV values to be 40.5°±4.1° and 20.6°±4.6°, respectively, demonstrating the effectiveness of the navigation system by small values of standard deviation. By contrast, the AT value measured for the stem showed wide variability (mean 23.6°±11.2°). Consequently, the resulting CA was also inconsistent (mean 44.4°±11.2°) and only 61 of the 79 THAs (77.2%) were defined as satisfactory.

Use of image-free navigation in determination of acetabular cup orientation: analysis of factors affecting precision

We have been using an image-free total hip arthroplasty (THA) navigation system (OrthoPilot; Aesculap, Tuttlingen, Germany) to ensure accurate and reproducible acetabular cup orientation. In this study, the accuracy of this system in the assessment of acetabular cup orientation was evaluated by comparing the intraoperative inclination and anteversion angles presented by the navigation system and the corresponding postoperative values obtained by computed tomography measurement. In the intraoperative accuracy analysis, we additionally examined the influence of factors such as body mass index and soft tissue thickness on assessment error. Intraoperative and postoperative results obtained from 115 consecutive navigated THAs were compared and analyzed. In both inclination and anteversion angles, good agreement was observed; a discrepancy of more than 5° was observed in 1 and 3 cases, respectively. In the analysis of factors potentially affecting the accuracy of the intraoperative assessment, no correlation between each parameter and the intraoperative and postoperative discrepancy was demonstrated.

Multiple pelvic insufficiency fractures in rheumatoid patients with mutilating changes

Multiple insufficiency fractures occurred in two patients with mutilating rheumatoid arthritis (RA), leading to substantial disabilities. Both patients received long-term oral glucocorticoid therapy and underwent multiple lower-extremity surgeries such as total hip arthroplasty (THA) or Total knee arthroplasty (TKA). The multiple fractures were located in the pelvis and lumbosacral region. Fractures in both patients were treated conservatively. Although bony union and resumption of activities were achieved in one patient, the other patient was not able to resume ambulation. For RA patients with combined risk factors for insufficiency fractures, aggressive preventive intervention and careful clinical assessment for early detection and management are warranted.

Results of total hip arthroplasty for dialysis arthropathy in long-term hemodialysis patients

BACKGROUND

The number of hemodialysis patients has progressively increased in Japan. Among the orthopedic complications in this population, chronic hip arthropathy associated with long-term hemodialysis is one of the most devastating problems. Total hip arthroplasty (THA) is often indicated. However, varying results have been reported for THA in these patients. This study was undertaken to assess the risk-benefit ratio of THA performed in patients with dialysis hip arthropathy.

METHODS

We evaluated 17 patients (19 hips) with dialysis hip arthropathy who underwent THA. The duration of hemodialysis before surgery ranged from 10 to 27 years. Histological examination of the tissue samples revealed accumulation of amyloid deposits in all cases. Three patients died within 2 years after operation; the remaining 14 patients (16 hips) were followed for a minimum of 3 years.

RESULTS

The cumulative survival rate of the prostheses in these 16 hips up to the latest follow-up was 94%. Regarding surgery-related complications, deep infection occurred in one hip, and revision THA was required in one patient with recurrent dislocation and aseptic loosening.

CONCLUSIONS

THA for dialysis hip arthropathy in long-term hemodialysis patients is associated with substantial local and general risks. Despite the substantial risk, THA for this patient population seems to afford reasonably satisfactory results.

[A case of Achilles tendon rupture in a patient of refractory Reiter's syndrome]

We herein report a case of spontaneous rupture of Achilles tendon in a 51-year-old man with refractory Reiter's syndrome. On the diagnosis in November, 2006, physical examinations and MR images showed a remarkable inflammation at the calcaneal insertion area of Achilles tendon. He required aggressive treatments with nonsteroidal anti-inflammatory drug (NSAID), oral prednisolone 30 mg daily and methotrexate (8 mg weekly) to control the disease. Two months later, the Achilles tendon ruptured at its insertion point. This ruptured lesion of Achilles tendon was an unusual site compared to previous reports. Histological findings in the ruptured lesion of Achilles tendon revealed the existence of granulomatous lesion consisted of severe infiltration of fibroblasts and vessels proliferation beside tendon. These findings suggest a prolonged inflammation. Although it is widely accepted that Reiter's syndrome is associated with enthesis, especially at the attachment of Achilles tendon to calcaneum, there have been only two reports of Achilles tendon rupture associated with Reiter's syndrome. The possible cause of the Achilles tendon rupture in this patient might be due to the weakened strength of the Achilles tendon by the prolonged and severe enthesis of Achilles tendon near the insertion lesion.

Beta 2-microglobulin amyloid deposit in HLA-B27 transgenic rats

Beta 2-microglobulin (beta 2-m) amyloid deposition develops serious orthopedic complications in patients with long-term hemodialysis. However, the exact pathogenesis of amyloid deposition in patients with dialysis is unknown. We used transgenic rats with HLA-B27 and beta 2-m to develop an in vivo animal model with beta 2-m amyloid-associated disorders to investigate the mechanism of formation and to report histological findings of beta 2-m amyloid deposition. Transgenic rats were divided into two groups: group 1, no treatment; group 2, arthritis induced by type II collagen. A large number of cells labeled with beta 2-m were observed in the bone marrow and synovium of the knee joint in transgenic rats. In addition, amyloid deposition, identified by Congo red staining, was found only in the knee joints of the transgenic rats with collagen-induced arthritis. Immunostaining with beta 2-m demonstrated the same pattern of tissue distribution as Congo red in serial sections. We hypothesized that elevated serum beta 2-m level-associated local chronic inflammation leads to the development of amyloid deposits and resultant arthropathy.

Bone graft for large bone cysts of the femoral neck in patients on hemodialysis

Pathologic fracture of the femoral neck from an amyloid bone cyst in patients on long-term hemodialysis causes substantial morbidity. For patients with a bone cyst occupying more than 1/2 of the neck width, we have performed prophylactic internal fixation with an autogenous iliac bone graft. We describe our surgical technique and present clinical results from consecutively surgically treated patients. We determined whether our procedure successfully induced healing of the bone cyst, thus preventing a problematic sequel of fracture. From 1990 to 2003, 14 hips in 12 patients were treated, and the clinical results from these patients were retrospectively reviewed. One patient died 3 months after surgery; the remaining patients were followed for at least 3 years. In those 11 patients, bony healing was achieved in all cases with no recurrence of the cystic lesion. Considering the comparatively unsatisfactory results of internal fixation for pathologic fracture and THA for patients receiving long-term hemodialysis, our procedure gives surgeons another option for treating this difficult problem.

Evidence for Involvement of p59fyn in Fasting-Induced Thymic Involution

p59fyn, a member of the src-family protein tyrosine kinase, is expressed abundantly in thymus. We examined the possible involvement of p59fyn in thymic involution induced by a fasting stress in Fyn-/- mice. An acute 48 h fast resulted in severe atrophy of the thymus and a marked decrease of the total thymocyte number with depletion of the CD4+CD8+[double positive (DP)] population in Fyn+/+ (control) mice. A remarkable increase in terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labelling-positive signals was detected in the fasted group of control mice. However, these findings were not observed in Fyn-/- mice. Interestingly, MRL/MPJ-lpr/lpr, a Fas-deficient model animal, also showed no significant decrease of DP cell numbers in the fasted group. p59fyn is known to interact with Fas signalling, and these findings suggest that p59fyn is involved in fasting-induced thymic involution, raising the possibility that Fas/p59fyn-mediated signalling may, at least partially, be associated with the phenomenon.

Sonographic appearance of fibrous nodules in patellar clunk syndrome: a case report

Patellar clunk syndrome is a rare complication causing pain after total knee arthroplasty. However, it is important to differentiate it from the other causes of patellofemoral pain. In this article, we apply ultrasonography for the first time to demonstrate the suprapatellar fibrous tissue causing this condition. A 50-year-old woman with rheumatoid arthritis had left total knee arthroplasty. The patient had excellent results until 2 years after surgery, when she complained of anterior knee pain. On physical examination, a patellar "catch" and "pop" were noted from 45 degrees flexion to full extension. Roentgenograms showed a radiolucent line at the upper pole of the patella and no subluxation of the patella on skyline view. Sagittal and transverse gray-scale sonographic images revealed an echogenic area attached to the quadriceps tendon. Corresponding color Doppler sonographic images showed marked vascularity in this echogenic area. The patient was treated with removal of the suprapatellar tissue and a patellar component revision. Intraoperatively, the suprapatellar tissue, which measured 4 x 4 x 2 cm, entered the notch area of the femoral component on flexion and caused the patellar "pop" on knee extension. Pain relief was obtained immediately after the operation when smooth gliding motion of the patella was restored.

Delivery of a normal newborn after intensive medical treatment for an acute exacerbation of ulcerative colitis during pregnancy: a case report

A 28-year-old woman developed an acute exacerbation of chronic ulcerative colitis in the second trimester of pregnancy. She was treated by intensive medical treatment with intravenous prednisolone, betamethasone enema, oral salazosulfapyridine, intravenous ceftazitim, and total parenteral nutrition. The acute relapse subsided after 73 days of the treatment and a normal female newborn weighing 2,208 g was delivered vaginally after 40 weeks' gestation. Our experience showed that the intensive medical therapy did not impair either the course of the pregnancy or the fetal outcome.

Can scores on alexithymia distinguish patients with peptic ulcer and erosive gastritis?

This study examined alexithymic characteristics of 57 patients with peptic ulcer and 198 with erosive gastritis. The prevalence rate of alexithymia, as measured on the 20-item Toronto Alexithymia Scale, was significantly higher for the peptic ulcer group (51%) than for the erosive gastritis group (21%). Scores of the Profile of Mood States were significantly higher for the peptic ulcer group than for the erosive gastritis group. The alexithymia scores were significantly correlated with the scores on the Profile of Mood States. However, discriminant analysis indicated that the alexithymia scores could account for significant additional variance beyond mood states as measured by the Profile of Mood States.

[The bone-implant-interface: an experimental study on the effects of micro-motion]

Aseptic loosening of a prosthesis is a hazardous problem after total joint replacement. In revision surgery, fibrous granulation tissue is always seen between the prosthesis and the bone or between the bone cement and the bone. We refer to this granulation tissue as the "bone-implant-interface" and it invades into the bone, resulting in osteolysis around the prosthesis. In order to investigate the histology of this granulation tissue and the mechanism of bone resorption, we produced an experimental model of the loosening of implants (alumina ceramic, PMMA, HDP) in the distal femoral condyles of rabbit. Each implant was inserted into the distal femoral condyle and connected with a Kirschner wire which was wired down to the tibia and fixed tightly to the tibial cortex. The implants could then be mobilized when the rabbits moved their knees. We called this a "micro-motion model". Besides doing this, we also developed a similar model in rabbit with ferritin-induced arthritis to investigate whether or not arthritis exacerbated the loosening of a prosthesis. The histological examinations of the bone-implant-interface in the micro-motion model in normal rabbit revealed three layers: a surface layer containing small round cells such as synovial lining cells, a middle layer containing many fibroblasts, macrophages and giant cells which phagocytize wear debris, and a deep layer adjacent to the bone containing many osteoclasts. In the models with ferritin-induced arthritis, more synovial lining cells were seen in the surface layer and more osteoclasts were seen in the deep layer. Also more osteolysis occurred around the implant in the arthritis model. In summary, the results suggested that the mechanical stress of motion stimulated the growth of synovial lining cells and macrophages in the bone-implant-interface, resulting in increased numbers of osteoclasts and in subsequent osteolysis.

Waveguiding properties of (Se,S)-based chalcogenide glass films and some applications to optical waveguide devices

Fundamental waveguiding properties of As-Se-S-Ge chalcogenide glass films and some applications to passive waveguide components are presented. The refractive index of the chalcogenide glass film annealed just below the glass transition temperature (200 degrees C) increases by light irradiation near the absorption edge. The refractive-index change amounted to 0.03 at 1.06 microm. The propagation loss of 0.4 dB/cm has been achieved at 1-microm thickness for As(40)Se(10)S(40)Ge(10) glass film. The photoinduced refractive-index change in the chalcogenide glass film was large enough to be applied to making passive waveguide components. The curved waveguide and optical directional coupler were designed as passive components.