Characteristics and Treatment Strategies for Basicervical and Transcervical Shear Fractures of the Femoral Neck.

This study aimed to define basicervical and transcervical shear fractures using area classification and to determine the optimal osteosynthesis implants for them. The clinical outcomes of 1042 proximal femur fractures were investigated. A model of the proximal femur of a healthy adult was created from computed tomography images, and basicervical and transcervical shear fractures were established in the model. Osteosynthesis models were created using a short femoral nail with a single lag screw or two lag screws and a long femoral nail with a single lag screw or two lag screws. The minimum principal strains of the fracture surfaces were compared when the maximum loads during walking were applied to these models using finite element analysis software. Basicervical fractures accounted for 0.96% of all proximal femur fractures, 67% of which were treated with osteosynthesis; the failure rate was 0%. Transcervical shear fractures accounted for 9.6% of all proximal femur fractures, 24% of which were treated with osteosynthesis; the failure rate was 13%. Finite element analysis showed that transcervical shear fracture has high instability. To perform osteosynthesis, multiple screw insertions into the femoral head and careful postoperative management are required; joint replacement should be considered to achieve early mobility.

Relationship between the Arthroscopic Findings and Pathology of Greater Trochanteric Pain Syndrome.

In recent publications on greater trochanteric pain syndrome (GTPS), the pathology receiving the most attention has been gluteus medius muscle tendinous injury, and surgical techniques such as gluteus medius tendon repair and their outcomes for GTPS have been reported. In our department-related facilities, arthroscopic surgeries are routinely performed for the patients with recalcitrant GTPS. A total of 51 patients were diagnosed with GTPS. Surgical treatment was carried out 22 patients (24 joints; 4 males and 18 females; mean age at surgery of 52.0 years). Arthroscopic findings confirmed bursitis in all 24 joints. In all cases, debridement of the greater trochanter bursa provided rapid relief of greater trochanter pain. The Numerical Rating Scale showed significant improvement, from the preoperative mean of 7.8 (range, 6-10) to the postoperative day 7 mean of 1.6 (range, 0-3). The modified Harris Hip Score was significantly improved from the preoperative mean of 65.5 (range, 52.5-78.3) to the final follow-up (average 2.9 months) mean of 96.0 (range, 85.2-100). Fascial damage of the gluteus medius muscle was observed in 21 joints while only 2 patients had a gluteus medius tendinous injury. Greater trochanteric bursitis and fascia or muscle-fiber injury of the gluteus medius muscle are the most common pathologies in patients with lateral hip pain.

Successful Treatment of Atypical Femoral Fracture with Bowed Femur Using Contralateral Intramedullary Nail Combined with Early Daily Teriparatide.

We report a case of atypical femoral fracture achieving early fracture union with combination therapy comprising contralateral nail and immediate teriparatide injection. Fracture union of atypical fractures is often delayed due to bowing deformity and bone metabolic disorders. Combination treatment that takes both problems into consideration represents a useful treatment option for atypical femoral fracture.

Evaluation of the Nature and Etiologies of Risk Factors for Diaphyseal Atypical Femoral Fractures.

OBJECTIVES: Differences in mechanisms of subtrochanteric and diaphyseal atypical femoral fractures (AFFs) are speculated in studies that analyzed differences in the patients' background. However, the etiologies of each type of AFF have not been studied in detail. This study aimed to investigate the nature and etiologies of the risk factors for diaphyseal AFFs. MATERIALS AND METHODS: Eighty consecutive Japanese patients with 91 diaphyseal AFFs (AFF group) and 110 age-matched women with osteoporosis (non-AFF control group) were included. Their clinical data were compared; factors affecting AFFs were investigated, and the etiologies of the risk factors for diaphyseal AFFs were examined. RESULTS: Multivariate analysis revealed that femoral serrated changes, bisphosphonate or denosumab usage, and lateral and anterior femoral curvatures were risk factors for diaphyseal AFFs (p < 0.0011, p = 0.0137, and p < 0.0001, respectively). Multivariate analyses revealed that serrated changes and low serum 25(OH)D levels affected the lateral curvature (p = 0.0088 and 0.0205, respectively), while serrated changes affected the anterior curvature (p = 0.0006), each significantly affected the femoral curvature. High serum calcium (Ca) levels, lateral femoral curvature, and anterior femoral curvature were predictors of serrated changes (p = 0.0146, 0.0002, and 0.0098, respectively). CONCLUSION: Risk factors for diaphyseal AFFs were bone resorption inhibitor usage, a strong femoral curvature, and serrated changes. Low serum 25(OH)D levels and serrated changes are risk factors for lateral curvature, while a high serum Ca level is a risk factor for serrated changes.

Preoperative medications is one of the factor affecting patient-reported outcomes after total hip arthroplasty.

Although the reported clinical outcomes of total hip arthroplasty (THA) for hip osteoarthritis are satisfactory, not all patients are completely satisfied. Thus, there is interest in predicting postoperative satisfaction before surgery. The influence of comorbidities and preoperative medications on the incidence of complications and duration of hospitalization following THA has become apparent. However, studies about the associations of preoperative medication with clinical outcomes of THA are limited. Therefore, this study aimed to clarify the relationship between preoperative medications and postoperative patient-reported outcomes. This retrospective cross-sectional multicenter study enrolled post-THA patients (79 patients, 90 hips) who were examined from February to March 2019 in eight general hospitals. Outcome measures included patient-reported outcome as Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) score. Preoperative medications were investigated from medical records. Medications were categorized, and analgesics were categorized into non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, pregabalin, duloxetine, neurotropin (an extract from inflammatory rabbit skin inoculated by vaccinia virus), and opioid. To identify the factors associated with JHEQ score, the patients were divided into lower (<55 score) and higher (≥55) JHEQ score groups. Spearman rank correlation coefficient (r) showed significant difference between the total number of preoperative medications and postoperative JHEQ movement subscale (r = -0.37, p < 0.01), mental subscale (r = -0.29, p < 0.01), and JHEQ (r = -0.30, p < 0.01) scores. In the multiple logistic regression analysis, only the total number of preoperative medications was identified as a risk factor for lower JHEQ score (p < 0.01). This study clarified an inverse correlation between the total preoperative medication count and postoperative outcomes and found that larger total count of preoperative medications is a risk factor of poor postoperative patient-reported outcomes of THA.

Teriparatide and exercise improve bone, skeletal muscle, and fat parameters in ovariectomized and tail-suspended rats.

INTRODUCTION: Although teriparatide (TPTD) and exercise may improve osteoporosis, muscle atrophy, and fat metabolism during ageing, the effects of treatment with a combination of TPTD and exercise on these factors remain unclear. Therefore, this study examined the effects of TPTD and exercise on bone, skeletal muscle, and fat in ovariectomized and tail-suspended rats. MATERIALS AND METHODS: Seven-month-old female Wistar rats were ovariectomized and subjected to tail suspension. The rats were then randomized into one of the following four groups (n = 20/group) after 4 weeks: control group, treated with TPTD vehicle and no exercise; TPTD group (30 µg/kg TPTD, 3 days/week); Exercise group (treadmill at 12 m/min, 60 min/day, 5 days/week); and Combined group treated with TPTD and treadmill exercise. After 1 and 8 weeks of treatment, bone, skeletal muscle, and fat tissue parameters were evaluated. RESULTS: TPTD improved bone mineral density (BMD), bone structure, bone strength at the femoral metaphysis, and the percentage of skeletal muscle mass, and decreased the percentage of fat mass and the adipose volume in the bone marrow. Treadmill exercise increased BMD, bone strength of cancellous bone, and the percentage of skeletal muscle mass, and decreased the percentage of fat mass as seen on dual-energy X-ray absorptiometry. Furthermore, combined treatment significantly affected BMD, bone structure, and bone strength of cortical bone at the femoral diaphysis. CONCLUSION: TPTD or treadmill exercise improved bone, skeletal muscle, and fat mass. Combination therapy with TPTD and exercise had synergistic effects on BMD, structure, and bone strength in ovariectomized, tail-suspended rats.

Evaluation of factors affecting the occurrence of second atypical fracture after bone union of the first atypical fracture.

PURPOSE: Teriparatide is sometimes used in the treatment of atypical femoral fracture (AFF). Even if bone union is achieved, orthopedic physicians must consider the risk of relapse. This study aimed to investigate the factors affecting AFF recurrence, and to determine the appropriate treatment for osteoporosis after bone union. METHODS: One hundred thirty-one consecutive AFFs in 113 Japanese patients were included. Eleven patients had AFF in the unaffected limb (9 patients) after the first AFF or re-fracture at the original fracture site (2 patients) after bone union of the first AFF was confirmed. We divided all patients into two groups: the second fracture group (22 AFFs in 11 patients) and non-second fracture group (109 AFFs in 102 patients). We compared clinical information between the 2 groups and investigated the factors affecting AFF recurrence using the Student t-, Welch t-, and chi-square tests. RESULTS: Although there was no significant difference in clinical characteristics between the 2 groups, multivariate analysis of factors associated with AFF recurrence identified short duration of treatment with teriparatide and active vitamin D3 (p = 0.0408 and 0.0366, respectively) as risk factors. Even in the analysis excluding subtrochanteric AFF, short periods of teriparatide and active vitamin D3 administration were observed as risk factors (p = 0.0484 and 0.0346, respectively). CONCLUSION: The administration of teriparatide for as long as possible after occurrence first AFF and the use of active vitamin D3 after completion of teriparatide therapy may be the most effective strategy to prevent the recurrence of AFF.

Characteristic imaging findings of tendinosis of the direct head of rectus femoris and their interpretation.

BACKGROUND: Tendinosis at the origin of the direct head of rectus femoris causing anterior hip pain is termed AIISpinitis, but no study has investigated its imaging findings. The aim of the present study was to determine the characteristic imaging findings of AIISpinitis and clarify their pathological significance. METHODS: We reviewed the preoperative imaging findings of 62 hips in 58 patients who had undergone endoscopy with a diagnosis of AIISpinitis. The origin of the direct head of rectus femoris was evaluated by ultrasound (US) and magnetic resonance imaging (MRI), and the positive rate of abnormal findings and their agreement with endoscopy regarding injury of the direct head of rectus femoris were measured. Signal changes in the fat pad around the anterior inferior iliac spine (AIIS fat pad) in MRI were compared with the pathological findings of that harvested endoscopically. RESULTS: Hypoechoic regions in US (53/62, 85%) and signal change in MRI (55/62, 89%) were observed with high frequency and corresponded with injury of the direct head of rectus femoris observed by endoscopy (58/62, 94%) (kappa coefficient, 0.43 [moderate agreement], 0.69 [good agreement] respectively). Hypoechoic regions had high sensitivity (85%) and specificity (86%) for AIISpinitis. Regarding the AIIS fat pad, punctate and completely hypo-intense change relative to normal fat corresponded to fibrosis and scar formation, respectively (weighted kappa coefficient, 0.51 [moderate agreement]). CONCLUSIONS: Hypoechoic regions on US which had high sensitivity and specificity; and signal change at the origin of the direct head of rectus femoris and hypo-intensity of the AIIS fat pad on MRI were characteristic findings of tendinosis of the direct head of rectus femoris. These findings correspond pathologically to injury of the direct head of rectus femoris and fibrosis or scar formation in the AIIS fat pad, respectively.

Initial Rotational Instability of the Tapered Wedge-Shaped Type Cementless Stem.

BACKGROUND: Because the tapered wedge-shaped type cementless stem has a small anteroposterior width and a low occupation rate in the medullary space, postoperative rotational instability and stem subsidence due to inadequate proximal fixation are concerns. The purpose of this study was to clarify the relationship between the rotational instability of the tapered wedge-shaped type cementless stem and femoral canal shape. METHODS: A total of 61 primary total hip arthroplasties with the tapered wedge-shaped type cementless stem Accolade® TMZF (11 males, 50 females; mean age 60 years) from January 2012 to June 2015 who underwent computed tomography before surgery and within 4 weeks and 1 year after surgery were evaluated. The preoperative femoral neck anteversion angle, preoperative femoral canal flair index, the degree of postoperative stem subsidence within 1 year after operation, and the degree of rotational change in the stem setting angle within 1 year after operation were investigated. RESULTS: The mean preoperative femoral neck anteversion angle was 32.2° ± 17.8° (0°-69°), and the mean preoperative canal flair index was 3.68 ± 0.58 (2.44-5.55). There were no stem subsidence cases within 1 year after operation. The mean degree of rotational change in the stem from immediately to 1 year after surgery was -0.4° ± 1.7° (-3°-3°). There was no significant correlation between the canal flair index and the rotational change in the stem. In addition, the mean difference between the preoperative femoral neck anteversion angle and the stem rotational angle immediately after surgery was only 1.3° ± 5.3° (-29°-15°). CONCLUSIONS: In all cases, including stove-pipe cases, the degree of rotational change in the Accolade® TMZF stem from immediately to 1 year after surgery was within 3°. In other words, regardless of femoral canal shape, the tapered wedge-shaped type cementless stem has little initial rotational instability.

The Differences in Imaging Findings Between Painless and Painful Osteoarthritis of the Hip.

PURPOSE: In osteoarthritis of the hip, the pain may be strong even if the deformity is mild, but the pain may be mild even if the deformity is severe. If the factors related to the pain can be identified on imaging, reducing such factors can alleviate the pain, and effective measures can be taken for cases where surgery cannot be performed. In addition, imaging findings related to the pain are also important information for determining the procedures and the timing of surgery. Thus, the purpose of this study was to identify the differences in features of osteoarthritis seen on imaging between painless and painful osteoarthritis of the hip. METHODS: The subjects were the patients with hip osteoarthritis who visited our department in 2015 and who underwent x-ray, computed tomography (CT), and magnetic resonance imaging (MRI), a total of 29 patients (54 hip joints; mean age 63 years; 8 males and 21 females). The degree of osteoarthritis was determined using the Tönnis grade from the x-ray image. The cartilage morphology, intensity changes of bone marrow on MRI (subchondral bone marrow lesions [BMLs]), osteophytes, joint effusions, and paralabral cysts were scored based on the Hip Osteoarthritis MRI Scoring System (HOAMS). The cross-sectional area of the psoas major muscle at the level of the iliac crest was measured on CT, and the psoas index (PI; the cross-sectional area ratio of the psoas major muscle to the lumbar 4/5 intervertebral disc) was calculated to correct for the difference in physique. Then, the relationships between these and visual analog scale (VAS) scores of pains were evaluated. RESULTS: The average VAS was 55.4 ± 39 mm. The PI and all items of HOAMS correlated with the VAS. The average VAS of Tönnis grade 3 osteoarthritis was 75.8 ± 26 mm. When investigating only Tönnis grade 3 osteoarthritis, the differences between cases with less than average pain and those with above average pain were the BML score in the central-inferior femoral head (P = .0213), the osteophyte score of the inferomedial femoral head (P = .0325), and the PI (P = .0292). CONCLUSION: Investigation of the differences between painless and painful osteoarthritis of the hip showed that the cases with more pain have BMLs of the femoral head on MRI that extend not only to the loading area, but also to the central-inferior area. Even with the same x-ray findings, the pain was stronger in patients with severe psoas atrophy. Thus, the instability due to muscle atrophy may also play a role in the pain of hip osteoarthritis.

A Comparison of the Incidences of Venous Thromboembolism after Total Hip Arthroplasty between the Direct Anterior Approach and the Direct Lateral Approach, Especially in the Early Period after Introduction of the Direct Anterior Approach.

OBJECTIVE: To compare the incidence of venous thromboembolism (VTE) after total hip arthroplasty (THA) using the direct anterior approach (DAA) with that using the direct lateral approach (DLA). In addition, patient background characteristics and the incidence of VTE were compared between the first half and the latter half of the period after introducing DAA and against DLA. METHOD: This was a retrospective, multicenter study involving 109 patients (116 hips) who had undergone primary unilateral THA. Thirty-six hips underwent THA using DAA and 80 hips underwent THA using DLA. Patient information including sex, age, and preoperative diagnosis was collected. The incidence of VTE was compared between DAA and DLA. Moreover, the patients who underwent THA using DAA were divided into 2 groups (first half and latter half groups), and sex, age, body mass index (BMI), and surgical time were compared between the 2 groups. Moreover, the incidence of VTE was compared among the 3 groups (first half of DAA, latter half of DAA, and DLA). RESULTS: The incidence of VTE in the DAA group was significantly higher than that in the DLA group (p=0.014). The incidence of VTE in the first half group was significantly higher than in the latter half group and the DLA group (p=0.035 and p=0.001, respectively), and there was no difference in the incidence of VTE between the latter half group and the DLA group (p=0.923). Surgical time was significantly longer in the first half group than in the latter half group (p=0.046). CONCLUSIONS: In the first half of the period after introducing the DAA, more VTEs occurred than in the DLA. It may be important to shorten the surgical time in the early stage of introducing the DAA, and aggressive anticoagulation therapy may be required until the surgeon becomes familiar with the procedure.

The location of the fracture determines the better solution, osteosynthesis or revision, in periprosthetic femoral fractures.

PURPOSE: Periprosthetic femoral fractures are difficult to treat, but few reports have included many periprosthetic femoral fractures. The purpose of this study was to investigate the trends and characteristics of a large number of periprosthetic femoral fractures and to determine the best treatment strategy for such fractures. METHODS: The fracture type according to the Vancouver classification, the stem fixation style of previous surgery, the elapsed time from previous surgery, and the treatment method for periprosthetic fractures of 51 patients with periprosthetic femoral fractures who were seen between 2006 and 2018 were investigated. RESULTS: The types of fractures according to the Vancouver classification were: type A 5.9%, type B1 47%, type B2 20%, type B3 2.0%, and type C 25%. Of the previous surgeries, 76% were cementless fixation, and 24% were cemented fixation. The mean duration from previous surgery to periprosthetic femoral fracture was 8 years and 7 months (1-358 months), and injury within 1 year from previous surgery was most commonly observed (24%). As treatment for periprosthetic femoral fractures, conservative treatment was performed in 8%, and surgery was performed in 92%. Of the surgery cases, 53% underwent osteosynthesis, and 39% underwent revision surgery. Of type B1 surgery cases, 58% were treated with osteosynthesis, and 33% underwent revision surgery, although type B1 had no stem loosening. CONCLUSION: Many periprosthetic femoral fractures occurred within 1 year after the previous surgery. Therefore, preventive measures for periprosthetic femoral fractures should be started immediately after total hip replacement. In addition, revision surgery was performed even if the stem was not loosened in cases where it was judged that sufficient osteosynthesis could not be performed.

Diagnosis of Presarcopenia Using Body Height and Arm Span for Postmenopausal Osteoporosis.

PURPOSE: Sarcopenia and osteoporosis are both serious health problems in postmenopausal women. The Asia Working Group for Sarcopenia recommends using the skeletal muscle index (SMI), which is height-adjusted appendicular skeletal muscle mass (ASMM). However, loss of height has been shown to be a common clinical finding in patients with osteoporosis. This study examined the prevalence of presarcopenia using height and arm span, which is a predictor of height, and investigated the diagnostic accuracy for presarcopenia. METHODS: A total of 55 post-menopausal osteoporotic patients aged 62-95 years underwent bioelectrical impedance analysis (BIA) for ASMM measurement and dual-energy X-ray absorptiometry (DXA) scan for bone mineral density (BMD). Anthropometric measurements, including height, weight, and arm span were taken, and body mass index (BMI), SMI, and arm span-adjusted SMI (Arm span SMI) were calculated. Presarcopenia was defined as SMI or Arm span SMI <5.7 kg/m2 in this study. RESULTS: The prevalence of presarcopenia was 27.3% and 38.2% evaluated by SMI and Arm span SMI, respectively. The prevalence of presarcopenia was higher when evaluated by Arm span SMI than by SMI. In the presarcopenia group diagnosed only by Arm span SMI (n=11), the arm span-height difference was significantly higher (p<0.001) and the percentage of young adult mean (YAM) femoral neck-BMD was significantly lower (p=0.013) compared to the normal group diagnosed by both SMI and Arm span-SMI (n=29). CONCLUSION: These results indicated that Arm span SMI might be useful for the diagnosis of sarcopenia in patients with severe osteoporosis and kyphosis.

Effects of bazedoxifene and low-intensity aerobic exercise on bone and fat parameters in ovariectomized rats.

INTRODUCTION: Postmenopausal osteoporosis and dyslipidemia are well-known skeletal and metabolic changes in middle-aged women. We investigated the effects of combined treatments with a selective estrogen receptor modulator (SERM) and exercise on bone and fat parameters in ovariectomized (OVX) rats. MATERIALS AND METHODS: Sixteen-week-old female Sprague-Dawley rats underwent bilateral ovariectomy, and rats were randomized to BZA (bazedoxifene at 0.3 mg/kg/day), Exe (treadmill exercise at 12-15 m/min, 60 min/day, 5 days/week), Comb (BZA and Exe), and Cont (control treated with vehicle and no exercise) groups 8 weeks after ovariectomy. After 4 or 8 weeks of treatment, bone mineral density (BMD) of the total femur and lumbar spine and whole-body percentage fat mass were determined by dual-energy X-ray absorptiometry, and mechanical testing of the femoral shaft, and bone and fat histomorphometric analyses of the proximal tibia were performed. RESULTS: Treadmill exercise had decreased bone marrow adipocytes from 4 weeks of treatment and whole-body percentage fat mass at 8 weeks. BZA increased BMD at the lumbar spine and decreased the whole-body percentage fat mass from 4 weeks and bone marrow adipocytes at 8 weeks. Combination therapy increased BMD for the lumbar spine and decreased bone marrow adipocytes and whole-body percentage fat mass from 4 weeks. CONCLUSION: Combination therapy with BZA and exercise appears effective to improve bone and fat parameters in OVX rats.

Micro-CT imaging analysis for the effects of ibandronate and eldecalcitol on secondary osteoporosis and arthritis in adjuvant-induced arthritis rats.

We investigated the effects of ibandronate, a bisphosphonate; eldecalcitol, an active vitamin D3 analogue; and combination treatment with both agents on secondary osteoporosis and arthritis using rats with adjuvant-induced arthritis. Arthritis was induced in 8-week-old male Lewis rats. Rats were randomized into four treatment groups and an untreated normal control group: ibandronate, eldecalcitol, ibandronate + eldecalcitol, vehicle, and control. Paw thickness was measured to evaluate arthritis. Joint destruction was evaluated histomorphometrically by the ankle joint stained with Fast Green and safranin O. The femur and lumbar spine were scanned using dual-energy X-ray absorptiometry, and the distal femur was scanned using micro-computed tomography for bone mineral density (BMD) and trabecular microstructural evaluations. Ibandronate and/or eldecalcitol increased BMD in both the lumbar vertebrae and femur and improved several microstructural parameters (bone volume/total volume, structure model index, trabecular number, and trabecular separation of the distal femur). In addition, there was an additive effect of combination treatment compared with single treatments for most trabecular parameters, including BMD and bone volume. However, ibandronate and/or eldecalcitol did not inhibit arthritis and joint destruction. Combination treatment with ibandronate and eldecalcitol may be effective for secondary osteoporosis associated with arthritis.

Incidence and Clinical Outcomes of Hip Fractures Involving Both the Subcapital Area and the Trochanteric or Subtrochanteric Area.

PURPOSE: Proximal femoral fractures involving both the subcapital area and the trochanteric or subtrochanteric area have rarely been reported, but they are not uncommon. However, few studies have reported the incidence or clinical outcomes of such fractures. This study investigated such fractures. METHODS: In area classification, the proximal femur is divided into 4 areas by 3 boundary planes: the first plane is the center of femoral neck; the second plane is the border between femoral neck and femoral trochanter; and the third plane links the inferior borders of greater and lesser trochanters. A fracture only in the first area is classified as a Type 1 fracture; one in the first and second areas is classified as a Type 1-2 fracture. Therefore, proximal femoral fractures involving both the subcapital area and the trochanteric area are classified as Type 1-2-3, and those involving both the subcapital area and the subtrochanteric area are classified as Type 1-2-3-4. In this study, a total of 1042 femoral proximal fractures were classified by area classification, and the treatment methods and the failure rates were investigated only for Types 1-2-3 and 1-2-3-4 cases. The failure rate was defined as the incidence of internal fixator cut-out or telescoping >10 mm. RESULTS: Types 1-2-3 and 1-2-3-4 fractures accounted for 1.72%. Surgical treatment was performed for 89%. Of these, 56% underwent osteosynthesis, but the failure rate was 33%. The other patients (44%) underwent prosthetic replacement. Fracture lines of all these fractures were present along trochanteric fossa to intertrochanteric fossa in posterior aspect and just below the femoral head in anterior aspect. CONCLUSION: Fracture involving the subcapital area to the trochanteric or subtrochanteric area was found in approximately 2%. In patients for whom prosthetic replacement was selected, good results were obtained. However, 1/3 of patients who underwent osteosynthesis had poor results.

Effects of activated vitamin D, alfacalcidol, and low-intensity aerobic exercise on osteopenia and muscle atrophy in type 2 diabetes mellitus model rats.

Diabetes mellitus causes secondary osteoporosis and muscle atrophy. The ability of alfacalcidol (ALF) and exercise (Exe) to inhibit osteoporosis and muscle atrophy in type 2 diabetes mellitus (T2DM) model rats was examined. Twenty-week-old Otsuka Long-Evans Tokushima Fatty rats were randomized to ALF (orally 0.1 µg/kg/day), Exe (treadmill exercise at 10 m/min, 60 min/day, 5 days/week), Comb (ALF and Exe), and Cont (T2DM control treated with vehicle and no exercise) groups (n = 8-10 per group). Sedentary Long-Evans Tokushima Otsuka rats were used as a non-hyperphagic control. After treatment for 2 or 6 weeks, blood glucose (BG) levels, cross-sectional area (CSA) of tibialis anterior muscle fibers, femoral bone mineral density (BMD), and relative quantities of muscle anabolic markers (Pax7, MyoD, and myogenin) and catabolic markers (Atrogin-1, MuRF1, and REDD1) of the soleus muscle assessed by real-time polymerase chain reaction assays were measured. Exe and Comb treatments for 6 weeks decreased BG levels compared with those of the Cont group. ALF, Exe, and Comb treatments for 2 and 6 weeks recovered the CSA compared with that of the Cont group. ALF and Comb treatments for 6 weeks increased femoral BMDs compared with those of the Cont group. After 2 weeks of treatment, Comb treatment increased MyoD expression and decreased MuRF1 expression. ALF or Exe monotherapy significantly decreased Atrogin-1 or MuRF1 expression after 2 weeks of treatment, respectively. After 6 weeks of treatment, ALF and Comb treatments decreased Atrogin-1 and REDD1. These results demonstrate that a combination of ALF and Exe improved CSA from the early phase of treatment by stimulating skeletal muscle differentiation and suppressing muscle catabolic genes. Improvements in BG, BMD, and CSA were observed as long-term effects of the combination therapy. Continued suppression of muscle catabolic genes was observed as a background to these effects.

Extra-articular Debridement of Hip Joint for Management of Anterior Hip Pain.

Groin pain is a common problem that is known to be a complex issue. The wide variety of possible pathologies in numerous anatomical structures contributes to this complexity. For patients who have anterior hip pain in Patrick's test and tenderness at Scarpa's triangle, we perform periarticular debridement based on the hypothesis that rectus femoris tendinosis, subacute/chronic fibrosis of the anterior inferior iliac spine fat pad, and gluteal muscle adhesion are responsible for such anterior hip pain. This Technical note illustrates the surgical procedure of periarticular debridement for extra-articular pathology-associated anterior hip pain. Repair of the injured labrum and correction of femoroacetabular impingement deformity have never been performed in this cohort. Arthroscopic periarticular debridement is a reliable surgical technique that can relieve anterior hip pain and provide a rapid to return to normal activities.

Effects of eldecalcitol and ibandronate on secondary osteoporosis and muscle wasting in rats with adjuvant-induced arthritis.

OBJECTIVES: Rheumatoid arthritis (RA) is characterized by chronic inflammation of the synovium, progressive erosion of the articular cartilage, and joint destruction. RA also causes secondary osteoporosis and muscle wasting. We investigated the effects of ibandronate (IBN), a bisphosphonate; eldecalcitol (ELD), an active vitamin D3 derivative; and combination treatment with both agents on secondary osteoporosis and muscle wasting using adjuvant-induced arthritis rats. METHODS: Arthritis was induced in 8-week-old male Lewis rats. Rats were randomized into 4 treatment groups and an untreated normal control group: IBN (subcutaneously, once every 2 weeks, 10 µg/kg), ELD (orally, once daily, 30 ng/kg/day), IBN + ELD, vehicle, and control. Paw thickness measurements were performed for evaluation of arthritis. The femur was scanned using dual-energy X-ray absorptiometry. Cross-sectional areas of left tibialis and anterior muscle fibers and the expression of MuRF1, atrogin-1, MyoD, and myogenin in the gastrocnemius muscle were measured to evaluate muscle wasting. RESULTS: IBN and/or ELD increased bone mineral density (BMD) in the femur. In addition, there was an additive effect of combination treatment compared with single treatments for BMD. However, IBN and/or ELD did not inhibit muscle wasting in adjuvant-induced arthritis rats. CONCLUSIONS: Combination treatment with IBN and ELD may be effective for secondary osteoporosis associated with RA. Other treatments are necessary for muscle wasting associated with RA. Studies in humans are needed to confirm these findings.

Effects of combined therapy of alendronate and low-intensity pulsed ultrasound on metaphyseal bone repair after osteotomy in the proximal tibia of glucocorticoid-induced osteopenia rats.

OBJECTIVES: Glucocorticoid (GC) treatment inhibits activation of runt-related transcription factor 2 (Runx2), which is essential for osteoblast differentiation from stem cells. As a result, GC treatment results in bone loss, GC-induced osteoporosis (GIO), elevated fracture risk, and delayed bone healing. Bisphosphonates such as alendronate (ALN) are recommended for treating or preventing GIO, and low-intensity pulsed ultrasound (LIPUS) facilitates fracture healing and maturation of regenerated bone. Combined therapy with ALN and LIPUS may stimulate cancellous bone healing in GIO rats. Here, we examined the effect of ALN and LIPUS on cancellous bone osteotomy repair in the proximal tibia of GIO rats. METHODS: Prednisolone (10 mg/kg body weight/day) was administered for 4 weeks to induce GIO in 6-month-old female Sprague-Dawley rats. Tibial osteotomy was then performed and daily subcutaneous injection of ALN (1-µg/kg body weight) was subsequently administered alone or in combination with LIPUS (20 min/day) for 2 or 4 weeks. RESULTS: ALN significantly increased bone mineral density (BMD) at 2 and 4 weeks, and ALN + LIPUS significantly increased BMD at 4 weeks. Bone union rates were significantly increased after 2 and 4 weeks ALN and ALN + LIPUS treatment. Lastly, ALN and ALN + LIPUS significantly increased the proportion of Runx2 positive cells at 4 weeks. CONCLUSIONS: ALN monotherapy and combined ALN and LUPUS treatment augmented BMD and stimulated cancellous bone repair with increased Runx2 expression at the osteotomy site in GIO rats. However, the combined treatment had no additional effect on cancellous bone healing compared to ALN monotherapy.