Revascularization of a Necrotic Femoral Head in Severely Slipped Capital Femoral Epiphysis With a Modified Dunn Procedure: A Case Report.

Avascular necrosis, a serious slipped capital femoral epiphysis (SCFE) complication, is difficult to treat. We report a rare case of revascularization of the necrotic femoral head in a 12-year-old male patient with a severe SCFE (posterior tilting angle, 87°). We performed the modified Dunn procedure (MDP), followed by long-term unloading therapy. Blood flow to the epiphysis had partially resumed 2.3 years postoperatively. At the final 4.5-year follow-up, blood flow had been restored, leading to epiphyseal closure without significant femoral head deformity or hip pain. The patient could walk unassisted, with a flexion range of 120°. These findings support the use of the MDP with long-term unloading therapy as a potential treatment option for severe SCFE.

The Short-term Outcomes of Physiotherapy for Patients with Acetabular Labral Tears: An Analysis according to Severity of Injury in Magnetic Resonance Imaging.

Purpose: The aim of this study was to evaluate the short-term outcome of physiotherapy in patients with acetabular labral tears and to assess the effectiveness of physiotherapy according to the severity of the labral tear. Materials and Methods: Thirty-five patients who underwent physiotherapy for treatment of symptomatic acetabular labral tears were enrolled. We evaluated the severity of the acetabular labral tears, which were classified based on the Czerny classification system using 3-T MRI. Clinical findings of microinstability and extra-articular pathologies of the hip joint were also examined. The International Hip Outcome Tool 12 (iHOT12) was use for evaluation of outcome scores pre- and post-intervention. Results: The mean iHOT12 score showed significant improvement from 44.0 to 73.6 in 4.7 months. Compared with pre-intervention scores, significantly higher post-intervention iHOT12 scores were observed for Czerny stages I and II tears (all P<0.01). However, no significant difference was observed between pre-intervention and post-intervention iHOT12 scores for stage III tears (P=0.061). In addition, seven patients (20.0%) had positive microinstability findings and 22 patients (62.9%) had findings of extra-articular pathologies. Of the 35 patients, eight patients (22.9%) underwent surgical treatment after failure of conservative management; four of these patients had Czerny stage III tears. Conclusion: The iHOT12 score of patients with acetabular labral tears was significantly improved by physiotherapy in the short-term period. Improvement of the clinical score by physiotherapy may be poor in patients with severe acetabular labral tears. Determining the severity of acetabular labral tears can be useful in determining treatment strategies.

Changes in Invasiveness and Latent Infection Rate Associated with Switching the Approach in Total Hip Replacement.

PURPOSE: Muscle-sparing approaches for total hip replacement (THR) involve learning curves. This study aimed to clarify changes in invasiveness and infection rate with changes in approach. METHODS: One surgeon changed the approach of THR from Dall's approach (Dall) to anterolateral modified Watson-Jones approach (OCM). Another changed from Dall to a direct anterior approach (DAA). Another 3 surgeons changed from posterolateral approach (PL) to OCM. Subjects were 150 cases, comprising the last 25 cases with conventional approaches and the first 25 cases with new approaches (Dall to OCM: 25 + 25; Dall to DAA: 25 + 25; PL to OCM: 25 + 25 cases). Differences in operative time, bleeding volume, hospital stay, haemoglobin (Hb), white blood cell count, lymphocyte count, creatine kinase (CK) and C-reactive protein (CRP) were investigated. RESULTS: In the change from Dall to OCM, only hospital stay decreased. In the change from Dall to DAA, hospital stay and CRP decreased, but bleeding volume increased. In the change from PL to OCM, operative time, CRP and CK decreased, but Hb also decreased. Cases with lymphocyte count <1000/µL or lymphocytes comprising <10% of total white blood cells at around day 4 after surgery were defined as latent infection cases. In these cases, operative time was longer, Hb was lower and CK was higher. CONCLUSION: Introducing muscle-sparing approaches improved many markers of invasiveness, but some items deteriorated. In the early stages of introducing a new approach, choosing cases without obesity and without high muscle volume may reduce the risk of infection.

Acetabular Morphology in Patients with Developmental Dysplasia of the Hip with High Dislocation.

PURPOSE: The current study aimed to investigate the morphology of the true acetabulum in developmental dysplasia of the hip (DDH) with high dislocation. A secondary was to evaluate the acetabular cup placement in patients with high dislocation who were treated with total hip arthroplasty (THA). MATERIALS AND METHODS: Using a retrospective design, 23 hips with DDH with high dislocation in patients who were treated with THA were included in this study. We measured the depth, width and thickness of the anterior and posterior walls of the original acetabulum using preoperative computed tomography images and investigated the cup size applied in these cases. RESULTS: The mean depth and width of the acetabulum was 18.4 and 16.2 mm proximal end, 18.4 and 24.3 mm in the middle, and 15.8 and 27.6 mm at the distal part. Mean thickness of the anterior and posterior walls was 10.9 and 23.9 mm at the proximal end, 10.3 and 22.2 mm in the middle, and 10.9 and 22.7 mm at the distal part. A 42-mm cup was using in one hip, a 46-mm cup in three hips, a 48-mm cup in 13 hips, and a 50-mm cup in six hips. CONCLUSION: In patients with Crowe IV DDH, the morphology of the acetabulum comprises a triangle that broadens from proximal to distal points, with a relatively thick posterior wall. Reaming the acetabulum posteriorly and inferiorly may enable the placement of a relatively larger cup to achieve stable fixation.

Successful reimplantation surgery after extraction of well-fixed cementless stems by femoral longitudinal split procedure.

BACKGROUND: Well-fixed cementless stems sometimes need to be extracted in patients with complications including periprosthetic infection, stem-neck breakage, or trunnionosis. The purpose of this study was to report the clinical outcome in patients undergoing reimplantation surgery after removal of a well-fixed porous-coated cementless stem by the femoral longitudinal split (FLS) procedure. METHODS: We conducted a retrospective study and radiographic review of 16 patients who had undergone reimplantation following the FLS procedure to remove a well-fixed stem due to periprosthetic infection, stem-neck breakage, or trunnionosis. The study group consisted of 2 men and 14 women with an average age of 68.4 years. Mean follow-up was 44.6 months. The Kaplan-Meier method was used to evaluate the longevity of the stem. RESULTS: The average operation time was 272 ± 63 minutes and intraoperative bleeding was 420 ± 170 mL. Although postoperative dislocation occurred in 5 hips and subsidence of the stem was found in 2 hips after surgery, no progressive subsidence was observed and the clinical JOA and JHEQ scores were both improved after reimplantation surgery. Reimplantation surgery with Zweymüller-type stems revealed evidence of osseointegration of the stem without femoral fracture. Kaplan-Meier survival analysis of stem revision for any reason as the end point revealed 70.0% survival at 9 years. CONCLUSIONS: In this study, we experienced some complications in patients with trunnionosis or periprosthetic infections. However, the FLS procedure is expected to confer successful clinical results without loosening of the reimplanted cementless stem, after safe extraction of well-fixed porous-coated cementless stems without fracture.

Restoration of proximal periprosthetic bone loss by denosumab in cementless total hip arthroplasty.

Denosumab contributed to the restoration of proximal periprosthetic bone loss around the femoral stem that were measured using a DEXA, especially in zone 7, at 1 year after cementless THA in elderly osteoporotic patients. INTRODUCTION: Although bone quality is an important issue in elderly osteoporotic patients who underwent total hip arthroplasty (THA) with a cementless stem, periprosthetic bone mineral density (BMD) in the proximal femur has been reported to be decreased by 15-40% postoperatively. Some authors have examined the use of several types of bisphosphonates to prevent decreases in BMD in the proximal femur after cementless THA; however, few reports have demonstrated success in restoring BMD in the proximal medial femoral bone, such as zone 7. METHODS: We conducted prospective study comparing patients who underwent cementless THA administered with denosumab (10 patients) and without denosumab (10 patients). BMD around the femoral stem were measured using a DEXA immediately after surgery, and at 6 months and at 1 year after surgery. No difference was found between the two groups referred to the patient's demographic data. RESULTS: We found that denosumab displayed definitive effects in increasing the % change in periprosthetic BMD at zone 7 by an average of 7.3% in patients with cementless THA, compared to control group who were given only vitamin D. CONCLUSION: Denosumab is one of a number of anti-osteoporotic agents to have a definitive effect on the restoration of proximal periprosthetic bone loss, especially in zone 7, after cementless THA. Denosumab contributed to the restoration of decreased periprosthetic BMD to normal levels. As the decrease in BMD in the proximal femur after THA is considered to be apparent at 6-12 months after surgery, it is believed that prevention of the deterioration of bone quality is important in the proximal femur immediately after cementless THA for elderly female patients with osteoporosis.

Chondrosarcoma mimicking MRI of the osteonecrosis of the femoral head: a case report.

A 25-year-old female visited our hospital with an 8-year history of arthralgia in the right hip joint. Plain radiography of the hip revealed a well-demarcated radiolucent lesion with a thin sclerotic rim in the epiphysis of the femoral head. T 1 weighted MRI revealed the demarcation line of a low-signal-intensity band in the femoral head. We were aware that this band did not split the signal of adipose tissue in the bone marrow. In cases of osteonecrosis, we usually find a low-signal-intensity band splitting the signal of normal bone marrow. However, we could not see such a low-signal-intensity band in this case. Therefore, we decided to perform other studies. Contrast-enhanced T 1 weighted MRI showed remarkable enhancement in the segment proximal to the low-signal-intensity band, indicating that this lesion might have blood perfusion. We decided to perform a bone biopsy to clarify the diagnosis. Histopathological examination of the biopsy specimen revealed chondrosarcoma. We found that contrast-enhanced MRI plays an important role to rule out osteonecrosis of the femoral head.

Three-dimensional orientation of the acetabulum.

This study was designed specifically to determine the normal acetabular orientation and femoral head covering, and whether these are affected by age or sex. Computed tomographic images of normal Japanese hip joints were used (males 60, females 60; mean age 48.3 years, range 15-79 years). Male and female age profiles were matched. The reconstructed 3-D pelvic images were aligned in the anatomical pelvic coordinate system. The acetabular orientation angles and femoral covering angles were measured in the sagittal, coronal, and horizontal planes. In the sagittal plane, the acetabular orientation angle was operative anteversion (O-av), and the femoral covering angles were the anterior and posterior center-edge angles (ACE and PCE). In the coronal plane, they were the Sharp angle (SA) and the lateral center-edge angle (LCE). In the horizontal plane, they were anatomical anteversion (A-av) and the anterior and posterior sector angles (ASA and PSA). The O-av, SA, and A-av were smaller in the male than the female acetabulum (P < 0.01). SA in both males and females was inversely correlated with age (P < 0.01). Both male PCE and PSA were significantly smaller than those of females, while male ASA was larger than female ASA (P < 0.05). The male acetabulum is directed further outward and downward than the female one. However, this does not indicate that the male acetabulum covers the femoral head more, because there is no significant sex difference in the LCE. Femoral coverage is more posteriorly biased in females than in males owing to pelvic inclination. Clin. Anat. 30:753-760, 2017. © 2017Wiley Periodicals, Inc.

Extraction of well-fixed extended porous-coated cementless stems using a femoral longitudinal split procedure.

We present a technique of posterior femoral longitudinal split (FLS) osteotomy. This technique allows the expansion of the metaphyseal-diaphyseal region of the proximal femur facilitating extraction of well-fixed extended porous-coated stems. The extractions were performed using extended transfemoral osteotomy (ETO) and FLS osteotomy between June 2002 and March 2014. The study group, which comprised patients with well-fixed extended porous-coated stems, consisted of two men and ten women with an average age of 63.2 years. The stem was successfully removed using the FLS procedure in 8 of the 10 hips. Reimplantation surgery was performed in 6 of the 12 hips with ARMD, periprosthetic infection, or metallosis. This FLS technique may allow the easy removal of well-fixed extended porous-coated stems and become an alternative method for the removal of all stems.

Experimental rat model for alcohol-induced osteonecrosis of the femoral head.

Alcohol-induced osteonecrosis of the femoral head (ONFH) is observed in alcohol abusers and patients with alcoholic fatty liver disease. It has been reported that Toll-like receptor 4 (TLR4) signalling plays a crucial role in the pathogenesis of alcoholic fatty liver disease. We previously reported a corticosteroid-induced ONFH rat model, and suggested that TLR4 signalling contributes to the pathogenesis of ONFH. Thus, it is thought that the pathogenesis of alcohol-induced ONFH is probably similar to that of corticosteroid-induced ONFH. The aim of this study was to develop a new animal model for alcohol-induced ONFH and to evaluate the relationship between the pro-inflammatory response via TLRs and the development of ONFH in rats. Male Wistar rats were fed a Lieber-DeCarli liquid diet containing 5% ethanol (experimental group) or dextran (control group) for 1-24 weeks. Histopathological and biochemical analyses were performed. Feeding the ethanol-containing liquid diet resulted in the development of ONFH with hepatic steatosis, hepatic dysfunction and hyperlipidaemia, whereas feeding the dextran-containing diet did not cause ONFH. However, we could not recognize any relationship between the pro-inflammatory response via TLR4 and the development of alcohol-induced ONFH. Thus in this study we have developed a new rat model for alcohol-induced ONFH based on the feeding of an ethanol liquid diet. ONFH was observed within seven days from the start of feeding with 5% ethanol-containing liquid diet. Although this was linked to hepatic steatosis, a TLR4 association was not a feature of this model.

High risk of osteonecrosis of the femoral head in autoimmune disease patients showing no immediate increase in hepatic enzyme under steroid therapy.

Aim of the study is to determine the relationship between liver function and the incidence of ONF after steroid therapy in AID patients. The present study investigated 58 AID patients who had received high-dose systemic steroid therapy to determine whether a correlation exists between parameters of hepatic function and steroid-induced ONF at the precise time-point when steroid-induced ONF develops. The patients were divided into two groups on the basis of MRI findings: ONF (n = 31) and non-ONF (n = 27). The ONF group showed no increase in AST, ALT, or LDH within 4 weeks after the commencement of steroid therapy. By contrast, the non-ONF group showed an immediate and significant increase in all of these parameters. In the ONF group, hepatic steatosis and elevated triglyceride levels were also observed. Following 4 weeks of steroid therapy, there were no significant differences in biochemical data between two groups. Patients showing no immediate increase in ALT and AST in response to steroid therapy were at high risk of ONF. These findings provide important insights into the pathogenesis of steroid-induced ONF and may facilitate the development of prevention strategies in patients with AID.

Weight bearing does not contribute to the development of osteonecrosis of the femoral head.

The hip joint is one of the major structures in the human body and the resultant force acting through the hip joint is 300% of body weight. Therefore, weight bearing, as a cause of ischaemia, may contribute to the development of non-traumatic osteonecrosis of the femoral head (ONFH). However, it remains unclear whether weight bearing is related to the development of non-traumatic ONFH. Therefore the aim of this study was to clarify the role of weight bearing in the development of non-traumatic ONFH. Non-weight-bearing (NWB) rats were tail suspended to prevent any weight coming to bear on the hindlimbs from day 1 to the time of sacrifice. The weight-bearing (WB) group rats were also housed individually, although without tail suspension. All rats were injected with lipopolysaccharide and methylprednisolone to promote the development of non-traumatic ONFH. All animals were sacrificed three weeks after the final methylprednisolone injection. Histopathological analysis was performed. Osteonecrosis of the femoral head was observed not only in the NWB but also in the WB rats; however, no osteonecrosis of the humeral head was observed in either group. We confirmed that non-traumatic ONFH developed in NWB rats, suggesting that weight bearing does not contribute to the development of non-traumatic ONFH in rats.

Epigenetic regulation of MIR-124 under ethanol dependence and withdrawal.

Withdrawal from chronic alcohol cause the persistent molecular alteration, such as changes in the release of neurotransmitter and gene expression. The alterations are thought to increase in the risk of relapse. Recent studies suggest that the gene expression regulated by histone acetylation may play an important role in the dependence of abused drugs, including of ethanol. Furthermore, miRNA, another regulator of gene expression, are also important molecules for the dependence. However, changes in the molecules under ethanol withdrawal and its relationship are poorly understood. In the present study, we investigated the expression of acetylated histone H3 and miR-124 in mouse brain at 3 days after ethanol withdrawal. 6-Week ages of C57BL/6J mice were treated with liquid diet containing ethanol for 10 days. Using the escalating ethanol dosage schedule, the mice were fed the ethanol diet as follows: 1st day: 1 w/v%: 2nd and 3rd day: 3 w/v%; 4th and 5th day: 4 w/v% and from the 6th to 10th day: 5 w/v% ethanol diet, respectively. The pair-fed control mice were given the same volume of ethanol-free liquid diet with glucose substituted in isocaloric quantities for ethanol. After feeding alcohol liquid diet, the mice showed severe withdrawal signs. The expression of acetylated histone H3 was significantly decreased in limbic forebrain at 3 days after withdrawal. We found that miR-124 also decreased in the limbic forebrain. It has been reported that Cdc42 regulates neuronal development as a target of miR-124. We found that Cdc42 protein markedly increased in both brain regions at 3 days after withdrawal. Our findings suggest that changes in the expression of miR-124 via histone acetylation leads to change the Cdc42 expression under ethanol withdrawal.

The suppression of TRIM21 and the accumulation of IFN-α play crucial roles in the pathogenesis of osteonecrosis of the femoral head.

Osteonecrosis of the femoral head (ONFH), the pathogenesis of which remains unclear, has been observed in autoimmune disease patients treated with corticosteroids. Recently, it has been shown that anti-tripartite motif-containing 21 (TRIM21) autoantibodies, which are often present in patients with systemic lupus erythematosis and Sjögren's syndrome, inhibit the E3 ligase activity of TRIM21. TRIM21 negatively regulates nuclear factor-κB (NF-κB) and interferon regulatory factors (IRFs) 3 and 7, three downstream transcription factors, via toll-like receptor 4 signaling. The aim of this study was to clarify the role of TRIM21 in the pathogenesis of ONFH using an animal model. Male Wistar rats were injected with lipopolysaccharide (LPS) twice and with methylprednisolone (MPSL) or saline three times. N-acetyl cysteine (NAC) was administered either concurrently with MPSL or once daily for the 3 days following the last MPSL injection. The incidence of ONFH in the MPSL group was 23.5%. Co-treatment of NAC and MPSL increased the incidence of ONFH to 55.6%. MPSL treatment decreased the activity of NF-κB in the liver and significantly increased the activity of both IRF3 and IRF7. No significant differences were observed in the activity of any of these three transcription factors between the MPSL and the co-treatment groups. In the femoral head, co-treatment with NAC and MPSL significantly decreased the expression of TRIM21 at 3 h and significantly increased the expression of interferon (IFN)-α at 24 h when compared with the MPSL group. IFN-α is known to induce cell death. These findings suggest that the suppression of TRIM21 in the femoral head causes an accumulation of IFN-α, which in turn leads to the development of ONFH. In conclusion, the suppression of TRIM21 resulting from altered NF-κB and IRF homeostasis accelerates the ONFH in rats treated with corticosteroids following LPS administration.

Expression of aquaporin-4 augments cytotoxic brain edema after traumatic brain injury during acute ethanol exposure.

We previously reported that ethanol consumption affects morbidity and mortality after traumatic brain injury (TBI) by accelerating brain edema via oxidative stress after TBI. Aquaporin-4 (AQP4), a water channel, is involved in brain edema formation. In this study, we found that acute ethanol administration increased AQP4 expression after TBI, leading to severe brain edema in rats. Rats were pretreated with ethanol (3 g/kg) or dl-buthionine-(S,R)-sulfoximine (BSO; 100 mg/kg), an oxidative stressor, before TBI. Acetazolamide, an AQP4 inhibitor, was administered to ethanol-pretreated rats 3 or 12 hours after TBI. Brain edema was increased 24 hours after TBI in both the ethanol- and BSO-pretreated groups. Ethanol pretreatment induced lipid peroxidation 24 hours after TBI. Transcription factors, NF-κB and hypoxia-inducible factor-1α, were activated 3 and 24 hours after TBI in the BSO- and ethanol-pretreated groups, respectively. In the ethanol-pretreated group, AQP4 was accumulated, particularly in astrocyte end feet, 24 hours after TBI. Acetazolamide treatment improved the survival rate to 100% and decreased brain edema and AQP4 in ethanol-pretreated rats. These findings suggest that ethanol induces up-regulation of AQP4, leading to brain edema. The accumulation of AQP4 may play an important role in the augmentation of brain edema after TBI under ethanol consumption.