Combined use of beta-tricalcium phosphate with different porosities can accelerate bone remodelling in open-wedge high tibial osteotomy.

Background/Objective: Beta-tricalcium phosphate (ß-TCP) is often used as a gap filler in open-wedge high tibial osteotomy (OWHTO). The aim of the present study was to investigate the effects of using ß-TCP with different porosities on bone remodelling after OWHTO.Methods: We evaluated 29 knees in 26 patients that underwent OWHTO using ß-TCP with porosities of 60% and 75% (combined group). A further 30 knees in 28 patients that underwent OWHTO using ß-TCP with 60% porosity alone were allocated as a control group. In the combined group, a ß-TCP block with 75% porosity was inserted into the gap at the cancellous bone site and a ß-TCP block with 60% porosity was inserted into the medial cortical bone side. In the control group, a ß-TCP block with 60% porosity was inserted into the osteotomy gap. The bone remodelling phases of the inserted ß-TCP blocks were evaluated on standard anteroposterior radiographs using the modified van Hemert classification at 3 and 6 months post-operatively. Results: The rate of satisfactory bone remodelling at the cancellous bone sites was 86.2% (25/29) in the combined group and 0% (0/30) in the control group at 3 months post-operatively (p<0.05), progressing to 96.6% (28/29) in the combined group and 20% (6/30) in the control group at 6 months post-operatively (p<0.05). Conclusion: The present study demonstrated that combined use of ß-TCP with high and low porosities can significantly enhance bone formation. The combined use of artificial bones with different porosities is useful for early bone remodelling in OWHTO.

Hybrid Assistive Limb improves restricted hip extension after total hip arthroplasty.

The Hybrid Assistive Limb (HAL) was developed as an exoskeleton robot that supports gait training. The purpose of this study was to assess the usefulness of training using the HAL after total hip arthroplasty (THA). We targeted 16 consecutive patients who underwent THA via the posterior approach. We randomized patients to the HAL group (8 hips), in which the HAL was used as part of physical therapy, or the control group (8 hips), in which only typical physical therapy was performed. Gait analysis was performed before and after surgery, and comparisons were made between the two groups. We evaluated the single support time (%), double support time (%), cadence (steps/min), velocity (cm/s), stride length (cm), and anteroposterior and lateral variability, and assessed the hip and knee joint range of motion in the sagittal plane. The results showed improvements in the hip extension angle and other gait parameters in the HAL group. Among gait-related problems after THA, a decreased peak hip extension angle is reported to be a significant factor that affects gait disability. This study revealed that HAL usage after THA seems to be a useful method to obtain sufficient extension angle.

Effect of Robot-assisted Rehabilitation to Botulinum Toxin A Injection for Upper Limb Disability in Patients with Chronic Stroke: A Case Series and Systematic Review.

Combining single-joint hybrid assistive limb (HAL-SJ) with botulinum toxin A (BTX-A) therapy is novel and has great therapeutic potential for the rehabilitation of stroke patients with upper limb paralysis. The purpose of this observational case series study was to evaluate the effect of BTX-A and HAL-SJ combination therapy on different exoskeleton robots used for treating upper limb paralysis. The HAL-SJ combination received a BTX-A injection followed by HAL-SJ-assisted rehabilitation for 60 min per session, 10 times per week, during 2 weeks of hospitalization. Clinical evaluations to assess motor function, limb functions used during daily activities, and spasticity were performed prior to injection, at 2-week post-treatment intervention, and at the 4-month follow-up visit. The total Fugl-Meyer assessment-upper limb (FMA-UE), proximal FMA-UE, action research arm test (ARAT), Motor Activity Log (MAL), and Disability Assessment Scale (DAS) showed a statistically significant difference, and a large effect size. However, the FMA distal assessment at 2-week post-treatment intervention showed no significant difference and a moderate effect size. The FMA-UE scores of the extracted systematic review articles showed that our design improved upper limb function. The change in the total FMA-UE score in this study showed that, compared to previous reports in the exoskeletal robotic therapy group, our combination therapy had a higher score than five of the seven references. Our results suggest that BTX-A therapy and HAL-SJ combination therapy may improve upper limb function, similar to other treatment methods in the literature.

Difference in Prognosis between Continuation and Discontinuation of A 5-Month Cardiac Rehabilitation Program in Outpatients with Heart Failure with Preserved Ejection Fraction.

BACKGROUND: Cardiac rehabilitation (CR) is a requisite component of care for patients with heart failure (HF). We aimed to evaluate the clinical outcomes in outpatients with HF with preserved ejection fraction (HFpEF) compared to those in patients with non-HFpEF who did and did not continue a 5-month CR program. METHODS: 173 outpatients with HF who participated in a 5-month CR program were registered. We divided them into two groups: HFpEF (n = 84, EF 63 ± 7%) and non-HFpEF (n = 89, EF 31 ± 11%). We further divided the patients into those who continued the CR program (continued group) and those who did not (discontinued group) in the HFpEF and non-HFpEF groups. The clinical outcomes at 5 months were compared among the groups. RESULTS: There were no significant differences in patient characteristics at baseline between the continued and discontinued groups in the HFpEF and non-HFpEF groups except for % diabetes mellitus in the non-HFpEF group. The rates of all-cause death and hospital admissions in the continued group in both the HFpEF and non-HFpEF groups were significantly lower than those in the discontinued group. The all-cause death and hospital admissions in each group were independently associated with the continuation of the CR program. CONCLUSIONS: The continuation of a 5-month CR program was associated with the prevention of all-cause death and hospital admissions in both the HFpEF and non-HFpEF groups.

Femoral Neck Fracture in a Hemodialysis Patient after Liver Transplantation: A Case Report.

BACKGROUND: Surgical treatment of femoral neck fractures is usually performed as an urgent procedure so that restoration of the ability to stand and walk can be achieved as quickly as possible. However, orthopedic surgeons need to be aware of undertreated or untreated diseases in their patients. Organ transplant recipients require immunosuppressive agents and steroids postoperatively. Hemodialysis patients also exhibit immunological deterioration and are included among immunocompromised patients. We report a case in which conservative treatment was chosen for a hepatic transplant recipient on hemodialysis who suffered a femoral neck fracture because signs of inflammation of unknown etiology were intermittently seen. CASE: The patient was a 70-year-old man who had undergone liver transplantation from a living donor as treatment for hepatocellular cancer and hepatic failure with cirrhosis. Dialysis for end-stage renal failure was initiated at approximately 1 year postoperatively. Cyclosporine was administered as an immunosuppressive agent. The patient subsequently fell off a bicycle and was unable to walk because of right hip pain. He was brought to our hospital by ambulance, and a right hip radiograph revealed a femoral neck fracture. His white blood cell count and C-reactive protein levels were intermittently elevated with unknown etiology. Conservative treatment was finally adopted, although a bipolar hip arthroplasty was planned. At 5 months after the injury, the patient was able to walk alone in a stable manner using a pair of crutches and was discharged. DISCUSSION: Conservative treatment for a femoral neck fracture, which generally requires surgery, may be acceptable in organ transplant recipients on hemodialysis.

Biofeedback Core Exercise Using Hybrid Assistive Limb for Physical Frailty Patients With or Without Parkinson's Disease.

Introduction: Elderly people often exhibit "frailty," and motor dysfunction occurs. Several studies have reported about the relationship between motor dysfunction and frailty in Parkinson's disease (PD). This study aimed to test whether the core exercise using the hybrid assistive limb lumbar type for care support (HAL-CB02) may improve the motor functions in frailty patients with or without PD and to explore the optimal patient selection from the frailty cohort. Materials and Methods: We recruited 16 frailty patients (PD = 8; non-PD = 8). The participants performed core exercise and squats using HAL-CB02 for five sessions a week. Outcome measures were 10-m walking test, step length, timed up-and-go test, 30-s chair stand test, and visual analog scale. Evaluation was conducted at baseline, post-exercise, and 1- and 3-month follow-ups. Results: Both PD and non-PD patients showed significant improvement in all evaluation items post-exercise. Moreover, no significant difference was found in the improvement value between the two groups. Conclusions: Our results suggest that biofeedback exercise with HAL-CB02 is a safe and promising treatment for frailty patients. Motor dysfunction in PD patients may be partly due to physical frailty, and biofeedback exercise with HAL-CB02 is proposed as a treatment option.

Feasibility of Robot-assisted Rehabilitation in Poststroke Recovery of Upper Limb Function Depending on the Severity.

The single-joint Hybrid Assistive Limb (HAL-SJ) robot is an exoskeleton-type suit developed for the neurorehabilitation of upper limb function. Several studies have addressed the usefulness of the robot; however, the appropriate patient selection remains unclear. In this study, we evaluated the effectiveness of the HAL-SJ exoskeleton in improving upper limb function in the subacute phase after a stroke, as a function of the severity of arm paralysis. Our analysis was based on a retrospective review of 35 patients, treated using the HAL-SJ exoskeleton in the subacute phase after their stroke, between October 2014 and December 2018. The severity of upper limb impairment was quantified using the Brunnstrom recovery stage (BRS) as follows: severe, BRS score 1-2, n = 10; moderate, BRS 3-4, n = 12; and mild, BRS 5-6, n = 13. The primary endpoint was the improvement in upper limb function, from baseline to post-intervention, measured using the Fugl-Meyer assessment upper limb motor score (ΔFMA-UE; range 0-66). The ΔFMA-UE score was significant for all three severity groups (P <0.05). The magnitude of improvement was greater in the moderate group than in the mild group (P <0.05). The greatest improvement was attained for patients with a moderate level of upper limb impairment at baseline. Our findings support the feasibility of the HAL-SJ to improve upper limb function in the subacute phase after a stroke with appropriate patient selection. This study is the first report showing the effect of robot-assisted rehabilitation using the HAL-SJ, according to the severity of paralysis in acute stroke patients with upper extremity motor deficits.

Feasibility of supplemental robot-assisted knee flexion exercise following total knee arthroplasty.

BACKGROUND: The Hybrid Assistive Limb (HAL) is a robotic exoskeleton designed to support impaired limbs. OBJECTIVE: We aimed to evaluate whether active exercise using a single-joint HAL (HAL-SJ) following total knee arthroplasty can facilitate the recovery of knee flexion. METHODS: Twenty-two patients who underwent total knee arthroplasty were randomly allocated to the HAL-SJ group (n= 12) or conventional physical therapy (CPT) group (n= 10). On postoperative day 5, patients performed active knee flexion exercises either with or without HAL-SJ assistance every second day. Outcome measures included active and passive knee flexion range of motion (ROM), muscle strength, and pain intensity, as assessed by the visual analog scale, and were assessed on postoperative days 5 (pre-treatment) and 10 (post-treatment). Active ROM was measured at 6 months postoperatively; further long-term follow-up was performed by telephone interview. RESULTS: Both groups showed significant improvement between postoperative days 5 and 10 in all outcome measures. Improvements in active ROM (p< 0.01), passive ROM (p< 0.01), muscle strength (p< 0.01), and pain (p< 0.01) were significantly greater in the HAL-SJ group than in the CPT group. Long-term outcomes were also significantly better in the HAL-SJ group. CONCLUSIONS: HAL therapy enables patients to perform painless active movements and facilitates the recovery of knee function.

Severe varus knees result in a high rate of undercorrection of lower limb alignment after opening wedge high tibial osteotomy.

PURPOSE: The purpose of this study was to clarify the indication for opening wedge high tibial osteotomy (OWHTO) in terms of lower limb alignment to achieve satisfactory clinical results. METHODS: Ninety-two patients (98 knees) with medial compartment knee osteoarthritis were investigated in this study. The average follow-up period was 34 months (range, 24-68 months). The average age of the patients at the time of surgery was 63 years (range, 41-77 years). RESULTS: The patients were divided into the following two groups according to the preoperative femorotibial angle (FTA) on anteroposterior full-length radiographs of the lower limbs while weight bearing: 29 knees with a preoperative FTA of ≥185° were defined as those with severe varus (S group), and the remaining 69 knees with a preoperative FTA of <185° were defined as those with mild varus (M group). Knees with a postoperative FTA of >175° were defined as undercorrected. The Lysholm score was used to assess the clinical results. The average postoperative FTA was 175.7° ± 4.1° in the S group and 174.6° ± 3.1° in the M group ( p = 0.013). Significantly, more undercorrected knees were observed in the S than M group ( p = 0.00035). The postoperative Lysholm score was 85.6 ± 8.5 in the S group and 88.5 ± 5.7 in the M group at the last follow-up ( p = 0.0033). CONCLUSION: Based on these results, we recommend that a preoperative FTA of <185° should be included as a criterion for OWHTO alone.

Patellar Dislocation in a Patient with Kabuki Syndrome with Severe Mental Retardation: A Case Report.

BACKGROUND: Kabuki syndrome is a rare congenital syndrome. Individuals with Kabuki syndrome have intellectual disabilities, often combined with skeletal anomalies and joint laxity. We herein report the first case of rehabilitation after reconstruction of the medial patellofemoral ligament in a patient with Kabuki syndrome. CASE: A 27-year-old woman with Kabuki syndrome and severe intellectual disability fell during an epileptic seizure. The right patella dislocated and then spontaneously reduced; similar episodes occurred repeatedly. Reconstruction of the medial patellofemoral ligament and lateral retinacular release were performed. Despite an intensive rehabilitation protocol, the patient's activities of daily living (ADL) did not quickly improve postoperatively because of her severe intellectual impairment and unwillingness to participate in rehabilitation exercises. About 3 months postoperatively, staff encouraged the patient to transfer from a wheelchair to a car, and she was able to get into the car with a little assistance. Subsequently, the patient's ADL gradually improved. By approximately 1 year postoperatively, the patient was able to ambulate independently for a few meters. DISCUSSION: The patient was thought to be interested in cars and in going for drives. Rehabilitation training for ADL improvement in patients with severe developmental disorders should include activities that the patients consider interesting.

Sports and Physical Activities of Elderly Patients with Medial Compartment Knee Osteoarthritis after High Tibial Osteotomy.

OBJECTIVE: We retrospectively investigated the preoperative and postoperative sports and physical activities (SPA) of elderly patients with medial compartment knee osteoarthritis who underwent opening-wedge high tibial osteotomy (OWHTO). METHODS: Fifty-six patients (62 knees) with medial compartment knee osteoarthritis were included in the study. The patients comprised 45 women and 11 men with a mean age at surgery of 71.6 years (range, 65-81 years). The mean follow-up period was 51±7 months. Patients who performed SPA to maintain their health for at least 30 min per session more than once a week were defined as SPA cases. The preoperative and postoperative ratios of SPA cases, the time to resuming or starting postoperative SPA, and the frequency of performing postoperative SPA were investigated. Clinical results were assessed using the Lysholm score. RESULTS: Fifteen patients (26.7%) performed SPA before OWHTO and 14 (25.0%) performed SPA after OWHTO (P=0.21). The mean time to resuming or starting SPA after surgery was 14.1±10.0 months, and the frequency of postoperative SPA sessions was 4.2±2.1 per week. The mean Lysholm score significantly improved from 60.8±8.9 preoperatively to 92.5±2.5 postoperatively (P<0.0001). CONCLUSION: The ratio of patients who performed SPA after OWHTO was still <30% , and it took a comparatively long time for patients to resume or start SPA after surgery.

Feasibility of rehabilitation using the single-joint hybrid assistive limb to facilitate early recovery following total knee arthroplasty: A pilot study.

We aimed to evaluate the feasibility of robot-assisted rehabilitation in an early postoperative setting to improve knee mobility following total knee arthroplasty (TKA). A total of 20 patients were alternatively assigned to robotassisted rehabilitation (n = 10; all women) or a control group (n = 10; 2 men and 8 women). The use of a single-joint hybrid assistive limb (HAL-SJ) in active assistive knee exercise was performed for the robot-assisted rehabilitation group while the control patients underwent conventional active assistive knee exercise. We measured the extension lag (defined as the difference between active and passive range of knee extension). We also evaluated the visual analog scale score (VAS) during active movements and active assistive movement. Concerning the extension lag, the robot-assisted rehabilitation group showed 89.4% ± 15.7% improvement (p < 0.01) while the control group showed 34.8% ± 32.1% improvement (p = 0.016). As to the VAS, the robot-assisted rehabilitation group showed 40.7% ± 23.5% improvement while the control group showed 20.4% ± 25.8% improvement (p < 0.01). The use of HAL-SJ may facilitate early recovery from knee surgery and prevent long-term complications such as quadriceps arthrogenic muscle inhibition.

Hip abductor muscle strength after total hip arthroplasty with short stems.

Excellent clinical results have been reported for total hip arthroplasty (THA) using a short stem. However, the range of variance in positioning of the stem has been reported to be wide. The authors hypothesized that the short stem position influences the femoral offset (FO) and hip abductor muscle strength (AMS) after surgery. The AMS was evaluated in 64 limbs in 32 patients who underwent unilateral THA using a short stem with a normal contralateral hip. The average time of AMS evaluation was 46.3 months postoperatively. The Harris Hip Score (HHS) was used for clinical evaluation. The ratio of the AMS on the reconstructed side to that on the contralateral side was calculated (strength ratio). The valgus angle (VA) of each stem and FO was measured on an anteroposterior hip radiograph. The FO ratio, as the normalized FO, was calculated. Linear regression analyses were performed to investigate the relationships among the VA, FO ratio and strength ratio. The average HHS improved from 57.7 points preoperatively to 94.6 points postoperatively. The VA negatively correlated with the FO ratio (r = -0.511, P = 0.028). The strength ratio negatively correlated with the VA (r = -0.505, P = 0.032) and positively correlated with the FO ratio (r = 0.479, P = 0.0056). The average postoperative HHS was generally satisfactory after THA using a short stem. A more valgus postoperative position of the short stem leads to reduced FO, which causes decreasing postoperative AMS after THA with a short stem.

Is the obturator artery safe when performing ischial osteotomy during periacetabular osteotomy?

The purposes of this study were (1) to evaluate the actual distance between the obturator artery and the ischial osteotomy site when performing periacetabular osteotomy via an anterior approach and (2) to determine a safe method to avoid injuring the obturator artery during this procedure. Twenty-nine hemipelves from cadavers were used in this study. The mean distance between the obturator artery and the ischial osteotomy site was 35.6 ± 7.5 mm and always exceeded 20 mm. Therefore, the procedure can be performed safely when a chisel blade of 20 mm or shorter is used.

Simultaneous analysis of human plasma catecholamines by high-performance liquid chromatography with a reversed-phase triacontylsilyl silica column.

The clinical importance of simultaneous analysis of 3,4-dihydroxyphenylglycol with other human plasma catecholamines has been investigated to better understand the sympathetic nervous system. However, previous reports have had analytical difficulties with both resolution and extraction. The current study uses a reversed-phase triacontylsilyl silica (C30) column under the mobile phase condition without ion-pair reagents to separate catecholamines and their metabolites, with above 91% recoveries for intra-assay, above 85% for inter-assay, and less than 10% (n=5) coefficient of variation. Lower detection limits (S/N=4) and quantification limits (S/N=6) were 40 and 100 pg/mL for norepinephrine, 3,4-dihydroxyphenylglycol, and 3,4-dihydroxyphenylalanine, 10 and 20 pg/mL for epinephrine, 10 and 40 pg/mL for dopamine. Linear ranges were from 40 to 5000 pg/mL for norepinephrine and 3,4-dihydroxyphenylalanine, from 100 to 5000 pg/mL for 3,4-dihydroxyphenylglycol, and from 10 to 2000 pg/mL for epinephrine and dopamine. The C30 column may prove clinically useful, as it provides a convenient and simultaneous method of evaluation of human plasma catecholamines.